Citation Nr: 22015343 Decision Date: 03/17/22 Archive Date: 03/17/22 DOCKET NO. 14-06 710 DATE: March 17, 2022 ORDER Entitlement to an initial disability evaluation in excess of 10 percent for service-connected right wrist disorder, to include carpal-tunnel syndrome (median nerve), is denied. Entitlement to an initial disability evaluation in excess of 10 percent for service-connected left wrist disorder, to include carpal-tunnel syndrome (median nerve), is denied. REMANDED Entitlement to an initial disability evaluation in excess of 10 percent for service-connected right-knee disorder is remanded. FINDINGS OF FACT 1. The Veteran's service-connected right wrist disorder, to include carpal-tunnel syndrome (median nerve), was characterized by mild, incomplete paralysis of the median nerve throughout the period on appeal. 2. The Veteran's service-connected left wrist disorder, to include carpal-tunnel syndrome (median nerve), was characterized by mild, incomplete paralysis of the median nerve throughout the period on appeal, with the exception of mild, incomplete paralysis of the ulnar nerve from July 8, 2013, to June 26, 2018. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability evaluation in excess of 10 percent for service-connected right wrist disorder, to include carpal-tunnel syndrome (median nerve), have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8515. 2. The criteria for entitlement to an initial disability evaluation in excess of 10 percent for service-connected left wrist disorder, to include carpal-tunnel syndrome (median nerve), have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Codes 8515, 8516. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from June 1970 to June 1994. Upon appeal to the United States Court of Appeals for Veterans Claims after the Board's December 2019 denial of the claims remaining on appeal, the Court noted in its June 2021 Memorandum Decision the Veteran does not appeal the Board's denial of total disability evaluation based on individual unemployability, due to service-connected disabilities (TDIU), and added any appeal of that matter is dismissed. Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 12627 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the relevant overall temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as "pyramiding," must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury, so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14. When evaluating musculoskeletal disabilities, VA, in addition to applying the schedular criteria, may assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while "pain may cause a functional loss, pain itself does not constitute a functional loss," and, is therefore, not grounds for entitlement to a higher disability rating). Additionally, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, actually painful, unstable or malaligned joints, due to a healed injury, are recognized as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see also Burton v. Shinseki at 5 (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). 1. Entitlement to an initial disability evaluation in excess of 10 percent for service-connected right wrist disorder, to include carpal-tunnel syndrome (median nerve). 2. Entitlement to an initial disability evaluation in excess of 10 percent for service-connected left wrist disorder, to include carpal-tunnel syndrome (median nerve). The Board denied these claims in its December 2019 decision. Upon appeal by the Veteran to the United States Court of Appeals for Veterans Claims (the Court), the Court in its June 2021 Memorandum Decision set aside entitlement to disability ratings greater than 10 percent for right wrist disorder, to include carpal tunnel syndrome, under Diagnostic Code 8515 and for left wrist disorder, to include carpal tunnel syndrome, under Diagnostic Codes 8515 and 8516. The Court found the Board's discussion of the incomplete paralysis of the Veteran's median and ulnar nerves to be inadequate because the Board did not explain, in the context of the facts presented, the rating criteria used in determining the category into which the Veteran's wrist symptoms fall. The Board noted only that the rating could be "mild" or "moderate" when the nerve involvement is wholly sensory, but it offered no explanation to distinguish the criteria required for those ratings. The Court added VA's Adjudication Procedures Manual (M21-1) provides benchmarks for mild, moderate, moderately severe, and severe peripheral nerve conditions, but the Board did not discuss them. The Court further added, although the Board is not bound by the M21-1, it "is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons or bases," citing Overton v. Willkie, 30 Vet. App. 257, 264 (2018). Lastly, the Court noted, although the "reasons-or-bases requirement" does not mandate that the Board precisely define such undefined terms, the requirement does dictate that the Board provide a statement of reasons or bases sufficiently detailed to enable the Veteran and the Court to understand how the Board applied these terms. Therefore, the Board's failure to articulate the distinction between "mild" and "moderate" degrees of impairment renders its reasons or bases inadequate and requires remand. Upon the case returning to the Board the Veteran submitted argument and a copy of M21-1 provisions. The Board will consider any other arguments not raised by the Veteran or the record waived. In Carter v. Shinseki, the Court held "when an attorney agrees to a joint motion for remand based on specific issues and raises no additional issues on remand, the Board is required to focus on the arguments specifically advanced by the attorney in the motion." 26 Vet. App. 534, 54243 (2014), rev'd on other grounds by Carter v. McDonald, 794 F.3d 1342 (Fed. Cir. 2015). The Board has done so here. See also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (declining to consider a duty to assist argument because the appellant failed to raise the issue to the Board); Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Paralysis of the median nerves evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8515, with neuritis and neuralgia of that group of nerves evaluated under Diagnostic Codes 8615and 8715. Under these criteria, mild incomplete paralysis is rated as 10 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 percent for the major extremity and 20 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis is rated as 70 percent for the major extremity and 60 percent for the minor extremity. Complete paralysis of the median nerve is characterized by the hand inclined to the ulnar side, the index and middle fingers more extended than normally, 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; and pain with trophic disturbances. 38 C.F.R. § 4.124a. Paralysis of the ulnar nerve is rated under 38 C.F.R. § 4.124a, Diagnostic Code 8616, with neuritis and neuralgia of that nerve group evaluated under Diagnostic Codes 8616 and 8716. Under these criteria, mild incomplete paralysis is rated as 10 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 percent for the major extremity and 20 percent for the minor extremity. Severe incomplete paralysis is rated as 40 percent for the major extremity and 30 percent for the minor extremity. Complete paralysis is rated as 60 percent for the major extremity and 50 percent for the minor extremity. Complete paralysis of the ulnar nerve is characterized by the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers; cannot spread the fingers (or reverse), cannot adduct the thumb; and flexion of wrist weakened. 38 C.F.R. § 4.124a. Paralysis of the lower radicular groups are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8512, with neuritis and neuralgia of those groups evaluated under Diagnostic Codes 8616 and 8716.) Under these criteria, mild incomplete paralysis is rated as 20 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 40 percent for the major extremity and 30 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis is rated as 70 percent for the major extremity and 60 percent for the minor extremity. Complete paralysis of the lower radicular group is characterized by all intrinsic muscles of hand, and some or all of flexors of wrist and fingers, paralyzed (substantial loss of the use of the hand). 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. 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 is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). As stated above by the Court, VA's M21-1 offers guidance in the assignment of mild, moderate, moderately severe, and severe evaluations for peripheral nerve condition, and, "[a]lthough the Board is not bound by the M21-1, the standards provided in the M21-1 are 'relevant guidance promulgated for the purpose of facilitating the efficient and proper resolution of claims,' which the Board must consider and address as part of its duty to provide a reasoned explanation for its decision." Chavis v. McDonough, 34 Vet. App. 4, 17-18 (2021) (citing Healy v. McDonough, 33 Vet. App. 321 (2021) and Overton v. Wilkie, 30 Vet. App. 257, 264 (2018)). In looking to that portion of the M21-1 addressing peripheral-nerve impairment when solely manifested by sensory impairment, it directs decision makers to assign the evaluation corresponding with the mild or, at most, moderate degrees of impairment, set forth in the Diagnostic Codes 8515 and 8516. The guidelines provided by the M21-1 for distinguishing the above levels of impairment first note (1) the "mild" level of evaluation would be more reasonably assigned when sensory symptoms are recurrent but not continuous, assigned a lower medical grade reflecting less impairment and/or affect a smaller area in the nerve distribution; (2) a moderate level of evaluation should reflect "the most significant and disabling cases of sensory-only involvement," indicated by continuous symptoms, when symptoms are a higher medical grade reflecting greater impairment and/or they affect a larger area in the nerve distribution. M21-1, Part V, Subpart iii, Chapter 12, Section A.2.b; see also 38 C.F.R. § 4.124a. "Moderately severe" incomplete paralysis is the maximum rating for sciatic nerve neuritis not characterized by the organic changes specified in 38 C.F.R. § 4.123. The term would be appropriate for "[m]otor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a high level of limitation or disability... Atrophy may be present. However, for marked muscular atrophy, see the criteria for a severe evaluation under 38 C.F.R. § 4.124a, Diagnostic Code 8520." Id.; see also M21-1, III. iv. 4. N. 4. c. In general, severe incomplete paralysis of a peripheral nerve involves motor and/or reflex impairment, "(for example atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability." Id. "Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain should be rated as high as severe incomplete paralysis of the nerve." Id. Turning to the record, the Board first notes from the May 2012 VA examination, the Veteran reported dropping things and past intermittent pain/cramping. He further reported current symptoms as "cramping at times," occurring once every 2 weeks and numbness at times ("comes/goes") at the palmar and dorsal sides of the hand about every 1-2 months, affecting all fingers. Findings on examination revealed no constant pain, but there was mild intermittent pain. There was no paresthesias and/or dysesthesias, but there was mild numbness of the bilateral upper extremities. The examiner found normal results for muscle, reflex and sensory testing. There were no trophic changes. Special tests for the median nerve were negative. The examiner indicated that all upper extremity nerves, to include the median, ulnar and lower radicular groups, were normal. However, a June 2012 addendum to the examination in fact indicated the affected nerves were the median nerves, bilaterally, which were affected by mild, incomplete paralysis. The examiner specifically noted that the findings were "completely based on subjective complaint, not objective findings." The Board concludes the above reports and examination findings support the Board's finding throughout the appeal period for mild, incomplete paralysis of the median nerve of the right upper extremity. Moreover, the reports and findings are consistent with M21-1 guidelines. For example, the Veteran reported sensory symptoms of past intermittent pain and cramping and current cramping and numbness "at times." Although recurrent, these symptoms plainly indicate they are not continuous and, although the Veteran's fingers may be affected, this, too, appears to be no more than intermittent, as the Veteran reported occurrences of numbness every 1 to 2 months. Although reported fairly precisely by the Veteran, neither the above reports nor any objective clinical findings on examination show the reported symptoms affected a wide area in the nerve distribution. For example, muscle, reflex and sensory testing were normal, there were no trophic changes and special tests for the median nerve were negative. As such, motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) were not in evidence. Moreover, as examination findings and the Veteran's reports do not rise to the level of a moderate evaluation, higher evaluations are not applicable, as there is no involvement of the sciatic nerve (moderately severe). Additionally, as the examiner found no motor and/or reflex impairment, no trophic changes and no signs or symptoms identical or similar to those of complete paralysis, this supports the finding of mild, incomplete paralysis of the right-upper-extremity median nerve. In a July 2013 VA electromyogram (EMG)/nerve conduction study (NCS), the Veteran reported intermittent hand numbness, "electrical-shocking sensations" and hand use can bring on cramping. He added these symptoms began in prior years, but improved somewhat with hand therapy. The treating professional provided the interpretation of the results of testing as right-median-distal motor latency is delayed with normal amplitude and forearm conduction. The left-median motor study is normal. Right-ulnar-motor study is normal. Left-ulnar-motor study is normal except for conduction slowing across the elbow. Radial and ulnar-sensory studies are normal. Left-median-sensory potential with mid-palm stimulation is normal. Stimulation at the wrist in both hands reveals delayed latencies with normal amplitudes. Lastly, an electronystagmogram (ENG) of the muscles sampled was also normal. From this, the treating professional gave his diagnostic impression as electrophysiologic evidence of left-arm mild carpal-tunnel syndrome and moderate ulnar neuropathy, right-arm moderate carpal-tunnel syndrome and otherwise normal studies with no electrophysiologic evidence of radiculopathy, other neuropathy or myopathy involving either arm. Based on M21-1 guidelines, the Board's overall findings for the appeal period of right wrist carpal-tunnel syndrome, left wrist carpal-tunnel syndrome and a separate rating for left wrist carpal-tunnel syndrome (ulnar nerve), each at a mild evaluation, are appropriate. For example, in addition to test-result data showing motor studies to be normal, relevant sensory studies indicated this as well. Additionally, whether or not the treating professional's diagnostic impression of right-arm "moderate" carpal tunnel syndrome and left-arm "moderate" ulnar neuropathy necessarily equate to "moderate" overall severity as that term is used in the rating criteria, in considering Veteran's reports of numbness, cramping and "shocking" sensations appearing only intermittently, such reports and the above test results do not support the conclusion that sensory symptoms are "affecting a larger area in the nerve distribution." As a factual determination by the Board and in consideration of the M21-1 guidelines, the foregoing does not plausibly rise to a moderate level of severity, defined in the M21-1 as "the most significant and disabling cases of sensory-only involvement." In the February 2014 VA examination, the examiner noted, based on the Veteran's reports, he "still has" pain, numbness and tingling, as well as experiencing difficulties carrying things, to include dropping them. Findings on examination revealed moderate constant pain, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and severe numbness of the bilateral upper extremities. The examiner found normal muscle, reflex and sensory testing results. There were no trophic changes. Special tests for the median nerve were positive, including both Phalen's sign and Tinel's sign. The examiner found the Veteran had mild, incomplete paralysis of the median nerve, bilaterally, and mild, incomplete paralysis of the left-ulnar nerve. The examiner indicated that all other upper-extremity nerves, to include the lower-radicular group, were normal. The examiner's findings were explicitly based on his own examination and review of the July 2013 VA EMG study, which is included in the middle of the February 2014 examination report and the examiner therefore was fully aware of its findings. Looking to the M21-1 factors to distinguish "mild" from "moderate" degrees of impairment, although the examiner found pain and tingling at moderate levels and numbness at a severe level, the examiner nonetheless assigned "lower medical grade[s]" of mild, incomplete paralysis of the right and left-median nerves, and mild, incomplete paralysis of the left-ulnar nerve, thereby reflecting less impairment. The Veteran's reports to the examiner appear not to have changed from what he reported at the July 2013 EMG test and thereby do not indicate continuous symptoms. Moreover, muscle, reflex and sensory testing were normal, there were no trophic changes and special tests for the median nerve were negative. The absence of reports to the contrary and findings of normal motor and/or reflex function indicate no larger area was affected in the medial or ulnar-nerve distributions and he overall finding of impairment being mild is appropriate. For the same reasons as stated for the May 2012 examination and the June 2012 addendum, the higher evaluations of moderately severe and severe are not applicable. A June 2018 Private Hospital EMG study, submitted by the Veteran, shows the treatment provider's summary of findings indicating right-median motor distal latency is at the upper limits of normal values and prolonged compared with the ipsilateral ulnar motor nerve, with normal conduction velocity, and right-median sensory distal latency is prolonged. Each of the other 11 nerve-study findings were normal. The treatment provider's diagnostic impression was tingling and pain in the bilateral hands and mild right-median compression neuropathy at the wrist (carpal-tunnel syndrome), "by electrodiagnostic study." In short, the June 2018 EMG study found only right wrist mild carpal-tunnel syndrome (median nerve), but, significantly, made no finding of left-wrist/arm mild carpal-tunnel syndrome (moderate ulnar nerve), as was found in the July 2013 EMG and the February 2014 examination. In considering once again the M21-1 factors, the treatment provider's diagnostic impression suggests even less effect on the nerve distribution area, as only the hands were affected with symptoms of tingling and pain. The examiner added right-median carpal tunnel syndrome was established, not by reports of impairment, but "by electrodiagnostic study." The foregoing does not reasonably suggest "significant and disabling" sensory involvement, indicating higher medical-grade findings "reflecting greater impairment" and a larger area in the nerve distribution affected. M21-1, Part V, Subpart iii, Chapter 12, Section A.2.b. For the same reasons as stated for the May 2012 examination and the June 2012 addendum, the higher evaluations of moderately severe and severe applicable. In the July 2018 VA examination, the Veteran made no particular reports, other than recounting right and left-release surgeries in 2005, subsequent therapy and his June 2018 EMG, noted by the examiner. The examiner found on subject symptoms upon examination to be mild constant pain, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness of the bilateral upper extremities. The examiner noted normal muscle, reflex and sensory testing, except for decreased sensation in the hand/fingers. There were no trophic changes. Special tests for the median nerve on this examination were negative. However, the examiner found only right-arm mild, incomplete paralysis of the median nerve. The examiner further found all other upper extremity nerves were normal, once again, most notably including both the left-ulnar nerve and the left-median nerve. For the same reasons discussed above for the June 2018 private EMG, the findings in the July 2018 examination are consistent with the M21-1 factors for the "mild" level of evaluation for sensory symptoms and a moderate or higher evaluation is not applicable. While the Veteran is competent to report things like "moderate symptoms" per 38 C.F.R. § 3.159(a)(2), assessing the severity of nerves can be complex and requires diagnostic testing to be considered. Laypersons have generally been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). The Board assigns the diagnostic testing and expert assessment of that testing via the clinicians more weight here. The above-summarized medical evidence establishes that, by June 2018, the ulnar nerve was no longer affected and so confirmed by the July 2018 VA examination findings. Moreover, throughout the record for the appeal period, not one of the VA examiners, nor either of the specialists conducting the EMGs, found the overall severity of the Veteran's carpal-tunnel-syndrome impairments to be more than mild, incomplete paralysis of the median or ulnar nerves, thereby identifying and assigning "a lower medical grade" reflecting less impairment. A moderate evaluation is not applicable based on the above findings for the reasons stated in earlier examinations and EMG studies. Nor for the same reasons as stated for the May 2012 examination and the June 2012 addendum are the higher evaluations of moderately severe and severe applicable. The Board has considered the M21-1 factors and, for the reasons stated, concludes right-arm mild, incomplete paralysis of the median nerve, establishing right wrist carpal-tunnel syndrome, is consistent with the reports and findings of record and the M21-1 guidelines for evaluating peripheral-nerve impairment when solely manifested by sensory impairment. The Board acknowledges the Veteran's assertion that his symptoms are not contemplated under the schedular criteria. In particular, he has argued he has trouble holding and manipulating objects with his hands. However, given the broad nature of § 4.120, finding symptoms not contemplated by 'impairment of motor, sensory or mental function' language presents quite a challenge." Spellers v. Wilkie, 30 Vet. App. 211, 218 (2018). The Veteran's subjective reports of symptoms and functional limitations were considered by the medical professionals in rendering their clinical evaluations. The severity of the Veteran's impairments based on examination findings, electrodiagnostic testing and the functional impacts he described fall within the functional deficiencies contemplated by the rating criteria. For these reasons, the Board finds no approximate balance of the evidence for the claims and an evaluation in excess of 10 percent disabling for service-connected right wrist carpal-tunnel syndrome (median nerve) remains denied. The Board further finds, as the AOJ has assigned an additional separate 10 percent rating under Diagnostic Code 8516 for left wrist carpal-tunnel syndrome (ulnar nerve) for the period July 8, 2013 to June 26, 2018, the record does not support higher ratings for the Veteran's service-connected left wrist disorder, to include carpal-tunnel syndrome (median nerve and ulnar nerve), and that current claim also remains denied. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As there is no approximate balance of the evidence for the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. REASONS FOR REMAND 3. Entitlement to an initial disability evaluation in excess of 10 percent prior to September 10, 2015 for right-knee instability. In its December 2017 decision, the Board assigned a separate 10 percent rating for right-knee lateral instability under Diagnostic Code 5257. The claim for a higher initial rating was denied in the Board's December 2019 decision and the Veteran appealed to the Court. The Court concluded the Board clearly erred when it relied on the July 2011, June 2014, September 2017, and July 2018 VA examinations to deny a higher right-knee disability rating before September 10, 2015, but failed to obtain a retrospective medical examination which complies with Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017) regarding active, passive, and weight bearing and non-weight bearing ranges of motion and ascertaining the frequency and limitation of motion caused by the Veteran's reported right-knee stiffness. For these reasons, the Board remands for a new examination adequate for VA rating purposes. The matter is REMANDED for the following action: 1. Contact the Veteran and/or his representative for information pertaining to any current treatment for right and left-ankle disorders any VA facility and by any private treatment provider. Obtain any records of the above treatments not yet associated with the claims file and associate them with the claims file. The assistance of the Veteran and/or his representative should be requested in obtaining any records of recent treatment as indicated. All attempts to obtain records should be documented in the claims file. 2. After all additional records have been obtained and associated with the claims file, but whether or not records are obtained, arrange for review of the claims file by an examiner with an appropriate specialty for producing findings for knee disorders. The complete electronic claims file must be made available to the examiner in conjunction with the review. The examiner should detail all findings. The examiner is specifically requested to provide retrospective findings based on historical range of motion testing to ascertain the severity of the Veteran's right-knee disorder in the period prior to September 10, 2015. For that period, the examiner is requested to provide range of motion measurements showing testing for active and passive motion and in weight-bearing and non-weight-bearing maneuvers and in comparison to the undamaged opposite joint (where appropriate). If the foregoing testing is impracticable, induces discomfort or pain or is medically inappropriate, the examiner should provide an explanation as to why. The examiner is further requested to provide findings for the same period reflecting the extent of impairment of function due to repeated use over time and due to flare-ups. If it is found that pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or during a flare-up, it will be insufficient for the examiner to fail to make any range of motion findings on the basis that testing did not occur for repeated use over time or for a flare-up or to make findings such as "would be mere speculation" or "there is no conceptual or empirical basis for making such a determination without directly observing function under these conditions" or similar statements. Even if pain on repeated use over time or flare-ups are neither reported nor exhibited during the examination, once again, it will be insufficient for the examiner to make entries such as "not applicable," "would be mere speculation" or similar statements or fail make any findings whatsoever. The examiner must elicit from the Veteran details as to the actual effects, or what might have been the effects, on function from repeated use over time or from flare-ups when pain, weakness, fatigability, or incoordination significantly limit functional ability. If the Veteran is unable to articulate sufficiently a description, then the examiner should request the Veteran to demonstrate the extent of limitation of motion by the movement of his right-knee/lower leg. After doing so, the examiner is requested for VA rating purposes to estimate the loss of range of motion and function in terms of actual degrees, using his or her professional medical training, knowledge and experience. Any commentary or opinion rendered by the examiner must be accompanied by a rationale, by which conclusions are supported by references to and discussion of findings on examination, to clinical findings in the medical evidence of record and/or to accepted medical literature. The examiner is requested to comment in the rationale on any relevant opinions found in the record. (Continued on the next page) The examiner is further requested to discuss any lay evidence of the Veteran or other persons in record pertaining to right-knee disorder, to include the Veteran's reports to treatment providers and examiners as they appear throughout the record. The Board urges the examiner to note that findings or opinions rendered without addressing and discussing lay evidence of the Veteran regarding his right-knee disorder will be deemed insufficient for VA rating purposes. 3. After completing the above development and any other indicated development, readjudicate the claim. If the benefits sought are not granted, provide the Veteran and his representative with a Supplemental Statement of the Case and allow an appropriate opportunity to respond before returning the case to the Board. EMILY TAMLYN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, Associate 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.