Citation Nr: 1309107 Decision Date: 03/18/13 Archive Date: 03/25/13 DOCKET NO. 09-05 760 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for migraine headaches. 2. Entitlement to an initial compensable rating for residuals of a 3rd metacarpal fracture. REPRESENTATION Appellant represented by: Illinois Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant (the Veteran) ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the Appellant, served on active duty from April 2002 to March 2006. This case comes to the Board of Veterans' Appeals (Board) on appeal of a May 2007 rating decision of the Chicago, Illinois, Regional Office (RO) of the Department of Veterans Affairs (VA), which, in pertinent part, denied service connection for a low back disability and migraine headaches, and awarded a noncompensable rating for residuals of a 3rd metacarpal fracture. In April 2011, a travel board hearing was held before the undersigned in Chicago, Illinois. A transcript of the hearing is associated with the Veteran's claims file. In September 2011, the Board granted service connection for a low back disorder and remanded the issues of service connection for migraine headaches and an initial compensable rating for residuals of a 3rd metacarpal fracture so that additional VA compensation examinations could be arranged. The case has been returned to the Board for further appellate consideration. The issue of service connection for migraine headaches 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 hand dominant. 2. Throughout the appeal, the residuals of a fracture of the 3rd metacarpal have been manifested by pain and subjective decrease in strength, with full range of motion and no objective evidence of disability; the Veteran's grip strength is normal, he is able to approximate his finger to the proximal transverse crease of the palm, with no evidence that there is a gap of one inch between the fingertip and the transverse crease or that extension that the finger is limited by 30 degrees; additional functional limitation due to pain, fatigue, weakness, lack of endurance, and incoordination is not shown. CONCLUSION OF LAW The criteria for an initial compensable rating for the residuals of a 3rd metacarpal fracture have not been met for any period. 38 U.S.C.A. § 1155 (West 2002); C.F.R. § 4.71a, Diagnostic Code (Code) 5223 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between a veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Regarding the 3rd metacarpal fracture residuals, as the May 2007 rating decision on appeal granted service connection and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess 19 Vet. App. at 490. A January 2009 statement of the case (SOC) provided notice on the "downstream" issue of entitlement to an increased rating; while June 2009 and later supplemental SOCs (SSOC) readjudicated the matter after the Veteran and his representative responded and further development was completed. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. The Veteran has also been afforded VA medical examinations in connection with the claim, most recently in January 2012. 38 C.F.R. § 3.159(c) (4) (2012). The Board finds that the opinions obtained are adequate. The opinions were provided by qualified medical professionals and were predicated on a full reading of all available records. The examiner also provided a detailed rationale for the opinion rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the Veteran's representative has challenged the adequacy of the examination obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012). Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2012). Where there is a question as to which of two evaluations shall be applied, the higher rating 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 there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012). In this case, the Board has considered the entire period of initial rating claim from March 2006, the effective date of service connection, to see if the evidence warrants the assignment of different ratings for different periods of time during these claims, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). As a fact finder, the Board is obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F. 3d 1331, 1336-1337 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr 21 Vet. App. at 303 (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F. 3d at 1377. Also, a veteran as a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; the person is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Rating Residuals of a 3rd Metacarpal Fracture Service connection for the residuals of a metacarpal fracture of the right ring finger was granted by the RO in a May 2007 rating decision. The noncompensable (0 percent) initial disability rating was awarded under the provisions of Code 5223 from the date of claim in March 2006. (It is noted that Code 5223 applies to disability of two fingers. While the Veteran does have two fingers, the May 2007 rating decision that was appealed established service connection for only the residuals of a ring finger fracture. As the RO utilized Code 5223, the Board will do likewise.) Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board notes that the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention 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. The Board further notes that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the Diagnostic Codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). 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. As demonstrated by the medical evidence of record, the Veteran is right-handed and as such, major, as opposed to minor, finger disability ratings are applicable. 38 C.F.R. § 4.69. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Here, the RO assigned Code 5223. Code 5223 pertains to favorable ankylosis of two digits on one hand. However, as will be discussed below, the Veteran's finger disabilities are not characterized by ankylosis at any point during this appeal. An alternative Code that may be utilized includes Code 5230 for limitation of motion of the ring or little fingers. Code 5230 assigns a noncompensable rating for any limitation of motion of the ring or little finger regardless of whether it affects the major or minor hand. 38 C.F.R. § 4.71a, Diagnostic Code 5230. On December 2006 VA examination, the Veteran complained of pain involving the mid-area of the right hand that fluctuated on a daily basis. The pain was described as a deep aching sensation that became sharp with activity. He took an average of six Advil per day for pain. This provided some degree of relief. He did not experience flare-ups. He also experienced occasional numbness of all fingertips, excluding the thumb and occasional stiffness of the hand. On examination, grip strength was within normal limits. He could oppose the thumb to all digits. Fingertips touched the palmer crease. Grasping small and large objects were performed without difficulty and were not painful. Pushing or pulling maneuvers were not compromised. There was a deformity of the distal fourth metacarpal that was depressed. The area was nontender on the palmar surface. There was diffuse nonreproducible tenderness over the base of the third and fourth metacarpal dorsally. Range of motion of the ring finger was from 0 to 90 degrees at the metacarpalphalangeal, from 0 to 110 degrees at the proximalinterphalangeal, and 0 to 85 degrees at the distalinterphalangeal. The motions were painless. The Veteran was able to open and close his fist 10 times, which did not reproduce pain, affect remeasurement of range of motion, or decrease strength. X-ray studies of the right hand were consistent with an old fracture of the base of the third metacarpal. This remained visible suggesting a fibrous union/nonunion, but there was no carpal instability and no degenerative changes involving the joints. It was commented that, despite the Veteran's complaints of numbness, the examiner could not find evidence of median or ulnar nerve entrapment, nor was there any evidence of vascular impairment. The Veteran was again evaluated by VA in July 2009. At that time, it was noted that the Veteran's claims file had not been provided to the examiner for review. At that time, the Veteran stated that he did not have major complaints regarding his hand, just that it hurt when he used it often. He elaborated to say that this involved use of the hand for two to three minutes and related that he had pain the previous day on his second trip while carrying groceries. Lifting, pulling, or pushing something that weighed over 20 pounds caused a pain episode. He denied other symptoms such as numbness or weakness, but stated that if he wrote more than a few sentences, his hand would start to ache. He stated that he iced his hand from time to time and tried to use his left hand as much as possible. On examination, there were no gross anatomical defects appreciated, but there was a well-healed, non-adherent, 1.5 cm scar on the fifth distal of the 3rd metacarpal that the Veteran stated was from a childhood injury. There was also a depression deformity of the distal 4th metacarpal. There was no pseudo-clawing or extensor lag appreciated. The Veteran was able to approximate the tip of his thumb to all fingers and all fingers could approximate the palmar crease without difficulty or complaints of pain. Grip, pushing, pulling, strength, and dexterity were within normal limits. The Veteran had full extension of all fingers without complaints of pain. Grip was 5/5, without thenar atrophy. The wrists and metacarpalphalangeal joints were without abnormality or complaints of pain on palpation, except for complaints of tenderness over the base of the 3rd, 4th and 5th metacarpals, dorsally. There was no swelling, erythema, heat, or other abnormality appreciated. There was no guarding or apprehension during the examination. X-ray studies showed no acute fracture or dislocation and no degenerative or erosive changes seen. The diagnosis was remote history of right 3rd metacarpal fracture (healed). An examination was conducted pursuant to remand by the Board, in January 2012. At that time, the diagnosis was healed fracture of the 3rd metacarpal. The examiner noted that the Veteran's claims file had been reviewed. The Veteran's current symptoms were of intermittent ulnar sided hand pain that radiated up the medial aspect of the arm towards the elbow. This occurred three days per week, on average. He described the pain as being sharp in quality, with the intensity reaching 9/10. The painful episodes were precipitated by increased use of the extremity. The pain resolved with 10 minutes of rest. It was associated with paresthesia. The Veteran also stated that he had occasional nocturnal wakening with numbness of the hand. He took over-the-counter Nsaids such as Advil, with some improvement. He also used an over-the-counter wrist splint two days per week on average, with some improvement. His activities of daily living were mildly compromised with difficulty dressing during painful episodes. Specific criteria for evaluation showed that the Veteran had no limitation of motion of the fingers or thumb. He was able to oppose the thumb without a gap between the thumb pad and any of the fingers. There was no objective evidence of painful motion. There was no gap between any of the fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips. There was no limitation of extension of any of the fingers. The Veteran was able to perform repetitive use testing without additional limitation of motion for any finger. There was no functional loss for the right hand, thumb, or fingers. There was no pain or tenderness to palpation for the joints of the right hand. Muscle strength was 5/5. There was no ankylosis of the thumb or fingers. On examination, there was a mild depression of the 3rd metacarpal that was of no clinical significance. There was no tenderness, soft tissue swelling, inflammation; there was no thenar or hypo-thenar muscle atrophy. Two-point discrimination was intact in the fingers and thumb. Grip strength was 5/5. The Veteran was able to oppose the thumb to all digits and the fully flexed fingers approached the mid-palmar crease without extensor lag. The Veteran was able to grasp and manipulate small and large objects without difficulty and range of motion of the thumb and fingers were full and pain-free. Vascular examination was unremarkable. Tinel sign was negative over the ulnar nerve at the wrist and elbow. X-ray studies of the hand showed no appreciable degenerative changes. The fracture site could no longer be identified. There could have been some mild residual volar angulation of the 3rd metacarpal that was difficult to evaluate and of no clinical significance. There was no functional impact on the Veteran's ability to work. The examiner concluded that the Veteran's metacarpal fracture had healed with acceptable alignment. It was difficult to explain the Veteran's symptoms of pain and numbness on the basis of the 3rd metacarpal fracture, with the Veteran's symptoms being suggestive of an ulnar nerve entrapment syndrome that would not be related to the metacarpal fracture. The examiner concluded that there was no ankylosis, no limitation of motion, no compromise of grip strength, and painless range of motion. Based on the evidence of record, the Board finds that compensable disability rating for the residuals of a fracture of the 3rd metacarpal is not warranted. As outlined above, a noncompensable disability evaluation represents the maximum schedular rating available for limitation of motion of the ring or little finger under Code 5230. Consequently, the Veteran is not entitled to an increased evaluation for any limitation of motion in the left ring finger, or the ring and little fingers of the right hand under this code. In order for the Veteran to receive a 10 percent disability rating, he has to show a gap between the fingertip and the proximal transverse crease of the palm, or limitation of extension. Here, the objective findings of the VA examinations indicated that these requirements were not met. In fact, range of motion on all examinations was normal, with no gap. Code 5227, which evaluates unfavorable or favorable ankylosis of the ring or little fingers, also only provides for a noncompensable evaluation. 38 C.F.R. § 4.71a, Code 5227. Therefore, even if ankylosis were shown, which it is not on any examination report, a higher disability rating could not be assigned under that code. A compensable rating for ring or little finger disabilities may also be assigned for amputation. See 38 C.F.R. § 4.71a, Codes 5155 and 5156. Ankylosis may also be rated as amputation, but in order for ankylosis to be rated as amputation, the condition must manifest with extremely unfavorable ankylosis. See Note (3)(i) preceding 38 C.F.R. § 4.71a, Code 5216. In other words, in order to be evaluated as amputation, there must be ankylosis of both the metacarpophalangeal and proximal interphalangeal joints either in extension or full flexion or with rotation or angulation of a bone. Id. Note (3)(ii) explains that, if both the metacarpophalangeal and proximal interphalangeal joints of a digit were ankylosed, it should be evaluated as unfavorable ankylosis even if each joint was individually fixed in a favorable position. Note (3)(iii) indicates that if only the metacarpophalangeal or proximal interphalangeal joint were ankylosed and there was a gap of more than 2 inches (5.1 cm.) between the fingertips and the proximal transverse crease of the palm, with the fingers flexed to the extent possible, the condition should be evaluated as unfavorable ankylosis. Amputation of the ring and little fingers warrant a 10 percent rating without metacarpal resection at the proximal interphalangeal joint, or proximal thereto. A 20 percent rating is warranted with full metacarpal resection (more than one-half the bone lost). 38 C.F.R. § 4.71a, Codes 5155 and 5156. The governing criteria provide for a compensable rating for the type of disability for which the Veteran has been service connected only where there is amputation of the finger or equivalent impairment (e.g., extremely unfavorable ankylosis as in the Note cited above). In this case, the Veteran's finger disability is not characterized by either ankylosis or amputation at any point during this appeal. Significantly, the Veteran has never been noted to have ankylosis in any of his fingers and has not alleged that there is ankylosis. As extremely unfavorable ankylosis is not shown, a compensable rating is not warranted. The Board has considered whether compensable disability ratings are warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran has complained of pain during his three VA compensation examinations and of numbness on two of three of the compensation examinations. Functional loss due to pain is rated at the same level as functional loss where motion is impeded. See Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). Here, though, despite the Veteran's complaints of pain, the VA examiners stated the range of motion was normal. As such, the noncompensable rating under Codes 5229 or 5230 remain warranted. Although pain may cause functional loss, pain itself does not constitute functional loss. Mitchell, 25 Vet. App. at 33, 43. Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. In the instant case, the VA compensation examiners were in agreement that the Veteran does not have additional functional impairment, including additional limitation of motion, on account of his pain, stiffness, and cold sensitivity. In considering other potentially applicable codes that would allow for a compensable rating, the Board finds that Diagnostic Code 5216 pertaining to impairment of the nerves is not applicable in this claim because the medical evidence does not show that the Veteran has any neurological disorder. Specifically, despite the Veteran's complaints of decreased grip strength and nerve pain in the ulnar distribution, the examiner in January 2012 specifically stated that there was no ulnar nerve involvement as a result of the 3rd metacarpal fracture. Therefore, a compensable rating under Diagnostic Code 5216 is not warranted. The Board has also considered the Veteran's statements with regard to the severity of his finger disability and any associated symptoms. As noted, he is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing chronic pain or discomfort in his fingers. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran has provided lay evidence with respect to the presence of pain and numbness, and the severity of such during his VA examinations and during his April 2011 Board hearing. He is competent to provide such statements, and the Board finds that the Veteran's statements are credible. The Veteran's reported symptomatology has been noted in the rating decisions above, and the Board has considered the Veteran's reports with respect to pain and numbness in evaluating his assigned rating. With respect to the Rating Schedule, the criteria set forth therein generally require medical expertise where the types of findings required are not readily observable by a lay person, which includes whether the Veteran's symptoms result in functional impairment. Therefore, the objective medical findings provided by the Veteran's VA examination reports have been accorded greater probative weight where applicable. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) ("[t]he probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches . . . the credibility and weight to be attached to these opinions [are] within the province of the adjudicator."). Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 extra-schedular rating. Id. The symptoms associated with the Veteran's finger disabilities, as described above, are not shown to cause any impairment that is not already contemplated by the rating criteria, and the Board finds that the rating criteria reasonably describe his disabilities. His complaints of pain and numbness associated with his finger disabilities are contemplated by the schedular rating criteria of Codes 5229 and 5230. Therefore, the Board need not proceed to consider the second factor, whether there are related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009), the Court held that when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a total disability rating based on individual unemployability (TDIU) will be considered "part and parcel" of the claim for benefits for the underlying disability. In the instant case, the Veteran has not contended, nor does the evidence demonstrate, that he is not unemployable as a result of his service-connected disabilities. Therefore, the Board finds that a claim for TDIU is not raised by the Veteran or reasonably raised by the record and, as such, need not be further addressed. In sum, as the preponderance of the evidence is against the claims for increased ratings, the benefit-of-the-doubt rule does not apply, and the claims must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial compensable rating for residuals of a 3rd metacarpal fracture is denied. REMAND As noted, the claim of service connection for migraine headaches was previously remanded by the Board for a VA compensation examination. This was undertaken in January 2012 when the Veteran was evaluated for migraine headaches and for traumatic brain injury (TBI) residuals. The initial examination, for migraine headaches included an opinion that it was at least as likely as not that the Veteran's migraine headaches were incurred in or caused by a claimed in-service injury. The rationale provided was that the Veteran had subjectively stated that he had sustained a head trauma while stationed in Israel in 2004 and that the headaches had started after this incident, the records of which were noted to have been lost. The examiner then referred to the TBI examination that was to be conducted. The TBI examination was performed the following day, with the examiner stating that it would be resorting to mere speculation to say that the Veteran's claim of migraine headaches started after his head trauma. The rationale provided was that the Veteran had given inconsistent reports of the onset of his migraine headaches, indicating that they had started while he was in Germany in 2003, after sustaining head injury in Israel in2004, and in 2005. That examination report also included a reference that the Veteran did not have subjective symptoms such as migraine headaches, a statement that is inconsistent with the Veteran's contentions for service connection for this disorder. The Board has reviewed the record and found two instances of head trauma while the Veteran was on active duty. In May 2002 he sustained a laceration of the top of his head when he hit a television. In April 2005, he sustained a face laceration while attempting to break up a fight. His original claim of service connection dated the onset of his migraines to May 2002. He has also advanced contentions that the onset was in Germany in February or in September 2003; while in Israel in 2004; and during his Board hearing in April 2011, in 2005. As the January 2012 VA examinations are not consistent and based, in part, on the incorrect history that the Veteran did not have a documented head trauma during service and did not have current complaints of migraine headaches, the Board finds that an additional examination must be undertaken. Cousino v. Derwinski, 1 Vet. App. 536 (1991) (Where there is a wide diversity of medical opinion, an additional examination should be performed.) Under these circumstances the matter needs to be remanded for additional development. Accordingly, the issue of service connection for migraine headaches is REMANDED for the following action: 1. The RO/AMC should arrange for the Veteran's claims folder to be reviewed by the VA examiners who completed the January 2012 VA evaluations for a supplemental opinion. The examiners should be requested to render opinions regarding whether the Veteran's migraine headaches are at least as likely as not (probability 50% or more) related to head traumas sustained during service, including documented head trauma in May 2002 and April 2005. The examiners should provide complete rationale for all conclusions reached. If the VA examiners are not available, the Veteran's claims folder should be evaluated by another VA examiner so that the requested opinion may be obtained. 2. Thereafter, the RO/AMC should readjudicate the issue on appeal. If the determination remains unfavorable to the appellant, he and his representative should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claim. The appellant should be given an opportunity to respond to the SSOC prior to returning the case to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2012). 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. 2012). ______________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs