VA Disability Ratings for Wrist Conditions
Michael Lostritto: Hi, and welcome to another edition of CCK Live. My name is Mike Lostritto, and I am joined today by Kevin Medeiros and by Matthew Fusco. Today we’re going to be discussing VA disability ratings for wrist conditions.
Veterans commonly experienced wrist injuries and pain as a direct result of their military service. So, today we will review some of the most common risk conditions among veterans and explain how each of those conditions are rated. So, Matt, why don’t we begin with you, and maybe you can set us off talking a little bit about wrist pain.
Matthew Fusco: Sure. So, wrist injuries such as sprains and fractures often result in wrist pain. Wrist injuries often occur when a person falls because they tend to reach out with their hands to catch themselves and land on their wrist incorrectly. Wrist injuries can sometimes go unnoticed and lead to a delay in treatment.
Other causes of wrist pain aside from a falling injury can include things like scaphoid fracture, which occurs when one of the small bones in the wrist, which is near to the thumb, is fractured. This can often be so small that it’s not detected on X-rays directly after the injury. Delaying treatment of a scaphoid fracture can typically cause additional complications and issues down the road.
Another common cause of wrist pain are ganglion cysts, which occur on the wrist, closer to the backside typically, and can cause pain that may worsen with movement of the wrist.
Repetitive stress or movement can also cause other conditions that lead to wrist pain such as osteoarthritis or rheumatoid arthritis. The first, osteoarthritis, can occur in the wrist when the cartilage which protects the ends of the bones deteriorates over time. People with prior wrist injuries are particularly more susceptible to developing osteoarthritis in the wrist. And rheumatoid arthritis occurs when a person’s immune system actually attacks their own tissues. Unlike osteoarthritis, rheumatoid arthritis will commonly affect both wrists rather than just one.
Michael: Yeah. Thank you, Matt. And that is certainly a common condition that I see, I’m sure all of you see, in our practice here representing veterans. Another very common condition injury that we see, Kevin, is wrist tendonitis. And so, maybe you can talk to us a little bit about that.
Kevin Medeiros: Sure. Tendonitis, like it sounds, affects the tendons in the wrist, which are the tissue that connect the muscle to the bone. Tendonitis is most commonly caused by inflammation, and that inflammation itself is generally caused when the proteins in the tendon start to break down and then, as a result, become inflamed.
Symptoms of tendonitis include swelling, like I mentioned, redness or warmth around the wrist, and sometimes a grinding sensation that you might feel with movement. In some cases, tendonitis can be so severe or debilitating that it needs to be remedied via surgery. Otherwise, generally, tendonitis is treated with ice, anti-inflammatory medication, and limiting the mobility of the wrist so as not to aggravate the condition. Sometimes also cortisone shots or hand therapy might be used to treat the condition. As far as the disability rating for tendonitis goes, the minimum rating is 10 percent, and then it can escalate from there depending on the severity of the condition.
Michael: Yeah, that’s exactly right. Thank you, Kevin. Another condition that we see very commonly is carpal tunnel. Carpal tunnel is a condition that occurs when one of the major nerves in the hand, the median nerve, is compacted or pinched really throughout the wrist. Symptoms of carpal tunnel include numbness, tingling, weakness in the hand or arm, and generalized pain.
Treatment for carpal tunnel often involves wearing a wrist splint, avoiding certain activities, or in some situations, unfortunately, surgery. Some risk factors that tend to increase a person’s chance of developing carpal tunnel include heredity, but also repetitive hand use involving certain hand positions, health conditions like diabetes, arthritis, thyroid gland imbalance, all things that can serve as risk factors for this condition.
VA typically rates carpal tunnel under the regulation 38 CFR section 4.124a in its schedule of ratings, and the specific diagnostic code for this condition is diagnostic code 8515. This diagnostic code generally rates neurological conditions but carpal tunnel specifically, the rating for it is based on paralysis of, again, that median nerve that we were talking about a second ago. So, for a rating of 70 or 60 percent, we’re really looking for complete paralysis by the absence of flexion of the index finger and feeble flexion of the middle finger, the inability to make a fist, index and middle fingers remain extended, and an inability to flex distal or a part of the thumb, weak in flexion, different symptoms that are more severe such as those.
If we’re looking for a kind of a next step down for the rating of 50 percent, we’re looking at incomplete paralysis that’s marked as severe. Continuing down, a 30 percent rating, we’re looking at an incomplete paralysis that’s deemed moderate. And then finally, a 10 percent rating, we’re looking at incomplete paralysis that’s mild.
One thing to note is VA does not further define what constitutes mild, moderate, or severe. So, unfortunately, veterans and veterans advocates are left having to do a little guesswork or use the evidence that’s in the file or develop the evidence in the case to determine, or to show rather, to demonstrate that the condition, the incomplete paralysis is either mild, moderate, or severe. Again, complete paralysis will be what a veteran would need to show in order to get the max 60 percent rating.
A higher rating is applied when carpal tunnel affects the dominant hand. So, one thing that I should just clarify is that for each of those different symptoms that I laid out, one of two different ratings can be applied. So, for incomplete paralysis that’s mild, we’re looking at a 10 percent rating regardless. But for incomplete paralysis that’s moderate, we’re looking at a 30 percent rating for dominant hand or a 20 percent rating for the non-dominant hand. For incomplete paralysis that’s severe, we’re looking at a 50 percent rating, again, for the dominant hand and a 40 percent rating for the non-dominant hand. For complete paralysis in the dominant hand, we’re looking at a 70 percent rating. But again, a lesser rating of a 60 percent rating for the non-dominant hand.
Again, VA is applying a lower percentage for the non-dominant hand as opposed to the veteran’s dominant hand that has carpal tunnel. Matt, I know we’ve talked about a few different conditions that are very common so far for veterans and how those conditions are rated. Can you maybe walk us through the next condition that’s pretty common that we see?
Matt: Sure. Bear with me on the pronunciation here, but there’s a condition called De Quervain’s tenosynovitis, which is a form of tendonitis that affects the tendons towards the thumb, making it painful to turn the wrist, grab things or form a fist. It is generally caused by repetitive overuse of the wrist, but sometimes it’s caused by a direct injury like a fracture or a sprain. Rheumatoid arthritis may also cause this condition, and risk factors such as sex, age, pregnancy, or jobs with repetitive wrist motion may increase a person’s chances of developing this disability.
When issuing a rating for de Quervain’s tenosynovitis, VA will consider if the impairment is mild or reaching total paralysis. If the condition is affecting the veteran’s dominant hand, it will receive a higher rating.
More on the topic of the rating for this condition. Motion limitation is generally the main determining factor for this rating criteria. For hand conditions such as de Quervain’s tenosynovitis, the combined rating may not exceed 70 percent for the dominant hand and 60 percent for the non-dominant hand. In cases where the veteran is ambidextrous, the hand or arm which is affected by the condition is considered the dominant hand for rating purposes.
Michael: Yeah. And so this is kind of a common thing that we see, right Matt, where the dominant hand is rated a little bit differently than the non-dominant hand. And so, it’s important for veterans and veterans advocates, I think, to keep that in mind when they’re looking at the rating that’s assigned or the rating that they’re arguing for, because it does change and the regulation does specify different ratings based on which hand is dominant. So, it’s something to keep in mind.
I have seen some mistakes being made or have been made in decisions where VA will not clearly grant the higher rating despite the fact that the condition, the wrist condition, was clearly with the veterans’ dominant hand. So, that’s a great point that you addressed. Thank you.
Kevin, turning back to you. The next condition that is kind of a common wrist condition we see in our practice is ankylosis of the wrist. Maybe you can walk us through that condition and also, again, how that condition is rated.
Kevin: Yeah. So, ankylosis is generally caused by arthritis. It can be osteoarthritis or other types of that condition, and it’s the stiffness of the joint due to abnormal adhesion and rigidity. So, basically, the wrist becomes so fixed in one place that it’s difficult for the veteran to move it. Ankylosis basically means that there’s no movement in the joint from where the joint is actually placed or where it sits.
The ratings are under diagnostic code 5214, and favorable ankylosis in 20 degrees to 30 degrees of dorsal flexion, which is bringing the wrist upwards, warrants a 30 or 20 percent rating depending on whether it’s the dominant hand or non-dominant hand, as we’ve been discussing. Any other position of ankylosis would be a 40 or 30 percent rating. An unfavorable ankylosis, which would be the wrist fixed and palm flexion in its downward movement would be a 50 or 40 percent rating.
As we’ve been discussing, those different ratings are based on which hand is dominant. And then, for cases where the joint is ankylosed in an extremely unfavorable position where basically functionally, the veteran has no more use of the hand, VA has separate diagnostic code that accounts for when joints are specifically found to be without any functioning whatsoever or basically no functional use of the joint. That’s rated as loss of use of the hand and that’s under diagnostic code 5215. So, there are varying ratings for ankylosis depending on how and where the joint is fixed. But when it comes down to having basically no functional ability of the joint at all, there are ratings available that contemplate the inability to use the hand.
Michael: One thing that is critical for VA — VA relies heavily upon in order to rate these conditions — are compensation and pension examinations, or VA exams, or C&P exams as they’re known. These are exams that I’m sure many veterans are familiar with who have been through the process. But in order to assess the veteran’s condition, VA oftentimes will request a C&P exam to assess the veterans’ wrist condition. As we’ve been talking a little bit here today, many of these conditions are rated by loss of range of motion. And so, in order for VA to assess the condition and then rate the condition, oftentimes they need to see the veteran in person, conduct the range of motion testing, and then derive a rating that’s based on that range of motion testing. The compensation and pension exams really allow VA to collect more information regarding the condition to, number one, establish if it’s related to service. But assuming that we’ve established that the condition is related to service, then like we’ve been saying hopefully accurately rate the condition.
During the C&P exam, veterans should be aware that the wrist condition will likely be evaluated based on range of motion testing as we’ve been discussing but also potentially X-rays. And so, since wrist conditions such as carpal tunnel are sometimes misdiagnosed as other chronic conditions, the exam can help to ensure that veterans receive the correct diagnosis.
Veterans may also wish to fill out a DBQ form on their own. I think this is actually a really good recommendation. Oftentimes, as many veterans are well aware, the C&P exam, the VA exam, doesn’t accurately or completely capture the entire disabling effect of their condition. Veterans often complain that they’re only in a C&P exam for a mere matter of minutes, and perhaps on that one particular day that they’re being seen, their condition isn’t acting up or isn’t flaring up or isn’t as bad as it had been for the preceding five years.
And so, supplementing the record, I think, with your own DBQ form, which is shorthand for Disability Benefits Questionnaire form, which can be filled out, downloaded from VA and then filled out from a private provider, or even just a submission of lay evidence or affidavits. All of that evidence, including potentially treatment records from a private healthcare provider, can help to establish a veteran’s claim and show that perhaps even if the C&P exam, the VA exam, is unfavorable or didn’t entirely capture the extent of the veterans’ condition, there’s other evidence, private evidence that can supplement the record and detail just exactly how severe and how limiting the condition is.
For condition, for wrist conditions that are extremely severe or otherwise impact to veteran’s ability to perform different aspects of employment. Matt, I’m going to turn to you next. Maybe you can talk a little bit about veterans’ options, what they could potentially apply for, what they could supplement the record with to apply for the TDIU benefit based on the disabling effects of the wrist condition.
Matt: Sure. So, veterans with wrist conditions may be entitled to total disability based on individual unemployability, or TDIU for short. I will just note that we discuss TDIU in a lot more detail in other videos, so feel free to check those out to get some additional information about this particular benefit. But to touch on it briefly, TDIU is a disability benefit that compensates veterans at the 100 percent level. What makes TDIU special is that it is available to those veterans who may not regularly or numerically meet the criteria needed to reach that 100 percent rating.
So, in order to be eligible for this benefit, a veteran needs to show that their service-connected disabilities cause them to be unable to secure and follow substantially gainful employment. And gainful employment refers to the ability to support oneself financially through your occupation. There are two main pathways to TDIU, again, we get into this in a lot more detail in TDIU specific videos, but those two main categories are schedular and extraschedular. If a veteran does not meet the criteria for schedular TDIU, they may still be eligible for extraschedular TDIU based on their wrist conditions, based on other conditions, but those are the two main pathways in order to secure that particular benefit.
Michael: Matt, extraschedular, that just means that the veteran does not meet the specific percentage requirements prescribed by law for VA to at least initially grant TDIU. Is that correct?
What you’re saying is, despite the fact that they may not meet those specific prescribed ratings, they can nevertheless apply and argue for TDIU based on the severity and limiting impact of the wrist conditions.
Michael: That’s really key and great, I think, to highlight. As we’ve been discussing here, a lot of the ratings for wrist conditions are far less than the total 100 percent rating. So, for instance, if we’re looking again at the carpal tunnel of the dominant hand and say a veteran was assigned a 70 percent rating. Despite the fact that they may not qualify for a total disability rating or a 100 percent rating, TDIU is still available if the veteran can show that that wrist condition, and really any other service-connected conditions that they have in combination, preclude the veteran from, you know, enduring or maintaining substantially gainful employment.
So, I think you highlighted that perfectly and I think that’s really critical for veterans to keep in mind. It’s a shortcut essentially to being compensated at the 100 percent rate despite the fact that they may not otherwise reach that 100 percent rate through the incremental additions of their ratings.
So, I think that about does it. I appreciate everyone tuning in today. For more information, please visit our blog as well as our other videos that are located on YouTube. And as always, please don’t forget to subscribe to our channel. Thank you.
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