Citation Nr: 1754416 Decision Date: 11/29/17 Archive Date: 12/07/17 DOCKET NO. 13-02 275 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent disabling for residuals, ulnar styloid displacement left wrist, with degenerative joint disease. 2. Entitlement to an evaluation in excess of 10 percent disabling prior to May 20, 2014, and in excess of 0 percent disabling from July 1, 2014, for a left trigger thumb disability. 3. Entitlement to a compensable evaluation for residual scars, status post left trigger thumb surgery and left wrist disability. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Rachel E. Jensen, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from February 1992 to March 1996. This matter comes to the Board of Veterans' Appeals (Board) on appeal from December 2010 and February 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In July 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A copy of the transcript has been associated with the Veteran's claim file. The issue of entitlement to TDIU on an extraschedular basis is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran is in receipt of the maximum schedular evaluation for the limitation of motion of her left wrist and there is no demonstrated ankylosis. 2. Prior to May 20, 2014, the Veteran's left thumb disability was manifested by weakness in grip, limitation of motion, and occasional locking, but not by a gap of more than two inches between the thumb pad and the fingers. 3. From July 1, 2014, the Veteran's left thumb disability was manifested by weakness in grip, limitation of motion, pain, and fatigability, but not by a gap of more than two inches between the thumb pad and the fingers. 4. The Veteran's residual left wrist and thumb scars are linear and stable with no objective evidence of pain or tenderness. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent disabling for residuals, ulnar styloid displacement left wrist, with degenerative joint disease, are not met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5003, 5010, 5215 (2017). 2. The criteria for an evaluation in excess of 10 percent disabling prior to May 20, 2014, for left trigger thumb disability are not met; however, the criteria for an evaluation of 10 percent disabling but no more from July 1, 2014, for left trigger thumb are met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5228 (2017). 3. The criteria for a compensable evaluation for residual scars, status post left trigger thumb surgery and left wrist, are not met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.118, DC 7805 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). This assists in determining, among other things, entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where the schedular criteria does not provide for a noncompensable rating, such a rating is assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. 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 (2017). Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2017). 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). When evaluating disabilities of the musculoskeletal system, 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). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that the pain actually sets in. See VAOPGCPREC 9-98. In determining if a higher rating is warranted based on greater limitation of motion due to pain on use, including use during flare-ups, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2012). Similarly, painful motion alone does not constitute limited motion for rating under diagnostic codes pertaining to limitation of motion. Id. Pain may result in functional loss, however, if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance, as provided in 38 C.F.R. §§ 4.40 and 4.45. Id. Words such as "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. 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. Use of terminology such as "severe" by VA examiners and others, although 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. In making all determinations, the Board must fully consider the Veteran's assertions of record. A layperson is competent to report on the onset and degree of her recurrent symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran's disabilities on appeal stem from an ulnar styloid displacement of the left wrist that occurred in service in 1993. Post-service, the Veteran was diagnosed with non-service-connected bilateral carpal tunnel syndrome. She developed degenerative joint disease in the left wrist, a left trigger thumb, and a non-service connected left wrist ganglion cyst in 2014. She underwent surgery in May 2014 to release the trigger thumb and remove the cyst. She reported having another surgery on her thumb in January 2015. She continues to have symptoms of and treatment for non-service-connected carpal tunnel syndrome in the left wrist. Degenerative changes have been observed in the left wrist and left thumb. I. Left Wrist The Veteran's left wrist disability is evaluated under 38 C.F.R. § 4.71a, DC 5215-5010, at 10 percent disabling, effective November 9, 2009. DC 5215 regards limitation of motion of the wrist. This diagnostic code distinguishes between the major (dominant) and minor (non-dominant) extremity. As the Veteran's left wrist has been designated as her minor side, the ratings for the minor side apply. DC 5010 is relevant to arthritis due to trauma, substantiated by x-ray findings, which is rated as degenerative arthritis under DC 5003. Pursuant to Diagnostic Code 5215, a 10 percent disability rating is warranted where palmar flexion is limited in line with the forearm, or where dorsiflexion is less than 15 degrees. 38 C.F.R. § 4.71a, DC 5215. This is the maximum schedular rating based on limitation of motion of the wrist under this diagnostic code. A higher schedular rating is only warranted when there is evidence of ankylosis. 38 C.F.R. § 4.71a, DC 5214 (2017). Arthritis under DC 5010 is to be rated on limitation of motion of the affected part as degenerative arthritis. Under DC 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, a 10 percent rating is awarded; when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent rating is awarded. 38 C.F.R. § 4.71a. The Board first notes that no higher disability evaluation under DC 5215 may be assigned for the Veteran's left wrist disability, as she is already in receipt of the maximum schedular rating. Furthermore, a higher rating for limitation of dorsiflexion or palmar flexion is not warranted, as DC 5215 already contemplates the effects of limitation of motion. In evaluating musculoskeletal disabilities, the VA must determine whether the joint in question exhibits weakened movement, excess fatigability, incoordination, and whether pain could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. See DeLuca v. Brown, 8 Vet. App. at 206-207; see also 38 C.F.R. §§ 4.40, 4.45. However, where a musculoskeletal disability is currently evaluated at the maximum schedular rating based on limitation of motion, DeLuca consideration is not applicable. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Therefore, no higher rating based on limitation of motion of the Veteran's left wrist is possible. The Board has considered the application of DC 5010 which allows for a separate 10 percent rating for limitation of motion, where there is radiographic evidence of arthritis. However, a separate additional rating under DC 5010 is not warranted because it applies only where limitation of motion under an applicable diagnostic code is non-compensable. In the present case, the Veteran is in receipt of a compensable rating for limitation of movement in her left wrist. Thus, a separate or increased rating is not warranted under DC 5010, for the Veteran's left wrist disability, at any time during the period on appeal. Furthermore, under 38 C.F.R. § 4.45(f), for the purpose of rating disability from arthritis, the only major joints are the shoulder, elbow, wrist, hip, knee and ankle. Additionally, groups of multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities; the interphalangeal, metatarsal and tarsal joints of the lower extremities; the cervical vertebrae; the dorsal vertebrae; and the lumbar vertebrae, are considered groups of minor joints, ratable on parity with major joints. 38 C.F.R. § 4.45(f). This implies that the Veteran's wrists are considered to be one joint. As such, no higher rating is applicable under DC 5003 and DC 5010. Therefore, in order to warrant a higher rating, the medical evidence must demonstrate that the Veteran has no range of motion within her left wrist or that she has effectively lost the functioning of her left hand. For example, DC 5214 offers a higher rating where there is medical evidence of ankylosis of the wrist. Ankylosis is defined as the "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). Under DC 5214, a 20 percent rating is warranted for favorable ankylosis of the minor (non-dominant) wrist in 20 to 30 degrees of dorsiflexion. A 30 percent rating is warranted for any other position, except favorable of the minor wrist; and a maximum 40 percent rating requires unfavorable ankylosis of the minor wrist in any degree of palmar flexion or with ulnar or radial deviation. A review of the Veteran's VA and private medical records indicates no evidence of ankylosis of the left wrist. At VA examinations from January 2010, June 2014, January 2015, July 2015, and November 2016, clinicians did not observe any ankylosis of the left wrist. Range of motion testing indicated dorsiflexion to 40 degrees (January 2010), to 70 degrees (June 2014), to 70 degrees (January 2015), to 55 degrees (July 2015), and to 55 degrees (November 2016); palmar flexion to 30 degrees (January 2010), to 80 degrees (June 2014), to 80 degrees (January 2015), to 50 degrees (July 2015), and to 65 degrees (November 2016); radial deviation to 20 degrees (June 2014), to 20 degrees (January 2015), to 20 degrees (July 2015), and to 15 degrees (November 2016); and ulnar deviation to 45 degrees (June 2014), to 45 degrees (January 2015), to 40 degrees (July 2015), and to 35 degrees (November 2016). The Veteran has given testimony of her difficulties with pain, typing, holding or lifting tools, and decreased range of motion of her left wrist. However, the medical evidence demonstrates that she does have range of motion and has not lost the functioning of her left hand. Accordingly, a higher rating under DC 5214 is not warranted. A 10 percent rating for the Veteran's left wrist disability is continued. II. Left Thumb The Veteran was granted service connection for her left thumb disability at 10 percent disabling from May 12, 2014, under 38 C.F.R. § 4.71a, DC 5228. She received a temporary 100 percent evaluation from May 20, 2014, due to her convalescence after undergoing a trigger thumb release surgery, and a noncompensable rating from July 1, 2014. She contends that she is entitled to a higher initial rating and a higher rating from July 1, 2014, as she has continued pain, a weakened grip, and occasional locking of her thumb, as well as difficulties with combing her hair, typing, and dropping objects. Under DC 5228, a 0 percent evaluation is assigned when the gap between the pad of the thumb and finger is less than one inch (2.5 cm), a 10 percent evaluation is assigned when the gap is one to two inches (2.5 to 5.1 cm), and a maximum 20 percent evaluation is assigned when the gap is more than two inches (5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Private and VA medical treatment records indicate the Veteran had problems with trigger thumbs that were treated with injections for several years. She was seen in January 2014 where a VA clinician referred her to an orthopedic clinic. Records from March and April 2014 indicate the Veteran was diagnosed with left trigger finger. The Veteran reported that the thumb would lock in flexion, especially when she woke up in the morning. Upon physical examination in April 2014, a clinician noted that there was no frank triggering of the left thumb. The Veteran opted to have a trigger thumb release surgery in May 2014. Following the procedure, she was examined in June 2014. She reported no further triggering of her thumb since surgery. Upon examination, the left thumb had a well-healed surgical incision, no erythema or drainage, no triggering, full active thumb flexion, and no swelling. In an October 2014 treatment record, the Veteran reported numbness and tingling in her left hand while driving, dropping objects, and nocturnal paresthesias. Bilateral wrist splints were prescribed for ongoing symptoms of non-service-connected carpal tunnel syndrome. The Veteran underwent a VA examination in January 2015. The examining clinician observed no limitation of motion or pain on motion, no limitation of motion after repetitive use testing, no gap between the thumb pad and fingers, no gap between any fingertips and the proximal transverse crease of the palm, no functional loss, no pain on palpation, normal muscle strength, no ankylosis, and no functional impact on the Veteran's ability to work. The Veteran reported she experienced flare-ups of shooting and throbbing pain as well as temporary loss of hand mobility. At a June 2015 Decision Review Officer hearing, the Veteran testified that her left thumb disability interfered with her ability to hold things, drive, and conduct daily functions requiring the use of hands. Additionally, the disability interfered with her ability to type, and therefore was impacting her ability to work, as the jobs she had had previously all involved at least some typing and her speed and accuracy was affected. In July 2015, the Veteran underwent another VA examination at which the clinician observed no limitation of motion or evidence of painful motion, no limitation of motion after repetitive use, no gap between the thumb pad and fingers, no gap between any fingertips and the proximal transverse crease of the palm, no pain on palpation, no functional loss, and no ankylosis. The Veteran reported symptoms of throbbing, aching, and swelling, and flare-ups which caused a loss of strength and pain. The examiner stated that the functional impact of the disability on the Veteran's ability to work was that at times, she had difficulty using hand tools. However, he pointed out that the Veteran is right-hand dominant. He concluded that there were contributing factors of pain, weakness, fatigability and/or incoordination, but no additional limitation of functional ability during flare-ups or repeated use over time. At another VA thumb examination in November 2016, the Veteran reported that she still experienced pain in her thumb since surgery, but it was a different type of pain. She also reported flare-ups of sharp and throbbing pain radiating into the lower arm region. She stated she experienced loss of strength and the inability to open some bottled drinks and containers. Range of motion testing revealed flexion to 85 degrees in the metacarpophalangeal joint (MCP) and to 80 degrees in the interphalangeal joint (IP) and did not itself contribute to a functional loss. There was no gap observed between the pad of the thumb and the fingers, nor between the fingers and proximal transverse crease of the hand on maximal finger flexion. Pain was noted upon examination, but the clinician found that it did not result in functional loss. Opposition with the thumb exhibited pain, and the base of the thumb was tender. Repetitive use testing did not result in any additional functional loss. No ankylosis was observed. Prior to May 20, 2014, there is no objective medical evidence that the Veteran had a gap more than two inches between the thumb pad and the fingers with the thumb attempting to oppose the fingers. A VA clinician did not observe any triggering of the left thumb in April 2014. The records indicate the Veteran was treated with injections to the thumb to lessen her symptoms, but chose to undergo the May 2014 trigger release surgery rather than continue non-surgical treatment options. She provided descriptions of her symptoms, including the thumb locked in flexion and weakened grip. Accordingly, the Board finds that a rating in excess of 10 percent disabling prior to May 20, 2014, is not warranted under the criteria of DC 5228. The rating takes into account the Veteran's diagnosis of trigger thumb and reported symptoms of weakness and pain. Therefore, a 10 percent disability rating for a left thumb disability from May 12, 2014, to May 20, 2014, is continued. For the rating period beginning July 1, 2014, the findings in the January 2015 and July 2015 VA examinations note no limitation of motion, pain on motion, and no gap between the thumb pad and finger. However, the July 2015 examiner did acknowledge the left thumb caused an impairment in occupational tasks and that there were contributing factors of pain, weakness, fatigability, and/or incoordination. The Veteran exhibited limited range of motion at the November 2016 examination, and pain and tenderness were observed. Additionally, the Veteran has provided credible testimony regarding the impact on her ability to hold items, drive, and type. Thus, the Board acknowledges that impaired function exists and the whole symptomatology satisfies the criteria for an evaluation of 10 percent for the left thumb disability under the guidelines provided in 38 C.F.R. §§ 4.40, 4.45, 4.59. See also, Deluca v. Brown, 8 Vet. App. At 204-07. The Board has considered whether a rating in excess of 10 percent is warranted for both the initial rating period and from July 1, 2014, but finds that it is not. The VA examination reports reflect that the Veteran's thumb did not exhibit any gaps between the thumb pad and the fingers, and thus, her disability does not warrant a greater evaluation under the 20 percent criteria per DC 5228. The Board has also considered whether evaluation under DC 5224 pertaining to ankylosis of the thumb is merited, but because no ankylosis of the left thumb has been demonstrated at any time, it is not. Similarly, there has been no amputation to any part of the Veteran's thumb, nor evidence of a functional loss of the use of her left hand. Therefore, additional consideration under DC 5152 pertaining to amputation of the thumb is not warranted. As such, a 10 percent disability rating for a left thumb disability from May 12, 2014, to May 20, 2014, is continued. Resolving doubt in the Veteran's favor, a rating of 10 percent, but no higher, for a left thumb disability is granted from July 1, 2014. See 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. at 49. III. Residual Scars The Veteran's residual scars, status post left trigger thumb surgery and left wrist associated with left trigger thumb, is evaluated under DC 7805 as noncompensable from May 20, 2014. DC 7805 applies to other scars (including linear scars) and other effects of scars evaluated under DC 7800, 7801, 7802, and 7804. Any disabling effects not considered in a rating provided under DC 7800 through 7804 must be evaluated under an appropriate diagnostic code. In every instance where the rating schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Following the May 2014 surgery, as noted above, a June 2014 VA treatment record stated that upon examination, the left thumb had a well-healed surgical incision, with no erythema or drainage. The Veteran underwent several VA examinations where it was noted that she had surgical scars but the scars were not painful and/or unstable, and the total area of the scars was not greater than 39 square cm (6 square inches). See June 2016 VA wrist examination, January 2015 VA wrist examination, and January 2015 VA thumb examination. At the January 2015 examinations, the clinician noted that the length and width of the surgical scars were determined to be 1.8 cm by 0.2 cm, 2.5 cm by 0.2 cm, and 1.2 by 0.2 cm. At a July 2015 VA wrist examination, scars measuring 2.5 cm by 0.1 cm and 1 cm by 0.2 cm were observed and determined not to be painful or unstable. A July 2015 VA thumb examination determined there was no visible scar from surgery. At a November 2016 VA scar examination, the Veteran reported that she experienced intermittent pain that varied in severity depending upon environment and use to scars of the left wrist and hand. The examiner observed that there were no unstable scars upon inspection and no tenderness on palpation. Two linear scars were noted, with the first measuring 2.0 cm in length on the palmar surface and second measuring 1.5 cm on the volar wrist. The examiner reported that the scars did not result in any limitation of function and that there were no other pertinent physical findings, complications, conditions, signs, or symptoms associated with the scars. The Board finds that the Veteran's surgical scars are noncompensable under DC 7805. There is no evidence of a disabling effect of the scars because of a limitation of function. Although the Veteran has reported intermittent pain at the location of the scars, there is no objective evidence of pain or tenderness and no limitation of function due to the scars has been suggested. The location of the scars is also where the Veteran has reported ongoing pain due to her left wrist and thumb disabilities. There is no medical evidence that the pain the Veteran is experiencing is separate from those underlying disabilities. The Board has considered whether an additional, separate compensable evaluation under DC 7804 is warranted. Under DC 7804, which applies to scars that are unstable or painful, a 10 percent evaluation is warranted for one or two scars that are unstable or painful. A 20 percent evaluation is warranted for three or four scars that are unstable or painful. A 30 percent evaluation is warranted for five or more scars that are unstable or painful. Note 1 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 provides that if one or more scars are both unstable and painful, 10 percent should be added to the evaluation that is based on the total number of unstable or painful scars. 38 C.F.R. § 4.118, DC 7804. However, there is no medical evidence that the scars are unstable. As there is no objective evidence of pain or instability, a compensable evaluation under DC 7804 is not warranted. Accordingly, the noncompensable rating under DC 7805 is continued. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, No. 15-2818, 2017 U.S. App. Vet. Claims LEXIS 319, *8-9 (Vet. App. March 17, 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 An evaluation in excess of 10 percent disabling for residuals, ulnar styloid displacement left wrist, with degenerative joint disease, is denied. An evaluation in excess of 10 percent disabling prior to May 20, 2014, for a left trigger thumb is denied, but an evaluation of 10 percent disabling and no more from July 1, 2014, for a left trigger thumb is granted. A compensable evaluation for residual scars, status post left trigger thumb surgery and left wrist, is denied. REMAND A total disability rating for compensation purposes may be assigned where the schedular rating is less than total and where it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The Veteran's service-connected disabilities meet a combined rating of 60 percent disabling from July 1, 2014. Nevertheless, in exceptional circumstances, where a veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). The Board has no authority to assign a TDIU rating under section 4.16(b) and may only refer the claim to the Director, Compensation Service, for extraschedular consideration. Bowling v. Principi, 15 Vet. App. 1 (2001). Although the Veteran does not meet the schedular requirements for a TDIU, there is ample evidence in the record that her disabilities and/or the medicines used to treat those disabilities have impacted her ability to maintain substantially gainful employment. As such, this issue is referred to the Director, Compensation Service, for extraschedular consideration of TDIU. The Board retains jurisdiction over the matter as the decision by the Director is reviewable by the Board. Wages v. McDonald, 27 Vet. App. 233 (2015). Accordingly, the case is REMANDED for the following action: 1. Refer to the Director, Compensation Service, the issue of extraschedular consideration of TDIU. 2. If the claim for extraschedular TDIU is not granted, provide the Veteran and her representative a supplemental statement of the case and an appropriate period of time to respond. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ H.M. WALKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs