Citation Nr: 18152104 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-43 835 DATE: November 20, 2018 ORDER Entitlement to a disability rating in excess of 10 percent for degenerative joint disease of the left wrist is denied. Entitlement to a compensable disability rating for a scar on the left wrist is denied. FINDINGS OF FACT 1. The Veteran’s degenerative joint disease of the left wrist is manifested by pain and limitation of motion; ankylosis of the left wrist is not shown. 2. The scar on the left wrist is not deep, unstable, or greater than six square inches in size, and it does not cause limitation of motion of the wrist. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating greater than 10 percent for degenerative joint disease of the left wrist have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5215. 2. The criteria for a compensable disability rating for a scar on the left wrist have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, 4.118, DC 5215, 7801-05. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1986 to August 1990 and January 1991 to March 1991. This matter comes before the Board of Veterans’ Appeals (Board) from a March 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. A subsequent August 2018 rating decision granted the Veteran a compensable rating for his left wrist disability effective the date his claim was received. During active service in 1989, the Veteran underwent arthroscopic surgery on the left wrist for fracture repair. The RO awarded service connection in August 1990 for status post fracture, left wrist with metallic screw. As noted above, this condition was rated as 10 percent disabling in an August 2018 decision. Service connection was also awarded for the related scar on the Veteran’s left wrist in March 2014, which was rated as noncompensable. Increased Rating 1. Entitlement to a disability rating greater than 10 percent for degenerative joint disease of the left wrist. Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability; resolving any reasonable doubt regarding the degree of disability in favor of the claimant; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity. See 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.10; see also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where an increase in the disability rating is at issue, the present level of a claimant’s disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings, however, are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to the 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 pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, once a particular joint has been evaluated at the maximum level in terms of limitation of motion, there can be no additional disability due to pain. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Degenerative or traumatic 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 involved is noncompensable under the appropriate diagnostic codes, a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined and not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. The Veteran’s degenerative joint disease of the left wrist disability is currently rated under 38 C.F.R. § 4.71a, DC 5215 (degenerative arthritis; wrist, limitation of motion). Pursuant to Diagnostic Code 5215, a 10 percent rating is warranted where palmar flexion of the wrist is limited in line with the forearm (zero degrees), or where dorsiflexion of the wrist is less than 15 degrees. Id. Ten percent 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, Diagnostic Code 5214. As opposed to limitation of motion, ankylosis is a distinct disability defined as the “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Under DC 5214, a 20 percent rating is warranted where there is favorable ankylosis of the wrist in 20 to 30 degrees of dorsiflexion. A 30 percent rating is warranted where there is ankylosis of the wrist in any other position, except favorable, and a 40 percent rating is warranted where there is unfavorable ankylosis in any degree of palmar flexion, or with ulnar or radial deviation. A note following DC 5214 states that extremely unfavorable ankylosis will be rated as loss of use of hands under DC 5125. 38 C.F.R. § 4.71a, DC 5214. Normal range of motion of the wrist includes dorsiflexion (extension) from zero to 70 degrees, palmar flexion from zero to 80 degrees, ulnar deviation from zero to 45 degrees, and radial deviation from zero to 20 degrees. 38 C.F.R. § 4.71a, Plate I. To assess the Veteran’s service-connected left wrist disability, the Veteran underwent VA examinations for wrist conditions in December 2013 and March 2015. In the Veteran’s December 2013 examination, the examiner confirmed the Veteran’s diagnosis of status post-fracture left wrist with retained metallic screw and moderate degenerative changes. The Veteran is right-hand dominant; thus, his service-connected left wrist disability involves his minor extremity. The examiner recorded no localized tenderness or pain on palpation of joints and soft tissue of the left wrist. For range of motion testing, the VA examiner reported range of motion testing of 80 degrees or greater palmer flexion and 70 degrees or greater dorsiflexion, with no objective evidence of painful motion for flexion or extension. The Veteran performed repetitive use motion with 3 repetitions, and there was no additional loss of motion. The Veteran did not manifest ankylosis of the left wrist. Muscle strength testing was normal for wrist flexion and extension. The Veteran’s March 2015 examination report notes flare-ups of pain and weakness in the left wrist that do not significantly limit functional ability. The left wrist’s range of motion was found to be abnormal, with up to 60 degrees palmer flexion and up to 55 degrees dorsiflexion, but the examiner opined that this abnormal range of motion does not contribute to functional loss. No objective evidence of crepitus, ankylosis, or localized tenderness or pain on palpation was observed. The Veteran also performed repetitive use motion without additional loss of motion. Muscle strength testing for wrist flexion and extension was normal, and there was no localized tenderness or pain observed on palpation of joints and soft tissue of the left wrist. The examiner opined that the conditions of the Veteran’s left wrist do not have a functional impact on the Veteran’s ability to perform occupational tasks. Notes by the Veteran’s private physician indicate that the Veteran has tenderness at the trapeziometacarpal joint and severe degenerative changes at this joint, as demonstrated by x-ray imaging. The Veteran’s private treatment has included several injections with corticosteroids for pain in the trapeziometacarpal joint. The record also includes testimony from the Veteran and his wife describing increasing pain in the Veteran’s left wrist that has markedly worsened over the last several years, limiting the Veteran’s ability to perform routine daily activities, including those involved in his employment. The Veteran asserts that he suffers shooting pains and numbness. With respect to the applicable rating criteria, the Veteran is currently assigned a 10 percent disability rating under Diagnostic Code 5215. A 10 percent disability rating is the highest schedular rating available for DC 5215. A careful review of the record demonstrates that the Veteran experiences functional loss and limitation of motion due to his left wrist disability (indeed, it is this functional loss and complaints of pain and related symptoms that has led to the Veteran’s compensable rating, as his range of motion remains above a compensable level); however, ankylosis of the left wrist is not shown, nor do the Veteran’s symptoms approximate ankylosis. Diagnostic Code 5214 (wrist, ankylosis of), which is the only other diagnostic code which specifically references the wrist, is not appropriate for application in this case because there is no evidence of ankylosis in the record. As such, a higher schedular rating is not warranted. The loss of function in the Veteran’s left wrist evidenced by the record is addressed by the maximum possible schedular rating under DC 5215. The rating criteria reasonably describe the Veteran’s disability level and symptomatology, and they only provide for higher ratings for symptoms more severe than those currently manifested. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell, 25 Vet. App. at 37. For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. As the Veteran’s service-connected left wrist disability has not resulted in ankylosis, the criteria for a disability rating in excess of 10 percent have not been met. 2. Entitlement to a compensable disability rating for a scar on the left wrist. Scar disorders not on the head, face, or neck are rated under DC 7801 through 7805 of 38 C.F.R. § 4.118. To warrant a compensable rating, a scar would need to be deep or cause limited motion and affect an area or areas exceeding at least 6 square inches (39 square centimeters) (DC 7801); be superficial and affect an area or areas of 144 square inches (929 square centimeters) or greater (DC 7802); be superficial and unstable (DC 7803); be superficial and painful on demonstration (DC 7804); or cause some limitation of the function of the part affected (DC 7805). 38 C.F.R. § 4.118, DCs 7800-7805. In this case, the scarring on the Veteran’s wrist was evaluated in both the Veteran’s VA examinations in December 2013 and March 2015. The Veteran’s scar was measured in his March 2015 VA examination to be 4.5 centimeters long and 0.2 centimeters wide. Upon examination, there is no evidence that the Veteran’s wrist scarring is deep, that it causes any limitation of motion or function, that it affects an area exceeding at least 6 square inches (39 square centimeters), or that it is unstable. There also is no evidence that the scar itself was painful on demonstration, and there is no other lay or medical evidence of any painful wrist scarring. The Veteran has not made any claims regarding pain or other symptoms associated specifically with his scarring and separate from the degenerative disease related to his status post fracture, left wrist with metallic screw. Hence, a separate, compensable rating for left wrist scarring is not warranted. Evan Deichert Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Ahsan, Associate Counsel