Citation Nr: 23027229 Decision Date: 05/08/23 Archive Date: 05/08/23 DOCKET NO. 18-24 028 DATE: May 8, 2023 ORDER Entitlement to an initial rating in excess of 10 percent for right wrist tendonitis with volar ganglion cyst is denied. Entitlement to an initial rating in excess of 10 percent for left wrist tendonitis with volar ganglion cyst is denied. FINDINGS OF FACT 1. The Veteran's right wrist tendonitis with volar ganglion cyst is manifested by flare-ups, pain, fatigue, weakness, locking up, and limited range of motion. It is not manifested by ankylosis nor functional ankylosis. 2. The Veteran's left wrist tendonitis with volar ganglion cyst is manifested by flare-ups, pain, fatigue, weakness, locking up, and limited range of motion. It is not manifested by ankylosis nor functional ankylosis. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right wrist tendonitis with volar ganglion cyst 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 5024-5215. 2. The criteria for an initial rating in excess of 10 percent for left wrist tendonitis with volar ganglion cyst 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 5024-5215. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1996 to June 2016. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2022, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge; a transcript is of record. An August 2022 Board decision remanded the issues on appeal for further development; there was substantial compliance with the remand directives. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. 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. Where 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 1. Entitlement to an initial rating in excess of 10 percent for right wrist tendonitis with volar ganglion cyst. 2. Entitlement to an initial rating in excess of 10 percent for left wrist tendonitis with volar ganglion cyst. The Veteran seeks initial ratings in excess of 10 percent for her right and left wrist tendonitis with volar ganglion cyst disability (hereafter bilateral wrist disability). For the reasons that follow, the Board finds that ratings in excess of 10 percent are not warranted. Service connection for the Veteran's bilateral wrist disability was granted in a September 2016 rating decision. Initial 10 percent ratings were assigned for each wrist, effective July 1, 2016, for painful motion under 38 C.F.R. § 4.59. The Veteran timely appealed from the initial ratings, therefore, the appeal period before the Board begins on July 1, 2016, the effective date for the grant of service connection. The Veteran's bilateral wrist tendonitis is rated under Diagnostic Codes 5024-5215. 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 limitation of motion of the wrist, Diagnostic Code 5215, is rated under the criteria for, among other things, tendonitis, Diagnostic Code 5024. Ratings for the wrists are available pursuant to Diagnostic Codes 5214 and 5215. Diagnostic Code 5214 provides evaluations for ankylosis of the wrist. Diagnostic Code 5215 provides the rating criteria for limitation of motion of the wrist. A 10 percent disability rating is warranted where palmar flexion is limited in line with the forearm, or where dorsiflexion is less than 15 degrees. 38 C.F.R. § 4.71a , Diagnostic Code 5215. Ten percent is the maximum schedular rating based on limitation of motion of the wrist under this diagnostic code. Normal ranges of motion of the wrist are dorsiflexion from 0 degrees to 70 degrees, and palmar flexion from 0 degrees to 80 degrees. 38 C.F.R. § 4.71, Plate I. Here, the Veteran is already in receipt of a 10 percent rating for her bilateral wrist disability. Thus, higher evaluations are not possible under Diagnostic Codes 5024 or 5215, even with consideration of additional functional loss during flare-ups or after repeated use. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016); 38 C.F.R. §§ 4.40, 4.45. A higher schedular rating is only warranted when there is evidence of ankylosis (frozen joint). 38 C.F.R. § 4.71a , Diagnostic Code 5214. Ankylosis is defined as immobility or consolidation of a joint due to disease, injury, or surgical procedure. Dorland's Illustrated Medical Dictionary, at 94 (32nd ed. 2012). Ankylosis of the wrist is rated under Diagnostic Code 5214. Unfavorable ankylosis, in any degree of palmar flexion or with ulnar and radial deviation warrants a 50 percent rating in the major extremity. Ankylosis in any other position, except favorable, warrants a 40 percent rating in the major extremity. Favorable ankylosis in 20 degree to 30 degree dorsiflexion warrants a 30 percent rating in the major extremity. 38 C.F.R. § 4.71a , Diagnostic Code 5214. The Board notes that these diagnostic codes were not modified by the February 2021 amendments to the rating schedule. At her February 2022 hearing, the Veteran testified that her wrists have gotten worse and that she has a lot of episodes, up to multiple times per day, where her wrists lock up in an excruciatingly painful way. She described the locking up as from her wrists down to her thumb, pointer, and middle finger being frozen. This results in her wrists being so fatigued that it impedes her ability to hold things, causing her to drop things all the time, preventing her from squeezing things, and preventing her from doing her hair and her daughter's hair, because the motion of twisting her wrist even a little bit is difficult. She also reported that she has trouble bending her hands back. Prior VA examination reports from February 2016, and September 2020 show that the Veteran was found to have no ankylosis of either wrist. Based on her hearing testimony, the August 2022 Board remand directed that the Veteran be afforded a new VA examination and a VA medical opinion regarding whether her limitations during a flare-up or with repeated use are akin to 'functional ankylosis.' See Chavis v. McDonough, 34 Vet. App. 1 (2021). The post-remand VA examination was provided in November 2022. At the examination, the Veteran reported that she experiences pain and fatigue and is limited in holding and grasping things, which affects her daily activities. Her current treatment was noted as braces, rest, massage, and a topical steroid cream. She reported severe flare-ups of the bilateral wrists that occur multiple times per week and last for hours, precipitated by regular activities. The flare-ups are alleviated by rest. Pain, fatigue and weakness from repeated use and flare-ups resulted in functional loss including difficulties with twisting, turning, and squeezing; an inability to drive because her wrists cannot grip the steering wheel; an inability to curl her hair; and having to hold her infant on her bed only, as her hands will give out over time, limiting how long she can hold her child. The examination report again shows that the Veteran was found to have no ankylosis of either wrist. The VA medical opinion regarding whether the Veteran's limitations during a flare-up or with repeated use are akin to functional ankylosis was provided in December 2022. The examiner stated that the Veteran's examination of November 2022 shows dorsiflexion, flexion, ulnar and radial deviation as 10, 25, 10, and 15 degrees respectively on the right wrist and 20, 20, 15, and 15 degrees respectively on the left wrist during a flareup. The examiner opined that medical judgement would interpret these values as not meeting criteria for functional ankylosis since there is movement with both repetitive use and during flare-ups. The treatment for the Veteran's wrists has all been through the VA and the treatment records show no evidence or assessment of ankylosis, neither actual nor functional. A March 2022 VA physical therapy report shows that the Veteran indicated that her wrists and fingers feel weak and fatigue quickly, leaving her unable to even hold a phone while making calls. She also reported that she has to massage her hands to assist with her fingers locking up. A September 2022 VA treatment record shows chronic pain in her wrists, with her wrists also noted to be weak and to fatigue easily. As noted above, to warrant a higher rating, the Veteran must demonstrate ankylosis or functional ankylosis of the wrists. Neither is shown here as the evidence does not reflect, nor does the Veteran assert, that she is completely unable to move her wrists or that her wrists are stuck in a single position. Based on the Veteran's statements, she experiences flare-ups, pain, fatigue, weakness, locking up, and limited range of motion of the bilateral wrists that results in functional loss, but not complete loss of movement. However, even considering these symptoms, and the resulting functional loss, the December 2022 VA clinician opined that her bilateral wrist disability does not meet the criteria for functional ankylosis since there is movement with both repetitive use and flare-ups. The Board finds the VA clinician's opinion probative as it was based on a review of the record. Moreover, the clinician clearly considered the Veteran's reported history as was provided by the Veteran and shown in the claims file. The examiner's opinion is the only competent opinion of record relating to functional ankylosis. While the Veteran has reported that her bilateral wrist disability causes symptoms including locking up, which is similar to functional ankylosis, she is not competent to provide a medical opinion regarding this issue. This issue is also medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As the Veteran is in receipt of the maximum schedular rating under DC 5215, a higher rating would only be available under DC 5214 which requires a diagnosis of ankylosis or the functional equivalent. As there is no evidence of ankylosis or the functional equivalent for either of the Veteran's wrists, the appeal for an increased rating is denied. As the evidence of record persuasively weighs against a rating in excess of 10 percent, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021). D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Caban, 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.