Citation Nr: 21062022 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 17-42 597 DATE: October 6, 2021 ORDER Service connection for an acquired psychiatric disorder to include, posttraumatic stress disorder (PTSD), and other specified trauma or stressor related disorder is granted. An initial rating more than 10 percent for left wrist sprain is denied. An initial rating more than 10 percent for right wrist sprain is denied. REMANDED The issue of an initial increased rating for reduced range of motion on extension of the left knee due to Osgood-Schlatter disease and arthritis is remanded. The issue of an initial increased rating for reduced range of motion on extension of the right knee due to Osgood-Schlatter disease and arthritis is remanded. The issue of a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's acquired psychiatric disorder is proximately due to his service-connected disabilities. 2. Throughout the period on appeal, the Veteran's left wrist disability is manifested by pain and limited motion but is not manifested by ankylosis. 3. Throughout the period on appeal, the Veteran's right wrist disability is manifested by pain and limited motion but is not manifested by ankylosis. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for an initial rating more than 10 percent for left wrist sprain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.21, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215. 3. The criteria for an initial rating more than 10 percent for right wrist sprain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.21, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from February 1984 to October 1988. These matters are before the Board of Veterans' Appeals (Board) on appeal from an October 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In June 2019, the Board remanded this appeal to obtain current medical treatment records and new VA examinations. There has been substantial compliance with previous remand directives regarding the claims of service connection for PTSD and increased ratings for the bilateral wrist. Stegall v. West, 11 Vet. App. 268 (1998). The record reflects that the Veteran's service-connected disabilities may have prevented him from working during the appeal period. Because a TDIU rating is inherently part and parcel to any claim for an increased rating where unemployability has been raised, it has been added as an issue. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Service Connection for an Acquired Psychiatric Disorder The Veteran's claim has been recharacterized as one for an acquired psychiatric disorder, including any disorder that may be reasonably encompassed by the Veteran's description of the claim, the Veteran's symptoms, and other information of the record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. A January 2020 PTSD VA examination report notes the Veteran's symptoms did not meet the criteria under the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: (DSM-V) for a diagnosis of PTSD. However, in a June 2017 VA treatment record, the examiner noted the Veteran had a diagnosis of PTSD based on DSM-V criteria. Additionally, VA treatment records continue to note the Veteran had a diagnosis of PTSD. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran has a current diagnosis of PTSD based on DSM-V criteria. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds the Veteran has a current diagnosis of PTSD. VA mental disorder examinations and treatment records show the Veteran's mental disorders are related to his service-connected knee and wrist disabilities. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for an acquired psychiatric disorder to include PTSD and other specified trauma or stressor related disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating for Bilateral Wrist Sprain Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, considering any part of the musculoskeletal system that becomes painful on use. The provisions regarding the avoidance of pyramiding, see 38 C.F.R. § 4.14, do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. However, those provisions should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable diagnostic code. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107. Diagnostic Code 5215 provides that limitation of motion of the major and minor wrist with palmar flexion limited in line with the forearm warrants a 10 percent disability rating. Alternatively, a 10 percent rating may be assigned for limitation of motion of dorsiflexion of the wrist less than 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5215. Higher ratings are warranted only where there is ankylosis of the wrist. Diagnostic Code 5214. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. As the Veteran is right-handed, the major wrist disability ratings are applicable to that side. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of an initial increased more than 10 percent for bilateral wrist disabilities. The Board notes that a 10 percent evaluation is the maximum available compensation available under Diagnostic Code 5215. An August 2016 VA examination report noted on initial range of motion testing that the Veteran's palmar flexion of both the left and right wrist was to 60 degrees and the dorsiflexion was to 60 degrees. Pain was noted to make gripping strength difficult. There was no ankylosis of the either wrist or any other pertinent physical findings. An April 2017 VA examination report noted on initial range of motion testing the Veteran's palmar flexion of both the left and right wrist was to 60 degrees and the dorsiflexion was to 60 degrees. Pain was noted to make gripping strength difficult. There was no ankylosis of the either wrist. The examiner also noted the Veteran had possible symptoms of carpal tunnel syndrome. A December 2018 VA examination report noted the Veteran's reports of bilateral wrist pain and swelling intermittently. He had an electromyography (EMG) test performed that yielded negative findings. The Veteran's palmar flexion in the left wrist was to 20 degrees and the dorsiflexion was to 15 degrees. The Veteran's palmar flexion in the right wrist was to 40 degrees and the dorsiflexion was to 30 degrees. There was no ankylosis of the either wrist. A January 2020 VA examination report noted the Veteran suffered from pain, stiffness, and decreased range of motion in both wrists. Palmar flexion in the right wrist was to 10 degrees and the dorsiflexion was to 65 degrees. Palmar flexion in the left wrist was to 5 degrees and the dorsiflexion was to 45 degrees. There was no ankylosis of either wrist. As the evidence does not show that the right or left wrist disabilities are ankylosed, the Veteran may not receive a higher rating under Diagnostic Code 5214. As noted above, none of the above referenced VA examination reports reflect ankylosis in either wrist. In sum, the preponderance of the evidence is against initial evaluations in excess of 10 percent for right and left wrist disabilities. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application, and the Veteran's claims are denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. REASONS FOR REMAND 1. The issue of an initial increased rating for reduced range of motion on extension of the left and right knee is remanded. 2. TDIU is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE ADJUDICATOR: There has not been substantial compliance with the Board's previous remand directives regarding the issues of increased ratings for service-connected left and right knees. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). In the June 2019 Board remand, the examiner was instructed to assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss, using lay observations specifically elicited from the Veteran. Review of the subsequent January 2020 VA examination report reveals this was not accomplished. The examiner noted that pain and fatigue significantly limited functional ability with repeated use and flare-ups but opined that there was no further range of motion loss anticipated during these scenarios, only increased symptoms of pain and fatigability and therefore, no range of motion estimate was warranted. Regarding TDIU, the Veteran's statements have raised the issue of entitlement. This issue must be remanded as it is inextricably intertwined with the claims for increased ratings. Also, additional development should take place with regard to this claim. The Veteran must be provided a VA Form 21-8940 (for TDIU) and requested to complete and provide it to VA. The remand directives follow. 2. Ask the Veteran to complete a VA Form 21-8940 with regard to the inferred claim for a TDIU. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left and right knee disabilities. The examiner must provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner must provide an estimate, if possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. After completing the requested actions, and any additional actions deemed warranted, readjudicate the claims on appeal, including the inextricably intertwined claim of TDIU. If the benefits sought on appeal remain denied, the Veteran must be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. K.A. KENNERLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. McDuffie, 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.