Citation Nr: 0020141	
Decision Date: 07/31/00    Archive Date: 08/02/00

DOCKET NO.  94-48 588	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Detroit, 
Michigan


THE ISSUE

Entitlement to an increased (compensable) evaluation for 
tenosynovitis of the right thumb and wrist, status post 
surgical tendon release with residual scar.


REPRESENTATION

Appellant represented by:	Disabled American Veterans


INTRODUCTION

The veteran had active service from September 1987 to June 
1992.

This matter originally came before the Board of Veterans' 
Appeals (Board) on appeal from March 1994 and September 1995 
rating decisions of the Department of Veterans Affairs (VA) 
Regional Office (RO) in Detroit, Michigan.  In the March 1994 
rating decision, the RO, in pertinent part, granted service 
connection for surgical scar, radial aspect right thumb, 
assigning a noncompensable disability evaluation, and denied 
service connection for tenosynovitis of both wrists.  In the 
September 1995 rating decision, the RO granted service 
connection for right wrist tenosynovitis and continued a 
noncompensable disability evaluation for the service-
connected tenosynovitis right thumb/right wrist, history of 
surgery for tendon release, residual scar.

In April 1997 and June 1998 decisions, the Board remanded the 
issue for further development.  The case was last returned to 
the Board in July 2000.


FINDINGS OF FACT

1.  All relevant evidence necessary for an equitable 
disposition of the veteran's appeal has been obtained by the 
originating agency.

2.  The current manifestations of the veteran's residuals of 
tenosynovitis of the right wrist include painful motion.


CONCLUSION OF LAW

A 10 percent disability evaluation for tenosynovitis of the 
right thumb and wrist, status post surgical tendon release 
with residual scar, is for assignment.  38 U.S.C.A. §§ 1155, 
5107 (West 1991); 38 C.F.R. §§ 4.45, Part 4, Code 5024-5003 
(1999).


REASONS AND BASES FOR FINDINGS AND CONCLUSION

The veteran is seeking a compensable evaluation for her 
tenosynovitis of the right thumb and wrist, status post 
surgical tendon release with residual scar.  We note that we 
have found that the veteran's claim is "well grounded" within 
the meaning of 38 U.S.C.A. § 5107(a).  That is, we find that 
she has presented a claim which is plausible.  We are also 
satisfied that all relevant facts have been properly 
developed and no further assistance to the veteran is 
required to comply with the duty to assist mandated by 38 
U.S.C.A. § 5107(a).

The veteran, who was granted service connection for 
tenosynovitis of the right thumb and wrist, status post 
surgical tendon release with residual scar, and initiated her 
appeal from the action granting service connection, has had 
several VA examinations.

At the time of an October 1993 VA general medical examination 
the veteran reported that she had been doing clerical work at 
a bank for the past eight months, and had lost one day of 
work during that period.  Her current complaints included 
pain in both wrists, more marked on the left.  On 
examination, a scar was noted over the radial aspect proximal 
to the right thumb from previous surgery.  There was no 
swelling of the tendons or joints and there was normal range 
of motion.  The impression on an X-ray examination of the 
right wrist was negative.  Diagnoses included history of 
tenosynovitis of both wrists, not active at this time.

VA outpatient treatment records show that in May 1997 the 
veteran complained of problems with both hands, especially a 
loose grip on the right.  She reported experiencing a 
tingling numbness occasionally.  An electromyogram and nerve 
conduction study of the veteran's upper extremities were 
conducted in August 1997.  The findings were interpreted to 
be normal.

A VA orthopedic examination was conducted in September 1997.  
The veteran reported, with respect to her right wrist, that 
she had a decreased grip and described a gelling-type 
phenomenon that lasted for an hour and one-half in the 
morning in all the fingers, thumb, wrist and hand.  This came 
and went.  It was tiring.  It was noted that she had 
nonspecific complaints.  She did not recall waking up at 
night shaking her hand.  There was no numbness, tingling, or 
dropping things.  When writing for a long time she apparently 
had some tiring sensations but no numbness, tingling, or 
dysfunction.  She had no symptoms regarding the thumb and 
thenar space.  She indicated that her index, middle, ring and 
fifth fingers seemed to have tingling occasionally in the 
tips but not currently.

On physical examination, over the volar surface on the right 
there was a 3.5 centimeter volar incision that was well 
healed without deformity, scar tissue, or dysfunction over 
the area of the radial artery at the wrist.  There was no 
ganglion deformity and no evidence of tenosynovitis.  The 
Finkelstein tests were normal.  The range of motion, power 
and function of both thumbs was normal.  Pinch power was 
normal.  Examination of the palms was normal.  The dorsa of 
the hands were normal as were the distal, radial and ulnar 
joints.  There was no deformity, wasting, dysfunction, or 
apprehension.  Examination of the power of the grip was 
normal bilaterally and equally.

Examinations of the hands showed good callus formation of 
present usage.  The pinch power was normal.  Grip strength 
was normal.  There was no intrinsic muscular dysfunction.  
Sensation was normal.  There was no evidence of trigger 
fingers, trigger thumb, or deformity.  Circumference of the 
right arm was 27.5 cm. compared to 27 cm. on the left.  
Measurement of the right forearm was 24.5 cm., compared to 24 
cm. on the left.  On examination of the neurovascular status 
of both upper extremities, power, function, and sensation 
were completely normal.

It was reported that X-rays taken of the right wrist and hand 
were normal.  It was the examiner's orthopedic opinion that 
the veteran at one time had tenosynovitis on the right wrist 
which was treated.  There was currently no evidence of 
residual other than a scar.  There was no evidence of a 
neurovascular problem.  There was no evidence of any 
disability.  There was no evidence of any need for treatment 
or care.  She had no evidence of any dysfunction and there is 
no evidence of any suggested upcoming problems or 
difficulties.

Additional VA outpatient treatment records show that in 
October 1997 it was reported that the veteran was attending 
occupational therapy which was focused on establishing a home 
splint program and educating the veteran with respect to 
carpal tunnel syndrome prevention and pain management.

Another VA orthopedic examination was conducted in December 
1998.  At this time the veteran related that she was working 
at a part-time volunteer job and there was not much use of 
her hands.  Her physical complaints included tingling of the 
right hand, especially in the morning, and sometimes only in 
the middle finger. 
Sometimes there was a cramp feeling near the wrist joint and, 
during sleep, she had to use a splint and sometimes used a 
splint in the day time.  She did not know if the splint was 
helping.  She never had pain in the morning.  It was 
difficult for her to open a bottle.  The wrist and the 
fingers got tired.

Right wrist and hand examination showed a normal looking 
wrist and hand without any swelling, deformity or atrophy.  
There was a one inch long surgical scar on the radial side of 
the wrist.  There was no adhesion and the scar was not 
tender.  The wrist joint movement was full with 90 degrees of 
flexion and 85 degrees of extension.  Radial deviation was 25 
degrees and ulnar deviation was 30 degrees.  Rotation was 80 
degrees in supination and pronation.  The power against 
resistance was good, but she complained of pain near the 
anterior part of the wrist on attempted flexion.  There is no 
tenderness or swelling anywhere around the wrist or hand.

Right hand examination showed that the finger movements were 
full with 0 to 90 degrees of flexion at the metacarpal 
phalangeal (MP), proximal interphalangeal, and distal 
interphalangeal joints of all fingers of both hands.  On the 
right thumb, the MP joint showed 90 degrees of flexion and 5 
degrees of extension and the interphalangeal joint showed 90 
degrees of flexion and 0 degrees of extension.  Pinching was 
good and grip strength was satisfactory.  There is no 
evidence of carpal tunnel syndrome.  Sensation was normal and 
there was no atrophy.

On X-ray examination of the right hand it was reported that 
there was no evidence of arthritis.  The diagnosis was status 
post surgery right wrist: normal right hand function, full 
range of motion of the fingers and thumb, no evidence of 
carpal tunnel syndrome, grip strength good and pinching 
satisfactory.  The examiner noted that there was no 
manifestation of gross pain during the examination except 
complaint of pain in front of the right wrist on attempted 
flexion.

It was the examiner's opinion that the subjective complaint 
of pain was not limiting the veteran's function and ability.  
The examiner noted that comment could not be made upon the 
functional ability during flare up or on extended use during 
this one examination in the office.  The clinical evidence 
was consistent with complaint of some pain, but the severity 
of the pain was in the examiner's opinion very minimal.  It 
was observed that there is no evidence of active 
tenosynovitis at this time in the right wrist and thumb and 
it was the examiner's opinion the veteran should be able to 
work consistent with her training experience and education.  
The examiner did not see any limitation of activities of the 
veteran's daily life per right hand complaint.  The affected 
joint did not exhibit any weakened movement or non-
coordination and there was no question of additional loss of 
motion.

In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, and 4.42 
(1999) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), 
the Board has reviewed the veteran's service medical records 
as well as all other evidence of record pertaining to the 
history of the veteran's service-connected tenosynovitis of 
the right thumb and wrist, status post surgical tendon 
release with residual scar.  The Board has identified nothing 
in this historical record which suggests that the current 
evidence of record is not adequate to fairly determine the 
rating to be assigned for this disability.  Moreover, the 
Board has concluded that this case presents no evidentiary 
considerations which would warrant an exposition of the 
remote clinical history and findings pertaining to this 
disability.

The veteran is seeking the compensable disability evaluation 
for the period beginning June 28, 1992, the date that the 
grant of service connection for tenosynovitis of the right 
thumb and wrist, status post surgical tendon release with 
residual scar, became effective.  A United States Court of 
Appeals for Veterans Claims decision, Fenderson v. West, 12 
Vet. App. 119 (1999), concluded that the rule from Francisco 
v. Brown, 7 Vet. App. 55, 58 (1994), "Where entitlement to 
compensation has already been established and an increase in 
the disability rating is at issue, the present level of 
disability is of primary importance", is not applicable to 
the assignment of an initial rating for a disability 
following an initial award of service connection for that 
disability.  Rather, at the time of an initial rating, 
separate ratings can be assigned for separate periods of time 
based on the facts found- a practice known as "staged" 
ratings.

Disability evaluations are based upon the average impairment 
of earning capacity resulting from a disability.  38 U.S.C.A. 
§ 1155.  With respect to the veteran's tenosynovitis of the 
right thumb and wrist, status post surgical tendon release 
with residual scar, the veteran is currently being rated 
under Diagnostic Code 7805 for the residual scar.  However, 
the veteran has contended that the symptoms of her 
tenosynovitis of the right thumb and wrist, status-post 
surgical tendon release with residual scar, have increased 
with restricted movement of her right thumb and right wrist, 
a cramping feeling and numbness and pain.

As the veteran's principal complaints relate not to the 
residual scar but to movement and use of the wrist, in the 
Board's opinion, the right wrist disability is best rated 
under Diagnostic Code 5024.  See Butts v. Brown, 5 Vet. 
App. 532, 539 (1993) (holding that the Board's choice of 
diagnostic code should be upheld so long as it is supported 
by explanation and evidence).  Under Diagnostic Code 5024 for 
tenosynovitis, this disability will be rated on limitation of 
motion, as degenerative arthritis.  Under the limitation of 
motion code for the wrist, Diagnostic Code 5215, a 10 percent 
disability evaluation is for assignment where palmar flexion 
is limited in line with the forearm.

Although the veteran does not meet the criteria for a 
compensable evaluation under Diagnostic Code 5215, under 
Diagnostic Code 5003 for rating degenerative arthritis, when 
the limitation of motion of the specific joint or joints 
involved is noncompensable under the appropriate diagnostic 
codes, a rating of 10 percent is for application for each 
such major joint or group of minor joints affected by 
limitation of motion, to be combined, not added under 
Diagnostic Code 5003.  Limitation of motion must be 
objectively confirmed by findings such as swelling, muscle 
spasm, or satisfactory evidence of painful motion.

38 C.F.R. § 4.45 states, in pertinent part, that for the 
purpose of rating disability from arthritis, the wrist is 
considered a major joint.  As the veteran's tenosynovitis of 
the right wrist is being rated for arthritis, and the 
evidence demonstrates that she was experiencing right wrist 
pain in 1993, sought out pain management in 1997 and 
experienced painful motion in 1998, the Board finds, 
resolving all reasonable doubt in the veteran's favor, that a 
10 percent disability evaluation should be assigned for the 
veteran's tenosynovitis of the right thumb and wrist, status 
post surgical tendon release with residual scar.

In reaching its decision, the Board has considered the 
complete history of the disability in question as well as the 
current clinical manifestations and the effect the disability 
may have on the earning capacity of the veteran.  38 C.F.R. 
§§ 4.1, 4.2, 4.10 (1999).  The nature of the original 
condition has been reviewed and the functional impairment 
which may be attributed to pain or weakness has been taken 
into account.  38 C.F.R. § 4.40 (1999).  Further, the Board 
finds in this case the disability picture is not so 
exceptional or unusual so as to warrant an evaluation on an 
extraschedular basis.  It has not been shown that the 
disability has caused marked interference with employment or 
necessitated frequent periods of hospitalization.  38 C.F.R. 
§ 3.321(b)(1) (1999).



ORDER

Entitlement to a compensable evaluation for tenosynovitis of 
the right thumb and wrist, status post surgical tendon 
release with residual scar is granted.  The appeal is 
allowed, subject to the law and regulations governing the 
payment of monetary benefits.



		
	HILARY L. GOODMAN
	Acting Member, Board of Veterans' Appeals