Citation Nr: 1759949 Decision Date: 12/22/17 Archive Date: 01/02/18 DOCKET NO. 09-29 517 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a lumbar spine disorder, to include arthritis. 2. Entitlement to an initial compensable rating for costochondritis (claimed as a chest injury). 3. Entitlement to an initial rating for right (major) carpal tunnel syndrome in excess of 10 percent prior to February 28, 2017, and in excess of 30 percent thereafter. 4. Entitlement to an initial rating for left carpal tunnel syndrome in excess of 10 percent prior to February 28, 2017, and in excess of 20 percent thereafter. 5. Entitlement to a rating in excess of 10 percent for right knee degenerative changes status post arthroscopy with chondroplasty and synovectomy. 6. Entitlement to a rating in excess of 10 percent for left knee degenerative changes. 7. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Robert V. Chisholm, Attorney-at-Law ATTORNEY FOR THE BOARD Polly Johnson, Associate Counsel INTRODUCTION The Veteran had active service from May 1980 to August 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2008, May 2013, September 2014, and June 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri (June 2008, September 2014, June 2015) and the Appeals Management Center (AMC) in Washington, DC (May 2013). The June 2008 rating decision denied service connection for a low back condition. The May 2013 rating decision granted service connection for costochondritis and assigned a noncompensable rating. The September 2014 rating decision continued 10 percent ratings for both knee disabilities, and denied entitlement to individual unemployability. The June 2015 rating decision granted service connection for right and left carpal tunnel syndrome and assigned a 10 percent rating for each disability. In a May 2015 decision, the Board denied the Veteran's claim of entitlement to service connection for a low back disorder and remanded the claim seeking an initial compensable rating for costochondritis. The Veteran appealed the Board's denial of service connection for a low back disorder to the United States Court of Appeals for Veterans Claims (Court). In January 2016, the Court granted a joint motion for partial remand (JMPR) of the Veteran and the Secretary of Veterans Affairs (Parties), vacated the portion of the May 2015 Board decision that denied service connection for a low back disorder, and remanded that matter to the Board. In September 2016, the Board remanded the claim for development consistent with the terms of the joint motion. During the pendency of this appeal, in a March 2017 rating decision, the RO increased the Veteran's rating for right carpal tunnel syndrome to 30 percent effective February 28, 2017, and increased the rating for left carpal tunnel syndrome to 20 percent effective February 28, 2017. The Veteran has not expressed satisfaction with these ratings, and in fact, his attorney filed a Notice of Disagreement with the March 2017 rating decision in June 2017. Notwithstanding this action, because a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded, the Veteran's claims for higher initial ratings for right and left carpal tunnel syndrome in this case, to include at all stages, remains at issue, notwithstanding the partial grant by the RO. See AB v. Brown, 6 Vet. App. 35 (1993). Thus, the Board will address the propriety of the ratings assigned throughout the appeal period. The Board notes that, subsequent to the issuance of the March 2017 supplemental statements of the case (costochondritis, low back) and the March 2017 statements of the case (carpal tunnel syndrome, knees, TDIU), additional evidence was added to the record, to include a private medical report. The Veteran, through his representative, waived initial agency of original jurisdiction (AOJ) consideration of this newly received evidence in an August 2017 letter. 38 C.F.R. § 20.1304(c) (2017). Therefore, the Board may properly consider such newly received evidence. Initially, in the Veteran's August 2009 VA Form 9 and February 2017 VA Form 9, he indicated that he did not want a hearing. However, in a June 2017 letter the Veteran, through his representative, requested a Board hearing for all pending claims. The Board remanded the claims for service connection for a low back disorder and entitlement to an initial, compensable rating for costochondritis in August 2017 for a hearing. However, in September 2017 correspondence, the Veteran indicated that he did not want a Board hearing on any pending issues. Accordingly, the Board deems his request for a hearing withdrawn. See 38 C.F.R. § 20.704(e) (2017). The issues of entitlement to increased ratings for each knee, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence of record is in equipoise as to whether a relationship exists between the Veteran's lumbar spine disabilities and his period of active duty service. 2. At no time during the appeal period has the Veteran's costochondritis been manifested by symptoms approximating impairment of the thoracic muscle group that are of moderate or worse severity. 3. Prior to April 21, 2016, the Veteran's right carpal tunnel syndrome was manifested by mild incomplete paralysis of the median nerve; from April 21, 2016, it has been manifested by moderate incomplete paralysis of the median nerve. 4. Prior to April 21, 2016, the Veteran's left carpal tunnel syndrome was manifested by mild incomplete paralysis of the median nerve; from April 21, 2016, it has been manifested by moderate incomplete paralysis of the median nerve. CONCLUSIONS OF LAW 1. Resolving all doubt in the Veteran's favor, the criteria for service connection for a lumbar spine disability, to include arthritis, are met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for a compensable rating for costochondritis have not been met at any time during the pendency of the appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.56, 4.73, Diagnostic Code 5399-5321 (2017). 3. The criteria for a rating in excess of 10 percent for right carpal tunnel syndrome have not been met for the period prior to April 21, 2016. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. § 4.1, 4.124a, Diagnostic Code 8515 (2017). 4. The criteria for a 30 percent rating, but no higher, for right carpal tunnel syndrome have been met from April 21, 2016. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. § 4.1, 4.124a, Diagnostic Code 8515 (2017). 5. The criteria for a rating in excess of 10 percent for left carpal tunnel syndrome have not been met for the period prior to April 21, 2016. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. § 4.1, 4.124a, Diagnostic Code 8515 (2017). 6. The criteria for a 20 percent rating, but no higher, for left carpal tunnel syndrome have been met from April 21, 2016. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. § 4.1, 4.124a, Diagnostic Code 8515 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Procedural Duties The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156 (a), 3.159, 3.326 (a). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C. § 5103 (a); 38 C.F.R. § 3.159 (b)(1). The Veteran was provided pre-adjudication notice in July 2007 and March 2014 regarding how to substantiate his claims. The Veteran was also told how VA would assist him in obtaining additional relevant evidence and how VA determines the effective date and disability rating. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination and/or opinion when necessary to make a decision on a claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). In the present case, the Board finds that the duty to assist has been fulfilled. The Veteran's service treatment records have been obtained. He has also been examined (in March 2013, June 2014, and February 2017). The reports of those examinations, taken together with other evidence of record, contain descriptions of impairment sufficient for the proper evaluation of the disabilities discussed below. There is no suggestion on the current record that there is any other evidence outstanding. As such, no further development action is required. Finally, in September 2016, the Board remanded the case and directed the AOJ to schedule the Veteran for VA examinations. The AOJ did so and readjudicated the issues on appeal in March 2017 supplemental statements of the case. For these reasons, the Board's prior remand instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). II. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Establishing service connection generally requires (1) a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For certain chronic disabilities identified under 38 C.F.R. § 3.309(a), such as arthritis, direct service connection may alternatively be established based on a finding of continuity of symptomatology. See 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). In addition, service connection for arthritis may also be granted if such disability becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C. §§ 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309 (a). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). It is undisputed that the Veteran has a current low back disability. Indeed, the February 2017 VA examiner noted a diagnosis of degenerative joint disease of the lumbar spine. Prior reports show diagnoses of intervertebral disc syndrome and degenerative disc disease. The Veteran contends that his current low back disabilities are directly related to multiple injuries sustained in-service. Specifically, he has asserted that in his capacity as an aircraft mechanic, he spent a lot of time doing repetitive work changing aircraft parts which required bending, kneeling, squatting, crawling and lying in several positions; and while deployed on aircraft carriers he would have to carry heavy aircraft parts up several levels to reach the flight deck. See March 2009 Notice of Disagreement; January 2013 Statement in Support of Claim. The Board in no way calls into question that the Veteran's in-service duties were physically demanding, and to the extent the Veteran currently asserts that he experienced pain and injury to his back in performance of lifting and bending duties as an aircraft mechanic, the Board will assume this to be true. The key question at issue is whether the Veteran's current back disabilities are related to his in-service wear and tear injuries to the back. The Board notes that the Veteran first sought treatment for back pain in 1994 and 1995, approximately five years after his separation from service. During a March 1995 evaluation, the Veteran reported experiencing low back pain that started in his thoracolumbar region and radiated into his lower back and left leg. At that evaluation, he said he did not know the exact incident or cause of the onset of his pain. He was diagnosed with strain and subluxation in the thoracolumbar spine. At a later March 1995 evaluation, the Veteran received diagnoses of chronic intervertebral disc syndrome (IVDS) with nerve root irritation and sciatic involvement complicated by severe deconditioning of the lumbar paraspinal muscles and recurrent subluxation/fixation of the left S-1 joint and thoracolumbar/lumbar spine. A VA treatment record dated February 1996 shows that the Veteran sought care for back pain and stated that he injured his back in service in 1986 when he fell from planes many times. An April 1996 VA treatment note shows that the Veteran stated he had back pain for ten years (i.e. 1986). X-ray images taken at that time, as discussed by the March 2013 VA examiner, showed a normal lumbar spine, without any evidence of fracture, bone destruction, bony defect, narrowing of the intervertebral disc spaces or other bone or joint abnormality. A subsequent March 2005 MRI shows mild multilevel degenerative disc disease. There are conflicting medical opinions of record addressing the etiology of the Veteran's lumbar spine disabilities. Upon examination in March 2013, a VA examiner opined that it was less likely than not that the Veteran's lower back condition was incurred in or caused by the Veteran's service. The examiner based this conclusion on observations that the Veteran had normal X-rays of his lumbar spine in April 1996, seven years after separation from service. Pertinently however, as pointed out by the parties in the above-referenced JMPR, the examiner did not adequately explain why a relationship still could not exist, based on prior diagnoses from 1995 showing chronic intervertebral disc syndrome (IVDS) with nerve root irritation and sciatic involvement. The Veteran submitted a private medical opinion authored by Dr. W.G. in May 2016. Dr. W.G. indicated a review of the entire claims file and noted extensive phone conversations with the Veteran and his spouse. It was Dr. W.G.'s opinion that the Veteran's low back disability was more likely than not incurred in service, specifically, as a direct result of multiple injuries to his spine suffered while performing his duties as an aircraft maintenance worker. Dr. W.G. specifically pointed to the above-reference 1996 X-ray that showed a normal lumbar spine, and stated that "the pathological conditions that were later found on an MRI evaluation of the lumbar spine would not have shown up on a plain x-ray examination of the lumbar spine when the veteran was only 34 years old. A fracture or fractures would have shown up, but not the herniated discs and beginnings of neuro-foraminal encroachment and facet joint degenerative arthritic changes that evolved over the years to cause the Veteran's present chronic low back pain syndrome." The Veteran subsequently underwent an additional VA spine examination in February 2017. The Veteran reported that he developed a back condition in approximately 1985 following lifting and carrying. The VA examiner again opined that the Veteran's low back disability was less likely than not related to his military service. The rationale was that the Veteran's back condition developed in 1994, approximately five years following discharge from service, in large part relying on an absence of documented treatment or report of injury during service. In response, the Veteran submitted an addendum opinion from Dr. W.G. in July 2017, which expounded on his May 2016 positive nexus opinion. Upon review of the above, the Board finds that the evidence both for and against the Veteran's service-connection claim for a lumbar spine disability is in relative equipoise. Therefore, the Board resolves all doubt in favor of the Veteran and finds that service connection his lumbar spine disabilities, to include arthritis is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. III. Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the appellant's favor. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). A. Costochondritis (claimed as chest injury) The Veteran's costochondritis, claimed as a chest injury, is currently evaluated as noncompensable by analogy under Diagnostic Code 5399-5321. 38 C.F.R. § 4.73. Chest pain is not specifically listed in the Rating Schedule. An unlisted condition may be rated under the Code for a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. When a disability is not specifically listed, the code will be "built up," meaning that the first two digits will be selected from that part of the schedule most closely identifying the part of the body involved, and the last two digits will be "99." 38 C.F.R. § 4.27. In this case, the Veteran's service-connected costochondritis has been rated by analogy as an injury to Muscle Group XXI, the muscles of respiration of the thoracic muscle group. For slight injury, a noncompensable rating is assigned. A moderate injury warrants a 10 percent rating. A (maximum) 20 percent rating is warranted for severe or moderately severe injury. 38 C.F.R. § 4.73, Diagnostic Code 5321. For VA rating purposes, the primary signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). Private treatments records show an incident of chest pain in April 2006. In September 2007, the Veteran underwent a chest radiograph. The Veteran underwent a VA muscle injuries examination in March 2013. The examiner noted the diagnosis of costochondritis from 2003. The Veteran stated that he had chest pain approximately every two months, lasting for one week. He also said he experienced chest pain, which could radiate to either arm, about twice monthly, typically lasting from one day to one week. Physical examination revealed that the Veteran did not have tenderness over the sternum or the ribs. The examiner stated that the Veteran's muscle injury did not affect muscle substance or function. The muscle injury did not show symptoms productive of loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, or uncertainty of movement. Muscle strength testing was normal and there was no muscle atrophy. The examiner stated that the condition caused mild, self-limiting symptoms, with occasional recurrences. In a May 2013 statement, the Veteran said he had recurring pain in his chest that warranted a higher rating. April 2015 and April 2016 VA treatment notes show that the Veteran denied chest pain and palpitations. In a July 2015 statement, he said that he had daily pain that radiated down his arms. He said he lived with the daily pain and took over the counter medication four times a day to reduce the pain to a tolerable level. In a May 2016 private medical opinion, Dr. W.G. stated that the Veteran's costochondritis had evolved over the years into degenerative arthritis of the sternum and ribs, was moderate/moderately severe, and should be rated as high as VA guidelines allow. The Veteran reported to Dr. W.G. that he had shooting pain occurring just below the heart level. The Veteran underwent another VA muscle injuries examination in February 2017. He reported to the examiner that he had daily mild chest pain on both sides of his anterior chest. The noted location of his injury was to Group XXI, muscles of respiration of the thoracic muscle group. He demonstrated full muscle strength and no muscle atrophy. There were no obvious signs of tenderness over the chest wall. A July 2017 addendum to the May 2016 private medical opinion stated that the Veteran's costochondritis caused the Veteran daily pain, but did not interfere with his activities of daily living. It was the doctor's opinion that a rating of 10 percent was warranted. The Board finds that the Veteran's chest pain does not present symptoms that are analogous to an impairment of Muscle Group XXI that is of moderate or worse severity. At the March 2013 VA examination, the examiner noted that the Veteran experienced mild symptoms. By his own statements, at his February 2017 VA examination, he reported mild pain. Though he wrote in a July 2015 statement that he had daily pain and reported to the doctor who authored the May 2016 and July 2017 private opinions that he had daily pain, he denied any chest pain at April 2015 and April 2016 VA medical appointments. Moreover, Dr. W.G., in the July 2017 addendum opinion, wrote that though the Veteran stated that he had daily pain, his chest pain did not interfere with his activities of daily living. Dr. W.G. did not physically examine the Veteran, and thus, the Board accords only limited probative value to his statements regarding the Veteran's chest condition. Accordingly, the Board finds that the Veteran's symptoms are productive of mild pain, and, as such, there is no basis for the assignment of a compensable rating for thoracic muscle group under Code 5321. Further, the Board notes that pain alone does not constitute a functional loss under VA regulations. Pain may cause a functional loss, but pain itself does not constitute functional loss; rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). Although the Veteran may experience chest pain, this symptom has not been shown to cause any functional impairment, nor has it risen to the level of a compensable disability rating under Code 5321 or any other applicable code. The Board further finds that there have been no specific periods when different and distinct levels of impairment were shown; thus, staged ratings are not warranted. Accordingly, a compensable rating for the Veteran's costochondritis is not warranted at any time during the course of the appeal. B. Right and Left Carpal Tunnel Syndrome The Veteran contends that his right and left carpal tunnel syndrome, which manifests in wrist and hand pain and weakness, is worse than the assigned ratings reflect. See February 2016 Notice of Disagreement (seeking the highest evaluation possible). The Veteran is right hand dominant. See March 2013 VA Examination. Historically, the Veteran was denied service connection for left and right carpal tunnel syndrome in a June 2008 rating decision. In a January 2013 decision, the Board reopened those issues and remanded them for further development. In a June 2015 rating decision, the RO assigned 10 percent ratings each to right and left carpal tunnel syndrome. A March 2017 rating decision increased the rating for right carpal tunnel syndrome to 30 percent effective February 28, 2017, and increased the rating for left carpal tunnel syndrome to 20 percent effective February 28, 2017. Disabilities of the median nerve are rated under the criteria of 38 C.F.R. § 4.124a (Diseases of the Peripheral Nerves), Diagnostic Code 8515 (complete or incomplete paralysis), Diagnostic Code 8615 (neuritis) and Diagnostic Code 8715 (neuralgia). A 10 percent rating is awarded for mild incomplete paralysis of the major extremity. A 30 percent rating is warranted for a major extremity with incomplete paralysis of the median nerve that is moderate. A 50 percent rating is warranted for a major extremity with incomplete paralysis of the median nerve that is severe. A 70 percent rating is warranted for complete paralysis of the median nerve of the major extremity, resulting in such symptoms as the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended, cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8615, 8715. The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild or at most the moderate degree. 38 C.F.R. § 4.124a, Note. On VA examination in March 2013, the Veteran reported pain with numbness, radiating to his fingers, which occurred weekly and lasted for a half day or longer. The examiner indicated that the Veteran had mild, dull, intermittent pain, mild numbness, and mild paresthesias and/or dysesthesias, in the right and left upper extremities. Muscle strength testing was normal. Reflexes and gait were normal. No trophic changes were present. Phalen's sign and Tinel's sign were negative. The examiner noted that the Veteran experienced mild incomplete paralysis of the right and left median nerves. In an April 2016 statement, the Veteran stated that he could no longer type due to the pain in his wrist and hands. His wife also submitted a statement in April 2016 stating that the Veteran had no strength in his wrist and hands and struggled to grip things, including a steering wheel. He was unable to do previous hobbies, such as gardening, mowing, and minor repairs on their vehicles. Two of the Veteran's stepsons submitted statements that the Veteran could no longer perform his hobby of woodworking. A May 2016 private medical opinion described the Veteran's reports of numbness and pain in both wrists. The physician stated that the left and right carpal tunnel syndrome disabilities had evolved into a condition involving nerves, muscles and tendons that have severely restricted the Veteran's ability to grasp or carry objects weighing more than five pounds, write or type for periods up to but usually less than 15 minutes, as well as to perform a multitude of services that he was once able to provide around the house. On VA examination in February 2017, the Veteran reported experiencing daily pain and tingling of both hands, with right hand numbness. The examiner indicated that the Veteran had moderate, intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness in his upper extremities. Muscle strength testing was normal. Light touch sensation testing was absent in the hands/fingers. No trophic changes were present. Phalen's sign and Tinel's sign were positive. The examiner noted that the Veteran experienced moderate incomplete paralysis of the right and left median nerves, radial nerves, and ulnar nerves. The examiner stated that because of his wrist and hand pain, he avoided using tools, and more than minimal writing. The examiner further stated that his carpal tunnel syndrome impaired the capacity for skilled motor movements by either hand. After a careful review of the lay and medical evidence, the Board finds that right carpal tunnel syndrome disability meets the criteria for a 30 percent rating as of April 21, 2016, and that left carpal tunnel syndrome disability meets the criteria for a 20 percent rating as of April 21, 2016. Prior to April 21, 2016, a rating in excess of 10 percent for both right and left carpal tunnel syndrome is not warranted. In this regard, prior to April 21, 2016, specifically at the Veteran's March 2013 VA examination, pain in his hands and wrists was noted to be mild, and the pain was dull and intermittent. To warrant the next higher ratings, the evidence must show moderate symptoms. Specifically, there must be evidence of moderate incomplete paralysis of the median nerve, or complete paralysis of the median nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8515. There is no evidence in the record, prior to April 21, 2016, that the Veteran's right or left carpal tunnel syndrome disability exceeded more than mild incomplete paralysis. However, on April 21, 2016, the Veteran submitted a statement advising that he could no longer type due to the pain in his wrist and hands. Statements from his wife and two stepsons submitted at that time showed that the Veteran struggled to perform his hobbies, to include woodworking, gardening, and household chores. The statements made in the Veteran and his family's statements are reflected in the findings of the May 2016 private medical report and the February 2017 VA examination report, and therefore the Board has no reason to doubt that the Veteran's worsened carpal tunnel symptoms were present as of April 21, 2016. Accordingly, the Board finds that a 30 percent rating for right carpal tunnel syndrome and 20 percent rating for left carpal tunnel syndrome are warranted from April 21, 2016. However, the Board does not find that the next higher ratings are warranted, in that the February 2017 VA examiner described only moderate incomplete paralysis of the right and left median nerves. To the extent Dr. W.G. asserts that higher ratings should be assigned for right and left carpal tunnel syndrome, the Board places less probative value on this assertion as Dr. W.G. did not examine the Veteran in person. Indeed, the Board places more probative weight on the assessments and observations of those physicians noted above who have conducted in-person nerve testing. In any event, by his own assessment, Dr. W.G. noted that the Veteran's disability included incomplete, "moderate" loss of function of both median nerves. The Board has considered whether staged ratings beyond what have been assigned herein are warranted but finds that they are not, as the evidence does not show that there are distinct periods of time where ratings in excess of what have been assigned are warranted. ORDER Service connection for the Veteran's lumbar spine disabilities, to include arthritis, is granted. An initial compensable rating for costochondritis, claimed as a chest injury, is denied. An initial rating in excess of 10 percent for right carpal tunnel syndrome, prior to April 21, 2016, is denied. An initial rating of 30 percent, but no higher, for right carpal tunnel syndrome, from April 21, 2016, is granted. An initial rating in excess of 10 percent for left carpal tunnel syndrome, prior to April 21, 2016, is denied. An initial rating of 20 percent, but no higher, for left carpal tunnel syndrome, from April 21, 2016, is granted. REMAND The Board finds that further development is required with regard to the Veteran's increased rating claims for both knees, as well as his claim for entitlement to a TDIU. With respect to the Veteran's knees, the Veteran reported at a June 2014 VA examination that reported flare-ups that resulted in a pain level of "8" out of "10;" otherwise he described his pain level as being at a "4" out of "10." Functional loss manifested on both sides with less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and instability of station. The June 2014 VA examiner indicated that it is not possible without mere speculation to estimate either loss of range of motion or describe loss of functionality due to pain flare ups, weakness, fatigability and or incoordination when joint is used repeatedly over a period of time, because there is no conceptual or empirical basis for making such a determination without directly observing function under these circumstances. In March 2015, the Veteran submitted a statement in which he said that his knees had become progressively worse and affected his entire quality of life. He reported constant pain, weakness, numbness, and loss of movement. He said he could no longer climb stairs, walk any distance, stand for long periods of time, or drive any distance, and that his knee problems were affecting other parts of his body. See March 2015 Notice of Disagreement. The Veteran underwent an additional VA examination February 2017. He reported daily constant pain of both knees, every day, worse after movement. He described flare-ups that occurred approximately four times per week which caused him to limit activity because of severe knee pain. Range of motion testing showed right knee flexion and extension each to 105 degrees. The examiner noted pain on flexion and said that it caused functional loss. Left knee flexion and extension was to 140 degrees. Pain was noted and caused functional loss. The Veteran could perform repetitive use testing without additional functional loss after three repetitions on both knees. Pain, fatigue, and weakness limited functional ability with repeated use over a period of time. The exam did not take place during a flare-up, but the examiner noted that pain, fatigue, and weakness would cause functional loss, though he too was not able to describe such loss in terms of range of motion. In Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the Court found that direct observation of functional impairment during a flare-up is not a prerequisite to offering an opinion as to the degree of such impairment in applying the principles enumerated in DeLuca v. Brown, 8 Vet. App. 202 (1995). Indeed, the examiner should provide an estimate, to include in terms of loss of range of motion if possible, based on all procurable and assembled medical evidence, to include eliciting relevant information from the veteran as to the flare-i.e. the frequency, duration, characteristics, severity, or functional loss, and such opinion cannot be based on the insufficient knowledge of the specific examiner. In light of the fact that the Veteran has reported limitation of function during flares, and VA examiners have not yet provided a complete assessment or estimation as to the extent of this limitation, the AOJ should schedule a new VA examination to evaluate the Veteran's bilateral knee disabilities that includes assessments of any functional loss during flare-ups and upon repetitive motion. As the development requested may be pertinent to the adjudication of the Veteran's TDIU claim, action on that matter is deferred. Accordingly, the case is REMANDED for the following action: 1. Arrange for a VA examination to determine the severity of the Veteran's service connected knee disabilities. The electronic record should be made available and reviewed by the VA examiner. Range of motion testing in active motion, passive motion, weight-bearing, and nonweight-bearing for each knee should be accomplished. If the examiner is unable to conduct such testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner must also address functional impairment, if any, during flare-ups. The range of motion lost during a period of flare-up or over-use must be indicated in degrees. If the examination occurs when a flare-up is not being experienced, or at a time without repeated use over a period of time, the examiner must ascertain adequate information, such as frequency, duration, characteristics, severity, or functional loss regarding the Veteran's flares by alternative means and estimate the Veteran's functional loss due to flares or repeated use based on all the evidence of record. 2. After completion of the above and any other warranted development, the AOJ should re-adjudicate the claims that have been remanded, to include entitlement to a TDIU. If a benefits sought on appeal remain denied, the AOJ should issue a Supplemental Statement of the Case. After the Veteran and his attorney are given opportunity to respond, the case should be returned 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). 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 (West 2014). ______________________________________________ V. Chiappetta Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs