Citation Nr: 1323440 Decision Date: 07/23/13 Archive Date: 08/01/13 DOCKET NO. 04-22 701 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an initial compensable disability rating for a right wrist disability. 2. Entitlement to an initial compensable disability rating for residuals of a scar, status post mole removal, of the left lower eyelid. 3. Entitlement to an initial compensable disability rating for residuals of a status post laceration of the left index finger with a residual well-healed scar. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD David Gratz, Counsel INTRODUCTION The Veteran served on active duty from October 1997 to January 2003. She has additional unverified periods of reserve service in the Army National Guard. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2003 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, which, inter alia, granted the Veteran's January 2003 claims for service connection for residuals of a scar, status post mole removal, of the left lower eyelid; (2) for residuals of a status post laceration of the left index finger with a residual well-healed scar; and (3) for a right wrist disability. For each disability, the RO assigned a noncompensable disability rating, effective January 3, 2003. The Board previously remanded the issues on appeal in July 2008, June 2011, and August 2012. They are now before the Board for further appellate review. The Veteran requested a hearing before a Veterans Law Judge at the RO (travel board hearing) in her May 2004 substantive appeal. In July 2004, in response to a letter from VA informing her of the delay in scheduling a travel board hearing, the Veteran requested a videoconference hearing. In a December 2007 letter, VA informed the Veteran that it would be more expeditious to provide her with a travel board hearing; the letter also informed the Veteran of the date and time of her scheduled hearing. Nonetheless, the Veteran failed to appear at her hearing. The appellant has neither given good cause for her failure to appear, nor asked that the hearing be rescheduled; therefore, the hearing request is deemed withdrawn. 38 C.F.R. § 20.704(d) (2012). FINDINGS OF FACT 1. The Veteran's right (minor) wrist strain manifests with objective evidence of painful motion. 2. The Veteran's left lower eyelid scar measures three-fourths of an inch; is neither painful nor unstable; and is characterized by no tenderness, adherence, edema, inflammation, underlying tissue loss, breakdown of skin, hypopigmentation, hyperpigmentation, keloid formation, ulceration, disfigurement, instability, abnormal texture, or limitation of motion or function. 3. Prior to May 7, 2005, the Veteran's left index finger residuals are characterized by x-ray evidence of no abnormality, no limitation of motion of the left index finger, no objective evidence of painful motion, and no unstable or painful scar. 4. As of May 7, 2005, the Veteran's left index finger residuals are characterized by x-ray evidence of involvement of 2 or more minor joint groups, namely early osteoarthritic changes of the distal interphalangeal joints of the 2nd through 5th fingers. CONCLUSIONS OF LAW 1. The criteria for a 10 percent disability evaluation, and no higher, for a right wrist strain have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.40, 4.45, 4.59, 4.71a Diagnostic Codes 5299-5215 (2012). 2. The criteria for a compensable disability rating for a left lower eyelid scar have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.118 Diagnostic Code 7800 (2012). 3. Prior to May 7, 2005, the criteria for a compensable disability rating for left index finger residuals have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.40, 4.45, 4.59, 4.71a, 4.118 Diagnostic Codes 5199-7805 (2012). 4. As of May 7, 2005, the criteria for a 10 percent disability evaluation, and no higher, for left index finger residuals have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. § 3.102, 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5103 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). 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, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice must inform the claimant of any information and 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 in accordance with 38 C.F.R. § 3.159(b)(1). Pelegrini v. Principi, 18 Vet. App. 112, 120-121 (2004). This notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA has met its duty to notify for this claim. Service connection for these issues was granted in a July 2003 rating decision. The Veteran is now appealing the downstream issues of the initial ratings that were assigned. Moreover, the Veteran received additional notice letters in April 2005 and July 2008, prior to the August 2005 and October 2010 supplemental statements of the case (SSOC), respectively. Therefore, additional notice under the Veterans Claims Assistance Act of 2000 (VCAA) is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1131 (Fed. Cir. 2007), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Next, VA has a duty to assist the Veteran in the development of his claim. This duty includes assisting her in the procurement of pertinent medical records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the RO has obtained and associated with the claims file the Veteran's available treatment records from service, VA clinicians, and the Madigan Army Medical Center (AMC) in Tacoma, Washington. The Veteran was afforded VA compensation and pension examinations germane to her claims on appeal in May 2003 and May 2005. These examination reports are adequate because the examiners based their findings upon consideration of the Veteran's prior medical history, described the disabilities in sufficient detail so that the Board's evaluations of the claimed disabilities would be fully informed, and supported all conclusions with analyses that the Board could consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet.App. 120, 124 (2007). Additionally, the VA examiners fully described the functional effects caused by the Veteran's disabilities on appeal. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). While the Veteran has reported worsening in her claimed disorders since her May 2005 VA examination, she failed to report for the VA examinations for which she was scheduled in August 2011 and, as such, her original compensation claims shall be rated based on the evidence of record. 38 C.F.R. § 3.655(b). These claims were remanded by the Board for additional development in July 2008, June 2011, and August 2012. In July 2008, the Board requested that the RO obtain any additional pertinent treatment records, and provide the Veteran with an orthopedic examination of her right wrist and a dermatology examination of her left eyelid and left index finger scarring. In response, the RO requested said records in a July 2008 letter. However, as the Board found in its June 2011 remand, the RO did not provide the Veteran with the requested examinations as to those issues. Consequently, in June 2011, the Board again requested that the RO obtain any additional pertinent treatment records, and provide the Veteran with an orthopedic examination of her right wrist and a dermatology examination of her left eyelid and left index finger scarring. In response, the RO requested said records in a June 2011 letter. The RO also scheduled the requested examinations for August 2011, but the Veteran failed to report. In August 2012, the Board again remanded the claims because the September 2011 SSOC did not properly address the issues on appeal. The Board requested that the RO obtain any additional pertinent treatment records, including from Madigan AMC, and readjudicate the claims. In response, the RO obtained the Veteran's additional VA and Madigan AMC treatment records, and readjudicated the claims in a February 2013 SSOC. Therefore, there has been substantial compliance with the Board's remand directives. D'Aries v. Peake, 22 Vet. App. 97 (2008); Stegall v. West, 11 Vet. App. 268 (1998). For the foregoing reasons, the Board concludes that VA made all reasonable efforts to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. Analysis Disability ratings are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity in civil occupations. 38 U.S.C.A. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. Where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged ratings" is required. Fenderson v. West 12 Vet. App. 119, 126 (1999). The Board notes that 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 the veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Right Wrist Disability The Veteran contends in her May 2004 substantive appeal that she should receive a compensable rating for her right wrist disability. In March 2013, her representative noted in the Appellant's Post-Remand Brief that the Veteran asserts that she has constant chronic pain and decreased range of motion in her right wrist, and that it continues to worsen. The Veteran informed the May 2003 and May 2005 VA examiners that her left hand is her dominant hand. The RO has evaluated the Veteran's right wrist strain under 38 C.F.R. § 4.71a, Diagnostic Codes 5299-5215, as noncompensable. The use of two rating codes and a "99" denotes a rating by analogy. 38 C.F.R. §§ 4.20, 4.27. Under 38 C.F.R. § 4.71a, Diagnostic Code 5215, a disability rating of 10 percent applies when there is limitation of motion of either (i.e., major or minor) wrist, with either dorsiflexion to less than 15 degrees, or palmar flexion limited in line with the forearm. 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 Mitchell Court 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 (38 C.F.R. §§ 4.40), 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 (38 C.F.R. § 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. Therefore, 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 Veteran's March 2003 service treatment record (DA Form 7349-R) included a physician's finding of right wrist pain and popping for one year. At her May 2003 VA examination, the Veteran reported having right wrist pain all the time, and being unable to use her right hand for a long period of time because of the pain. She denied ever having been told by a physician to have bed rest for her right wrist disability. The VA examiner found that the Veteran's range of motion in her right wrist was normal, with dorsiflexion to 70 degrees and palmar flexion to 80 degrees, although the Veteran reported some discomfort over the ulnar side. Range of motion was limited by pain at the extreme range. There was no fatigue, weakness, incoordination, or lack of endurance of the right wrist. An x-ray of the right wrist demonstrated no abnormality. The examiner diagnosed the Veteran with a right wrist strain with objective evidence of mild painful range of motion. At her May 2005 VA examination, the Veteran reported having right wrist popping, weakness, and constant pain with some pain travelling to the forearm and shoulder. She also reported having trouble using her right hand for long periods of time, including grabbing and holding objects, due to pain. She denied any incapacitation or time lost from work due to her right wrist disorder. The VA examiner found that the Veteran's right wrist was within normal limits; had no ankylosis; and had no pain, fatigue, weakness, lack of endurance, or incoordination with range of motion after repetitive use. She had dorsiflexion from 0 to 70 degrees, and palmar flexion from 0 to 80 degrees. An x-ray of the right wrist was normal. The VA examiner's diagnosis was status post right wrist strain. After reviewing all of the clinical evidence and subjective complaints since the effective date of service connection, the Board finds that a 10 percent rating for a right wrist strain is warranted throughout the appellate period-i.e., since January 3, 2003. Significantly, the Veteran's reports of right wrist pain are consistent with the findings of both the March 2003 physician and the May 2003 VA examiner. Furthermore, the Veteran continues to assert that she experiences right wrist pain, which she is competent to report. See, e.g., Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also 38 C.F.R. § 3.159(a)(2). Moreover, the absence of arthritis in the Veteran's May 2003 and May 2005 x-ray reports does not preclude a compensable rating for painful motion. See Burton v. Shinseki, 25 Vet. App. 1 (2011); see also 38 C.F.R. § 4.59. Although the Board acknowledges the May 2005 VA examiner's finding that the Veteran's right wrist was without pain on range of motion testing, the Board finds that the evidence as a whole, including the objective medical findings and the Veteran's competent lay statements, are sufficient to find that a 10 percent rating for the Veteran's right wrist pain is warranted. The Board further finds that a rating in excess of 10 percent is not warranted because the Veteran does not have ankylosis of the right wrist. The May 2005 VA examiner specifically found that the Veteran's right wrist had no ankylosis, and no other diagnosis of right wrist ankylosis during the pendency of the claim is of record. See 38 C.F.R. § 4.71a, Diagnostic Code 5214. A rating in excess of 10 percent is also not warranted for the Veteran's reported travelling pain into the forearm and shoulder because the aforementioned May 2003 and May 2005 VA examiners' diagnoses and objective findings of no weakness or incoordination are inconsistent with a neurological deficit of the right wrist. The Board finds that the examiners' findings outweigh the Veteran's own report of travelling pain because they are based on objective evidence from examinations. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the applicable rating criteria adequately contemplate the manifestations of the Veteran's right wrist strain with painful motion. Thus, referral for consideration of an extraschedular rating is not warranted. Moreover, even if the established schedular criteria are found to be inadequate to describe the severity and symptoms of the Veteran's right wrist disability, the case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, the Veteran expressly denied any incapacitation or time lost from work due to her right wrist disorder at her May 2005 VA examination. The Board thus finds that the manifestations of the Veteran's symptoms do not qualify as an exceptional or unusual disability picture. Finally, the Court of Appeals for Veterans Claims has held that a total disability rating based on individual unemployability (TDIU) is a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied, and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The Veteran has denied losing any time from work due to her right wrist disability, and the evidence does not show that she is unemployable as a result of that disability. Thus, TDIU is not raised by the record. Left Lower Eyelid Scar The Veteran contends in her May 2004 substantive appeal that she should receive a compensable rating for her left lower eyelid scar. In March 2013, her representative noted in the Appellant's Post-Remand Brief that the Veteran asserts that her scars are disfiguring, and her left eye is numb. The RO has evaluated the Veteran's left lower eyelid scar under 38 C.F.R. § 4.118, Diagnostic Code 7800, as noncompensable. The Board notes that the Veteran is in receipt of a separate 80 percent rating for her facial scarring status post acne under 38 C.F.R. § 4.118, Diagnostic Code 7828-7800, which is not currently before the Board. Disability ratings under 38 C.F.R. § 4.118, Diagnostic Code 7800 apply to burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. The eight characteristics of disfigurement are: (1) Scar 5 or more inches (13 or more cm.) in length; (2) Scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) Surface contour of scar elevated or depressed on palpation; (4) Scar adherent to underlying tissue; (5) Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches; (7) Underlying soft tissue missing in an area exceeding six square inches; and (8) Skin indurated and inflexible in an area exceeding six square inches. A 10 percent rating applies when there is one characteristic of disfigurement. A 30 percent rating applies when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes [including eyelids], ears [auricles], cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent rating applies when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. An 80 percent rating applies when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. At the Veteran's May 2003 VA examination, she reported having left lower eyelid pain all the time. The examiner found that the scar was tiny and nontender to touch, and did not cause difficulty with closing or opening her eyelids. The examiner diagnosed the Veteran with status post left lower eyelid mole removal, with subjective evidence of pain and objective evidence of a tiny scar over the inner part of the left lower eyelid border. The examiner found that the scar had no tenderness, adherence, edema, inflammation, underlying tissue loss, breakdown of skin, hypopigmentation, hyperpigmentation, or keloid formation. The color blended with the skin, and the texture was soft and regular. There was no limitation of function by the left eyelid scar, and no objective finding to support the complaint of pain. At the Veteran's May 2005 VA examination, she reported having itching and redness, although it is unclear whether this pertained to her left eye or eyelid. The Veteran denied any time lost from work due to the left lower eyelid scar. The examiner found that the scar is a 3/4 inch irregularity, and that one must walk rather close-up to the Veteran in order to see it. There was no tenderness, ulceration, disfigurement, instability, tissue loss, keloid formation, adherence, hypo- or hyper-pigmentation, abnormal texture, or limitation of motion due to the left lower eyelid scar. The examiner diagnosed the Veteran with a well healed and barely visible scar from surgical removal of a mole on the left lower eyelid. The examiner further characterized the left lower eyelid scar as very subtle, and noted that the Veteran was able to continue with her usual activities despite this condition. After reviewing all of the clinical evidence and subjective complaints since the effective date of service connection, the Board finds that the preponderance of the evidence shows that a compensable disability rating for the Veteran's left lower eyelid scar is not warranted. The Veteran does not have any characteristic of disfigurement, and she does not have visible or palpable tissue loss and either gross distortion or asymmetry of one or more feature or paired set of features, attributable to her left lower eyelid scar. See 38 C.F.R. § 4.118, Diagnostic Code 7800. A compensable disability rating for the Veteran's left lower eyelid scar is also not warranted based on her assertion that her left eye is numb or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804. The VA examiners' objective findings regarding the size and properties of the scar are inconsistent with numbness of the left eye. Furthermore, the May 2003 VA examiner expressly found that the Veteran's subjective report of pain was unsupported by objective findings. As such, the Board finds that the Veteran's assertion of left eye pain and numbness lacks credibility. As a finder of fact, when considering whether lay evidence is credible, the Board may properly consider the internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). Here, the Veteran's report of pain and numbness is inconsistent with the objective evidence of record, and, as such, the Board finds that it is not credible. As discussed above, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the Veteran's left lower eyelid scar includes no manifestations which are not adequately contemplated by the applicable rating criteria. Thus, referral for consideration of an extraschedular rating is not warranted. Moreover, even if the established schedular criteria are found to be inadequate to describe the severity and symptoms of the Veteran's left lower eyelid scar, the case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, the Veteran expressly denied any time lost from work due to her left lower eyelid scar at her May 2005 VA examination. The Board thus finds that the manifestations of the Veteran's symptoms do not qualify as an exceptional or unusual disability picture. Finally, the Veteran has denied losing any time from work due to her left lower eyelid scar, and the evidence does not show that she is unemployable as a result of that disability. Thus, TDIU is not raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). Residuals of a status post Laceration of the Left Index Finger with a Residual Well-Healed Scar The Veteran contends in her May 2004 substantive appeal that she should receive a compensable rating for her left index finger residuals. In March 2013, her representative noted in the Appellant's Post-Remand Brief that the Veteran asserts that her scars are disfiguring. The RO has evaluated the Veteran's left index finger residuals 38 C.F.R. § 4.118, Diagnostic Code 5199-7805, as noncompensable. Under 38 C.F.R. § 4.45(f), for the purpose of rating disability from arthritis, multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities are considered groups of minor joints, ratable on a parity with major joints. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, a 10 percent rating applies when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating applies when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Under 38 C.F.R. § 4.71a, Diagnostic Code 5229, a 10 percent rating applies for limitation of motion of the major or minor index finger when there is 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. A noncompensable rating applies when there is a gap of less than one inch 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. Under 38 C.F.R. § 4.118, Diagnostic Code 7805, any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 are to be evaluated under an appropriate diagnostic code. The criteria for Diagnostic Code 7800 are inapplicable because the Veteran's left index finger residuals are not of her head, face, or neck. The criteria under Diagnostic Codes 7801 and 7802 are inapplicable because there is no evidence of a nonlinear scar of the Veteran's left index finger. Under 38 C.F.R. § 4.118, Diagnostic Code 7804, a 10 percent rating applies when there are one or two scars that are unstable or painful. A 20 percent rating applies when there are three or four scars that are unstable or painful. A 30 percent rating applies when there are five or more scars that are unstable or painful. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Scars that are both unstable and painful warrant an additional ten percent rating. At the Veteran's May 2003 VA examination, she reported that her left index finger laceration is constantly bothersome and painful and that she cannot hold objects for a long period of time. The examiner found that the Veteran had normal range of motion in her left index finger, and no ankylosis. An x-ray of the Veteran's left hand demonstrated no abnormality. The examiner diagnosed the Veteran with status post left index finger distal phalanx laceration, with subjective complaint of pain and no objective factors. The examiner found that the Veteran had a non-disfiguring, well-healed 2-to-3 millimeter (mm) scar on the left index finger, distal phalanx, with no tenderness, adherence, edema, inflammation, underlying tissue loss, breakdown of skin, hypopigmentation, hyperpigmentation, or keloid formation. The color blended with the skin, and the texture was soft and regular. The examiner found that there were no objective findings to support the subjective complaint of pain in the left index finger. The examiner determined that the Veteran's left index finger had no limitation of function. At the Veteran's May 2005 VA examination, she asserted that her left index finger was partly split off, constantly painful, bothersome, and weak. The Veteran stated that she has trouble writing for long periods of time or holding objects, but denied any time loss from work. The examiner found that the Veteran had no ankylosis of the fingers; no compromise in range of motion; and no pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The examiner found no sign of any left index finger scar. An x-ray showed early osteoarthritic changes of the distal interphalangeal joints of the 2nd through 5th fingers. The examiner diagnosed the Veteran with status post left index finger split with residual of osteoarthritis by x-ray. After reviewing all of the clinical evidence and subjective complaints since the effective date of service connection, the Board finds that a 10 percent rating for left index finger residuals is warranted as of May 7, 2005-the date of the examination on which x-ray evidence of the Veteran's early osteoarthritic changes of the distal interphalangeal joints of the 2nd through 5th fingers was initially found. The 10 percent rating as of May 7, 2005 is warranted under 38 C.F.R. § 4.71a, Diagnostic Code 5003, based on x-ray evidence of involvement of 2 or more minor joint groups. Giving the benefit of the doubt to the Veteran, the Board finds that the arthritis of the other fingers of the Veteran's left hand identified by the May 2005 VA examiner is attributable to her service-connected left index finger disability based on the in-service crushing trauma. See Mittleider v. West, 11 Vet. App. 181 (1998); see also 38 C.F.R. § 4.3. Significantly, an earlier date for the 10 percent rating is not warranted because the previous left hand x-rays, conducted in May 2003, demonstrated no abnormality. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Furthermore, an earlier 10 percent rating is not warranted for painful motion under 38 C.F.R. § 4.59 and Burton v. Shinseki, 25 Vet. App. 1 (2011), because the May 2003 VA examiner expressly found that there were no objective findings to support the subjective complaint of pain in the left index finger. The Board finds that this objective evidence based on the examiner's medical expertise is more probative than the Veteran's subjective assertion of left finger pain. Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007). A rating in excess of 10 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5003 is not warranted because the most probative evidence does not show occasional incapacitating exacerbations. To the contrary, the most probative evidence of record-the May 2005 examiner's objective findings-show that the Veteran had no ankylosis of the fingers; no compromise in range of motion; and no pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Neither an earlier compensable nor an additional rating as of May 7, 2005 is warranted under 38 C.F.R. § 4.71a, Diagnostic Code 5229 because the Veteran has not had limitation of motion of the left index finger at any time during the appeal. Neither an earlier compensable nor an additional rating as of May 7, 2005 is warranted under 38 C.F.R. § 4.118, Diagnostic Code 7804 because the Veteran's left index finger scar is neither unstable nor painful. No finding of instability in the Veteran's left index finger scar is of record. With respect to pain, the May 2003 VA examiner expressly found that there are no objective findings to support the subjective complaint of pain in the left index finger. Additionally, the May 2005 VA examiner found no scar on the Veteran's left index finger. As such, the Board finds that the Veteran's assertion of left index finger scar pain lacks credibility. Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007). Here, the Veteran's report of pain is inconsistent with the objective evidence of record, and, as such, the Board finds that it is not credible. As discussed above, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the Veteran's left index finger residuals include no manifestations which are not adequately contemplated by the applicable rating criteria. Thus, referral for consideration of an extraschedular rating is not warranted. Moreover, even if the established schedular criteria are found to be inadequate to describe the severity and symptoms of the Veteran's left index finger residuals, the case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, the Veteran expressly denied any time lost from work due to her left index finger residuals at her May 2005 VA examination. The Board thus finds that the manifestations of the Veteran's symptoms do not qualify as an exceptional or unusual disability picture. Finally, the Veteran has denied losing any time from work due to her left index finger residuals, and the evidence does not show that she is unemployable as a result of that disability. Thus, TDIU is not raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER A rating of 10 percent, but no higher, for a right wrist strain is granted, subject to the applicable criteria governing the payment of monetary benefits. A compensable rating for a left lower eyelid scar is denied. CONTINUED ON THE NEXT PAGE Prior to May 7, 2005, a compensable rating for left index finger residuals is denied. As of May 7, 2005, a rating of 10 percent, but no higher, for left index finger residuals is granted, subject to the applicable criteria governing the payment of monetary benefits. ______________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs