Citation Nr: 1752825 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 11-05 538A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an initial disability rating higher than 20 percent for peripheral neuropathy of the right lower extremity. 2. Entitlement to an initial disability rating higher than 20 percent for peripheral neuropathy of the left lower extremity. 3. Entitlement to an initial disability rating higher than 20 percent for peripheral neuropathy of the right upper extremity (non-dominant). 4. Entitlement to an initial disability rating higher than 30 percent for peripheral neuropathy of the left upper extremity (dominant). REPRESENTATION Appellant represented by: Peter J. Meadows, Attorney ATTORNEY FOR THE BOARD A.Lech, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1963 to January 1992. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The July 2010 rating decision, in relevant part, granted service connection for diabetic peripheral neuropathy of the right and left lower extremities, and the right and left upper extremities, and assigned 10 percent disability ratings for all four extremities, effective July 23, 2009. In a July 2011 rating decision, the RO increased the disability ratings for the service-connected peripheral neuropathy of the bilateral lower extremities and the right upper extremity to 20 percent and the rating for peripheral neuropathy of the left upper extremity to 30 percent, all effective July 23, 2009. In a March 2012 statement, the Veteran withdrew his request for a hearing before a RO Decision Review Officer in lieu of a VA examination. The Board notes that a January 2011 statement of the case (SOC) included the specific issues of entitlement to service connection for left and right sciatica nerve conditions (radiculopathy). The Veteran did not submit a substantive appeal to perfect an appeal as to these issues, and they were not certified to the Board. 38 C.F.R. § 20.202 (2017). As such, the Board has adjusted the issues in appeal, as shown above. This case was previously before the Board in January 2016 and February 2017, when it was remanded for further development. While this appeal was pending, the Veteran submitted additional evidence and waivers (in September 2016 and in February 2017, in VBMS) indicating that he wished to waive its review by the agency of original jurisdiction (AOJ). 38 C.F.R. §§ 19.37, 20.1304 (2017). The Board has thereby considered the said evidence in its decision. FINDINGS OF FACT 1. The Veteran's peripheral neuropathy of the right lower extremity most nearly approximates severe incomplete paralysis of the sciatic nerve. 2. The Veteran's peripheral neuropathy of the left lower extremity most nearly approximates severe incomplete paralysis of the sciatic nerve. 3. The Veteran's peripheral neuropathy of the right upper extremity (non-dominant) most nearly approximates moderate incomplete paralysis. 4. The Veteran's peripheral neuropathy of the left upper extremity (dominant) most nearly approximates moderate incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 60 percent for peripheral neuropathy of the right lower extremity have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.124a, Diagnostic Code (DC) 8520 (2017). 2. The criteria for an initial rating of 60 percent for peripheral neuropathy of the left lower extremity have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.124a, DC 8520 (2017). 3. The criteria for an initial rating of 30 percent for peripheral neuropathy of the right upper extremity (non-dominant) have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.124a, DC 8513 (2017). 4. The criteria for an initial rating of 40 percent for peripheral neuropathy of the left upper extremity (dominant) have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.124a, DC 8513 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran asserts that his peripheral neuropathy of the upper and lower extremities is more severe than currently rated. In this case, the record indicates that the Veteran had the following diagnosed diabetic complications: (1) bilateral lower extremity peripheral neuropathy involving the sciatic nerve, (2) bilateral upper extremity peripheral neuropathy involving the radial nerve VA examination April 2012 , (3) bilateral upper extremity peripheral neuropathy involving the median nerve, and (4) bilateral upper extremity peripheral neuropathy involving the ulnar nerve. Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2017). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The United States Court of Appeals for Veterans Claims (Court) has also found that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where a service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis-characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating-is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Since no guidance is provided as to what the degrees of incomplete paralysis actually mean in terms of impairment, the Board must use some criteria to define the "mild," "moderate," and "severe" terms, and must explain what criteria it has used. See Ohland v. Derwinski, 1 Vet.App. 147 (1991) (Board's reasoning is flawed when it fails to explain the criteria it used in determining whether the evidence fell into a particular PTSD rating category, e.g., total, severe, considerable, definite, and mild.) It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69 (2017). In this case, the Veteran's left upper extremity has been found to be his major or dominant extremity for purposes of evaluation. See April 2017 VA examination, in Legacy Content Manager (LCM). 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. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Evidence The Veteran underwent a VA peripheral nerves examination in June 2010. The Veteran told the examiner that he has experienced the onset of burning pain and numbness in his feet starting in 2006, and started to experience numbness in his hands "recently." The Veteran also stated that he experienced sciatic-type pain in the left back which radiated down the left leg to his ankle for the past four-five years. The examiner noted that the Veteran experienced numbness and pain, and has not had any EMG or nerve conduction studies performed. The Veteran took Gabapentin and Neurontin, as well as medications for diabetes. The Veteran stated that he had pain on walking and prolonged standing, difficulty engaging in sports and doing yard work, and that his hands became numb when he gripped things. The Veteran denied the use of any assistive devices. Upon examination, the examiner noted that the Veteran had decreased sensation in the hands (on the dorsum and palms) and feet (on the dorsum and soles) to light touch and pinprick. He had normal sensation in his ankles, and normal vibratory sensation in the upper and lower extremities. His deep tendon reflexes were normal. Straight leg raises produced pain in the low back which radiated down the sciatic nerve, and stress of the sciatic nerve intensified the pain. Pulses in the feet show a normal dorsalis pedis and posterior tibial both the right and the left, there was no edema, there were no trophic skin changes and no ulcerations of the feet. The ranges of motion in the ankles and feet were normal, muscle strength was normal in the upper and lower extremities, the Veteran had good grip strength bilaterally. There was no tenderness on the lateral epicondyle, normal exam to resisted middle finger extension or resisted forearm supination, and no muscle atrophy. The examiner diagnosed the Veteran with sensory polyneuropathy of both lower and upper extremities, secondary to diabetes mellitus type II, and sciatic neuropathy of the left lower extremity which was not associated with diabetes mellitus type II. See June 2010 VA examination, in VBMS. The Veteran underwent another VA peripheral nerves examination on April 3, 2012. The examiner related that the Veteran was left-hand dominant. The examiner noted that the Veteran has no constant pain in his extremities; had no pain in the right upper extremity, moderate intermittent pain in the left upper extremity, no pain in the right lower extremity, and moderate intermittent pain in his left lower extremity. There was no paresthesias and/or dysesthesias in any of the extremities. There was no numbness in the right upper extremity, moderate numbness in the left upper extremity, moderate numbness in the right lower extremity, and no numbness in the left lower extremity. Muscle strength testing was 4/5, active movement against some resistance. The Veteran has no muscle atrophy, and deep tendon reflexes were absent. Sensory exam for both the upper and lower extremities was normal. Further, the examiner noted that the Veteran experienced no trophic changes attributable to peripheral neuropathy. His gait was normal. All the nerve groups tested were normal and experienced no paralysis. The Veteran used no assistive devices, and there were no other pertinent physical findings or symptoms. No EMG studies were performed. The examiner opined that the Veteran's peripheral nerve condition did not impact his ability to work, and that the Veteran's lower extremities experienced mild impairment due to peripheral neuropathy, and experienced major impairment in function and symptomatology related to obesity. The examiner also opined that the Veteran's upper extremities experienced mild impairment due to peripheral neuropathy. See April 2012 VA examination, in VBMS. The Veteran underwent a diabetic sensory-motor peripheral neuropathy VA examination on April 17, 2012. The examiner noted that the Veteran's peripheral neuropathy has been symptomatic for two-three years. The Veteran related that he experienced pins and needles type pain in toes, and weakness and paresthesia in the left hand, left thumb, and fourth and fifth finger. The examiner noted that the Veteran experienced no intermittent pain in the right upper extremity, and mild intermittent pain in the left upper extremity; mild paresthesias in the left upper extremity and the lower extremities; and mild numbness in the left upper extremity and the lower extremities. Muscle strength testing was 4/5, active movement against some resistance. The Veteran has no muscle atrophy, and deep tendon reflexes were decreased. Light touch testing was normal in the upper extremities, and absent in the ankles and feet. Grip sensation was normal. Vibration sensation was normal in the upper extremities and decreased in the lower extremities. Cold sensation was normal. There was no muscle atrophy. The Veteran had no atrophic changes. The examiner opined that the Veteran had no upper extremity diabetic peripheral neuropathy, and did have lower extremity diabetic peripheral neuropathy. All the nerve groups tested were normal and experienced no paralysis. The Veteran used no assistive devices, and there were no other pertinent physical findings or symptoms. EMG studies were performed - results were pending. See April 2012 VA examination, in VBMS. The EMG testing was performed on the left upper and both lower extremities. The physician who reviewed it opined that there was evidence of a left ulnar neuropathy localized to the elbow that was moderate in degree. Bilateral sural sensory responses were absent. The physician opined that this was consistent with a sensory neuropathy as can be seen in diabetic neuropathy. See April 2012 EMG testing, in VBMS. The Veteran underwent another VA examination in March 2016. The examiner noted that the Veteran was diagnosed with diabetic neuropathy in 2010. The Veteran told the examiner that he has experienced burning in his feet (right more than left) for 16 years, and that it has become progressively worse since then. The Veteran stated that the pain became more frequent and the length of it has increased, and that the pain was more severe. The Veteran said that the pain and burning were now constant, and it felt worse if he sat too long, and that the burning in the feet went up his legs the longer he stood or walked. The examiner noted that the Veteran experienced constant severe pain in the right lower extremity, and moderate constant pain in the left lower extremity (no constant pain in the upper extremities). There was no intermittent pain in any of the extremities. The Veteran experienced severe paresthesias and/or dysesthesias in the right lower extremity, and moderate paresthesias and/or dysesthesias in the left lower extremity (upper extremities were not affected). He also experienced mild numbness in his lower extremities, and no numbness in his upper extremities. A neurologic examination showed normal muscle strength, decreased deep tendon reflexes, normal light touch testing, and normal position sense in all extremities. There was no muscle atrophy. The Veteran experienced trophic changes - he had no hair, his skin was smooth and shiny, and his feet were cool. The examiner opined that the Veteran did not have diabetic peripheral of the upper extremities. The examiner opined that the Veteran did have diabetic peripheral of the lower extremities, with moderate incomplete paralysis of the right lower extremity and mild incomplete paralysis of the left lower extremity. There was no complete paralysis. The examiner also noted that the Veteran had sciatica diagnosed three months before the examination. No EMG studies were performed. The examiner opined that the Veteran's peripheral neuropathy did not impact his ability to work, and noted that the Veteran would not be able to stand on his feet for a long time, or walk for prolonged periods, but should be able to perform sedentary employment. In a somewhat contradictory statement, the examiner added that the Veteran has been treated with poor results, has continued to work at a sedentary job, and was no longer able to tolerate the pain in his legs and feet. This caused him to quit a job he loved because he could not increase his time on his feet without increasing the pain in his feet and legs. The examiner also stated that diabetic peripheral neuropathy was not the paralysis of a specific nerve, but rather it involved sensory nerves bilaterally. The examiner added that one can have the absence of a paralysis of a specific nerve and still have diabetic peripheral neuropathy, as it was a clinical diagnosis. See March 2016 VA examination, in VBMS. The Veteran underwent another VA examination in April 2017. The examiner related that the Veteran was diagnosed with peripheral neuropathy of the hands and feet in 2012, with an onset of symptoms in 2005. The examiner noted that the Veteran has no constant pain in his extremities; had mild intermittent pain in the right upper extremity, severe intermittent pain in the left upper extremity, and moderate intermittent pain in his lower extremities. There were moderate paresthesias and/or dysesthesias in all extremities, and mild numbness in all extremities. Muscle strength testing was all normal. The Veteran has no muscle atrophy, and all reflexes were normal. Sensory exam for the upper extremities was normal. Sensation testing was normal in the upper anterior thighs, thigh/knee, and lower leg/ankle. The sensation in his foot/toes on the right was normal, and on the left was absent. Further, the examiner noted that the Veteran experienced trophic changes on both legs characterized by very smooth shiny skin with no hair. The Veteran's gait was normal. Median nerve tests were negative. In the upper extremities, right and left radian, median, and ulnar nerves experienced mild incomplete paralysis. In the lower extremities, right and left sciatic and external popliteal nerves experienced mild incomplete paralysis. The examiner noted that the Veteran used no assistive devices, had no further impairment of his extremities, and there were no other pertinent physical findings, symptoms, or complications. The examiner related that electromyography (EMG) studies performed in June 2012 showed abnormalities in the left upper extremity and both lower extremities that were consistent with diabetic neuropathy. The examiner reported that she reviewed the conflicting medical evidence, and opined that the Veteran had no sensation to the touch on the bottom of the left foot and no vibration sensation in either foot, indicating a moderate degree of sensory neuropathy in both lower extremities. The examiner noted that the upper extremity neuropathy was based on the Veteran's history of numbness and pain, as well as the June 2012 EMG findings which were consistent for diabetic neuropathy. She noted that at the time of the April 2012 VA examination, the Veteran had mild upper and lower extremity radiculopathy. The examiner added that the Veteran retired in 2011 as he reached retirement age, and that the current physical examination revealed no functional impact and any impairment which would preclude employment or the Veteran's ability to operate in an occupational environment. See April 2017 VA examination, in LCM. The Veteran's private and VA treatment records reflect complaints and diagnoses congruent with those reflected in the VA examinations. These records show a history of treatment for the peripheral neuropathy of the upper and lower extremities with pain and numbness. Analysis - Peripheral Neuropathy of the Lower Extremities The Veteran's diabetic peripheral neuropathy of the lower extremities is rated under DC 8520 at 20 percent disabling. Under DC 8520, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve; a 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve; a 40 percent rating is assigned for moderately severe incomplete paralysis; a 60 percent rating is assigned for severe incomplete paralysis, with marked muscular atrophy; and a maximum 80 percent rating is assigned for complete paralysis of the sciatic nerve; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. See 38 C.F.R. § 4.124a, DC 8520. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. DC 8620 refers to neuritis of the sciatic nerve, while DC 8720 refers to neuralgia of the sciatic nerve. As the Veteran does not have a diagnosis of either disorder, these DCs are not applicable in this case. The Veteran has also been diagnosed with mild incomplete paralysis of the external popliteal nerve, which falls under DC 8521. Under DC 8521, incomplete paralysis of the popliteal nerve in either lower extremity warrants 10, 20, or 30 percent ratings if it is mild, moderate, or severe, respectively. A 40 percent rating is warranted for paralysis of the popliteal nerve in the lower extremity if the paralysis is complete, with foot drop and slight droop of the first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of the proximal phalanges of toes lost; abduction of the foot lost, adduction weakened, and anesthesia covers entire dorsum of foot and toes. 38 C.F.R. § 4.124a, DC 8521 (2017). While the Veteran's diabetic peripheral neuropathy does affect two different nerves in his lower extremities, his disability cannot be rated under two separate DCs. This is due to the fact that both affected nerves result in the same symptoms in the same extremity. Rating the nerves under separate DCs would constitute "pyramiding" and is prohibited under 38 C.F.R. § 4.14. Because the disability ratings available under DC 8520 are higher than those available under DC 8521, the Board will use DC 8520, which is more advantageous to the Veteran, to evaluate his diabetic peripheral neuropathy of the lower extremities. The multiple DCs available to evaluate other lower extremities nerve disabilities which apply to nerves other than the sciatic nerve and the external popliteal nerve are also not for application in this case, as the Veteran has only been diagnosed with diabetic peripheral neuropathy affecting the sciatic and the popliteal nerves. In sum, the record shows that Veteran experienced burning pain, numbness, sciatic-type pain in the left back which radiated down the left leg to his ankle, pain on walking and prolonged standing, decreased sensation in the feet to light touch and pinprick, no pain in the right lower extremity, and moderate intermittent pain in his left lower extremity, moderate numbness in the right lower extremity, and no numbness in the left lower extremity, decreased muscle strength, absence of deep tendon reflexes, mild paresthesias and mild numbness in the lower extremities, light touch testing was absent in the ankles and feet, decreased vibration sensation in the lower extremities, absent bilateral sural sensory responses, constant severe pain in the right lower extremity, moderate constant pain in the left lower extremity, trophic changes (no hair, his skin was smooth and shiny, cool feet), moderate incomplete paralysis of the right lower extremity, mild incomplete paralysis of the left lower extremity, moderate intermittent pain in his lower extremities, moderate paresthesias and/or dysesthesias in all extremities, and mild numbness in all extremities, absent sensation in his left foot/toes, and mild incomplete paralysis of the right and left sciatic and external popliteal nerves. The Veteran's symptoms interfered with walking, sitting, prolonged standing, engaging in sports, and performing yard work. The evidence establishes that the Veteran's peripheral neuropathy of the lower extremities resulted in, at most, severe incomplete paralysis of the sciatic nerves. In addition to pain (both intermittent and constant, moderate to severe), numbness, burning, decreased sensation, absence of light touch testing, decreased vibration sensation, and trophic changes, the Veteran experienced weakness and absence of deep tendon reflexes in his lower extremities. As such, a rating of 60 percent is warranted for the Veteran's peripheral neuropathy of the lower extremities. The Board has considered whether a rating in excess of 60 percent was warranted, but there is no showing that the Veteran experienced complete paralysis of the sciatic nerve at any point during the appeals period - he did not experience symptoms such as foot dangling or drop, lack of active movement below the knee, or weak or lost flexion of the knee. Therefore, a rating in excess of 60 percent is not warranted for the peripheral neuropathy of the lower extremities. Analysis - Peripheral Neuropathy of the Upper Extremities The Veteran's peripheral neuropathy of the upper extremities is rated under DC 8516, with the left (dominant) extremity rated at 30 percent and the right extremity at 20 percent. In addition to being diagnosed with peripheral neuropathy involving the ulnar nerve, the Veteran has also been diagnosed with bilateral upper extremity peripheral neuropathy involving the radial nerve and bilateral upper extremity peripheral neuropathy involving the median nerve, The Veteran does not have diagnoses of neuritis and neuralgia and, as such, ratings criteria applicable to those nerve impairments will not be discussed in this case. Under DC 8516, which provides the criteria for rating injuries to the ulnar nerve, a 10 percent evaluation is warranted for mild incomplete paralysis of either the major or the minor extremity. Moderate incomplete paralysis warrants a 30 percent for the major extremity and 20 percent for the minor extremity. Severe incomplete paralysis warrants 40 percent for the major extremity and 30 percent for the minor extremity. A 60 percent for the major extremity or 50 percent for the minor extremity is warranted for complete paralysis, described as the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened. See 38 C.F.R. § 4.124 (a), DC 8516. Diagnostic Code 8514 provides the rating criteria for paralysis of radial nerve. Mild incomplete paralysis is rated as 20 percent disabling for the major extremity and the minor extremity. Moderate incomplete paralysis is rated as 30 percent disabling for the major extremity and 20 percent disabling for the minor extremity. Severe incomplete paralysis is rated as 50 percent disabling for the major extremity and 40 percent disabling for the minor extremity. Complete paralysis of the radial nerve is rated as 70 percent disabling for the major extremity and 60 percent for the minor extremity, and contemplates drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of the wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity. 38 C.F.R. § 4.124a, DC 8514 (2017). DC 8515 provides the rating criteria for paralysis of the median nerve, as well as neuritis and neuralgia of those nerves. Complete paralysis of such nerve, which is rated as 70 percent disabling for the major arm, and as 60 percent disabling for the minor arm, contemplates 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 phlanx of thumb, defective opposition and abduction of the thumb, at right angles to palm, flexion of wrist weakened, and pain with trophic disturbances. Disability ratings of 10 percent, 30 percent, and 50 percent are assignable for incomplete paralysis which is mild, moderate, or severe in degree, for the major arm, and as 10 percent, 20 percent, and 40 percent, for the minor arm, respectively. 38 C.F.R. § 4.124a, DC 8515. As the evidence of record, to include VA examinations, reflect that the Veteran is left hand dominant, the ratings referable to the major arm are for consideration for such side. 38 C.F.R. § 4.124a, DC 8515 (2017). While the Veteran's diabetic peripheral neuropathy does affect three different nerves in his upper extremities, his disability cannot be rated under three separate DCs. This is due to the fact that all three affected nerves result in the same symptoms in the same extremity. Rating the nerves under separate DCs would constitute "pyramiding" and is prohibited under 38 C.F.R. § 4.14. Since the Veteran's hands and arms up to and including the elbows are what is affected by his diabetic peripheral neuropathy, his disability can also be evaluated as a whole (inclusive of all the three different nerves affected) under DC 8513, which rates peripheral neuropathy of all radicular groups of the upper extremities. DC 8513 provides that mild, incomplete paralysis of the lower radicular group is assigned a 20 percent rating for either extremity. Moderate incomplete paralysis merits a 40 percent rating for the major extremity and a 30 percent rating for the minor extremity. Severe incomplete paralysis merits a 70 percent rating for the major extremity and a 60 percent rating for the minor extremity. Complete paralysis merits a 90 percent rating for the major extremity and an 80 percent rating for the minor extremity. 