Citation Nr: 0810750 Decision Date: 04/01/08 Archive Date: 04/14/08 DOCKET NO. 04-38 225A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an increased rating for gastroesophageal reflux disease (GERD), currently evaluated as 10 percent disabling. 2. Entitlement to an increased (compensable) rating for osteoporosis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S.M. Cieplak, Counsel INTRODUCTION The veteran served on active duty from April 1986 to June 1996. This appeal comes before the Board of Veterans' Appeals (Board) on appeal from a July 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In July 2005, the Board remanded this matter to the RO to afford due process and for other development. Following its completion of the Board's requested actions, the RO continued the denial of the veteran's claim (as reflected in a September 2007 supplemental SOC (SSOC)) and returned this matter to the Board for further appellate consideration. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claims on appeal has been accomplished. 2. The veteran's symptoms of GERD have been manifested by a history of gas and diarrhea and occasional epigastric distress without anemia, signs of significant weight loss or malnutrition, or significant effect on usual occupation or usual daily activities, without considerable or greater impairment of health. 3. The clinical evidence indicates that service connected osteoporosis does not manifest by pain or functional limitation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for GERD are not met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 4.20, 4.114, Diagnostic Code 7346 (2007). 2. The criteria for a compensable disability rating for osteoporosis have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5013 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (the Court) have been fulfilled by information provided to the veteran in letters from the RO dated in March 2003, May 2004, September 2004 and November 2005. Those letters notified the veteran of VA's responsibilities in obtaining information to assist the veteran in completing his claim, identified the veteran's duties in obtaining information and evidence to substantiate his claim. (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006), Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006). During the pendency of this appeal, on March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all elements of a claim. The record does not reflect that the veteran was provided with such notice. However, as the Board's decision herein denies the appellant's claim, no disability rating or effective date is being assigned; there is accordingly no possibility of prejudice to the appellant under the notice requirements of Dingess/Hartman. The Board also acknowledges a recent decision from the Court that provided additional guidance of the content of the notice that is required to be provided under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) in claims involving increased compensation benefits. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). In that decision, the Court stated that for an increased compensation claim, 38 U.S.C.A. § 5103(a) requires, at a minimum, that the VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask the VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Further, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the VA must provide at least general notice of that requirement to the claimant. See Vazquez-Flores v. Peake, supra. While the veteran was clearly not provided this more detailed notice, the Board finds that the veteran is not prejudiced by this omission in the adjudication of his increased rating claim. In this regard, during the course of this appeal the veteran has been represented at the RO and before the BVA by a National Veterans Service Organization (VSO) recognized by the VA, specifically the Disabled American Veterans and the Board presumes that the veteran's representative has a comprehensive knowledge of VA laws and regulations, including particularly in this case, those contained in Part 4, the Schedule for Rating Disabilities, contained in Title 38 of the Code of Federal Regulations. In addition, after the veteran and his VSO representative were provided copies of the Statement of the Case by the RO, the representative submitted a VA Form 646 (Statement of Accredited Representative in Appealed Case) in which the representative essentially acknowledged receipt of the Statement of the Case and provided additional argument in response to that document, which the Board notes contained a list of all evidence considered, a summary of adjudicative actions, included all pertinent laws and regulation, including the criteria for evaluation of the veteran's disability, and an explanation for the decision reached. Moreover, the Informal Hearing Presentation submitted by the veteran's representative contained detailed references to the evaluation criteria listed in the pertinent Diagnostic Codes. In the Board's opinion all of this demonstrates actual knowledge on the part of the veteran and his representative of the information that would have been included in the more detailed notice contemplated by the Court in the Vazquez- Flores case. As such, the Board finds that the veteran is not prejudiced based on this demonstrated actual knowledge. The veteran has been made aware of the information and evidence necessary to substantiate his claim and has been provided opportunities to submit such evidence. The RO has properly processed the appeal following the issuance of the required notice. Moreover, all pertinent development has been undertaken, examinations have been performed, and all available evidence has been obtained in this case. The appellant has not identified any additional evidence that could be obtained to substantiate the claim. In a statement dated in October 2007, the veteran indicated that he had no additional evidence to submit. Clearly, from submissions by and on behalf of the veteran, he is fully conversant with the legal requirements in this case. Thus, the content of these letters complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). No further action is necessary for compliance with the VCAA. Factual Background Pursuant to an October 1996 rating action. service connection was established for osteoporosis and for GERD, on the basis of service incurrence. The ratings assigned for those disorders were based on the service treatment records as well as the results of an August 1996 VA medical examination. The present appeal derives from a claim for increased rating filed in August 2002. Private treatment records from M.A.U., D.O., dated in August 2001 reflect complaints of foot pain assessed as metarsalgia. In March 2002, bilateral calcaneal spurs were appreciated on VA foot X-rays. Private treatment records from M.A.U., D.O., dated in August 2002 reflect reports of back pain after loading bricks; assessment was lumbar strain versus early vertebral disc disease- negative neurological examination. The veteran was afforded a VA examination in October 2002. The patient stated that while he was in the service in 1993 he experienced some progressive abdominal pain and indigestion which was worse at night when he laid down in bed and it was associated with indigestion and acid reflux. Current symptoms were claimed to be associated with nausea and vomiting. The patient stated that he was given Nexium which helped significantly the pain and the acid reflux symptoms. In 1997 he underwent upper GI endoscopy, x-ray and also he had pH probe. He was told that he had some weakness in the lower esophageal sphincter and acid reflux. Regarding the osteoporosis, in 1991, he complained of chronic joint and bone pain, and was found to have osteoporosis. His current complaints were of generalized bone aches and pain mainly in the lower back and the knees and also acid reflux is constant, but it is significantly improved with Nexium. He reported significant weight gain in recent months. Objective examination revealed his body weight to be 221 lb. His height was 178 cm. His abdomen was slightly obese, but soft, nontender, nondistended with normal bowel sounds. He had a good range of motion of all joints including the shoulders, elbows, lumbar spine, knees and hips, according to the joint exam guideline. There was no pain or tenderness on palpation of his joints or the spine. There was no evidence of swelling, edema, effusion of the joints. He was afforded an upper GI series which showed normal motility and emptying of the stomach, duodenal bulb and duodenal loop. There was no evidence of peptic ulcer disease and the patient has no evidence of acid reflux. The study was unremarkable and was within normal limits. Veteran also had Bone Density study which reported no evidence of osteoporosis or osteopenia seen in the femur, particularly radius and ulna, bilaterally. The study was basically normal without evidence of osteoporosis. A VA upper gastrointestinal series from November 2002 was a normal study. Private treatment records includes a chart of the veteran's weight. His weight ranged from 222 pounds in October 2002, to a low of 214 pounds in August 2003, and rising to 235 pounds in August and September 2004. Private treatment records from August 2004 reflect the veteran being seen for diarrhea claimed for the past several months lasting for 5 out of 7 days. He denied melena, rectal bleeding or hematemesis. Abdomen was soft bowel sounds were hyperactive. There was no organomegaly or masses but there was some generalized tenderness without rebounding or guarding. Efforts to obtain additional private treatment records produced some duplicate records. In January 2006, VA GI consultation records reflect denial of any abdominal pain, nausea, vomiting, fever or chills but the veteran claimed diarrhea off and on approximately 3-4 times per week for the last 2-3 years, varying in color from yellow to dark, no blood - varied in consistency and at times foul smelling. He also has flatulance, burping and GERD for which he has been on many meds. He denies any ulcers in past. On examination, the abdomen was soft, not tender, not distended. Bowel sounds were positive. An upper gastrointestinal series revealed no abnormalities. In March 2007, the veteran was afforded a VA orthopedic examination. His chief complaint was bilateral shoulder pain with the right being more severe than the left, associated with weakness, stiffness, instability, giving way, easy fatigability and lack of endurance secondary to focal bilateral shoulder pain. The patient reported that he had pain with or without motion. He denied any history of inflammatory arthritis. The veteran disclosed the following information concerning the characteristics of pain, severity of the pain in the Analog Pain Scale was 4-7/10 on the left and 4-10/10 on the right. The quality of the pain was sharp. Timing of the pain was intermittent. When questioned about what circumstance or events precipitated the pain or intensified the pain, the patient was unable to determine a pattern or influences that created change. In regard to alleviation of pain, rest was the only activity that seemed to result in relief of pain as well as analgesic medications. He also reported bilateral hip pain with right being equal to the left associated with weakness, stiffness, swelling, instability, giving way, easy fatigability and lack of endurance secondary to focal hip pain. The veteran reported that he had joint pain of the hips with or without motion. The veteran reported the flare-ups of symptoms associated with chief complaints reduced his functional capacity by 100%. The occurrence of these flare-ups was frequent. There was also bilateral ankle pain, right being equal to the left, associated with pain, weakness, instability, giving way, easy fatigability and lack of endurance secondary to focal pain of the ankles, right equals left. The veteran reported the joint pain occurred with and without motion. The veteran reported the flare-up of symptoms associated with the chief complaint reduced his usual functional capacity by 80%. Recurrence of these flare-ups was continuous. The veteran was right-hand dominant and appeared in no acute distress, appeared to be well developed and well nourished. His gait appeared to be normal although the veteran indicated he did experience gait unsteadiness and reported frequent falls requiring him to support himself against the wall or other stationary objects. He denied the use of corrective shoes. Subjective complaints include pain complaints, motion restriction, functional restriction. Objectively, there was point tenderness over the above-mentioned sites. Ranges of motion were measured after repetitive motion in various planes of motion tested. The recorded motion represented the maximum motion the patient could perform without the onset of significant pain. Any attempted motion beyond these recorded measurements resulted in complaints of pain and loss of function. Examination of the shoulder revealed no swelling or effusion noticed. There was global tenderness on palpation. The bilateral forward flexion of his shoulders was 0-110 degrees/ with 0-180 degrees being normal. The bilateral abduction of the shoulders was 0-140 degrees/0-180 degrees normal. The adduction bilaterally of the shoulders was 0-35 degrees/0-180 degrees normal. The extension of his shoulders bilaterally was 0-40 degrees/0-50 degrees normal. The bilateral internal rotation of the shoulders was 0-70 degrees/0-90 degrees normal. Bilateral external rotation of the shoulders was 0-80 degrees/0-90 degrees normal. Examination of the patient's hips revealed no swelling, ecchymosis or significant tenderness to palpation over the trochanteric area or associated areas. The range of motion of bilateral hips was 0-90 degrees/0-125 degrees normal bilaterally. The bilateral abduction of the hips was 0-40 degrees/0-45 degrees normal. The right hip adduction was 0- 20 degrees/0-30 degrees normal. The left hip adduction was 0-25 degrees/0-30 degrees normal. The right hip extension was 0-10 degrees/0-15 degrees normal. Left hip extension was 0-12 degrees/0-15 degrees normal. The right internal rotation is 0-20 degrees/0-40 degrees normal. The left internal rotation was 0-20 degrees/0-40 degrees normal. The external rotation bilaterally was 0-40 degrees/0-45 degrees normal. The ankle exam demonstrated no obvious swelling or effusion. There was tenderness over the lateral ligaments. No muscle spasm was appreciated on examination. The dorsiflexion of bilateral ankles was 0-10 degrees/0-20 degrees normal. The plantar flexion of the bilateral ankles was 0-30 degrees/0-45 degrees normal. Neurological exam appeared to be within normal limits with no evidence of abnormal reflexes. There appeared to be no neuropathy or pathological reflexes. Bilateral shoulder x-rays were noted to have no significant bony abnormalities and thought to be negative studies. There were mild degenerative changes in hip joints bilaterally, evidenced by mild narrowing of the joint spaces. There was bilateral posterior inferior calcaneal spurs of the ankles; there also appeared to be hypertrophic bone changes arising from the right lateral malleolus inferiorly most likely related to old trauma or old fracture. Impression was: Bilateral shoulders with the right being more painful, left arthralgia; bilateral hips, right equalling left, minimal degenerative changes; and bilateral ankles, bilateral posterior and inferior calcaneal spurs and hypertrophic changes of the right medial malleolus inferiorly, which was thought to be secondary to old fracture. The examiner noted the diagnosis of osteoporosis was not an orthopedic diagnosis but rather was one made by medical community in regard to a proven biopsy of the bone. The examiner commented that it was interesting to note that in x-ray studies, none noted that there was osteopenia, which would suggest decreased bone mass. While the veteran had complaints of pain, the examiner did not see any evidence to suggest that this was in any way related to osteoporosis. The veteran was also afforded a VA gastrointestinal examination in March 2007. It was noted that in 2006, the patient underwent an upper GI, which was completely normal along with a colonoscopy that was normal other than some minimal diverticulosis. Presently, the patient was having frequent symptoms. The veteran reported symptoms of at least five out of every seven days per week. He usually got gas and abdominal distention and with this he frequently had some cramping pain and diarrhea, which occurred two to three times daily. These stools were sometimes met with great urgency. He noted that carbonated beverages made this worse and he had stopped this. He occasionally had vomiting and regurgitation at night on about an every-other-month basis. He had no weight loss. He denied any melena, hematochezia and he had no hematemesis. He did not have dysphagia or real heartburn. He had the feeling of acid regurgitation up into his throat, about two to three time's per week. He denied any retrosternal pain or shoulder pain associated with the GERD. His social history showed that he was a nonsmoker and used no alcohol. He worked as a communications officer for the sheriff's department on 12 hour nightly shifts. He occasionally had to leave his desk urgently to go to the bathroom. On physical examination, he was overweight. His chest was clear on auscultation. Cardiac exam revealed a regular rhythm. Abdominal exam revealed a soft, obese abdomen with no masses, no rebound, no guarding, and no tenderness. Bowel sounds were active. By history, the veteran had GRED, which was fairly consistent with his historical symptomatology. In addition, he probably had irritable bowel syndrome with the diarrhea on most days. He probably experienced some aggravation of his reflux because of the Dicyclomine that he took for the irritable bowel because it would delay gastric emptying and also possibly affected the esophageal motility. An esophageal function test was scheduled, which included the esophageal motility with impedance for both liquids and viscus. The esophageal motility was essentially normal, and his impedance for both liquids and viscous material was normal. In addition to this, he underwent a 24-hour pH study with impedance and this showed a definitely abnormal study, with some mild acid reflux, but very significant non-acid reflux. The patient had symptoms during the 24 hour period with very strong correlation to his non-acid reflux, giving him a definitely positive symptom index. The examiner's final impression was that the veteran had irritable bowel syndrome, symptomatic, and less than one time per week, required him to leave his work station to go to the bathroom urgently. From the standpoint of his reflux symptoms, he was under fair control with his proton pump inhibitor, but he had symptoms a few days out of each week. Regarding whether the disability resulted in considerable or severe impairment to health, it was the examiner's professional opinion, as a board certified gastroenterologist, that the irritable bowel syndrome did not cause an impairment to his health, but was more of an inconvenience at the work place on some occasions. From the standpoint of his reflux esophagitis, the veteran definitely had symptoms, but they were somewhat mild. Analysis Disability ratings are rendered upon the VA's Schedule for Rating Disabilities as set forth at 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations and the disability must be viewed in relation to its history. 38 C.F.R. § 4.1. The higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. While lost time from work related to a disability may enter into the evaluation, the rating schedule is "considered adequate to compensate for considerable loss of working time from exacerbations proportionate" with the severity of the disability. 38 C.F.R. § 4.1. Functional loss of use as the result of a disability of the musculoskeletal system may be due to the absence of bones, muscles, or joints, or may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Both limitation of motion and pain are necessarily regarded as constituents of a disability. 38 C.F.R. §§ 4.40, 4.45, 4.55, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). The present appeal involves the veteran's claim that the severity of his service-connected GERD and osteoporosis warrant higher disability ratings. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service- connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In adjudicating the claim, the Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim: the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). GERD 734 6 Hernia hiatal: Ratin g Symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health 60 Persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health 30 With two or more of the symptoms for the 30 percent evaluation of less severity 10 38 C.F.R. § 4.114, Diagnostic Code 7346 (2007). The evidence associated symptoms do not demonstrate an impairment of health beyond that contemplated by the current 10 percent rating. There is no evidence of substernal or arm or shoulder pain associated with GERD. The October 2002 VA upper GI series showed normal motility and emptying of the stomach, duodenal bulb and duodenal loop. There was no evidence of peptic ulcer disease and the patient has no evidence of acid reflux. The study was unremarkable and was within normal limits. A VA upper gastrointestinal series from November 2002 revealed no abnormalities. Private treatment records from August 2004 reflect the veteran being seen for diarrhea, but he denied melena, rectal bleeding or hematemesis. The November 2007 VA examination reported occasional vomiting and regurgitation at night and this on about an every other month basis. He has had no weight loss and denied any melena, hematochezia and he has had no hematemesis. He does not have dysphagia or real heartburn. He just gets the feeling of acid regurgitation up into his throat, which is on about an every two to three time's per week basis. He denies any retrosternal pain or shoulder pain associated with the GERD. The examiner characterized his symptoms as mild and a minor inconvenience to his health. In sum, the veteran's symptoms of GERD have been manifested by a history of gas and diarrhea and occasional epigastric distress without anemia, signs of significant weight loss or malnutrition, or significant effect on usual occupation or usual daily activities, without considerable or greater impairment of health. The symptoms he does experience appear to be fully contemplated by the currently assigned 10 percent rating. The preponderance of the evidence is against the claim and there is no reasonable doubt to be resolved in the veteran's favor, and a higher rating under the applicable schedular criteria is not warranted. Osteoporosis 5013 Osteoporosis, with joint manifestations. The diseases under diagnostic codes 5013 through 5024 will be rated on limitation of motion of affected parts, as arthritis, degenerative, except gout which will be rated under diagnostic code 5002. 38 C.F.R. § 4.71a, Diagnostic Code 5013 (2007). 520 0 Scapulohumeral articulation, ankylosis of: Major Minor Favorable, abduction to 60°, can reach mouth and head 30 20 520 1 Arm, limitation of motion of: Major Minor At shoulder level 20 20 520 3 Clavicle or scapula, impairment of: Major Minor Dislocation of 20 20 Nonunion of: With loose movement 20 20 Without loose movement 10 10 Malunion of 10 10 Or rate on impairment of function of contiguous joint. 520 6 Forearm, limitation of flexion of: Major Minor Flexion limited to 100° 10 10 Flexion limited to 110° 0 0 520 7 Forearm, limitation of extension of: Major Minor Extension limited to 60° 10 10 Extension limited to 45° 10 10 520 8 Forearm, flexion limited to 100° and extension to 45 degrees 20 20 5213 Supination and pronation, impairment of: Major Minor Motion lost beyond last quarter of arc, the hand does not approach full pronation 20 20 Limitation of supination: To 30º or less 10 10 Note: In all the forearm and wrist injuries, codes 5205 through 5213, multiple impaired finger movements due to tendon tie-up, muscle or nerve injury, are to be separately rated and combined not to exceed rating for loss of use of hand. 521 5 Wrist, limitation of motion of: Major Minor Dorsiflexion less than 15º 10 10 Palmar flexion limited in line with forearm 10 10 Limitation of Motion of Individual Digits Majo r Mino r 522 8 Thumb, limitation of motion: With a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers 20 20 With a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers 10 10 With a gap of less than one inch (2.5 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 0 0 522 9 Index or long finger, limitation of motion: With a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees 1 0 1 0 With a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees 0 0 523 0 Ring or little finger, limitation of motion: Any limitation of motion 0 0 General Rating Formula for Diseases and Injuries of the Spine: Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis 2 0 Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height 1 0 For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 525 1 Thigh, limitation of extension of: Extension limited to 5º 10 525 2 Thigh, limitation of flexion of: Flexion limited to 30º 20 Flexion limited to 45º 10 525 3 Thigh, impairment of: Limitation of abduction of, motion lost beyond 10º 20 Limitation of adduction of, cannot cross legs 10 Limitation of rotation of, cannot toe-out more than 15º, affected leg 10 526 0 Leg, limitation of flexion of: Flexion limited to 45° 10 Flexion limited to 60° 0 526 1 Leg, limitation of extension of: Extension limited to 10° 10 Extension limited to 5° 0 527 1 Ankle, limited motion of: Marked 20 Moderate 10 38 C.F.R. § 4.71A, Diagnostic Codes 5200-5271 (limitation of motion) (2007) In this case, a VA physician in the context of the November 2007 examination indicated that the range of joint motion of the veteran various joints was restricted by pain producing loss of full function. The examiner noted degenerative changes in some joints, calcaneal spurs in the ankles and arthralgia in the veteran's shoulders. Earlier reports of back pain are associated with recent lifting of bricks. It bears particular emphasis, however, that the November 2007 examiner also expressly disassociated the veteran's pain as not in any way related to his service connected osteoporosis. The examiner also noted that no decreased bone mass was identified on X-rays. In the absence of pathology or functional limitation associated with the service connected disorder, accordingly, there is no basis to award a compensable rating. After consideration of all of the evidence, the Board finds that the preponderance of the evidence is against the claims. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107 (West 2002); Ortiz v. Principi, 274 F.3d 1361 (2001) (the benefit of the doubt rule applies only when the positive and negative evidence renders a decision "too close to call"). There is no competent evidence of record which indicates that the veteran's GERD or osteoporosis has caused marked interference with employment beyond that which is contemplated under the schedular criteria, or that there has been any necessary inpatient care. Thus, there is no basis for consideration of an extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b)(1). Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). There is nothing in the evidence of record to indicate that the application of the regular schedular standards is impractical in this case. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996). ORDER Entitlement to increased evaluation for GERD is denied. Entitlement to increased (compensable) evaluation for osteoporosis is denied. ____________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs