Citation Nr: 1310345 Decision Date: 03/27/13 Archive Date: 04/09/13 DOCKET NO. 09-05 779 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a rating in excess of 10 percent for residuals of a right wrist fracture of the navicular bone with degenerative changes. 2. Entitlement to a rating in excess of 10 percent for chronic right ankle sprain. 3. Entitlement to service connection for a back disability. 4. Entitlement to service connection for a right knee disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Andrew Mack, Counsel INTRODUCTION The Veteran had active service from May 1978 to July 1981. He also had active duty for training in the National Guard from May 1977 to September 1977. These matters come before the Board of Veterans' Appeals (Board) from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. They were before the Board in July 2012, were then remanded for further development, and have been returned for further appellate consideration. In August 2007, the Veteran raised the issue of entitlement to a total disability rating for individual unemployablity due to service-connected disabilities (TDIU). See Rice v. Shinseki, 22 Vet. App. 447, 453-454 (2009). However, in the July 2008 rating decision, the RO denied the TDIU claim, and the matter was not appealed by the Veteran. Therefore, the issue of entitlement to a TDIU is not currently on appeal and will not be further addressed in this decision. In July 2012, January 2013, and February 2013 the Veteran submitted additional evidence directly to the Board. However, the Veteran has submitted a written waiver of initial RO consideration of the evidence, and it is therefore accepted for inclusion in the record on appeal. See 38 C.F.R. §§ 20.800, 20.1304 (2012). The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issue of entitlement to service connection for neurologic disability of the right hand, to include as secondary to the Veteran's service-connected residuals of a right wrist fracture of the navicular bone with degenerative changes, has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and, while the Board addresses the Veteran's orthopedic wrist disability below, it will not address any such neurologic disability in this decision, and the matter is referred to the AOJ for appropriate action. The issues of entitlement to service connection for a back disability and a right knee disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. During the period pertinent to the Veteran's August 2007 claim for an increased rating, his orthopedic right wrist disability has been primarily manifested by pain, limitation of motion, tenderness, occasional edema, stiffness, some weakness, and periods of flare-ups; such disability has resulted in functional impairment such as difficulty lifting, grabbing, carrying, and performing certain types of work with his right hand, and has required a wrist brace; the disability has not approximated ankylosis of the right wrist. 2. During the period pertinent to the Veteran's December 2007 claim for an increased rating, his chronic right ankle sprain disability has been manifested by pain, weakness, limitation of motion, and stiffness, with flare-ups, affecting his ability to stand, walk, and climb; it has not approximated marked limitation of ankle motion. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for residuals of a right wrist fracture of the navicular bone with degenerative changes have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.2, 4.6, 4.21, 4.20, 4.27, 4.40, 4.45, 4.59, 4.71, 4.71a, Plate I, Diagnostic Codes 5214-5215 (2012). 2. The criteria for a rating in excess of 10 percent for chronic right ankle sprain have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.2, 4.6, 4.21, 4.40, 4.45, 4.59, 4.71, 4.71a, Plate II, Diagnostic Codes 5270-5274, 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist After review of the claims file, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions in this case with respect to the issues herein decided. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The information contained in October 2007 and April 2008 letters satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Moreover, the Veteran was notified of regulations pertinent to the establishment of an effective date and disability rating in the October 2007 and April 2008 letters. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records, VA medical treatment records, identified private medical records, VA vocational rehabilitation records, Social Security Administration (SSA) records, and lay statements submitted on the Veteran's behalf have been obtained. Also, the Veteran was provided VA examinations in December 2007, April 2008, and January 2011. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2012). These examinations were adequate because, along with the other evidence of record, they provided sufficient information to decide the appeal, and were based on examination of the Veteran and a review of the relevant medical records and the claims file by examiners with appropriate expertise. 38 C.F.R. § 3.159(c)(4) (2012); Barr v Nicholson, 21 Vet. App. 303 (2007). The Veteran's most recent VA examination of his disabilities was in January 2011, and when a veteran claims that his condition is worse than when originally rated, and the available evidence is too old for an adequate evaluation of the veteran's current condition, VA's duty to assist includes providing a new examination. See Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993). While a new examination is not required simply because of the time that has passed since the last examination, VA's General Counsel has indicated that a new examination is appropriate when there is an assertion of an increase in severity since the last examination or other evidence of worsening. VAOPGCPREC 11-95 (1995). However, in this case, the record does not reflect, and the Veteran has not asserted, that his symptoms have worsened since his January 2011 VA examination. While the Veteran was provided private evaluations in May 2011 and September 2012, neither the reports of these evaluations nor any other record establishes that either of the Veteran's disabilities has worsened since his January 2011 VA examination. Therefore, the Board finds that remand for a new examination is not warranted in this case. Moreover, the RO has substantially complied with the Board's July 2012 remand instructions with respect to the disabilities herein decided. The Veteran's SSA records and vocational rehabilitation file have been obtained and associated with the claims file. Under these circumstances, the Board finds that there has been substantial compliance with the July 2012 remand instructions, and an additional remand to comply with the Board's directives is not required. See D'Aries v. Peake, 22 Vet. App. 97, 104-106 (2008); Stegall v. West, 11 Vet. App. 268 (1998). There is no indication in the record that any additional evidence relevant to the issues herein decided is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. All of the evidence in the Veteran's claims file has been thoroughly reviewed. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence, and on what the evidence shows or fails to show with respect to the matters decided. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). II. Analysis Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In all claims for increase, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's residuals of a right wrist fracture of the navicular bone with degenerative changes is currently rated under Diagnostic Code (DC) 5010-5215, and are thus rated by analogy under the criteria for limitation of motion of the wrist. See 38 C.F.R. §§ 4.20, 4.27, 4.71a, DC 5215. The record reflects that the Veteran is right-hand dominant. Under DC 5215, limitation of motion of both the minor and major wrists warrants a 10 percent rating for dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm. 38 C.F.R. § 4.71a, DC 5215. Higher ratings are available where there is ankylosis of the wrist. See 38 C.F.R. § 4.71a, DC 5214. Normal range of motion for the wrist is 70 degrees dorsiflexion (extension), 80 degrees palmar flexion, 45 degrees ulnar deviation, and 20 degrees radial deviation. 38 C.F.R. § 4.71, Plate I. The Veteran's chronic right ankle sprain is rated under DC 5271, which provides ratings based on limitation of extension of the ankle. Moderate limitation of motion of the ankle is rated as 10 percent disabling; and marked limitation of motion of the ankle is rated as 20 percent disabling. 38 C.F.R. § 4.71a, DC 5271. Higher ratings than 20 percent are available where there is ankylosis of the ankle. See 38 C.F.R. § 4.71a, DC 5270. Normal ranges of motion of the ankle are dorsiflexion from 0 degrees to 20 degrees, and plantar flexion from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. The words "slight," "moderate" and "severe," as used in the various diagnostic codes, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to ensure that its decisions are "equitable and just." 38 C.F.R. § 4.6. The Board also notes that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of the Board's determination of an issue. The Board evaluates all evidence in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. In addition, when evaluating joint disabilities rated on the basis of limitation of motion, VA may 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, 204-07 (1995). In this case, as reflected in his August 2007 claim for increase for his right wrist disability, the Veteran contends that his wrist disability has gotten worse, and that weakness in his right wrist affected his work as a cook. The Veteran asserted that his wrist would get weak and swollen and locked up, so that he would drop pans of food. Also, as reflected in December 2007 claim for increase for his right ankle disability and in a January 2012 statement, he contends that his right ankle has been a serious employment handicap since the time it was service-connected and should be rated higher. VA treatment records reflect that in August 2007, the Veteran reported that he could no longer work in food service due to fatigue and poor function in the right hand. In September 2007, he requested a new ankle support and new right wrist brace. On a Daily Activity Questionnaire for Disability Determination Services in June 2007, the Veteran stated that, because of his right wrist condition, he was unable to write or hold an object for an extended period, and that his right wrist and right ankle caused him problems standing, walking, lifting, using his hands, climbing, and driving, and performing housework, yard work, and personal care. The report of an August 2007 private evaluation reflects that the Veteran reported right ankle and right wrist pain and weakness, and that he could not work without his right hand swelling, and would have to stop working due to hand pain and wrist pain every few months. On examination, right wrist flexion was 75 percent normal and painful to execute, and his right wrist was tender over the anatomical snuffbox area. There was pain with dorsiflexion and plantar flexion of the right ankle. The initial assessment was right wrist pain suggestive of scaphoid bone fracture in 1979 with non-union which may have progressed to osteoarthritis, and right ankle pain and reduced flexion and extension with suspected osteoarthritis. X-rays of the right wrist revealed degenerative joint disease of the radiocarpal and intercarpal joint seen, with subchondral cysts present. The report of a December 2007 VA wrist examination reflects that the Veteran reported that he was unable to attend culinary school due to his disability, and that he had a weak right hand grip and always wore a wrist brace. The Veteran reported no giving way or instability of the right wrist, but pain, stiffness, and weakness, locking, and effusion and swelling. He also reported severe flare-ups weekly, at which times he could not shave, bathe, cook, or complete personal care. On physical examination, the Veteran had 20 degrees of ulnar and radial deviation active against gravity, with passive range of motion the same, and range of motion against strong resistance of 10 degrees. Pain began and ended at 10 degrees, with no additional loss of motion on repetitive use. The Veteran had 0 to 30 degrees of active dorsiflexion against gravity, passive dorsiflexion to 40 degrees, and dorsiflexion to 20 degrees with strong resistance, and no additional loss of motion on repetitive use. Palmar flexion against gravity was from 0 to 45 degrees active and 0 to 50 passive. Palmar flexion against strong resistance was from 0 to 25 degrees, with no additional loss of motion on repetitive use. There was noted to be no loss of bone or part of a bone, no inflammatory arthritis, and no joint ankylosis. The Veteran was noted to have had crepitus, tenderness, painful movement, and weakness of the right wrist. X-rays reflected degenerative cystic changes in the carpal bones. The report of an April 2008 VA examination reflects that the Veteran reported that his right ankle stiffened and gave out, which caused him to fall, and that his right ankle felt numb. He further reported that he stumbled frequently when he worked due to his right ankle giving out. It was noted that there was no history of hospitalization or surgery. On examination, there was noted to be pain affecting both ankles and the right wrist, with flare-ups every two to three weeks lasting for hours, of moderate severity reported. He reported decrease in strength and dexterity of the right hand, as well as pain and flare-ups, at which time he could not shave, bathe, eat or dress. On physical examination, gait was antalgic, motor strength was full in the bilateral upper extremities, and 4/5 in the bilateral lower extremities. There was no joint swelling, effusion, tenderness, laxity, or ankylosis. There was also no evidence of inflammatory arthritis or other objective joint abnormalities. Right ankle motion revealed dorsiflexion of 0 to 20 degrees and plantar flexion of 0 to 30 degrees, with no limitation of motion noted after repetitive use, and no pain on motion. The right wrist had dorsiflexion of 0 to 60 degrees, palmar flexion of 0 to 45 degrees, and ulnar deviation from 0 to 25 degrees with no limitation of motion after repetitive use noted and no pain on motion. X-rays of the wrists revealed degenerative cystic changes in the carpal bones. The report of an April 2008 VA examination of the right ankle reflects that the Veteran reported not being able to stand three hours or more, that he was unable to walk more than a few yards, and that his right ankle had instability, stiffness, weakness, effusion, inflammation, with moderate weekly flare-ups. On physical examination, gait was antalgic, dorsiflexion was 0 to 20 degrees against gravity passive and active with no additional limitation of motion on repetitive use; plantar flexion was from 0 to 20 degrees active and passive with no limitation of motion on repetitive use. There was no joint ankylosis, no objective abnormalities, no ankle instability, and no tendon abnormality. The diagnosis was chronic right ankle strain. A statement received in May 2008 from the Veteran's friend, L.M., reflects that L.M. witnessed the Veteran's pain and aches, that such pain was severe and that it was hard for him to get out of bed due to his back, right knee and ankle pain. L.M. further stated that his ankle sometimes gave out so that he fell back on the bed. In a May 2008 statement, the Veteran asserted that his right hand and wrist pain and right ankle pain contributed in preventing him from living an independent life. The report of a January 2011 VA examination reflects that the Veteran stated that since the April 2008 VA examination, he had had constant right ankle pain, and that at his age it was becoming difficult to be mobile and do things like take the trash out. There was no history of hospitalization or surgery. The Veteran reported right wrist deformity, instability, pain, stiffness, weakness, incoordination, but no episodes of locking, effusion, or giving out. He reported warmth, redness, swelling and tenderness of the joint with weekly severe flare-ups of one to two days duration, during which he cannot cook, clean, complete personal hygiene habits or tie his shoes. He also reported right ankle deformity, giving way, instability, stiffness, weakness, incoordination, decreased speed of motion, but no dislocation, subluxation, locking episodes, or effusion. He reported warmth, redness, swelling, and tenderness of the joint with severe weekly flare-ups lasting one to two days during which he could not walk, stand, or sit for prolonged periods of time, had to be in a reclining position, and had to elevate his ankle. He further reported using a cane and brace. On physical examination, gait was normal, there was no abnormal weight bearing, loss of bone, or inflammatory arthritis. The right ankle had tenderness but no instability, tendon abnormality, or angulation. The right wrist had edema and tenderness. Range of motion with active motion showed pain with right wrist motion and right dorsiflexion from 0 to 45 degrees, right palmar flexion from 0 to 50 degrees, right radial deviation from 0 to 25 degrees, and right ulnar deviation of 0 to 20 degrees, with objective evidence of pain following repetitive motion but no additional limitations after three repetitions of range of motion. There was no objective evidence of pain with active motion of the right ankle, and dorsiflexion was from 0 to 15 degrees and plantar flexion was from 0 to 20 degrees. There was no joint ankylosis or objective evidence of pain following repetitive motion, or additional limitations after three repetitions of range of motion. Right wrist X-rays showed degenerative cystic changes in the carpel bones, and right ankle X-rays showed no bone, joint, or soft tissue abnormality identified. The Veteran reported that he last worked in 2004 as a line cook but had to quit working at the time as he could not stand for a four-hour period, could not trust his grip and dropped things frequently, and stumbled over his own feet due to the right ankle giving out. He also reported not being able work every day. It was noted that the Veteran's disabilities prevented sports, had moderate effects on chores, shopping, and exercise, and had mild effects on recreation, travelling, bathing, dressing, toileting, and grooming. A May 2011 SSA evaluation report reflects that the Veteran complained of wrist and ankle pain, right wrist redness and swelling, and his right ankle giving way and being unstable, stiff, and weak. It was noted that the Veteran used a cane and a brace on his wrist, that his gait was normal, that X-ray of the right wrist showed degenerative cystic changes in the carpal bones, and that X-ray of the right ankle showed no abnormality. His diagnoses were right ankle sprain and right wrist degenerative joint disease. The report of a September 2012 private evaluation in connection with a claim for SSA disability benefits reflects that the Veteran reported difficulty with repetitive activities involving his right hand such as grabbing, handling, and lifting, which affected his ability to work. He also reported chronic shooting pain, stiffness, and swelling in the right ankle exacerbated by standing and physical activity. He further reported functional limitations from his service-connected and nonservice-connected disabilities of standing four to six hours, walking one-half of a block, and lifting and carrying 10 pounds frequently and 20 pounds occasionally due to arthritic pain and carpal tunnel syndrome. It was noted that the Veteran had an asymmetric, slow, antalgic, and limping gait, and that he used a cane and could not walk around the examination room without it. Muscle strength for right wrist flexion and extension and hand strength, as well as for right ankle planter flexion and dorsiflexion, was full. The Veteran was able to lift, carry, and handle light objects. Range of motion was noted to have been within normal limits in the wrists and ankles. The Veteran submitted a statement in January 2013 from a neighbor, C.W., who stated that she met the Veteran in January 2007 and was his neighbor in the year 2009, and that she and her husband had been witness to the Veteran's physical pain that would leave him unable to do anything for days at a time. She stated that the Veteran has always had his cane due to severe back pain, and that she and her husband would help the Veteran buy groceries and cook dinner. Considering the pertinent evidence in light of the governing legal authority, the Board finds that a higher rating for both the Veteran's right wrist disability and his right ankle disability must be denied. The record reflects that, during the period pertinent to the Veteran's August 2007 claim for an increased rating, the Veteran's right wrist orthopedic disability has been primarily manifested by pain, limitation of motion, tenderness, occasional edema, stiffness, some weakness, and periods of flare-ups. Such disability has resulted in functional impairment such as difficulty lifting, grabbing, carrying, and performing certain types of work with his right hand, and has required a wrist brace. However, while painful motion of the wrist has been repeatedly noted, the most to which the Veteran's right wrist motion has ever been noted to be limited is from 0 to 30 degrees of active dorsiflexion, and active palmar flexion from 0 to 45 degrees, with no additional loss of motion on repetitive use, which is significantly greater motion that even dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm, which are the criteria for a 10 percent rating under DC 5215. Ankylosis of the right wrist has repeatedly been noted not to be present. Even considering any additional functional loss due to pain, weakness, excess fatigability, incoordination, or other such factors, given the objective medical evidence, the Veteran's right wrist disability more closely approximates dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm than ankylosis of the wrist. Therefore, the Veteran's right wrist disability more closely approximates the criteria for a 10 percent rating than those for a higher rating under the applicable rating criteria. The Veteran has asserted symptoms such as right wrist deformity and instability, and severe flare-ups preventing him from being able to shave, bathe, cook, eat, complete personal care, clean, or tie his shoes. While such problems as pain and limited motion, as well as functional impairment related to the Veteran's ability to lift, carry, or otherwise bend or use his wrist, are consistent with the medical findings of record, even considering such symptoms and functional impairment, the Board finds that the Veteran's right wrist disability more closely approximates dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm than ankylosis of the wrist, given the record as a whole, including the range of motion findings noted above. Moreover, while the Veteran has reported joint instability and deformity, and while degenerative joint disease has consistently been found on X-ray examination, he has consistently been found not to have instability or deformity of the right wrist joint, and there are no medical findings indicating that, or explanations by the Veteran of how, his wrist disability prevented such basic activities as bathing, eating, tying his shoes, or attending to personal hygiene. Again, as discussed in the introduction above, any neurological disability involving the hand that might be secondary to the Veteran's right wrist disability is not being considered in this decision, and has been referred to the AOJ for appropriate action. Regarding the Veteran's right ankle disability, during the period pertinent to the Veteran's December 2007 claim for an increased rating, the record reflects that such disability has been manifested by pain, weakness, limitation of motion, and stiffness, with flare-ups, affecting his ability to stand, walk, and climb. The most to which the Veteran's right ankle motion has been noted to be limited was on January 2011 VA examination, at which time it was noted that there was no objective evidence of pain with active motion of the right ankle, and dorsiflexion was from 0 to 15 degrees and plantar flexion was from 0 to 20 degrees. There was no joint ankylosis or objective evidence of pain following repetitive motion, or additional limitations after three repetitions of range of motion. While the Veteran's plantar flexion at the time of this examination revealed less than half of the normal range, the Board nonetheless finds that the Veteran's right ankle disability has more closely approximated moderate limitation of ankle motion than marked limitation. Even during this examination, the Veteran's right dorsiflexion was noted to have been from 0 to 15 degrees, out of a full 20 degrees, and it was noted that there was no objective evidence of pain with active motion of the right ankle. Furthermore, the report of the September 2012 private evaluation in connection with a claim for SSA disability benefits reflects findings of full muscle strength for right ankle planter flexion and dorsiflexion and range of motion within normal limits in the ankles. Thus, even considering all additional functional loss due to pain, weakness, or other such factors, in light of the record as a whole, the Board finds that the Veteran's right ankle disability has more closely approximated moderate limitation of ankle motion than marked limitation. The Veteran has asserted symptoms such as right ankle instability, deformity, and giving way, and reported that such symptoms had caused his ankle to give out, causing him to fall. The Veteran has also reported severe weekly flare-ups lasting one to two days during which he could not walk, stand, or sit for prolonged periods of time, had to be in a reclining position, and had to elevate his ankle. Also, the May 2008 statement from L.M. reflects that L.M. witnessed the Veteran's pain and aches, that such pain was severe and that it was hard for him to get out of bed due to his back, right knee, and ankle pain, and that his ankle sometimes gave out so that he fell back on the bed. However, while medical evidence is consistent with such problems as pain and limited motion and functional impairment related to the Veteran's ability to perform tasks such as extensive walking or standing, the medical findings of record are not consistent with the Veteran's assertions of such severe symptomatology as instability, deformity, frequent giving out of the ankle, or severe weekly flare-ups lasting one to two days during which he cannot walk, stand, or sit for prolonged periods of time, and has to be in a reclining position and elevate his ankle. The medical evidence has consistently revealed no laxity, instability, tendon abnormality, or effusion, and X-rays have consistently shown no bone, joint, soft tissue, or other abnormality. The Veteran and L.M. are competent to report matters within their own personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, to the extent that the Veteran or L.M. report symptoms or functional impairment not consistent with the medical evidence specifically relating to the severity of the Veteran's right ankle condition, the Board finds such assertions not to be credible. The Board has considered DCs 5270, 5272, 5273, and 5274. However, the record does not reflect, and the Veteran has not contended, that any time during the appeal period there has been ankylosis of the ankle, ankylosis of the subastragalar or tarsal joint, malunion of os calcis or astragalus, or astragalectomy. See 38 C.F.R. § 4.71a, DCs 5270, 5272, 5273, and 5274. Furthermore, the Board has considered the criteria for DC 5284 for foot injuries, other, but finds that such rating criteria are not applicable. The Veteran's disability of chronic right ankle sprain is most accurately rated as disability of the ankle rather than disability of the foot. Also, the Veteran's current right ankle disability has been manifested primarily by pain, weakness, stiffness, and some flare-ups, affecting his ability to stand, walk, and climb, and approximates "moderate" limitation of motion. The Board finds that such disability would not approximate "moderately severe" foot injury more closely than "moderate" foot injury. See 38 C.F.R. § 4.71a, DC 5284. The Board has also considered the applicability of other diagnostic codes for rating the Veteran's disabilities, but finds that no other diagnostic code provides a basis for higher rating. The rating codes discussed above specifically pertain to orthopedic disability of the wrist and ankle. Neither of the Veteran's disabilities has been shown to involve any factors that warrant evaluation under any other provision of VA's rating schedule. The Board has further considered the January 2013 statement from C.W. indicating that she and her husband had been witness to the Veteran's physical pain that would leave him unable to do anything for days at a time, that the Veteran has always had his cane due to severe back pain, and that she and her husband would help the Veteran buy groceries and cook dinner. However, the statement only refers to the Veteran's physical pain generally, and the only body part mentioned in the statement is the Veteran's back. As the Veteran's right wrist and right ankle are not even noted in the statement, the Board finds it to be of little probative value in evaluating the severity of the Veteran's right wrist and right ankle conditions. Also, this case should not be referred to the Director of the VA Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 3.321(b). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, which involves 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. 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. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The Veteran has asserted that his disabilities have significantly affected his ability to work, particularly in his job as a cook. He has asserted that his wrist gets weak, swollen, and locked up, so that he dropped pans of food and has been forced to stop working every few months due to hand pain, and that he stumbled frequently when he worked due to his right ankle giving out. The Board recognizes that the Veteran's disabilities have been productive of functional impairment. The assigned rating of 10 percent for each reflects that each disability is productive of impairment in earning capacity. However, the record does not reflect that the average industrial impairment from his disabilities would be in excess of that contemplated by either assigned rating. The Veteran's right wrist disability has been primarily manifested by pain, limitation of motion, tenderness, occasional edema, stiffness, some weakness, and periods of flare-ups, and such disability has resulted in functional impairment such as difficulty lifting, grabbing, carrying, and performing certain types of work with his hand, and has required a wrist brace. However, such manifestations are reasonably contemplated by the schedular criteria for a 10 percent rating under DC 5215, which contemplates wrist disability of the nature and severity of disability producing limitation of wrist dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm. The record does not reflect that the Veteran's wrist disability has caused impairment in earning capacity above what would be average for such disability. The Veteran's right ankle disability has been primarily manifested by pain, weakness, limitation of motion, and stiffness, with flare-ups, affecting his ability to stand, walk, and climb. However, such manifestations are reasonably contemplated by the schedular criteria for a 10 percent rating under DC 5271, which contemplates ankle disability of the nature and severity of moderate limitation of ankle motion. The record does not reflect that the Veteran's ankle disability has caused impairment in earning capacity above what would be average for such disability. Also, aside from the Veteran's bare assertions, the record does not reflect that his disabilities have been productive of marked interference with employment, and there is no indication in the record of frequent hospitalizations related to such disabilities. To the extent that the Veteran argues that limitations caused by his right wrist and right ankle disability negatively affected his ability to maintain performance levels as a cook, specifically, the Board notes that when the RO or Board evaluates whether the criteria in the rating schedule adequately correspond to the symptomatology and severity of a claimant's disability, § 3.321(b)(1) does not contemplate or require a calculation of the income that may not have been realized because of a service-connected disability. Thun, 22 Vet. App. at 117. Rather, it requires an assessment of whether the veteran's schedular disability rating adequately contemplates the average impairment in earning capacity from the veteran's disability. Id. at 116 (explaining that "given that the average impairment in earning capacity is the standard, within the current rating schedule, many veterans receiving benefits may experience a greater or lesser impairment of earning capacity than average as a result of their disability," but that "extraschedular consideration cannot be used to undo the approximate nature that results from the rating system based on average impairment of earning capacity authorized by Congress"). In sum, the Board has determined that there are no unusual or exceptional factors in this case warranting the referral of the claim for extraschedular consideration. Accordingly, neither a rating in excess of 10 percent for residuals of a right wrist fracture of the navicular bone with degenerative changes, nor a rating in excess of 10 percent for chronic right ankle sprain, is warranted, and there is no basis for staged rating of either of the Veteran's disabilities pursuant to Hart. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2012); Gilbert, 1 Vet. App. at 53-56. ORDER A rating in excess of 10 percent for residuals of a right wrist fracture of the navicular bone with degenerative changes is denied. A rating in excess of 10 percent for chronic right ankle sprain is denied. REMAND In a May 2008 statement, the Veteran asserted that he did not begin receiving medical attention for his claimed disabilities until approximately 2000, after being denied medical attention in 1983 because a physician stated that he only had arthritis, so that he should come back when he was older. In a January 2013 statement, the Veteran again asserted that he had been previously denied medical treatment. He reported that before being discharged from service in July 1981 he was advised during his "outprocessing briefing" to immediately apply to register for medical care and benefits, no longer than six months after being discharged. He further reported that on February 1, 1982, he rode with a World War II veteran, F.C, and was advised by medical personnel that he was too young, that his pain was arthritis, and that he should return when he was older. The Veteran has not, however, indicated what VA facility, if any, he visited in 1982 or 1983, or whether at such time he had sought treatment for either his back or his right ankle. Records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The earliest VA treatment records in the claims file are dated in December 2001, and the record does not indicate that the RO unsuccessfully attempted to obtain any VA records dated from February 1982 to December 1983. Thus, as the Veteran has indicated that there might be outstanding VA treatment records pertinent to his service connection claims, the Veteran's service connection claims must be remanded for the RO or AMC to attempt to obtain any such records. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he provide sufficient information to obtain any additional VA treatment records pertinent to the claims on appeal that is not currently of record, and specifically any records of visiting a VA facility from February 1982 to December 1983. 2. Then, obtain any such outstanding VA medical records related to the Veteran's claimed back and right knee disabilities, specifically any dated from February 1982 to December 1983. All records and/or responses received should be associated with the claims file. 3. After completing the above development, and any other development deemed necessary, readjudicate the issues remaining on appeal. If any benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board for appellate review, after the Veteran has had an adequate opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matters 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. 2012). ______________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs