Citation Nr: 21000176 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 06-29 839 DATE: January 4, 2021 ORDER Entitlement to a rating in excess of 20 percent for degenerative disc disease, L5-S1, from May 22, 2004, to March 28, 2020, is denied. Entitlement to a rating in excess of 40 percent for degenerative disc disease, L5-S1, effective from March 29, 2020, is denied. Entitlement to an initial compensable rating of 20 percent, but not higher, for a left-hand disability from May 22, 2004, to April 22, 2015, is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to a rating of 20 percent, but not higher, for left hand median nerve paralysis, diagnosed as carpal tunnel syndrome, from April 23, 2015, to March 28, 2020, is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a rating of 40 percent, but not higher, for left hand median nerve paralysis, diagnosed as carpal tunnel syndrome, effective from March 29, 2020, is granted, subject to the law and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. Prior to March 29, 2020, the forward flexion of the thoracolumbar spine was not limited to 30 degrees or less. 2. Throughout the course of the appeal, the Veteran’s spine did not exhibit ankylosis. 3. The Veteran’s left hand is his minor hand. 4. The Veteran’s left hand, carpal tunnel syndrome has been manifested by no more than moderate incomplete paralysis of the minor median nerve prior to April 23, 2015. 5. The Veteran’s left hand, carpal tunnel syndrome has been manifested by no more than moderate incomplete paralysis of the minor median nerve from April 23, 2015 to March 29, 2020. 6. The Veteran’s left hand, carpal tunnel syndrome has been manifested by no more than severe incomplete paralysis of the minor median nerve since March 29, 2020. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for degenerative disc disease, L5-S1, effective from May 22, 2004 to March 29, 2020, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5242. 2. The criteria for a rating in excess of 40 percent for degenerative disc disease, L5-S1, effective from March 29, 2020, have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5242. 3. The criteria for a rating of 20 percent, but not higher, for a left-hand disability prior to April 23, 2015, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Codes 5214, 5215, 5237, 5307, and 8515. 4. The criteria for a rating in excess of 20 percent, but not higher, for left hand median nerve paralysis, diagnosed as carpal tunnel syndrome, from April 23, 2015, to March 29, 2020, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Codes 5214, 5215, 5237, 5307, and 8515. 5. The criteria for a rating of 40 percent, but not higher, for left hand median nerve paralysis diagnosed as carpal tunnel syndrome effective from March 29, 2020, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Codes 5214, 5215, 5237, 5307, and 8515. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1984 to January 1985, July 1991 to October 1991, and February 2003 to May 2004. This case comes before the Board of Veterans’ Appeals (Board) on appeal from March 2005 and October 2008 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In March 2010, January 2013, and March 2015, the Board remanded the issues to the Agency of Original Jurisdiction (AOJ) for additional development. In May 2015, the RO issued a rating decision that increased the Veterans’ left-hand disability to 10 percent disabling effective from April 23, 2015. The May 2015 rating decision, recharacterized the left-hand disability as left-hand median nerve paralysis diagnosed as carpal tunnel syndrome. The RO discontinued the noncompensable rating under Diagnostic Code 5307 and assigned a 10 percent under Diagnostic Code 8515, effective April 23, 2015. Since the Veteran is presumed to seek the maximum available benefits, this issue remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In June 2018, the Board denied entitlement to service connection for a respiratory disability, to include allergic rhinitis. In addition, the Board granted entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to November 30, 2009. Moreover, the Board remanded the Veteran’s claims for entitlement to service connection for a left leg disability because the Board found the Veteran’s April 2015 VA examination to be inadequate. The Board reached that conclusion because the examiner based their opinion on an inaccurate set of facts. Furthermore, the Board remanded the Veteran’s lumbar spine disability in order to provide the Veteran with an examination in accordance with the provisions set forth in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Lastly, the Board remanded the Veteran’s claim for an increased rating for his service-connected left-hand disability because the RO did not issue a supplemental statement of the case (SSOC) following the March 2015 Board remand. In February 2020, the case returned to the Board. The Board found the Veteran’s left leg disability examination inadequate and remanded the Veteran’s claim in order for the Veteran to be afforded an additional examination. The Board also remanded the Veteran’s claims for entitlement to increased ratings for a lumbar spine disability and a left-hand disability in order for the Veteran to attend additional examinations. In May 2020, the RO issued a rating decision that increased the rating for the Veteran’s degenerative disc disease, L5-S1, to 20 percent disabling effective from May 22, 2004. The RO also increased the rating for the Veteran’s degenerative disc disease to 40 percent disabling effective from March 29, 2020. In addition, the RO increased the Veteran’s rating for left hand median nerve paralysis diagnosed as carpal tunnel syndrome to 30 percent disabling effective from March 29, 2020. Lastly, the RO awarded service connection for left leg, status post tibia fracture residuals. Thus, the Veteran’s left leg disability is no longer before the Board. In February 2020, the Veteran attended a VA examination in order to evaluate the Veteran’s flareups in his lumbar spine. At the VA examination, the Veteran did not report that he experienced any flareups nor did he identify any lost range of motion that occurred during a flareup. Thus, the Board finds that the Regional Office substantially complied with the Board’s remand directive and an additional examination is not required to evaluate the Veteran’s lumbar spine flareups. The Board also notes that the RO awarded service connection for bilateral lower extremity radiculopathy. The Board further notes that the Veteran has not expressed his dissatisfaction with these ratings. Thus, the Board finds that the Veteran’s bilateral lower extremity radiculopathy is not properly before the Board at this time. Increased Rating The Veteran contends that his disabilities warrant increased ratings throughout the course of the appeal. A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in such cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that 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). Instead, in Mitchell, the Court explained that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, and less or more movement than is considered normal, weakened movement, excess fatigability, and pain on movement (with swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. In considering the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to a rating in excess of 20 percent for degenerative disc disease prior to March 29, 2020 The Board notes that the Veteran is challenging his initial rating. The Veteran’s disability during this period of the appeal was awarded a 20 percent rating according to Diagnostic Code 5243. Arthritis under Diagnostic Code 5003 is to be rated on limitation of motion of the affected part as degenerative arthritis. Under Diagnostic Code 5003, degenerative 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 or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 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. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made 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. The General Rating Formula for Diseases and Injuries of the Spine provides a 20 percent rating is warranted for forward flexion of the lumbar spine greater than 30 degrees but less than 60 degrees, or combined range of motion of the lumbar spine not greater than 120 degrees, or muscle spasm, guarding or localized tenderness resulting in abnormal gait or an abnormal spinal contour. A 40 percent rating is warranted for forward flexion of the lumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent, the maximum available, is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. These ratings are made 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. Id. Note (2) of the General Rating Formula provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, DC 5242. As to a current diagnosis, the Board notes that the Veteran’s disability has been diagnosed as degenerative disc disease of the lumbar spine. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in August 2008 and that at the examination, the Veteran’s wife reported that the Veteran’s back will go out sometimes and he will have to lay down. The Veteran reported flare ups. The Veteran stated that flares occur every 2 to 3 weeks and last for 3 to 7 days. The Veteran stated that flares are brought on from lifting and bending. The Veteran rated these flares as severe. The Veteran stated that these flare-ups are completely incapacitating. Upon examination, the examiner indicated that the Veteran exhibited flexion 0 to 45 degrees with pain at 0 to 45 degrees, passive motion exhibited pain from 0 to 55 degrees, extension 0 to 30 degrees with pain at 30, left lateral flexion 0 to 30 degrees without pain, right lateral flexion 0 to 40 degrees with pain at 30, left lateral rotation with pain at 30 degrees, right lateral rotation 0 to 15 degrees with pain 0 to 15 degrees. In February 2010, the Veteran attended a VA examination. The Veteran reported dull and aching pain in the mid and low back. The Veteran reported that he has sharp pain if he “bends down to pick up something” and he has stiffness in the morning. Upon examination, the examiner indicated that the Veteran exhibited flexion to 85 degrees with pain at the end. The Veteran exhibited extension to 20 degrees. The Veteran exhibited lateral flexion 30 degrees to the right and 35 degrees to the left. The Veteran exhibited rotation 20 degrees to the right and 35 degrees to the left. The record shows that the Veteran complained of pain upon repetitive movements. After repetitive movements, the Veteran exhibited flexion to 80 degrees, extension to 20 degrees, lateral flexion 22 degrees to the right and 20 degrees to the left, rotation 25 degrees to the right and 25 degrees to the left, rotation 25 degrees to the right and 25 to the left. The examiner indicated that the Veteran did not exhibit muscle spasms. In September 2010, the Veteran attended a VA examination. Upon examination, The Veteran exhibited flexion 0 to 50 degrees, extension 0 to 20 degrees, left lateral flexion 0 to 30 degrees, left lateral rotation 0 to 25 degrees, right lateral flexion 0 to 30 degrees, right lateral rotation 0 to 25 degrees. The examiner indicated that there was no objective evidence of pain on motion. The examiner indicated that there was evidence of pain after repetitive motion and the examiner was unable to test for limitations after repetitions because the Veteran reported severe pain. The examiner indicated that the Veteran did not have ankylosis or muscle spasms. The examiner indicated that the Veteran exhibited guarding. In April 2015, the Veteran attended a VA examination. The Veteran reported that he has chronic dull aching pain in his lower back which worsens with repetitive or prolonged use of the back. The examiner indicated that the Veteran reported no pattern of flares. The examiner indicated that the Veteran reported worsening pain with prolonged or repetitive use. Upon examination, the examiner indicated that the Veteran exhibited forward flexion 0 to 70 degrees, extension 0 to 25 degrees, right lateral flexion 0 to 30 degrees, left lateral flexion 0 to 30 degrees, right lateral rotation 0 to 20 degrees, and left lateral rotation 0 to 20 degrees. The examiner indicated that pain was noted on forward flexion, extension, right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation. The examiner reported that observed repetitive use was as follows: forward flexion 0 to 35 degrees, extension 0 to 15 degrees, right lateral flexion 0 to 25 degrees, left lateral flexion 0 to 25 degrees, right lateral rotation 0 to 20 degrees, left lateral rotation 0 to 20 degrees. The examiner indicated that the Veteran exhibited muscle spasm of the thoracolumbar spine that resulted in abnormal gait or abnormal spinal contour. Lastly, the examiner indicated that the Veteran did not have IVDS or ankylosis. In May 2019, the Veteran attended a VA examination. The Veteran reported that he was having a flare during the physical exam and stated that performing ROM would likely increase current pain level. The examiner indicated that testing was not conducted due to risk of injuring Veteran. The examiner indicated that the Veteran exhibited guarding and muscle spasm that resulted in abnormal gait or abnormal spine contour. The examiner indicated that the Veteran had IVDS, but his disability did not require bed rest prescribed by a physician. The Board has also reviewed the Veteran’s medical treatment records. The Board finds that the Veteran’s records do not show lost range of motion greater than what was reported at his VA examinations. In addition, the Veteran’s records do not show that the Veteran was prescribed bed rest by a physician. In sum, the Board finds that the Veteran’s disability has remained consistent during this period of the appeal and that an increased rating is not warranted. After a review of the record, the Board finds that the most probative evidence of record are the results of the Veteran’s VA examinations. These examinations did not show that the Veteran had forward flexion of the thoracolumbar spine of 30 degrees or less nor did these examinations show that the Veteran’s spine exhibited any signs of ankylosis. Moreover, the record did not reflect that the Veteran had incapacitating episodes that required physician prescribed bedrest. Furthermore, the Board has additionally considered the Veteran’s reports of pain on motion and his symptoms during a flareup; however, the Board does not find that the Veteran’s symptomatology, even when considering pain on motion, demonstrates that his disability results in lost thoracolumbar range of motion which warrants a rating in excess of 20 percent. Specifically, the Board notes that the repetitive testing that was conducted at the VA examinations did not show lost range of motion that met the criteria for an increased rating. In addition, the Veteran’s medical records do not show any reports that the Veteran experiences flareups that result in lost range of motion that meet the criteria for an increased rating. For the above stated reasons, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim for entitlement to a rating in excess of 20 percent for his lumbar spine disability prior to March 29,2020, must be denied. 2. Entitlement to a rating in excess of 40 percent for degenerative disc disease since March 29, 2020 The Board notes that the Veteran’s disability was awarded a 40 percent rating during this period of the appeal. As to a current diagnosis, the Board notes that the Veteran’s condition has been diagnosed as degenerative disc disease of the lumbar spine. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination in March 2020. The Veteran reported pain in his back and that he was not experiencing flareups. Upon examination, the examiner indicated that the Veteran exhibited forward flexion 0 to 15 degrees, extension 0 to 20 degrees, right lateral flexion 0 to 9 degrees, left lateral flexion 0 to 9 degrees, right lateral rotation 0 to 9 degrees, and left lateral rotation 0 to 9 degrees. The examiner indicated that pain was noted on examination, but it did not cause functional loss. The examiner indicated the Veteran exhibited pain with forward flexion, extension, right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation. The examiner indicated that the Veteran was able to perform repetitive testing with no loss of range of motion after three repetitions. The examiner indicated that the Veteran did not exhibit guarding, muscle spasm, or IVDS. The Board has also reviewed the Veteran’s medical treatment records during this period of the appeal. The Board finds that the Veteran’s records do not show evidence of ankylosis. In addition, the Veteran’s records do not show that the Veteran was prescribed bed rest by a physician. In sum, the Board finds that the Veterans’ disability has remained consistent during this period of the appeal and a rating increase is not warranted. The Board has considered a rating in excess of 40 percent; however, the record does not contain any evidence that the Veteran’s spine exhibits signs or symptoms of ankylosis. Moreover, the record does not show that the Veteran’s disability exhibited incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. The Board has also considered the Veteran’s reports of pain on movement; however, the Veteran’s pain did not result in the development of ankylosis. For the above stated reasons, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim for entitlement to a rating in excess of 40 percent for his lumbar spine disability since March 29, 2020, must be denied. 3. Entitlement to an initial compensable rating for a left-hand disability prior to April 23, 2015 The Board notes that the Veteran is challenging his initial rating. The record reflects that the Veteran is right-hand dominant. During this period of the appeal, the Veteran’s left-hand disability was awarded a noncompensable evaluation according to Diagnostic Code 5307. Diagnostic Code 5307 (injuries to muscle group VII) authorizes a non-compensable rating when the injury is slight; a 10 percent rating is assigned when the injury is moderate; and for the dominant extremity, a 30 percent rating for moderately severe and a 40 percent rating for severe injury, respectively. Id. For guidance on the meaning of the terms “moderate” or “severe”, the Board looks to 38 C.F.R. § 4.56. Under this regulation, muscle disabilities are evaluated as follows: (a) an open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal; (b) a through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged; and (c) for VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. Id. Muscle disability is considered slight if it was a simple wound of muscle without debridement or infection. The history of a slight muscle disability should include service department record of a superficial wound with brief treatment and return to duty, as well as healing with good functional results. There should be no cardinal signs or symptoms of muscle disability. The objective signs of slight disability include minimal scars; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. Id. Muscle disability is considered moderate if it was caused by a through-and-through or deep penetrating wound of short track from a single bullet, small shell, or shrapnel fragment, without the explosive effect of a high velocity missile, residuals of debridement, or prolonged infection. The history of a moderate muscle disability should include service department records or other evidence of in-service treatment for the wound as well as a record of consistent complaints of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. The objective signs of moderate disability include small or linear entrance and (if present) exit scars indicating a short track of the missile through muscle tissue; some loss of deep fascia or muscle substance; impairment of muscle tonus and loss of power; or a lowered threshold of fatigue when compared to the sound side. Id. Muscle disability is moderately severe if it results from a through-and-through or deep penetrating wound by a small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. The history of a moderately severe muscle injury should include service department records or other evidence showing hospitalization for a prolonged period for treatment of the wound; consistent complaints of the cardinal signs and symptoms of muscle disability as noted above; and, if present, evidence of inability to maintain work requirements. The objective evidence of a moderately severe muscle disability includes entrance and (if present) exit scars that indicate a track of the missile through one or more muscle groups; the loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side; and impairment of strength and endurance in comparison to the sound side. Id. Severe disability consists of through-and-through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. Furthermore, objective findings of a severe disability include the following: ragged, depressed, and adherent scars that indicate wide damage to the muscle groups in the missile track; palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in the wound area; muscles swell and harden abnormally in contraction; and tests of strength, endurance, or coordinated movements in comparison to the corresponding muscles of the uninjured side indicate severe impairment of function. Id. If present, the following are also signs of severe muscle disability: (1) x-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; (2) adhesion of a scar to one of the long bones, scapula, pelvic bones, sacrum, or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where the bone is normally protected by muscle; (3) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (4) visible or measurable atrophy; (5) adaptive contraction of an opposing group of muscles; (6) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (7) induration or atrophy of an entire muscle following simple piercing by a projectile. Id. The Board will also consider Diagnostic Codes 5214, 5215 and 8515 when evaluating the Veteran’s left hand disability. Diagnostic Code 5214 provides for a 30 percent disability evaluation when there is favorable ankylosis in 20 to 30 degrees dorsiflexion in the major wrist. A 40 percent disability evaluation is contemplated for ankylosis of the major wrist in any other position, except favorable. A maximum 50 percent rating is assigned for ankylosis of the major wrist when ankylosis is unfavorable, in any degree of palmar flexion, or with ulnar or radial deviation. 38 C.F.R. § 4.71a. A note to Diagnostic Code 5214 states that extremely unfavorable ankylosis will be rated as loss of use of hands under Diagnostic Code 5125. The term “unfavorable ankylosis” is not defined in the VA Schedule for Rating Disabilities. In such a case, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Normal range of motion for the wrist is 70 degrees of dorsiflexion (extension) and 80 degrees of palmar flexion. 38 C.F.R. § 4.71, Plate I. Normal ulnar deviation is 45 degrees, while normal radiation deviation is 20 degrees. Id. “Ankylosis” is defined as “immobility and consolidation of a joint due to disease, injury or surgical procedure.” See Colayong v. West, 12 Vet. App. 524, 528 (1999); Shipwash v. Brown, 8 Vet. App. 218, 221 (1995); see also Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Diagnostic Code 5215 provides for a maximum rating of 10 percent for limitation of motion of the wrist for either the dominant or non-dominant hand when dorsiflexion is less than 15 degrees or when palmer flexion is limited in line with the forearm. 38 C.F.R. § 4.71a. A 10 percent rating is the maximum rating available under Diagnostic Code 5215. Diagnostic Code 8515 provides ratings for both the “minor” and the “major” hand impacted. In this context “minor” and “major” refer to the dominant or nondominant side. Diagnostic Code 8515 addresses complete and incomplete paralysis of the median nerve. Under Diagnostic Code 8515, mild incomplete paralysis of the median nerve on the major side warrants a 10 percent rating. Moderate incomplete paralysis warrants a 20 percent rating for the minor hand. Severe incomplete paralysis of the minor hand warrants a 40 percent rating. Complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of thenar eminence, the thumb in the plane of the hand; pronation incomplete and effective, absence of flexion of the index finger and feeble flexion of the middle finger, that cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of the thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances warrants a 60 percent disability rating for the minor hand. See 38 C.F.R. § 4.124a, DC 8515. The term “incomplete paralysis” used in reference to evaluation of peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, 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, Diseases of the Peripheral Nerves. The words “slight,” “moderate” and “severe” as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “severe” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Neurological disorders are ordinarily to be rated in proportion to the impairment of motor, sensory, or mental function. In rating peripheral nerve injuries and their residuals, attention is given to the site and character of the injury, and the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. As to a current diagnosis, the Board notes that the Veteran’s disability has been diagnosed as left-hand carpal tunnel syndrome. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in August 2008, at which time the Veteran reported being right hand dominant. The Veteran stated that there is generalized numbness, weakness, and occasional pain in his hand. The Veteran stated that he has flareups every 2 to 3 weeks. The Veteran stated that the duration will last for a few hours and the Veteran stated that they were moderate in nature. Upon examination, the examiner indicated that the Veteran exhibited left hand weakness, numbness, and paresthesia. The examiner also found that the Veteran had no impaired strength or dexterity in hand. Lastly, the examiner found no signs of ankylosis in the hand. In February 2010, the Veteran attended a VA examination for this issue, at which time it was noted that the Veteran’s dominant hand was on the right. The Veteran reported that he has pain in the left forearm. The examiner indicated that the Veteran can make a fist without any gap and there is no restriction of movement of the hand joints. The examiner indicated that there is mild tenderness without induration or swelling of the lateral left forearm muscles. The examiner indicated that there is no tenderness, no changes of inflammation, and no swelling. The examiner indicated that flexion is 75 degrees, extension is 75 degrees, ulnar deviation is 46 degrees, radial deviation is 20 degrees. The examiner indicated that repetitive movements offered no complaints and the range of movement is unchanged following repetitive movements. Lastly, the examiner indicated that the Veteran’s sensory examination was normal. In September 2010, the Veteran attended a VA examination for this issue, and it was again noted that the Veteran’s dominant hand was on the right. The Veteran reported a history of left-hand numbness after a wreck in Iraq. The Veteran reported current hand numbness. The Veteran stated that it is intermittent with remissions. On examination, the examiner indicated that the Veteran reported limited motion, locking, and weakness. The Veteran reported flare-ups that occur every 2 to 3 weeks. The Veteran reported these flare-ups as severe. The examiner indicated that the Veteran exhibited no objective evidence of pain. The examiner indicated that the Veteran had normal range of motion. Lastly, the examiner noted that the Veteran’s EMG test results were normal. The Board has also reviewed the Veteran’s medical treatment records for this period of the appeal. The Board finds that the Veteran’s records do not show reports of pain or numbness that are worse than what was reported at the Veteran’s VA examinations. In addition, the Board finds that the Veteran’s medical records do not show reports of lost range of motion in the Veteran’s hand and wrist that were worse than what was reported at the Veteran’s VA examinations. In sum, the Board finds that the Veteran’s left-hand disability has remained consistent during this period of the appeal and that an increased rating is warranted. After a review of the record, the Board finds that the medical evidence of record demonstrates that Diagnostic Code 8515 is the most applicable Diagnostic Code to evaluate the Veteran’s claim. After weighing all of the evidence, both positive and negative, the Board finds that the pain and numbness in the Veteran’s left hand demonstrates that he exhibits moderate incomplete paralysis of the median nerve. The Board has also considered a rating in excess of 20 percent and a separate compensable rating; however, the medical evidence of record does not show that the Veteran exhibits moderately severe incomplete paralysis of the median nerve, complete paralysis of the median nerve, a moderately severe or a severe injury to muscle group VII, or limitation of motion in the wrist to include ankylosis. Under such circumstances, and granting the Veteran the benefit of any doubt in this matter, the Board finds that the criteria for a 20 percent rating, but not higher, is warranted for the Veteran’s left-hand carpal tunnel syndrome effective from May 22, 2004, to April 22, 2015. 4. Entitlement to a rating in excess of 10 percent for left hand median nerve paralysis, diagnosed as carpal tunnel syndrome, since April 23, 2015 During this period of the appeal, the Board notes that the Veteran’s disability was awarded a 10 percent rating according to Diagnostic Code 8515. As to a current diagnosis, the Board notes that the Veteran’s disability has been diagnosed as degenerative arthritis and carpal tunnel syndrome. The Board further notes that the April 2015 VA examiner stated that there is an orthopedic condition and a peripheral nerve condition associated with his left hand symptoms. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in April 2015 and that the Veteran reported that his dominant hand was on the right and that he feels intermittent numbness in his left hand. The Veteran reported no flareups. Upon examination, the examiner indicated that the Veteran had full range of motion in his left hand. The examiner indicated that the Veteran exhibited no pain during use of the hand. The examiner indicated that the Veteran was able to perform repetitive testing with no additional lost range of motion. The examiner indicated that the Veteran exhibits mild intermittent pain and moderate numbness. Lastly, the Board notes that the examiner indicated that the Veteran exhibited mild incomplete paralysis of the median nerve. The Board has also reviewed the Veteran’s medical treatment records for this period of the appeal. The Board finds that the Veteran’s records do not show reports of pain or numbness that are worse than what was reported at the Veteran’s VA examination. In addition, the Board finds that the Veteran’s medical records do not show any reports of lost range of motion in the Veteran’s hand and wrist that were worse than what was reported at the Veteran’s VA examination. In sum, the Board finds that the Veteran’s left-hand disability has remained consistent during this period of the appeal and that an increased rating is warranted. After a review of the record, the Board finds that the medical evidence of record demonstrates that Diagnostic Code 8515 is the most applicable Diagnostic Code to evaluate the Veteran’s claim. The Board acknowledges that the April 2015 VA examiner opined that the Veteran’s disability exhibited mild incomplete paralysis; however, after weighing all of the evidence, both positive and negative, the Board finds that the pain and numbness in the Veteran’s left hand demonstrates that he exhibits moderate incomplete paralysis of the median nerve. The Board has also considered a rating in excess of 20 percent and a separate compensable rating; however, the medical evidence of record does not show that the Veteran exhibits moderately severe incomplete paralysis of the median nerve, complete paralysis of the median nerve, a moderately severe or a severe injury to muscle group VII, or limitation of motion in the hand or wrist to include ankylosis. Under such circumstances, and granting the Veteran the benefit of any doubt in this matter, the Board finds that the criteria for a 20 percent rating, but not higher, is warranted for the Veteran’s left-hand carpal tunnel syndrome effective from April 23, 2015 to March 29, 2020. 5. Entitlement to a rating in excess of 30 percent for left hand median nerve paralysis diagnosed as carpal tunnel syndrome effective March 29, 2020 During this period of the appeal, the Board notes that the Veteran’s disability was awarded a 30 percent rating according to Diagnostic Code 8515. As to a current diagnosis, the Board notes that the Veteran’s disability has been diagnosed as carpal tunnel syndrome. Turning to the medical evidence at hand, the Board notes that the Veteran attended a VA examination for this issue in March 2020 and that the Veteran reported pain, numbness, and tingling in his hand. The Veteran reported no flareups. Upon examination, the examiner reported that the Veteran exhibited lost range of motion in his fingers and that he had pain upon movement. The examiner indicated that the Veteran did not have ankylosis in any of his fingers. The examiner indicated that the Veteran was able to perform repetitive testing with no additional lost range of motion. The examiner indicated that the Veteran exhibits severe constant pain, paresthesias and or dysesthesias, and numbness Lastly, the Board notes that the examiner indicated that the Veteran exhibited severe incomplete paralysis of the median nerve. The Board acknowledges that the March 2020 VA examiner indicated that the Veteran was left hand dominant. The overall medical evidence of record since August 2008 has otherwise established that he is right hand dominant, however, and there were no indications that the Veteran was ambidextrous. Thus, the Board will evaluate the Veteran’s left hand as being his minor hand and not his dominant hand. The Board has also reviewed the Veteran’s medical treatment records for this period of the appeal. The Board finds that the Veteran’s records do not show reports of pain or numbness that are worse than what was reported at the Veteran’s VA examination. In addition, the Board finds that the Veteran’s medical records do not show reports of lost range of motion in the Veteran’s hand that were worse than what was reported at the Veteran’s VA examination. In sum, the Board finds that the Veteran’s left-hand disability has remained consistent during this period of the appeal and that an increased rating is warranted. After a review of the record, the Board finds that the medical evidence of record demonstrates that Diagnostic Code 8515 is the most applicable Diagnostic Code to evaluate the Veteran’s claim. After weighing all of the evidence, both positive and negative, the Board finds that the pain, paresthesias, and numbness in the Veteran’s left hand demonstrates that he exhibits severe incomplete paralysis of the median nerve. The Board has also considered a rating in excess of 40 percent; however, the medical evidence of record does not show that the Veteran exhibits complete paralysis of the median nerve. The Board has also considered a separate compensable rating; however, the medical evidence of record does not show an injury to muscle group VII or ankylosis in the fingers or wrist. Under such circumstances and granting the Veteran the benefit of any doubt in this matter, the Board finds that the criteria for a 40 percent rating, but not higher, is warranted for the Veteran’s left-hand carpal tunnel syndrome effective from March 29, 2020. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Rescan, Associate 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.