Citation Nr: 21028814 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 13-10 827 DATE: May 12, 2021 ORDER Entitlement to a disability rating in excess of 40 percent for Raynaud's syndrome is denied. Entitlement to a disability rating in excess of 10 percent for residuals of a right wrist fracture, based on limitation of motion, is denied. Entitlement to a disability rating in excess of 10 percent for residuals of a left wrist fracture, based on limitation of motion, is denied. Entitlement to a separate 10 percent rating, effective June 19, 2007, for muscle impairment affecting dexterity and grip strength of the right hand, is granted. Entitlement to a separate 10 percent rating, effective June 19, 2007, for muscle impairment affecting dexterity and grip strength of the left hand, is granted. Entitlement to a total disability rating based on individual unemployability (TDIU), effective June 19, 2007, is granted. REMANDED Entitlement to a separate compensable rating for mental health symptoms associated with service-connected Raynaud's syndrome and residuals of right and left wrist fractures is remanded. FINDINGS OF FACT 1. Throughout the entire period on appeal, symptoms associated with the Veteran's Raynaud's syndrome include characteristic attacks occurring at least daily; two or more digital ulcers are not shown. 2. The Veteran is in receipt of the maximum rating provided under Diagnostic Code 5215 for right wrist limitation of motion. 3. The Veteran is in receipt of the maximum rating provided under Diagnostic Code 5215 for left wrist limitation of motion. 4. The evidence demonstrates that the Veteran's service-connected Raynaud's syndrome and wrist disabilities also manifest in muscle impairment affecting dexterity and grip strength of the both hands, respectively. 5. The evidence of record favors a finding that the Veteran's service-connected disabilities have prevented him from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 40 percent for Raynaud's syndrome have not been met. 38 U.S.C.§ § 1155, 5107; 38 C.F.R. §§ 4.14. 4.71, 4.104, Diagnostic Code 7117. 2. The criteria for a rating higher than 10 percent for residuals of a right wrist fracture, based on limitation of motion, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5215 (2020). 3. The criteria for a rating higher than 10 percent for residuals of a left wrist fracture, based on limitation of motion, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5215 (2020). 4. The criteria for the award of a separate 10 percent rating for muscle impairment affecting dexterity and grip strength of the right hand, effective June 19, 2007, are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.73, Diagnostic Code 5309 (2020). 5. The criteria for the award of a separate 10 percent rating for muscle impairment affecting dexterity and grip strength of the left hand, effective June 19, 2007, are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.73, Diagnostic Code 5309 (2020). 6. The criteria for the award of a TDIU, effective June 19, 2007, on a schedular basis are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1973 to April 1975. These matters are on appeal from a September 2008 rating decision and was previously remanded by the Board of Veterans' Appeals (Board) in March 2017 and September 2018. The Veteran testified before the undersigned Veterans Law Judge during October 2016 and November 2020 hearings. Procedural Background and Contentions The Veteran filed a claim for increase for his service-connected wrist conditions on June 19, 2007. The Veteran also raised entitlement to a TDIU during the pendency of the appeal. In a September 2008 rating decision, the agency of original jurisdiction (AOJ), in pertinent part, continued the Veteran's 40 percent rating for Raynaud's syndrome, continued the Veteran's two 10 percent ratings for residuals of wrist fractures, and denied entitlement to a TDIU. The Veteran disagreed with these determinations and initiated this appeal. The Veteran's disabilities have been assessed on numerous occasions during the pendency of the appeal. Complicating this case is the fact the Veteran's Raynaud's syndrome and wrist disabilities have several overlapping symptoms. The Veteran and his attorney have clearly articulated their concern that the rating criteria VA has used thus far to evaluate the Veteran's disabilities do not capture all of the Veteran's symptoms, and they have argued that the Veteran's claims should be referred to the Director of Compensation Service for extraschedular consideration. As discussed below, the Board finds that the rating schedule, when looked at in its entirety, adequately contemplates and compensates all disabling manifestations of the Veteran's disabilities; as such, a referral for extraschedular consideration is unnecessary. Indeed, although application of the diagnostic criteria specific to Raynaud's syndrome and limitation of motion of the wrists do not allow for higher ratings in this case, the Board is awarding separate ratings under the muscle impairment diagnostic criteria (specifically Diagnostic Code 5309) to contemplate additional symptoms of muscle impairment affecting dexterity and grip strength of the both hands. The Board also agrees with the Veteran and his attorney that the question of whether a separate rating may be awarded for mental health symptoms associated with service-connected Raynaud's syndrome and residuals of right and left wrist fractures has been raised, and such is being remanded for additional development as part of this appeal. In addition, a TDIU for the entirety of the period under review is granted herein. Rating Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule of 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. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. (1999); Hart v. Mansfield, 21 Vet. App. (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. Generally, separate disability 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. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Court has also held that within a particular diagnostic code, a claimant is not entitled to more than one disability rating for a single disability unless the regulation expressly provides otherwise. Cullen v. Shinseki, 24 Vet. App. 74 (2010). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 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 innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40; see also 38 C.F.R. §§ 4.45, 4.59. Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In Morgan v. Wilkie, 31 Vet. App. 162 (2019), the United States Court of Appeals for Veterans Claims (Court) reminded the Board that, in evaluating the rating of a disability, VA has a duty to maximize benefits, and that this includes determining whether secondary service connection is warranted for additional symptoms and effects not contemplated by an applicable diagnostic code. See Morgan, 31 Vet. App. at 167. In Bailey v. Wilkie, 33 Vet. App. 188 (2021), the United States Court of Appeals for Veterans Claims (Court) held that "VA is required to develop and adjudicate related claims for secondary service connection for disabilities that are reasonably raised during the adjudication of a formally initiated claim for the proper evaluation level for the primary service-connected disability." In Copeland v. McDonald, 27 Vet. App. 333 (2015), the Court made clear that "when a condition is specifically listed in the Schedule, it may not be rated by analogy." Raynaud's syndrome is, in fact, specifically listed in the Schedule, and is evaluated under 38 C.F.R. § 4.104, DC 7117. That diagnostic code provides for a 40 percent rating where there are characteristic attacks occurring at least daily; a 60 percent rating with two or more digital ulcers and a history of characteristic attacks; and a 100 percent rating with two or more digital ulcers plus autoamputation of one or more digits and a history of characteristic attacks. 38 C.F.R. § 4.104, DC 7117. For rating purposes, a characteristic attack consists of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias, and precipitated by exposure to cold or emotional upsets. Id. Note. The evaluations set forth in the DC are for the disease as a whole, regardless of whether the nose and ears are involved. Id. The Veteran's residuals of right and left wrist fractures are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5215, for limitation of motion of the wrist. Under Diagnostic Code 5215, a maximum 10 percent rating is warranted for dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm. 38 C.F.R. § 4.71a, Diagnostic Code 5215. Diagnostic Code 5214 provides compensation for ankylosis of the wrist. 38 C.F.R. § 4.71a. Where ankylosis is favorable with dorsiflexion of 20 degrees to 30 degrees, a 20 percent rating is appropriate for the minor joint and a 30 percent rating is appropriate for the major joint. Where there is ankylosis in any other position, except favorable, a 30 percent rating is appropriate for the minor joint and a 40 percent rating is appropriate for the major joint. Where ankylosis is unfavorable in any degree of palmar flexion, or with ulnar or radial deviation, a 40 percent rating is appropriate for the minor joint and a 50 percent rating is appropriate for the major joint. Also, under this code, extremely unfavorable ankylosis will be rated as loss of use of hands under Diagnostic Code 5125. Id. Muscle impairment, impacting the hand, can be rated separately under 38 C.F.R. § 4.73, Diagnostic Code 5309. Indeed, the relevant portion of the regulatory rating schedule which pertains to Muscle Group IX involving the forearm muscles and the intrinsic muscles of the hand provides that the hand is so compact a structure that isolated muscle injures are rare, being nearly always complicated with injuries of bones, joints, tendons, etc. Therefore, injuries to muscles in the hands are to be rated on limitation of motion, with a minimum of a 10 percent disability rating. 38 C.F.R. § 4.73, Diagnostic Code 5309. Evidence and Analysis At a December 2007 VA examination, the Veteran reported that he noted weakness and stiffness, lack of endurance, giving way, heat, fatiguability of the wrists and discoloration of the fingers. On examination, he did not have weakness, stiffness, swelling, heat, redness, giving way, lack of endurance, locking, fatigability and dislocation. Due to the joints condition he had pain located at wrists and hands for over 10 years. The pain occurred constantly. The pain traveled to the forearm and fingers. The characteristic of the pain was squeezing, burning, aching, oppressing, sharp and cramping. The pain could be elicited by physical activity and stress and was relieved by stress. He reported that he could not function when there was arm pain. He was not receiving any treatment for his condition. He did not have any prosthetic implants of the joint. He reported that he could not use the mouse to work on the computer. He claimed that he had to stop working on activities after using his hands for an hour. He alleged that he had a high tolerance to pain. He was right hand dominant. On examination, range of motion studies showed limited and painful motion of the bilateral wrist. There was tenderness on both sides, but no edema, effusion, weakness, redness, heat, guarding of movement and subluxation. Regarding the right and left wrists, dorsiflexion was to 50 degrees with pain at 50 degrees, palmar flexion was to 60 degrees with pain at 60 degrees, radial deviation was to 10 degrees with pain at 10 degrees, and ulnar deviation was to 30 degrees with pain at 30 degrees. The bilateral wrist joints were limited by pain after repetitive motion but not limited due to fatigue, weakness, lack of endurance and incoordination. The bilateral wrist joints were additionally limited by 5 degrees. X-rays of the bilateral wrists showed periarticular osteopenia on the right side and osteoarthritis of metacarpal joint and post traumatic calcification of the triangular fibrocartilage on the right side. The effect of the condition on the Veteran's daily activities was that he could not do any prolonged activities using both hands. On May 2008 VA examination, the Veteran reported a history of erythromelalgia involving the hands for 10 years that occurred as often as four times a day and each episode lasted for two hours. He reports that he has a history of Raynaud's syndrome involving the hands for 15 years, which occurred as often as two times per day. The typical attack was as follows: hands were bluish, cold and painful. The claimant was not receiving any treatment for his condition. The condition prevented him from exertion or from performing some types of exercise, such as hand gripping and any manipulative use of hands. He reported that he had a nerve conduction study showing polyneuropathy of bilateral hands. Raynaud's syndrome was present at bilateral hands with blue discoloration and cold to touch. There was no digital ulceration or autoamputation of the digits. No erythromelalgia was present. Examination of the right and left peripheral pulses revealed femoral pulse 2+, popliteal pulse 2+, dorsalis pedis pulse 2+ and posterior tibial pulse 2+. The examiner noted that the Veteran's condition progressed to Raynaud's syndrome and polysensory neuropathy of the bilateral hands. There was evidence of mild effect on daily activities as a result of the condition. In February 2010 correspondence, the Veteran's representative claimed that the Veteran had characteristic attacks of Raynaud's syndrome several times per day due to minimal movement such as blowing his nose and moving during sleep. He experienced sudden, acute, and paralyzing bursts of pain with concomitant changes in hand coloration. He refrained from engaging in daily activities in fear of a surprise attack. He has been unable to use his hands to hold a can or pour a bag of dog food. The Veteran indicated that he was unable to work because he was unable to use his fingers, hands, wrists, and forearms without experiencing constant throbbing and intermittent pains of "acid burning through [his] skin." The Veteran's representative also reported that the Veteran experienced extreme pain and ankylosis of the wrists on a daily basis. The pain was precipitated by simple usage of the hands when performing activities of daily living, but also occurred without any triggers, i.e. during sleep. The pain became significantly worse with minimal activity and overwhelming with repetitive use, i.e. cleaning and using the computer. His wrists became stiff and paralyzed at varying intervals throughout the day. When he experienced ankylosis of the wrists and hands, he lost his motor abilities and became totally unable to flex his wrists, manipulate fine objects, and open and close his hands. During VA examination in February 2010, the Veteran reported weakness, stiffness, swelling, heat, redness, giving way, lack of endurance, locking, fatigability, deformity, tenderness and pain. He indicated that he did not experience drainage, effusion, subluxation and dislocation. The claimant reported experiencing the flare-ups as often as four times per day and each time lasts for 6 hours. The flare-ups were precipitated by physical activity, stress and cold weather. The flare-ups occurred spontaneously. It was alleviated by rest, spontaneously and by Naproxen. During the flare-ups, he experienced functional impairment described as pain, weakness, and limitation of motion of the joint which was described as decreased range of motion. He never was hospitalized nor had any surgery for this condition. He stated that his condition, in the past 12 months, has not resulted in any incapacitation. He did not have any joint replacement. The Veteran reported the following overall functional impairments: difficulty lifting and carrying objects, and manipulative actions that involve the hands and fingers. On physical examination, on the right and left side, there was abnormal movement, weakness, tenderness, redness and guarding of movement. There were no signs of edema, instability, effusion, heat, deformity, malalignment and drainage. There was no subluxation. Upon examination of the wrist, there was no ankylosis. Range of motion studies, showed, bilaterally, dorsiflexion to 40 degrees with pain at 40 degrees, palmar flexion to 30 degrees with pain at 40 degrees, radial deviation was to 10 degrees with pain, and ulnar deviation to 30 degrees to with pain at 30 degrees. On repetitive motion dorsiflexion was to 30 degrees, palmar flexion was to 30 degrees, radial deviation was to 10 degrees, and ulnar deviation was to 25 degrees. Dorsiflexion was limited by 10 degrees, palmar flexion was limited by 10 degrees, and ulnar deviation limited by 5 degrees. Bilaterally joint function was additionally limited by the following after repetitive use: pain, fatigue, weakness, and lack of endurance had the major functional impact. The joint function on the right side was not additionally limited by incoordination; however, it was additionally limited by incoordination on the left side. He wore a brace on the left side. X-rays of the right wrist showed the possibility of old post-traumatic changes of the triquetrum. The left wrist showed osteoarthritic changes, navicular multangular joint calcification distal to the ulna could be in the triangular cartilage and could be due to old trauma. The examiner described the residuals of the wrists as decreased motion, pain, weakness, fatigue, lack of endurance, and incoordination leading to the development of post-traumatic osteoarthritic changes and difficulty lifting and carrying objects, and manipulative actions that involve the hands and fingers. The effect of the condition on the Veteran's usual occupation and daily activity was difficulty lifting and carrying objects, and manipulative actions that involve the hands and fingers. At an April 2012 VA examination, the examiner reported that the Veteran had characteristic attacks of Raynaud's syndrome one to three times a week. The Veteran did not have two or more digital ulcers or autoamputation of one or more digits. There was no amputation of an extremity due to a vascular condition. The Veteran did not use any assistive devices. There was remaining effective function of the extremities. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms. The vascular condition impacted his ability to work in that he required mild to moderate increased time to complete occupational tasks such as grasping and fingering secondary to pain; however, it was not a contraindication for him not to perform these tasks in most occupation. The examiner reported that the examination was normal, and the diagnosis was based on clinical history. During his October 2016 Board hearing, the Veteran testified that his Raynaud's syndrome impacted his fingers and his hands and that he never had any associated ulcers. He described an attack of Raynaud's syndrome occurring any time the temperature went below 70 degrees or when he put his hand in the freezer. His hands would get cold and he felt an unbearable burning sensation in his fingertips. The attacks could last from 15 to 20 minutes to hours depending on the exposure. He could not use his hands during an attack due to not having sensation in the fingers and mobility issues. The sensitivity in his fingers made them feel like bloated sausages and he was unable to pick up anything. During his October 2016 Board hearing, the Veteran also testified that his symptoms felt more intense in his left hand, but both hands were constantly in pain. He reported that any sudden movement, any extreme rotation of the hands, and any impact with an object produced intense, acute pain that lasted up to several minutes. See hearing transcript, pg. 5. He reported that any repetitive movement worsened the pain and caused a cramp in the hand by contracting the muscles the palm of the hand, and the position the fingers. For relief, he had to message his hands repeatedly. Supra, pg. 6. He also reported that his wrists became weak and his hand would lock in a certain position while doing anything. He had pain and stiffness and was unable to use the hand until the muscles relaxed. This also occurred during his sleep when keeping his hands in one position for a long period of time. Supra, pgs. 7-8. He further explained that his fingers would be splayed out at any random angle in one position and he was unable to move them again until he assisted them. An episode would last from minutes to half a day. He reported that his symptoms impacted his daily life. He claimed that he learned to ignore a lot of the pain until it became unbearable. He indicated that it impacted him brushing his teeth, combing his hair, making his bed, or whatever, in that he did it until the pain became unbearable and he would stop doing the activity. Supra, pg. 13. He reported that he could not drive long distances. On November 2017 VA examination, the Veteran reported an onset of symptoms in 1975/1976. He stated that the symptoms began spontaneously with slow color change, numbness, tingling, burning, and a feeling of swelling of fingers when exposed to cold that affecting the entire hand. He indicated that the condition has stayed the same since 1997. The examiner reported that the Veteran had characteristic attacks of Raynaud's syndrome at least daily. The Veteran did not have two or more digital ulcers or autoamputation of one or more digits. There was no amputation of an extremity due to a vascular condition. The Veteran did not use any assistive devices. There was remaining effective function of the extremities. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms. The vascular condition impacted his ability to work due to impaired manipulation with fingers, thumbs, and hands during flare-ups. At a November 2017 VA wrist conditions examination, the Veteran was diagnosed with tendinitis, ostearthritis, and De Quervain's syndrome of the bilateral wrist. He also had bilateral wrist periarticular osteopenia. The Veteran reported an onset of the symptoms in 1973. There was an initial healing of fracture that included pain in the wrists that radiated into the hands and forearms that was associated with cramping of fingers, swelling of hand and forearm, and total loss of dexterity. He had flare-ups and functional impairment/loss in the wrists that he described as being limited by pain in activities such as repetitive firm grabbing, gripping, holding, forceful pushing, pulling, and heavy lifting and carrying. Range of motion studies in both wrists showed palmar flexion to 60 degrees, dorsiflexion to 50 degrees, ulnar deviation to 30 degrees, and radial deviation to 15 degrees. Pain was noted on all ranges of motion and caused functional loss. There was evidence of pain with weight bearing. There was objective evidence of mild to moderate tenderness to palpation of the entire wrist joint. There was objective evidence of crepitus. There was additional loss of range of motion after three repetitions. Palmar flexion was to 55 degrees, dorsiflexion was to 45 degrees, ulnar deviation was to 30 degrees, and radial deviation was to 10 degrees. Pain caused this functional loss. Regarding repeated use over time, pain caused additional functional loss. Palmar flexion was to 45 degrees, dorsiflexion was to 35 degrees, ulnar deviation was to 25 degrees, and radial deviation was to 5 degrees. The examiner reported that pain, fatigue, and lack of endurance caused functional loss during flare-ups, by was unable to report the ranges of motion without mere speculation. The examiner explained that the objective determination of whether the Veteran was experiencing a flare-up or not could only be determined by someone like a primary medical doctor/primary care provider who had prior acquaintance with the Veteran's body and determined a non-flare-up base like for comparison. The examiner reported that he or she could neither confirm nor refute flare-up status because he or she only saw the Veteran once. There was no reduction in muscle strength and there was no muscle atrophy. There was no ankylosis. There were no other pertinent physical findings, complications, conditions, signs or symptoms related to the condition. There were no scars. The Veteran did not use any assistive devices. There was remaining effective function of the extremities. X-rays of the bilateral wrists revealed minimal osteoarthritis, in the navicular, trapezium, and trapezoid joints and the first carpometacarpal joint. In the right wrist there was also periarticular osteopenia. The functional impact of the bilateral wrist disability was that there was impaired repetitive firm gripping, grabbing, holding, forceful pushing, pulling, and heavy lifting and carrying. There was objective evidence of pain on passive range of motion testing and on non-weight bearing testing of the bilateral wrist, The examiner added that the bilateral wrist fracture residuals caused impairment in handling of objects, as well pushing, pulling, heavy lifting and carrying of objects. This impairment undermined the Veteran's ability to perform sedentary and physical activities of employment but not to such a degree as to render him unable to procure and maintain substantially gainful employment. The examiner did not observe that the Veteran's fingers and hand sometimes remained in a locked position for a period of time after use. At an August 2019 VA examination, the Veteran reported a medical history of symptoms starting in 1996 with feelings of swelling and decreased sensation in his fingers. He stated that his fingers did not physically swell, but he could not pick up things during an episode. His symptoms were worse in the cold and had improved since he moved to the desert. He also had polyneuropathy in his hands that was diagnosed by an EMG in 1998 that had progressed from intermittent symptoms to constant symptoms. He also had carpal tunnel syndrome bilaterally. Symptoms were constant around his thumbs and traveled around the fingers and to the wrists. The examiner reported that the Veteran had characteristic attacks of Raynaud's syndrome. He did not have two or more digital ulcers, did not have autoamputation of one or more digits and did not have an amputation of an extremity due to a vascular condition. He occasionally used braces for both wrists for his carpal tunnel/polyneuropathy. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally served by an amputation with prosthesis. The examiner noted that during the range of motion examination of the hands, both hands became red and warm compared to the start of the examination. Capillary refill remained at least three seconds on both hands. There were no scars. At an August 2019 VA wrist examination, the Veteran was diagnosed with osteoarthritis and residuals of wrist fracture, bilaterally. Flare-ups of the bilateral wrists occurred three to six times per day and lasted seconds to a minute. The flare-ups were moderate, precipitated by unknown causes, and were alleviated by nothing because it did not last long enough to try anything. Functional loss/impairment was described as painful to grip cup of coffee, hairbrush, or toothbrush. He could not hold a coffee cup longer than three minutes. He had difficulty with holding a book more than 5 - 10 minutes to read. His hands/wrists started to shake when he lifted more than 2 pounds. He had difficulty pushing a door open due to limited motion. He had difficulty opening medication bottles due to the twisting motion. He reported that he occasionally wore braces on his wrist. A physical examination of the right wrist evidenced the following ranges of motion: palmar flexion to 30 degrees, dorsiflexion to 40 degrees, ulnar deviation to 20 degrees, and radial deviation to15 degrees. Painful motion was noted in radial deviation. There was no objective evidence of localized tenderness or pain on palpation, pain with weight bearing, or crepitus. On the left wrist, palmar flexion was to 25 degrees, dorsiflexion was to 40 degrees, ulnar deviation was to 20 degrees, and radial deviation was to 20 degrees. There was pain with all ranges of motion. There was no evidence of pain with eight bearing or crepitus. There was moderate localized tenderness or pain on palpation to the posterior joint line. In both wrists range of motion contributed to functional loss. The examiner restated these functional limitations and added that it would be difficult for the Veteran to have a job that required the use of his hands. There was no additional loss of function or limitation of motion in either wrist after repetitive use. Bilaterally, pain, fatigue, and weakness caused functional loss with repeated use over time. Palmar flexion as limited to 20 degrees, dorsiflexion was limited to 32 degrees, and ulnar and radial deviation were each limited to 16 degrees. Regarding flare-ups, pain limited range of motion in both wrists. On the right-side palmar flexion was to 30 degrees, dorsiflexion was to 40 degrees, ulnar deviation was to 20 degrees, and radial deviation was to 15 degrees. On the left side, palmar flexion was to 25 degrees, dorsiflexion was to 40 degrees, ulnar deviation was to 20 degrees, and radial deviation was to 20 degrees. There was swelling on the left side that contributed to the disability. Muscle strength on right wrist flexion was 3/5 and extension was 4/5. On the left wrist, muscle strength with flexion was 3/5 and extension was 4/5. There was no muscle atrophy. There was no ankylosis or other pertinent findings on either side. He occasionally used a brace. There was remaining effective function of the extremities. There was degenerative arthritis of both wrists. The examiner added that there was no evidence of pain on passive range of motion testing of the left wrist. There was objective evidence of pain on non-weight bearing testing of the left wrist. There was no evidence of pain on passive range of motion testing of the right wrist. There was objective evidence of pain on non-weight bearing testing of the right wrist. A goniometer was used for all joint range of motion measurements. For the VA established diagnosis of residuals of right wrist fracture the diagnosis was changed and it was a progression of the previous diagnosis. Now, he had severe degenerative joint disease to the carpal bones with several osteophytes throughout the joints. For the VA established diagnosis of residuals of left wrist fracture, the diagnosis was changed, and it was a progression of the previous diagnosis. Now, he had severe degenerative joint disease to the carpal bones with several osteophytes throughout the joints. There were also radial head degenerative changes. The VA examiner found that the locking up or fixing of the fingers, hands, or wrists could be due to both the Raynaud's syndrome and the residuals of the wrist fractures. The examiner explained that Raynaud's syndrome could result in atrophy of the subcutaneous muscle and tissue in addition to the skin. The Veteran's Raynaud's syndrome had reportedly improved since the claimant moved to the desert; however, his fingers changed color and temperature during the examination. The residuals of the wrist fractures progressed to arthritis with several osteophytes that not only restricted movement but could cause irritation of the tendons or tendon sheaths that passed near them. Per the claimant, the locking of the fingers, hands, and wrists occurred when he needed to use his hands a great deal at one time, therefore, the frequency could vary. The examiner noted that by the end of the examination, the claimant was visibly having difficulty grasping the medical records he brought with him to put them back in the envelope; however, the fingers were stiff but not completely locked. The Veteran stated that despite the significant increase in pain with use of the hands, he lived alone and had to do everything for himself, so he must function despite the pain. Therefore, the flare ups could not equate to complete ankylosis of the fingers, hands, and wrists. The Veteran repeatedly stated that after repetitive use over time he believed that he had the same amount of motion, just a significant increase in the pain, muscle weakness and fatigue. Therefore, the examiner found that it was hard to estimate the degree of functional impairment without some speculation; however, with what the examiner observed, she estimated that his range of motion had decreased by about 20 percent. At the August 2019 VA Hand and Finger Examination, the Veteran was diagnosed with De Quervain's tenosynovitis and sequelae of Raynaud's syndrome, bilaterally. Bilaterally, ranges of motion of the index fingers, long fingers, ring fingers, little fingers were as follows: metacarpophalangeal joint (MCP) flexion to 90 degrees; proximal interphalangeal joint (PIP)flexion to 100 degrees; and distal interphalangeal joint (DIP) flexion to 70 degrees. MCP flexion of the thumb was to 50 degrees and PIP flexion was to 70 degrees. Pain was noted on finger flexion but did not cause additional loss. There was evidence of pain with use of the hand. The examination was positive for evidence of moderate localized tenderness/pain on palpation of the joint or associated soft tissue due to De Quervain's tenosynovitis. There was no gap between the pad of the thumb and the fingers. On the right side, a 1.5 cm gap was noted between the index finger and proximal transverse crease of the hand on maximal finger flexion. A 1.0 cm gap was noted between the long finger and proximal transverse crease of the hand on maximal finger flexion. On the left side, a 1.0 cm gap was noted between the index finger and proximal transverse crease of the hand on maximal finger flexion. A.5 cm gap was noted between the long finger and proximal transverse crease of the hand on maximal finger flexion. There was no additional functional loss or range of motion after three repetitions. Regarding the thumbs, MCP flexion was increased to 100 degrees and PIP was increased to 90 degrees. The examiner indicated that pain, fatigue, and weakness limited functional ability with repeated use over a period of time. Bilaterally, ranges of motion of the index fingers, long fingers, ring fingers, little fingers were as follows: MCP flexion was to 90 degrees; proximal PIP flexion was to 100 degrees; and DIP flexion was to 70 degrees. MCP flexion of the thumb was to 50 degrees and PIP flexion was to 70 degrees. There was no gap between the thumb and the fingers. On the right side, a 1.5 cm gap was noted between the index finger and proximal transverse crease of the hand on maximal finger flexion. A 1.0 cm gap was noted between the long finger and proximal transverse crease of the hand on maximal finger flexion. On the left side, a 1.0 cm gap was noted between the index finger and proximal transverse crease of the hand on maximal finger flexion. A.5 cm gap was noted between the long finger and proximal transverse crease of the hand on maximal finger flexion. Regarding flare-ups, bilaterally, ranges of motion of the index fingers, long fingers, ring fingers, little fingers were as follows: MCP flexion was to 45 degrees; and the proximal PIP flexion was to 50 degrees. DIP flexion of the index finger was to 25 degrees and to 35 degrees for the long finger, ring finger, and little finger. MCP flexion of the thumb was to 25 degrees and PIP flexion was to 35 degrees. There was no gap between the thumb and the fingers. On the right side, a 2.0 cm gap was noted between the index finger and proximal transverse crease of the hand on maximal finger flexion. A 1.5 cm gap was noted between the long finger and proximal transverse crease of the hand on maximal finger flexion. On the left side, a 1.5 cm gap was noted between the index finger and proximal transverse crease of the hand on maximal finger flexion. A.1.0cm gap was noted between the long finger and proximal transverse crease of the hand on maximal finger flexion. Bilaterally, there was weakened movement due to muscle or peripheral nerves injury. Hand grip was 3/5 and there was a reduction of muscle strength and muscle atrophy. There was mild hypothenar eminence of the thenar eminence predominantly of 0 cm. The examiner explained that the thenar eminence did not have a circumferential measurement, so there was no normal to compare to during the examination. There was no ankylosis and no other pertinent physical findings, complications, conditions, signs, symptoms, and scars. The Veteran occasionally used a brace. There was remaining effective function of the extremities. There was no evidence of pain on passive range of motion and non-weight bearing testing of the bilateral hands. The thumbs exhibited pain for finger flexion. During his November 2020 Board hearing, the Veteran reported that the symptoms in his hands were the same but became more intense and frequent over the last four years. He indicated that regarding his wrists, he had to modify his movement if he had to perform a task. His pain increased, was accompanied with numbness and cramps, and made him unable to move his fingers. He had to assist his hands to get them moving again. See hearing transcript, pg. 3. He indicated that frequent or repetitive movement and motions affected the severity and frequency of his symptoms. For example, it was hard for him to button his shirt. Sometimes when he brushed his teeth, hid fingers get stuck being curled around his toothbrush. It was the same on both sides. All activities including cleaning, grooming, bathing, and eating were all hampered by his hand condition. Supra, pg. 7. He reported that he was unable to open jars or squeeze anything because he had no strength in his thumbs, and they were useless. Supra, pg. 8. He had pain in his thumb. His right hand and thumb swelled up after it was in one position for too long during his sleep. He indicated that he drank to help him sleep, otherwise every 15 minutes if his hand was positioned in a certain way, he woke up due to increased pain in his hand. He explained that he drank because his system did not tolerate opiates and Advil did not do much for him. Supra, pgs. 8-11. As noted above, the 40 percent rating in effect for the Veteran's Raynaud's syndrome specifically contemplates at least daily characteristic attacks, and the regulations note that "characteristic attacks" consist of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias, and precipitated by exposure to cold or emotional upsets. There is no question the Veteran experiences such attacks on a more than daily basis, and that such are accompanied by pain and paresthesias in the hands and fingers, as well as color changes of the digits. As noted above, because Raynaud's syndrome has its own specific criteria outlined in the rating schedule, the Board may not rate this disability by analogy. See Copeland, supra. Importantly, the evidence of record has established that the Veteran has never experienced ulceration of the digits, and he has denied the development of ulcers at both hearings. Because the rating criteria under Diagnostic Code 7117 are cumulative, without the presence of ulceration, a higher 60 or 100 percent is simply not warranted. Accordingly, a With respect to the Veteran's wrist fracture residuals, Diagnostic Code 5215 provides the rating criteria for limitation of motion of the wrist. A maximum 10 percent rating is provided for dorsiflexion limited to less than 15 degrees and for palmar flexion limited in line with the forearm for the major and minor wrist. The Veteran is already in receipt of the maximum rating provided under Diagnostic Code 5215 for his bilateral wrist, and higher ratings are unavailable under this code for either wrist. The Board has considered whether a higher rating for the Veteran's right and left wrist fracture residuals can be awarded based on a finding of ankylosis. The Veteran's representative has argued that such should be considered given the fixation of the Veteran's wrists, hands and fingers at times during flare-ups, and the Board will consider whether the functional equivalent of ankylosis exists when considering Deluca factors. See Chavis v. McDonough, No. 18-2928, 2021 U.S. App. Vet. Claims LEXIS 660 (April 16, 2021) Ankylosis is the complete immobility of a joint in a fixed position, either favorable or unfavorable. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). The evidence described above demonstrates that the Veteran's wrists, hands and fingers stiffen to the point of being unable to move at times during flare-ups, and such can last as little as a few seconds, to several minutes, requiring the Veteran to manually manipulate his joints to mobilize them again. Crucially, although the medical examiners above discussed the Veteran's locking episodes in their respective evaluations, no examiner affirmatively found that ankylosis existed in the fingers, hands or wrists, to include during these locking flare-ups. Rather, all examiners have opined against the presence of ankylosis, to include during flare-ups and the Board places high probative value on their expert medical opinion on the topic. That stated, although the Board declines to award a higher rating for either wrist based on the presence of favorable or unfavorable ankylosis, the Board is awarding separate compensable ratings under the muscle impairment codes for each extremity based on this phenomenon and the impact it has on the Veteran's dexterity and grip strength. The Board finds that separate compensable ratings under the neurological codes or the limitation of motion codes of the individual fingers would amount to prohibited pyramiding. As discussed above, the Veteran's painful and limited motion is contemplated by ratings under both 7117 and 5215, and the Veteran's loss of sensation, paresthesias, and shooting hand and finger pain, color changes and sensitivities to temperature and stress are contemplated under Diagnostic Code 7117. The impact of the Veteran's disabilities on his finger dexterity, stiffness and grip strength are contemplated in the separate ratings discussed immediately below. In this connection, the August 2019 examiner specifically found that the locking up or fixing of the fingers, hands, or wrists could be due to both the Raynaud's syndrome and the residuals of the wrist fractures. The examiner explained that Raynaud's syndrome could result in atrophy of the subcutaneous muscle and tissue in addition to the skin. The examiner specifically noted the presence of weakened movement due to obvious thenar atrophy, and mild hypothenar atrophy. Impairment of Muscle Group IX, under Diagnostic Code 5309 discusses the forearm muscles, and how they act in strong grasping movements and are supplemented by the intrinsic muscles in delicate manipulative movements. Intrinsic muscles of the hand include the thenar eminence and hypothenar eminence. Diagnostic Code 5309 directs that, because the hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc., VA is to rate on limitation of motion, with a minimum 10 percent rating. Given the weakened grip strength and limited finger dexterity described above, to specifically include during flare-ups, the Board believes that the assignment of separate 10 percent ratings for each hand, effective the date of the Veteran's claim, adequately contemplates these un-addressed manifestations of both Raynaud's syndrome and wrist fracture residuals. In sum, the Board finds that the Veteran's appeal for the assignment of a rating higher than 40 percent for Raynaud's syndrome under Diagnostic Code 7117 must be denied. Similarly, the assigment of a rating higher than 10 percent for each wrist respectively, based on limitation of motion under Diagnostic Code 5215 is also denied. However, separate 10 percent ratings for the right and left hand based on muscle impairment affecting dexterity and grip strength are granted, both effective June 19, 2007. As it is not factually ascertainable that an increase in the Veteran's disabilities actually occurred specifically during the one-year period prior to the filing of his June 19, 2007 claim, an effective date earlier than the date of claim for the award of the separate 10 percent ratings is not warranted. TDIU A total disability rating may be assigned where the schedular rating is less than total when the Veteran is, in the judgment of the rating agency, unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16. In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. If the Veteran has only one service-connected disability, this disability shall be ratable at 60 percent or more. 38 C.F.R. § 4.16 (a). If there are two or more service-connected disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. The phrase "unable to secure and follow a substantially gainful occupation" has an economic component and a noneconomic component. See Ray v. Wilkie, 31 Vet. App. 58, 72 (2019). The economic component considers the Veteran's ability to secure and follow an occupation earning more than marginal income. See 38 C.F.R. § 4.16a (marginal employment shall not be considered substantially gainful employment). The noneconomic component considers such factors as the Veteran's employment history, education, skill, training, physical ability, and mental ability. The Court of Appeals for Veterans Claims (Court) has held that the Veteran's ability or inability to engage in substantial gainful activity has to be looked at in a practical manner, and the test is whether a particular job is realistically within the physical and mental capabilities of the Veteran. Moore v. Derwinski, 1 Vet. App. 356, 359 (1991). The ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one, but a factual determination for the adjudicator. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). In this case, the Board finds entitlement to a TDIU is granted on a schedular basis, effective June 19, 2007, the date he filed his claim for increase. The Board initially notes that the Veteran now meets the schedular eligibility requirements for a TDIU under the provisions of 38 C.F.R. § 4.16(a), with the award of two separate 10 percent ratings for the Veteran's hands above. Indeed, under 4.16(a), for the purposes of establishing schedular eligibility for a TDIU, disabilities affecting the upper extremities can be combined to satisfy the requirement that a claimant has one disability at 60 percent. Second, the Veteran has not worked in any gainful capacity since well before his June 2007 claim. As such, the economic component described above is satisfied. Regarding the non-economic component, the Veteran's Raynaud's syndrome and his wrist fracture residuals clearly impair the Veteran's ability to perform manual labor involving lifting, pushing, and pulling. Moreover, his disabilities impair fine motor skills, and would prevent the Veteran from working in jobs involving typing or writing with a pen. His flare-ups are frequent and unpredictable, triggered at times by changes in the weather or his mood. At times, his flare-ups cause his hands to lock and he must pay them special attention to mobilize them again. Although the Veteran maintains the ability to perform his daily activities, he is often in pain and his disability requires significant attention, to include during a flare-up. Physicians have noted that the Veteran's service-connected disabilities impede his ability to work, and the Board finds no reason to call into question the Veteran's assertion that he could not even perform sedentary work (i.e., seated work) at this time. Resolving all doubt in the Veteran's favor, the Board finds that a TDIU is warranted throughout the period under review, effective June 19, 2007. The benefit sought on appeal is granted. As it is not factually ascertainable that the Veteran's service-connected disabilities became so severe so as to preclude gainful employment specifically during the one-year period prior to the filing of his June 19, 2007 claim, an effective date earlier than the date of claim for the award of a TDIU is not warranted. REASONS FOR REMAND Entitlement to a separate compensable rating for mental health symptoms associated with service-connected Raynaud's syndrome and residuals of right and left wrist fractures. The evidence of record reasonably raises the question of whether additional compensation may be awarded for symptoms of depression caused by the Veteran's service-connected Raynaud's syndrome and residuals of right and left wrist fractures. As noted above, in Morgan v. Wilkie, 31 Vet. App. 162 (2019), the United States Court of Appeals for Veterans Claims (Court) reminded the Board that, in evaluating the rating of a disability, VA has a duty to maximize benefits. See Morgan, 31 Vet. App. at 167. Here, the Veteran and his attorney have argued that the Veteran's physicians have linked his depression and trouble sleeping to his service-connected pain symptoms, and cited to treatment records where the Veteran's depressed mood has been discussed in relation to his pain. On remand, the Veteran should be scheduled for a psychiatric examination to assess the nature and etiology of his symptoms. Following completion of this development, the AOJ should adjudicate whether a separate compensable rating is warranted for mental health symptoms associated with service-connected Raynaud's syndrome and residuals of right and left wrist fractures. The matters are REMANDED for the following action: 1. Schedule the Veteran for a psychiatric examination to assess the nature and etiology of his depression symptoms. The claims file should be sent to, and reviewed by the examiner. The examiner should take a history from the Veteran as to the progression of his symptoms. Upon review of the record, interview and examination of the Veteran, the examiner should indicate whether it is at least as likely as not (50 percent or greater probability) that the Veteran suffers from a psychiatric disability that is related to pain from service-connected Raynaud's syndrome and residuals of right and left wrist fractures. The severity of all symptoms identified should be discussed. 2. Then adjudicate the issue of whether a separate compensable rating is warranted for mental health symptoms associated with service-connected Raynaud's syndrome and residuals of right and left wrist fractures. If such is denied, send the Veteran and his attorney a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Crohe, 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.