Citation Nr: 20052479 Decision Date: 08/06/20 Archive Date: 08/06/20 DOCKET NO. 15-21 512 DATE: August 6, 2020 ORDER Entitlement to an initial disability rating in excess of 10 percent for right wrist ligament tear status post open repair and arthroscopic debridement with residual chronic wrist arthrofibrosis is denied. An initial compensable disability evaluation for hypertension is denied. FINDINGS OF FACT 1. The Veteran's service-connected right wrist disability is manifested by complaints of decreased strength and pain, with objective evidence of limitation of motion; there has been no demonstration of ankylosis. 2. The Veteran has been shown to require the use of continuous blood pressure medication throughout the appeal period; he does not have diastolic pressure which is predominantly 100 or more or systolic pressure predominantly 160 or more. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 10 percent for right wrist ligament tear status post open repair and arthroscopic debridement with residual chronic wrist arthrofibrosis have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.10, 4.40, 4,.45, 4.59, 4.71a, Diagnostic Codes 5214-5215 (2019). 2. The criteria for a compensable rating for hypertension have not been met throughout the appeal period. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7101 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, served on active duty from September 1985 to January 1992 and from November 2001 to June 2004. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision of the Department of Veterans Affairs (VA)Regional Office (RO). This matter was most recently before the Board in December 2018, at which time it was remanded for further development. The requested development has been completed and the matter is now ready for appellate review. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2019). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Right Wrist Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance. Weakness is as important as limitation of motion, and a part which becomes disabled on use must be regarded as seriously disabled. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is to be considered in evaluating the degree of disability, but a little-used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, the condition of the skin, absence of normal callosity, or the like. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. § 4.45 contemplate inquiry into whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as at least minimally compensable. See also DeLuca v. Brown, 8 Vet. App. 202 (1995) (indicates that pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain may be the basis for a rating for a disability rated based on limitation of motion, regardless of whether the limitation of motion specified in the Diagnostic Code criteria is shown). In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must provide opinions regarding flare-ups based upon estimates derived from information procured from relevant sources, including lay statements, when a flare-up is not observable at the time of examination. The evidence of record, to include VA examinations, is sufficient for rating purposes. Disabilities of the wrist are rated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5215, relating to limitation of motion, and Diagnostic Code 5214, relating to ankylosis. Pursuant to Diagnostic Code 5215, 10 percent disability rating is warranted if palmar flexion is limited in line with the forearm or if dorsiflexion is less than 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5215. This is the maximum schedular rating for limitation of motion of the wrist under this diagnostic code. A higher disability rating is warranted if there is evidence of ankylosis. 38 C.F.R. § 4.71a, Diagnostic Code 5214 (2019). In conjunction with his claim, the Veteran was afforded a VA examination in June 2013. The Veteran reported having difficulty with writing, grasping, gripping, and lifting. Ranges of motion were as follows: Right wrist flexion was 0-60 degrees. At 60 degrees, the Veteran complained of increased pain. Extension was 0-60 degrees. At 60 degrees, the Veteran complained of increased pain. After repetitive use times three, there was change in range of motion. The Veteran was noted to have less movement than normal; weakened movement; and pain on movement. Muscle strength was 5/5 for flexion and extension. The examiner specifically indicated that the Veteran did not have ankylosis. The Veteran reported having tenderness and stiffness. It was indicated that the Veteran’s wrist disability did not impact his ability to work. Pain, weakness, fatigability, or incoordination did not cause significant limitation during flare-ups. At the time of a January 2016 VA examination, ranges of motion were as follows: Right wrist flexion was 0-60 degrees. At 60 degrees, the Veteran complained of increased pain. Extension was 0-50 degrees. At 50 degrees, the Veteran complained of increased pain. Ulnar deviation was 0-15 degrees and radial deviation was from 0 to 10 degrees. Pain was noted on examination but did not result in functional loss. There was pain with weightbearing. There was also evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. Crepitus was also present. After repetitive use times three, there was no change in range of motion. Muscle strength was 5/5 for flexion and extension. The examiner specifically indicated that the Veteran did not have ankylosis. The Veteran occasionally used a brace when he had severe pain. The Veteran reported having difficulty typing or using the computer. He worked as a security guard and carried a firearm. Sometimes, during training, he had pain. At the time of an October 2019 VA examination, the Veteran reported having chronic pain and difficulty with use of wrist/hand. He worked security and had trouble with opening doors and writing reports due to wrist pain. At home, he had difficulty with cooking and cleaning. At times, he had difficulty dressing due to wrist pain. He noted that the other day he was trying to mash potatoes and could not do it due to wrist pain. When he tried to mop, he had to put the mop under his left arm and not use the right wrist. He would wake up if he hit his wrist while sleeping. He tried to wear a sweatshirt with a front pouch pocket to keep his wrist in like a sling. The Veteran noted increased pain with flares. Right wrist flexion was 0-20 degrees. At 20 degrees, the Veteran complained of increased pain. Extension was 0-20 degrees. At 20 degrees, the Veteran complained of increased pain. Ulnar deviation was 0-10 degrees, and radial deviation was from 0 to 5 degrees. Pain was noted to cause functional loss. There was pain with weightbearing. There was evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. It was severely tender. The Veteran could not perform repetitive motion testing due to pain. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. Pain, weakness, fatigability or incoordination also did not significantly limit functional ability with flare-ups. Muscle strength was 3/5 for flexion and extension. The examiner specifically indicated that there was no ankylosis. As it relates to limitation of motion, applying the range of motion measurements to the diagnostic criteria outlined above, the evidence demonstrates the Veteran is not entitled to an evaluation in excess of 10 percent for his right wrist disability. 38 C.F.R. § 4.71a, Diagnostic Code 5215. As noted above, the Veteran is already receiving the maximum rating available under Diagnostic Code 5215. The Veteran could receive an increased evaluation if favorable or unfavorable ankylosis of the wrist was found. However, as discussed, there is no objective evidence of ankylosis of the wrist. Therefore, Diagnostic Code 5214 is not relevant to the claim. While the Board is sympathetic to the Veteran's reports of pain, objective testing did not reveal that any pain on use or during flare-ups, abnormal movement, fatigability, incoordination, or any other such factors resulting in the right wrist being limited in motion to the extent required for a 20 percent rating for limitation of motion for the right wrist. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). Hypertension With regard to hypertension, the rating schedule provides a 10 percent evaluation when diastolic pressure is predominantly 100 or more, or when systolic pressure is predominantly 160 or more, or for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted when diastolic pressure is predominantly 110 or more, or; systolic pressure is predominantly 200 or more. A 40 percent evaluation requires diastolic pressure of predominantly 120 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. Diagnostic Code 7101 contemplates the ameliorative effect of medication, the Board need not consider the severity of the Veteran's blood pressure when not taking his prescribed continuous medication. See McCarroll v. McDonald, 28 Vet. App. 267, 271-73 (2016) (holding that Jones v. Shinseki, 26 Vet. App. 56, 63 (2012), does not apply to Diagnostic Code 7101). The Veteran maintains that the symptomatology associated with his hypertension warrants an increased evaluation. A review of the record demonstrates that the Veteran has been prescribed medication for his hypertension throughout the appeal period. Treatment records associated with the file reveal continuous use of blood pressure medication throughout this time. At the time of a July 2013 VA examination, the Veteran was noted to be taking lisinopril, HCTZ, nifedipine, and aspirin. The Veteran was noted to have had blood pressure readings of 142/71 in October 2011, 144/75 in January 2012, and 173/85 in July 2013. The Veteran stated that his average blood pressure reading at home was 127-133/80. The examiner indicated that the Veteran did not have a history of diastolic blood pressure elevation of 100 or more. In an August 2014 letter, the Veteran’s private physician indicated that the Veteran was on medication for hypertension and that if he did not take antihypertensive medication, it was likely that his blood pressure would rise, possibly to dangerous levels. At the time of a March 2015 VA examination, the Veteran was again noted to be on three blood pressure medications. Blood pressure readings were 138/83, 140/82, and 144/94. The average blood pressure reading was 140/86. At the time of a December 2015 VA examination, the Veteran was again noted to be taking three anti-hypertensive medications with no complications or hospitalizations. Blood pressure readings were recorded as 136/66, 141/65, and 142/67. There were no other complications noted. At the time of the Veteran’s October 2019 VA examination, he was again noted to be on nifedipine, lisinopril, and hctz for his hypertension. Blood pressure readings of 130/74 in February 2019 and 151/69 and 148/67 at the time of the October 2019 examination were reported. There were no other complications from the hypertension. After considering the totality of the evidence, the Board finds an increased (compensable) disability is not warranted. The Veteran has continuously been on blood pressure medication throughout the appeal period. He does not however, have a history of diastolic pressure 100 or more, or systolic pressure predominantly 160 or more. The preponderance of the evidence is against the claim for a higher initial rating. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. S. Kelly, 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.