Citation Nr: 0004672 Decision Date: 02/23/00 Archive Date: 02/28/00 DOCKET NO. 98-01 719A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to an increased rating for hypertension, currently evaluated as 10 percent disabling. 2. Entitlement to an increased rating for postoperative carpal tunnel decompression surgery of the right median nerve, currently evaluated as 10 percent disabling. 3. Entitlement to an increased rating for postoperative carpal tunnel decompression surgery of the left median nerve, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant INTRODUCTION The veteran served on active duty from February 1957 to December 1966 and from March 1967 until his retirement in May 1977. This matter comes to the Board of Veterans Appeals (Board) from a May 1997 rating decision of the Regional Office (RO) which denied the veteran's claim for an increased rating for the service-connected disabilities at issue. Effective March 1, 1999, the name of the United States Court of Veterans Appeals was changed to the United States Court of Appeals for Veterans Claims ("the Court"). FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The veteran's diastolic pressure is predominantly less than 100, and he requires medication for control of hypertension. 3. His systolic pressure is not predominantly 200 or more. 4. The recent Department of Veterans Affairs (VA) examination showed no evidence of carpal tunnel syndrome of the right upper extremity. It is not productive of more than mild impairment. 5. There was no clinical evidence of carpal tunnel syndrome of the left hand on the most recent VA examination. 6. Carpal tunnel syndrome of the left median nerve does not result in more than mild impairment. CONCLUSIONS OF LAW 1. A rating in excess of 10 percent for hypertension is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.104, Diagnostic Code 7101 (as in effect prior to January 12, 1998), as amended by 38 C.F.R. § 4.104, Diagnostic Code 7101 (effective on January 12, 1998); Karnas v. Derwinski, 1 Vet. App. 308 (1991). 2. A rating in excess of 10 percent for postoperative status right carpal tunnel decompression surgery is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.123, 4.124a, Diagnostic Codes 8515, 8615 (1999). 3. A rating in excess of 10 percent for postoperative status left carpal tunnel decompression surgery is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.123, 4.124a, Diagnostic Codes 8515, 8615 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The initial question before the Board is whether the veteran has submitted well-grounded claims as required by 38 U.S.C.A. § 5107. The Court has held that a well-grounded claim is one which is plausible, meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In this case, the veteran's statements concerning the severity of the symptoms of his service-connected disabilities that are within the competence of a lay party to report are sufficient to conclude that his claims are well grounded. Proscelle v. Derwinski, 2 Vet. App. 629; Espiritu v. Derwinski, 2 Vet. App. 492 (1992). No further development is necessary in order to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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, see 38 C.F.R. § 4.1 (1999), the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). I. An Increased Rating for Hypertension Factual background The service medical records disclose that the veteran was seen for hypertension in April 1965, and that he was hospitalized in December 1966 for labile hypertension. On the retirement examination in February 1977, blood pressure was 150/80. The veteran was afforded a VA examination in July 1981. Blood pressure readings were 140/98, 160/92 and 166/98. The pertinent diagnosis was essential hypertension. Based on the evidence summarized above, the RO, by rating action dated in August 1981, granted service connection for hypertension, and assigned a noncompensable evaluation. This evaluation remained in effect for many years. Another VA examination was conducted in February 1991. The veteran related that he began to take medication for hypertension in 1990. Serial blood pressure readings were 158/96, 154/92 and 140/92. The diagnosis was hypertensive cardiovascular disease. In a rating decision dated in March 1991, the RO increased the evaluation for hypertension to 10 percent, effective February 1990. The veteran was afforded an examination by the VA in May 1997. He reported that he was still on medication for hypertension and that his blood pressure levels had been fairly well controlled. On examination, serial blood pressure readings were 160/98, 155/96 and 155/95. The diagnosis was hypertension. During a VA examination in September 1998, the veteran related that he tolerated his blood pressure medication well, with borderline control of blood pressure. Serial blood pressure readings were 142/90, 142/92 and 142/90. The pertinent diagnosis was hypertension. Private medical records dated in 1997 and 1998 have been associated with the claims folder. Numerous blood pressure readings were recorded. Systolic pressure ranged from 134 to 170, and diastolic pressure ranged from 75 to 107. Analysis A 20 percent evaluation may be assigned for hypertensive vascular disease (essential arterial hypertension) when the diastolic pressure is predominantly 110 or more with definite symptoms. A 10 percent evaluation is assignable when the diastolic pressure is predominantly 100 or more. Diagnostic Code 7101 (as in effect prior to January 12, 1998). A 20 percent evaluation may be assigned for hypertensive vascular disease (hypertension and isolated systolic hypertension) when the diastolic pressure is predominantly 110 or more, or; systolic pressure predominantly 200 or more, a 20 percent evaluation may be assigned. When diastolic pressure is predominantly 100 or more, or; systolic pressure is predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more or who requires continuous medication for control, a 10 percent evaluation is assignable. Diagnostic Code 7101 (effective January 12, 1998). In Karnas, 1 Vet. App. 308, the Court held that "where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to appellant" shall apply. Accordingly, the Board will consider both versions of the VA's Schedule for Rating Disabilities in light of Karnas. In this regard, the Board points out that the veteran has been furnished the old criteria in the statement of the case issued in December 1997, and the new criteria in the supplemental statement of the case which was issued in February 1999. A review of the record confirms that the veteran has been on medication for hypertension for many years. Many blood pressure readings have been recorded on VA examinations and in private medical records during the course of the appeal. At no time, however, has the diastolic pressure exceeded 110 or the systolic pressure exceeded 200. There is no basis, therefore, for a higher evaluation to be assigned. The veteran argues that his symptoms of hypertension include chest pain, shortness of breath and heart palpitations. The fact remains, however, that the rating for hypertension is predicated on the blood pressure readings which, in this case, do not afford a basis for an increased rating. The veteran's statements have been considered, but the Board concludes that the medical findings on examination are of greater probative value. The weight of the evidence is against the claim for an increased rating for hypertension. II. An Increased Rating for Postoperative Right Carpal Tunnel Decompression Surgery and An Increased Rating for Postoperative Left Carpal Tunnel Decompression Surgery Factual background The service medical records reflect the fact that the veteran underwent surgery for release of right carpal tunnel syndrome in March 1977 and the following month for left carpal tunnel syndrome. The veteran was afforded a VA examination in July 1981. An examination of both wrists revealed soft, non-tender and non- adherent scars. Range of motion was normal, bilaterally. There was no Tinel's sign. There was no evidence of muscular atrophy in the thenar or hypothenar areas. The grip was strong bilaterally. Reflexes were normal. Based on the evidence summarized above, the RO, by rating decision dated in August 1981, granted service connection for postoperative right and left carpal tunnel syndrome, and assigned a noncompensable evaluation for each disability. Another VA examination was conducted in February 1982. The veteran related that the symptoms of numbness and pain had recurred. It was indicated that he was right-handed. An examination of the wrists showed no erythema, warmth or effusion. Limitation of motion was noted. Pinprick sensation was diminished in the distribution of the median nerve on the right and was nonreproducibly diminished in the left hand. The diagnosis was status post bilateral carpal tunnel release with hypesthesia in the median nerve distribution on the right and subjective pain with nerve conduction study compatible with nerve entrapment. By rating action dated in March 1982, the RO assigned a 10 percent evaluation for postoperative left carpal tunnel syndrome and a 10 percent evaluation for psychiatric right carpal tunnel syndrome. These ratings have remained in effect since then. The veteran was afforded an examination by the VA in May 1997. He related that following the surgery in service, the symptoms were completely resolved for approximately five years, but they then gradually recurred and were increased with a degree of physical activity. This was a factor which led him to consider retiring from welding in 1996. An examination revealed well-healed scars over the volar aspect of both wrists. He had no overt tenderness over these areas. Range of motion of the wrists was within normal limits, and no neurologic abnormalities were observed in the upper extremities. The impression was status postoperative right carpal tunnel decompression surgery and status post postoperative left carpal tunnel decompression surgery. On VA examination in September 1998, the examiner noted that he had reviewed the claims folder. It was stated that the veteran was on medication for multiple joint pains. The veteran did not report nerve entrapment symptoms of dysesthesias of the first three fingers of the hands, nor did he report persistent weakness of the hands. He gave a history of bilateral shoulder pain and some aching of the wrist bilaterally which was not consistent with carpal tunnel syndrome. It was indicated that this tended to be worse with driving an automobile which caused pain diffusely in the upper extremities without any radicular weakness to his hands. An examination showed scars on the wrists of each hand which were hypopigmented and flat. Both hands revealed negative Tinel's skin test and negative Phalen's maneuver. There was no thenar eminence atrophy. Handgrip strength was 5/5 in both hands. There was somewhat diminished range of motion of the wrists with dorsiflexion to 45 degrees; ulnar deviation to 40 degrees; and radial deviation to 20 degrees. There were no palpable deformities of the wrists. A neurologic evaluation with respect to carpal tunnel syndrome showed that deep tendon reflexes were 2+ and symmetric at the biceps, triceps and brachial radialis. The impression was status post carpal tunnel syndrome decompression. The examiner commented that the wrist pain appeared to be the result of degenerative arthritis or arthralgias associated with overuse for many years. There was no evidence of persistent carpal tunnel syndrome on physical examination. The veteran was seen by a private physician in December 1998 for joint pain. It was reported that he recently had had to give up his welding business because any amount of vibration was uncomfortable for his hands, and even driving bothered his shoulder. He had pain in his wrists and shoulders, as well as numbness in his hands. The veteran thought this was due to recurrent carpal tunnel. An examination disclosed tenderness over each wrist, but no synovitis. The small joints of the hands were somewhat gnarled, but otherwise not very tender. The assessment was that the veteran might have a combination of rotator cuff disease of long standing and recurrent carpal tunnel, or he could combine these with an inflammatory process. The examiner recommended getting old records. In January 1999, the private physician who saw the veteran in December 1998 wrote a letter to another physician. He stated that there was no local tenderness over the wrist. There was not a clear-cut median hypesthesia nor Tinel's. The physician did not have a clear diagnosis. He recommended an electomyelogram to determine if there was median or ulnar neuropathy. He could not document these clinically. Analysis Neuritis, cranial or peripheral, 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. See nerve involved for diagnostic code number and rating. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124a. A 70 percent evaluation may be assigned for complete paralysis of the median nerve of the major extremity; the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. a 60 percent evaluation is assignable for complete paralysis of the median nerve of the minor extremity. A 30 percent evaluation is assignable for incomplete paralysis of the median nerve of the major extremity which is moderate. When mild, a 10 percent evaluation may be assigned. A 20 percent evaluation is assignable for moderate incomplete paralysis of the median nerve of the minor extremity. When mild, a 10 percent evaluation is assignable. Diagnostic Codes 8515, 8615. Since he submitted a claim for an increased rating, the veteran has been examined twice by the VA. The first examination, conducted in May 1997, revealed no tenderness over the wrist scars, and full range of motion. There was no indication of any neurologic abnormalities. Clearly, the findings recorded on this examination provide no basis for an increased rating. Similarly, the findings on the most recent VA examination in September 1998 also fail to support the veteran's claim for an increased rating. In this regard, the Board points out that there were no palpable deformities of the wrist. The Board acknowledges that there was some limitation of motion of the wrist. Of utmost significance is the fact that the examiner opined that the wrist pain was due to degenerative arthritis or arthralgias. He found no clinical evidence of carpal tunnel syndrome. The Board notes that a private physician who examined him in December 1998 suggested that the veteran might have recurrent carpal tunnel syndrome. It must be observed, however, that a letter accompanying his clinical notes indicates that he did not have a clear diagnosis. He suggested getting the old records and further study to ascertain whether median neuropathy was present. The fact remains that it was not documented clinically. The VA examiner had the old records, reviewed them, and concluded that the veteran did not have any signs of carpal tunnel syndrome. This opinion is probative of the issue. The clincal evidence of record fails to demonstrate that carpal tunnel syndrome is more than mild. The Board finds, therefore, that the weight of the evidence is against the veteran's claim for an increased rating for postoperative carpal tunnel decompression surgery on the right and left. ORDER An increased rating for hypertension is denied. An increased rating for postoperative right carpal tunnel decompression surgery is denied. An increased rating for postoperative left carpal tunnel decompression surgery is denied. James R. Siegel Acting Member, Board of Veterans' Appeals