POSTTRAUMATIC STRESS DISORDER (PTSD)

Summary

The Veteran, a veteran who served from September 1988 to September 1992, including service in the Southwest Asia theater of operations, appealed several claims. The Veteran withdrew his appeal regarding entitlement to a rating in excess of 50 percent for PTSD, leading to its dismissal. The Board granted entitlement to an initial 40 percent rating for left upper extremity carpal tunnel syndrome (CTS) prior to June 20, 2019, finding the evidence supported a disability picture consistent with severe incomplete paralysis on the minor (left) side. However, the Board denied entitlement to a rating higher than 40 percent for the left upper extremity CTS, noting the Veteran's right hand dominance and the lack of evidence for complete paralysis or specific symptoms warranting a higher rating. The Board also denied entitlement to an initial compensable rating for a left wrist scar, finding the evidence did not support a rating under Diagnostic Codes 7802 or 7804, as the scar was superficial, nonlinear, not painful, and measured less than 144 square inches, with no specific functional loss or pain attributed to it.

Rationale

Veteran withdrew appeal prior to decision; No allegations of error of fact or law remain

Full Decision Text

Citation Nr: 22065644
Decision Date: 11/23/22	Archive Date: 11/23/22

DOCKET NO. 20-02 011
DATE: November 23, 2022

ORDER

Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is dismissed.

Entitlement to an initial 40 percent rating prior to June 20, 2019, for left upper extremity (minor) carpal tunnel syndrome is granted.

Entitlement to a rating in excess of 40 percent, for left upper extremity (minor) carpal tunnel syndrome is denied.

Entitlement to an initial compensable rating for left wrist scar is denied.

FINDINGS OF FACT

1. In a May 2022 letter, prior to promulgation of a decision in the appeal the Veteran withdrew his appeal as to the claim of entitlement to a rating in excess of 50 percent for PTSD.

2. Throughout the pendency of the appeal, to include prior to June 20, 2019, the Veteran's left upper extremity carpal tunnel syndrome has been characterized by pain, numbness, and severe incomplete paralysis of the median nerve.

3. The Veteran's left wrist is not characterized by painful or instability; and covers an area of less than 144 square inches.

CONCLUSIONS OF LAW

1. The criteria for dismissal of entitlement to a rating in excess of 50 percent for PTSD have been met.  38 U.S.C. § 7105; 38 C.F.R. § 19.55.

2. The criteria for entitlement to a 40 percent rating for left upper extremity carpal tunnel syndrome, prior to June 20, 2019, have been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8515.

3. Throughout the appeal, to include prior to June 20, 2019, the criteria for entitlement to a rating in excess of 40 percent for left upper extremity carpal tunnel syndrome have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8515.

4. The criteria for an initial compensable disability rating for left wrist scar have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.14.14, 4.118, Diagnostic Code 7802.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from September 1988 to September 1992, to include service in the Southwest Asia theater of operations.

In October 2020 and May 2022, the Board remanded the case for further development.

1. Entitlement to a rating in excess of PTSD.

The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed.  38 U.S.C. § 7105.  An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision.  38 C.F.R. § 19.55.  Withdrawal may be made by a claimant or by his or her authorized representative.  Id.

Here, the Veteran submitted written correspondence, received on May 2022, in which he requested specifically to withdraw his appeal as to the issue of entitlement to a rating in excess of 50 percent for PTSD.

As no allegations of errors of fact or law remain for appellate consideration regarding these matters, the Board does not have jurisdiction to review these claims, and they must be dismissed.

2. CTS

The Veteran's left upper extremity carpal tunnel syndrome is rated at 20 percent prior to June 20, 2019, and 40 percent thereafter, under Diagnostic Code 8515.  The Veteran is noted to be ambidextrous.  See June 2018 and December 2020 VA examination.  The Board notes the Veteran reported to be right hand dominant at prior VA examinations.  See April 2019 VA examination.  The Board notes, the Veteran is service connected for right upper extremity (major) carpal tunnel syndrome.

Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination.  Only one hand shall be considered dominant.  The injured hand, or the most severely injured hand, of an ambidextrous
 to June 20, 2019, and 40 percent thereafter, under Diagnostic Code 8515.  The Veteran is noted to be ambidextrous.  See June 2018 and December 2020 VA examination.  The Board notes the Veteran reported to be right hand dominant at prior VA examinations.  See April 2019 VA examination.  The Board notes, the Veteran is service connected for right upper extremity (major) carpal tunnel syndrome.

Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination.  Only one hand shall be considered dominant.  The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69.  Here, the evidence of record shows that the Veteran's right hand is his dominant hand.  The Veteran's right side is therefore his dominant side, and considered the "major" extremity, and the left side is his "minor" side.

Under Diagnostic Code 8615, moderate incomplete paralysis is rated 20 percent disabling on the minor side and 30 percent disabling on the major side; and severe incomplete paralysis is rated 40 percent disabling on the minor side and 50 percent disabling on the major side.  38 C.F.R. § 4.124a, Diagnostic Code 8615.  As noted above, the Veteran is right hand dominant for rating purposes and therefore, his left upper extremity is considered the minor side under this diagnostic code.

When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree.  In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis.  The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis.  38 C.F.R. § 4.123.

Private treatment records reflect left wrist pain (2 out of 10), decreased range of motion and strength, numbness, and tingling, which worsens with gripping, lifting, pinching, twisting, and weightbearing.  See, e.g., PTR (February 6, 2018)

The Veteran was afforded a VA examination in June 2018.  The examination revealed symptoms that included mild left upper extremity constant pain; moderate paresthesias and/or dysesthesias and moderate numbness.  The Veteran was noted to have active movement against some resistance with his grip and pinch.  The Veteran was noted to have moderate incomplete paralysis.  See June 2018 VA examination. 

The Veteran underwent a VA examination in December 2020.  The Veteran has a history of gradual and progressive onset of tingling in both hands.  The examination reveals symptoms of his left-hand include mild left upper extremity constant pain; mild left upper extremity paresthesias and/or dysesthesias and mild numbness.  The Veteran had normal grip and muscle strength.  There was no muscle atrophy.  The Veteran's left median nerve is positive for Phalen's sign and Tinel's sign.  The Veteran has left severe incomplete paralysis.  The December 2020 VA examiner noted abnormal left upper extremity EMG studies from March 2018 and January 2020. 

The Veteran underwent a VA examination in April 2019.  The examination revealed symptoms of his left-hand numbness and weakness and reports using a wrist brace at night.  The Veteran has had physical therapy.  There is moderate left upper extremity numbness and mild dysesthesias.  Muscle strength and tone was normal.  The left grip was affected.  There was no muscle atrophy.  His sensation testing for light touch was decreased.  The Veteran has severe incomplete paralysis.  See April 2019 VA examination.  

Based on the evidence of record, throughout the pendency of the appeal, to include the period prior to June 20, 2019, a 40 percent rating, but not higher for left hand carpal tunnel syndrome is not warranted, as the evidence supports a disability picture consistent severe incomplete paralysis.  While the VA examiners found decreased grip, strength testing also revealed normal muscle strength.  Reflexes were found to be normal.  The examination did not reveal evidence of complete paralysis of median nerve.  There is no competent evidence that shows that the Veteran has experienced symptoms of complete paralysis of his carpal tunnel syndrome of the left upper extremity at any point.

Additionally, there is no evidence of record that the service
 VA examination.  

Based on the evidence of record, throughout the pendency of the appeal, to include the period prior to June 20, 2019, a 40 percent rating, but not higher for left hand carpal tunnel syndrome is not warranted, as the evidence supports a disability picture consistent severe incomplete paralysis.  While the VA examiners found decreased grip, strength testing also revealed normal muscle strength.  Reflexes were found to be normal.  The examination did not reveal evidence of complete paralysis of median nerve.  There is no competent evidence that shows that the Veteran has experienced symptoms of complete paralysis of his carpal tunnel syndrome of the left upper extremity at any point.

Additionally, there is no evidence of record that the service connected disability is productive of a hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of thenar eminence, the thumb in the plane of the hand; pronation incomplete and effective, absence of flexion of the index finger and feeble flexion of the middle finger, that cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of the thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances.  Indeed, the Veteran's attorney agrees that a 40 percent rating is warranted throughout the appeal.  For these reasons, the evidence shows that the Veteran's symptomology is consistent with the criteria contemplated by a 40 percent rating for his left upper extremity carpal tunnel syndrome.

The Board has also considered whether the Veteran could receive a higher rating under other applicable diagnostic codes, including under 38 C.F.R. § 4.123 or 4.124, for neuritis or neuralgia, respectively.  Nevertheless, the evidence of record does not demonstrate that the Veteran has experienced symptoms of loss of reflexes, muscle atrophy, or sensory disturbances of such severity that his left major upper carpal tunnel syndrome warrants a higher rating under any of these or any other diagnostic codes.  The Board finds that the medical evidence supports the determinations as offered above.

Accordingly, the Board finds that a rating of 40 percent rating, but not higher, for the left carpal tunnel syndrome is warranted throughout the appeal, to include prior to June 20, 2019.

3. Entitlement to an initial compensable rating for a left wrist scar.

The Veteran seeks a compensable rating for his left wrist scar.  

In a July 2018 rating, the Veteran was granted service connection for left wrist scar with an evaluation of 0 percent, effective November 17, 2017, under Diagnostic Code 7802. 

Diagnostic Code 7802

Effective October 23, 2008, Diagnostic Code 7802 provides compensation for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118.  A 10 percent rating is provided for area or areas of 144 square inches (929 square centimeters) or greater.  Id.

Note (1) provides that a superficial scar is one not associated with underlying soft tissue damage.  38 C.F.R. § 4.118.

Note (2) provides that if multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. 38 C.F.R. § 4.118.  The midaxillary line on each side separates the anterior and posterior portions of the trunk.  Id.  Combine the separate evaluations under § 4.25.  Id.  Qualifying scars are scars that are nonlinear, superficial, and are not located on the head, face, or neck.  Id.

Effective August 13, 2018, Diagnostic Code 7802 provides compensation for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage.  38 C.F.R. § 4.118.  The recent amendments changed the Notes associated with Diagnostic Code 7802 but did not change the rating criteria.

Note (1) now states that the six (
 the anterior and posterior portions of the trunk.  Id.  Combine the separate evaluations under § 4.25.  Id.  Qualifying scars are scars that are nonlinear, superficial, and are not located on the head, face, or neck.  Id.

Effective August 13, 2018, Diagnostic Code 7802 provides compensation for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage.  38 C.F.R. § 4.118.  The recent amendments changed the Notes associated with Diagnostic Code 7802 but did not change the rating criteria.

Note (1) now states that the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk.  38 C.F.R. § 4.118.  The midaxillary line divides the anterior trunk from the posterior trunk.

Note (2) now states that a separate evaluation may be assigned for each affected zone of the body under Diagnostic Code 7802 if there are multiple scars, or a single scar, affecting multiple zones of the body.  38 C.F.R. § 4.118. Under such circumstances, separate evaluations are to be combined under § 4.25.  Id.  Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under Diagnostic Code 7802.  Id.

Diagnostic Code 7804

Effective October 23, 2008, Diagnostic Code 7804 provides compensation for painful or unstable scars.  38 C.F.R. § 4.118.  A 10 percent rating is provided for one or two scars that are unstable or painful.  Id.  A 20 percent rating is provided for three or four scars that are unstable or painful.  Id.  A 30 percent rating is provided for five or more scars that are unstable or painful.  Id.

Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.  38 C.F.R. § 4.118. Note (2) states that if one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is based on the total number of unstable or painful scars.  Id.  Note (3) states that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under Diagnostic Code 7804, when applicable.  Id.

No changes to Diagnostic Code 7804 were made by the amendments that went into effect on August 13, 2018.

The June 2018, April 2019 and December 2020 VA examinations reference a left wrist scar status post carpal tunnel release.  Neither the Veteran's lay statements nor his medical records specifically reference pain or functional loss associated with the left wrist scar.  On both examinations, it was noted that the scars were not painful.  Further the scar is measured at 4 x 0.3 centimeters, covering less than 144 square inches.  There is also no evidence that the Veteran used any treatments to alleviate any discomfort that was specific to his left wrist scar.  In light of this evidence, the Board finds that the weight of evidence is against and initial compensable rating for left wrist scar.  

 

 

Joshua Castillo

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Jordan, Jacquelynn

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.