Citation Nr: 0812110 Decision Date: 04/11/08 Archive Date: 04/23/08 DOCKET NO. 06-13 764 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an initial rating in excess of 20 percent for a thoracolumbar spine disorder. 2. Entitlement to an initial rating in excess 10 percent for a cervical spine disorder. 3. Entitlement to an initial rating in excess 10 percent for a right foot disorder. 4. Entitlement to an initial rating in excess 10 percent for a left foot disorder. 5. Entitlement to an initial rating in excess 10 percent for residuals of left hand anatomical snuffbox occult fracture. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD L. Crohe, Associate Counsel INTRODUCTION The appellant is a veteran who served on active duty from April 2002 to April 2005 This case is before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision by the Muskogee Regional Office (RO) of the Department of Veterans Affairs (VA) that granted service connection for residuals of left hand anatomical snuffbox occult fracture, right foot disorder, left foot disorder, thoracolumbar spine disorder, and cervical spine disorder, and assigned 10, 10, 10, 20, and 10 percent ratings, respectively, effective from the date of the claim. In March 2008, the Board granted a motion to advance the case on the Board's docket due to the severe financial hardship. FINDINGS OF FACT 1. At no time during the appeal period was forward flexion of the thoracolumbar spine only to 30 degrees or less; incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, and ankylosis of the spine were not shown. 2. At no time during the appeal period was forward flexion of the cervical spine 30 degrees or less; or, the combined range of motion of the cervical spine 170 degrees or less; incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, muscle spasm, guarding, abnormal spinal contour and ankylosis of the spine were not shown. 3. Throughout the appeal period, the competent medical evidence, overall, demonstrates that the veteran's plantar fasciitis of the right foot is not moderately severe. 4. Throughout the appeal period, the competent medical evidence, overall, demonstrates that the veteran's plantar fasciitis of the left foot is not moderately severe. 5. Throughout the appeal period, the service-connected residuals of left hand anatomical snuffbox occult fracture was manifested by limitation of motion in the left wrist; ankylosis or limitation of motion in any of the left digits was not shown. CONCLUSIONS OF LAW 1. An initial rating in excess of 20 percent for the veteran's service-connected thoracolumbar spine disorder is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes (Codes) 5242 and 5243 (effective September 26, 2003). 2. An initial evaluation in excess of 10 percent for cervical spine disorder is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 4.7, 4.71a, Codes 5242 and 5243 (effective September 26, 2003). 3. An initial evaluation in excess of 10 percent for right foot disorder is not warranted. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (Code) 5284 (2007). 4. An initial evaluation in excess of 10 percent for left foot disorder is not warranted. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Code 5284 (2007). 5. An initial rating in excess of 10 percent for residuals of left hand anatomical snuffbox occult fracture is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Codes 5214, 5215 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify & Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his possession that pertains to the claim, in accordance with 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The Board also notes that during the pendency of this appeal, on March 3, 2006, the 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 five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. A January 2005 letter (prior to the adjudication on appeal) advised the appellant of what type of evidence was needed to substantiate the claim, and of his and VA's responsibilities in the development of the claim. The January 2005 letter advised him to submit any evidence or information in his possession that pertained to the claims. The April 2005 rating decision granted service connection for residuals of left hand anatomical snuffbox occult fracture, right foot disorder, left foot disorder, thoracolumbar spine disorder, and cervical spine disorder, and assigned 10, 10, 10, 20, and 10 percent ratings, respectively, effective from the date of the claim. January, March, and May 2006 letters informed the appellant of what was required to substantiate the "downstream" issue of an increased initial rating for residuals of left hand anatomical snuffbox occult fracture, right foot disorder, left foot disorder, thoracolumbar spine disorder, and cervical spine disorder. The March and May 2006 letters discussed the manner in which VA determines disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Additionally, the Board has considered the adequacy of the VCAA notice in light of the recent Court decision in Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008). The Boards finds that the VCAA notice is adequate as the March and May 2006 letters, which includes Dingess/Hartman notice, informs the appellant that, in evaluating claims for increase, VA looks at the nature and symptoms of the condition, severity and duration of the symptoms, and impact on employment. The evidence that might support a claim for an increased rating was listed. The veteran was told that ratings were assigned with regard to severity from 0 percent to 100 percent, depending on the specific disability. In addition, the March 2006 statement of the case provided notice regarding the specific rating criteria used to evaluate the veteran's disability. The veteran has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. The actions taken by VA have essentially cured any error in the timing of notice. Thus, the Board concludes that the veteran had actual knowledge of all notice requirements regarding increased rating claims. Therefore, the veteran has been provided with all necessary notice regarding his claim for an increased evaluation. Vazquez-Flores v. Peake, supra. As the Federal Circuit Court has stated, it is not required "that VCAA notification must always be contained in a single communication from the VA." Mayfield, supra, 444 F.3d at 1333. With respect to VA's duty to assist, the veteran has been provided with VA examinations. Neither the veteran nor his representative has identified any additional evidence or information which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that the RO has complied with the duty to assist requirements of the VCAA and the implementing regulations. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. II. Factual Background, Criteria & Analysis Disability evaluations are assigned by applying a schedule of ratings which represent, as far as can practicably be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Such evaluations involve consideration of the level of impairment of the veteran's ability to engage in ordinary activities, to include employment, as well as an assessment of the effect of pain on those activities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59. Where there is a question as to which of two evaluations should 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 determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Because the instant appeal is from the initial rating assigned with the grant of service connection, the possibility of "staged" ratings for separate periods during the appeal period, based on the facts found, must be considered. See Fenderson v. West, 12 Vet. App. 119 (1999). A. Thoracolumbar Spine Disorder The criteria for rating intervertebral disc syndrome and disabilities of the spine, generally, were revised (effective September 23, 2002 and September 26, 2003, respectively). As the veteran filed his increase rating claim in April 2005, he is only entitled to ratings under the revised Code. Here, the RO assigned a 20 percent rating for the veteran's degenerative disc disease of the thoracolumbar spine. The criteria for rating disabilities of the spine essentially provide that degenerative disc disease is rated under the General Rating Formula for Diseases and Injuries of the Spine (Code 5242) and that intervertebral disc disease (Code 5243) is rated either under the General Rating Formula or based on Incapacitating Episodes. Under the General Rating Formula, a 20 percent rating is assigned when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 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 kyphosisa; a 40 percent rating is assigned when there is forward flexion of the thoracolumbar spine only to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine; a 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is warranted when there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. On February 2005 VA examination, a history of degenerative disc disease (DDD) of the thoracolumbar spine was reported since 2003. The veteran had constant pain the upper and lower back that traveled into the hips. The characteristic of pain was aching, oppressing, sharp, and cramping in nature. The pain was elicited by physical activity and stress, or by itself. It was relieved by rest, medication (oxycodone) and spinal manipulation. At the time of pain, the veteran could function with medication. He had stiffness, pain, and catching in his back constantly. This condition did not cause incapacitation. The functional impairment included the inability to lift, walk long distances, run, or stay in one position for long periods of time. The condition resulted in three times lost from work per month. On examination, his posture and gait were within normal limits. He did not require an assistive device for ambulation. The diagnosis was DDD. A February 2005 addendum reported that the examination of the thoracolumbar spine revealed no complaints of radiating pain on movement. Muscle spasm was absent. There was no tenderness noted. There was negative straight leg raising on the right and left. There was no ankylosis present. Range of motion of the thoracolumbar spine was as follows: Flexion was 0 to 60 degrees with pain at 60 degrees; extension was 0 to 20 degrees with pain at 15 degrees; right and left lateral flexion was 0 to 30 degrees with pain on left lateral flexion at 20 degrees; right rotation was 0 to 30 degrees with pain at 30 degrees; and left rotation was 0 to 20 degrees with pain at 20 degrees. With repetitive motion, the range of motion of the spine was additionally limited by pain and pain was the major functional impact. It was not additionally limited by fatigue, weakness, lack of endurance and incoordination with repetitive motion. There were no signs of intervertebral disc syndrome present. Neurological examination of the lower extremities showed that motor function was within normal limits. Sensory function was within normal limits. The right and left lower extremity reflexes revealed knee jerk 1 + and ankle jerk 1 +. The general appearance of the bilateral hips was within normal limits. There was no ankylosis of the hips. On February 2006 VA examination it was noted that the claims file was reviewed. The veteran reported upper t-spine and low back pain everyday. His upper back pain was constant. The pains were described as a sharp pain and then an ache. There was no radiation of pain. He denied any numbness of the upper and lower extremities. He used no braces or supports. There was no additional limitation following repetitive use or additional limitation during flare-up. He was not employed. The back disorder interfered with his daily activities, especially with lifting or sitting for long periods of time. He had two incapacitating episodes in the past year that lasted three days. X-rays of the lumbar spine in August 2005 were normal. Examination showed no deformity, no swelling, and no palpable tenderness. Forward flexion was 0 to 85 degrees without pain, extension was 0 to 30 degrees without pain, left and right lateral rotation was 0 to 40 degrees without pain, and left and right lateral rotation was 0 to 40 degrees without pain. Active range of motion did not produce any weakness, fatigue, or incoordination. There was good strength and good pinprick sensation in both lower extremities. There was negative foot-drop bilaterally and normal motor skills. There was no muscle spasm or muscle atrophy. Straight leg raising was 0 to 85 degrees bilaterally without pain. The diagnosis included DDD of the thoracolumbar spine with chronic low back pain in the thoracic and lumbar spine. With consideration of the DeLuca factors, the Board finds that the veteran's thoracolumbar spine disorder was manifested by forward flexion greater than 30 degrees but not greater than 60 degrees (see February 2005 VA examination), warranting a 20 percent rating under the General Rating formula. As ankylosis has never been shown, a rating in excess of 20 percent under the General Rating Formula is not warranted. Therefore, the focus shifts to whether a rating in excess of 20 percent is warranted under any other applicable rating codes. Under Code 5243 for intervertebral disc syndrome, a 40 percent rating was warranted for incapacitating episodes that had a total duration of at least four weeks but less than six weeks during the past 12 months. On February 2005 VA examination, the examiner specifically noted that the veteran did not have intervertebral disc syndrome. Although on February 2006 VA examination, the veteran reported that he had two episodes of incapacitating episodes in the past year that lasted three days, this self-reported time frame still falls far short of the minimum of four weeks of incapacitating episodes required to warrant a higher 40 percent rating. Regardless, the medical evidence does not show that he was prescribed bed rest by a physician and treated by a physician for at least four weeks due to an incapacitating episode. Note 1 following Code 5243 provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Consequently he does not qualify for a higher than 20 percent (i.e. 40 percent) rating for incapacitating episodes under Code 5243. In summary, a 20 percent rating is warranted for the veteran's thoracolumbar spine disorder under the General Rating Formula. However, the veteran's service connected thoracolumbar spine disorder does not warrant a rating in excess of 20 percent under any applicable criteria at any point during the appeal period. "Staged" ratings are not warranted. B. Cervical Spine Disorder The criteria for rating intervertebral disc syndrome and disabilities of the spine, generally, were revised (effective September 23, 2002 and September 26, 2003, respectively). As the veteran filed his increase rating claim in April 2005, he is only entitled to ratings under the revised Code. Here, the RO assigned a 10 percent rating for the veteran's degenerative disc disease of the cervical spine. Like shown above, the criteria for rating disabilities of the spine essentially provide that degenerative disc disease is rated under the General Rating Formula for Diseases and Injuries of the Spine (Code 5242) and that intervertebral disc disease (Code 5243) is rated either under the General Rating Formula or based on Incapacitating Episodes. Under the General Rating Formula, a 20 is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 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. A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted when there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. February 2005 VA examination reported a history of DDD of the cervical spine since 2003. The pain was constant and traveled to the head and shoulders. The pain could be elicited by physical activity or by itself. It was relieved by rest and medication (oxycodone). At the time of pain, the veteran could function with medication. The symptoms were the same as the thoracolumbar spine although the neck "catches" more. This condition did not cause incapacitation. The functional impairment included the inability to lift, walk long distances, run, or stay in one position for long periods of time. The condition resulted in three times lost from work per month. On examination it was noted that the cervical spine revealed no evidence of radiating pain on movement as well as no evidence of muscle spasm. There was no evidence of tenderness. Range of motion was as follows: flexion was 0 to 45 degrees; extension was 0 to 30 degrees with pain at 25 degrees; right and left lateral flexion was 0 to 45 degrees; and right and left rotation was 0 to 80 degrees. Range of motion of the spine was additionally limited by pain after repetitive use. Pain had the major functional impact. Range of motion was not additionally limited by fatigue, weakness, lack of endurance, and incoordination. There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement. Neurological findings of the upper extremities showed that motor function was within normal limits. Sensory function was within normal limits. The right and left upper extremity reflexes revealed biceps jerk +2 and triceps jerk +2. The diagnosis included DDD. On February 2006 VA examination it was noted that the claims file was reviewed. The veteran did not report any current neck pains, radiation of pain, or numbness in his arms. He did not use any assistive devices. There was no additional limitation following repetitive use or additional limitation during flare-up. The cervical spine disorder did not interfere with his daily activities. He had no incapacitating episodes in the past year. Examination showed a normal curvature with no deformities. He was tender at C6- T1. Forward flexion was 0 to 40 degrees without pain, extension was 0 to 40 degrees without pain, left and right lateral flexion was 0 to 40 degrees without pain, and left and right lateral flexion was 0 to 40 degrees without pain. Active range of motion did not produce any weakness, fatigue, or incoordination. Deep tendon reflexes of the upper extremities were 1 + equal bilaterally. There was good pinprick sensation and good strength in the upper extremities. The gait was normal. The diagnosis included DDD at C4-C7 with no residuals and no complaints. With consideration of the DeLuca factors, the Board finds that the veteran's cervical spine disorder was manifested by forward flexion greater than 30 degrees but not greater than 40 degrees, warranting a 10 percent rating under the General Rating formula. As forward flexion has not been 30 degrees or less, or combined range of motion of the cervical spine has not been 170 degrees or less, or muscle spasm or ankylosis has never been shown, a rating in excess of 10 percent under the General Rating Formula is not warranted. Therefore, the focus shifts to whether a rating in excess of 10 percent is warranted under any other applicable rating codes. Under Code 5243 for intervertebral disc syndrome, a 20 percent rating was warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. On February 2005 VA examination, the examiner specifically noted that the veteran did not have intervertebral disc syndrome. Also on February 2006 VA examination, the veteran, himself, reported that he did not have any incapacitating episodes. Also, the medical evidence does not show that he was prescribed bed rest by a physician and treated by a physician for at least two weeks due to an incapacitating episode. Note 1 following Code 5243 provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Consequently, he does not qualify for the next higher rating (i.e. 20 percent) rating for incapacitating episodes under Code 5243. In summary, the veteran's service connected cervical spine disorder does not warrant a rating in excess of 10 percent under any applicable criteria at any point during the appeal period. "Staged" ratings are not warranted. C. Bilateral Foot Disorders On February 2005 VA examination, a history was reported of a stress fracture of the second right metatarsal in 2002 and plantar fasciitis in the left foot. In the right foot, the veteran reported pain, stiffness, and swelling. In the left foot, he indicated that he had stiffness and swelling at rest. While standing or walking, he reported that he had pain, weakness, swelling, and fatigue. The functional impairment included the inability to run or walk with weight without pain Both feet had tenderness on the plantar surface over the arch. Pes planus was not present. He did not have any limitation with standing or walking. He required arch supports. The symptoms of pain were relieved by corrective shoe wear. The right foot had pain over the dorsum corresponding to where the fracture was located. The diagnosis included status post fracture of right second metatarsal right foot. The subjective factors were right foot tenderness with walking. The objective factors were tenderness to touch over the right dorsum of the foot. The veteran also had bilateral plantar fasciitis. The subjective factors in the left foot were pain, swelling, weakness, and fatigue worse with first few steps of the day. The objective factors were pain over the medial calcaneus bilaterally. On February 2006 VA examination it was noted that the claims file was reviewed. The veteran reported that he had right foot pain occasionally or an aching sensation with standing or walking too far. There was not constant pain on a daily basis. The pain was on the top of the right foot and medially. There was no swelling or numbness. He did not use special shoes. He wore over the counter Dr. Scholl's inserts, which did not help. He did not use any other assistive devices. He reported that he still had left foot pains only with increased walking. The pains were usually medially and near the left heel. He avoided walking for long periods of time. He did not use medication. For the left and the right foot, there was no additional limitation following repetitive use or additional limitation during flare-up. Neither the left foot nor the right foot disorders interfered with his daily activities. Physical examination revealed slight tenderness in the right 2nd and 3rd metatarsal. There was no pes planus. Bilateral Achilles tendon alignment was normal. There was normal weight bearing. There was no pain on manipulation. Walking and standing was normal. Active range of motion did not produce any weakness, fatigue, or incoordination. There were no calluses or ulcerations. The diagnoses included left plantar fasciitis, with no real residuals; and fractured right 2nd metatarsal with plantar fasciitis and mild pain in 2nd metatarsal area. The veteran asserts that he is entitled to a higher rating for his service-connected residuals of right second metatarsal with plantar fasciitis and left foot plantar fasciitis, currently evaluated by analogy as 10 percent disabling for each foot under Diagnostic Codes 5284. 38 C.F.R. § 4.73. Under Diagnostic Code 5284, a 10 percent rating is warranted for a moderate foot injury. A 20 percent rating is warranted for a moderately severe foot injury. A 30 percent rating is warranted for a severe foot injury. 38 C.F.R. § 4.72. The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Board finds that the competent medical evidence does not support a higher rating for either the right foot or the left foot disorders. The post-service medical records simply do not show that the veteran's bilateral foot disorders results in symptoms that can reasonably be described as moderately severe under Diagnostic Code 5284. The VA examiners' clinical findings showed that the manifestations of the veteran's right and left foot disabilities were already contemplated by the 10 percent rating currently assigned for moderate disability of each foot. As discussed, on February 2005 VA examination, both feet had tenderness on the plantar surface over the arch. On February 2006 VA examination, tenderness was only found in the right 2nd and 3rd metatarsal. Both examinations found that there was normal weight bearing. There were no limitations with walking or standing. February 2006 VA examination revealed that bilateral Achilles tendon alignment was normal. Also, active range of motion did not produce any weakness, fatigue or incoordination. Even considering the DeLuca factors, the Board concludes that the veteran's service-connected right and left foot disorders have been shown to be no more than moderate in severity throughout the pendency of this claim. The Board has also considered other potentially applicable Diagnostic Codes that provide for evaluations in excess of 10 percent. The competent medical evidence of record, however, is negative for corresponding diagnoses or findings associated with the service-connected right and left foot disorders and thus they are not appropriate. See Butts v. Brown, 5 Vet. App. 532 (1993) (choice of diagnostic code should be upheld if supported by explanation and evidence). Also, as malunion or nonunion of the metatarsal bones has not been shown, consideration under Code 5283 is not warranted. The veteran's statements as to the severity of his symptoms have been considered. However, the Board attaches greater probative weight to the clinical findings of skilled, unbiased professionals than to the veteran's statements. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (holding that interest in the outcome of a proceeding may affect the credibility of testimony). There is a preponderance of the evidence against a rating higher than 10 percent for the veteran's right and left foot disorders. 38 U.S.C.A. § 5107(b). D. Residuals of Left Hand Anatomical Snuffbox Occult Fracture On February 2005 VA examination a history was noted of bilateral hand tendonitis was reported since 2004. The symptoms included left hand pain and weakness with turning and lifting objects. In both hands, there was decreased grip strength, and numbness and tingling. The functional impairment included difficulty maneuvering and gripping objects at work. The condition did not result in any lost time from work. It was noted that the veteran was right hand dominant. He could tie his shoelaces and fasten buttons without difficulty. He could pick up a piece of paper and tear it without difficulty. A hand dexterity examination showed that the left hand fingertips could approximate the proximal transverse crease of the palm and his hand strength was within normal limits. Range of motion of the left thumb was as follows: radial abduction to 70 degrees; palmar abduction to 70 degrees; MP flexion to 60 degrees; IP flexion to 60 degrees; and the opposition of the thumb was within normal limits. The range of motion of the left index finger was as follows: DIP flexion to 70 degrees; PIP flexion to 110 degrees; and MP flexion to 90 degrees. The range of motion of the left long finger was as follows: DIP flexion was to 70 degrees; PIP flexion was to 110 degrees; and MP flexion was to 90 degrees. The range of motion of the left ring finger was as follows: DIP flexion was to 70 degrees; PIP flexion was to 110 degrees; and MP flexion was to 90 degrees. The range of motion in the left little finger was as follows: DIP flexion was to 70 degrees; PIP flexion was to 110 degrees; and MP flexion was to 90 degrees. The left hand had pain over the anatomical snuffbox. X-rays were negative. On February 2006 VA examination it was noted that the claims file was reviewed. It was also noted that the veteran fractured his left wrist. The veteran indicated that he had left wrist pain that radiated into the left forearm when he grabbed an object. This only occurred while grabbing or pulling. He did not have constant pain on a daily basis. There was no numbness. He did not use any braces or supports. There was no additional limitation following repetitive use or additional limitation during flare-up. Examination showed mild tenderness at the snuffbox area. There were no deformities, and no swelling. Wrist extension was 0 to 60 degrees with mild pain at the snuffbox area at 60 degrees, minus 10 degrees secondary to pain; palmar flexion was 0 to 75 degrees with mild pain at the snuffbox area at 75 degrees, minus 5 degrees secondary to pain; ulnar deviation was 0 to 40 degrees without pain; and wrist radial deviation 0 to 20 degrees without pain. Active range of motion did not produce any weakness, fatigue, or incoordination. The diagnosis included left hand anatomical snuffbox fracture with tenderness on palpitation and no other residuals. X- rays were negative. The veteran asserts that he is entitled to a higher rating for his service-connected residuals of left hand anatomical snuffbox occult fracture currently assigned a 10 percent evaluation. T In the veteran's case, the service-connected disability residuals of left hand anatomical snuffbox occult fracture do not have a specific Diagnostic Code. Where the particular disability for which the veteran has been granted service- connection is not listed in the Rating Schedule, it may be rated by analogy to a closely related disease in which not only the functions affected, but also the anatomical location and symptomatology are closely analogous. See 38 C.F.R. §§ 4.20, 4.27. See also Lendenmann v. Principi, 3 Vet. A38 C.F.R. §pp. 345, 349- 350 (1992); Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Accordingly, the symptomatology associated with residuals of left hand anatomical snuffbox occult fracture is rated by analogy to limitation of wrist motion under Diagnostic Code 5215. At the outset, it is noteworthy that the veteran is right hand dominant. The injured let hand is considered to be the minor hand for rating purposes. See 38 C.F.R. § 4.69. Under Code 5215 (for limitation of wrist motion), a single 10 percent rating is assigned where dorsiflexion of either wrist is less than 15 degrees or when palmar flexion is limited in line with the forearm. 38 C.F.R. § 4.71a, Code 5215. Code 5214 provides for higher ratings for wrist disability where the wrist is ankylosed. 38 C.F.R. § 4.71a, Code 5214. Normal wrist dorsiflexion is at 70 degrees; normal wrist palmar flexion is at 80 degrees. 38 C.F.R. § 4.71, Plate I. A 10 percent rating for the veteran's service connected residuals of left hand anatomical snuffbox occult fracture is the maximum rating provided for limitation of motion of either wrist (under Code 5215). To establish entitlement to a rating in excess of the current 10 percent, the veteran must show that his wrist is ankylosed (See Code 5214, for ankylosis). Not only is the wrist not shown to be ankylosed, February 2006 VA examination found that the veteran had a significant range of motion of the wrist. Even considering the 10 degrees additional loss secondary to pain during dorsiflexion (resulting in 50 degrees dorsiflexion) and 5 degrees additional loss for palmar flexion secondary to pain (resulting in 70 degrees palmar flexion), the remaining function of the wrist would still not exceed the limitations which warrant a 10 percent rating under Code 5215. Also, the Board has considered ratings that pertained to multiple digits as well as individual digits, but as ankylosis had not been shown in any of the left hand digits and the range of motion in each of the left hand digits was normal. Hence, Codes 5220 through 5227 do not apply. February 2005 VA examination showed that the left hand fingertips could approximate the transverse crease of the palm and his left hand strength was within normal limits. The range of motion of his individual digits, including his thumb was normal and the opposition of the thumb was within normal limits. On February 2006 VA examination, the examiner specifically found that there were no other residuals other than tenderness on palpitation. As such Codes 5228 (limitation of motion regarding the thumb), 5229 (limitation of motion regarding the index or long finger), and 5230 (limitation of motion regarding the ring or little finger) do not apply. Furthermore, there is no competent medical evidence of record of a diagnosis of arthritis in any of the veteran's left hand digits or in his left wrist. There also are no medical findings of additional limitation of function or limitation of motion due to pain, fatigue, weakness, or lack of endurance. There is thus no basis to assign a higher rating under 38 C.F.R. §§ 4.40, 4.45, 4.59 or under the holding in DeLuca, supra. The veteran's statements as to the severity of his symptoms have been considered, particularly his complaints of increased pain when he had to pick up or grab an object. However, the Board attaches greater probative weight to the clinical findings of skilled, unbiased professionals than to the veteran's statements. See Cartright, supra. Here, the objective medical evidence noted when the veteran experienced pain and such results were accounted for in the assigned 10 percent evaluation. For these reasons, a rating in excess of 10 percent for residuals of left hand anatomical snuffbox occult fracture is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as there is a preponderance of the evidence against the veteran's claim, that doctrine is not applicable to this claim. See 38 U.S.C.A. 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). E. Extraschedular The Board has considered whether the facts presented suggest that referral of the case for extraschedular consideration under 38 C.F.R. § 3.321 is warranted. Inasmuch as it is neither shown nor alleged that the veteran's thoracolumbar spine, cervical spine, or bilateral foot disabilities or residuals of left hand anatomical snuffbox occult fracture have required frequent hospitalizations, caused marked interference with employment, or involve any other factors of similar gravity, referral for extraschedular consideration is not indicated. ORDER Entitlement to an initial rating in excess of 20 percent for service-connected thoracolumbar spine disorder is denied. Entitlement to an initial rating in excess of 10 percent for service-connected cervical spine disorder is denied. Entitlement to an initial rating in excess of 10 percent for service-connected right foot disorder is denied. Entitlement to an initial rating in excess of 10 percent for service-connected left foot disorder is denied. Entitlement to an initial rating in excess of 10 percent for service-connected residuals of left hand anatomical snuffbox occult fracture is denied. ____________________________________________ V. L. JORDAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs