Citation Nr: 21073606 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 17-48 072 DATE: December 9, 2021 ORDER Entitlement to an initial rating in excess of 30 percent for right ulnar nerve paralysis/forearm strain is denied. Entitlement to a 40 percent rating, but no higher, for left wrist median/ulnar neuropathy is granted from October 5, 2010. A separate 10 percent rating for a left wrist scar is granted from October 5, 2010. Revision of the January 2019 rating decision, which reduced the disability rating of the Veteran's right wrist disability from 10 percent to noncompensable from April 1, 2019 to August 1, 2019, on the basis of clear and unmistakable error (CUE), is warranted. Entitlement to an initial rating in excess of 10 percent for a right wrist disability is denied. A total disability evaluation based on individual employability due to a service-connected disability (TDIU) is denied. REMANDED Entitlement to service connection for a disorder manifested by left hand cold sensitivity, numbness, and circulatory problems as secondary to service-connected left wrist median/ulnar neuropathy is remanded. FINDINGS OF FACT 1. The Veteran is right-arm dominant. 2. From October 5, 2010, the Veteran's right ulnar nerve paralysis/forearm strain is manifested by no more than moderate incomplete paralysis of the major extremity. 3. From October 5, 2010, the Veteran's left median/ulnar nerve neuropathy has been manifested by no more than severe incomplete paralysis of the minor extremity. 4. From October 5, 2010, the Veteran has had a painful left wrist scar. 5. A January 2019 rating decision reduced the Veteran's disability rating for a right wrist disability from 10 percent to noncompensable, effective April 1, 2019. As the Veteran did not timely appeal the effective date of that award, and new and material evidence was not received within the one-year appeal period, the January 2019 rating decision is final. 6. The clear and unmistakable errors of fact and law committed by the RO in the January 2019 rating decision, compels the conclusion, to which reasonable minds could not differ, and that the result would have been manifestly different had the error not been made. 7. The Veteran has not displayed ankylosis of the right wrist at any point during the appeal period. 8. The evidence of record indicates the Veteran has remained employed in a substantially gainful occupation throughout the appeal period. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent for right ulnar nerve paralysis/forearm strain are not met. 38 U.S.C. §§ 1155, 5107 ; 38 C.F.R. §§ 3.102; 4.3; 4.7, 4.124a, Diagnostic Code (DC) 8516. 2. The criteria for a 40 percent rating, but no higher, for left median/ulnar nerve are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.124a, DC 8515. 3. The criteria for a separate 10 percent rating, but no higher, for a painful left wrist scar are met from October 5, 2010. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, DC 7804. 4. The January 2019 decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 5. The criteria for revising or reversing the January 2019 rating decision that reduced the Veteran's right wrist disability from 10 percent disabling to noncompensable from April 1, 2019 to August 1, 2019, on the basis of CUE are met. 38 U.S.C. § 5109A(b); 38 C.F.R. §§ 3.105(a)(1), 4.71, DC 5215. 6. The criteria for an initial rating in excess of 10 percent for a right wrist disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5215. 7. The criteria for entitlement to a TDIU are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from July 1980 to July 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in March 2020. In May 2021, the Veteran waived the right to have the agency of original jurisdiction (AOJ) review additional evidence received at the Board following the August 2019 Supplemental Statement of the Case (SSOC). 38 C.F.R. § 20.1304(c). The Board acknowledges that rating reduction claims are separate from increased rating claims. Dofflemeyer v. Derwinski, 2 Vet. App. 277, 279-80 (1992). However, in this case, the rating reduction resulted from the Veteran's claim for an initial increased rating. Therefore, both the increased rating claim and the propriety of the rating reduction are on appeal. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 ; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 ; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 1. An initial rating in excess of 30 percent for the Veteran's right ulnar nerve paralysis/forearm strain is denied. 2. A 40 percent rating, but no higher, for left wrist median/ulnar neuropathy is granted from October 5, 2010. The Veteran's right ulnar nerve paralysis/forearm strain is currently rated as 30 percent disabling under DC 8516. The appeal period is from October 5, 2010, the date of award of service connection for his right ulnar nerve paralysis. The Veteran's left wrist median/ulnar neuropathy is currently rated as 20 percent disabling under DC 8515. The appeal period begins on October 5, 2010, the date VA received the Veteran's claim for an increased rating, plus the one-year "look back" period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). Diseases of the peripheral nerves provides ratings for both the "minor" and the "major" wrist. In this context "minor" and "major" refer to the dominant or nondominant side. Here, the Veteran's major hand (dominant) is the right, and the minor hand (nondominant) is the left. There are several potentially applicable diagnostic codes for peripheral neuropathy. Diagnostic Code 8510 applies to the upper radicular group, Diagnostic Code 8511 to the middle radicular group, and Diagnostic Code 8512 to the lower radicular group. Diagnostic Code 8513 applies to complete or incomplete paralysis of all radicular groups. 38 C.F.R. § 4.124a. Diagnostic Codes 8514-8519 apply to complete or incomplete paralysis of the specific nerves: musculospiral (radial) nerve (Diagnostic Code 8514), median nerve (Diagnostic Code 8515), ulnar nerve (Diagnostic Code 8516), musculocutaneous nerve (Diagnostic Code 8517), circumflex nerve (Diagnostic Code 8518), and long thoracic nerve (Diagnostic Code 8519). As relevant, under DC 8512, mild incomplete paralysis of the lower radicular group is rated as 20 percent disabling on the major side and 20 percent on the minor side; moderate incomplete paralysis is rated 40 percent disabling on the major side and 30 percent on the minor side; and severe incomplete paralysis is rated 50 percent disabling on the major side and 40 percent on the minor side. Complete paralysis of the lower radicular group with all intrinsic muscles of hand, and some or all of flexors of wrist and fingers, paralyzed (substantial loss of use of hand) is rated 70 percent disabling on the major side and 60 percent on the minor side. 38 C.F.R. § 4.124a, DC 8512. Under DC 8514, a 20 percent rating for mild incomplete paralysis of the radial nerve for both major and minor side. Moderate incomplete paralysis warrants a 30 percent rating for the major side and 20 percent rating for the minor side. Severe incomplete paralysis warrants a 50 percent rating for the major side and 40 percent rating for the minor side. Complete paralysis of the musculospiral nerve, with a drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of the wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity, is rated 70 percent disabling for the major side and 60 percent disabling for the minor side. 38 C.F.R. § 4.124a, DC 8514. Under DC 8515, moderate incomplete paralysis warrants a 30 percent rating for the major wrist, and a 20 percent rating for the minor wrist. Severe incomplete paralysis warrants a 50 percent rating for the major wrist, and a 40 percent rating for the minor wrist. 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 70 percent disability rating for the major wrist and a 60 percent rating for the minor wrist. 38 C.F.R. § 4.124a, DC 8515. Under DC 8516, a 10 percent rating is assigned for mild incomplete paralysis of the ulnar nerve of the major and minor hand. A 30 percent rating is assigned for moderate incomplete paralysis of the ulnar nerve of the major hand and 20 percent for the minor hand. A 40 percent rating is assigned for severe incomplete paralysis of the ulnar nerve of the major hand and a 30 percent rating is assigned for the minor hand. A 60 percent rating is assigned for complete paralysis of the ulnar nerve of the major hand and a 50 percent rating is assigned for "griffin claw" deformity, due to flexor contraction of the ring and little fingers, very marked atrophy in dorsal interspace and thenar and hypothenar eminences; loss of extension of the ring and little fingers; flexion of wrist weakened. See 38 C.F.R. § 4.124a, DC 8516. Under DC 8519, a noncompensable rating is warranted for mild incomplete paralysis affecting either the major or minor extremity of the long thoracic nerve. A 10 percent rating is warranted for moderate incomplete paralysis affecting either the major or minor extremity. A 20 percent rating is warranted for severe incomplete paralysis affecting either the major or minor extremity. The maximum rating of 30 percent is warranted for complete paralysis affecting the major extremity; an inability to raise the arm above shoulder level, with a winged scapula deformity. 38 C.F.R. § 4.124a , DC 8519. Where, as is the case here, there are combined nerve injuries, the rating is assigned based on the major involvement, or if sufficient in extent, consideration is to be given to radicular group ratings. 38 C.F.R. § 4.124a. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, a disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a, Note at Diseases of the Peripheral Nerves. Words such as "mild," "moderate," and "severe" are not defined in the Rating Schedule. 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. Although prior to the appeal period, a February 2008 VA treatment record noted mild atrophy of the left thenar area and an inability to pinch the thumb and index finger in a circle. An April 2011 VA treatment record indicates that the Veteran suffered a left index finger injury in April 2011 when his finger was caught between a cable while winching an all-terrain vehicle (ATV) onto a trailer. The Veteran was afforded a VA peripheral nerves examination in August 2011. The Veteran reported tingling in the right hand that becomes "stop me in my tracks" pain and right finger numbness in the morning. The examiner diagnosed a right forearm strain and right ulnar nerve paralysis (cutaneous branch). The examination revealed symptoms of severe right upper extremity intermittent pain, paresthesias and/or dysesthesias, and numbness. The examination revealed a normal left upper extremity. Muscle strength and deep tendon reflex examinations were normal bilaterally. Sensory testing was absent in the right hand and fingers (cutaneous ulnar nerve branch) but was otherwise normal. No muscle atrophy or trophic changes were indicated. The examiner endorsed moderate incomplete paralysis of the right ulnar nerve. The median nerve was normal bilaterally. The examiner noted no assistive devices and stated his ability to work was impacted due to his limitations. The Board notes that while the August 26, 2011 VA examination noted completely normal findings with respect to the left upper extremity, a contemporaneous August 8, 2011 VA treatment record notes "progressively decreased strength and dexterity in the left hand," and that his left "hand and forearm are globally smaller than his right," which was attributed to atrophy and/or a tumor on his median and ulnar nerves. Critically, the examiner noted that "[h]e has and can anticipate progressive growth and progressive functional decline." The Board finds, that when considering this contemporaneous record showing much more severe symptomatology with regard to the left sided neuropathy than was demonstrated on VA examination, the August 2011 VA examination is of no probative value and will not be used to rate the Veteran's left wrist neurological disability. Indeed, given the lack of any left side peripheral nerve diagnosis or review of the above-noted VA treatment record, the Board is not convinced the examiner was even performing any sort of physical examination on the left side at that time. A November 2012 VA treatment record notes normal sensation over the right median, ulnar, and radial nerves with the ability to open and close hand with no abnormalities. The treatment record also noted decreased muscle mass in the left upper arm and forearm, thenar and hypothenar muscle wasting, and left index finger slightly flexed position at proximal interphalangeal joints when digits were extended. A June 2013 EMG revealed moderate right median neuropathy at the wrist (carpal tunnel syndrome) and polyneuropathy or cervical radiculopathy in the right upper extremity. The Veteran underwent an additional VA examination in April 2014. The examiner noted radicular symptoms of moderate right and left upper extremity constant pain, moderate right upper extremity paresthesias and/or dysesthesias, and severe right and left upper extremity numbness. Muscle strength testing was reduced (4/5) in his left elbow flexion, elbow extension, wrist extension, and grip, but otherwise normal. Reflex testing was hypoactive in left bicep, left tricep, left brachioradialis, and left and right knee, but was otherwise normal. Sensory examination was normal bilaterally. Left forearm, hand, and wrist atrophy was noted. The right forearm (near elbow) measured 31.5 centimeters and the left forearm measured 30.5 centimeters. The right wrist measured 19 centimeters and the left wrist measured 18.5 centimeters. The right forearm (middle) measured 25.4 centimeters and the left forearm measured 25.5 centimeters. The right hand measured 25.5 centimeters and the left hand measured 20.6 centimeters. No trophic changes were indicated. The Phalen's and Tinel's signs were positive bilaterally. The examiner endorsed moderate incomplete paralysis of the right long thoracic nerve. The examiner endorsed moderate incomplete paralysis of the left radial, median, ulnar, and lower radicular nerve groups. The Veteran reported an occasional use of a wrist and shoulder brace. The examiner indicated that the bilateral upper extremity disabilities impacted the Veteran's ability to work due to pain, numbness, and weakness in his hands, following repetitive use. The Veteran was also afforded an April 2014 VA hand and finger examination. The Veteran reported daily cramping, spasms and ticks, and flare-ups that occur with movements and use of his hands and wrists. Range of motion studies revealed limitation of motion or evidence of painful motion for all ten fingers. There was no gap between the thumb pad and fingers, pain began at gap of more than two inches bilaterally. Finger flexion studies also revealed gaps of less than one inch between the left index and long fingers, with pain at one inch gap. Finger extension of the left index and long fingers was limited by no more than 30 degrees with painful motion at that point. There was no additional limitation of motion after repetitive use testing. The examiner noted that the Veteran's functional loss included bilateral pain on movement, less movement than normal in the left index and long finger, and atrophy of disuse in the left thumb, index finger, long finger, ring finger, and little finger. An October 2017 EMG revealed moderate severity of left and mild severity of right median neuropathy at the wrist (carpal tunnel syndrome). There was evidence of a left ulnar neuropathy, which appeared predominantly axonal in nature found to be likely located in the forearm segment. Tinel's and Phalen's testing were negative bilaterally. A February 2018 VA shoulder examination report includes a finding of severe atrophy of the left arm from the upper forearm to the hand, with noticeable weakness and paralysis caused by overcompensating with the right upper extremity. See also August 2019 VA medical opinion (finding left forearm muscle atrophy). The Veteran was afforded a VA peripheral nerves examination on August 2, 2019. The Veteran reported progressively worse strength and functioning, increased numbness, tingling, and pain in the wrist and hand, decreased range of motion, decreased grip ability, increased cramping with use or weight bearing. The examiner noted radicular symptoms of moderate right and left upper extremity constant pain, moderate right and left upper extremity paresthesias and/or dysesthesias, and moderate right and left upper extremity numbness. Muscle strength testing was reduced (4/5) in his left elbow flexion and extension, wrist flexion and extension, and grip, 2/5 in left pinch (thumb to index finger), but otherwise normal. Left wrist atrophy measured as 18.6 centimeters on the right and 19 centimeters on the left. Reflex testing was hypoactive in left bicep, tricep, and brachioradialis, but was otherwise normal. Sensation testing was decreased in the shoulder area, inner/outer forearm, and hand/fingers, bilaterally. Trophic changes were not indicated. Phalen's and Tinel's signs were positive bilaterally. The examiner endorsed mild incomplete paralysis of the right radial, median, and ulnar nerves; mild incomplete paralysis of the left radial and median nerve; and severe incomplete paralysis of the left ulnar nerve. The examiner noted no assistive devices were used and stated the Veteran's ability to work was impacted due to his limitations, such as difficulty working with tools, ladders, tight spaces requiring dexterity, and prolonged use of fine or gross motor skills. During his March 2020 Board hearing, the Veteran testified that his left upper extremity is worse than his right upper extremity and that he has experienced severe pain in the bilateral upper extremities throughout the appeal period. Specifically, the Veteran testified that he has had to "compensate over many decades now for lack of function in my left hand..." See March 2020 Board Hearing at 4. The Veteran and his representative drew attention to the physical size difference of the left hand versus the right hand. The Veteran testified that his symptoms include an inability to make a complete fist, weakened grip strength, atrophy, fatigue, and loss of dexterity and mobility. The Veteran reported that the functional impact of his left hand disability includes an inability to zip a jacket or hold toilet paper and difficulty tying his shoes and holding a gallon of milk for more than a few steps. Id. at 13-14. The Veteran rated his pain as six to an eight out of ten, with eight being more drastic following repetitive use. Id. at 17. The Veteran was afforded a VA peripheral nerves examination in September 2020. The examination revealed symptoms of moderate right upper extremity and severe left upper extremity constant pain, moderate right upper extremity and severe left upper extremity intermittent pain, moderate right upper extremity and severe left upper extremity paresthesias and/or dysesthesias, and moderate right upper extremity and severe left upper extremity numbness. Muscle strength testing was reduced (4/5) in all areas. Left hand atrophy was documented. The right side measured 30 centimeters and the left side measured 24 centimeters. Reflex examination was hypoactive in all areas. Sensory testing was normal. Trophic changes were not indicated. Phalen's sign and Tinel's sign were positive. The examiner endorsed moderate incomplete paralysis of the right ulnar and median nerves and severe incomplete paralysis of the left median and ulnar nerves. The examiner noted no assistive devices were utilized and stated the Veteran's ability to work was impacted due to his inability to lift, push, or pull more than fifty pounds. Further, his ability to run and climb and descend ladders was impacted. At the September 2020 VA Hand and Finger Examination, the Veteran was diagnosed with bilateral hand strain and left hand atrophy. The Veteran reported daily flare-ups precipitated by lifting objects that is alleviated with rest. Bilaterally, range of motion testing of the hands were normal. There was no gap between the pad of the thumb and fingers and there was no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. Pain was noted on examination on rest and during non-movement, bilaterally. There was no additional functional loss or range of motion after three repetitions. The examiner determined that the examination was medically consistent with the Veteran's statements regarding function loss with repetitive use over time and during a flare-up. Muscle strength testing was 4/5. Right Upper Extremity Neuropathy The Board finds that the Veteran's right upper extremity disability has resulted in significant sensory changes that impact both occupational and day-to-day functioning. 38 C.F.R. § 4.124a ("When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree."). Non-sensory changes have been shown, too; however, their functional impact is of a much lower degree. Moreover, the August 2011 and September 2020 VA examiners also characterized this level of disability as moderate incomplete paralysis of the ulnar nerve. It is significant that these medical assessments were made in consideration of the Veteran's symptoms and functional impairment. The Board agrees with this determination and, after consideration of the medical and lay evidence of record, the Board finds that the Veteran's neuropathy of the right upper extremity approximates "moderate incomplete paralysis" or average or medium incomplete paralysis, for his right ulnar nerve disability, corresponding to a 30 percent rating. See 38 C.F.R. § 4.124a , DC 8516. Higher ratings are available for severe incomplete paralysis of the ulnar nerve, but the Veteran's right upper extremity disability has not more nearly approximated that level of disability at any point during the appeal period. As noted above, the functional manifestations of the Veteran's right upper extremity disability has been caused primarily by significant sensory changes, such as pain, tingling, and numbness. While the September 2020 VA examination noted decreased motor and reflex changes they have been of a much lower degree. A review of VA examination reports dated in August 2011, April 2014, August 2019, and September 2020 reveal no findings of muscle atrophy or abnormal tone or bulk. Moreover, none of VA medical examiners characterized the severity of the right upper extremity as severe. Additionally, severe incomplete paralysis was not indicated in the above mentioned EMG reports. Notably, the Veteran testified that his left upper extremity disability was worse than his right upper extremity disability. See August 2019 VA examination report; March 2020 Board Hearing at 5, 16. To the extent that the Veteran argues his right upper extremity neurological impairment is more severe than represented by the VA examinations, he does not have either the education or training to offer a medical opinion challenging the adequacy of the testing, and as there is no competent evidence of record to support that his disability is, in fact, more severe than indicated on examination, the Veteran's assertions are not probative. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Thus, the most probative medical evidence as to the severity of the Veteran's right upper extremity neurological impairment for the period discussed herein are findings shown on VA examination. The Board has also considered evaluation of these disabilities under alternate codes. The Note following 38 C.F.R. § 4.124a, DC 8917 indicates that combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, to consider radicular group ratings. In this regard, the Board notes that the August 2011 VA examination found involvement of the right ulnar nerve; April 2014 VA examination found involvement of the right long thoracic nerve; the August 2019 VA examination found involvement of the right median, radial, and ulnar nerves; and the September 2020 VA examination found involvement of the right median and ulnar nerves. While the VA examiners failed to specify which nerve was the nerve of major involvement, the Board finds that the failure to do so does not affect the evaluation of the Veteran's disorder, as his right upper extremity paralysis has been found to be no worse than moderate throughout the appeal. Under either rating criteria, for both the median and ulnar nerves, no more than a 30 percent rating is warranted. 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8516. The Board notes further that an evaluation for mild, incomplete paralysis of a major extremity warrants the assignment of a 20 percent rating under Diagnostic Codes 8514 (radial nerve). An evaluation for moderate, incomplete paralysis of a long thoracic nerve warrants the assignment of a 10 percent rating under Diagnostic Codes 8519. Accordingly, the Veteran's right upper extremity paralysis will be evaluated under the more advantageous Diagnostic Code 8516 (ulnar nerve). Furthermore, the Board finds that the Veteran's demonstrated symptomatology in the right upper extremity is fully contemplated by the rating assigned for the ulnar nerve under DC 8516. There is no competent evidence showing more severe symptomatology to meet the criteria for the next higher ratings, for severe incomplete paralysis or complete paralysis, under DCs 8514, 8515, 8516, or 8519. Additionally, separate ratings for each nerve group (radial, ulnar, median, long thoracic nerves), based on the same neurological symptoms and overlapping functional impairment, cannot be assigned as it would constitute pyramiding. 38 C.F.R. § 4.14. Accordingly, the Board concludes that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent for the right upper extremity neuropathy. Left Upper Extremity Neuropathy In light of the August 2019 and September 2020 VA examinations findings of severe incomplete paralysis of the ulnar nerve, the Veteran's complaints throughout the appeal period, the findings of atrophy throughout the appeal period, the inadequate 2011 VA examination, and the 2014 VA examination showing multiple nerve involvements of moderate severity in the left extremity, the Board finds that the Veteran's neuropathy of the left upper extremity approximates "severe incomplete paralysis," corresponding to a 40 percent rating under DC 8515, effective the date of his claim, October 5, 2010. See 38 C.F.R. § 4.124a , DC 8515. The Board has also considered evaluation of left upper extremity disability under alternate codes. The Note following 38 C.F.R. § 4.124a, DC 8917 indicates that combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, to consider radicular group ratings. In this regard, the Board notes that the April 2014 VA examination found moderate involvement of the left radial, median, ulnar, and lower radicular group nerves; the August 2019 VA examination found mild involvement of the left radial and median nerves, and severe involvement of the ulnar; and the September 2020 VA examination found severe involvement of the left median and ulnar nerves. While the VA examiners failed to specify whether the ulnar or median nerve was the nerve of major involvement, the Board finds that the failure to do so does not affect the evaluation of the Veteran's disorder, as his left upper extremity paralysis has been found to be no worse than severe throughout the appeal. Here, it is more advantageous to the Veteran to evaluate his disability under Diagnostic Code 8515 (median nerve) than Diagnostic Code 8516 (ulnar nerve). Compare Diagnostic Code 8515 (assigning a 40 percent rating for severe incomplete paralysis of the "minor" median nerve) with Diagnostic Code 8516 (assigning a 30 percent rating for severe incomplete paralysis of the "minor" ulnar nerve). The Board notes further that an evaluation for moderate, incomplete paralysis of a minor extremity warrants the assignment of a 20 percent rating under Diagnostic Code 8514 (radial nerve) or a 30 percent rating under Diagnostic Code 8512 (lower radicular nerve group). There is no competent evidence showing more severe symptomatology to meet the criteria for the next higher ratings, under DCs 8512 or 8514. Accordingly, the Board finds that the predominant impairment is in the median nerve and the Veteran's left upper extremity paralysis will be evaluated under the more advantageous Diagnostic Code 8515 (median nerve). However, separate ratings for each nerve group (radial, ulnar, lower radicular group nerves), based on the same neurological symptoms and overlapping functional impairment, cannot be assigned as it would constitute pyramiding. 38 C.F.R. § 4.14. As noted above, the next higher schedular rating of 50 percent under DC 8516, the Veteran's left upper extremity disability would need to approximate complete paralysis of the ulnar nerve, to include the "griffin claw" deformity and a 60 percent rating under DC 8515 would need to approximate complete paralysis of the median nerve, which has not been demonstrated in the present case. While the Veteran does have incomplete nerve paralysis, resulting in weakness and loss of sensation, he continues to have some motion of both the wrist and the hand, with the ability to make a fist and grasp objects. See August 2011 VA treatment record. During the September 2020 VA examination, the Veteran had only slightly limited hand grip strength of 4 out of 5 in the left hand. See also August 2019 VA examination report; July 2020 VA treatment record. The Board recognizes that the Veteran does have demonstrated atrophy of the intrinsic muscles of the left hand, but he retains the ability to use his hand and muscle strength testing does not indicate the functional equivalent of complete paralysis of the ulnar or median nerves. His level of disability was most recently characterized as severe by a VA examiner, who also diagnosed only incomplete paralysis of the left upper extremity. See September 2020 VA examination report. Throughout the appeal period, no medical examiner has diagnosed the Veteran with complete paralysis of the median or ulnar nerve, or the functional equivalent thereof. Overall, the preponderance of the evidence is against a finding of complete paralysis of the median or ulnar nerve. Thus, the Board finds the evidence of record supports an evaluation of 40 percent for the Veteran's left (minor) peripheral neuropathy for the entire period on appeal. However, the Board concludes that the preponderance of the evidence is against the assignment of a rating in excess of 40 percent for the left upper extremity neuropathy. 3. From October 5, 2010, a separate 10 percent rating for a left wrist scar is granted. VA regulations provide that a 10 percent rating is warranted for one to two painful or unstable scars, with an additional 10 percent added if at least one scar is painful and unstable. See 38 C.F.R. § 4.118, DC 7804. The Board finds that a separate 10 percent rating, but no higher, is warranted for the Veteran's single painful left wrist surgical scar measuring 15 centimeters long by .5 centimeters. 38 C.F.R. § 4.118, DC 7804. While the September 2020 VA examiner noted that the Veteran's scar was not painful or unstable, it was noted that the left wrist scar has swelling. Furthermore, the Veteran competently and credibly testified that his scar is extremely sensitive. See March 2020 Board Hearing at 15-16. The Board finds that this more closely approximates the criteria for a painful scar, warranting a separate 10 percent rating. A higher rating is not warranted as the evidence does not show more painful and/or unstable scars, or scars covering his exposed area of skin or larger areas of unexposed skin. 4. The reduction of the disability rating for a right wrist disability from 10 percent to noncompensable, effective April 1, 2019, was improper. By way of background, a September 2011 rating decision granted service connection for right wrist sprain with 1st carpometacarpal joint osteoarthritis and assigned an initial noncompensable disability rating, effective October 5, 2010. This rating was assigned under DCs 5010-5215 based on a diagnosed right wrist disability without compensable symptomology. The September 2011 rating decision also granted service connection for right ulnar nerve paralysis/foreman strain and assigned an initial 30 percent disability rating effective, October 5, 2010. This rating was assigned under DC 8516 based on moderate incomplete paralysis of finger or wrist movements (major). An August 2017 rating decision assigned a 10 percent rating for right wrist sprain with 1st carpometacarpal joint osteoarthritis, effective October 5, 2010. This rating was assigned under DC 5215 based on painful motion of the wrist. A December 2017 rating decision proposed to reduce the evaluation of right wrist sprain with 1st carpometacarpal joint osteoarthritis from 10 percent to noncompensable. The RO indicated that the Veteran had two separate ratings for painful motion of the wrist: the 10 percent rating under DC 5215 and the 30 percent rating under DC 8516, maintaining both ratings would involve pyramiding by providing separate disability ratings for the same manifestation of the disability under different diagnostic codes. The reduction was implemented in a January 2019 rating decision, effective April 1, 2019. The Veteran did not disagree with this decision or otherwise submit new and material evidence within a year, and it became final. See 38 C.F.R. § 20.1103. Decisions are final when the underlying claim is finally adjudicated as provided in §3.160(d). Final decisions will be accepted by VA as correct with respect to the evidentiary record and the law that existed at the time of the decision, in the absence of clear and unmistakable error. At any time after a decision is final, the claimant may request, or VA may initiate, review of the decision to determine if there was a clear and unmistakable error in the decision. Where evidence establishes such error, the prior decision will be reversed or amended. 38 C.F.R. § 3.105(a)(1). Turning to the question of whether CUE was shown, the Board notes that "clear and unmistakable error" is a very specific and rare kind of error. It is the kind of error, of fact or of law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error. Fugo v. Brown, 6 Vet. App. 40 (1993). There is a three-pronged test for clear and unmistakable error (CUE). The criteria are: (1) either the correct facts, as they were known at the time, were not before the adjudicator (i.e., there must be more than a simple disagreement as to how the facts were weighed or evaluated) or the statutory or regulatory provisions in effect at the time were incorrectly applied; (2) the error must be undebatable and of the sort which, had it not been made, would have manifestly changed the outcome at the time it was made; and (3) a determination that there was clear and unmistakable error must be based upon the record and law that existed at the time of the prior adjudication in question. Russel v. Principi, 3 Vet. App. 310 (1992); Fugo, 6 Vet. App. 40, 43-44. In the present case, the Veteran alleges CUE in a January 2019 rating decision that reduced his disability rating for a right wrist disability from 10 percent to noncompensable effective April 1, 2019. As an initial matter, the Board finds the allegations of CUE made by the Veteran and his representative are adequate to meet the threshold pleading requirements. See Simmons v. Principi, 17 Vet. App. 104 (2003); Phillips v. Brown, 10 Vet. App. 25 (1997) (distinguishing denial of CUE due to pleading deficiency and denial of CUE on merits). Here, the CUE described is a violation of the rule against pyramiding, the evaluation of the same disability under two Diagnostic Codes. 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 condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The three-pronged test for CUE is met. The January 2019 rating decision determined that rating the right wrist disability (orthopedic) and right ulnar nerve paralysis (neurologic) separately for overlapping symptoms was impermissible pyramiding. However, the Board finds that the orthopedic and neurologic ratings contemplate different symptoms. In this regard, the September 2011 rating decision, granted service connection for right ulnar nerve paralysis at 30 percent under DC 8516, based on an August 2011 VA examination report noting right upper extremity numbness, paresthesias/ dysesthesias, absent sensory of the cutaneous ulnar nerve branch, and moderate incomplete paralysis of the ulnar nerve. The August 2017 rating decision assigned an initial 10 percent rating for right wrist sprain with 1st carpometacarpal joint osteoarthritis, under DC 5215 based on an April 2014 VA wrist examination report which noted flare-ups, cramping with general use of the wrist, and limitation of motion of the right wrist in palmar flexion, dorsiflexion, ulnar deviation, and radial deviation. By the August 2017 rating decision's reasoning, the 10 percent rating under DC 5215 addressed orthopedic painful motion of the wrist, which is not explicitly addressed by the 30 percent rating under DC 8616 for neurological impairment of the right upper extremity addressed in the January 2019 rating decision. The Board finds that the Veteran's orthopedic manifestations are separate and distinct from the Veteran's neurological manifestations. Thus, the Board finds that the RO committed a clear and unmistakable error by failing to apply the plain language of the criteria of DC 5215 and 8516. But for this error of law, the Veteran's disability rating would not have been reduced from 10 percent to a noncompensable rating. Again, CUE is a very specific and rare kind of "error." It is the kind of error, of fact or law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error. In this case, the Board finds that reasonable minds could not differ as to whether Diagnostic Codes of 5212 and 8516 addressed different symptoms of the right upper extremity. As such, the decision to assign a noncompensable schedular rating for the right wrist disability was clearly and unmistakably erroneous. Consequently, the reduction of the 10 percent rating to noncompensable beginning April 1, 2019 was improper. See 38 C.F.R. § 3.105(a). Accordingly, the January 2019 rating decision was the product of CUE, and restoration of the 10 percent schedular rating for the Veteran's service-connected right wrist disability, is warranted, effective April 1, 2019, the current effective date of reduction. 5. Entitlement to an initial rating in excess of 10 percent for a right wrist disability is denied. In light of the restoration granted above, the Veteran is assigned a 10 percent rating for a right wrist disability for the entire appeal period. The Veteran asserts that he is entitled a rating in excess of 10 percent for his chronic right wrist disability. The Board notes that the Veteran's current 10 percent rating was assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5003-5215. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.2. DC 5003 specifies that arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a , DCs 5003, 5010. If the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. Id. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. For purposes of rating disability from arthritis, VA regulations consider major joints to be the shoulder, elbow, wrist, hip, knee, and ankle. 38 C.F.R. § 4.45(f). DC 5215 provides for maximum 10 percent ratings for limited palmar flexion (palmar flexion limited in line with forearm) and limited dorsiflexion (dorsiflexion less than 15 degrees), regardless of whether the major or minor extremity is involved. 38 C.F.R. § 4.71a , DC 5215. Accordingly, the Veteran is already in receipt of the maximum rating pursuant to Diagnostic Code 5215. In order to assign a rating greater than 10 percent for impairment of the wrist, ankylosis, i.e., fixation or the absence of movement of a joint, must be present. Dorland's Illustrated Medical Dictionary 94 (31st ed. 2007). Specifically, 38 C.F.R. § 4.71a Diagnostic Code 5214, indicates that a 30 percent rating is assignable for favorable ankylosis in 20 degrees to 30 degrees dorsiflexion. As mentioned previously in the Findings of Fact section, the Veteran's right hand is his dominant hand. The period for appellate consideration is from October 5, 2010, the date service connection is established. Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. For purposes of the Veteran's disability, however, the rating criteria did not change. The Board has reviewed the evidence of record and finds that a rating in excess of 10 percent is not warranted for the Veteran's right wrist disability. Even considering the Veteran's objective evidence of painful and limited motion upon examination with a confirmed diagnosis of arthritis, which is adequately contemplated by the 10 percent rating criteria under DC 5003. The Veteran is currently in receipt of the maximum available rating on the basis of limitation of motion under DC 5215. A higher rating is also not available pursuant to DC 5214, the only other diagnostic code pertaining to the wrist, which requires ankylosis of the wrist. At no time has the Veteran been shown to have right wrist ankylosis. See August 2011, April 2014, August 2019, and September 2020 VA examination reports. Those findings are consistent with range of motion testing noted in the four VA examination reports, showing some, though limited and painful, right wrist range of motion. As 10 percent is the maximum rating for limitation of motion, as opposed to ankylosis, the regulatory provisions pertaining to functional loss are not applicable. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202; Spencer v. West, 13 Vet. App. 376, 382 (2000); Johnston v. Brown, 10 Vet. App. 80, 85 (1997). 6. Entitlement to a TDIU is denied. The Veteran asserts that he is entitled to TDIU benefits. As this matter has been raised on a derivative basis, as part and parcel of his claim for a higher rating for his left wrist disability, this matter is considered to be before the Board from October 5, 2010. See Rice v. Shinseki, 22 Vet. App. 447 (2009). VA will grant a TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from securing or following "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). TDIU can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that he has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16(a). The Veteran is service-connected for right and left upper extremity neuropathy, left wrist scar, bilateral tinnitus, and a right wrist sprain from October 5, 2010. Thus, beginning on October 5, 2010, the Veteran has met the minimum percentage requirements for a TDIU. 38 C.F.R. § 4.16(a). The main question before the Board is whether the Veteran's service-connected disabilities render him unable to obtain substantially gainful employment. The question is whether the claimant is capable of performing the physical and mental acts required by employment, not whether he or she can actually find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15, 4.16(a)). The determination as to whether a veteran can secure or follow a substantially gainful occupation includes an economic component and a noneconomic component. The economic component means that a veteran must not receive income from employment outside of a protected environment that exceeds the poverty threshold for one person. The noneconomic component requires consideration of a veteran's ability to secure or follow substantially gainful employment, including factors such as the veteran's history of education, skill, and training, as well as his or her ability to perform the physical and mental activities required by the occupation in question. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). Regarding the economic component of a TDIU, the Veteran's March 2020 VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability indicates that he is currently employed by VA. A February 2008 VA treatment record indicates that the Veteran was actively employed by VA as a carpenter. A May 2020 Request for Employment Information confirms that the Veteran has been employed on a full-time basis by VA since March 2014 as an air conditioning equipment operator. There has been no indication that this employment has been terminated. On his March 2020 VA Form 21-8940, the Veteran reported that his position pays him $5,400 per month. Additionally, the Veteran's employer indicated that he earns $73,232.83 annually. The poverty threshold in 2010 was $22,350 and $26,500 in 2020. Therefore, the Veteran's occupation has provided income above the poverty threshold established by the U.S. Department of Commerce, Bureau of the Census. Thus, the Veteran's employment is substantially gainful. As noted above, a TDIU cannot be assigned where the Veteran's employment was more than marginal unless the work was in a protected environment, such as a family business or sheltered workshop. However, the Veteran has not provided evidence of working in a protected environment. In this regard, the May 2020 Request for Employment Information left blank any concessions to the Veteran because of age or disability. The Veteran testified that he worked for United Airlines as an aircraft mechanic for 18.5 years. See March 2020 Board Hearing at 7. Following September 2001, he was laid off, was retrained, and went into building maintenance and construction. He was employed as a contractor on a VA construction project and was then hired as a permanent VA employee. Id. At that point, the Veteran reported an inability to carry a bag of tools up a ladder, loss of strength, atrophy, inability to do things with two hands, and having to compensate and perform tasks with his right hand. Id. He indicated that VA was aware of his limitations. Since then, the Veteran reported that he changed jobs from construction to an air-conditioning mechanic within VA. In his current position, he is not required to perform physical labor. The Veteran contends that if he did not have his upper extremity disabilities, he would be leading a construction crew. Id. at 11. In his VA Form 21-8940, the Veteran indicated that his current physically less demanding employment provided lower wages. The Board notes in a July 2012 statement, the Veteran indicated that his service-connected disabilities will eventually cause him to stop working in his field. However, the possibility of termination at a future and uncertain date cannot be used to establish a current need for TDIU. The Board finds that his current position is not a protected environment. While he has benefited from changing his position to a less demanding occupation within VA, the Veteran has not provided any indication that in his current position he has been provided with any special treatment or accommodations to deal with his service-connected disabilities. The evidence of record does not indicate that the Veteran's current position is similar to a family business or a sheltered workshop. As the Veteran has not been provided with special accommodations due to his service-connected symptoms, the Board finds that the Veteran's position during the appeal while in excess of poverty thresholds, is not tantamount to work in a protected environment and the economic component of a TDIU are not met. 38 C.F.R. § 4.16(a). In making this finding, the Board emphasizes that the rating schedule is intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. To the extent that service-connected disabilities affect the Veteran's employment, the assigned schedular ratings for his disabilities compensate the Veteran for such impairment. Accordingly, the Board finds that the preponderance of the evidence is against finding that the Veteran's service-connected disabilities have prevented him from securing or following a substantially gainful employment. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and the claim for entitlement to a TDIU must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Recognition is given to the fact that the issue of entitlement to service connection for a circulatory disorder is the subject of the below Remand. However, there is no prejudice in adjudicating the TDIU issue as a rating assigned to any circulatory disorder would not change the disposition. As indicated, the TDIU issue is being denied on the basis that the Veteran has remained employed in a substantially gainful occupation throughout the appeal. REASONS FOR REMAND 7. Entitlement to service connection for a disorder manifested by left hand cold sensitivity, numbness, and circulatory problems as secondary to service-connected left wrist median/ulnar neuropathy is remanded. An increased rating claim may raise issues of secondary service connection. See Morgan v. Wilkie, 31 Vet. App. 162, 164 (2019). Here, the Veteran testified that his left upper extremity neuropathy causes left hand cold sensitivity, numbness, and circulatory problems. See March 2020 Board Hearing at 17-18. On remand, the Veteran should be afforded an examination as to the presence and etiology of any disorder productive of left hand cold sensitivity, numbness, and circulatory problems and a medical opinion should be obtained. Updated VA and private treatment records should also be secured. The matter is REMANDED for the following actions: 1. Obtain any outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain all outstanding private treatment records. If any records are unavailable, notify the Veteran pursuant to 38 C.F.R. § 3.159(e). 3. Then schedule the Veteran for an examination to determine the current nature and etiology of any left hand circulatory disorder. The claims file should be made available to and be reviewed by the examiner. All findings should be reported in detail. After examining the Veteran, and considering his pertinent medical history and lay statements regarding reported symptoms, the examiner should address the following: (a) Diagnose all current left hand circulatory disorder(s) and/or functional impairment found, to include but limited to any cold sensitivity and numbness, present since October 2010, even if now resolved. If the examiner does not diagnose a left upper extremity circulation disorder, please explain why not. (b) If a disorder and/or functional impairment is identified in part (a), other than left upper extremity neuropathy, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that each such disorder is: (i) proximately due to service-connected disabilities, to include left upper extremity neuropathy; or (ii) aggravated (worsened) by service-connected disabilities, to include left upper extremity neuropathy. In addressing secondary service connection, please note that the service-connected disability need not be diagnosed or service-connected at the time the secondary condition (here, circulatory disorder) is incurred to establish secondary service connection, and reliance on this fact will render any secondary opinion inadequate. A complete rationale must be provided for all opinions expressed. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why this is the case. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Forde, 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.