Citation Nr: 1007366 Decision Date: 02/26/10 Archive Date: 03/05/10 DOCKET NO. 03-30 745 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to an initial compensable disability rating for the residuals of a fracture of the fifth proximal metacarpal of the left hand. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Michael J. A. Klein, Associate Counsel INTRODUCTION The Veteran had active service from June 1972 to June 1975. This appeal comes to the Board of Veterans' Appeals (Board) from an October 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, which, inter alia, granted the Veteran's service connection claim for the residuals of a fracture of the fifth proximal metacarpal of the left hand, rated at 0 percent (noncompensable). In February 2004, the Veteran testified before a Decision Review Officer (DRO) at the RO; a copy of the transcript has been associated with the record. In his October 2003 substantive appeal (VA Form 9), the Veteran requested a videoconference hearing before a Veterans Law Judge at the RO. Such a hearing was scheduled for November 2004, and the Veteran was so notified in September 2004. However, he failed to report at his scheduled time and thus far has not offered an explanation for his absence. Accordingly, the Board will adjudicate the Veteran's appeal as if the hearing request had been withdrawn. 38 C.F.R. § 20.704(d) (2009). This case previously reached the Board in May 2005 and in January 2008. In May 2005, the Board remanded the Veteran's claims for an initial compensable evaluation for residuals of a fracture of the fifth proximal metacarpal of the left hand, as well as service connection for a cold injury of the left and right lower extremities, and the residuals of a right ankle sprain. Subsequently, in a November 2005 rating decision, the agency of original jurisdiction (AOJ) granted the above claims with the exception of his claim for an initial compensable evaluation for the residuals of a fracture of the fifth proximal metacarpal of the left hand. The grant of service connection was a complete grant of the benefits which had been sought on appeal for the service connection claims. See Grantham v. Brown, 114 F.3d 1156. 1158-59 (Fed. Cir. 1997) (the Veteran must separately appeal downstream issues). As such the issues of service connection for a cold injury of the left and right lower extremities, and the residuals of a right ankle sprain are no longer on appeal. In January 2008, the Board again remanded the Veteran's initial compensable disability rating claim for the residuals of a fracture of the fifth proximal metacarpal of the left hand. This issue has now been returned to the Board for further appellate consideration. FINDING OF FACT The Veteran's service-connected residuals of a fracture of the fifth proximal metacarpal of the left hand is assigned a 0 percent (noncompensable) rating for the entirety of the appeal period, the maximum rating authorized under Diagnostic Code 5227, and is not shown to interfere with employment or to require frequent hospitalization. CONCLUSION OF LAW There is no legal basis for the assignment of an initial schedular disability rating in excess of 0 percent for the Veteran's residuals of a fracture of the fifth proximal metacarpal of the left hand, and referral to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for an extraschedular rating is not warranted. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.71a, Diagnostic Code 5227 (2009). REASONS AND BASES FOR FINDING AND CONCLUSION The Duties to Notify and Assist Review of the claims folder reveals compliance with the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The duty to notify was accomplished by way of the VCAA letters from the AOJ to the Veteran dated in July 2002, October 2003, and March and June 2008. Those letters effectively satisfied the notification requirements of the VCAA consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) by: (1) informing him about the information and evidence not of record that was necessary to substantiate his initial claim; (2) informing him about the information and evidence the VA would seek to provide; and (3) informing him about the information and evidence he was expected to provide. See also Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Furthermore, the March 2008 letter from the AOJ further advised the Veteran of the elements of a disability rating and an effective date, which are assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). With regard to the timing of VCAA notice, the Board sees the AOJ did not provide the Veteran with all general VCAA notice prior to the determination on appeal. But in Pelegrini II, the U.S. Court of Appeals for Veterans Claims (Court) clarified that in these situations the VA does not have to vitiate that decision and start the whole adjudicatory process anew, as if that decision was never made. Rather, the VA need only ensure the Veteran receives (or since has received) content-complying VCAA notice, followed by readjudication of his claims, such that he is still provided proper due process. In other words, he must be given an opportunity to participate effectively in the processing of his claims. The United States Court of Appeals for the Federal Circuit (Federal Circuit Court) has held that a Statement of the Case (SOC) or Supplemental SOC (SSOC) can constitute a "readjudication decision" that complies with all applicable due process and notification requirements if adequate VCAA notice is provided prior to the SOC or SSOC. Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV). In fact, as a matter of law, the provision of adequate VCAA notice prior to a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. See also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the timing error was cured. After initially providing VCAA notice in July 2002, the AOJ adjudicated the claim in the October 2002 rating decision and again in the May 2004, and December 2005 SSOCs. And after providing additional VCAA notice in March 2008, the AOJ again went back and readjudicated the claim in the more recent December 2009 SSOC. The record demonstrates that each time after providing the required notice, the AOJ reconsidered the claim - including to address any additional evidence received in response to the notice. Therefore, the timing defect in the notice has been rectified. Prickett, 20 Vet. App. at 376. In addition, the Veteran has never alleged how any timing error prevented him from meaningfully participating in the adjudication of his claim. As such, the Veteran has not established prejudicial error in the timing of VCAA notice. See Shinseki v. Sanders / Simmons, 129 S. Ct. 1696 (2009). However, with regard to content, it is noted the claim at issue stems from an initial rating assignment. In this situation, the Court has held that an appellant's filing of a notice of disagreement (NOD) regarding an initial disability rating or effective date, such as the case here, does not trigger additional section 5103(a) notice. Indeed, the Court has determined that to hold that section 5103(a) continues to apply after a disability rating or an effective date has been determined would essentially render sections 7105(d) and 5103A and their implementing regulations insignificant and superfluous, thus disturbing the statutory scheme. Dingess at 491, 493, 500-501. The Court, however, more recently clarified its holding in Dingess, indicating it was limited to situations where service connection was granted and the disability rating and effective date assigned prior to the enactment of the VCAA - so prior to November 9, 2000. If, as here, this did not occur until after that date, the Veteran is entitled to pre- decisional notice concerning all elements of his claims, including these downstream disability rating and effective date elements. And if he did not receive this notice, for whatever reason, it is VA's obligation to explain why this is not prejudicial error, i.e., harmless. See Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Notwithstanding its holding in Dunlap, the Court most recently clarified in Goodwin v. Peake, 22 Vet. App. 128, 137 (2008), that where a service connection claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream initial rating and effective date elements. The Court added that its decision was consistent with its prior decisions in Dingess and Dunlap, supra. In this regard, the Court emphasized its previous holding in Dingess that "once a decision awarding service connection, a disability rating, and an effective date has been made, section 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess, 19 Vet. App. at 490. Thereafter, once a NOD has been filed, only the notice requirements for rating decisions and SOCs described within 38 U.S.C. §§ 5104, 7105 control as to the further communications with the appellant, including as to what "evidence [is] necessary to establish a more favorable decision with respect to downstream elements ...." Id. Applying the above analysis to the present case, the Veteran does not contend, nor does the evidence show, any notification deficiencies with respect to content that have resulted in prejudice. See Shinseki v. Sanders / Simmons, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). In fact, with respect to content, the AOJ actually provided the Veteran with downstream Dingess notice in a March 2008 letter pertaining to the disability rating and effective date elements of his claim. Further, after the Veteran filed an NOD as to a higher initial rating for his residuals of a fracture of the fifth proximal metacarpal of the left hand, the additional notice requirements described within 38 U.S.C. §§ 5104, 7105 were met by the May 2004, November 2005, and December 2009 SSOCs. Specifically, these documents provided the Veteran with a summary of the pertinent evidence as to his claim, a citation to the pertinent laws and regulations governing a higher rating for his claim, and a summary of the reasons and bases for the AOJ's decision to deny a higher rating for his claim. Therefore, the Veteran has not met his burden of establishing any prejudice as to notice provided for the downstream initial rating and effective date elements of his claim, such that there is no prejudicial error in the content of VCAA notice. In addition to notification, the VA is required to assist the Veteran in finding evidence to support his claim. See 38 U.S.C.A. § 5103A (West 2002). The AOJ has secured service treatment records (STRs), VA treatment records, three VA medical examinations, and private medical evidence as identified by the Veteran. The Veteran has submitted personal statements, and hearing testimony. The Veteran has not provided authorization for the VA to obtain any additional private medical records, nor has he indicated that such records exist. Therefore, the Board concludes that the duty to assist the Veteran in gathering information to advance his claim has been met. Furthermore, the Board is also satisfied as to substantial compliance with its May 2005 and January 2008 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). In regards to the May 2005 Board remand, the AOJ was to provide the Veteran with an orthopedic examination of his left hand. This was accomplished by the June 2005 VA medical examination. In January 2008 the Board again remanded the Veteran's claim. First, the AOJ was to provide proper VCAA notice, in particular notice compliant with the requirements of Dingess, supra. This was accomplished by the VCAA notice letter of March 2008. Second, the AOJ was also to request that the Veteran identify all health care providers which have treated him for the residuals of a fracture of the fifth proximal metacarpal of the left hand, and attempt to obtain any records identified. The March 2008 letter requested this information from the Veteran. The Veteran did not provide any information regarding treatment for the residuals of a fracture of the fifth proximal metacarpal of the left hand; in fact, the Veteran responded in March 2008 and in January 2010 by indicating that he had "no other information or evidence to give" to the VA. Therefore, the Board concludes that the AOJ has complied with this remand requirement. Third, the AOJ was to provide the Veteran with an orthopedic/neurological examination of his left hand and to provide detailed clinical findings of the symptomatology attributable to any residuals of a fracture of the fifth proximal metacarpal of the left hand. This examination was provided in December 2009. Finally, the AOJ was to readjudicate the Veteran's claim, which was accomplished in the December 2009 SSOC. Therefore, the Board concludes that the prior remand directives have been fully complied with. Governing Laws and Regulations for Higher Disability Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Because the Veteran has perfected an appeal as to the assignment of an initial rating following the initial award of service connection for the residuals of a fracture of the fifth proximal metacarpal of the left hand, the Board is required to evaluate all the evidence of record reflecting the period of time between the effective date of the initial grant of service connection (August 20, 1999) until the present. This could result in "staged ratings" based upon the facts found during the period in question. Fenderson v. West, 12 Vet. App. 119, 126 (1999). That is to say, the Board must consider whether there have been times since the effective date of his award when his disabilities have been more severe than at others. Id. at 126. 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. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). With any form of arthritis, painful motion is an important factor of disability. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59. Analysis- Compensable Initial Disability Rating for the Residuals of a Fracture of the Fifth Proximal Metacarpal of the Left Hand Service connection was granted for the Veteran's residuals of a fracture of the fifth proximal metacarpal of the left hand and assigned a noncompensable (0 percent) rating under 38 C.F.R. § 4.71a, Diagnostic Code 5227 (for ankylosis of the ring or little finger) in October 2002, with an effective date of August 20, 1999. The Veteran currently seeks a compensable rating for the residuals of a fracture of the fifth proximal metacarpal of the left hand. A June 2005 VA consultation report confirmed that the Veteran is right hand dominant, thus confirming that his residuals of a left fifth proximal metacarpal fracture affects the non-dominant, hand. See 38 C.F.R. § 4.69. The Veteran's earliest records of finger pain relevant to the Veteran's current claim are VA medical treatment records which indicate pain in the left hand in June 1998, and pain in the "left small finger" in September 1998. Subsequently, in December 2001, the Veteran was noted to be receiving treatment for bilateral arthritis. However, a December 2001 X-ray only indicated "mild deformity, subarticular sclerotic changes, and marginal spurring involving the articular surface of the distal ulna of the left wrist. There are no other significant abnormalities seen." A VA medical examination provided in August 2003 indicated that the Veteran's left hand exhibited no deformity, some pain on manipulation, but noted that the Veteran had the full range of motion and could approximate the fingers including the fifth finger to the palm of the hand and the thumb to the fifth finger. The examiner did note that the Veteran's strength was "3/5 to the thumb to the fifth fingers secondary to some pain within the [metacarpal phalangeal] joint." A contemporary X-ray indicated that the Veteran's left hand exhibited "some deformed left fifth metacarpal bone," but that the Veteran's left hand, including the soft tissue, was otherwise normal. A VA medical examination was later conducted in June 2005. The examiner reviewed the Veteran's claims file and examined the Veteran. The examiner noted that the left hand showed no scar, and the Veteran had a good grip of the hands bilaterally. There was no gap between the thumb and the tips of the fingers. The examiner also noted that the Veteran exhibited pain, weakness, and stiffness. Furthermore, the examiner noted that the Veteran's left hand is weak and he drops tools at work. Finally, he noted that the Veteran indicated that he was not able to use his hand once or twice a month when the hand hurts more. The painful period were reported as occurring a few times a month and lasting 3-7 days. At this time, an X-ray of the Veteran's left hand indicated mild degenerative changes of the distal left radial ulnar joint and the distal interphalangeal joints, but concluded that there was "[n]o acute abnormality." The examiner also reviewed the Veteran's range of motion in his left hand and found that the Veteran's range of motion and joint function of the left digits was "additionally limited by pain, fatigue, weakness, and lack of endurance." However, the June 2005 VA medical examiner concluded that the Veteran's left hand pain was "not at least as likely as not produced by the [service-connected] left hand injury," and that "there was no evidence of nerve involvement." Finally, a VA medical examination was conducted in December 2009. The examiner reviewed the Veteran's case file, medical records, and examined the Veteran. The examiner concluded that the Veteran experienced a decrease in hand strength and dexterity, and exhibited pain, limited motion, swelling, deformity, and stiffness; however, there was no objective evidence of pain or additional limitation of motion following repetitive motion. The examiner also noted that the left fifth digit exhibited strength reduced to 3/5 due to downward angulation of the distral metacarpal and residual arthritic change. He also noted the limitations of motion of the fifth digit of the Veteran's left hand. However, he also noted that there was "[n]o history of neurologic deficit." An X- ray was conducted which indicated that there were "no significant degenerative changes," and that the "[s]oft tissues are within normal limits." The X-ray did note a "[p]osttraumatic deformity of the fifth metacarpal bone" and a "possible posttraumatic deformity of the third tuft." Furthermore, there was "[n]o evidence of productive or erosive arthritis identified in the left wrist." The December 2009 VA medical examiner concluded that the Veteran's residuals of a fracture of the fifth proximal metacarpal of the left hand exhibited "[n]o significant effects" on the Veteran's usual occupation or usual daily activities. In addition to medical evidence provided by treatment records, the Board notes that the Veteran has presented lay testimony regarding his claim. The Veteran has repeatedly indicated that he experiences problems holding things in his left hand. See the Veteran's October 2003 and January 2010 statements, the February 2004 DRO hearing transcript, and the June 2005 and December 2009 VA medical examinations. The Board notes that in 2002, the VA revised the rating criteria pertaining to ankylosis and limitation of motion of the fingers. See 67 Fed. Reg. 48784-48787 (July 26, 2002). The revisions became effective on August 26, 2002. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C.A. § 5110(g); VAOPGCPREC 3- 2000. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. The amendment above established the effective dates without a provision for retroactive application. Thus, the amendments may be applied after, but not prior to, August 26, 2002. Prior to August 26, 2002, there were no diagnostic codes that addressed limitation of motion of the fingers. Instead, under Diagnostic Code 5227 a noncompensable rating was provided for favorable or unfavorable ankylosis of the little finger. A following note indicated that extremely unfavorable ankylosis of the little finger would be rated as amputation under Diagnostic Code 5156. 38 C.F.R. § 4.71a. As there is no evidence in the record of extremely unfavorable ankylosis of the little finger for the duration of the appeal period, the pre-August 26, 2002, Diagnostic Code does not allow for a compensable evaluation for the Veteran's residuals of a fracture of the fifth proximal metacarpal of the left hand. Nor was there any evidence that the Veteran's disorder caused him to experience favorable or unfavorable ankylosis of multiple fingers to allow for a compensable rating under Diagnostic Codes 5216-5223. 38 C.F.R. § 4.71a. The Board notes that the change in regulations did not specifically amend the criteria for Diagnostic Code 5227 which continues to provide a noncompensable evaluation for favorable ankylosis of the little finger of both the major and minor hand. 38 C.F.R. § 4.71a (2009). The note that now follows Diagnostic Code 5227 states that it should also be considered 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. Id. Applying the revised rating criteria, the Veteran's service- connected residuals of a fracture of the fifth proximal metacarpal of the left hand have already been assigned the maximum schedular rating available for ankylosis of the little finger. 38 C.F.R. § 4.71a, Diagnostic Code 5227. Furthermore, there is no compensable evaluation for limitation of motion of the little finger (Diagnostic Code 5230). The Veteran is also not entitled to a compensable rating under 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5223, because there is no evidence that the Veteran's service- connected residuals of a fracture of the fifth proximal metacarpal of the left hand causes favorable or unfavorable ankylosis of multiple digits of the left hand, nor is there evidence that the Veteran's disorder causes limitation of motion of other digits. However, in the Note applicable to the revised Diagnostic Code 5227, effective after August 26, 2002, the Board is directed to "consider whether evaluation as amputation is warranted and whether additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand." As such, Diagnostic Code 5156, directs the rater to evaluate amputation of the little finger: as 10 percent disabling without metacarpal resection, at proximal interphalangeal joint or proximal thereto, and as 20 percent disabling with metacarpal resection (more than one half-the bone lost). There is no evidence of record to indicate that the Veteran's residuals of a fracture of the fifth proximal metacarpal of the left hand result in the equivalent of amputation of the little finger either at the proximal interphalangeal joint, or with metacarpal resection. Furthermore, there has been no evidence presented that the Veteran's residuals of a fracture of the fifth proximal metacarpal of the left hand causes him to experience a resulting limitation of motion of other digits, sufficient to allow for a compensable evaluation for limitation of motion of multiple digits under an alternate code. Finally, the rater is also directed to consider "interference with overall function of the hand." Although the Veteran has complained of weakness and pain in his left hand, and the VA medical examinations have further indicated that the Veteran experiences pain and weakness in his left hand, none of the examinations reveal that the Veteran experiences the equivalent of amputation at any level, favorable or unfavorable ankylosis multiple digits, or limitation of motion of multiple digits. As such, despite the evidence of interference in the overall function of his hand, there is no evidence that this interference rises to the level of a compensable rating. Finally, as to functional loss for the appeal period, the Board acknowledges that, the VA medical examinations, and the Veteran himself, have consistently reported that the Veteran's residuals of a fracture of the fifth proximal metacarpal of his left hand have caused him to experience decreased motion of the little finger as well as pain. Unfortunately, all of the evidence of functional loss simply does not show that the Veteran's disability causes him to experience equivalent of amputation, favorable or unfavorable ankylosis of multiple digits, or limitation of motion of multiple digits. Furthermore, the Board acknowledges that there is some evidence of treatment for arthritis dating from VA medical treatment records December 2001. However, the X- rays conducted in December 2001, August 2003, June 2005, and December 2009 do not reveal any arthritis of multiple minor joints as necessary under Diagnostic Codes 5003 and 5010. 38 C.F.R. § 4.71a. In fact, the X-rays do not diagnose the Veteran with any arthritis connected to his service-connected disorder. As such, the Board concludes that there is inadequate evidence of arthritis due to the Veteran's residuals of a fracture of the fifth proximal metacarpal of the left hand to allow the Board to grant a rating above noncompensable. Therefore, the Veteran is not entitled to a compensable rating through application of 38 C.F.R. § 4.59 or DeLuca, supra, because none of the applicable rating codes allow for a compensable evaluation. Finally, in Johnston v. Brown, 10 Vet. App. 80, 85 (1997), the Court determined that if a claimant is already receiving the maximum disability rating available, as here, it is not necessary to consider whether 38 C.F.R. §§ 4.40, 4.45, are applicable. In conclusion, the Veteran's residuals of a fracture of the fifth proximal metacarpal of the left hand has been properly rated as noncompensable for the entire appeal period. The Board adds that it does not find that the Veteran's service- connected residuals of a fracture of the fifth proximal metacarpal of the left hand should be increased for any other separate period based on the facts found during the appeal period. Fenderson, 12 Vet. App. at 125-26. Extra-Schedular Consideration The Court recently clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111, 115-116 (2008). First, the AOJ or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the AOJ or Board must determine whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the Rating Schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Id. The Board finds no reason to refer the case to the Compensation and Pension Service for consideration of an extraschedular evaluation under 38 C.F.R. § 3.321(b). As noted above, the Veteran has repeatedly indicated that he experiences problems holding things in his left hand, which interferes with his ability to work. See the Veteran's October 2003 and January 2010 statements, the February 2004 DRO hearing transcript, and the June 2005 and December 2009 VA medical examinations. As such, there is some evidence that the residuals of a fracture of the fifth proximal metacarpal of the left hand have caused some impairment in his occupational functioning. However, the Board notes that the Veteran has not presented, nor has he directed the VA to obtain, any objective evidence of lost productivity. Furthermore, the Veteran currently is apparently fully employed as a "pilot car driver" (see the December 2009 VA medical examination). Finally, there is also no evidence of exceptional or unusual circumstances, such as frequent hospitalization, to suggest that the Veteran is not adequately compensated by the regular Rating Schedule. The Board notes that, generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1; VAOPGCPREC 6-96. See also, Bagwell v. Brown, 9 Vet. App. 337, 338 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial compensable rating for residuals of a fracture of the fifth proximal metacarpal of the left hand is denied. ______________________________________________ A. BRYANT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs