Citation Nr: 20032991 Decision Date: 05/12/20 Archive Date: 05/12/20 DOCKET NO. 15-89 810A DATE: May 12, 2020 ORDER A 30 percent rating beginning March 7, 2014, but not greater and not prior to that date, for left carpal tunnel syndrome is granted. A rating in excess of 10 percent for right carpal tunnel syndrome is denied. FINDINGS OF FACT 1. Beginning March 7, 2014, the evidence shows moderate, but not severe, left carpal tunnel syndrome. 2. Prior to March 7, 2014, the left carpal tunnel syndrome presented with only mild impairment. 3. The weight of the evidence is against finding more than mild impairment from right carpal tunnel syndrome. CONCLUSIONS OF LAW 1. The criteria for a 30 percent rating beginning March 7, 2014, but not greater and not prior to that date, for left carpal tunnel syndrome have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code (DC) 8515. 2. The criteria for a rating in excess of 10 percent for right carpal tunnel syndrome have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8515. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Air Force from April 1997 to June 2000. In September 2018, the Board previously considered the Veteran’s appeal, granted the 10 percent ratings, and denied ratings in excess of 10 percent. The Veteran appealed to the Court of Appeals for Veterans Claims, which granted a joint motion for remand (JMR) to the Board in September 2019. Increased Rating 1. A rating in excess of 10 percent for left carpal tunnel syndrome 2. A rating in excess of 10 percent for right carpal tunnel syndrome The Veteran contends her bilateral carpal tunnel syndrome is worse than the ratings assigned. 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 percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, 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 reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. The Veteran’s carpal tunnel syndrome is rated under Diagnostic Code 8515, which addresses paralysis of the median nerve and provides for different ratings for involvement of the major (dominant) or minor hand. 38 C.F.R. § 4.124a. Mild incomplete paralysis of the median nerve warrants a 10 percent rating in both the major and minor hands. Moderate incomplete paralysis warrants a 30 percent rating for the major hand and a 20 percent rating for the minor hand. Severe incomplete paralysis warrants a 50 percent rating for the major hand and 40 percent rating for the minor hand. Complete paralysis warrants a 70 percent rating for the major hand and 60 percent for the minor hand. Complete paralysis is evidenced by the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscle 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; and pain with trophic disturbances. 38 C.F.R. § 4.124a, DC 8515. The evidence shows the Veteran is left hand dominant. During the August 2013 examination, the Veteran reported mild weakness in her wrists while using her hands, joint stiffness, and wrist pain as 4/10. She denied burning, numbness, tingling, weakness, and muscle pain. The examiner found normal strength, reflexes, and sensation and no clinical signs of carpal tunnel syndrome. In a statement dated March 7, 2014, the Veteran reported that her wrists had become steadily weaker and aching over the years and she randomly dropped things. During the March 2015 examination, the Veteran reported that she could not depend on her wrists, had weakness, and never knows when her wrists will be so weak that she cannot lift or grasp. She endorsed numbness, weakness when carrying items, difficulty grasping, dropping items, difficulty typing, and “seizures” with increased symptoms. The examiner noted that when “seizures” or spasms occurred, it would affect her lifting, typing, and grasping and would require her to stop working for five to ten minutes to rest and stretch. The examiner recorded no symptoms of constant pain but moderate intermittent pain in the right upper extremity and severe intermittent pain in the left extremity. The examiner noted mild right and severe left upper extremity paresthesias/dysesthesias and mild right and severe left upper extremity numbness. On testing, the Veteran had full strength, normal reflexes, and normal sensation. She had trophic changes, positive Phalen’s sign on the left and negative on the right, and negative Tinel’s sign on both sides. An April 2015 EMG report shows abnormal findings consistent with mild left median nerve entrapment mononeuropathy across the wrists (CTS). In a December 2015 statement, the Veteran reported random, unpredictable spasms that became aggravated when lifting objects and were much like seizures and starting to notice tingling and spasms occurring more frequently. Based on the record, the Board finds that a 10 percent rating is most appropriate for right carpal tunnel syndrome and for left carpal tunnel syndrome prior to March 7, 2014, but a 30 percent rating is warranted for left carpal tunnel syndrome beginning March 7, 2014. Indeed, comparison of the August 2013 examination to the March 2015 examination shows a general increase in left-sided symptoms from reports of mild weakness and pain to severe intermittent pain, paresthesias/ dysesthesias, and numbness. The examination shows objective evidence of impairment in the form of trophic changes and positive Phalen’s sign. March 7, 2014 is the first date from which worsening disability is factually ascertainable in the record and is the appropriate effective date for the staged rating. Regarding right carpal tunnel syndrome, the evidence is most consistent with mild impairment. As noted, the Veteran described her wrist weakness and pain as mild during the August 2013 examination, and the March 2015 examiner found she suffered from no constant pain, moderate intermittent pain, mild paresthesias/ dysesthesias, and mild numbness on the right side. Similarly, the April 2015 EMG report classified the carpal tunnel syndrome as mild. Objective testing during both examinations was normal, ruling out more severe functional impairment. The Board has considered the Veteran’s reports of impairment, including difficulty grasping, dropping items, and difficulty typing, but finds this evidence outweighed by the classification of symptoms as mild by the 2015 examiner and EMG report and lack of objective evidence of muscle weakness. The medical experts that completed the examination and EMG report have qualifying experience and training to best assess the severity of carpal tunnel syndrome. The Board is further persuaded that the condition was mild as VA treatment records are largely silent for complaints of right carpal tunnel syndrome. Thus, the criteria for a rating in excess of 10 percent for right carpal tunnel syndrome are not met. When considering left carpal tunnel syndrome prior to March 7, 2014, the evidence similarly shows mild impairment. The Veteran described mild weakness and pain during the August 2013 examination, and the examiner found normal strength, reflexes, and sensation with no objective signs or symptoms. VA treatment records from the date of claim through March 2014 do not show complaints or treatment for carpal tunnel syndrome. There is simply no evidence suggesting more than mild symptoms prior to the Veteran’s March 2014 report of increased symptoms and dropping items. A rating in excess of 10 percent for left carpal tunnel syndrome prior to March 7, 2014, is not warranted. Although the evidence can be resolved in the Veteran’s favor to find moderate impairment beginning March 7, 2014, the evidence does not show severe impairment. While the examination shows severe left-sided symptoms such as pain and numbness, testing did not reveal any weakened muscles, reduced reflexes, or reduced sensation, and the April 2015 EMG report classified the carpal tunnel syndrome as mild. The Board considered the Veteran’s reports of symptoms, such as difficulty grasping and dropping items, as well as trophic changes and positive Phalen’s sign in finding moderate disability. However, a severe disability picture is evidenced by more than sensory involvement. See 38 C.F.R. § 4.124a, DC 8515. The Board finds the examination results and EMG report highly probative that the Veteran’s symptom presentation is not analogous to severe impairment. The objective testing shows normal functioning. The weight of the evidence does not support a finding of severe impairment of the left upper extremity. (Continued on the next page)   The Board has considered the December 2003 examination, as directed by the JMR. Specifically, the examination report notes complaints of tingling and numbness and objective findings of median nerve involvement revealing neuritis with sensory dysfunction of tingling. Initially, the Board notes that his evidence was nearly 10 years prior to the rating period on appeal. As such, this evidence holds extremely limited probative value as to the nature of the Veteran’s disability during the period on appeal, which begins with the Veteran’s informal claim for increase on August 29, 2012. Next, although the term “tingling” is not used, the subsequent VA examinations considered paresthesias/dysesthesias – pins and needles or burning sensation. Moreover, service treatment records and the Veteran’s own statements indicate that she experienced worse carpal tunnel symptoms when she was pregnant. The evidence shows her daughter was born on August [REDACTED], 2003. Therefore, it is reasonable to find that the December 2003 examination, two months after giving birth, would show increased symptoms that would have returned to a lower baseline by the August 2013 examination. For the foregoing reasons, the Board finds the lay statements and examinations that took place contemporaneously with the appeal period are significantly more probative than the December 2003 examination. In summary, the evidence is at least in equipoise for finding moderate impairment in the left upper extremity beginning March 7, 2014, but the weight of the evidence is against finding more than mild impairment in the right upper extremity and left upper extremity prior to March 7, 2014, and more than moderate impairment in the left upper extremity thereafter. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.P. Armstrong, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.