Citation Nr: 21040752 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 16-40 688A DATE: July 6, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for residuals of a left wrist navicular fracture (left wrist disability) is denied. REMANDED Entitlement to a separate compensable rating for a left wrist neurological disability is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDING OF FACT The Veteran's left wrist disability has not manifested in ankylosis or its functional equivalent. CONCLUSION OF LAW The criteria for an initial rating in excess of 10 percent for a left wrist disability are not met. 38 U.S.C. § 1155 (2018); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5215 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from January 1976 to September 1982. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a July 2014 rating decision issued by a Regional Office of the Department of Veterans Affairs (VA). In December 2019, the Board remanded the claim to the Agency of Original Jurisdiction (AOJ) for additional development. The case has since been returned to the Board. Increased Rating Left Wrist In a July 2014 rating decision, the RO granted service connection and assigned an initial 10 percent rating for a left wrist disability effective October 18, 2013. The Veteran appealed, requesting a rating in excess of 10 percent. The Veteran's left wrist disability has been rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5215. Under Diagnostic Code 5215, a 10 percent rating is warranted for limitation of the wrist with dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm, i.e., to zero degrees. Higher ratings are warranted for ankylosis of the wrist under Diagnostic Code 5214. For the minor extremity, a 20 percent rating is warranted for favorable ankylosis of the wrist in 20 to 30 degrees of dorsiflexion. A 30 percent rating is warranted for ankylosis of the wrist in any other position, except favorable. A 40 percent rating is warranted for unfavorable ankylosis, in any degree of palmar flexion, or with ulnar or radial deviation. The report of a June 2014 VA examination noted that the Veteran sustained a navicular fracture playing basketball during service. He reported having problems with his left wrist for three months. Prior to that, he stated that he had no issues. He stated that he had no strength in his wrist, which preventing him from lifting. He denied flare-ups but stated that he had increased pain with extension in winter months. He stated he had throbbing pain in the morning, but not at the time of the examination. On examination, palmar flexion was limited to 70 degrees with no evidence of painful motion. Dorsiflexion was limited to 65 degrees with pain at the endpoint. With repetitive testing, there was no additional limitation in range of motion or functional loss/impairment. There was no localized tenderness on palpation. Muscle strength was 5/5, i.e., normal. There was no ankylosis. X-rays of the left wrist were essentially negative. A left lunate bone cyst was noted. The examiner noted that the Veteran was working in the laundry department at the VA Medical Center (VAMC) and that he had no problems folding clothes. The examiner indicated that the Veteran's presentation was out of proportion to imaging findings. The examiner noted that pain could significantly limit functional ability during flare-ups or when the joint was used repeatedly over a period of time. It was noted that there was pain on motion, weakened movement, limited motion, and pain on palpation. During an April 2019 VA examination, the Veteran reported experiencing chronic left wrist pain, stiffness, and weakness. He stated that he could not hold objects well or carry heavy objects. He also reported experiencing a numbness and tingling sensation in his fingers and painful motion. He denied having flare-ups. He stated that with repetitive use, he experienced decreased grip strength and decreased range of motion. On examination, palmar flexion was limited to 70 degrees; dorsiflexion was limited to 40 degrees; ulnar deviation was limited to 20 degrees; and radial deviation was limited to 15 degrees. With repetitive use testing, there was no additional loss of function or range of motion. Pain was noted on examination; however, the examiner indicated that it did not result in functional loss. There was evidence of localized tenderness or pain on palpation of the dorsal wrist, which was described as moderate. There was evidence of pain with weight bearing. There was no objective evidence of crepitus. The examiner indicated that the Veteran was not being examined immediately after repetitive use over time or during a flare-up. The examiner indicated that pain, fatigue, and weakness would significantly limit functional ability with repeated use over a period of time, but not during flare-ups, which the Veteran denied experiencing. The examiner indicated that there was no ankylosis. X-rays of the left wrist showed mild osteoarthritic changes in the triscaphe joint and thumb carpometacarpal joint. There was a nonspecific subcortical cystic change in the lunate. The examiner indicated that there was evidence of pain on non-weight bearing, that passive range of motion was the same as active range of motion, and that there was no objective evidence of pain on passive range of motion testing. The examiner indicated that the Veteran's left wrist had progressed with residual tendinitis and traumatic degenerative joint disease. During an August 2020 VA examination, the Veteran reported experiencing left wrist chronic numbness, stiffness, weakness, and pain with movement. He reported that he was taking Gabapentin. He stated that flare-ups occurred three to four times per week, which he described as moderate in nature and they lasted 15 to 30 minutes. He stated that flare-ups were precipitated by overuse and lifting/carrying heavy objects. He stated that he had difficulty with household chores, heavy lifting/carrying, and gripping/grasping. On examination, left wrist palmar flexion was normal to 80 degrees. Dorsiflexion was limited to 50 degrees. Ulnar deviation and radial deviation were normal. The examiner stated that range of motion resulted in it being hard to push or lift items. Pain was noted on examination and caused functional loss. There was evidence of localized tenderness, pain with weight bearing, and crepitus. With repetitive use testing, there was no additional loss of function or range of motion. The examiner indicated that the Veteran was being examined immediately after repetitive use over time, but not during a flare-up. The examiner indicated that pain and fatigue significantly limited functional ability with repeated use over time and during flare-up. The examiner estimated that with repeated use overtime and during flare-up, range of motion would be additionally limited to 70 degrees of palmar flexion, 40 degrees of dorsiflexion, 40 degrees of ulnar deviation, and 15 degrees of radial deviation. Muscle strength was 4/5 and it was noted that there was a reduction in muscle strength, but no muscle atrophy. There was no ankylosis. The examiner indicated that there was objective evidence of pain on passive range of testing. There was no evidence of pain on non-weight bearing. The examiner stated that due to severity of pain and limited range of motion from osteoarthritis of the left wrist, the Veteran would have a hard time pushing or lifting items with his left wrist. It was also noted that motions such as twisting, e.g.., using a screwdriver, would aggravate the left wrist pain and that activities of daily living were affected in that the had to stay at home and sweeping and over-cleaning aggravated the left wrist pain. In this case, the evidence does not indicate that a rating in excess of 10 percent is warranted for the Veteran's left wrist disability at any time during the appeal period. To warrant a higher rating, the evidence must show evidence of ankylosis of the left wrist. 38 C.F.R. § 4.71a. Ankylosis is generally defined as the complete immobility of a joint in a fixed position. Here, the evidence does not indicate that the Veteran has ankylosis of the left wrist or that his overall symptomatology more closely approximates ankylosis. At worst, dorsiflexion was limited to 40 degrees and palmar flexion was limited to 70 degrees. Furthermore, the August 2020 VA examiner indicated that during flare-ups and with repeated use over time, dorsiflexion would be limited to 40 degrees and palmar flexion would be limited to 70 degrees. The Board does not find that the symptoms described by him, his treating physicians, and VA examiners are functionally equivalent to ankylosis of the left wrist even when considering repeated use over time and flare-ups. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Therefore, a rating in excess of 10 percent is not warranted. 38 C.F.R. § 4.71a. The Board notes that effective February 7, 2021, the rating criteria pertaining to musculoskeletal disabilities were revised. See 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). However, the rating criteria pertaining to the Veteran's service-connected left wrist disability were not substantively changed. In sum, the Board finds that the Veteran's symptomatology is consistent with a 10 percent rating throughout the appeal period. A higher rating is not warranted for the left wrist disability. 38 C.F.R. § 4.71, Diagnostic Code 5215. REASONS FOR REMAND The Board finds that additional development is required before the remaining claims on appeal are decided. Left Wrist Neurological Disability The Veteran reported that he experienced numbness and tingling in his left wrist and fingers and that he was treated with Gabapentin; however, it is unclear whether he has a separate neurological disability associated with the service-connected left wrist navicular fracture. Therefore, the Board finds that a remand is necessary for a VA examination and medical opinion. TDIU The Veteran has also raised the issue of entitlement to TDIU in connection with his claim for an increased rating for his service-connected left wrist disability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). On remand, the AOJ should adjudicate this matter in the first instance. See Bernard v. Brown, 4 Vet. App. 384 (1993). Additionally, current treatment records should be identified and obtained before a decision is made with regard to the issues remaining on appeal. The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 2. Then, schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of his claimed left wrist and hand numbness and tingling. Any indicated studies should be performed. Based on the examination results and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that any currently present left wrist neurological disability was incurred in or is otherwise related to the Veteran's active service, to include the left wrist navicular fracture. If so, the examiner should also comment on the severity of symptomatology and report all signs and symptoms necessary for evaluating the disability under the rating criteria. A rationale for all opinions expressed must be provided. 3. Confirm that the VA examination report and all opinions provided comport with this remand and undertake any other development found to be warranted. 4. Then, readjudicate the issues remaining on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mishalanie, 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.