Citation Nr: 21042468 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-47 663 DATE: July 13, 2021 ORDER A rating in excess of 10 percent for limitation of motion of the left wrist, status post excision of ganglion cyst (left wrist disability), is denied. REMANDED Entitlement to a separate compensable rating for numbness of the left hand is remanded. FINDING OF FACT Throughout the period on appeal, the Veteran's left wrist disability has most nearly approximated painful motion of the left wrist resulting in functional loss, without ankylosis or the functional equivalent thereof. CONCLUSION OF LAW The criteria for an evaluation in excess of 10 percent for limitation of motion of the left wrist have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Coast Guard from January 2002 to December 2006. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office in Decatur, Georgia. The issue of entitlement to an evaluation in excess of 10 percent for the Veteran's left wrist disability was previously before the Board in November 2018, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. After taking further action, the AOJ confirmed and continued the prior rating and returned the case to the Board. See June 2020 supplemental statement of the case (SSOC). In the November 2018 remand, the Board directed the AOJ to schedule the Veteran for a VA joints examination for purposes of assessing the current severity of his left wrist disability, specifically requesting that the examiner test for pain with active and passive motion, and with weight-bearing and non-weight-bearing, as well as testing the range of motion of the opposite wrist joint (if undamaged). The claims file reflects that the AOJ requested the appropriate examination and that the examiner addressed the specific questions regarding the enumerated tests. There has been at least substantial compliance with the Board's remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). The Board notes, however, that the Veteran's original January 2007 claim for service connection for a left wrist disability included an assertion of tingling and numbness in his fingers. While he was granted compensation for his left wrist disability based on limitation of motion of the wrist in a June 2007 rating decision, that decision did not address his contentions relative to neurologic abnormalities of the left hand. The Veteran again noted numbness in his fingers when he filed his February 2013 Application for Compensation and/or Pension seeking a rating in excess of 10 percent for the left wrist, and the record reflects numerous other complaints of numbness in his fingers during the period on appeal. While the Veteran has not filed a specific claim for a neurologic disability related to his left wrist or hand, based on the totality of the record, and the Veteran's implicit desire to obtain compensation for the entirety of his symptoms, the Board finds that his entitlement to compensation for such symptomatology is best viewed as part and parcel of the current claim for increased rating, rather than a separate matter. See 38 C.F.R. § 3.155(d)(2). The Board has expanded the issues on appeal to incorporate the totality of his asserted symptoms. Entitlement to an increased rating for limitation of motion of the left wrist. The Veteran contends, in essence, that he is entitled to a higher evaluation for his left wrist disability. He is currently rated as 10 percent disabled for the left wrist under Diagnostic Code 5215-5003. Disability evaluations are determined by the application of a schedule of ratings, which is in turn based on the average impairment of earning capacity caused by a given disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the evaluations to be assigned to the various disabilities. If there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If different disability ratings are warranted for different periods of time over the life of a claim, "staged" ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). In evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss, including due to weakness and pain, affecting the normal working movements of the body in terms of excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. With respect to disabilities of the joints, it must be considered whether there is less movement or more movement than normal, weakened movement, excess fatigability, incoordination, or pain on movement, as well as whether there is swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. These provisions require a determination as to whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca v. Brown, 8 Vet. App. 202, 206 07 (1995). However, a higher rating based on functional loss may not exceed the highest rating available under the applicable diagnostic code(s) pertaining to range of motion. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a veteran's lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev'd on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). In determining if a higher rating is warranted, pain itself does not constitute functional loss. Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance, as provided in §§ 4.40 and 4.45. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The intent of the Rating Schedule is to recognize actually painful, unstable or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Painful motion should be considered to determine whether a higher rating is warranted on such basis, whether or not arthritis is present. See Burton v. Shinseki, 25 Vet. App. 1. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record, but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the claim. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that the Veteran's left wrist disability is rated, by analogy, under the criteria for degenerative arthritis (Diagnostic Code 5003) and limitation of motion of the wrist (Diagnostic Code 5215). Under Diagnostic Code 5003, degenerative 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. When, however, the limitation of motion is non-compensable 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. In the absence of limitation of motion, x-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, x-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings will not be combined with ratings based on limitation of motion. Id. Under Diagnostic Code 5215, a 10 percent rating is warranted for limitation of palmar flexion of the major or minor wrist in line with the forearm. Id. A 10 percent rating is also warranted under Diagnostic Code 5215 for limitation of dorsiflexion of the major or minor wrist to less than 15 degrees. Id. Pertaining to ankylosis of the wrist, Diagnostic Code 5214 directs that a 30 percent rating is warranted for the major wrist, and a 20 percent rating is warranted for the minor wrist, for favorable ankylosis in 20 degrees to 30 degrees of dorsiflexion. Id. A 40 percent rating is warranted for the major wrist, and a 30 percent rating is warranted for the minor wrist, for ankylosis in any other position, except favorable. Id. A 50 percent rating is warranted for the major wrist, and a 40 percent rating is warranted for the minor wrist, for unfavorable ankylosis in any degree of palmar flexion, or with ulnar or radial deviation. Id. Diagnostic Code 5214 further directs that extremely unfavorable ankylosis of the wrist is to be rated as loss of use of the hand under Diagnostic Code 5125. Id. at Note. When adjudicating an increased rating claim, the relevant time period for consideration begins one year before the claim was filed. See 38 C.F.R. § 3.400(o); Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). The record reflects that VA received the Veteran's increased rating claim on February 4, 2013. In a December 2013 VA examination, the Veteran reported that since the excision of a left wrist ganglion cyst in March 2013, the cyst reoccurred. He stated that he had a pulling sensation to the left dorsum of his wrist and hand with heavy lifting. He noted that he experienced numbness in his third and fourth fingers after performing physical tasks at work. He indicated that he experienced flare-ups with heavy lifting and repetitive use that resulted in increased pain and swelling. The examiner documented a range of motion in the Veteran's left wrist of 80 degrees or greater of palmar flexion, with painful motion at 70 degrees or greater, and 70 degrees or greater of dorsiflexion, with no objective evidence of painful motion. The examiner indicated that there was no additional loss of range of motion after repetitive use testing, and stated that the Veteran exhibited functional loss, functional impairment, and/or additional limitation of range of motion of his left wrist after repetitive use, in the form of pain on movement and swelling. Muscle strength testing was normal and no ankylosis was noted. The examiner concluded that the Veteran would have pain and difficulty with heavy lifting and repetitive use of his wrist. In his February 2014 notice of disagreement, the Veteran stated that when he performed daily routine tasks (e.g., vacuuming, sweeping, mopping, etc.) with his left hand, his fingers would go numb. He claimed that he was unable to do anything that would result in pressure being put on his left wrist due to pain. He noted that the cyst in his left wrist was reforming and he would likely need another surgery to remove it. In his July 2015 VA Form 9, the Veteran reported that by the end of his workday, during which he prepared food in a school cafeteria and cleaned the school, his left wrist would be extremely stiff and sore. He noted that he took over-the-counter pain medication for relief, but stated that it did little to address his pain. He claimed that he was recently required to take a CPR course, and was barely able to complete the chest compressions portion due to pain in his wrist. He indicated that he also experienced numbness in his fingers on a daily basis, and that he was unable to drive long distances without his wrist becoming stiff and painful. He further claimed that he could not fully do yard work without pain, and that he also experienced pain with activities such as typing, fishing, and playing with his young family members. He stated that his symptoms had progressively worsened. A June 2016 VA primary care physician note indicated that the Veteran reported mild soreness in his left wrist after the removal of a ganglion cyst in April 2016. In a February 2019 VA physical medicine rehab consultation note, the Veteran denied experiencing any numbness or tingling in his left hand. A June 2019 VA physical medicine rehab note indicated that the Veteran had mild apparent weakness of his left hand. During a September 2019 VA authorized examination, the Veteran reported that his pain had worsened over the years, despite removal of the cyst. He indicated that he experienced throbbing pain in his left wrist with movement, and noted that he took over-the-counter pain medication two to three times per day. He stated that he did not experience flare-ups. The examiner recorded a range of motion in the Veteran's left wrist of 70 degrees of palmar flexion, 70 degrees of dorsiflexion, 45 degrees of ulnar deviation, and 20 degrees of radial deviation. The examiner indicated that pain was noted on examination in dorsiflexion, but that it did not result in functional loss. The examiner stated that there was no additional loss of range of motion after repetitive use testing, and indicated that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. The examiner found that after review of the record, there was no basis to offer additional losses of function or motion with repeated use over time. Muscle strength testing was normal, and no ankylosis was noted. The examiner documented that there was no evidence of pain on passive range of motion testing and no evidence of pain when used in non-weight bearing. The examiner concluded that the Veteran's left wrist disability did not impact his ability to perform any type of occupational task. On review of the record, the Board finds that a rating in excess of 10 percent for limitation of motion of the Veteran's left wrist is not warranted for any portion of the period on appeal. There is no evidence that the Veteran has had actual ankylosis of the left wrist, or the functional equivalent thereof. Although he has experienced functional loss, the Board notes that the limitation of motion in his left wrist, as assessed on examination, has not risen to a level that meets the requirements for a compensable rating under Diagnostic Code 5215. Rather, the 10 percent rating assigned for his disability represents compensation for an otherwise noncompensable disability on the basis of functional loss. As there has been no ankylosis of the left wrist during the period on appeal, there is no basis for a higher rating under Diagnostic Code 5214. Moreover, as 10 percent is the maximum available under DC 5215, an increased rating is not warranted under that Diagnostic Code. In summary, the Board finds that the preponderance of the evidence is against a finding that the Veteran's left wrist disability symptoms have more nearly approximated the criteria for an evaluation in excess of 10 percent. To that extent, the appeal must be denied. REASONS FOR REMAND Entitlement to a separate compensable rating for numbness of the left hand is remanded. As noted above, the Veteran has reported on multiple occasions that he experiences numbness and/or tingling in the fingers of his left hand. The record does not reflect that he has been afforded a VA examination aimed at assessing neurologic symptoms. As such, additional development is necessary. This matter is REMANDED for the following action: 1. Arrange to have the Veteran scheduled for a VA neurological examination of his left hand. The examiner should review the record. All indicated tests should be conducted and the results reported. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner should identify any neurologic disabilities of the left hand that are present. The examiner should then provide an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that any such disabilities have been (a) caused or (b) aggravated by the Veteran's service-connected left wrist disability. The clinician must provide a rationale for all opinions expressed. If the clinician cannot provide the requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. Specifically, the clinician must indicate whether there was a further need for information or testing, or whether an opinion could not be rendered due to limitations of knowledge in the medical community at large. 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraph, the issue remaining on appeal should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran should be issued a SSOC. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Ferguson, 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.