Citation Nr: 1104472 Decision Date: 02/03/11 Archive Date: 02/14/11 DOCKET NO. 04-33 535 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Fargo, North Dakota THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for residuals of grenade fragmentation wounds of the left hand. 2. Entitlement to an evaluation in excess of 10 percent for residuals of grenade fragmentation wounds of the left wrist. 3. Entitlement to an initial evaluation in excess of 20 percent for degenerative changes of the lumbar spine as residual of grenade fragmentation wounds. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Peters, Associate Counsel INTRODUCTION The Veteran had active duty service from March 1951 to March 1953. The Veteran served honorably and heroically in the Korean War, where he earned the Purple Heart for wounds received in combat. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 1997 and December 2003 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In March 1999, the Board remanded the left arm claim for clarification of the Veteran's actual left arm disabilities, noting that such involved his left wrist, as well as his upper left arm. The Board later assigned a separate 10 percent evaluation for the Veteran's left wrist disability in a November 2000 decision. The Board continued a 10 percent rating for the left hand (as distinguished from the wrist) and denied a compensable evaluation of an upper left arm disability at that time. That decision was vacated by the United States Court of Appeals for Veterans Claims (Court) in a March 2001 Order, and was remanded back to the Board. In a January 2002 decision, the Board denied evaluations in excess of those already assigned, essentially leaving the Veteran in the same position as after the overturned November 2002 decision. That decision was then vacated by the Court in a November 2002 Order, and it was remanded back to the Board again. The case was then in turn remanded to the RO in June 2003. Consequently, the RO issued a December 2003 rating decision that continued the Veteran's wrist and upper left arm disability evaluations (at 10 percent and 0 percent, respectively). The December 2003 rating action also implemented the Board's 10 percent evaluation for a left hand disability, effective April 4, 1997-the date on which the Veteran filed an increased evaluation claim for his left arm disability-and granted service connection for a lumbar spine disability, assigning a 20 percent evaluation effective April 4, 1997. Following additional remands of the above issues by the Board in September 2006, April 2008, and October 2009. Claims of entitlement to earlier effective dates, including for a grant of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), were denied in the April 2008 Board decision. Furthermore, the Board denied a compensable evaluation for the Veteran's upper arm disability in the October 2009 Board decision. Such issues are thus no longer in appellate status. The Board notes, however, that the issues of a temporary total rating under 38 C.F.R. § 4.29 and 4.30 for back surgeries in May 1997 and March 2004 have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). Unfortunately, the issue of an increased initial evaluation for the lumbar spine is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran is right-handed. 2. The competent evidence does not show any ankylosis of the left hand; a normal range of motion of all digits is demonstrated throughout the appeal period. 3. The preponderance of the evidence of record demonstrates degenerative changes involving the Veteran's interphalangeal and metacarpal minor joint groups, as well as objective evidence of painful motion without a compensable limitation of motion of his left hand. 4. Throughout the appeal period, the Veteran's left wrist disability has been manifested by limitation of motion which more closely approximates palmar flexion limited in line with the forearm, with no showing of any ankylosis. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 10 percent for residuals of grenade fragmentation wounds of the left hand have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5216- 5227 (1997) and 5216-5230 (2010), 4.73, Diagnostic Code 5309 (2010). 2. The criteria for a separate initial evaluation of 10 percent for residuals of grenade fragmentation wounds of the left hand have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, 4.73, Diagnostic Codes 5309-5003 (2010). 3. The criteria for an evaluation in excess of 10 percent for residuals of a grenade fragmentation wound of the left wrist have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Codes 5003, 5010, 5214, 5215 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a 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. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim. Accordingly, notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Regarding the issue of entitlement to an increased evaluation claim for a left hand disability, that claim arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA as to that issue. With respect to for the Veteran's claim for increased evaluation for his left wrist and upper arm, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009). In this case, the Veteran was sent letters in October 2006 and May 2008 that included information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. Moreover, those letters informed the Veteran of what type of information and evidence was needed to establish a disability rating and effective date. Moreover, the Board further notes that the Veteran was specifically informed of the rating criteria for his left wrist and upper arm disabilities in the May 2008 letter. The Board acknowledges that, in the present case, complete notice was not issued prior to the adverse determination on appeal. However, fully compliant notice was later issued in those October 2006 and May 2008 communications, and the claims were thereafter readjudicated most recently in October 2010. Accordingly, any timing deficiency has here been appropriately cured. Mayfield, 444 F.3d 1328 (Fed. Cir. 2006). Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA treatment and examination. Moreover, the Veteran and his representative's statements in support of the claims are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's left hand and wrist claims. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Analysis of Claims The Board has reviewed all of the evidence in the Veteran's claims file. Although there is an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2010). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2010); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2010); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2010); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2010). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the claimant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 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. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2010); see also 38 C.F.R. § 4.45 (2010). Under Diagnostic Code 5010, traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (emphasis added). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion (emphasis added). When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent evaluation will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. The 10 and 20 percent evaluations based on X-ray evidence may not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. With any form of arthritis, painful motion is an important factor. It is the intention of the rating schedule to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. A compensable evaluation under Diagnostic Code 5003 and 38 C.F.R. § 4.59 (for painful motion) is in order where arthritis is established by X-ray findings and no actual limitation of motion of the affected joint is demonstrated. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Where compensable limitation of motion is demonstrated in the joint, the Lichtenfels rule is not applicable. 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 (2010). In this case, VA treatment records and examination reports demonstrate that the Veteran is right-handed. Thus, the Veteran's minor extremity is at issue in this case. Left Hand Claim The Veteran was granted a separate award of service connection for his left hand disability in the December 2003 rating decision; that disability was assigned a 10 percent evaluation, effective April 4, 1997. Such an evaluation was assigned under 38 C.F.R. § 4.73, Diagnostic Code 5309. Legal Criteria Diagnostic Code 5309, which has remained unchanged throughout the appeal period, notes that the hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc. Such a disability is thus rated on the limitation of motion of the hand, with a minimum 10 percent evaluation being assigned. See 38 C.F.R. § 4.73, Diagnostic Code 5309, Note (2010) (emphasis added). Limitation of motion of the hand is found in the Rating Schedule at 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5230. The criteria for rating disabilities of individual fingers of the hand were revised during the pendency of this appeal, effective August 26, 2002. See 67 Fed. Reg. 48784 (July 26, 2002). Under the criteria effective prior to August 26, 2002, disabilities of the individual fingers were rated under Diagnostic Codes 5224, 5225, 5226 and 5227, based upon ankylosis of the thumb, index finger, middle finger and any other finger, respectively. 38 C.F.R. § 4.71a, Diagnostic Codes 5224, 5225, 5226, 5227 (1997). Under Diagnostic Codes 5216-5227, in classifying the severity of ankylosis and limitation of motion of single and multiple digits, the following rules are applicable: (1) Ankylosis of both the metacarpophalangeal and proximal interphalangeal joints, with either joint in extension or in extreme flexion, will be rated as amputation; (2) Ankylosis of both the metacarpophalangeal and proximal interphalangeal joints, even though each is individually in favorable position, will be rated as unfavorable ankylosis; (3) With only one joint of a digit ankylosed or limited in its motion, the determination will be made on the basis of whether motion is possible to within 2 inches (5.1 cms.) of the median transverse fold of the palm, and when so possible, the rating will be for favorable ankylosis, otherwise unfavorable ankylosis; and (4) With the thumb, the carpometacarpal joint is to be regarded as comparable to the metacarpophalangeal joint of the other digits. See 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5227, Notes (1997). Thus, in order to warrant an increased rating under the regulations effective prior to August 26, 2002, the Veteran's left hand disability must be characterized by unfavorable ankylosis of the thumb; unfavorable ankylosis of two or more digits of the same hand; or, favorable ankylosis of any two digits of the same hand, except for the following combinations: middle and ring, middle and little, or ring and little. See 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5227 (1997). Under the rating criteria that became effective August 26, 2002, the above diagnostic codes remained unchanged, based upon ankylosis of the individual fingers, and new Diagnostic Codes 5228, 5229 and 5230 were added addressing limitation of motion of the individual digits. 38 C.F.R. § 4.71a, Diagnostic Codes 5228, 5229, 5230 (2010). Put another way, the pre-amended regulations only considered individual fingers with respect to ankylosis, whereas the revised provisions evaluate both ankylosis and limitation of motion for individual fingers. The Board notes that full range of motion for the index, long, ring, and little fingers is metacarpal phalangeal joint (MCP) flexion from 0 to 90 degrees; proximal interphalangeal joint (PIP) flexion from 0 to 100 degrees; and distal interphalangeal joint (DIP) flexion from 0 to 70 or 80 degrees. See 38 C.F.R. § 4.73, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note (1). Moreover, if there is limitation of motion of two or more digits, each digit is to be evaluated separately and the evaluations are to be combined. See Id. at Note (5). In order to warrant an increased rating under the regulations for the period beginning August 26, 2002, the Veteran's left hand disability must be characterized by unfavorable ankylosis of the thumb; ankylosis of two or more digits of the same hand, except for the following combinations: long (middle) and ring, long and little, or ring and little; limitation of motion of the thumb with a gap of more than two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers; or, a compensable limitation of motion of any two fingers. See 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5230 (2010). Background VA treatment notes dated throughout the appeal period reflect intermittent treatment for a left hand disability, primarily for pain. The Board notes that in March 1999, the Veteran's grip strength in both hands was strong and equal bilaterally. Additionally, in February 2009, the Veteran sought treatment for a left hand hematoma that was a result of a slip-and-fall accident on a patch of ice. A hematoma of the left hand was noted at that time. Subsequent treatment records are void of any further treatment or complaint involving the Veteran's left hand. The Veteran underwent a VA examination of his left hand in June 1999. At that time, he reported that he was right-handed. He complained of left hand pain, particularly during weather change and with cold exposure, as a result of shell fragment wounds sustained in combat in Korea. On examination, left hand grip was noted as being 1/2 over 5, with mild atrophy of the web space and thenar area, without any evidence of edema, discoloration or any other deformity noted. The Veteran was able to perform the finger-thumb loop by opposing the left thumb to all the other fingers of his left hand. He was also able to pick up a dime, paperclip and a 5-millimeter button, as well as wring his left hand. He could form a fist ten times, though there was noted grimacing indicative of pain. There was no loss of function in the left hand, and there was no excessive fatigability or incoordination noted. X-rays demonstrated small metallic densities near the thumb base and near the MP joint of the little finger. There was also moderate narrowing of the MP joint of the middle finger. The Veteran underwent another VA examination in September 2003. He reported left hand pain at that time, due to shell fragment wounds he received in service. On examination, there was a .5 centimeter, non-tender, non-keloid scar located on the lateral aspect of the first MCP region of the left hand. The left hand did not demonstrate any tenderness, edema or bony deformity. Left hand grip strength in was somewhat subdued, but was adequate. The Veteran was able to perform the finger-thumb loop opposing the ipsilateral second through fifth fingers, and was able to pick up a dime, paperclip, and a 5-millimeter button. He could form a fist with his left hand, and after doing so ten times, did not demonstrate any evidence of pain, excessive fatigability, incoordination or additional loss of function. Most recently, the Veteran underwent a VA examination of his left hand in August 2010. He reported that he was fully functional in his activities of daily living, except for needing help putting on his socks and shoes. He shared household duties with his wife. Though he noted weakness in his left hand with lifting heavy objects, he did not have any problems with fine motor control. On examination, the left hand did not have any herberdens or bouchards nodes, synovitis, calor, rubor, and there was no noted ankylosis of the digits. The Veteran's left hand position of function was normal with wrist dorsiflexion 20-30 degrees, MCP flexion about 30 degrees, PIP flexion about 30 degrees and the thumb pad faced the fingers. Grip strength testing demonstrated give-way (not true) weakness, and there were no noted scars or ulcerations. The Veteran had a negative Murphy's sign and grind test, without a boutonniere deformity. The Veteran's MPT joint movement was to 0 degrees extension and 90 degrees of flexion; PIP joint movement was to 0 degrees extension and 110 degrees flexion; and, DIP joint movement was to 0 degrees extension and 70 degrees of flexion. There was no evidence of pain, excessive fatigability, weakened movement, or incoordination on repetitive motion. The gap between the Veteran's thumb and fingers was 0 inches; the gap between the tip of his fingers and the proximal transverse crease of the palm was 0 inches; and, the gap between the thumb pad and fingers in opposition was 0 inches. X-rays of the Veteran's left hand demonstrated degenerative changes at the third distal IP joint, third MCP joint and first MCP joint, with metallic densities as noted in previous x-rays above. Analysis Again, the Veteran has been assigned a 10 percent evaluation under Diagnostic Code 5309, which instructs that the disability should be evaluated based on limitation of motion of the hand, and which specifically mandates a minimum 10 percent rating. Throughout the appeal period, there has been no demonstration of ankylosis, either favorable or unfavorable, of any digits of the left hand including the thumb. Likewise, there is no noted limitation of motion, even considering DeLuca factors. In fact, the Veteran had normal range of motion of the left hand at his most recent VA examination in August 2010, the only examination of record expressly addressing range of motion of the fingers. There was also no gap between the thumb pad and the fingers. Accordingly, there is no basis for a higher evaluation under either the pre- amended or revised regulations. The Board acknowledges a loss of grip strength, as well as weakness, in the left hand throughout the appeal period. Notably, the Veteran's left hand demonstrated mild atrophy at the June 1999 VA examination-the first time VA examined the left hand during the rating period on appeal. However, the Board concludes that the minimum 10 percent rating under Diagnostic Code 5309 contemplates the muscle weakness symptomatology demonstrated throughout the appeal period. The Board also recognizes the evidence of record demonstrating subjective complaints of left hand pain, as well as objective evidence of painful motion in the left hand. X-ray evidence from the appeal period demonstrates degenerative changes of the interphalangeal and metacarpal minor joint groups of the Veteran's left hand. Since the Veteran's left digits and thumb do not have a compensable limitation of motion under Diagnostic Codes 5216-5230, but x-ray evidence of arthritis and painful motion exists, the Board finds that a separate 10 percent evaluation under Diagnostic Code 5003 is warranted throughout the rating period on appeal. Such rating contemplates symptoms apart from the muscle atrophy deemed to be contemplated by the 10 percent evaluation already in effect. See Lichtenfels, supra; see also Esteban v. v. Brown, 6 Vet. App. 259 (1994) (in cases where separate and distinct manifestations have arisen from the same injury, separate disability ratings may be assigned where none of the symptomatology of the conditions overlaps). In this manner, assignment of a separate 10 percent rating for left hand arthritis does not violate the principles against pyramiding under 38 C.F.R. § 4.14. Accordingly, the Board finds that a separate 10 percent evaluation, in addition to the currently assigned 10 percent evaluation, is warranted for the arthritic symptomatology demonstrated during the appeal period. An evaluation in excess of 10 percent under Diagnostic Code 5309, however, is not warranted under either the pre-amended or revised regulations. Indeed, there is no showing of incapacitating episodes such as to enable a 20 percent rating under Diagnostic Code 5003. In reaching the above conclusions, the benefit of the doubt doctrine has been appropriately applied. See 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Wrist Claim In a November 1990 rating decision, the Veteran was granted service connection for his left wrist disability. A noncompensable evaluation was assigned, effective August 23, 1990. He filed his claim for increased rating for that disability on April 4, 1997. During the pendency of the Veteran's claim for increase, such disability was assigned a 10 percent evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5215. Under Diagnostic Code 5215, a 10 percent rating represents the maximum available benefit. Thus, the Veteran is in receipt of the maximum evaluation assignable for limitation of motion. Additionally, as the Veteran is already in receipt of a compensable rating pursuant to a range of motion diagnostic code, he is no longer entitled to an evaluation under Diagnostic Code 5003 for arthritis, as such only applies where the a range of motion based rating is noncompensable under the relevant code section for the affected body part. See 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5003 (2010); see also 38 C.F.R. § 4.14 (2010). Consequently, in order to warrant a higher rating under alternate Diagnostic Code 5214, the evidence must demonstrate favorable ankylosis (frozen joint) in 20 to 30 degrees of dorsiflexion; such warrants a 20 percent evaluation. Ankylosis in any other position other than favorable warrants a 30 percent evaluation. Unfavorable ankylosis of the wrist, in any degree of palmar flexion, or with ulnar or radial deviation, warrants a 40 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5214 (2010). The Board notes that Diagnostic Codes 5214 and 5215 have been in effect, without any changes, since the Veteran filed his claim for increase on April 4, 1997. VA treatment records throughout the appeal period fail to demonstrate any treatment for a left wrist injury associated with the Veteran's grenade fragmentation wounds. He did seek treatment for his left wrist following a slip-and-fall accident in February 2009. X-rays revealed no fracture at that time, though there was some noted swelling. No further treatment was sought following that incident. The Veteran underwent a VA examination of his left wrist in June 1999. The examiner noted shell fragment wounds on the left distal wrist area, and indicated that a fragment was removed from the left volar aspect of his left wrist during active duty. The Veteran reported aching pain, especially during cold exposure or weather change, as well as numbness of the dorsal aspect of his left arm. The examiner noted no gross edema, discoloration or any other deformity. On examination, there were several scars of the left wrist that were non-tender and non-keloid, and which were not adherent, depressed, or invigilated in appearance. The left wrist demonstrated 45 degrees of palmar flexion, 40 degrees of dorsiflexion, 45 degrees of ulnar deviation, and 15 degrees of radial degrees, with pain at all those points. There was no evidence of further loss of range of motion following repetition, or any incoordination or excessive fatigability. The Veteran underwent another VA examination in September 2003. At that time, he reported pain and loss of sensation when he lay on his left arm. Objectively, the Veteran had 40 degrees of palmar flexion, 35 degrees of dorsiflexion, 35 degrees of ulnar radiation, and 15 degrees of radial deviation. There was no evidence of pain on motion, incoordination, excessive fatigability, or further loss of motion with repetitive use. X- rays demonstrated a slight widening between the navicular and lunate, which was of debatable significance. Shell fragments were noted in the left hand. The Veteran underwent another VA examination of his left wrist in August 2010. He reported that he could function in all activities of daily activity, except that he has some trouble putting on his socks and shoes. He reported left wrist pain and has some weakness of hand grip when lifting heavy objects. He noted that some pain in his wrist was weather dependant, and was worse with wet, cold and rainy weather. The Veteran took over- the-counter medications for pain, though he often did not need them for several days. On examination, there was no calor, rubor or effusion of the left wrist, and Finkelsteins' test was negative. There was no noted tenderness at the intersection or at the snuff box. The Veteran also had a negative Tinels test, Phalens test and reverse Phalens test. There was no thenar, hypothenar or intrinsic muscle atrophy, nor was there any evidence of any ganglion cysts or radiocarpal tenderness. The Veteran had a negative Murphy's sign, grind test, and ulnar foveal sign, and did not have any boutonniere deformities. The left wrist had 45 degrees of dorsiflexion, 18 degrees of palmar flexion, and 15 degrees of radial deviation and ulnar deviation, after exercise; there was no evidence of further loss due to pain, excessive fatigability, weakened movement or incoordination. Based on the foregoing evidence, the Board finds that an increased evaluation for the Veteran's left wrist disability is not warranted. Specifically, there no indication of ankylosis at any time during the appeal period. Rather, the Veteran had significant range of motion of his left wrist throughout the appeal period. Such limitation of motion, particularly the significant decrease in palmar flexion demonstrated in the most recent VA examination, more closely approximates to palmar flexion limited in line with the forearm, which is commensurate with the currently assigned 10 percent rating under Diagnostic Code 5215. Given the range of motion findings throughout the appeal period, the Veteran's left wrist disability is not deemed to more nearly approximate an evaluation based on ankylosis. There are no other diagnostic codes for consideration here. Accordingly, the Board finds that an evaluation in excess of 10 percent for his left wrist disability is not warranted on the evidence of record and must be denied. See 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5214, 5215. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55- 56 (1990). Other Considerations The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2010). An extra- schedular evaluation is for consideration where a service- connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115- 116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluations are adequate. Evaluations in excess of those assigned provide for certain manifestations of the service-connected left hand and wrist disabilities, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's left hand and wrist disabilities. As the rating schedule is adequate to evaluate the disabilities, referral for extraschedular consideration is not in order. Finally, a remand is not necessary in this case in order to determine whether the Veteran is entitled to TDIU as such has already been granted and assigned, effective April 4, 1997. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER An initial evaluation in excess of 10 percent for residuals of grenade fragmentation wounds of the left hand is denied. A separate initial 10 percent evaluation for residuals of grenade fragmentation wounds of the left hand based on arthritis is granted. An evaluation in excess of 10 percent for residuals of grenade fragmentation wounds of the left wrist is denied. REMAND The Board notes that beginning in 1998, treatment records appear to demonstrate that the Veteran was seeing a private chiropractor for treatment for his lumbar spine disability. Subsequent treatment records, as well as the November 2006 VA examination report, indicate ongoing treatment for his back with a chiropractor throughout the appeal period. In January 2010, the Veteran was sent a letter which asked him to identify relevant treatment referable to the lumbar spine since December 2008. He responded in a November 2010 response that he had no further evidence. Despite the above, the Board finds that in order for VA to fully comply with its duty to assist the Veteran in the development of his increased evaluation for his lumbar spine disability, a remand is necessary in order to inform him of records potentially relevant to his claim and to obtain those records. Such has not been fully accomplished in this case because the January 2010 letter only asked for relevant records since December 2008, when records from the entire appeal period would be relevant to the Veteran's claim. Moreover, the possibility exists that the Veteran stopped seeing his chiropractor for treatment prior to December 2008. Moreover, the January 2010 letter did not specifically note that VA was aware of any private chiropractic treatment which was potentially relevant to the Veteran's lumbar spine claim, nor was any further attempt other than the single January 2010 letter generically requesting information on treatment history sent to the Veteran. Accordingly, on remand, the Veteran should be asked to provide information as to his private chiropractic treatment since April 1997. See 38 U.S.C.A. § 5103A(b) (West 2002); 38 C.F.R. § 3.159(c) (2010). Ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). Expedited handling is requested.) 1. Obtain any relevant outstanding VA treatment records since November 2009 from the Fargo VA Medical Center, or any other VA medical facility that the Veteran may have been treated at since that time, and associate them with the claims file. 2. The Veteran should be asked to identify any private treatment that he may have had for his lumbar spine disability, to include any private chiropractic treatment, since filing his claim in April 1997. After securing the necessary release forms, attempts to obtain and associate those identified records with the claims file should be made by VA. If VA is unable to obtain those identified records and further attempts would be futile, such should be noted in the claims file and the Veteran should be so notified so that he can make an attempt to obtain those records on his own behalf. 3. Following the above development, the RO/AMC should review the claims file and readjudicate the increased evaluation claim for his lumbar spine disability. If the benefits sought on appeal remain denied, the Veteran and his representative, if any, should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ ERIC S. LEBOFF Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs