Citation Nr: 1320968 Decision Date: 06/28/13 Archive Date: 07/05/13 DOCKET NO. 06-36 499 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to a disability rating in excess of 20 percent for a right hand disability, described as status postoperative (PO) fracture of the proximal phalanx, right ring finger, and status postoperative (PO) tendon repair, right middle finger. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The Veteran served on active duty from October 1978 to February 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina which decreased the 20 percent evaluation for a right hand disability to noncompensable. Historically, service connection was granted for fracture of the proximal phalanx, ring finger by rating action in March 1990. A noncompensable rating was assigned. By rating action in November 2003, the RO determined that a torn ligament injury of the right middle finger was secondary to the right ring finger injury. A temporary 100 percent evaluation was awarded from September 22, 2003, based on a period on convalescence from ligament repair surgery of the middle finger for the right hand disorder. Subsequent to this period the 0 percent evaluation was increased to 20 percent from November 1, 2003. A January 2004 rating action extended the period of convalescence to January 1, 2004. The Veteran filed a claim for an increased rating in excess of 20 percent in December 2004. By rating action in July 2005, the RO proposed to reduce the 20 percent evaluation to 0 percent. A rating action in October 2005 reduced the 20 percent evaluation to 0 percent, effective from January 1, 2006. This case was previously before the Board in November 2010, at which time the Board restored the 20 percent evaluation for a right hand disorder. In addition the matter of a rating in excess of 20 percent was remanded to the agency of original jurisdiction (AOJ) for additional development. In April 2012, the case was again remanded to the AOJ for additional development. The case has been returned to the Board for further appellate review. The Veteran, in a statement submitted in August 2009, indicates that he no longer able to perform his usual occupation of a truck driver and a mechanic. The Board interprets this statement as a claim for a total rating based on individual unemployability due to service connected disabilities (TDIU). This claim has not yet been addressed by the RO, and is referred to them for appropriate action. See Rice v. Shinseki, 22 Vet. App. 447 (2009). FINDINGS OF FACT 1. The Veteran is left hand dominant. 2. The Veteran's right hand disability is shown to have been productive of moderately decreased grip strength, and decreased dexterity; however, there is no evidence of loss of use of right hand (by analogy), amputation of the right ring and long finger (by analogy). CONCLUSION OF LAW The criteria for a rating in excess of 20 percent for service-connected right hand disability, described as PO fracture of the proximal phalanx, right ring finger, and PO tendon repair, right middle finger have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321(b) (1), 4.7, 4.71a, 4.124a, Diagnostic Codes 5003, 5010, 5125-5156, 5223-5230 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); Pub.L. 112-154, §§ 504(a) (1)-(2), 505(a)-(b) (Aug. 6, 2012) (to be codified at 38 U.S.C.A. §§ 5103(a)-(b), 5103A (b)-(c)); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b) (1). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the 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 (2006). In a claim for increase, 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 (Fed. Cir. 2009). Here, the Veteran was sent letters in December 2004 and March 2006 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The letters also explained what type of information and evidence was needed to establish a disability rating and effective date. The Board acknowledges that due to the complex nature of this case complete notice may not have been issued to the Veteran prior to the adverse determination on appeal. However, fully compliant notice has been issued, and the claim was thereafter readjudicated most recently in an October 2012 supplemental statement of the case (SSOC). Thus, 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, the VCAA requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The Veteran's relevant service, VA, and private medical treatment records have been obtained. There is no indication of any additional, relevant records that the RO failed to obtain. The Veteran has been given adequate VA examinations, most recently in February 2011. The Board noted that an X-ray report from that examination was missing from the claims file and remanded the case in April 2012 to obtain and review this X-ray report. This was accomplished and the X-rays were reviewed in October 2012. The examination report including the X-ray report were thorough and contains necessary findings to base a decision with regard to the Veteran's claim. The examiner personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information necessary to decide the claim. Brief but relevant and important opinions were provided. The Board finds the opinions to be adequate, as they were predicated on a full reading of the claims file and the Veteran's own statements. Therefore, the Board finds that no further action is necessary in this regard. The Board finds that all necessary assistance has been provided to the Veteran. In sum, the Board finds that the duty to assist and duty to notify provisions of the VCAA have been fulfilled and no further action is necessary under the mandates of the VCAA. II. Legal Criteria Initially, the Board notes all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal, has been reviewed. Although there is 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) (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 analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran asserts that he is entitled to a rating in excess of 20 percent for his service-connected right hand disability, described as PO fracture of the proximal phalanx, right ring finger, and PO tendon repair, right middle finger. He argues that he has right hand pain, and a weakened grip. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings 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); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Where the Rating Schedule does not provide for a noncompensable evaluation for a diagnostic code, a noncompensable evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (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). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. 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 it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant 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. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2012). Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14 (2012). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Also, functional loss due to pain must be supported by pathology and shown through objective observation. Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997) (citing 38 C.F.R. § 4.40). Pain alone does not constitute functional loss under VA regulations that evaluate disabilities based upon loss of motion. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). 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 (2012). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2012). The Board must evaluate disabilities under multiple diagnostic codes to determine if there is any basis to increase the assigned rating. Such evaluations involve consideration of the level of impairment of a veteran's ability to engage in ordinary activities, to include employment, as well as an assessment of the effect of pain on those activities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2012). Here, the RO assigned Diagnostic Codes 5299-5223. Diagnostic Code 5299 indicates the disability is not listed in the Schedule for Rating Disabilities, and it has been rated by analogy under a closely related disease or injury. 38 C.F.R. §§ 4.20, 4.27. Diagnostic 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. Moreover, the current 20 percent evaluation is the highest available under this rating code for any two fingers of the minor hand. Therefore, the Board finds that Diagnostic Codes 5299-5229 for limitation of motion of the index or long fingers, and 5299-5230 for limitation of motion of the ring or little fingers, are the appropriate codes under which the Veteran's finger disabilities should be rated. Diagnostic Code 5229, regardless of whether it affects the major or minor hand, assigns a noncompensable rating for limitation of motion of the long or index finger with a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. A 10 percent disability rating is assigned for limitation of motion of the long or index finger with a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. Id. Diagnostic 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. A noncompensable disability evaluation represents the maximum schedular rating available for limitation of motion of the ring or little finger under Diagnostic Code 5230. Consequently, the Veteran is not entitled to an increased evaluation for any limitation of motion in the right ring finger under this diagnostic code. Diagnostic 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, Diagnostic Code 5227. Therefore, even if ankylosis were shown, higher disability ratings cannot be assigned under that diagnostic code. A compensable rating for ring or little finger disabilities requires amputation. See 38 C.F.R. § 4.71a, Diagnostic Codes 5155, 5156. With ankylosis, consideration must also be given to whether an additional evaluation is warranted for resulting limitation of motion of other digits or for interference with overall function of the hand. See Note following Diagnostic Code 5227. 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, Diagnostic 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 angluation 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, Diagnostic Codes 5155, 5156. III. Background The Veteran's service treatment reports show that in 1984, he sustained a fracture to his right fourth proximal phalanx during a football game. The Veteran underwent an open reduction with internal fixation (ORIF) with screws. A June 2005 VA examination report noted the Veteran reported pain and weakness of the 3rd and 4th fingers of no definitive or definable frequency. The pain may last from minutes to a day depending on what he had been doing. He had intermittent swelling of the 4th digit which was alleviated with time. There was additional decreased ROM during flare ups. He was employed as a truck driver but indicated his disability made it more difficult to shift gears. The examiner noted that there was no evidence of ankylosis. There was angulation of the digits. Range of motion (ROM) testing revealed the Veteran was able to extend all his digits fully to 0 degrees. The right, 4th digit phalanx angle was 31 degree and the right 3rd digit at 2nd phalanx palmarly was 41 degrees. Extension was to 0 degrees, passively. ROM, 3rd finger was full flexion and extension. The gap from his thumb to fingers with all extended was from the thumb to the 5th digit-17 cm, to the 4th digit-15 cm, to the 3rd digit -13 cm, and to the 2nd digit -12 cm. The Veteran was able to bring the distal aspect of all digits to the transverse crease of the palm. The Veteran was able to oppose his thumb to all fingers with the exception of the 4th digit which fell 3 cm short of being so. The diagnosis was laxity of the 3rd and 4th digits secondary to prior injury with pain being the primary limiting factor secondary to injury and subsequent surgeries related to his time in service with pain being the primary limiting factor. The Veteran in May 2009 underwent surgery at the VAMC to remove the hardware which had been left in place since his right ring finger repair. The appellant was afforded a VA medical examination in February 2011. The examiner reviewed the appellant's claims file and medical records. The Veteran was left handed. The Veteran fractured the right ring finger in service. An ORIF was performed with screws. He also underwent surgery to the right 3rd finger in 2000 from a torn flexor ligament. In 2009 he underwent dorsal exotosis and removal of hardware from the right 4th finger. He does not wear a brace or use medication. His main complaints were weakness and swelling of the right hand made worse by manual labor or with activity. This was severe and lasted 3-4 hours. He has loss of motion of 50 percent with flare ups. The effect on activities of daily living was that he used his left hand more. He last worked two years ago as a truck driver, and he reported difficulty changing gears while driving. ROM of his fingers right hand were; index finger flexion was MCP 0-90 degrees, PIP 0-110 degrees, DIP 0-70 degrees; Long finger ROM was MCP 0-90 degrees, PIP 0-90 degrees, DIP 5-70 degrees; the fourth (ring finger) was MCP 0-90 degrees, PIP 10-90 degrees, DIP 0-70 degrees; the little finger ROM was MCP 0-90 degrees, PIP 0-110 degrees, DIP 0-70 degrees. There was no change in ROM with repetition. There was pain with repetition in the PIP of the long finger and the ring finger, and palm. The index, long, and ring fingers miss touching the proximal transverse crease of the palm by 0.5 cm. The little finger miss touches the proximal transverse crease of the palm. He was able to oppose the thumb to all fingers. The PIP joint, ring finger, has 10 degrees of angulation. All PIP joints were enlarged. The only area of palpable tenderness was in the center of the palm. There was a linear scar 7 cm x 0.2cm over the dorsum of the 4th finger which was tender. There was also a multi-segmented diagonal scar 9 cm x 4 cm x 5 cm x 4 cm across the wrist extending up to the PIP joint of the 3rd finger which was tender as well. The first scar was 0.2 cm wide. There was no swelling in the hand. X-rays taken in March 2009 showed 2 screws around the PIP joint of the 4th finger with flexor deformity. The examiner ordered new X-rays for comparison. These were not attached to the examination report. The impression was fracture right 4th finger, 1986; removal of hardware 4th finger, 2009; torn flexor tendon 3rd finger, repaired. 2000. VA X-rays dated in February 2011 were reviewed by the examiner in October 2012. A clinical history was noted of fracture right 4th finger, and torn flexor tendon repair, 3rd finger. The reviewer noted evidence of an old trauma of the proximal phalanx 4th finger with very mild deformity with radiopaque foreign bodies and/or bone fragment adjacent. The remaining bones of the right hand were unremarkable. IV. Analysis The Board finds that the claim must be denied. There is no basis for assigning a higher rating based on limitation of motion of the ring and long (3rd) fingers. See Diagnostic Codes 5229, 5230. There is no evidence to show ankylosis of any finger. Indeed, even if ankylosis of the ring and long fingers were shown, Diagnostic Code 5227 does not provide for even a compensable rating, while Diagnostic Code 5226 provides for only a 10 percent rating. And, for that matter, ankylosis of the ring and long finger, if such were shown, would only be a 10 percent rating. See Diagnostic Code 5223. Indeed, the Veteran is already receiving a 20 percent rating, in excess of the maximum rating available under Diagnostic Codes 5223, 5227, and 5230. In this regard, the Court has determined that if, as here, a claimant is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are thereby not for consideration. There is also no basis for assigning a higher rating by analogy for loss of use (amputation) of the ring and long finger as there is no higher rating available under Diagnostic Codes 5149. There is also no basis for assigning a higher rating by analogy for loss of use (amputation) of the right hand (60 percent). See Diagnostic Codes 5125. Even in considering his documented pain on motion, decreased strength, and decreased dexterity, the Veteran continues to enjoy the full use of his fingers. He is capable in engaging in a large array of tasks, to include all his activities of daily living. The Board finds it unfathomable that he would be better served by an amputation stump. Accordingly, the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. In deciding the Veteran's increased rating claim, the Board has considered the determination in Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. As noted above, the Board does not find evidence that the Veteran's evaluation should be increased for any separate period based on the facts found during the whole appeal period. The evidence of record supports the conclusion that the Veteran is not entitled to increased compensation during any time within the appeal period. The Board therefore finds that the evidence is insufficient to show that the Veteran had a worsening of the disability on appeal such that an increased rating is warranted. The Board has considered the Veteran's statements that he should be entitled to higher disability rating for his right hand disorder. He reports periods of flare up along with decreased function due to pain, weakness, and reduced dexterity. The Board is required to assess the credibility and probative weight of all relevant evidence. McClain v. Nicholson, 21 Vet. App. 319, 325 (2007). In doing so, the Board may consider factors such as facial plausibility, bias, self interest, and consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. at 511; see Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007); cf. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board may consider the absence of contemporaneous medical evidence when determining the credibility of lay statements, but may not determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d at 1331. Personal interest may affect the credibility of the evidence, but the Board may not disregard testimony simply because a claimant stands to gain monetary benefits. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). In this case, the Veteran is competent to report his current right hand symptoms as these observations come to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board also acknowledges the Veteran's belief that his symptoms are of such severity as to warrant a higher rating. However, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. Therefore, the Board finds that the medical findings, which directly address the criteria under which the disabilities are evaluated, more probative than the Veteran's assessment of the severity of his disability. Those examinations also took into account the Veteran's competent (subjective) statements with regard to the severity of his hand disability. Consideration has also been given to whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits 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) (2012); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b) (1) (2012); Thun, 22 Vet. App. at 116. The schedular evaluation in this case is not inadequate. When comparing the Veteran's disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that manifestations of the service-connected right hand disability are congruent with the disability picture represented by the disability rating assigned herein. The criteria for the 20 percent rating assigned herein more than reasonably describes the Veteran's disability level and symptomatology. The Veteran is shown to have some decreased strength and dexterity in his right hand. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. In reaching this decision, the Board has considered the oral and written testimony of the Veteran. The Board points out that, although a lay person is competent to testify only as to observable symptoms, see Falzone v. Brown, 8 Vet. App. 398, 403 (1995), a layperson is not, however, competent to provide evidence that the observable symptoms are manifestations of chronic pathology or diagnosed disability, unless such a relationship is one to which a lay person's observation is competent. See Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). In this case, the Board has determined that the medical evidence is more probative of the issue, and that it outweighs the lay statements. Accordingly, the Veteran's claim must be denied. Finally, although the Veteran has submitted evidence of medical disability, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable. He reports employment as a truck driver although with some work restriction due to his right hand disorder. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER A disability rating in excess of 20 percent for a right hand disability, described as status postoperative (PO) fracture of the proximal phalanx, right ring finger, and status postoperative (PO) tendon repair, right middle finger is denied. _________________________________________________ JOHN L. PRICHARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs