Citation Nr: 1754532 Decision Date: 11/29/17 Archive Date: 12/07/17 DOCKET NO. 15-38 382 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Propriety of the reduction in the disability rating assigned to degenerative joint disease, thoracolumbar spine, from 40 percent to 20 percent, effective January 16, 2013. 2. Entitlement to a disability rating in excess of 40 percent for degenerative joint disease, thoracolumbar spine. 3. Entitlement to a disability rating in excess of 10 percent for left lateral epicondylitis from June 10, 2008, to January 16, 2013. 4. Entitlement to a disability rating in excess of 20 percent for right (major) lateral epicondylitis from June 10, 2008, to January 16, 2013. 5. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a left wrist disability, separate and distinct from left lateral epicondylitis and carpal tunnel syndrome. 6. Entitlement to service connection for an acquired psychiatric disability, to include as secondary to service-connected disabilities. 7. Entitlement to service connection for bilateral carpal tunnel syndrome, to include as secondary to service-connected disabilities. REPRESENTATION Veteran represented by: J. Michael Woods, Attorney ATTORNEY FOR THE BOARD M. M. Celli, Counsel INTRODUCTION The Veteran had National Guard and Reserve service from September 1980 to October 2002, including a period of active duty for training from January 1981 to May 1981. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in April 2009, August 2011, February 2013, and February 2014 by the Department of Veterans Affairs (VA) Regional Offices (RO) in Cleveland, Ohio, and Louisville, Kentucky. Since the Agency of Original Jurisdiction (AOJ) last considered the appeals, the Veteran and his representative have submitted additional evidence in support of certain claims. As neither the Veteran nor his representative has requested in writing that the AOJ initially review the evidence, the Board's initial review of the evidence is appropriate. See 38 U.S.C. § 7105(e) (West 2012). The Board notes the complicated procedural history of these appeals, to include the Veteran's July 2013 withdrawal of the claims pertaining to his service-connected degenerative joint disease, thoracolumbar spine. However, a September 2015 Statement of the Case re-adjudicated these claims, and the Veteran's subsequent October 2015 substantive appeal reflects the intent to appeal all claims addressed therein. As such, the Board finds the Veteran has perfected an appeal with respect to these claims, thereby rendering them under the Board's jurisdiction. In addition, the Board finds the Veteran's statement in support of claim received on April 5, 2010, should be considered a timely Notice of Disagreement with the April 10, 2009, rating decision. As the April 10, 2009 rating decision addressed the Veteran's June 10, 2008, initial claims for increased disability ratings, the Board has characterized the periods on appeal as those shown on the title page. Further, to the extent that the Veteran's claim for an increased disability rating for degenerative joint disease, thoracolumbar spine, is affected by whether the rating reduction for the disability was proper, the claims are inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other.) In the present case, the Veteran seeks an increased evaluation and also disagrees with the reduction. Therefore, whether the Veteran's degenerative joint disease, thoracolumbar spine, is evaluated as 40 percent disabling or 20 percent disabling, he is seeking a higher evaluation. As such, the Board has characterized the Veteran's claims as stated on the title page. Further, the RO characterized two of the issues on appeal as entitlement to effective dates earlier than January 16, 2013, for the award of a 30 percent disability rating and 40 percent disability rating for left lateral epicondylitis and right lateral epicondylitis, respectively. However, the Board finds these issues are more appropriately characterized as entitlement to disability ratings in excess of 10 and 20 percent from June 10, 2008, to January 16, 2013, respectively, for the reasons stated above. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (West 2012). The issues of entitlement to service connection for bilateral carpal tunnel syndrome, to include as secondary to service-connected disabilities, and entitlement to a disability rating in excess of 40 percent for degenerative joint disease, thoracolumbar spine, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's 40 percent disability rating for degenerative joint disease, thoracolumbar spine, had been in effect for more than five years at the time of the rating reduction. 2. The evidence is at least in relative equipoise as to whether the Veteran's degenerative joint disease, thoracolumbar spine, has demonstrated sustained material improvement which will be maintained under the ordinary conditions of life. 3. From June 10, 2008, to January 16, 2013, flexion of the left elbow was limited to, at most, 145 degrees, without limitation of extension and with supination limited to 80 degrees. 4. From June 10, 2008, to January 16, 2013, flexion of the right elbow was limited to, at most, 145 degrees, without limitation of extension and with supination limited to 75 degrees. 5. Evidence received since the time of the May 2003 rating decision does not raise a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for a left wrist disability. 6. The probative, competent evidence demonstrates that the Veteran's anxiety disorder is proximately due to and/or aggravated by his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for restoration of a 40 percent disability rating for degenerative joint disease, thoracolumbar spine, have been met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 3.105, 3.344, 4.71a, Diagnostic Code 5243 (2017). 2. From June 10, 2008, to January 16, 2013, the criteria for a disability rating in excess of 10 percent for limitation of flexion due to left lateral epicondylitis have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.21, 4.71a, Diagnostic Code 5206 (2017). 3. From June 10, 2008, to January 16, 2013, the criteria for a disability rating in excess of 20 percent for limitation of flexion due to right lateral epicondylitis have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.21, 4.71a, Diagnostic Code 5206 (2017). 4. The May 2003 rating decision is final. 38 U.S.C.A.§ 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2003); currently, 38 U.S.C. § 7105(c) (West 2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 5. Evidence submitted to reopen the claim of entitlement to service connection for a left wrist disability is not new and material, and therefore, the claim is not reopened. 38 U.S.C. §§ 5108, 7105 (West 2012); 38 C.F.R. § 3.156 (2017). 6. The criteria for service connection for anxiety disorder have been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has met all statutory and regulatory notice and duty to assist provisions with respect to the issues decided herein. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017). The information contained in letters dated in July 2008, May 2010, and January 2014 satisfied the duty to notify provisions. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). With regard to the propriety of the reduction in rating for the Veteran's degenerative joint disease, thoracolumbar spine, 38 C.F.R. § 3.105(e) contains its own notice provisions and procedures. Where a reduction in an evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons. In addition, the RO must notify the Veteran that he has 60 days to present additional evidence showing that compensation should be continued at the present level. 38 C.F.R. § 3.105(e). In this case, the RO did not issue a rating decision proposing the reduction. However, as the lower evaluation assigned for the Veteran's degenerative joint disease, thoracolumbar spine, did not result in a reduction of his overall compensation payments, such notice was not necessary. With respect to the duty to assist, the Veteran's service treatment records, VA examination reports and treatment records, and lay evidence are associated with the record. In connection with the issues decided herein, the Veteran underwent multiple examinations. The examiners reviewed the medical evidence and lay statements and performed physical and psychiatric examinations. As a result, the Board finds the examination reports provide sufficient information to rate the service-connected disabilities and decide the service connection claim addressed herein. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). The examiners also provided opinions as to the clinical findings, with adequate rationale for the opinions stated, relying on and citing to the records reviewed. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). As such, the Board finds the examinations to be sufficient and adequate for rating purposes and for determining entitlement to service connection. There is no indication in the record that any additional evidence relevant to the issues determined herein is available and not part of the electronic file. See Pelegrini, 18 Vet. App. 112. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). The Board has thoroughly reviewed all of the evidence in the Veteran's electronic file. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matters decided herein. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Increased Disability Ratings Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4 (2017). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule but findings sufficient to identify the disease and the resulting disability, and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Propriety of the Reduction for Degenerative Joint Disease, Thoracolumbar Spine, effective January 16, 2013 The law provides that where a rating reduction is made without observance of law, although a remand for compliance with that law would normally be an adequate remedy, the erroneous reduction must be vacated and the prior rating restored. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). A veteran's disability rating shall not be reduced unless an improvement in the disability is shown to have occurred. See 38 U.S.C. §1155 (West 2012). When an RO reduces a rating without following the applicable regulations, the reduction is void ab initio. Greyzck v. West, 12 Vet. App. 288, 292 (1999). As noted above, VA's General Counsel has held that the provisions of 38 C.F.R. § 3.105(e) do not apply where there is no reduction in the amount of compensation payable. See VAOPGCPREC 71-91 (Nov. 1991); see also VAOPGCPREC 29-97 (Aug. 1997). It reasoned that this regulation is only applicable where there is both a reduction in evaluation and a reduction or discontinuance of compensation payable. In the February 2013 rating decision, the RO increased the assigned evaluations for left and right lateral epicondylitis and reduced the evaluation assigned evaluation for degenerative joint disease, thoracolumbar spine, both effective January 16, 2013. As the Veteran's overall compensation actually increased on January 16, 2013, the Board finds 38 C.F.R. § 3.105(e) was not applicable. Therefore, the remaining question is whether, based upon a review of the entire recorded history of the disability, the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. Brown v. Brown, 5 Vet. App. 413, 419 (1993); 38 C.F.R. § 4.13 (2017). Moreover, 38 C.F.R. §§ 4.2 (2017) and 38 C.F.R. § 4.10 (2017) provide that, in any rating reduction case, not only must it be determined that improvement in the disability has occurred, but also that improvement reflects an improvement in the Veteran's ability to function under the ordinary conditions of life and work. Additionally, in certain rating reduction cases, VA benefits recipients are to be afforded greater protections. 38 C.F.R. § 3.344 provides that rating agencies will handle cases affected by change of medical findings or diagnosis so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. Id. Under 38 C.F.R. § 3.344, if a rating has been in effect for five years or more, there must be material improvement in the disability before there is any rating reduction. Id. Ratings on account of diseases subject to temporary or episodic improvement, among which are listed skin conditions, will not be reduced on any one examination, except in those instances where all the evidence clearly warrants the conclusion that sustained improvement has been demonstrated. See Peyton v. Derwinski, 1 Vet. App. 282, 286-87 (1992). First, the Board notes that the 40 percent disability rating had been in effect for five years or more, and therefore the evidence must show material improvement. In addition, the question of whether a disability has improved involves consideration of the applicable rating criteria. From June 10, 2007, to August 8, 2011, the Veteran's service-connected degenerative joint disease, thoracolumbar spine, was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237 and under Diagnostic Code 5242 from August 8, 2011, to and after the reduction in January 16, 2013. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage and the functional loss with respect to all these elements. 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 it 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 that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45 (2017); see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2017). The factors involved in evaluating and rating disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint; or pain on movement. Id.; 38 C.F.R. § 4.45. The general rating formula for diseases and injuries of the spine (General Rating Formula) provides for the disability ratings under Diagnostic Codes 5235 to 5243, unless the disability is rated under 5243 and considered under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes for diseases and injuries of the spine, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a. Under the General Rating Formula, a 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is awarded for unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. After review of the relevant lay and medical evidence, the Board finds that a sustained improvement of the Veteran's degenerative joint disease, thoracolumbar spine, has not been demonstrated, and it is not reasonably certain that the improvement will be maintained under the ordinary conditions of life. The October 2010 VA examination shows the Veteran had decreased motion, stiffness, spasms, pain, guarding, and tenderness. Although the evidence did not reflect incapacitating episodes or an abnormal gait, flexion was limited to 40 degrees and pain began at 30 degrees. The upper extremities were affected, and the Veteran's back disability affected his activities of daily living. In January 2011, the Veteran requested reasonable accommodations for school, to include an ergonomic workstation. He reported symptoms of numbness, lightheadedness, and difficulty walking in April 2011. In comparison, the January 2013 VA examination shows reports of symptoms to include numbness, tingling, and pain. Although there were no reports of flare-ups, there were reports of functional loss that included less movement and pain on movement. The Board notes that forward flexion was only limited to 55 degrees, which would warrant a 20 percent disability rating under 38 C.F.R. § 4.71a. However, the Veteran reported that the impact on his ability to work included difficulty sitting and walking for long periods of time and difficulty with repetitive bending, twisting, and lifting. Additionally, VA treatment records dated in February 2013 reflect that the Veteran's back disability was aggravated by activities of daily living, immobilization, and prolonged sitting. He reported that he required bed rest approximately two times per month when he experienced increased muscle spasms, and the evidence reflects his continued request for reasonable accommodations in order to perform his Vocational Rehabilitation work. Subsequent to the January 2013 VA examination, VA treatment records show the Veteran reported flare-ups of his back pain. Treatment records show that he requested alternative medical treatment for his chronic back pain, as physical therapy had failed to decrease the pain that was affecting his activities of daily living. Upon review, the Board finds the evidence does not reflect a sustained improvement in the Veteran's service-connected disability from June 2007 to the period including the reduction in January 2013. In particular, VA treatment records demonstrate continued symptoms of chronic pain that affected the Veteran's activities of daily living as well as his ability to perform his Vocational Rehabilitation work, rather than sustained material improvement capable of being maintained under the ordinary conditions of life. Therefore, resolving the benefit of the doubt in favor of the Veteran, the Board finds the rating reduction was improper, and a restoration of a 40 percent disability rating for degenerative joint disease, thoracolumbar spine, is warranted, effective January 16, 2013. 38 C.F.R. § 4.71a, Diagnostic Code 5242; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left and Right Epicondylitis from June 10, 2008, to January 16, 2013 Initially, the Board notes the Veteran does not disagree with the increased disability ratings assigned for left and right lateral epicondylitis in the February 2013 rating decision. Rather, he disagrees with the effective date assigned for the increased disability ratings and specifically argues that the grant of increased disability ratings should date back to the date of his claim. As such, the Board considers the issues on appeal as entitlement to increased disability ratings for the Veteran's left and right lateral epicondylitis from June 10, 2008, the date of the Veteran's claim, to January 16, 2013, the effective date assigned for the increased disability ratings. During the period on appeal, the Veteran's left lateral epicondylitis has been rated as 10 percent disabling under Diagnostic Code 5206. Diagnostic Code 5206 provides a 10 percent disability rating for flexion of the minor forearm limited to 100 degrees, a 20 percent disability rating for flexion limited to 90 degrees, a 30 percent disability rating for flexion limited to 55 degrees, and a 40 percent disability rating for flexion limited to 45 degrees. As such, the medical evidence must show flexion limited to 90 degrees or less to warrant an increased disability rating under this Diagnostic Code. Additionally, when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Accordingly, the Board notes separate disability ratings could be granted for the Veteran's service-connected left lateral epicondylitis under other applicable Diagnostic Codes. Specifically, Diagnostic Code 5207 provides a 10 percent disability rating for extension of the minor forearm limited to 60 degrees, a 20 percent disability rating for extension limited to 90 degrees, a 30 percent disability rating for extension limited to 100 degrees, and a 40 percent disability rating for extension limited to 110 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5213 provides a 10 percent disability rating for limitation of supination to 30 degrees or less, a 20 percent disability rating for limitation of pronation of the minor wrist with motion lost beyond the middle of the arc or motion lost beyond the last quarter of the arc, or loss of bone fusion with the hand fixed near the middle of the arc or moderate pronation or the hand fixed in full pronation. In addition, a 30 percent disability rating is warranted for loss of bone fusion with the minor hand fixed in supination or hyperpronation. 38 C.F.R. § 4.71a. Upon review, the Board finds the clinical evidence does not reflect flexion of the minor forearm limited to 90 degrees or less. On VA examination in October 2010, flexion was to 145 degrees with no objective evidence of pain on active motion. In addition, there was no pain on motion after three repetitions and no additional limitation of motion. Although the Veteran reported symptoms of pain and tenderness, the VA examiner found these symptoms did not affect the motion of the joint. Additionally, there was no limitation of extension or pronation, and supination was only limited to 80 degrees. As such, the Board does not find that a disability rating in excess of that already assigned or a separate disability rating is warranted for left lateral epicondylitis at any time during the period on appeal. 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207, 5213. During the period on appeal, the Veteran's right lateral epicondylitis has been rated as 20 percent disabling under Diagnostic Code 5206. Diagnostic Code 5206 provides a 10 percent disability rating for flexion of the major forearm limited to 100 degrees, a 20 percent disability rating for flexion limited to 90 degrees, a 30 percent disability rating for flexion limited to 70 degrees, a 40 percent disability rating for flexion limited to 55 degrees, and a 50 percent disability rating for flexion limited to 45 degrees. Diagnostic Code 5207 provides a 10 percent disability rating for extension of the minor forearm limited to 60 degrees, a 20 percent disability rating for extension limited to 75 degrees, a 30 percent disability rating for extension limited to 90 degrees, a 40 percent disability rating for extension limited to 100 degrees, and a 50 percent disability rating for extension limited to 110 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5213 provides a 10 percent disability rating for limitation of supination to 30 degrees or less, a 20 percent disability rating for limitation of pronation of the major wrist with motion lost beyond the last quarter of the arc or loss of bone fusion with the hand fixed near the middle of the arc or moderate pronation, a 30 percent disability rating for limitation of pronation of the major wrist beyond the middle of the arc or loss of bone fusion with the hand fixed in full pronation, and a 40 percent disability rating for loss of bone fusion with the major hand fixed in supination or hyperpronation. 38 C.F.R. § 4.71a. Upon review, the Board finds the clinical evidence does not reflect flexion of the major forearm limited to 70 degrees or less. On VA examination in October 2010, flexion was to 145 degrees with no objective evidence of pain on active motion. In addition, there was no pain on motion after three repetitions and no additional limitation of motion. Although the Veteran reported symptoms of pain and tenderness, the VA examiner found these symptoms did not affect the motion of the joint. Additionally, there was no limitation of extension or pronation, and although resisted supination produced pain beginning at zero degrees, it was only limited to 75 degrees. As such, the Board does not find that a disability rating in excess of that already assigned or a separate disability rating is warranted for right lateral epicondylitis at any time during the period on appeal. 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207, 5213. Again, the Board recognizes the Veteran's competent lay statements describing his symptoms and their effects on his daily life and occupation. Jandreau, 492 F.3d at 1377; Layno, 6 Vet. App. at 469; see also Buchanan, 451 F.3d 1331. Here, VA treatment records in June, July, and August 2010 reflect reports of pain, weakness, and numbness. A January 2011 VA treatment record shows the Veteran reported severe pain with typing and performing work functions, and a June 2011 VA treatment record shows the Veteran reported pain with straightening his elbows. Here, however, the Board finds the objective medical evidence deserves greater probative value, as it demonstrates consideration of the Veteran's statements and the information necessary to rate the Veteran's disability under the rating criteria. Despite the Veteran's reports of pain during work, the October 2010 VA examination report indicates the Veteran's service-connected left and right epicondylitis did not affect his employment. In addition, the record shows the Veteran continued to work and/or go to school throughout the period on appeal. Based on a review of all the evidence, the Board finds the evidence does not support disability ratings in excess of those already assigned for the Veteran's service-connected left and right lateral epicondylitis at any time from June 10, 2008, to January 16, 2013. The Board has considered the benefit of the doubt, but as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable. 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207, 5213; 38 C.F.R. § 4.124a, Diagnostic Code 8516; Gilbert, 1 Vet. App. 49. Total disability rating based on individual unemployability (TDIU) The Court has held that a TDIU claim is part and parcel of an increased rating claim when raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). As a result, the Board has jurisdiction to consider the Veteran's possible entitlement to a TDIU when the issue is raised by assertion or reasonably indicated by the evidence and is predicated, at least in part, on the severity of the service-connected disability in question, regardless of whether the RO has expressly addressed this additional issue. See VAOPGCPREC 6-96 (Aug. 16, 1996); see also Caffrey v. Brown, 6 Vet. App. 377 (1994); Fanning v. Brown, 4 Vet. App. 225, 229 (1993); EF v. Derwinski, 1 Vet. App. 324 (1991). In this case, the RO denied entitlement to a TDIU in the April 2009 rating decision, and the Veteran did not specifically disagree with that denial. In addition, although the Veteran has asserted that his back disability affected his ability to work and perform his school duties, to include requiring reasonable accommodations, he has not contended that he is totally unemployable as a result of his disability. Accordingly, the Board concludes that a claim for entitlement to a TDIU has not been raised by the record. New and Material Evidence Claim The Veteran asserts that he has a left wrist disability, separate and distinct from left lateral epicondylitis and carpal tunnel syndrome, related to military service. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Pertinent procedural regulations provide that "[n]othing in [38 U.S.C. § 5103A] shall be construed to require [VA] to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in [38 U.S.C. § 5108]." 38 U.S.C. § 5103A(f) (West 2012). Reopening a claim for service connection which has been previously and finally disallowed requires that new and material evidence be presented or secured since the last final disallowance of the claim. 38 U.S.C. § 5108; Evans v. Brown, 9 Vet. App. 273, 285 (1996); see also Graves v. Brown, 8 Vet. App. 522, 524 (1996). New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the United States Court of Appeals for the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). In Elkins v. West, 12 Vet. App. 209 (1999), the United States Court of Appeals for Veterans Claims (Court) held the Board must first determine whether the claimant has presented new and material evidence under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C. § 5108. Then, if new and material evidence has been submitted, the Board may proceed to evaluate the merits of the claim, but only after ensuring that VA's duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The Court also held that the law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Here, the Veteran did not appeal the denial of the claim of entitlement to service connection for a left wrist disability following a May 2003 rating decision. Thus, it is final. 38 U.S.C. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2003); currently, 38 U.S.C. § 7105(c) (West 2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). As the May 2003 rating decision is the last final disallowance with respect to this claim, the Board must review all of the evidence submitted since then to determine whether the Veteran's claim should be reopened and re-adjudicated on a de novo basis. In the May 2003 rating decision, the RO denied the claim because the evidence did not demonstrate a current chronic left wrist disability incurred in or caused by service. Thus, in order to reopen the Veteran's claim, new evidence must have been added to the record since the May 2003 rating decision that addresses this basis or provides a new theory of entitlement. Here, the Board finds it determinative that the evidence added to the record since the May 2003 rating decision does not demonstrate a clear diagnosis of a left wrist disability. 38 U.S.C. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997). Evidence must show that the veteran has the disability for which benefits are being claimed. See also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that the requirement of a current disability is met if the disability was present at any point during the claim period). In the absence of proof of a present disability, there can be no valid claim. Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). An October 2009 VA treatment record indicates X-ray examination showed a normal left wrist. The October 2010 and January 2013 VA examiners did not provide a diagnosis of a left wrist disability. Rather, the symptoms were associated with diagnoses of left lateral epicondylitis and carpal tunnel syndrome, both of which are addressed as separate disabilities for service connection purposes. Although the electronic file contains reports of pain in the forearms, VA treatment records do not reflect a separate and distinct diagnosis of a left wrist disability. The Board acknowledges the evidence demonstrating an in-service left wrist injury and the Veteran's assertions that he suffers from pain. In addition, the Board recognizes that the Veteran is competent to provide evidence about the symptoms he experiences. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Charles v. Principi, 16 Vet. App. 370 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board further notes that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, a wrist disability is not the type of disability that is subject to lay diagnosis. Hence, while the Veteran is competent to report the symptoms he experiences, he is not competent to diagnose such a disability, as he has not been shown to have the medical training necessary to do so. In this case, the Veteran reported his symptoms to VA physicians; however, after considering the Veteran's statements and performing physical examinations, the physicians did not provide a clear diagnosis of a current disability for which service connection may be granted. Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of service connection for a left wrist disability. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55-56. Acquired Psychiatric Disability Service connection may be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). The Veteran and his representative submitted a February 2015 disability benefits questionnaire that demonstrates a diagnosis of anxiety disorder due to another medical condition. As such, the Board finds the Veteran has established a current disability for purposes of service connection. Additionally, the February 2015 examination report reflects a positive opinion concerning secondary service connection. Specifically, the private provider opined that the Veteran's service-connected right and left lateral epicondylitis and degenerative joint disease, thoracolumbar spine, caused the Veteran's anxiety disorder and were more likely than not aggravating his anxiety disorder. Based on the foregoing, the Board finds the preponderance of the evidence demonstrates that the Veteran's anxiety disorder is proximately due to his service-connected disabilities. As such, service connection for anxiety disorder is warranted. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55-56. ORDER A restoration of a 40 percent disability rating for degenerative joint disease, thoracolumbar spine, is granted, effective January 16, 2013. A disability rating in excess of 10 percent for limitation of flexion due to left lateral epicondylitis is denied from June 10, 2008, to January 16, 2013. A disability rating in excess of 20 percent for limitation of flexion due to right lateral epicondylitis is denied from June 10, 2008, to January 16, 2013. As new and material evidence has not been submitted, the claim of entitlement to service connection for a left wrist disability is denied. Entitlement to service connection for anxiety disorder is granted. REMAND Increased Disability Rating for Degenerative Joint Disease, Thoracolumbar Spine In connection with his claim for an increased disability rating, the Veteran last underwent VA examination in January 2013. A February 2014 VA treatment record shows the Veteran reported that flare-ups of back pain made it difficult to perform his activities of daily living. An August 2014 VA treatment record shows the Veteran was requesting an alternative to physical therapy for treating his back pain. Upon review, the Board finds this evidence indicates that the Veteran's service-connected disability has worsened in severity since the last VA examination. In Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993), the Court found that, when a veteran claims that his condition is worse than when originally rated, and the available evidence is too old for an adequate evaluation of the veteran's current condition, VA's duty to assist includes providing a new examination. While a new examination is not required simply because of the time that has passed since the last examination, VA's General Counsel has indicated that a new examination is appropriate when there is an assertion of an increase in severity since the last examination. VAOPGCPREC 11-95; see also Green v. Derwinski, 1 Vet. App. 121 (1991) (holding that VA's duty to assist includes conducting a thorough and contemporaneous examination that takes into account the records of prior examinations and treatment). As such, additional examination is warranted to determine the current nature and severity of the service-connected disability. Bilateral Carpal Tunnel Syndrome The Veteran asserts that he has bilateral carpal tunnel syndrome as the result of military service, to include as secondary to service-connected left and right lateral epicondylitis. The October 2010 VA examination report reflects a diagnosis of carpal tunnel syndrome, bilateral wrists. With respect to secondary service connection, the VA examiner opined that the Veteran's current carpal tunnel syndrome was not likely caused by or permanently aggravated beyond its natural progression by his bilateral epicondylitis. The VA examiner reported that current medical literature did not support the contention that carpal tunnel syndrome could be either caused by or permanently aggravated by elbow epicondylitis. The VA examiner stated that the pathophysiology of carpal tunnel syndrome was not completely understood but could be considered to be compression of the median nerve traveling through the carpal tunnel. Although the VA examiner reported that the risk factors for carpal tunnel syndrome were primarily genetic rather than environmental, he also indicated that risk factors with weaker associations included wrist size and shape and general deconditioning. Here, the Board finds the October 2010 VA examiner's opinion inadequate for determining service connection as it did not address the theory of entitlement to service connection on a direct basis. When VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Specifically, the VA examiner did not provide an opinion as to whether the Veteran's diagnosed bilateral carpal tunnel syndrome was related to the documented wrist injury incurred during military service. In this respect, an April 2006 VA treatment record reflects a history of bilateral carpal tunnel syndrome, and an October 2012 VA treatment record shows the Veteran's bilateral wrist pain was a chronic illness. As such, the Board finds remand is warranted for an addendum opinion with respect to this theory of entitlement. 38 U.S.C. §§ 5107(a), 5103A (West 2012); 38 C.F.R. § 3.159 (2017). Additionally, as it appears the Veteran receives continuous treatment through the VA, the Board finds the RO or AOJ should obtain any outstanding VA treatment records dated from September 2015 to the present. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain and associate with the record all VA treatment records for the Veteran dated from September 2015 to the present. All actions to obtain the requested records should be fully documented in the record. If any records cannot be located or no such records exist, the Veteran and his representative should be so notified in writing. 2. Schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected degenerative joint disease, thoracolumbar spine. The electronic file, including a copy of this Remand, must be provided to the examiner in conjunction with the examination. Any medically indicated tests should be accomplished, and all pertinent symptomatology and findings must be reported in detail in accordance with VA rating criteria. The examiner must conduct range of motion and function testing using both active and passive motion, and including weight-bearing and non-weight-bearing motion. A complete rationale should be provided for any opinion or conclusion expressed. 3. Then, determine the specific dates for when the Veteran served on active duty, active duty for training (ACDUTRA), and/or inactive duty for training (INACDUTRA). Based on this review, create a timeline of these dates and associate this timeline with the Veteran's electronic file. Then, forward the Veteran's electronic file, to include a copy of this Remand, to the October 2010 VA examiner, or an appropriate substitute if unavailable, for an addendum opinion as to the nature and etiology of the Veteran's bilateral carpal tunnel syndrome. If the examiner finds additional examination necessary, schedule the Veteran for a VA examination. After review of all the evidence, including the summary of any confirmed periods of active duty, ACDUTRA, and INACDUTRA, service treatment records, VA examination reports and treatment records, and lay evidence, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's bilateral carpal tunnel syndrome is related to an injury that occurred during a period of active duty, ACDUTRA, or INACDUTRA. The examiner is asked to specifically address the service treatment records reflecting a left wrist injury and complaints related to the Veteran's wrists. Additionally, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's bilateral carpal tunnel syndrome is related to a disease that was incurred during a period of active duty or ACDUTRA. If not, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any bilateral carpal tunnel syndrome was aggravated by a period of active duty or ACDUTRA. Aggravation is defined as a permanent worsening beyond the natural progression of the disease or disability. In formulating the opinions, the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. A complete rationale should be provided for any opinion or conclusion expressed. 4. Then, re-adjudicate the claims remanded herein. If any of the benefits sought on appeal remain denied, provide the Veteran and his representative a Supplemental Statement of the Case and an appropriate period of time in which to respond. Then, return the appeal to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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 (West 2012). ______________________________________________ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs