Citation Nr: 1000082 Decision Date: 01/04/10 Archive Date: 07/08/10 DOCKET NO. 06-27 690 DATE JAN 04 2010 On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a bilateral knee disorder. 2. Entitlement to a disability rating greater than 10 percent for service-connected lumbosacral strain with degenerative disc disease for the period of time prior to October 9, 2007. 3. Entitlement to a disability rating greater than 20 percent for service-connected lumbosacral strain with degenerative disc disease for the period of time beginning October 9, 2007. 4. Entitlement to a compensable disability rating for service-connected residuals, fracture, fourth metacarpal shaft, right hand (dominant). REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran served on active duty from May 1972 to May 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran indicated on his August 2006 VA Form 9 that he wished to testify at a Board hearing. A Travel Board hearing was scheduled for July 2009 and the Veteran was provided notice of this hearing in June 2009. However, the Veteran failed to report to the scheduled hearing and failed to explain his absence. Therefore, the Board hearing request is considered withdrawn. See 38 C.F.R. § 20.704(d) (2009). FINDINGS OF FACT 1. There is no evidence of a bilateral knee disorder in service, or within one year after service, and no competent medical evidence linking the Veteran's current bilateral knee disorder with his period of military service. 2. Prior to October 9, 2007, the Veteran's lumbosacral strain with degenerative disc disease was manifested by forward flexion to 70 degrees due to pain. 3. Beginning October 9, 2007, the Veteran's lumbosacral strain with degenerative disc disease has been manifested by forward flexion to 40 degrees due to pain. - 2 - 4. The Veteran's residuals, fracture right fourth metacarpal are manifested by normal grip strength, normal range of motion of the fingers and no gaps between the tip of the thumb and the fingers, between the tips of the fingers and the proximal transverse crease of the palm, or between the thumb pad and the fingers with the thumb attempting to oppose the fingers. The Veteran is right-hand dominant; therefore, his residuals, fracture right fourth metacarpal is part of his major extremity. CONCLUSIONS OF LAW 1. Service connection for a bilateral knee disorder is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2009). 2. The criteria for a disability rating greater than 10 percent for service-connected lumbosacral strain with degenerative disc disease for the period prior to October 9, 2007, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1 -4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5237-5243 (2009). 3. The criteria for a disability rating greater than 20 percent for service-connected lumbosacral strain with degenerative disc disease for the period prior to October 9, 2007, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1 -4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5237-5243 (2009). 4. The criteria for a compensable rating for the residuals, fracture, fifth metacarpal shaft, right hand (dominant) are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5299-5227 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This appeal arises out of the Veteran's claim that his current bilateral knee disorder is related to his service with the United States Army from May 1972 to May 1992. He also contends that his service-connected lumbosacral strain with degenerative - 3 - disc disease and residuals, fracture, fourth metacarpal shaft, right hand (dominant) are more disabling than currently evaluated. Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In addition, certain chronic diseases, such as arthritis, may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 C.F.R. §§ 3.307, 3.309. Disorders diagnosed more than one year after discharge may still be service connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status do not constitute competent medical evidence. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Bilateral Knee Disorder The Veteran's service treatment records are negative for a bilateral knee disorder in service. While the Veteran was treated for laceration to the left knee in July 1973, there is no indication this injury was orthopedic in nature. Significantly, periodic examination reports dated in May 1978, May 1979, and January 1983 showed -4- normal lower extremities. The Veteran's November 1991 separation examination also showed normal lower extremities. Also, in his November 1991 Report of Medical History, the Veteran denied "'trick' or locked knee," "bone, joint, or other deformity," and "arthritis, rheumatism, or bursitis." The earliest evidence of a bilateral knee disorder is a VA treatment record dated in January 2003 in which the Veteran complained of knee pain. A June 2003 VA treatment report shows that X-rays of the knees were ordered to rule out a diagnosis of degenerative joint disease. The results of this X-ray do not appear to be associated with the claims file, however, VA treatment records show continued complaints of bilateral knee pain in October 2005, January 2006, and May 2006. The Board finds that the preponderance of the evidence is against service connection for a bilateral knee disorder. First, there is no evidence of a disorder of the knees in service or within one year after service. As above, the November 1991 separation examination showed normal lower extremities and the Veteran denied any knee problems. Furthermore, there is no evidence of a bilateral knee disorder until at least 2003, approximately 11 years after service. Such a lapse of time is a factor for consideration in deciding a service connection claim. Maxson v. Gober, 230 F.3rd 1330, 1333 (Fed. Cir. 2000). Finally, there is no medical evidence in the record that links any current bilateral knee disorder to an incident of the Veteran's active military service. Increased Rating If a disability is determined to be service connected it will be assigned a disability rating. Disability evaluations are determined by the application of a schedule of ratings, which are based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. The governing regulations provide that the higher of two evaluations will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 - 5 - (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Furthermore, when an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. Also, the VA General Counsel held in VAOPGCPREC 9-98 after reiterating its holding in VAOPGCPREC 23-97 that pain as a factor must be considered in the evaluation of a joint disability with arthritis and that the provisions of 38 C.F.R. § 4.59 are for consideration. 1. Lumbosacral Strain with degenerative disc disease The Veteran's service treatment records show complaints of back pain beginning in April 1979 after he sustained a lumbosacral strain. Service connection was granted and a noncompensable percent rating assigned for lumbosacral strain with degenerative disc disease by rating decision dated in March 1995. In November 2001 the Veteran submitted a claim for an increased rating. He underwent a VA examination of the spine in March 2003 and by rating decision dated in May 2003 the RO increased the Veteran's disability rating from noncompensable to 10 percent disabling, effective November 30,2001, the date of the Veteran's claim for an increased rating. The Veteran submitted a subsequent claim for an increased rating on November 9, 2005. He was afforded a VA examination in March 2006 and by the April 2006 rating action on appeal, the RO continued the 10 percent disability rating assigned. The Veteran perfected an appeal of this decision and was afforded - 6 - another VA examination in October 2007. By rating decision dated in December 2007 the RO increased the Veteran's disability rating from 10 percent to 20 percent disabling effective October 9, 2007, the date of the Veteran's VA examination. Rating Criteria The Veteran's lumbosacral strain with degenerative disc disease is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5237-5243. Under DC 5237 a 100 percent evaluation is appropriate for unfavorable ankylosis of the entire spine; a 50 percent evaluation is appropriate for unfavorable ankylosis of the entire thoracolumbar spine; a 40 percent evaluation is appropriate for favorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 30 percent evaluation is appropriate for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 20 percent evaluation is appropriate where there is 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. A 10 percent evaluation is appropriate where there is 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. 38 C.F.R. § 4.71a, DC 5237. Disorders of the spine may also be rated under DC 5243, Intervertebral Disc Syndrome Based on Incapacitating Episodes. Under this code a 10 percent -7- disability evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months; a 20 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months; a 40 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. 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. 38 C.F.R. § 4.71a, DC 5235-43, Note (2). Medical Evidence Evidence relevant to the severity of the Veteran's low back disorder includes VA examination reports dated in March 2006 and October 2007. During the March 2006 VA examination the Veteran complained of daily but not constant low back pain. Some days are more severe than others, depending on whether there is cold weather. The pains are described as an ache most of the time. Occasionally, it is sharp. Pains usually average 5/10 and occasionally go to 8/10. They are aggravated by twisting or lifting wrong. It does not radiate anywhere. He does not notice any numbness in his legs. He denies using braces, supports, canes, or crutches. He has an occupation in housekeeping with VA. His back does not bother his occupation - 8 - and does not interfere with daily activities. There was no additional limitation with flare-ups. There was also no additional limitation with repetitive use. He has had zero incapacitating episodes in the past year. He stated that he has missed approximately eight days of work in the past year due to low back pain. He denied any urinary or fecal incontinency. He took Flexeril, Tramadol, Naproxen, and Mobic. All of these medications are for his back or knee pain. He had normal gait. Examination of the lumbar spine revealed normal curvature, nontender on palpation, and no deformities. He had forward flexion of 0 to 80 degrees with pains at L3/L4 at 80 degrees, minus 10 degrees secondary to pain. Extension was 0 to 20 degrees with pains at L4 at 20 degrees, minus 10 degrees secondary to pain. Left and right lateral flexion was 0 to 30 degrees with pains in the musculature to the right and the left of the lumbar spine at 30 degrees. Left and right lateral rotation was 0 to 40 degrees with pains to the right and left of the musculature of the lumbar spine at 40 degrees. Active range of motion did not produce any weakness, fatigue, or incoordination. Deep tendon reflexes were 1+ and equal in bilateral lower extremities. There was normal pinprick and normal strength of both lower extremities. There was a negative foot drop bilaterally. There were normal motor skills, no muscle atrophy, and no muscle spasms. Straight leg raising was from 0 to 45 degrees bilaterally with pains at L4/L5 at 45 degrees, minus 45 degrees secondary to pain. Gait was normal. An X-ray of the low back revealed no evidence of compression fracture. Anterior osteophytes were shown at the L1-L2 level and intervertebral spaces were maintained. Pedicles were intact and there was minimal increase in lordosis. The diagnosis was low back strain with osteophytes. During the October 2007 VA examination the Veteran complained of 7.5-8/10 mechanical low back pain in a longitudinal band across the lower lumbar region, sometimes radiating into bilateral buttocks. He complained of flare-up pain 10/10 in intensity, which occurred 2 to 3 times per week and lasted for half an hour to 45 minutes. The examiner noted that the Veteran had an antalgic gait. - 9 - The Veteran also complained of bilateral leg paresthesias and dysthesias in an S1 radicular pattern. He stated that he has had 5 days of physician prescribed bed rest for this condition in the last 12 months. The Veteran indicated that he was employed by VA as a housekeeper and missed many days of work due to acute exacerbations of his low back pain. He reported increased low back pain associated with lifting, bending, or twisting at the waist. He also reported increased right hand pain associated with repetitive strenuous use. Physical examination of the low back revealed normal spinal curvature. There was tenderness of the lumbar spinous processes, bilateral lumbar perivertebral musculature without spasm. There was no sacral iliac joint tenderness and no sciatic notch tenderness. Neurological examination revealed intact sensation to light touch for all dermatones of the bilateral lower extremities. Motor extremities were 5/5 for all muscle groups of bilateral lower extremities. Reflexes were physiologic and symmetric and Babinski was negative. Straight leg raising test was subjectively positive bilaterally. Range of motion testing revealed the following: flexion was 0 to 40 degrees prerepetitive motion, 60 degrees postrepetitive motion; extension was 0 to 20 degrees prerepetitive motion, 22 degrees postrepetitive motion; right and left lateral flexion was 0 to 30 degrees prerepetitive and postrepetitive motion; right and left lateral rotation was 0 to 30 degrees prerepetitive and postrepetitive motion. The Veteran complained of pain on the extremes of motion in each plane. There was no apparent weakness, fatigability or loss of coordination during or following these repetitions of range of motion. The assessment was lumbar degenerative joint disease. Also of record are VA outpatient treatment reports dated through May 2006 which reflect treatment for the Veteran's low back disorder. Analysis There are two periods of time at issue here: prior to October 9, 2007, when the Veteran's low back disorder was evaluated as 10 percent disabling; and beginning October 9, 2007 to the present, while the Veteran's low back disorder was evaluated - 10- as 20 percent disabling. The Board will consider the proper evaluation to be assigned for both time periods. See Hart, 21 Vet. App. at 505. a. Prior to October 9, 2007 Given the evidence of record, the Board finds that a disability rating greater than 10 percent prior to October 9, 2007 is not warranted for the Veteran's lumbosacral spine strain under the scheduler criteria. Prior to October 9, 2007 the Veteran's range of motion did not meet the criteria for a 20 percent rating under DC 5237 as his forward flexion was greater than 60 degrees, both with pain and without pain, and the combined range of motion of the thoracolumbar spine is greater than 120 degrees. Prior to October 9, 2007, there was also no evidence of incapacitating episodes relating to intervertebral disc syndrome having a total duration of at least two weeks but less than four weeks during the past 12 months. During the March 2006 VA examination the Veteran specifically denied any incapacitating episodes and the examiner noted there were no signs of intervertebral disc syndrome. Thus, a disability rating greater than 10 percent under either DC 5237 or DC 5243 is not warranted. Furthermore, there are no other alternative diagnostic codes under 38 C.F.R. § 4.71a that could apply to the Veteran's lumbar spine disorder. The Board also finds that a disability rating greater than 10 percent is not warranted for the Veteran's lumbar spine disorder under DeLuca. While the March 2006 VA examiner reported additional limitation of joint function of 10 degrees following repetitive use, the March 2006 VA examiner also reported that the Veteran had 80 degrees flexion in his lumbar spine. Even taking into account the additional 10 degrees of loss of motion under DeLuca the Veteran still did not meet the criteria for a disability rating greater than 10 percent under DC 5237 prior to October 9, 2007. Thus, the Board finds that the 10 percent rating assigned prior to October 9, 2007 for the lumbar spine is already taking into consideration the provisions of Deluca. - 11 - b. Beginning October 9, 2007 Given the evidence of record, the Board finds that a disability rating greater than 20 percent is not warranted for the Veteran's lumbosacral strain beginning October 9, 2007 under the scheduler criteria. The Veteran's range of motion does not meet the criteria for a 30 percent rating under DC 5237 as a 30 percent rating pertains to limitation of motion of the cervical spine, not the lumbar spine. The Veteran's range of motion also does not meet the criteria for a 40 percent rating under DC 5237 as his forward flexion is greater than 30 degrees, both with pain and without pain, there is no evidence of favorable ankylosis of the entire thoracolumbar spine. There is also no evidence of any incapacitating episodes relating to intervertebral disc syndrome during the past 12 months. Thus, a disability rating greater than 20 percent under either DC 5237 or DC 5243 is not warranted. Furthermore, there are no other alternative diagnostic codes under 38 C.F.R. § 4.71a that could apply to the Veteran's low back disorder. The Board also finds that a disability rating greater than 20 percent is not warranted for the Veteran's lumbosacral spine strain under DeLuca. The October 2007 VA examiner specifically noted that there was no apparent weakness, fatigability, or loss of coordination during or following three repetitions of range of motion. As for the potential for a separate compensable disability rating for neurological manifestations of the low back disorder, the Board notes the Veteran's complaints of bilateral leg paresthesias and dysthesias during the October 2007 VA examination. However, the Board also notes that the neurological examination in October 2007 was normal. As such, a separate disability rating for neurological manifestations of the low back disorder is not warranted. 2. Residuals, fracture, fourth metacarpal shaft, right hand (dominant) The Veteran's service treatment records show that he sustained a fracture of the fourth metacarpal shaft of the right hand in October 1987. Service connection was granted and a noncompensable percent rating assigned for residuals, fracture, fourth metacarpal shaft, right hand (dominant) by rating decision dated in March 1995. In - 12 - November 2001 the Veteran submitted a claim for an increased rating. He underwent a VA examination in March 2003 and by rating decision dated in May 2003 the RO continued the noncompensable rating. The Veteran submitted a subsequent claim for an increased rating in November 2005. He was afforded a VA examination in March 2006 and by rating decision dated in April 2006 the RO continued the noncompensable disability rating assigned. The Veteran perfected an appeal of this decision and was afforded another VA examination in October 2007. Rating Criteria The Veteran's residuals, fracture, fourth metacarpal shaft, right hand (dominant) is currently rated under 38 C.F.R. § 4.7la, Diagnostic Code (DC) 5299-5227 for unfavorable or favorable ankylosis. Ankylosis is the immobility and consolidation of a joint due to disease, injury or surgical procedure. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) and Lewis v. Derwinski, 3 Vet. App. 259 (1992) [citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)]. Disabilities may be rated by analogy to a closely related disease where the functions affected and the anatomical location and symptomatology are closely analogous. 38 C.F.R. §§ 4.20, 4.27. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69. In this case, evidence, indicates the Veteran is right-hand dominant. Under DC 5227, unfavorable or favorable ankylosis of the ring or little finger, regardless of whether it involves the major or minor hand, warrants at most a noncompensable (i.e., 0 percent) rating. A note in this code indicates that VA should also consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. - 13 - If both the metacarpophalangeal and proximal interphalangeal joints of the little finger are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone, the finger should be evaluated as amputation without metacarpal resection, at proximal interphalangeal joint or proximal thereto. 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note (3)(i). If both the metacarpophalangeal and proximal interphalangeal joints of the little finger are ankylosed, the finger should be evaluated as unfavorable ankylosis, even if each joint is individually fixed in a favorable position. Id. at Note (3)(ii). If only the metacarpophalangeal or proximal interphalangeal joint is ankylosed, and there is a gap of more than two inches between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, the finger should be evaluated as unfavorable ankylosis. Id. at Note (3)(iii). If only the metacarpophalangeal or proximal interphalangeal joint is ankylosed, and there is a gap of two inches or less between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, the finger should be evaluated as favorable ankylosis. Id. at Note (3)(iv). Under DC 5156 a 20 percent evaluation may be assigned for amputation of the little finger with metacarpal resection (more than one-half the bone lost). A 10 percent evaluation may be assigned for amputation of the little finger of the major or minor extremity without metacarpal resection, at the proximal interphalangeal joint or proximal thereto. 38 C.F.R. § 4.71a, DC 5156. Medical Evidence Evidence relevant to the current severity of the Veteran's residuals, fracture, fourth metacarpal shaft, right hand (dominant) includes VA examination reports dated in March 2006, June 2007, and October 2007. During the March 2006 VA examination the Veteran complained of daily pain in his right hand, described as numbing. He denied any swelling. The pains average about 4/10. He used no - 14- assistive devices. Nothing seemed to aggravate the hand pain including the Veteran's occupation. It did not interfere with his daily activities and there was no additional limitation with flare-ups. There was no additional limitation with repetitive use. Physical examination of the right hand revealed no deformities, no swelling, and no palpable tenderness. The examiner found no abnormalities and there was no pain on manipulation. Wrist and hand showed extension of 0 to 70 degrees without pain. Palmar flexion was 0 to 75 degrees without pain and 0 to 40 degrees of ulnar deviation without pain. Wrist radial deviation was 0 to 20 degrees without pain. Active range of motion did not produce any weakness, fatigue, or incoordination. X-ray examination revealed no evidence of acute fracture or dislocation and old fracture fourth metacarpal with some shortening. Accessory ossicle along the doral margin of the head of the third metacarpal associated with soft tissue swelling. The impression was status post right hand fracture, no residuals. During the June 2007 VA examination the Veteran complained of numbness of the entire right hand for the past one and a half years. This progressed to where he was dropping small items also. He saw a private physician and was diagnosed with carpal tunnel syndrome, bilaterally. More recently, the Veteran had began having the same symptoms in the left hand. The examiner noted a previous X-ray showing a well healed, slightly shortened right fourth metacarpal fracture. He did not complain of any pain at the fracture site. He did complain of some stiffness of the proximal interphalangeal (PIP) joints of his fingers of both hands. In February 2007, he had a right carpal tunnel release and has had some improvement. His grip strength is improving. The Veteran reported that he was working regularly for VA as a housekeeper. Physical examination of the right hand revealed no atrophy. There was a small, well-healed scar over the carpal tunnel. Examination of the fourth metacarpal revealed slight shortening but no palpable deformity and no tenderness. He had full active and passive pain free range of motion of all digits. He could make a tight fist. His grip strength was 5/5. Repetitive motion with maximum flexion and - 15 - extension of all fingers produced no pain, loss of motion, weakness, fatigability, or incoordination. The impression was asymptomatic, well-healed, slightly shortened fourth metacarpal fracture of the right hand and bilateral carpal tunnel syndrome, unrelated to fourth metacarpal fracture. During the October 2007 VA examination the Veteran complained of daily, chronic, and mechanical right hand pain with an intensity of 6/10. He also complained of flare-up pain 9/10 in intensity once or twice per day which is momentary. The Veteran also reported increased right hand pain associated with repetitive strenuous use. The examiner noted that the Veteran underwent right wrist carpal tunnel release in February 2007. Physical examination of the right hand revealed a visibly and minimally depressed fourth distal metacarpal head. Right hand grip strength was 5/5 in intensity. The gap distance between the distal palmar pad of the ring finger and the median transverse fold of the palm was 0 centimeters. It appears that range of motion testing was completed for the left ring finger and not the right ring finger. Also of record are VA outpatient treatment reports dated through May 2006 showing complaints of right hand pain and private treatment records dated from December 2006 through June 2007 showing treatment for carpal tunnel syndrome. Analysis Given the above evidence, the Board finds the preponderance of it is against a compensable disability rating for residuals, fracture, fourth metacarpal shaft, right hand (dominant). As above, a zero percent rating is the maximum schedular rating available for ankylosis of the ring finger under DC 5227. Again, this is true irrespective of whether the ankylosis is unfavorable or favorable and regardless of whether it affects this finger on the major (dominant) or minor hand. To warrant a higher rating, the evidence must show what amounts to amputation of the finger at - 16 - the PIP joint or proximal thereto pursuant to DC 5156. The evidence fails to establish amputation of this finger or impairment tantamount to it. Also, the Veteran does not have ankylosis of the metacarpal phalangeal (MCP) joint of his right ring finger to warrant rating his condition as if this finger were amputated. Further, the June 2007 and October 2007 VA examination reports reflect no gaps which would warrant a finding of ankylosis. Thus, the Veteran's right ring finger must be evaluated as unfavorable ankylosis and, as noted, DC 5227 provides at most a zero percent rating for this. See 38 C.F.R. § 4.7la, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note (3)(i). The Board also has considered whether an increased disability rating is warranted for the Veteran's right fourth metacarpal disability based on functional loss due to pain, weakness and flare-ups, pursuant to 38 C.F.R. §§ 4.40 and 4.45 and DeLuca v. Brown, supra. However, if a claimant is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable. Johnston v. Brown, 10 Vet. App. 80 (1997). Here, the Veteran has a noncompensable evaluation for his right fourth metacarpal disorder under DC 5227, and as mentioned this is the maximum rating allowable under this DC. Hence, the aforementioned provisions of38 C.F.R. § 4.40 and § 4.45 are not for consideration. The Board also finds that the Veteran is not entitled to a separate compensable disability rating for any neurological manifestations of the service-connected right fourth metacarpal disability. While the Veteran has a diagnosis of carpal tunnel syndrome the June 2007 VA examiner specifically opined that the Veteran's bilateral carpal tunnel syndrome was unrelated to the Veteran's right fourth metacarpal fracture. General Increased Rating Matters The Board also finds that no higher evaluations can be assigned pursuant to any other potentially applicable diagnostic codes. Because there are specific diagnostic - 17 - codes to evaluate the above discussed disorders, consideration of other diagnostic codes for evaluating the disability does not appear appropriate. See 38 C.F.R. § 4.20 (permitting evaluation, by analogy, where the rating schedule does not provide a specific diagnostic code to rate the disability). See Butts v. Brown, 5 Vet. App. 532 (1993). Extraschedular Consideration At the October 2007 VA examination, the Veteran reported that he "missed many days of work" because of his back condition. As such, the Board must adjudicate the issue of whether referral for an extraschedular rating is warranted. See Barringer v. Peake, 22 Vet. App. 242 (2008). Here, the record does not establish that the rating criteria are inadequate for rating the Veteran's service-connected back disability. The competent medical evidence of record shows that his back disability is primarily manifested by pain, tenderness and limitation of motion. Many of the applicable diagnostic codes used to rate the Veteran's back disability provide for ratings based on limitation of motion. The effects of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The effects of the Veteran's service-connected back disability have been fully considered and are contemplated in the rating schedule; hence, referral for an extraschedular rating is unnecessary at this time. Thun v. Peake, 22 Vet. App. 111 (2008). Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfieldv. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions - 18 - that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). For an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary 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; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant [DC's]," and that the range of disability applied may be between 0% and 100% "based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, --- F.3d , No.2008-7150, (Fed. Cir. Sept. 4, 2009). Complete notice was sent in November 2005, May 2007, and May 2008 letters and the claims were readjudicated in a June 2008 supplemental statement of the case. Mayfield, 444 F.3d at 1333. Moreover, the record shows that the appellant was represented by a Veteran's Service Organization and its counsel throughout the adjudication of the claims. Overton v. Nicholson, 20 Vet. App. 427 (2006). VA has obtained service treatment records, assisted the appellant in obtaining evidence, afforded the appellant physical examinations, obtained medical opinions as to the etiology and severity of disabilities, and afforded the appellant the opportunity to give testimony before the Board although he declined to do so. VA need not conduct an examination with respect to the service connection claim decided herein because the information and evidence of record contains sufficient competent medical evidence to decide the claim. 38 C.F.R. § 3.159(c)(4). There is no competent evidence that suggests a causal link between the Veteran's bilateral knee disorder and any incident of active duty. Indeed, in view of the absence of bilateral knee complaints during military service and the 11 year gap between the - 19 - claimed disorder and active duty, relating the Veteran's current bilateral knee disorder to his military service would be entirely speculative. Therefore, there is no duty to provide an examination or a medical opinion. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3. 159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). All known and available records relevant to the issues on appeal have been obtained and associated with the appellant's claims file; and the appellant has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. ORDER Service connection for a bilateral knee disorder is denied. A disability rating greater than 10 percent for service-connected lumbosacral strain with degenerative disc disease for the period of time prior to October 9, 2007 is denied. A disability rating greater than 20 percent for service-connected lumbosacral strain with degenerative disc disease for the period of time beginning October 9, 2007 is denied. A compensable disability rating for service-connected residuals, fracture, fourth metacarpal shaft, right hand (dominant) is denied. M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals - 20-