Citation Nr: 21006973 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 17-03 352 DATE: February 8, 2021 ORDER For the period prior to December 28, 2016, a rating of 20 percent for carpal tunnel syndrome (CTS) of the left upper extremity is granted. A rating in excess of 20 percent for CTS of the left upper extremity is denied. REMANDED A rating in excess of 30 percent for generalized anxiety disorder is remanded. A total disability rating based on individual unemployability as the result of service-connected disabilities (TDIU) is remanded. FINDING OF FACT Throughout the period on appeal, the Veteran’s CTS of the left upper extremity has been manifested, at worst, by moderate incomplete paralysis of the median nerve. CONCLUSIONS OF LAW 1. Before December 28, 2016, the criteria for a rating of 20 percent for CTS of the left upper extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8515. 2. The criteria for a rating in excess of 20 percent for CTS of the left upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.124a, Diagnostic Code 8515. REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from March 1996 to January 2006. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision. The Veteran participated in a hearing before the undersigned in June 2020, and a transcript has been associated with the record. Increased Rating for CTS of the Left Upper Extremity The Veteran filed a claim for increased compensation for CTS of the left upper extremity in April 2014. He appealed the July 2014 rating decision that continued the 10 percent rating. During the pendency of the appeal, the 10 percent rating assigned for CTS of the left upper extremity was increased to 20 percent, effective from December 28, 2016. Such created a staged rating. He now argues that his CTS of the left upper extremity warrants a rating in excess of 10 percent before December 28, 2016, and in excess of 20 percent on and after that date. The Veteran’s left upper extremity is his non-dominant, or “minor” extremity, and it is rated under Diagnostic Code 8515, applicable to paralysis of the median nerve. See 38 C.F.R. § 4.124a. This diagnostic code provides for the following ratings for the minor extremity: a 10 percent rating applies to mild incomplete paralysis, a 20 percent rating applies to moderate incomplete paralysis, and a 40 percent rating applies to severe incomplete paralysis. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture 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. A maximum 60 percent rating applies to complete paralysis of the median nerve, with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. Turning to the facts in this case, the Veteran underwent a VA examination in May 2014, at which time the examiner diagnosed the Veteran with CTS of the left upper extremity. The Veteran stated that his wrists bothered him all day. The examiner stated that the Veteran’s CTS did not result in symptoms such as constant pain, intermittent pain, paresthesias, dysesthesias, numbness, or trophic changes. Muscle strength, reflex, and sensory testing of the left upper extremity were normal. Phalen’s and Tinel’s signs of median nerve dysfunction were both positive. The examiner did not explicitly address the severity of the Veteran’s CTS of the left upper extremity. In October 2014, the Veteran underwent a surgical procedure to release his left CTS. The Veteran underwent an additional VA examination in January 2015, at which time the examiner diagnosed the Veteran with CTS of the left upper extremity. The Veteran stated he experienced paresthesias in his left palm, thumb, index, and middle fingers. The examiner stated that the Veteran’s left CTS resulted in severe paresthesias and dysesthesias of the left upper extremity, but no pain or numbness. Muscle strength, reflex, and sensory testing of the left upper extremity were normal. Phalen’s and Tinel’s signs of median nerve dysfunction were both positive. The examiner stated that the Veteran’s left CTS resulted in mild incomplete paralysis of the median nerve. The Veteran underwent an additional VA examination in September 2016 primarily addressing the Veteran’s symptoms of right CTS. With that said, muscle strength and reflex testing of the left upper extremity were normal. The Veteran’s left upper extremity had decreased sensitivity to light touch. Phalen’s and Tinel’s signs of median nerve dysfunction were both positive. In a December 2016 examination, the Veteran reported that his symptoms were worsening, with pain and numbness in his left hand upon use. The examiner noted that the Veteran’s left CTS resulted in mild intermittent pain, and moderate paresthesias, dysesthesias, and numbness. The Veteran’s pinch of the thumb to the index finger showed active movement against some resistance; muscle strength testing was otherwise normal. There were no trophic changes. Reflex examination was normal, but sensory examination was decreased at the left hand and fingers. Phalen’s and Tinel’s signs of median nerve dysfunction were both positive. The examiner stated that the Veteran’s left CTS resulted in moderate incomplete paralysis of the median nerve. On the basis of the symptoms that the Veteran showed at this time, a December 2016 rating decision increased the rating of the Veteran’s left CTS to 20 percent effective as of the date of this examination. In December 2019, the Veteran stated that he experienced numbness and tingling of the left hand that worsened with activity, at night, and in the cold. A private clinician assessed the Veteran had moderate CTS of the left upper extremity. During the Veteran’s June 2020 hearing before the undersigned, the Veteran described his symptoms of left CTS. For example, the Veteran stated that his left hand went “completely numb” when driving, and he described experiencing a loss of grip strength. In an August 2020 Disability Benefits Questionnaire (DBQ), at which time the Veteran reported experiencing increased numbness, weakness, tingling, and sharp pains. The examiner stated that the Veteran’s left CTS resulted in moderate constant pain, paresthesias, dysesthesias, and numbness. Muscle strength testing showed that the left grip had active movement against some resistance; muscle strength was otherwise normal, and no atrophy was present. Reflex testing was normal. Sensory testing showed decreased sensation to light touch of the left hand and fingers; sensory testing was otherwise normal. There were no trophic changes. Phalen’s and Tinel’s signs of median nerve dysfunction were both positive. The clinician stated that the Veteran’s left CTS resulted in moderate incomplete paralysis of the median nerve. Turning to an analysis of these facts, the Board finds that the symptom picture associated with the Veteran’s left CTS warrants a single 20 percent rating throughout the period on appeal, i.e. since his 2014 application for an increased rating. The findings of the December 2016 examination report supported a finding that the Veteran had moderate incomplete paralysis of the median nerve of the minor extremity. The December 2016 examination report is by nature a backwards-looking summary of the effects of the Veteran’s symptoms of his left CTS on his functioning. The report describes longstanding symptoms of left CTS, and it does not support a finding that the Veteran’s symptoms of left CTS worsened only as of the date of the examination. The Board thus finds that the weight of the evidence supports the award of a single 20 percent rating for the Veteran’s left CTS at all times on appeal. With that said, the weight of the evidence does not support a rating in excess of 20 percent for left CTS at any time. Such a rating requires that the Veteran’s symptoms of left CTS approximate severe incomplete paralysis or complete paralysis of the median nerve. The Veteran has never contended, nor does the evidence show, that he has complete paralysis of the median nerve. Moreover, the Veteran’s symptoms of left CTS, which primarily include pain, numbness, paresthesias, and dysesthesias, have not produced severe incomplete paralysis. Consistent with this finding, no clinician has characterized the overall manifestation of the Veteran’s left CTS as either severe incomplete paralysis or complete paralysis. In sum, the Board finds that the Veteran’s CTS of the left upper extremity warrants a single 20 percent rating throughout the period on appeal. REASONS FOR REMAND The Board must remand the Veteran’s claims for an increased rating for generalized anxiety disorder and a TDIU in order to ensure that the Veteran’s claims are decided upon a complete evidentiary record. Regarding the Veteran’s claim for an increased rating for generalized anxiety disorder, the Veteran last received a psychiatric examination in December 2016. The evidence suggests that the Veteran’s symptoms of generalized anxiety disorder may have worsened since the time of that examination. For example, during the Veteran’s June 2020 hearing before the undersigned, the Veteran suggested that he experienced panic attacks and had “no” social interactions. The Board notes that the December 2016 examiner did not indicate that the Veteran experienced panic attacks, and the Veteran described having a more robust social life to the December 2016 examiner. With a suggesting of a worsening of the Veteran’s psychiatric symptoms, the Veteran should be provided with an additional examination to address the current severity of his generalized anxiety disorder. Regarding the Veteran’s claim for a TDIU, the Veteran has alleged that he is unemployable due, in part, to his psychiatric symptoms. The resolution of the pending claims for an increased rating may affect the Veteran’s eligibility for a TDIU. The Board thus finds that the claim of entitlement to a TDIU is inextricably intertwined with the remanded claim for an increased rating for generalized anxiety disorder. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). (CONTINUED NEXT PAGE)   Accordingly, the matters are REMANDED for the following actions: Schedule the Veteran for a VA examination to determine the current nature and severity of his generalized anxiety disorder. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.A. Flynn, 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.