Citation Nr: 1324669 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 09-15 531A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for right hand essential tremor. 2. Entitlement to an initial rating in excess of 10 percent for left hand essential tremor. 3. Entitlement to a compensable initial rating for left ring finger tendonitis status post fracture. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD E. Joyner, Counsel INTRODUCTION The Veteran served on active duty from August 2001 to December 2001, and from June 2006 to October 2007. These matters come to the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in May and June 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The May 2008 rating decision granted service connection for essential tremor. A 10 percent initial rating was assigned, effective from October 11, 2007. The June 2008 rating decision granted service connection for left ring finger tendonitis, status post fracture. A noncompensable initial rating was assigned, effective from October 11, 2007. In a June 2012 rating decision, the RO assigned separate 10 percent ratings for essential tremor of the right hand and of the left hand, effective from October 11, 2007. As the Veteran is in receipt of less than the maximum schedular rating for his right and left hand essential tremor disabilities, the matters therefore remain in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). FINDINGS OF FACT 1. Throughout the initial evaluation period, the competent medical, and competent and credible lay, evidence of record reflects that the Veteran's right hand essential tremor is not productive of more than mild impairment. 2. Throughout the initial evaluation period, the competent medical, and competent and credible lay, evidence of record reflects that the Veteran's left hand essential tremor is not productive of more than mild impairment. 3. Throughout the initial evaluation period, the competent medical, and competent and credible lay, evidence of record reflects that the Veteran's left ring finger tendonitis status post fracture is manifested by ankylosis; the evidence does not reflect that it results in impairment such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right hand essential tremor have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8715 (2012). 2. The criteria for an initial rating in excess of 10 percent for left hand essential tremor have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8715 (2012). 3. The criteria for an initial compensable rating for left ring finger tendonitis status post fracture have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5230 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2010); 38 C.F.R. § 3.159(b) (2010); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA 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. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess/Hartman held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, 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. Upon receipt of an application for "service connection," therefore, VA is required to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, it will assist in substantiating or that is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the Veteran is appealing the initial rating assignment as to his right and left hand essential tremor disabilities, and his left ring finger tendonitis status post fracture. Once service connection has been granted, the context in which the claim initially arose, the claim has been substantiated; therefore, additional VCAA notice under § 5103(a) is not required because the initial intended purpose of the notice has been fulfilled, so any defect in the notice is not prejudicial. Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Rather, thereafter, once a notice of disagreement (NOD) has been filed, for example contesting a downstream issue such as the initial rating assigned for the disability, only the notice requirements for a rating decision and statement of the case (SOC) described in 38 U.S.C. §§ 5104 and 7105 control as to the further communications with the Veteran, including as to what evidence is necessary to establish a more favorable decision with respect to downstream elements of the claim. 38 C.F.R. § 3.159(b)(3) (2012). The RO has provided the Veteran the required SOC discussing the reasons and bases for not assigning higher initial ratings and citing the applicable statutes and regulations. Duty to assist With regard to the duty to assist, the claim's file contains the Veteran's service treatment records, and VA treatment and examination reports, and the Veteran's statements in support of his claims. The Board has carefully reviewed the Veteran's statements and concludes that there has been no identification of further available evidence not already of record. The Board has also reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a further duty to obtain. With respect to the VA examinations of record, the Veteran was afforded VA examinations with respect to his claims in December 2007, November 2012, and January 2013. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that together the December 2007, November 2012, and January 2013 VA examination reports are adequate. The January 2013 examination report reflects that the examiner reviewed the claims file, all VA examiners conducted an examination, and together, the examination reports provide the medical information addressing the rating criteria in this case. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Consequently, the Board finds that the VA examinations are adequate. The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claims. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, the Board is satisfied as to compliance with the instructions from its October 2012 remand. Specifically, the October 2012 Board remand instructed the RO to contact the Veteran and request that he identify all health care providers who may possess additional records dating since August 2011 which are pertinent to his claims. Then the RO was instructed to obtain any VA treatment records dating from August 2011 to the present, and to obtain any identified private treatment records. The RO was also requested to provide the Veteran with a VA examination to determine the severity of his service-connected left ring finger disability and his right and left hand tremors The Veteran failed to respond to the Appeal Management Center's November 2012 letter requesting information regarding private treatment since August 2011. However, additional VA treatment records were obtained and associated with the claims folder. The Board finds that the RO has complied with the Board's instructions and that the November 2012 and January 2013 VA examination reports substantially comply with the Board's October 2012 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Legal Analysis Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating 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 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). VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. Fenderson v. West, 12 Vet. App. 119 (1999); See Hart v. Mansfield, 21 Vet. App. 505 (2007). 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 (2012). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2012). The Veteran's statements describing the symptoms of his service-connected disorders are deemed competent evidence. 38 C.F.R. § 3.159(a)(2) (2012). However, these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. The following paragraphs specifically apply to claims in which evaluating joint disabilities are rated on the basis of limitation of motion. VA must consider functional loss due to pain, weakness, excess fatigability, or incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59. Application of 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis and when raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, VA should address its applicability. Burton v. Shinseki, 25 Vet. App. 1 (2011). More 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. 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). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Right and Left Hand Essential Tremors The Veteran's right and left hand essential tremors have each been rated as 10 percent disabling throughout the entire evaluation period, under 38 C.F.R. § 4.124a, Diagnostic Code 8799-8715. Pursuant to 38 C.F.R. § 4.27, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen; unlisted disabilities requiring rating by analogy will be coded first with the numbers of the most closely related body part and "99." Diagnostic Code 8715 pertains to neuralgia of the median nerve. In rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a (2012). When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The ratings for peripheral nerves are for unilateral involvement; when bilateral, they are combined with application of the bilateral factor. Id. The use of terminology such as "mild," "moderate" and "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. §§ 4.2, 4.6. Under 38 C.F.R. § 4.124, neuralgia, peripheral, characterized usually by a dull and intermitted pain of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (2012). Under 38 C.F.R. § 4.123, neuritis, either cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. 38 C.F.R. § 4.123 (2012). The maximum rating which may be assigned for neuritis not characterized by organic changes as noted above will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Under Diagnostic Code 8515, a 10 percent evaluation is assigned for mild incomplete paralysis of the median nerve of the major or minor hand. A 20 percent evaluation is assigned for moderate incomplete paralysis of the median nerve of the minor hand. A 30 percent evaluation is assigned for moderate incomplete paralysis of the median nerve of the major hand. A 40 percent evaluation is assigned for severe incomplete paralysis of the median nerve of the minor hand. A 50 percent rating is assigned for severe incomplete paralysis of the median nerve of the major hand. A 60 percent disability rating is assigned for complete paralysis of the median nerve of the minor upper extremity. See 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2012). Diagnostic Codes 8615 and 8715 address the criteria for evaluating neuritis and neuralgia of the median nerve, respectively. The criteria are consistent with the criteria for evaluating degrees of paralysis as set forth above. See 38 C.F.R. § 4.124a, Diagnostic Codes 8615, 8715 (2012). The medical evidence of record includes a November 2007 VA treatment record, which notes that the Veteran denied any paralysis. The December 2007 VA examination report reflects that the Veteran complained of a mild tremor with any type of movement or action. He does not notice the tremor at rest, but he stated that when he is nervous or anxious, the tremor is even worse. Examination revealed that deep tendon reflexes were 1+ and equal in the upper extremities. Tremor was noted with action, but not at rest. The impression was tremor. A February 2008 VA treatment record reflects full range of motion of the upper extremities and full muscle strength. Fine tremors were noted when the upper extremities were outstretched. Deep tendon reflexes were 2+. The diagnosis was essential tremors of upper extremities. A March 2008 VA Persian Gulf examination report notes that there were tremors which began in service. The Veteran denied paralysis. There was no weakness, numbness, or tingling. Examination of the upper extremities reflected full strength and reflexes. An August 2008 VA treatment record from the Veteran's virtual claims file reflects that the Veteran's tremors remain unchanged. A February 2009 VA treatment record from the Veteran's virtual claims file reflects that the Veteran began taking Inderal for his tremors. An April 2009 VA treatment record from the Veteran's virtual claims file reflects his complaint of continuing to have benign tremors since service. A November 2012 VA examination report notes that the Veteran's left hand is his dominant hand. A January 2013 VA examination report notes that the Veteran is diagnosed with benign essential tremors of the bilateral upper extremities. The Veteran indicated that his tremor has worsened and that it is worse when he is anxious and when he tries to write. He is able to qualify for firearms at work but he has to rest his head on his right shoulder in order to qualify. He has been tried on Inderal for the tremors, but it has not worked and he currently takes no medication. It was noted that the Veteran is left hand dominant. Examination revealed that there was no muscle weakness in the upper extremities. Neurologic examination revealed full strength of the elbows, wrists, grip, and pinch (thumb to index finger). Deep tendon reflexes were normal (2+) for the biceps, triceps, and brachioradialis. The examiner specifically found that there was no upper extremity muscle weakness for either extremity. The examiner stated that there were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the Veteran's essential tremors. The examiner stated that there is no functional impairment of an extremity such that no effective function remains other than which would be equally well served by amputation with prosthesis. Examination revealed no sensory deficits to light touch or pin prick/painful stimuli in the upper extremities. Tinel's and Phalen's signs were negative bilaterally. The examiner commented that on examination, the Veteran has a fine tremor with outstretched hands, bilaterally. He has no sensory or motor deficits of any extremities, and Tinel's and Phalen's tests were normal. The examiner classified the tremor as a familial/benign essential tremor. The examiner further described essential tremors as the most common neurologic disorder that causes postural or action tremor. The examiner stated that this disability does not involve any complete or incomplete paralysis of either hand, and none was noted on this examination; therefore, the question of whether incomplete paralysis is mild, moderate, or severe, is inapplicable. A June 2012 VA treatment record from the Veteran's virtual claims file notes a diagnosis of essential tremors. The Veteran was noted to have discontinued his medication for his tremors. Based on the evidence of record, the most pertinent of which is discussed above, the Board finds that throughout the initial evaluation period, the evidence of record does not more closely approximate moderate incomplete paralysis of the median nerve. In this regard, the evidence shows that the Veteran has full strength, no weakness, generally normal reflexes and no complaints of numbness or tingling. Importantly, there are no abnormal sensory findings and even the Veteran has indicated that the tremors are mild. Thus, the Board concludes that the evidence does not indicate that the Veteran's right and left hand essential tremors more closely approximate moderate disability. The Board has considered whether the Veteran is entitled to staged ratings. However, the evidence throughout this appeal demonstrates that the Veteran's service-connected right and left hand essential tremors are manifested by no more than mild incomplete paralysis of the median nerve, if that. Thus, the Board finds that the disability picture for the Veteran's service-connected right and left hand essential tremors more closely approximates that contemplated by the currently assigned 10 percent evaluation for each extremity throughout this appeal. In making its determination, the Board considered the applicability of the benefit of the doubt rule. 38 U.S.C.A. § 5107(b) ; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). However, as a preponderance of the evidence is against the assignment of a higher initial disability rating, such rule does not apply and the claims must be denied. In reaching this conclusion, the Board acknowledges the Veteran's belief that his right and left hand essential tremor symptoms are more severe than the current disability evaluations reflect. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the ratings schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, as a lay person without demonstration of requisite training, he is not competent to assess whether the symptomatology meets a specific disability rating under the applicable diagnostic code criteria. As such, the Board finds that the medical evidence of record is more persuasive regarding whether he is entitled to a higher disability rating in accordance with the schedular criteria. The VA examiners considered the Veteran's reported symptoms and provided the clinical findings to rate the Veteran's disabilities with respect to the rating criteria. Therefore, the Board finds that the medical evidence is more persuasive than the Veteran's own statements regarding his increased neurologic symptomatology. Left Ring Finger Tendonitis The Veteran's service-connected left ring finger tendonitis, status post fracture, is rated as noncompensable under 38 C.F.R. § 4.71a, Diagnostic Code 5230, for the entire initial evaluation period. Limitation of motion of the ring or little finger is evaluated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5230. Any limitation of motion of the ring or little finger of either hand is rated as noncompensable. Unfavorable or favorable ankylosis of the ring finger is also evaluated as noncompensable. 38 C.F.R. § 4.71a, Diagnostic Code 5227. Amputation of the ring finger without metacarpal resection, at the proximal interphalangeal joint or proximate thereto warrants a 10 percent rating. Amputation of the ring finger with metacarpal resection (more than half the bone lost) warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5155. The December 2007 VA examination report notes that the Veteran reported pain in the left ring finger when he grips, tries to lift weights, or straighten his finger out all the way. The finger is bent at the joint and it will not straighten completely. He denied swelling. He has some pain when gripping small objects, but he usually has pain when lifting heavier things such as weightlifting to exercise. Grip strength in the right hand was 120 pounds and 70 pounds in the left hand. Examination revealed normal thumb opposition, finger to mid palm opposition, and fist formation. It was reported that the "right" ring finger was fixed at 20 degrees of flexion at the proximal interphalangeal (PIP) joint. He was unable to fully extend to 10 degrees. Range of motion of the digit was normal other than at the PIP joint. He had normal flexion. The November 2012 VA examiner noted that the Veteran is left hand dominant. The Veteran complained that he cannot fully extend the left ringer from the proximal phalanx, and he has pain in the PIP joint of this finger when lifting weights for exercise. He also has pain in the joint when lifting a gallon of milk. The pain with lifting has worsened since onset with less weightlifting. On examination, the Veteran had painful motion of his left ring finger. There was no gap between the thumb pad and the finger. The examiner stated that there is a gap of less than one inch between the ring finger and the proximal transverse crease of the palm. The painful motion begins at a gap of less than one inch. On examination the Veteran was able to perform repetitive use testing with three repetitions. There was no additional limitation of motion for any fingers after the three repetitions. There was no gap between the thumb pad and the fingers after three repetitions. There was a gap of less than one inch between left ring fingertip and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips after three repetitions. The examiner stated that the Veteran had functional loss or functional impairment but no additional limitation in range of motion of the ring finger following repetitive use testing. The functional loss for the left ring finger involved less movement than normal and pain on movement. Specifically, the left ring finger lacked 30 degrees from full extension at the PIP joint. There was tenderness or pain on palpation for joints or soft tissue of the left ring finger. Strength of the left ring finger was full. The examiner further stated that the Veteran has proximal interphalangeal joint ankylosis of the left ring finger in extension. Specifically, there is a gap of two inches or less between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible. The ankylosis condition does not result in limitation of motion of other digits or interference with overall function of the hand, however. The Veteran does not have any scars, surgical or otherwise, related to his left ring finger tendonitis. The Veteran does not use any assistive device. He does not have any other pertinent physical findings, complications, conditions, signs, and/or related symptoms. The examiner opined that the Veteran's left ring finger is not represented by functional impairment such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. X-rays of the left fourth finger were unremarkable. The examiner stated that the left ring finger condition does not impact the Veteran's ability to work. The January 2013 VA examination report reflects a diagnosis of residuals of mid-phalanx fracture of the fourth finger. The Veteran states that he cannot fully extend the finger from the proximal phalanx. He complained of pain in the PIP joint of this finger when lifting weights. There was evidence of painful motion of the left ring finger. There is no gap between the thumb pad and the fingers. Regarding finger flexion, there was a gap of less than one inch between the left ring fingertip and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips. Painful motion begins at a gap of less than one inch of the left ring finger. The Veteran was able to perform repetitive use testing with three repetitions. There was no additional limitation of motion for the left ring finger after the repetitive testing. There was no gap between the thumb pad and the fingers after three repetitions. There was a gap between the left ring fingertip and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips after three repetitions. The examiner stated that there was functional loss or functional impairment of the left ring finger in terms of less movement than normal and that the left ring finger lacks 30 degrees from full extension at the PIP joint. There was no additional limitation in range of motion of following repetitive use testing. There was tenderness or pain to palpation for the joints or soft tissue of the left ring finger. Muscle strength testing was full. The Veteran was noted to have ankylosis of the left ring finger PIP joint in extension. Specifically, there is a gap of two inches between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible. The ankylosis condition does not result in limitation of motion of other digits or interference with overall function of the hand. The Veteran does not have any scars, surgical or otherwise, related to his left ring finger tendonitis. The Veteran does not use any assistive devices. The Veteran's left ring finger condition does not result in impairment such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. Imaging studies of the left ring finger were normal. The examiner opined that the Veteran's left ring finger condition does not impact his ability to work. On review of the evidence above, the Board notes the rating schedule does not compensate for loss of motion or ankylosis of the fourth (ring) finger, regardless of how severe such limitation may be. Further, there is no evidence of osteoarthritis of the right ring finger to consider 38 C.F.R. § 4.71a, Diagnostic Code 5003. Accordingly, a compensable rating under the rating schedule is simply not available. The Board has also considered whether a higher rating is warranted under any other diagnostic code. In this regard, the Board finds that a higher rating is not warranted under Diagnostic Code 5155 because the Veteran's disability picture does not more nearly approximate amputation of the left ring finger. Specifically, the November 2012/January 2013 VA examiner opined that the functional impairment from the Veteran's left ring finger tendonitis status post fracture is not to the extent that no effective function remains other than that which would be equally well served by amputation with prosthesis. There is no contrary opinion of record. Therefore, a higher, 10 percent rating is not warranted under Diagnostic Code 5155. The Board has considered whether a compensable rating is necessary based upon functional loss due to flare-ups, pain, fatigability, incoordination, lack of endurance, and weakness. Pain on movement was noted; however, this is already contemplated by the current noncompensable rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-7. Thus, even considering the Veteran's pain and functional loss, a compensable rating is not warranted because there is no compensable schedular evaluation available for limitation of motion of the fourth finger. Cf. Burton, 25 Vet. App. 1 (2011). Furthermore, the functional impairment due to pain and less movement than normal does not rise to the level of functional impairment which would be equally well served by amputation with prosthesis. The Veteran has difficulty lifting weights for exercise, has pain on motion, and his left ring finger is ankylosed such that there is a gap of two inches between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible. He also has some difficulty lifting smaller objects. However, nothing in the medical evidence suggests functional impairment which would equate to that which would be as well served by amputation with prosthesis. The January 2013 VA examiner opined as such. Therefore, a higher rating based upon functional impairment is not warranted. Instead, the pain on movement and loss of motion is already contemplated by the assigned noncompensable rating. In sum, there is simply no basis upon which to grant a compensable rating for the Veteran's left ring finger tendonitis, status post fracture. Staged ratings are not warranted, as there appears to be no identifiable period on appeal during which the disability manifested symptoms meriting a compensable disability rating. The preponderance of the evidence therefore is against the Veteran's claim for a higher rating, and the benefit of the doubt rule does not apply. 38 U.S.C.A. § 5107(b). In making its determination, the Board considered the applicability of the benefit of the doubt rule. 38 U.S.C.A. § 5107(b) ; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). However, as a preponderance of the evidence is against the assignment of a compensable initial disability rating, such rule does not apply and the claim must be denied. In reaching this conclusion, the Board acknowledges the Veteran's belief that his left ringer finger tendonitis status post fracture is more severe than the current disability evaluations reflect. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the ratings schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, as a lay person without demonstration of requisite training, he is not competent to assess whether the symptomatology meets a specific disability rating under the applicable diagnostic code criteria. As such, the Board finds that the medical evidence of record is more persuasive regarding whether he is entitled to a higher disability rating in accordance with the schedular criteria. The VA examiners considered the Veteran's reported symptoms and provided the clinical findings to rate the Veteran's disability with respect to the rating criteria. Therefore, the Board finds that the medical evidence is more persuasive than the Veteran's own statements regarding his increased left ring finger symptomatology. Other Considerations According to VA regulation, in exceptional cases where schedular ratings are found to be inadequate, the RO may refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extraschedular 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). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and it is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, the evidence does not reflect that the available schedular evaluations for the service-connected right and left hand essential tremors and left ring finger tendonitis, status post fracture are inadequate. A comparison between the level of severity and symptomatology of the Veteran's hand tremor disabilities shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Moreover, there are higher schedular ratings for the right and left hand essential tremors, but they are for symptoms which are not present in this case. The Board recognizes that the Veteran's right and left hand essential tremors result in the Veteran having to perform his firearm qualification test slightly different than he would otherwise. However, the Board concludes that the Veteran's essential tremors of the hands have not causes marked interference with employment, or symptoms that are not already contemplated in the rating criteria. Moreover, the Veteran has not in any way alleged that his left ring finger tendonitis in any way interferes with his employment. Furthermore, the evidence does not show that his hand tremors or left ring finger tendonitis have necessitated frequent periods of hospitalization during the appeal period or otherwise rendered impracticable the regular schedular standards for rating such disabilities. Under these circumstances, referral for extraschedular consideration under 38 C.F.R. § 3.321(b)(1) is not warranted. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not argued, and the record does not otherwise reflect, that the disabilities at issue render him totally unemployable. In fact, the Veteran is currently employed full time. Accordingly, the Board concludes that a claim for TDIU has not been raised. ORDER Entitlement to an initial rating in excess of 10 percent for right hand essential tremor is denied. Entitlement to an initial rating in excess of 10 percent for left hand essential tremor is denied. Entitlement to a compensable initial rating for left ring finger tendonitis status post fracture is denied. ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs