Citation Nr: 21071106 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 10-41 575A DATE: November 29, 2021 ORDER Entitlement to an initial rating in excess of 10 percent disabling for right wrist disability is denied. REMANDED Entitlement to an initial compensable rating for left hand and thumb disability is remanded. Prior to November 12, 2019, entitlement to an initial compensable rating for left long and index finger disability is remanded. Effective November 12, 2019, entitlement to a rating in excess of 10 percent disabling for left long and index finger disability is remanded. Entitlement to an initial compensable rating for left ring finger disability with postoperative scar is remanded. FINDING OF FACT Throughout the period on appeal, the service-connected right wrist disability has not been manifested by ankylosis. CONCLUSION OF LAW The criteria for a disability rating in excess of 10 percent disabling for the right wrist disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5214, 5215. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1995 to November 2000. This matter is before the Board of Veterans' Appeals (Board) on appeal from June 2009 (left ring finger) and July 2014 (right wrist, left hand and thumb, left long and index fingers) rating decisions by a Department of Veterans Affairs Regional Office (RO). In March 2018, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. In July 2018, the Board remanded this case and instructed the Agency of Original Jurisdiction (AOJ) to obtain updated VA examinations and VA medical records. The Board notes that the requested VA examinations and updated VA medical records have been associated with the claims file. Accordingly, with regard to the issue decided below, after reviewing the actions of the AOJ, the Board finds there was substantial compliance with the requested development. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). During the pendency of the appeal, a June 2021 rating decision granted an increased 10 percent rating for left long and index fingers effective November 12, 2019. Additionally, as noted more fully in the Remand section below, other diagnostic codes may be relevant to rating this condition. Accordingly, these issues remain on appeal. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When rating musculoskeletal disabilities on the basis of limited motion of a joint, VA must consider functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered only in conjunction with diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1995). Right Wrist The Veteran filed a service connection claim for right wrist condition in May 2008. That claim was granted in a July 2014 rating decision which assigned a 10 percent evaluation effective May 14, 2008. The Veteran has appealed his initial rating. The evidence of record includes a September 2013 VA examination noting a diagnosis for healed right lunate fracture. The Veteran was right hand dominant. Range of motion (ROM) testing revealed palmar flexion to 45 degrees with painful motion beginning at 0 degrees, and dorsiflexion to 60 degrees with painful motion beginning at 0 degrees. ROM remained the same following repetitive use testing. Functional loss was found to cause less movement than normal and weakened movement. Pain was not found during the examination. Muscle strength testing revealed active movement against some resistance for wrist flexion and extension. The right wrist was not manifested by ankylosis or degenerative arthritis. A May 2016 VA medical record shows the Veteran complained of chronic worsening hand pain. He also reported constant numbness and pain to both hands to the point where he was unable to function. He further reported limited ROM. The physician noted an old right hand wrist fracture. See VA Medical Records Received August 2017. At a March 2018 Board hearing, the Veteran testified that his right wrist had worsened since his last VA examination. Specifically, he testified that his right wrist periodically would "go out" once per month during which it would swell up preventing him from effectively using it. In addition, he testified that he could not flatten his right wrist out or put any pressure on it. During a November 2019 VA examination, the Veteran reported flare-ups and functional loss including dropping things, problems turning doorknobs and screw drivers, and pain rated a 4 on a scale to 10. Cold weather reportedly increased stiffness and made his right wrist ache. In addition, he reported occasional swelling and a tearing sensation on the dorsum of the right wrist if he circumducted it. The examiner noted a diagnosis for chronic right wrist strain. ROM testing revealed palmar flexion to 45 degrees, dorsiflexion to 60 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. Pain was noted with palmar flexion and dorsiflexion that resulted in function loss, but ROM was not found to contribute to functional loss. Repetitive use testing did not result in further loss of ROM. The examiner did estimate that during flare-ups and following repeated use over time, that there was a greater than 50 percent likelihood of an additional 25 percent loss of ROM. Muscle strength testing was normal for flexion, and active movement against some resistance was found for extension. The right wrist was not manifested by muscle atrophy or ankylosis. The Veteran's right wrist has been rated pursuant to 38 C.F.R. § 4.124a, DC 5215, limitation of motion, wrist. That diagnostic code provides a maximum 10 percent rating for limitation of dorsiflexion of the major or minor wrist to less than 15 degrees, or limitation of palmar flexion in line with forearm. 38 C.F.R. § 4.71a, DC 5215. Diagnostic Code 5214 pertains to ankylosis of the wrist. Under this diagnostic code, favorable ankylosis in 20 degrees to 30 degrees dorsiflexion warrants a 30 percent rating for the major extremity. Ankylosis of the wrist in any other position, except favorable, warrants a 40 percent rating for the major extremity. Unfavorable ankylosis in any degree of palmar flexion or with ulnar or radial deviation warrants a 50 percent rating for the major extremity. Extremely unfavorable ankylosis is rated on the basis of a loss of use of the hands. 38 C.F.R. § 4.71a, DC 5214. Normal range of motion for the wrist is plantar flexion to 80 degrees, dorsiflexion to 70 degrees, ulnar deviation to 40 degrees, and radial deviation to 20 degrees. 38 C.F.R. § 4.71, Plate I. The record reflects that the Veteran is right-handed. As such, the service-connected right wrist disability affects his major extremity. 38 C.F.R. § 4.69. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent disabling for the service-connected right wrist disability. The Veteran is currently in receipt of a 10 percent rating for his right wrist disability. The Board notes that 10 percent is the maximum rating available on the basis of impaired motion of the wrist under DC 5215. In order to receive a higher rating under the rating criteria, the right wrist would need to be manifested by ankylosis; a condition not shown by the record. Accordingly, the Board finds that the Veteran is currently in receipt of the maximum schedular rating available under either DC 5214 or 5215. The Board has also considered assigning higher disability ratings pursuant to 38 C.F.R. §§ 4.40 and 4.45, and acknowledges the Veteran's reports of pain and flare-ups and functional loss. In this regard, his right wrist disability has been rated based on limitation of motion (i.e., functional loss) which takes pain into consideration. As such, the Board finds that the currently assigned disability rating takes into account functional limitations based on painful motion and there is no basis for the assignment of additional disability due to pain, weakness, fatigability, or incoordination. See 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Therefore, the Board finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for right wrist disability and the claim is denied. 38 U.S.C. § 5107(b), 38 C.F.R. § 4.3. REASONS FOR REMAND Left Hand and Fingers The service-connected left hand and finger conditions have been rated pursuant to 38 C.F.R. § 4.71a, DCs 5228 (left thumb), 5229 (left long and index fingers), and 5230 (left ring finger). Accordingly, the ratings pertain to the musculoskeletal system. Additionally, throughout the course of this appeal, the Veteran has been afforded multiple VA hand and finger examinations which have evaluated the musculoskeletal nature of these conditions. However, a September 2013 VA examination notes diagnoses for left ring finger trigger finger release and left hand reflex sympathetic dystrophy (RFD) type syndrome. Thereafter, a July 2014 rating decision granted service connection for RFD affecting the left hand and thumb, and left long and index fingers. During his November 2019 VA examination, the Veteran reported symptoms of intermittent left hand swelling and hypersensitivity in his left hand and arm. The examiner noted diagnoses for left ring finger trigger finger release and left hand RFD type syndrome. He last underwent a VA examination in May 2021. The examiner noted RFD diagnoses for left hand and left thumb, index, and long fingers. The examination report also appears to reflect diagnoses for RFD affecting the left ring and little finger, however, this is unclear. Functional loss was reported including an inability to close his finger to grasp items, make a fist, play guitar, type or rock climb. The Veteran reported swelling and sharp needle-like pain. RFD is a condition also known as complex regional pain syndrome (CRPS), type 1. See Dorland's Illustrated Medical Dictionary, 585 (32nd ed. 2012). The Board notes that CRPS is a neurological condition. According to the National Institute of Neurological Disorders and Stroke, Complex Regional Pain Syndrome Fact Sheet "[i]n more than 90 percent of cases, CRPS is triggered by nerve trauma or injury to the affected limb that damages the thinnest sensory and autonomic nerve fibers." See https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Complex-Regional-Pain-Syndrome-Fact-Sheet. The Board further notes that CRPS is most commonly rated based on the affected nerve group. However, a VA examination examining the left upper extremity nerve groups has not been obtained. Accordingly, the Board is unable to adjudicate these increased rating claims as there is insufficient competent medical evidence of record. See 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Charles v. Principi, 16 Vet. App. 370 (2002); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Therefore, an additional VA examination is needed in order to properly adjudicate these claims. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records not already associated with the file. 2. Then, schedule the Veteran for an examination by an appropriate examiner to evaluate the current symptoms and severity of his service-connected left hand/fingers reflex sympathetic dystrophy (RFD), also known as complex regional pain syndrome (CRPS). A thorough peripheral nerve examination of the left upper extremity should be conducted describing all associated symptomatology. In evaluating the severity of the service-connected disabilities, the examiner should specifically render an opinion with supporting rationale as to whether the service-connected left ring finger condition is manifested by RFD/CRPS, and an etiological opinion with supporting rationale noting any involvement concerning the left little finger. The examiner should review pertinent documents in the Veteran's claims file and this Remand in connection with the examination. All indicated studies should be completed, and all pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. (Continued on the next page) 3. Thereafter, the RO should readjudicate the claims on appeal. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Lamb, 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.