Citation Nr: 1741024 Decision Date: 09/20/17 Archive Date: 10/02/17 DOCKET NO. 12-04 871 DATE THE ISSUES 1. Entitlement to a compensable (greater than 0 percent) initial disability rating for tinea pedis. 2. Entitlement to an initial disability rating in excess of 30 percent prior to August 30, 2010 and after December 1, 2010 for right carpal tunnel syndrome (CTS). 3. Entitlement to an initial disability rating in excess of 20 percent prior to November 14, 2016 and after March 1, 2017 for left CTS. 4. Entitlement to an initial disability rating in excess of 10 percent for status post right wrist fracture. 5. Entitlement to an initial disability rating in excess of 10 percent for status post left wrist fracture. ORDER Entitlement to a compensable (greater than 0 percent) initial disability rating for tinea pedis is denied. Entitlement to a disability rating of 50 percent prior to August 30, 2010 for right CTS is granted, but a rating greater than 30 percent since December 1, 2010 is denied. Entitlement to an initial disability rating in excess of 20 percent prior to November 14, 2016 and after March 1, 2017 for left CTS is denied. Entitlement to an initial disability rating in excess of 10 percent for status post right wrist fracture is denied. Entitlement to an initial disability rating in excess of 10 percent for status post left wrist fracture is denied. FINDINGS OF FACT 1. The Veteran's tinea pedis required only topical treatment, manifested in an area covering less than five percent of the body and none of the exposed area, and did not result in any scarring. 2. Prior to August 30, 2010, the Veteran's right CTS manifested with severe incomplete paralysis of the median nerve; from December 1, 2010 forward, the Veteran's right CTS manifested with moderate incomplete paralysis of the median nerve. 3. Prior to November 14, 2016 and after March 1, 2017, the Veteran's left CTS manifested with no more than moderate incomplete paralysis of the median nerve. 4. The Veteran's status post right wrist fracture manifested with painful limited motion, but without ankylosis of the wrist. 5. The Veteran's status post left wrist fracture manifested with painful limited motion, but without ankylosis of the wrist. CONCLUSIONS OF LAW 1. The criteria for a compensable disability rating for tinea pedis have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107 (West 2014); 38 C.F.R. § 4.118, Diagnostic Code 7813 (2016). 2. The criteria for a disability rating of 50 percent, but no greater, prior to August 30, 2010 for right CTS have been met; the criteria for a disability rating in excess of 30 percent from December 1, 2010 forward for right CTS have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2016). 3. The criteria for a disability rating in excess of 20 percent prior to November 14, 2016 and after March 1, 2017 for left CTS have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2016). 4. The criteria for a disability rating in excess of 10 percent for status post right wrist fracture have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107 (West 2014); 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5215 (2016). 5. The criteria for a disability rating in excess of 10 percent for status post left wrist fracture have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107 (West 2014); 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5215 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from June 1982 to August 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the issue for further development in March 2014, July 2015, and December 2016. The Board notes that actions requested in the prior remands have been undertaken. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The case has been returned to the Board for appellate review. Here, the Veteran's increased rating claims arise from his disagreement with the initial evaluations that were assigned following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (section 5103(a) notice is no longer required after service-connection is awarded). In addition, the Board finds that the duty to assist a claimant has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records. Multiple VA examinations have been conducted and any necessary opinions obtained. With respect to the right and left wrist disabilities, the Board is cognizant of the holding in Correia v. McDonald, 28 Vet. App. 158 (2016), which held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. As the Veteran has been awarded the maximum rating for motion loss and the next higher rating requires ankylosis, the provisions of 38 C.F.R. § 4.59 as well as 38 C.F.R. §§ 4.40 and 4.45 are no longer applicable. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In general, the Veteran seeks higher disability ratings for service-connected disability. Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). For diseases of the peripheral nerves, disability ratings are based on whether there is complete or incomplete paralysis of the particular nerve. The term "incomplete paralysis," indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. See 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury and the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40; see also 38 C.F.R. §§ 4.45, 4.59. Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Board finally observes that, following the last adjudication of the claims in the April 2017 supplemental statement of the case (SSOC), additional VA treatment records and a VA PTSD examination report have been added to the record. As none of this evidence is pertinent to the claims at hand, the Board may proceed to adjudicate the appeal without prejudice to the Veteran. 1. Entitlement to a compensable initial disability rating for tinea pedis. The Veteran contends that his tinea pedis warrants a compensable disability rating. This disability is rated under Diagnostic Code 7813 for dermatophytosis (ringworm: of body, tinea coporis; of head, tinea capitis; of feet, tinea pedis; of beard area, tinea barbae; of nails, tinea unguium; of inguinal area (jock itch), tinea cruris). That regulation notes that dermatophytosis should be rated as disfigurement of the head, face, or neck (DC 7800), scars (DC's 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the predominant disability. 38 C.F.R. § 4.118. Diagnostic Code 7806 addresses dermatitis and eczema. That regulation is, in part, as follows: At least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period warrants a 10 percent disability rating; Less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period warrants a noncompensable disability rating. 38 C.F.R. § 4.118. The rating criteria for scars, to include Diagnostic Codes 7801, 7802, 7804, and 7805, allows for a compensable disability rating with deep and nonlinear scars covering an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.), superficial and nonlinear scars covering an area or areas of 144 square inches (929 sq. cm.) or greater, or unstable or painful scars. 38 C.F.R. § 4.118. The Board notes that as the Veteran's tinea pedis is confined to his feet, the rating criteria regarding scars of the head, face, or neck in Diagnostic Code 7800 is not applicable. The question for the Board is whether the Veteran's tinea pedis covers an area of at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period, or resulted in deep and nonlinear scars covering an area or areas of at least 6 square inches but less than 12 square inches, superficial and nonlinear scars covering an area or areas of 144 square inches or greater, or unstable or painful scars. The Board finds that competent, credible, and probative evidence establishes that the Veteran does not meet the criteria for a compensable disability rating for tinea pedis. The Veteran was afforded a VA examination in August 2006. At that time, he reported a history of tinea pedis present for a few years. He used antifungal powders. He had mild itching without bleeding. Between the Veteran's toes, he had some mild erythema in the webs along with some whitish pigmentation. The examiner noted no fissuring and no tenderness. The tinea pedis was mildly pruritic. In a March 2009 VA treatment record, the Veteran complained of Athlete's Foot since service. Over the counter medication was not working anymore. The examiner diagnosed tinea and prescribed clotrimazole 1% twice per day and as needed to feet. The Veteran was afforded a VA examination in December 2009. The Veteran reported tinea pedis of both feet. The Veteran used antifungal cream on a daily basis with no side effects. The examiner noted no systemic symptoms. The Veteran's treatment had been continuous for the prior twelve months. The examiner noted local skin irritation as well as itchiness and mild pain. The examiner noted a fungal infection, which was scaly and mildly reddened in between the first and second toe, second and third toe, third and fourth toe, and fourth and fifth toe on the feet bilaterally. The Veteran applied antifungal cream bilaterally. The skin areas were described were scaly as well as mildly reddened. The examiner noted no scarring. The examiner noted no disfigurement or hyperhidrosis. Both feet were neurovascularly intact. Pedal pulses and posterior tibialis pulses were palpable and the examiner noted no edema. During a May 2014 VA examination, the examiner diagnosed tinea pedis bilaterally. The Veteran used an over-the-counter cream. He stated that he used it once per week when the condition flared up. The Veteran's condition did not cause scarring or disfigurement of the head, face or neck. The Veteran did not have any benign or malignant skin neoplasms. He also did not have any systemic manifestations due to any skin diseases (such as fever, weight loss or hypoproteinemia associated with skin conditions such as erythroderma). The Veteran was treated with topical medication for six weeks or more but not constantly over the prior 12 months. The Veteran did not have any debilitating or non-debilitating episodes in the past 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. The Veteran's disability affected no area of the body at the time of examination. The examiner found that the Veteran's tinea pedis did not impact his ability to work. The Veteran was afforded a VA examination again in February 2017. The Veteran was diagnosed with tinea pedis. During service, the Veteran noted bilateral foot itching, redness, flaky skin, and skin peeling between his toes. He was diagnosed with tinea pedis and advised to use over-the-counter antifungal cream and to keep his feet dry. He now has intermittent flare-ups, for which he continued to use antifungal creams. The examiner noted no scarring or disfigurement of the head, face, or neck. He had no benign or malignant skin neoplasms. The Veteran did not have any systemic manifestations due to any skin diseases such as fever, weight loss, or hypoproteinemia. The Veteran had not been treated with oral or topical medications in the prior 12 months for any skin condition. The examiner noted that the Veteran had not had any treatments or procedures other than systemic or topical medications in the prior 12 months. The Veteran has not had any debilitating or non-debilitating episodes of urticarial, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. The examiner noted infections of the skin affecting less than five percent of the total body area and none of the exposed area. The examiner noted that the Veteran's skin condition did not impact his ability to work. The Veteran's treatment records do not indicate any additional findings regarding the Veteran's tinea pedis. The Board notes that no lay or medical evidence of record shows tinea pedis covering at least five percent of the exposed body or five percent of the entire body. The February 2017 examiner noted that the disability covered less than five percent of the total body area and none of the exposed areas. The Veteran does not contend otherwise. Additionally, the Veteran used only topical fungal medications and did not require any systemic therapy. The lay and medical evidence of record also does not indicate that the Veteran's tinea pedis has resulted in any scarring. In so finding, the Board acknowledges the Veteran's credible report of recurrent tinea pedis infections manifested by symptoms such as itching, pain, redness, flaky skin, and skin peeling between his toes. The rating criteria specifically for dermatophytosis contemplate such symptoms, but require a higher percentage of bodily involvement to warrant a compensable rating. As such, the Board finds that a preponderance of the evidence is against the claim for a compensable disability rating for the Veteran's tinea pedis. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to an initial disability rating in excess of 30 percent prior to August 30, 2010 and after December 1, 2010 for right CTS. The Veteran contends that his right CTS warrants a disability rating in excess of 30 percent. The Board notes that the Veteran was granted a temporary total disability rating due to convalescence from surgery for the period of August 30, 2010 to December 1, 2010. As the Veteran has received the maximum schedular rating for that period, the Board will not consider a claim for an increased rating during that time. The Board notes that the Veteran is right-handed and, as such, the regulations discussed below will address the rating for the major or dominant extremity. The Veteran's right CTS is rated under Diagnostic Code 8515 for paralysis of the median nerve. Under that regulation, complete paralysis of the median nerve, to include the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances, warrants a 70 percent disability rating. Severe incomplete paralysis of the median nerve warrants a 50 percent disability rating. Moderate incomplete paralysis of the median nerve warrants a 30 percent disability rating. Mild incomplete paralysis of the median nerve warrants a 10 percent disability rating. 38 C.F.R. § 4.124a. The question before the Board is whether the Veteran's incomplete paralysis of the right median nerve manifested to a severe level of impairment. The Board finds that the weight of the competent, credible, and probative evidence establishes that the Veteran does meet the criteria for a 50 percent disability rating for right CTS prior to August 30, 2010. An August 2006 VA examination noted symptoms of bilateral CTS. Both hands became numb intermittently throughout the day, resolving within ten to fifteen minutes. The Veteran did not feel that wrist splints helped. He had mild stiffness in the wrists. The examiner noted normal strength against resistance. The examiner noted no loss of dexterity and the Veteran's grip strength was normal. The examiner noted no muscular atrophy or sensory deficits. The Veteran had a positive Phalen sign on the right wrist with tingling in the index and middle fingers. An October 2008 VA treatment record showed bilateral hand numbness with right significantly worse than left. A December 2008 VA treatment record indicated moderately severe right CTS with clinically suspected CTS on the left, but normal median nerve conduction velocity study. The examiner noted that the Veteran wanted to wait and see if he improved with a brace. In August 2009, the Veteran reported that the right hand was worse than the left. The Veteran had to type a lot at his work. He tried splinting with limited success. He reported that the pain was worse at night. The Veteran had EMG studies that showed moderate to severe right CTS. The Veteran received a steroid injection. Follow up treatment records showed moderate success of the steroid injection. The Veteran was afforded a VA examination in December 2009. The examiner noted that the Veteran's October 2008 EMG showed moderately severe right carpal tunnel syndrome. The Veteran asserted that the pain in the right wrist and radiating numbness and tingling sensation to all his fingers was worse. He used a brace mostly at night and took Motrin for pain. Current symptoms included numbness and tingling sensation on all his fingers on the right hand emanating from the wrist area. The condition affected his usual occupation as the Veteran was right-handed and had severe weakness of the right hand due to the CTS. Fine motor activities as well as grasping and lifting movement rendered his right hand and wrist painful. The specific nerve involved was noted as the median nerve of the right wrist and hand. A May 2010 VA treatment record noted right hand and wrist pain worsening. He requested physical therapy. The Veteran worked on computers all day and noted intermittent numbness and tingling. A June 2010 VA treatment record showed that the Veteran had known severe right CTS. He had some symptom relief with steroid injection and splinting. The Veteran was very tender. The Board notes that prior to the Veteran's carpal tunnel release surgery, the Veteran's right CTS symptoms were consistently described as severe. In fact, the word severe was used to describe the Veteran's CTS in December 2008, August 2009, December 2009, and June 2010. The extent of tingling and numbness extended to all fingers and affected fine motor activities, and involved stiffness and weakness. When considering the site and extent of involvement of the dominant right hand and fingers, the weakness of motor functioning and overall interference with work and life activities, the Board finds that a 50 percent disability rating is warranted for the right CTS due to severe incomplete paralysis of the median nerve prior to August 30, 2010. To receive a disability rating in excess of 50 percent during that period, the evidence must show complete paralysis of the median nerve with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. At no point during that period on appeal did the Veteran's right CTS exhibit symptoms of complete paralysis of the median nerve. The Veteran does not contend otherwise, and did not describe these aspects of disability. The Board must also consider whether the Veteran is entitled to a disability rating in excess of 30 percent after the CTS release surgery. The question for the Board, again, is whether the Veteran's right CTS manifested with severe incomplete paralysis of the median nerve. In February 2011, the Veteran noted that symptoms had improved since the surgery, but still complained of numbness. The Veteran also complained of bilateral wrist pain. Examination showed a negative Tinel's test and negative thenar atrophy. The examiner noted right wrist with ulna deformity. The Veteran had an abnormal Watson shift test with limited extension. A March 2011 VA treatment record showed that the Veteran had bilateral pain in the wrists with numbness of all fingers that radiates up the medial aspect of the arm. His symptoms worsened at night. He noted increased weakness. On examination, he had normal bulk and tone with full strength. He had hypoactive reflexes at the biceps, triceps, and fingers. He had slightly diminished light touch on the right palmar aspect of the fingers, but was otherwise intact to all modalities. The results of nerve conduction studies were abnormal for increased right median sensory peak latency and reduced right median mixed nerve conduction velocity across the wrist as assessed by the orthodromic palm to wrist study. The abnormal electrodiagnostic studies provide evidence for a mild right median neuropathy at the wrist (CTS). The Veteran was afforded a VA examination in May 2014. The examiner diagnosed bilateral CTS. The examiner noted mild constant pain bilaterally, mild numbness bilaterally, mild paresthesias or dysesthesias of the left upper extremity, and moderate paresthesias or dysesthesias of the right upper extremity. Muscle strength testing showed active movement against some resistance when pinging with thumb to index finger bilaterally and when gripping with the right hand. The examiner noted no muscle atrophy. Reflex examination showed absent reflexes of the biceps and triceps with normal reflexes of the brachioradialis. Sensory examination was normal for the shoulder, forearm, hand, and fingers. The examiner noted no trophic changes. Phalen's sign was positive bilaterally. The examiner noted moderate incomplete paralysis of the median nerve bilaterally. The examiner determined that the Veteran's CTS impacted his ability to work as he was unable to perform manual labor, but was able to perform sedentary labor that did not involve a lot of typing. In October 2016, the Veteran attended a VA consult. The Veteran previously underwent an endoscopic right carpal tunnel release with good symptom relief in 2010. His hands were warm and well perfused. He had full range of motion of the hands. His grip strength was 5/5 on the right. The Veteran's most recent VA examination took place in February 2017. The examiner diagnosed bilateral CTS status post bilateral carpal tunnel release. The Veteran had surgery on both the left and right wrists. He did not receive complete relief. At the time of the examination, he still experienced bilateral hand pain, weakness, tingling, and numbness. The pain was exacerbated by cold. He reported difficulty lifting, pushing, and pulling. He had difficulty holding or opening jars and difficulty typing. He required breaks at work to stretch his hands and he used braces. The examiner noted moderate constant pain of the bilateral upper extremities with severe intermittent pain, moderate bilateral upper extremity paresthesias or dysesthesias, and moderate numbness. Muscle strength testing was noted as 4/5 bilaterally regarding wrist flexion, wrist extension, hand grip, and pinch of thumb to index finger. The Veteran did not have muscle atrophy. Reflex examination revealed hypoactive deep tendon reflexes of the brachioradialis. The Veteran had decreased sensation for light touch of the hands and fingers. The examiner noted positive Phalen's sign and Tinel's sign bilaterally. The examiner noted moderate incomplete paralysis of the median nerve bilaterally. EMG studies in 2013 were abnormal, signifying CTS. The examiner noted that the Veteran's condition impacted his ability to work. The Veteran was limited in lifting, carrying, pushing, pulling, gripping, grabbing, or typing due to his CTS. The Board notes that the Veteran's incomplete median nerve paralysis was described as moderate in May 2014 and February 2017. The Veteran's symptoms were generally described as mild or moderate after December 1, 2010. There were intermittent exacerbations of severe pain. The Veteran overall exhibited greater strength than prior to his surgery - described as 4/5 strength rather than severe as previously described. There were mild sensory abnormalities and abnormal reflexes. However, there was no thenar atrophy or trophic changes. When considering the site and extent of involvement of the dominant right hand and fingers, the mild weakness of motor functioning, the mild sensory deficit and absent reflexes, the Board finds that the Veteran's overall right CTS disability does not meet, or more nearly approximate, severe incomplete paralysis of the median nerve since December 1, 2010 forward. In so finding, the Board has considered the Veteran's description of right hand CTS symptoms of tingling, numbness, weakness and functional impairment to be competent and credible evidence in support of the claim. As it pertains to the clinical findings such as extent of sensory disturbance, reflex abnormality, muscle weakness, etc., the Board places greater probative weight on the findings from VA examiners and clinicians who have greater training and expertise in evaluating and clinically describing neurologic impairment. As the preponderance of the evidence is against any additional disability rating, the benefit of the doubt rule is not applicable, and entitlement to any additional increased disability rating must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to an initial disability rating in excess of 20 percent prior to November 14, 2016 and after March 1, 2017 for left CTS. The Veteran contends that his left CTS warrants a disability rating in excess of 20 percent. The Board notes that the Veteran was granted a temporary total disability rating due to convalescence from surgery for the period of November 14, 2016 to March 1, 2017. As the Veteran has received the maximum schedular rating for that period, the Board will not consider a claim for an increased rating during that time. The Board notes that the Veteran is right-handed and, as such, the regulations discussed below will address the rating for the minor or non-dominant extremity. The Veteran's left CTS is rated under Diagnostic Code 8515 for paralysis of the median nerve. Under that regulation, complete paralysis of the median nerve, to include the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances, warrants a 60 percent disability rating. Severe incomplete paralysis of the median nerve warrants a 40 percent disability rating. Moderate incomplete paralysis of the median nerve warrants a 20 percent disability rating. Mild incomplete paralysis of the median nerve warrants a 10 percent disability rating. 38 C.F.R. § 4.124a. The question before the Board is whether the Veteran's incomplete paralysis of the left median nerve manifested to a severe level of impairment. The Board finds that the weight of the competent, credible, and probative evidence establishes that the Veteran does not meet the criteria for a 40 percent disability rating for left CTS at any time during the period on appeal. The Veteran was afforded a VA examination in August 2006. The Veteran reported that he developed symptoms of bilateral carpal tunnel syndrome. Both hands became numb intermittently throughout the day, resolving within ten to fifteen minutes. He did not feel that wrist splints helped. He had mild stiffness in the wrists. He was able to lift weights without a problem. The examiner noted no tenderness over the wrists. The examiner noted normal strength against resistance. The examiner showed no further decreased range of motion, lack of endurance, or pain with repetitive movement. The examiner noted no loss of dexterity and the Veteran's grip strength was normal bilaterally. The examiner noted no muscular atrophy or sensory deficits. The Veteran had a positive Tinel sign on the left wrist with tingling in the index and middle fingers bilaterally. In October 2008, the Veteran reported bilateral hand numbness with right significantly worse than left. The left wrist had full range of motion. In December 2008, the examiner noted moderately severe right CTS with clinically suspected CTS on the left, but normal median nerve conduction velocity study. The examiner noted that the Veteran wanted to wait and see if he improved with a brace. In August 2009, the Veteran reported that his right hand was worse than his left. The Veteran had to type a lot at his work. He has tried splinting with limited success. The pain was worse at night. EMG on the left was negative. The Veteran was afforded another VA examination in December 2009. The examiner noted that the Veteran's October 2008 EMG showed clinically suspected left CTS with normal median nerve conduction velocity study. He used a brace mostly at night and took Motrin for pain. The Veteran noted complaints of tingling and numbness as well as moderate pain of the left hand. The nerve conduction studies were normal. The Veteran reported mild tingling, numbness, and pain of the left wrist to the left hand and fingers. The condition interfered with his daily activity and occupation, though not as much as the right hand. The specific nerve involved was the median nerve of the left upper extremity. In May 2010, the Veteran reported worsening pain in the left wrist. He requested physical therapy. The Veteran worked on computers all day and noted intermittent numbness and tingling. In February 2011, the examiner reported that the left wrist was within normal limits upon examination. In March 2011, the Veteran reported intermittent pain, numbness, and tingling of the left hand. He noted bilateral pain in the wrists with numbness of all fingers that radiated up the medial aspect of the arm. His symptoms worsened at night. He noted increased weakness. On examination, he had normal bulk and tone with full strength. He had hypoactive reflexes at the biceps, triceps, and fingers. He was intact to all modalities on the left. The median motor, sensory, and orthodromic palm to wrist studies on the left side were normal. The examiner noted no electrodiagnostic evidence for a median neuropathy on the left side. The examiner acknowledged, however, that the Veteran's symptoms were consistent with a mild CTS that may not be detected by studies. In January 2013, a VA examiner noted worsening numbness and tingling of the left hand. EMG of March 2011 showed no electrographic evidence for CTS. The exam noted normal bower and bulk with slightly reduced sensation to pin in median nerve distribution. The results of the nerve conduction studies were abnormal for reduced median mixed nerve conduction velocity across the wrist as assessed by the orthodromic palm to wrist study. These abnormal electrodiagnostic studies provided evidence for a mild left median neuropathy at the wrist (CTS). The Veteran attended a VA examination in May 2014. The examiner diagnosed bilateral CTS. The examiner noted mild constant pain bilaterally, mild numbness bilaterally, and mild paresthesias or dysesthesias of the left upper extremity. The examiner noted no muscle atrophy. Reflex examination showed absent reflexes of the biceps and triceps with normal reflexes of the brachioradialis. Sensory examination was normal for the shoulder, forearm, hand, and fingers. The examiner noted no trophic changes. Phalen's sign was positive bilaterally and Tinel's sign was positive on the left. The examiner noted moderate incomplete paralysis of the median nerve bilaterally. The examiner determined that the Veteran's CTS impacted his ability to work as he was unable to perform manual labor, but was able to perform sedentary labor that did not involve a lot of typing. The Veteran presented for evaluation of left CTS at an October 2016 VA consult. The Veteran was seen several times for left CTS with an EMG in 2013 demonstrating mild compression neuropathy of the median nerve at the wrist. He had several steroid injections and now complained of worsening pain, numbness, and weakness in the left hand. He had wrist splints but did not wear them because they were too bulky. His hands were warm and well perfused. The left wrist had mild edema and diffusely TTP. The examiner noted mild left thenar wasting. His grip strength was 4+/5 on the left. The Veteran had slightly decreased sensation in the left hand median nerve distribution and positive left Tinel's. The examiner noted that a 2013 EMG showed mild left median neuropathy at the wrist. The examiner again diagnosed left CTS. The Veteran was afforded a VA examination in February 2017. The examiner diagnosed bilateral carpal tunnel syndrome status post bilateral carpal tunnel release. The Veteran reported bilateral hand pain, weakness, tingling, and numbness in his hands. He had surgery on both the left and right wrists. He did not receive complete relief. At the time of the examination, he still experienced bilateral hand pain, weakness, tingling, and numbness. The pain was exacerbated by cold. He reported difficulty lifting, pushing, and pulling. He had difficulty holding or opening jars and difficulty typing. He was unable to bear weight on his left hand and wrist. He required breaks at work to stretch his hands and he used braces. The examiner noted moderate constant pain of the bilateral upper extremities with severe intermittent pain, moderate bilateral upper extremity paresthesias or dysesthesias, and moderate numbness. Muscle strength testing was noted as 4/5 bilaterally regarding wrist flexion, wrist extension, hand grip, and pinch of thumb to index finger. The Veteran did not have muscle atrophy. Reflex examination revealed hypoactive deep tendon reflexes of the brachioradialis. The Veteran had decreased sensation for light touch of the hands and fingers. The examiner noted positive Phalen's sign and Tinel's sign. The examiner noted moderate incomplete paralysis of the median nerve bilaterally. EMG studies in 2013 were abnormal, signifying CTS. The examiner noted that the Veteran's condition impacted his ability to work. The Veteran was limited in lifting, carrying, pushing, pulling, gripping, grabbing, or typing due to his bilateral CTS. The Board notes that the evidence of record does not indicate severe left CTS at any time during the appeal period. The Veteran's left CTS was described as moderate incomplete paralysis of the median nerve in May 2014 and February 2017. The Veteran's symptoms were consistently described as mild or moderate. The Veteran described moderate pain with mild symptoms in the fingers and hand with intermittent severe episodes of pain. His clinic findings were significant for mild thenar atrophy which resolved after surgery, muscle strength no worse than 4/5, reflex abnormality and only slight sensory deficits. When considering the site and extent of involvement of the non-dominant left hand and fingers, the mild weakness of motor functioning, the mild sensory deficit, absent reflexes and mild muscle atrophy which later resolved, the Board finds that the Veteran's overall left CTS disability does not meet, or more nearly approximate, severe incomplete paralysis of the median nerve at any time during the appeal period. In so finding, the Board has considered the Veteran's description of left hand CTS symptoms of tingling, numbness, weakness and functional impairment to be competent and credible evidence in support of the claim. As it pertains to the clinical findings such as extent of sensory disturbance, reflex abnormality, muscle weakness, etc., the Board places greater probative weight on the findings from VA examiners and clinicians who have greater training and expertise in evaluating and clinically describing neurologic impairment. The Board finds that a preponderance of the evidence is against the claim for a disability rating in excess of 20 percent for the Veteran's left CTS. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 4. Entitlement to an initial disability rating in excess of 10 percent for status post right wrist fracture. The Veteran contends that his right wrist disability warrants a disability rating in excess of 10 percent. His right wrist disability is rated under Diagnostic Code 5215 for limitation of motion of the wrist. Under that regulation, dorsiflexion less than 15 degrees warrants a 10 percent disability rating and palmar flexion limited in line with the forearm warrants a 10 percent disability rating. 38 C.F.R. § 4.71a. Under Diagnostic Code 5214 a higher disability rating may be assigned for ankylosis of the wrist. 38 C.F.R. § 4.71a. The Veteran's current 10 percent evaluation is granted under the criteria related to painful motion noted in 38 C.F.R. § 4.59. Under that regulation, functional loss due to painful motion to may be rated at the minimum compensable rating for a particular joint. The question for the Board is whether the Veteran's right wrist disability manifests with ankylosis of the wrist. The Board finds that the weight of the competent, credible, and probative evidence establishes that the Veteran does not meet the criteria for a disability rating in excess of 10 percent for status post right wrist fracture. The Veteran reported a history of wrist fractures after falling from his truck in the early 1980s. He reported current pain occasionally in both wrists that did not interfere with his function. He had mild stiffness in the wrists. He was able to lift weights without a problem. The examiner noted no tenderness over the wrists. The Veteran's range of motion was dorsiflexion to 70 degrees, wrist palmar flexion to 50 degrees, wrist ulnar deviation to 20 degrees, forearm pronation to 80 degrees, and forearm supination to 85 degrees. The examiner noted normal strength against resistance. The examiner showed no further decreased range of motion, lack of endurance, or pain with repetitive movement. The examiner noted no loss of dexterity and the Veteran's grip strength was normal. The examiner noted no muscular atrophy or sensory deficits. The Veteran had a positive Phalen sign with tingling in the index and middle fingers. In an October 2008 treatment record, the Veteran's range of motion of the right wrist was 50 degrees flexion and 60 degrees extension with radial and ulnar deviations within normal limits. In a December 2009 VA examination, the examiner noted the history of fracture. The Veteran reported pain precipitated by cold weather, lifting, pulling, and fine motor movements. The Veteran did not have any arthritis on recent X-ray. The examiner noted pain, weakness, and swelling of the wrist. Upon examination, the examiner noted a lateral bone protrusion of the right wrist from previous trauma during service. Range of motion of the right wrist was measured at 60 degrees flexion, 0 degrees extension, 70 degrees dorsiflexion, 20 degrees radial deviation, and 45 degrees ulnar deviation. The examiner noted mild to moderate pain during range of motion testing and incoordination on flexion. All range of motion examination was done in three repetitions with no change in range of motion. The examiner noted mild pain on manipulation and mild pain on motion. The grip of the right hand was about one pound. The examiner noted no joint deformity of the fingers. He had positive Tinel's test on the right wrist. The Veteran was able to touch the base of the fifth, fourth, third, and second finger without any problem bilaterally. The right hand was neurovascularly intact. The examiner noted mild swelling of the right wrist. A February 2011VA treatment record showed complaints of bilateral wrist pain. Examination showed a negative Tinel's test and negative thenar atrophy. The examiner described right wrist with ulna deformity. The Veteran had an abnormal Watson shift test with limited extension. The Veteran was afforded an additional VA examination in May 2014. The Veteran's claims file was reviewed. The examiner noted a diagnosis of status post right wrist fracture. The Veteran was right hand dominant. He reported that flare-ups impacted the function of the wrists as he noted increased aching pain bilaterally. Range of motion testing revealed right wrist palmar flexion to 40 degrees with pain at 40 degrees and dorsiflexion (extension) to 45 degrees with pain at 40 degrees. Upon repetitive testing, the examiner noted no additional limitation in range of motion of the wrist. The examiner described the functional loss or functional impairment as weakened movement and pain on movement bilaterally. The examiner also noted localized tenderness or pain on palpation of the joints and soft tissue of both wrists. Muscle strength testing showed normal strength bilaterally with extension and flexion. The Veteran had no ankylosis. The Veteran's disability impacted his ability to work as he was unable to perform manual labor, but was able to perform sedentary labor. An October 2016 VA consult noted that the Veteran presented, in part, for evaluation of bilateral wrist pain. His hands were warm and well perfused. He had full range of motion of the hands with limited wrist range of motion due to pain. The right wrist showed moderate edema and diffusely TTP. The examiner noted swelling and callous formation over the ulnar wrist. His grip strength was 5/5 on the right. X-rays demonstrated mild radiocarpal arthritis. The examiner diagnosed early radiocarpal arthritis. The Veteran was afforded a VA examination in February 2017, at which time the examiner diagnosed status post bilateral wrist fractures and surgeries, residuals. The Veteran reported hand pain, weakness, tingling, and numbness. Pain increased with cold exposure. He had difficulty lifting, pushing, or pulling. He was unable to bear weight on his left hand and wrist. The Veteran specifically reported pain and difficulty typing, opening jars, and gripping. The Veteran's range of motion testing showed right wrist palmar flexion to 60 degrees, dorsiflexion to 50 degrees, ulnar deviation to 25 degrees, and radial deviation to 20 degrees. The examiner noted that the Veteran's abnormal range of motion was caused by pain, which limits the Veteran's ability to type, grip, or hold objects. The Veteran had bilateral wrist pain in all range of motion testing and with weight bearing. The examiner noted no objective evidence of localized tenderness or pain on palpation of the right wrist. The examiner noted no objective evidence of crepitus. The Veteran had no additional loss of function after three repetitions. The examiner noted that pain and weakness limited the Veteran's functional ability regarding the right wrist, but found no additional limitation of motion. Muscle strength testing showed active movement against some resistance bilaterally. The Veteran did not have muscle atrophy or ankylosis. The Veteran's conditions did impact his ability to perform occupational tasks. Specifically, the Veteran was limited in lifting, carrying, pushing, pulling, gripping, grabbing, holding, or typing due to his wrist condition. The Board notes that no lay or medical evidence of record shows status post right wrist fracture manifesting with ankylosis. The VA examiners specifically noted no ankylosis in May 2014 and February 2017. The Board notes that 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). However, as the Veteran has been afforded the maximum rating for motion loss, the provisions of 38 C.F.R. §§ 4.40 and 4.45 are not for application. See Johnston, 10 Vet. App. at 85 (consideration of 4.40 and 4.45 is unnecessary where an appellant is in receipt of the maximum rating for limitation of motion). Based on the evidence cited above, the Board finds that a preponderance of the evidence is against the claim for a disability rating in excess of 10 percent for the Veteran's status post right wrist fracture. The Veteran's report of right wrist symptoms and functional limitations are deemed credible, but he has been awarded the maximum available rating for motion loss. The applicable criteria require ankylosis which is not alleged or show. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 5. Entitlement to an initial disability rating in excess of 10 percent for status post left wrist fracture. The Veteran contends that his left wrist disability also warrants a disability rating in excess of 10 percent. His left wrist disability is rated under Diagnostic Code 5215 for limitation of motion of the wrist. Under that regulation, dorsiflexion less than 15 degrees warrants a 10 percent disability rating and palmar flexion limited in line with the forearm warrants a 10 percent disability rating. 38 C.F.R. § 4.71a. Under Diagnostic Code 5214 a higher disability rating may be assigned for ankylosis of the wrist. 38 C.F.R. § 4.71a. The Veteran's current 10 percent evaluation is granted under the criteria related to painful motion noted in 38 C.F.R. § 4.59. Under that regulation, functional loss due to painful motion to may be rated at the minimum compensable rating for a particular joint. The question for the Board is whether the Veteran's left wrist disability manifests with ankylosis of the wrist. The Board finds that the weight of the competent, credible, and probative evidence establishes that the Veteran does not meet the criteria for a disability rating in excess of 10 percent for status post left wrist fracture. The Veteran was afforded a VA examination in August 2006. The Veteran reported a history of wrist fractures after falling from his truck in the early 1980s. He reported current pain occasionally in both wrists that did not interfere with his function. He had mild stiffness in the wrists. He was able to lift weights without a problem. The examiner noted no tenderness over the wrists. The Veteran's range of motion of the left wrist was dorsiflexion to 70 degrees, wrist palmar flexion to 80 degrees, wrist ulnar deviation to 20 degrees, forearm pronation to 80 degrees, and forearm supination to 85 degrees. The examiner noted normal strength against resistance. The examiner showed no further decreased range of motion, lack of endurance, or pain with repetitive movement. The examiner noted no loss of dexterity and the Veteran's grip strength was normal bilaterally. The examiner noted no muscular atrophy or sensory deficits. The Veteran had a positive Tinel sign on the left wrist with tingling in the index and middle fingers. An October 2008 VA treatment record showed full range of motion of the left wrist. The Veteran was provided another VA examination in December 2009. The examiner noted the history of fracture. The Veteran reported pain in both wrists precipitated by cold weather, lifting, pulling, and fine motor movements. The Veteran did not have any arthritis on recent X-ray. The examiner noted pain and weakness of the left wrist. Upon examination, the examiner noted a lateral bone protrusion on the left wrist from previous trauma during service. Range of motion of the left wrist was measured at 80 degrees flexion, 0 degrees extension, 70 degrees dorsiflexion, 20 degrees radial deviation, and 45 degrees ulnar deviation. The examiner noted no pain during range of motion testing and no incoordination. All range of motion examination was done in three repetitions with no change in range of motion. The grip on the left hand was twenty pounds. The examiner noted no joint deformity of the fingers. He had a negative Tinel's test and Phalen's test. The Veteran was able to touch the base of the fifth, fourth, third, and second finger without any problem bilaterally. The left hand was neurovascularly intact. A February 2011 VA treatment record showed complaints of bilateral wrist pain. Examination showed a negative Tinel's test and negative thenar atrophy. The left wrist was within normal limits upon examination. The Veteran was afforded an additional VA examination in May 2014. The Veteran's claims file was reviewed. The examiner noted a diagnosis of status post left wrist fracture. The Veteran was right hand dominant. He reported that flare-ups impacted the function of the wrists as he noted increased aching pain bilaterally, somewhat less in the left wrist. Range of motion testing of the left wrist revealed palmar flexion to 45 degrees with pain at 40 degrees and dorsiflexion (extension) to 50 degrees with pain at 45 degrees. Upon repetitive testing, the examiner noted no additional limitation in range of motion of the wrist. The examiner described the functional loss or functional impairment as weakened movement and pain on movement bilaterally. The examiner also noted localized tenderness or pain on palpation of the joints and soft tissue of the wrists. Muscle strength testing showed normal strength with extension and flexion. The Veteran had no ankylosis. The Veteran's disability impacted his ability to work as he was unable to perform manual labor, but was able to perform sedentary labor. An October 2016 VA consult noted that the Veteran presented, in part, for evaluation of bilateral wrist pain. His hands were warm and well perfused. He had full range of motion of the hands with limited wrist range of motion due to pain. The left wrist showed moderate edema and diffusely TTP. The examiner noted mild thenar wasting. His grip strength was 4+/5 on the left. X-rays demonstrated mild radiocarpal arthritis. The examiner diagnosed early radiocarpal arthritis. The Veteran attended a VA examination in February 2017. The examiner diagnosed status post bilateral wrist fractures and surgeries, residuals. The Veteran reported hand pain, weakness, tingling, and numbness. Pain increased with cold. He had difficulty lifting, pushing, or pulling. He was unable to bear weight on his left hand and wrist. The Veteran specifically reported pain and difficulty typing, opening jars, and gripping. Left wrist range of motion testing revealed palmar flexion to 60 degrees, dorsiflexion to 50 degrees, ulnar deviation to 20 degrees, and radial deviation to 20 degrees. The examiner noted that the Veteran's abnormal range of motion was caused by pain, which limited the Veteran's ability to type, grip, or hold objects. The Veteran had bilateral wrist pain in all range of motion testing and with weight bearing. The examiner noted objective evidence of localized tenderness or pain on palpation of the left wrist and described it as moderate tenderness on the volar aspect of the wrist and distal palmar hand. The examiner noted no objective evidence of crepitus. The Veteran had no additional loss of function after three repetitions. Muscle strength testing showed active movement against some resistance. The Veteran did not have muscle atrophy or ankylosis. The Veteran's condition impacted his ability to perform occupational tasks. Specifically, the Veteran was limited in lifting, carrying, pushing, pulling, gripping, grabbing, holding, or typing due to his wrist condition. The Board notes that no lay or medical evidence of record shows status post left wrist fracture manifesting with ankylosis. The VA examiners specifically noted no ankylosis in May 2014 and February 2017. The Board notes that 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca, 8 Vet. App. 202 (1995). However, as the Veteran has been afforded the maximum rating for motion loss, the provisions of 38 C.F.R. §§ 4.40 and 4.45 are not for application. See Johnston, 10 Vet. App. at 85 (consideration of 4.40 and 4.45 is unnecessary where an appellant is in receipt of the maximum rating for limitation of motion). Based on the evidence cited above, the Board finds that a preponderance of the evidence is against the claim for a disability rating in excess of 10 percent for the Veteran's status post left wrist fracture. The Veteran's report of left wrist symptoms and functional limitations are deemed credible, but he has been awarded the maximum available rating for motion loss. The applicable criteria require ankylosis which is not alleged or show. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. ______________________________________________ T. MAINELLI Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD Patricia Veresink, Associate Counsel Copy mailed to: Disabled American Veterans Department of Veterans Affairs