38 C.F.R. § 4.124a, DC 8513 (2017). In sum, the record shows that Veteran experienced pain, numbness, numbness upon gripping, decreased sensation in the hands to light touch and pinprick, moderate intermittent pain in the left upper extremity, no numbness in the right upper extremity, moderate numbness in the left upper extremity, decreased muscle strength, absence of deep tendon reflexes, mild intermittent pain in the left upper extremity, mild paresthesias in the left upper extremity, mild numbness in the left upper extremity, absent bilateral sural sensory responses, moderate left ulnar neuropathy localized to the elbow, mild intermittent pain in the right upper extremity, severe intermittent pain in the left upper extremity, moderate paresthesias and/or dysesthesias in all extremities, and mild numbness in all extremities, mild incomplete paralysis of the right and left radian, median, and ulnar nerves. The Veteran's symptoms interfered with grasping, typing/keyboarding, and caused his hands to become numb when he gripped things. Notably, the March 2016 examiner reported that the Veteran did not have symptoms of pain, constant or intermittent, paresthesias and/or dysesthesias, or numbness. The evidence establishes that the Veteran's peripheral neuropathy of the upper extremities resulted in, at most, moderate incomplete paralysis of the radicular groups although there was significant evidence that his disability at times was described as mild or not at all in the March 2016 examination. In addition to pain (both intermittent and constant, mild to severe), numbness, moderate paresthesias and/or dysesthesias, absent bilateral sural sensory responses, and decreased sensation in the hands to light touch and pinprick, the Veteran experienced weakness (decreased muscle strength) and absence of deep tendon reflexes in his upper extremities. As such, a rating of 40 percent is warranted for his left (major/dominant) extremity and a 30 percent rating is warranted for his right (non-dominant) extremity for the Veteran's peripheral neuropathy of the lower extremities. The Board has considered whether ratings in excess of 40 and 30 percent are warranted. However, the evidence has not demonstrated that during the appeal period the Veteran's disability has been considered severe throughout. In fact, in the March 2016 VA examination it was reported that the Veteran did not have any symptoms of constant or intermittent pain, paresthesias and/or dysesthesias, numbness, symptoms which were previously considered mild. Furthermore, the March 2017 VA examination found the Veteran's symptoms to be mild, except where the Veteran had intermittent left upper extremity pain that was severe. His muscle strength was normal, he had no muscle atrophy, and his sensory examination was normal. Indeed, the examiner even in light of the intermittent pain, described the Veteran's incomplete paralysis of the radial, ulnar, median as mild. In light of such, the Board finds that the Veteran's disability is more closely associated with moderate. See 38 C.F.R. §§ 4.3, 4.7. As such, a higher rating is not warranted. The Board has also considered whether ratings in excess of 70 and 60 percent are warranted, but there is no showing that the Veteran experienced complete paralysis of all radicular groups at any point during the appeals period. Therefore, ratings in excess of 70 percent and 60 percent are not warranted for the peripheral neuropathy of the upper extremities. Other Considerations In reviewing the Veteran's appeal, the Board has also taken into consideration the Veteran's lay statements in support of his claim. Even conceding that many of the Veteran's symptoms are capable of lay observation, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the Veteran does not assert that he possesses the necessary medical skill and expertise to assess the severity of his neuropathy. See e.g., Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-7 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Entitlement to an initial disability rating of 60 percent for peripheral neuropathy of the right lower extremity is granted. Entitlement to an initial disability rating of 60 percent for peripheral neuropathy of the left lower extremity is granted. Entitlement to an initial disability rating of 40 percent for peripheral neuropathy of the right upper extremity (non-dominant) is granted. Entitlement to an initial disability rating of 40 percent for peripheral neuropathy of the left upper extremity (dominant) is granted. ______________________________________________ YVETTE R. WHITE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs