BVA9501872 
DOCKET NO.  93-13 596     )       DATE
          )
          )

On appeal from the decision of the
Department of Veterans Affairs Regional Office in Huntington,
West Virginia

THE ISSUES

1.  Entitlement to an increased disability evaluation for post-
operative laceration of the superficial branch of the radial
nerve of the right wrist, currently evaluated as
20 percent disabling.

2.  Entitlement to a permanent and total disability rating for
pension purposes.

REPRESENTATION

Appellant represented by: Disabled American Veterans

ATTORNEY FOR THE BOARD

Theresa M. Catino, Associate Counsel

INTRODUCTION

The veteran served on active duty from January 1969 to July 1970
and from March 1974 to September 1975.

CONTENTIONS OF APPELLANT ON APPEAL

The veteran contends, in essence, that the regional office (RO)
committed error in denying his claim of entitlement to a
disability evaluation greater than 20 percent for post-operative
laceration of the superficial branch of the radial nerve of the
right wrist.  He claims that this service-connected disability is
more severely disabling than currently evaluated.  Specifically,
he maintains that cramping in his right hand prevents him from
holding anything.  In addition, he asserts that he experiences
stiffness in his right index and right middle fingers and a great
deal of pain in his right hand and fingers.  He also contends
that the VA examination which the RO used as the basis for its
denial of his claim was inadequate.  He maintains, therefore,
that he is entitled to a disability evaluation greater than
20 percent for his service-connected right wrist disability.

In addition, the veteran asserts, in essence, that the RO
committed error in denying his claim of entitlement to a
permanent and total disability rating for pension purposes.  He
contends that he currently has arthritis of his spine and
shoulders, residuals of a back injury, stomach problems, high
blood pressure, and disabilities involving both knees and his
service-connected right wrist.  He further maintains that he is
unable to work as a result of these medical problems.  Therefore,
he asserts that he is entitled to a permanent and total
disability rating for pension purposes.

DECISION OF THE BOARD

The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991), has reviewed and considered all of the
evidence and material of record in the veteran's claims file.
Based on its review of the relevant evidence in this matter, and
for the following reasons and bases, it is the decision of the
Board that the preponderance of the evidence is against the claim
of entitlement to a disability evaluation greater than 20 percent
for post-operative laceration of the superficial branch of the
radial nerve of the right wrist.  It is also the decision of the
Board that the preponderance of the evidence is against the claim
of entitlement to a permanent and total disability rating for
pension purposes.

FINDINGS OF FACT

1.  All relevant evidence necessary for an equitable disposition
of the veteran's claim has been obtained insofar as possible.

2.  The veteran's right (major) wrist disability is manifested by
complaints of cramping, stiffness, and pain and by medical
evidence of adequate ability to move the right wrist and right
hand, no intrinsic atrophy of the right hand muscles, and
superficial sensory neuropathy, which is productive of not more
than mild incomplete paralysis of the right radial nerve.

3.  The veteran was born in August 1950, has a high school
education and additional training as a mechanic and a heavy
equipment operator, and has reported work experience as an
auto-mechanic.

4.  The veteran's principal disabilities are a right wrist
disability, a back condition, mild bilateral deformity of the
intercondyloid eminence of the tibia with leg pain, and
hypertension; he otherwise has a history of arthritis of the
shoulders and gastritis.

5.  The veteran's back condition is manifested by repeated
complaints of pain and requests for medication and by the
diagnoses of chronic back ache and minimal degenerative changes
of the thoracic spine, which is productive of no more impairment
than characteristic pain on motion and which warrants no more
than a 10 percent evaluation.

6.  The veteran does not have malunion of either tibia or fibula
and less than slight impairment of either knee or ankle and is,
therefore, not entitled to a rating higher than zero percent.

7.  The veteran's hypertension is manifested by diastolic
pressure predominantly 100 or more, but less than 110, which
warrants no more than a 10 percent evaluation.

8.  Arthritis of the shoulders is by history only, with no
residual disability shown and, therefore, does not warrant a
rating higher than zero percent.

9.  Gastritis is by history only, with no residual disability
shown and, therefore, does not warrant a rating higher than zero
percent.

10.  The veteran's disabilities, when combined, warrant a 40
percent evaluation.

11.  The veteran's disabilities do not preclude him from engaging
in substantially gainful employment, consistent with his age,
education and occupational history.

12.  The veteran's disabilities are not productive of total
disability and are not sufficient to render the average person
unable to follow a substantially gainful occupation.

CONCLUSIONS OF LAW

1.  The criteria for a disability rating in excess of 20 percent
for post-operative laceration of the superficial branch of the
radial nerve of the right wrist have not been met.  38 U.S.C.A.
§§ 1155, 5107 (West 1991); 38 C.F.R. Part 3, § 3.321(b)(1),
Part 4, §§ 4.40, 4.71a, Code 8514 (1993).

2.  The veteran is not permanently and totally disabled within
the meaning of governing law and regulations.  38 U.S.C.A.
§§ 1502, 1521, 5107 (West 1991); 38 C.F.R. Part 3, §§ 3.321,
3.340, 3.342, and Part 4, §§ 4.15, 4.16, 4.17 (1993).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The veteran's claims are well-grounded within the meaning of
38 U.S.C.A. § 5107(a) (West 1991).  That is, the Board finds that
the veteran has presented claims which are plausible.  The Board
is also satisfied that all relevant facts have been properly
developed.  No further assistance to the veteran is required to
comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a).
Murphy v. Derwinski, 1 Vet.App. 78 (1990); Littke v. Derwinski,
1 Vet.App. 90 (1990).

The Board notes that in an April 1993 statement, the veteran
contended that the January 1993 VA examination was inadequate.
The veteran claimed that the examining physician did not take
X-rays and did nothing except have the veteran squeeze his hand.
As a review of the examination report demonstrates, although
X-rays of the veteran's right wrist and right hand were not
taken, the examining physician conducted a thorough examination
with numerous specific findings concerning the veteran's right
wrist.

Furthermore, the United States Court of Veterans Appeals (Court)
recently reiterated its belief that a VA examination should be
conducted when the record does not adequately reveal the current
state of the veteran's disability.  Francisco v. Brown,
7 Vet.App. 55, 57 (1994), citing, Schafrath v. Derwinski,
1 Vet.App. 589, 595 (1991).  However, after a thorough review of
the entire claims folder, the Board concludes that the January
1993 and April 1992 VA examinations as well as the recent
outpatient treatment records adequately describe the current
extent of the veteran's service-connected right wrist disability.
The Board finds that an additional VA examination would not
provide any more detailed information.

I.  Right Wrist

In evaluating the severity of a particular disability, it is
essential to consider its history.  38 C.F.R. §§ 4.1 and 4.2
(1993).  In an April 1985 rating decision, the RO granted service
connection for residuals of a post-operative laceration of the
superficial branch of the radial nerve of the right wrist and
rated this service-connected disability as noncompensably
disabling, effective from March 1985.  In a March 1986 rating
decision, the RO granted the veteran a 10 percent disability,
effective from March 1985, for this service connected disorder on
the basis of evidence which showed tenderness of the scar on his
right wrist.

Subsequently, in an April 1987 decision, the Board granted the
veteran a 20 percent rating.  The Board explained that the
evidence of involvement of the radial nerve, with a neuroma and
paresthesia of the right thumb, index finger, and
metacarpophalangeal joint of the middle finger upon palpation
demonstrated sensory involvement resulting from his
service-connected right wrist disability.  In a May 1987 rating
decision, the RO implemented this decision and assigned the
veteran a 20 percent disability rating, effective from March
1985.  The veteran is currently evaluated for his
service-connected right wrist disability under Diagnostic
Code 8514.

Disability evaluations are administered under the Schedule for
Rating Disabilities which is found in 38 C.F.R. Part 4 (1993) and
is designed to compensate a veteran for reductions in earning
capacity.  38 U.S.C.A. § 1155 (West 1991).  Separate diagnostic
codes identify the various disabilities.  Id.  Although the
evaluation of a service-connected disability requires a review of
the veteran's medical history with regard to that disorder, the
primary concern in a claim for an increased evaluation for a
service-connected disability is the present level of disability.
The United States Court of Veterans Appeals (Court) has recently
held that, 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 concern.
Although a rating specialist is directed to review the recorded
history of a disability in order to make a more accurate
evaluation, the regulations do not give past medical reports
precedence over current findings.  Francisco v. Brown, No. 93-76,
slip op. at 5 (U.S. Vet. App. Sept. 27, 1994).

With these regulations and this Court decision in mind, the Board
will address the issue of the evaluation of the veteran's present
level of disability resulting from his service-connected right
wrist disorder.  This disability is currently evaluated as
20 percent disabling under Diagnostic Code 8514.  Complete
paralysis of the musculospiral (radial) nerve involves drop of
the hand and fingers, wrist and fingers perpetually flexed, the
thumb adducted falling within the line of the outer border of the
index finger; cannot extend hand at wrist, extend proximal
phalanges of fingers, extend thumb, or make lateral movement of
wrist; supination of hand, extension and flexion of elbow
weakened, and the loss of synergic motion of extensors impairs
the hand grip seriously; total paralysis of the triceps occurs
only as the greatest rarity.  38 C.F.R. § 4.124a, Code 8514.  A
20 percent evaluation is provided for mild incomplete paralysis
of the radial nerve of a major extremity and a 30 percent
evaluation is provided for moderate incomplete paralysis of the
radial nerve of a major extremity, with a 50 percent evaluation
provided for severe incomplete paralysis of the radial nerve of a
major extremity.  Id.  The term "incomplete paralysis" indicates
a degree of lost or impaired function substantially less than the
type picture for complete paralysis given for the nerve.
38 C.F.R. § 4.124a.

The veteran's claim for an increased disability rating involving
his right wrist was received at the RO in May 1991.  According to
the medical records received pursuant to this claim, in September
1987, the veteran complained of experiencing a drawing sensation
in his right hand and a tingling feeling in his right elbow area
and in several of the fingers of his right hand.  Examination of
his right hand demonstrated the presence of a small cystic growth
on his right wrist area.  In October 1987, examination of the
veteran's right wrist showed it to be tender.  Range of motion of
the right wrist was within normal limits, and pain on motion was
noted.

A February 1988 evaluation of the veteran's right wrist
demonstrated that although he had sensation limitations, he had
no motor limitations.  The examiner noted that the veteran had
developed a neuroma to the dorsal radial nerve, and his right
wrist was freely mobile.  The examiner also specifically stated
that no motor weakness was involved and that the veteran was able
to use his right hand without limitation.  In August 1988, the
veteran maintained that his right wrist was still painful.  The
examiner noted that the neuroma was localized at the point of
pain on the veteran's wrist.  The examiner informed the veteran
that he could undergo local anesthesia to have the neuroma
removed and/or to explore.  In February 1991, the veteran sought
treatment for complaints of cramping in his right hand.  He was
found to have a painful and tender soft tissue tumor on his right
wrist.  The examiner diagnosed neuroma of the right wrist.

With complaints of cramping and stiffness in the right hand and
right wrist, in May 1991 the veteran again sought treatment.  At
that time, the examiner noted a well-healed scar through the
radial aspect of the right wrist and mild swelling and some
calluses in this area.  According to the examination report, the
veteran had adequate range of motion, including flexion and
extension, of his right wrist.  There was no evidence of any
apparent intrinsic atrophy of the muscles of his right hand.  The
veteran complained of some hyperesthesia through the dorsum of
the thumb up to the third metacarpal level.  He also maintained
that, when he is touched in this area, he experiences sensation
through the entire area.  The examiner noted that the veteran
could make a full fist and could flex the volar aspect.  The
examiner concluded that the laceration of the terminal branch of
the veteran's right radial nerve had been ruptured and that there
was some paresthesia.

The April 1992 VA examination indicated that the veteran had a
well-healed one-inch scar over the lateral aspect of his right
wrist.  It was noted that he was right-handed.  The January 1993
VA neurological examination demonstrated that the veteran had
fair grip and fair dorsiflexion power of his right hand, fair
abduction of the right fingers, and opposition of the right thumb
to the small finger with strength of 4-5/5.  Sensory evaluation
showed that the veteran's right hand and forearm was intact to
pinprick. No atrophy of the intrinsic muscles of the right hand
was found.  The veteran reported that he could still write with
his right hand.  The examination also demonstrated evidence of
tenderness on pressure over the proximal segment of the right
index finger and over the surgical scar over the radial side of
the right wrist with radiating pain to the right thumb and index
finger.  The examiner concluded that the veteran had superficial
sensory neuropathy.

A review of the outpatient treatment records and VA examination
reports demonstrates that the veteran's right wrist disability is
manifested by his complaints of cramping in his right hand,
stiffness in his right index and right middle fingers, and pain
in his right hand and fingers.  This service-connected disability
is also manifested by a well-healed scar through the radial
aspect of the right wrist, adequate range of motion of the right
wrist, fair grip power of the right hand, no intrinsic atrophy of
the right hand muscles, the ability to make a full fist and to
flex the volar aspect, and a right hand and forearm which is
intact to pinprick as well as by mild swelling, some calluses,
some paresthesia described as superficial sensory neuropathy, and
tenderness to pressure over the proximal segment of the right
index finger and over the surgical scar over the radial side of
the right wrist, with pain radiating to the right thumb and index
finger.

These medical records show that the veteran is able to make a
full fist with his right hand; has only mild impairment of motion
of his right fingers, hand, wrist, and forearm; no intrinsic
atrophy of the right hand muscles; fair grip strength;
superficial sensory neuropathy; and complaints of pain.  Given
the picture presented for complete paralysis of the radial nerve
found in Diagnostic Code 8514, these findings represent no more
than mild incomplete paralysis of the musculospiral, or radial,
nerve.  Consequently, the veteran is not entitled to a disability
evaluation greater than 20 percent under Diagnostic Code 8514.
See, 38 C.F.R. Part 4, § 4.124a, Code 8514 (1993).

The Schedule for Rating Disabilities contains no other applicable
code under which a disability specifically involving the
musculospiral, or radial, nerve can be evaluated.  The veteran's
service-connected wrist disability may, however, be evaluated
under the diagnostic codes relating to the musculoskeletal
defects of the wrist.  The only such code which could provide the
veteran with an evaluation greater than 20 percent is Code 5214,
which rates a wrist disability based upon the extent of ankylosis
of the wrist.  38 C.F.R. Part 4, § 4.71a, Code 5214 (1993).
Significantly, however, none of the outpatient treatment records
or the VA examination reports provides any findings of ankylosis
of the veteran's right wrist.  Consequently, the veteran cannot
receive a disability evaluation greater than 20 percent under
Code 5214.  A separate evaluation cannot be assigned based on the
musculoskeletal aspects of the veteran's disability, since all of
the manifestations of the disability, including limitation of
motion, weakness and pain, are contemplated by the evaluation
assigned under Diagnostic Code 8514.  See 38 C.F.R. § 4.14
(1993).

Furthermore, the provisions of 38 C.F.R. Part 4, § 4.40, require
that the evaluation of a disability of the musculoskeletal system
must take into account the functional loss due to pain of the
damaged part of the system.  38 C.F.R. Part 4, § 4.40 (1993).
The Board again notes the veteran's complaints of pain but finds
that this complaint and any related functional loss are
contemplated by the current 20 percent evaluation.  The recent
outpatient treatment records and VA examination reports do not
demonstrate a level of pain which is above that contemplated by a
rating of 20 percent.

No more than mild incomplete paralysis of the musculospiral, or
radial, nerve has been demonstrated.  Consequently, the
preponderance of the evidence is against the claim of entitlement
to an increased disability evaluation on a schedular basis for
post-operative laceration of the superficial branch of the radial
nerve of the right wrist.  38 U.S.C.A. §§ 1155, 5107 (West 1991);
38 C.F.R. Part 4, §§ 4.14, 4.40, 4.71a Plate I, 4.124a,
Codes 5214, 8514 (1993); Gilbert v. Derwinski, 1 Vet.App. 49
(1990).

In exceptional cases where the schedular evaluations are found to
be inadequate, an extraschedular evaluation commensurate with the
average earning capacity impairment due exclusively to the
service-connected disability or disabilities may be approved,
provided the case presents such an exceptional or unusual
disability picture with such related factors as marked
interference with employment or frequent periods of
hospitalization as to render impractical the application of the
regular schedular standards.  38 C.F.R. § 3.321(b)(1) (1993).
The records in the present case do not show such an exceptional
or unusual disability picture as would warrant an evaluation on
an extraschedular basis.  Accordingly, the Board concludes that
an increased evaluation is not warranted on an extraschedular
basis.  38 C.F.R. § 3.321(b)(1) (1993).

II.  Pension

As the Board has previously discussed, the veteran has submitted
a well-grounded claim, and the VA has met its duty to assist the
veteran.  A review of the veteran's file reflects that reports of
outpatient treatment and VA examinations conducted during the
current appeal period have been associated with the claims
folder.  The Board finds that these medical records provide
sufficient evidence to rate each of the veteran's disabilities.
In addition, the Board notes that the April 1992 and January 1993
VA examinations, which were both conducted after the RO had
obtained the veteran's outpatient treatment records, adequately
evaluate the extent of his physical condition and provide
sufficient diagnoses of his present disabilities.  See, Roberts
v. Derwinski, 2 Vet.App. 387, 390 (1992) and Abernathy v.
Principi, 3 Vet.App. 461, 464-465 (1992).

A.  Entitlement to a Permanent and Total Disability Evaluation
For Pension Purposes

Under 38 U.S.C.A. § 501 (West 1991), the Secretary of the VA has
the authority to prescribe all rules and regulations which are
necessary or appropriate to carry out the laws administered by
the VA.  With regard to claims for pension benefits, the
Secretary's authority to prescribe regulations providing for
determinations of permanent and total disability may be based in
whole or in part upon subjective criteria.  Talley v. Derwinski,
2 Vet.App. 282, 286 (1992).  Both objective and subjective
standards are often set forth within the same statutory provision
or regulation.  The basic law referable to pension benefits, for
example, states that pension is payable to a veteran who served
for ninety days or more during a period of war and who is
permanently and totally disabled due to nonservice-connected
disabilities not the result of his own willful misconduct.
38 U.S.C.A. § 1521 (West 1991).

A finding of total disability is warranted where the person
experiences any disability which is sufficient to render it
impossible for an average person to follow a substantially
gainful occupation.  The "average person" standard is implemented
by VA regulations, including 38 C.F.R. § 3.340(a) (1993) and
38 C.F.R. § 4.15 (1993), which also adds that the total rating is
based primarily upon the average impairment in earning capacity,
i.e., the economic or industrial handicap which must be overcome.
In addition, 38 U.S.C.A. § 1502(a)(2) (West 1991) essentially
provides that permanent and total disability may exist in any
disorder determined by the Secretary to be of such a nature and
extent as to justify that persons suffering therefrom are
permanently and totally disabled.

Initially, the Board notes that a total disability rating is
based primarily upon the average impairment of earning capacity.
38 C.F.R. Part 4, § 4.15 (1993).  The VA's Schedule for Rating
Disabilities (Rating Schedule) also provides a means for
objective determination of total disability.  When impairment is
commensurate with a 100 percent rating in accordance with
schedular criteria, a total rating on a schedular basis is
warranted.  38 C.F.R. § 3.340(a)(2) (1993).  38 C.F.R. Part 4,
§ 4.17 (1993), provides that all veterans basically eligible and
unable to secure or follow a substantially gainful occupation by
reason of disability likely to be permanent shall be rated
permanently and totally disabled.  For pension purposes, the
permanence of the percentage requirements of 38 C.F.R. Part 4,
§ 4.16 (1993), is a requisite.  38 C.F.R. Part 4, § 4.17 (1993).
Total disability ratings for compensation may be assigned, where
the schedular rating is less than total, when the disabled person
is, in the judgment of the rating agency, unable to secure or
follow a substantially gainful occupation as a result of service-
connected disabilities:  Provided, that, if there is only one
such disability, this disability shall be ratable at 60 percent
or more, and that, if there are two or more disabilities, there
shall be at least one disability ratable at 40 percent or more,
and sufficient additional disability to bring the combined rating
to 70 percent or more.  38 C.F.R. Part 4, § 4.16 (1993).

For pension purposes, when the percentage requirements are met
and the disabilities involved are of a permanent nature, a rating
of permanent and total disability will be assigned if the veteran
is found to be unable to secure and follow substantially gainful
employment by reason of such disability.  38 C.F.R. Part 4,
§ 4.17 (1993).  In making such determinations, marginal
employment may be consistent with unemployability if the
restriction of securing or retaining better employment is due to
disability.  Id.

Subjective factors for consideration are also included in
38 C.F.R. Part 4, § 4.15 (1993), which provides that in
individual cases, full consideration will be given to such
factors as unusual physical or mental effects in individual
cases, peculiar effects of occupational activities, defects in
physical or mental endowment preventing the usual amount of
success in overcoming the handicap or disability, and the effect
of combinations of disabilities.  In addition, 38 C.F.R. Part 4,
§ 4.17(b) (1993), states that where the veteran fails to meet the
percentage requirements, but meets the basic eligibility criteria
and is unemployable, consideration of 38 C.F.R. § 3.321(b)(2)
(1993) is appropriate.  In turn, 38 C.F.R. § 3.321(b)(2) provides
that where the veteran does not meet the percentage requirements
of the Rating Schedule, but is unemployable by reason of his age,
occupational background, or other related factors, a permanent
and total disability rating on an extra-schedular basis is
warranted.

B.  The Veteran's Disabilities

The veteran in the present case served on active duty for a
period in excess of ninety days during the Vietnam era.
Therefore, his entitlement to pension, apart from income and net
worth factors, will be determined based on whether or not he is
permanently and totally disabled as a result of his disabilities.
A complete review of the claims folder indicates that the
veteran's principal disabilities are a right wrist disability, a
back condition, mild bilateral deformity of the intercondyloid
eminence of the tibia with leg pain, and hypertension.  In
addition, he otherwise has a history of arthritis of the
shoulders and gastritis.

The veteran's right wrist disability was previously discussed in
part I of this decision.  As the Board concluded in part I, the
veteran is no more than 20 percent disabled as a result of his
right wrist disability.

With regard to the veteran's nonservice-connected back condition,
the Board notes that in the March 1993 rating decision the RO has
rated this disability as noncompensably disabling under
Diagnostic Code 5295.  Pursuant to this Code, evidence of only
slight subjective symptoms of lumbosacral strain warrants a
noncompensable evaluation.  Evidence of characteristic pain on
motion is required to assign a 10 percent rating, and evidence of
muscle spasm on extreme forward bending, with loss of lateral
spine motion, is required for the assignment of a 20 percent
evaluation.  38 C.F.R. Part 4, § 4.71a, Code 5295 (1993).

According to a VA outpatient treatment record dated in October
1987, the veteran requested medication to alleviate his back
pain.  In August 1988, the veteran sought treatment for
complaints of generalized arthritis of the back resulting in pain
and stiffness radiating to his neck.  Upon examination of the
veteran's back, the examining physician noted that the veteran
was ambulatory and in no acute distress.  He was assessed to have
arthritis of the spine.  No X-rays of the veteran's spine appear
to have been taken at that examination.  In August 1989, the
veteran sought treatment for back ache.  His back was found not
to be tender.  The examiner noted that the veteran was ambulatory
and diagnosed him to have chronic back ache.  In February 1990,
the veteran reported that he had had increased back pain over the
prior two years.  Subsequently, in November 1990, the veteran was
treated for complaints of back pain.  No tenderness of his back
was shown.  He was diagnosed to have chronic back ache.

In January 1992, the veteran again requested medication to
alleviate his back pain.  He reported that his back pain was
persistent.  The examining physician assessed the veteran to have
arthritis of his back.  The VA general medical examination
conducted in April 1992 did not note any limitation of motion of
the veteran's back or any significant back abnormality.
According to the report of the X-rays of the veteran's chest, the
mediastinum, or bony thorax, and diaphragm appeared unremarkable
except for a very little amount of anterior wedging of a few
middle thoracic vertebral bodies and a very little amount of
osteophyte formation of a few of the thoracic vertebrae.  The
examiner diagnosed the veteran to have minimal degenerative
changes of the thoracic spine.

Although the VA examination failed to demonstrate any significant
abnormality, including limitation of motion, of the veteran's
back, X-rays taken at this examination showed mild degenerative
changes of the thoracic spine.  The examiner diagnosed the
veteran to have minimal degenerative changes of the thoracic
spine.  Moreover, the prior outpatient treatment records clearly
show that the veteran has pain on movement of his back.  On at
least two occasions, the veteran requested medication for back
pain.  However, because neither the VA examination nor the
outpatient treatment records demonstrated any evidence of muscle
spasm on extreme forward bending and loss of lateral spine
motion, the veteran is not entitled to a rating of 20 percent
under Code 5295.

Because the veteran has been diagnosed to have minimal
degenerative changes of his thoracic spine, his back condition
may be evaluated under the diagnostic code pertaining to
arthritis.  When arthritis is involved, 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. Part 4,
§ 4.71a, Code 5003 (1993).  Evidence of moderate limitation of
motion of the thoracic, or dorsal, spine is required to allow a
10 percent rating.  38 C.F.R. Part 4, § 4.71a, Code 5291 (1993).

With any form of arthritis, painful motion is an important factor
of disability, and the facial expression, wincing, etc., on
pressure or manipulation, should be carefully noted and
definitely related to affected joints.  The intent of the
schedule is to recognize painful motion with joint or
periarticular pathology as productive of disability.  38 C.F.R.
Part 4, § 4.59 (1993).  Under 38 C.F.R. Part 4, § 4.40 (1993),
disability of the musculoskeletal system is primarily the
inability, due to damage or infection in the part of the system,
to perform the normal working movements of the body with normal
excursion, strength, speed, coordination and endurance.  It is
essential that the examination on which ratings are based
adequately portray the anatomical damage, and the functional
loss, with respect to all these elements.  The functional loss
may be due to absence of part, or all, of the necessary bones,
joints and muscles, or associated structures, or to deformity,
adhesions, defective innervation, or other pathology, or it may
be due to pain, supported by adequate pathology and evidenced by
the visible behavior of the claimant undertaking the motion.

Significantly, the April 1992 VA examination and the outpatient
treatment records regarding the veteran's back failed to
demonstrate any evidence of limitation of motion of the veteran's
spine.  Therefore, the veteran is not entitled to an evaluation
greater than 10 percent based on arthritis and limitation of
motion of his back.

In essence, therefore, in consideration of the diagnoses of
chronic back ache and minimal degenerative changes of the
thoracic spine and the repeated requests for medication to
alleviate the back pain, a rating in excess of 10 percent for a
back condition is not in order.  The Board also finds that the
rating of 10 percent adequately evaluates the veteran's
complaints of pain and any functional loss he may experience as a
result of his back condition.

With regard to the veteran's bilateral deformity of the
intercondyloid eminence of the tibia with leg pain, the Board
notes that in the March 1993 rating decision the RO rated this
disability separately as mild deformity of the intercondyloid
eminence with leg pain (left tibia) and as mild deformity of the
intercondyloid eminence with right leg pain.  Under Diagnostic
Code 5262, the RO assigned a zero percent rating for each of
these disabilities.  According to Code 5262, evidence of malunion
of the tibia and fibula, with slight knee or ankle disability, is
required for the assignment of a 10 percent rating.
38 C.F.R. Part 4, § 4.71a, Code 5262 (1993).

The outpatient records show treatment for various complaints and
disabilities from 1987 to January 1992.  According to these
records, the veteran did not seek treatment for any complaints
involving either of his lower extremities.  Evaluation of the
veteran's extremities during general physical examinations in
February 1990 and in January 1991 showed them to be nontender.

At the April 1992 VA examination, the examiner diagnosed mild
deformity of the intercondyloid eminence of both tibiae.  This
diagnosis was based on X-rays taken of both of the veteran's
knee.  The radiologist explained that it was unclear whether
these deformities resulted from normal variation or
post-traumatic change.  In addition, X-rays of the right knee
showed a tiny osteophyte formation at the patella indicating very
little degenerative change.  Furthermore, X-rays of the left knee
demonstrated an ovoid area of slight increase in density in the
soft tissue lateral to the distal femur.  No additional
abnormalities were noted on the examination report.

Significantly, the VA examination, including the X-rays taken of
the veteran's knees, failed to find any evidence of a malunion of
the right or left tibia or fibula.  Moreover, the abnormalities
noted on the examination revealed less than slight impairment of
the veteran's knees or ankles.  An evaluation of the veteran's
musculoskeletal system did not find any significant
abnormalities, including limitation of motion, of the veteran's
knees or ankles.  Consequently, the veteran cannot be rated
compensably under Code 5262.

The Board notes that X-rays of the veteran's right knee did
demonstrate a "very little" amount of degenerative changes of
this joint.  Significantly, however, no limitation of motion of
the veteran's right knee has been shown.  Therefore, the veteran
cannot receive a rating higher than zero percent for this right
knee condition.  38 C.F.R. Part 4, § 4.71a, Codes 5003, 5260,
5261 (1993).  In addition, because no limitation of motion of the
veteran's left knee has been shown, he cannot receive a rating
greater than zero percent for this joint under the diagnostic
codes involving limitation of motion of the knee.  38 C.F.R.
Part 4, § 4.71a, Codes 5260, 5261 (1993).

Moreover, according to VA examination report and the outpatient
treatment records, the veteran has not complained of pain in
either his right or his left knee.  Significantly, no evidence of
pain on motion, or other significant impairment, of either knee
was shown on the VA examination or at any of the outpatient
treatment sessions.  No functional impairment of either lower
extremity has been demonstrated.  Therefore, the veteran is not
entitled to a rating greater than zero percent under 38 C.F.R.
Part 4, §§ 4.40, 4.59 and 4.71a, Code 5257 (1993).

With regard to the veteran's hypertension, the Board notes that
in the March 1993 rating decision the RO rated this disability
zero percent under Code 7101.  Pursuant to this Code, evidence of
diastolic pressure predominantly 100 or more is required for the
assignment of a 10 percent rating.  Evidence of diastolic
pressure predominantly 110 or more with definite symptoms is
required for a rating of 20 percent.  38 C.F.R. Part 4, § 4.104,
Code 7101 (1993).  Note 2 to this Code also explains that, when
continuous medication is shown to be necessary for control of
hypertension with a history of diastolic blood pressure
predominantly 100 or more, a minimum rating of 10 percent will be
assigned.

In September 1987, the veteran's blood pressure was determined to
be 156/92.  In October 1987, his blood pressure was determined to
be 140/110.  In August 1988, his blood pressure was found to be
144/98.

A February 1990 record indicated that the veteran continued to
have hypertension.  In May 1991 when the veteran was receiving
treatment at the VA orthopedic clinic, his blood pressure was
determined to be 158/104.  In January 1992, the veteran's blood
pressure was determined to be 166/108.

At the April 1992 VA examination, the veteran's blood pressure
was determined to be 150/100 in the sitting position, 140/90 in
the recumbent position, and 150/100 in the standing position.  It
was noted that he was not taking any medication for hypertension.
X-rays of the veteran's chest were essentially negative.  The
examiner diagnosed hypertension.

As these outpatient treatment records and the VA examination
report show, the veteran has diastolic pressure which is
predominantly 100 or more, but less than 110.  Consequently, the
veteran's hypertension should be rated 10 percent but no higher.

With regard to an evaluation of the veteran's arthritic
shoulders, the Board notes that in the March 1993 rating
decision, RO defined this disability as a history of arthritis of
the shoulders and rated it as noncompensably disabling under
Code 5003.  As previously discussed, when arthritis is involved,
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. Part 4, § 4.71a, Code 5003 (1993).  Evidence of
limitation of motion of the arm to the shoulder level is required
for the assignment of a 20 percent rating under Diagnostic
Code 5201.  38 C.F.R. Part 4, § 4.71a, Code 5201 (1993).

Furthermore, § 4.40 requires that the evaluation of a disability
of the musculoskeletal system must take into account the
functional loss due to pain of the damaged part of the system.
38 C.F.R. Part 4, § 4.40 (1993).  In addition, § 4.59 requires
that the rating of a disability involving any form of arthritis
must include consideration of the extent of pain on motion of the
arthritic joint.  38 C.F.R. Part 4, § 4.59 (1993).

According to the outpatient treatment records associated with the
claims folder pursuant to the present appeal, the veteran was
treated in December 1988 for complaints of pain in his right
shoulder.  Examination revealed some tenderness of the right
shoulder.  Range of motion of the shoulder was found to be within
normal limits.  The examining physician diagnosed the veteran to
have musculoskeletal pain and prescribed Motrin and Robaxin.  In
November 1990, the veteran sought treatment for complaints of
pain over his shoulders.  Examination of his shoulders found them
not to be tender.

At the April 1992 VA examination, the veteran complained of pain
in his joints but did not specifically mention his shoulders.
Evaluation of his musculoskeletal system did not find any
significant abnormality of either shoulder.  X-rays taken of the
veteran's left shoulder were negative for residuals of injury or
arthritis.  The examiner diagnosed a history of arthritis of the
shoulders and explained that no arthritis of the shoulders was
clinically found on examination.

According to these medical records, the veteran has normal range
of motion of his right shoulder.  Furthermore, there is no
evidence of any limitation of motion of the veteran's left
shoulder.  Therefore, the veteran is not entitled to a rating
above zero percent for this condition.  38 C.F.R. Part 4,
§§ 4.71a, Codes 5003, 5201.  Moreover, neither the outpatient
treatment records nor the VA examination report demonstrated any
evidence of pain on motion of the veteran's shoulders.  No
significant shoulder abnormality was demonstrated on the VA
examination.  Consequently, the veteran is not entitled to a
compensable rating under § 4.40 or § 4.59.

With regard to the veteran's gastritis, the Board notes that in
the March 1993 rating decision, the RO defined this disability as
a history of gastritis and rated it zero percent under Diagnostic
Code 7307.  Pursuant to this Code, hypertrophic gastritis
identified by gastroscope is rated 10 percent when the evidence
shows that the disability is chronic with small nodular lesions
and symptoms.  38 C.F.R. Part 4, § 4.114, Code 7307 (1993).

According to the outpatient treatment records, in February 1990,
November 1990 and January 1991 the veteran's abdomen was found to
have no rigidity.  In July 1991, the veteran sought treatment for
epigastric pain he had been experiencing for the prior two weeks.
He explained that, when he ate, the pain cut him across his upper
abdomen.  The examiner noted that the abdomen was flat and soft
and that the epigastrium was tender and diagnosed gastritis.  In
November 1991, the veteran sought treatment for complaints of
stomach pain.  The examiner diagnosed gastritis and associated
this disability with the veteran's medication and alcohol.  In
January 1992, the veteran reported that his stomach pain had
improved somewhat but that he continued to experience some pain
in his stomach.

The April 1992 VA examination included an evaluation of the
veteran's digestive system.  According to the examination report,
the examiner found that the veteran's digestive system was normal
and diagnosed the veteran to have a history of gastritis due to
Motrin.

Significantly, the veteran has not been found to presently have
chronic gastritis.  The current diagnosis is by history only.
Moreover, there is no evidence of small nodular lesions or
symptoms of gastritis, except for the veteran's earlier
complaints of stomach pain.  This evidence does not warrant a
rating of 10 percent for gastritis.

C.  Analysis

The Board finds, therefore, that the veteran is rated at
20 percent, 10 percent, zero percent, zero percent, 10 percent,
and zero percent for his right wrist, back, shoulder, bilateral
leg, hypertension, and gastritis conditions, respectively.  These
ratings comprise a 40 percent combined disability evaluation in
accordance with the provisions of 38 C.F.R. Part 4, §§ 4.25, 4.26
(1993), referable to combined ratings.  The combined 40 percent
rating represents the average wage-earning impairment caused by
the veteran's disabilities.

As noted above, entitlement to pension benefits may be
objectively determined if the veteran is unemployable as a result
of a permanent disability or experiences a disability which would
preclude an average person from following a substantially gainful
occupation, if it is reasonably certain that such disability is
permanent.  38 U.S.C.A. § 1502(a) (West 1991); 38 C.F.R. Part 4,
§ 4.15 (1993).  The Board also notes that a total disability
rating for the veteran's disorders is not warranted under the
applicable schedular criteria contained in the Rating Schedule.
With a combined 40 percent evaluation, the disorders are clearly
not representative of a total disability in accordance with
applicable schedular criteria or applicable regulations.
38 C.F.R. Part 4, including §§ 4.16 and 4.17 (1993).

Upon a review of the clinical findings of record referable to the
veteran's disabilities and in consideration of the Rating
Schedule with regard to such disabilities, the Board concludes
that the veteran's disabilities would not preclude an average
person from securing and following substantially gainful
employment.  The Board emphasizes that the veteran's combined
rating represents the average wage-earning impairment.  Two of
the veteran's disabilities are by history, and none of them,
either in combination or alone, is so severely disabling as to
render him unemployable.  As such, the evidence of record does
not support a conclusion that the veteran experiences disability
which, even if permanent, would render the average person unable
to follow a substantially gainful occupation.  38 U.S.C.A.
§ 1502(a) (West 1991).  Accordingly, a permanent and total
disability evaluation based upon the objective "average person"
standard of review is not warranted.

Since the veteran's disabilities do not meet the percentage
requirements of 38 C.F.R. Part 4, § 4.17 (1993), applied to
pension cases through 38 C.F.R. Part 4, § 4.16 (1993), the Board
must determine whether the veteran would be eligible for pension
benefits based upon subjective criteria, including consideration
of the veteran's age, education and occupational history, and
unusual physical or mental effects.  38 C.F.R. Part 3, § 3.321,
Part 4, § 4.15 (1993).  In this regard, the Board notes that the
veteran was born in August 1950.  He has a high school education
including additional training as a mechanic and a heavy equipment
operator.  He has reported work experience as an auto-mechanic.

Although the veteran primarily has work experience as a manual
laborer, he also has a high school education.  This education,
along with his background and training as an auto-mechanic and
heavy equipment operator, could provide him with other manual
labor not requiring extensive use of the right hand,
non-physical, or clerical, vocational opportunities in these
fields.  Clerical work would significantly lessen the amount of
strain the veteran would have to place on his right wrist, back,
and legs while he is working.

Upon consideration of the combined effect of the veteran's
disabilities and resulting functional limitations, in addition to
his age, education, and occupational history, the Board is not
persuaded that the veteran is permanently and totally disabled.
An allowance of pension benefits, therefore, is also not
warranted based upon subjective criteria.  38 C.F.R. Part 3,
§ 3.321, Part 4, § 4.15 (1993).  The veteran's claim of
entitlement to a permanent and total disability evaluation for
pension purposes must, therefore, be denied.

ORDER

An increased disability evaluation for post-operative laceration
and superficial branch of the radial nerve of the right wrist is
denied.

A permanent and total disability rating for pension purposes is
denied.

          WILLIAM J. REDDY
          Member, Board of Veterans' Appeals

The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___
(1994), permits a proceeding instituted before the Board to be
assigned to an individual member of the Board for a
determination.  This proceeding has been assigned to an
individual member of the Board.

NOTICE OF APPELLATE RIGHTS:  Under 38 U.S.C.A. § 7266 (West
1991), a decision of the Board of Veterans' Appeals granting less
than the complete benefit, or benefits, sought on appeal is
appealable to the United States Court of Veterans Appeals within
120 days from the date of mailing of notice of the decision,
provided that a Notice of Disagreement concerning an issue which
was before the Board was filed with the agency of original
jurisdiction on or after November 18, 1988.  Veterans' Judicial
Review Act, Pub. L. No. 100-687, § 402 (1988).  The date which
appears on the face of this decision constitutes the date of
mailing and the copy of this decision which you have received is
your notice of the action taken on your appeal by the Board of
Veterans' Appeals.