Citation Nr: 1325359 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 07-00 526 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an increased (compensable) rating for Dupuytren's disease, including residuals of excisions of benign nodules of the knuckle pads of the hands. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The Veteran had active service from May 1992 to February 2000 and from January 2004 to December 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2006 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in St. Louis, Missouri. In June 2010, February 2012, and February 2013, the Board remanded this case for additional development. The purposes of these remands have been met and the case is ready for appellate consideration. The Board notes that the issue of entitlement to service connection for an ear disorder was originally developed for appellate review; however, service connection for chronic, recurrent left external otitis was ultimately granted by the RO in a May 2013 rating action. Therefore, this issue is no longer before the Board. FINDING OF FACT The Veteran's Dupuytren's disease and residuals of excisions of benign nodules of the knuckle pads of the hands are manifested by subjective complaints of pain and objective evidence of some limitation of motion of the left thumb and long finger, but there is no objective evidence of arthritis or compensable limitation of motion. CONCLUSION OF LAW The criteria for an increased (compensable) rating for Dupuytren's disease, including residuals of excisions of benign nodules of the knuckle pads of the hands, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5024, 5228, 5229, 5230 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA enhanced VA's duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA also redefined the obligations of VA with respect to the duty to assist the veteran with the claim. Id. In the instant case, the Board finds that VA fulfilled its duties to the Veteran under the VCAA. Duty to Notify VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. The Board concludes that the letters dated in July 2005, November 2005, March 2006, February 2012, and March 2013 that were sent to the Veteran adequately apprised him of the information and evidence needed to substantiate the claim. The RO thus complied with VCAA's notification requirements. In order to meet the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Additionally, on March 3, 2006, the United States Court of Appeals for Veterans' Claims (Court) issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006), which 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. The Board finds that VA has met these duties with regard to the claim adjudicated on the merits in this decision. There is no issue as to providing an appropriate application form or completeness of the application. Written notice provided in July 2005, November 2005, March 2006, February 2012, and March 2013 fulfills the provisions of 38 U.S.C.A. § 5103(a). That is, the Veteran received notice of the evidence needed to substantiate his claim, the avenues by which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 394, 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005) (Mayfield I) rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In addition, the March 2006 letter also informed the Veteran about how VA determines effective dates and disability ratings, as required by Dingess. The Board also recognizes that, according to Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004), proper VCAA notice must "precede an initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service-connection claim." Written notice was provided in July 2005, November 2005, and March 2006, prior to the appealed from rating decision, along with the subsequent notice provided in February 2012 and March 2013, after the decision that is the subject of this appeal. With respect to any timing deficiency, the Board notes that the case was subsequently readjudicated in October 2007, June 2009, November 2009, November 2011, November 2012, and May 2013 supplemental statements of the case (SSOCs) and, as such, the Veteran has not been prejudiced thereby. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the Veteran has been prejudiced thereby). During the pendency of this appeal, the Court issued a decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), which pertains to a greater degree of specificity with respect to notice of the criteria necessary for an increased rating. However, this decision was recently vacated by the United States Court of Appeals for the Federal Circuit (Federal Circuit). See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). The Board finds that the July 2005, November 2005, March 2006, February 2012, and March 2013 letters substantially satisfy the current notification requirements for the claim on appeal. As the Veteran has not indicated any prejudice caused by a content error and no such error is apparent, the Board finds no basis for finding prejudice against the Veteran's appeal of the issue adjudicated in this decision. Shinseki v. Sanders, 129, S. Ct. 1696 (2009) regarding the rule of prejudicial error. The Veteran has been provided the opportunity to respond to VA correspondence and over the course of the appeal has had multiple opportunities to submit and identify evidence. Furthermore, he has been provided a meaningful opportunity to participate effectively in the processing of his claim by VA. Duty to Assist VA also has a duty to assist the veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence, and the Veteran received VA examinations in May 2006, July 2007, September 2007, May 2009, and April 2013, which were thorough in nature and adequate for the purposes of deciding this claim. The aforementioned VA examinations revealed findings that are adequate for rating the Veteran's Dupuytren's disease, including residuals of excisions of benign nodules of the knuckle pads of the hands. Thus, the Board finds that the medical evidence of record is sufficient to resolve this appeal; VA has no further duty to provide an examination or medical opinion. 38 C.F.R. §§ 3.326, 3.327. The Board also notes substantial compliance with the remand directives in its previous remands in June 2010, February 2012, and February 2013. In the June 2010 remand, the Board noted that the most recent SSOC did not address evidence that was pertinent to the issue of entitlement to an increased rating for benign nodules of the knuckle pads. Thus, upon remand, the RO was to readjudicate the claim for an increased rating for Dupuytren's disease, including residuals of excisions of benign nodules of the knuckle pads of the hands, based on a review of the entire evidentiary record. Subsequently, the RO readjudicated the claim in a November 2011 SSOC and considered all pertinent evidence. In the February 2012 remand, the Board noted that according to VA Medical Center (VAMC) outpatient treatment records, dated in March 2011, a VA examiner recommended that the Veteran undergo a left hand needle aponeurotomy so that offending knuckle pads could be excised. However, because the evidence of record was negative for any subsequent surgery reports, the Board remanded this case and directed the RO to obtain all pertinent VA treatment records, to include records created after March 2011. In addition, the RO requested that the RO afford the Veteran a VA examination in order to determine the current severity of his service-connected Dupuytren's disease and nodules of the knuckle pads of the hands. The Veteran's electronic ("Virtual VA") file includes VAMC outpatient treatment records, dated from March 2011 to October 2012. In March 2011, when the left hand needle aponeurotomy was recommended, it was noted that the Veteran did not want to undergo the procedure until fall 2011. However, the remaining outpatient treatment records are negative for any evidence showing that the Veteran subsequently underwent the left hand needle aponeurotomy. Thus, it appears that the Veteran did not undergo the procedure. In February 2013, the Board noted that although the Veteran failed to report to a scheduled VA examination, there was a question as to whether he had received notification of the examination at his most recent address. The Veteran had recently moved and it was not clear if the notification regarding his VA examination was sent to his new address. Thus, the Board remanded this case once again in order to afford the Veteran a VA examination. Pursuant to the February 2012 and 2013 remands, the Veteran underwent a VA examination in April 2013 that was pertinent to his claim for an increased (compensable) rating for Dupuytren's disease, including residuals of excisions of benign nodules of the knuckle pads of the hands. The examination provided information needed to assess the severity of the Veteran's Dupuytren's disease and nodules of the knuckle pads of the hands. In light of the above, the Board is satisfied there has been substantial compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). Based on the foregoing, it is the Board's determination that the VA fulfilled its VCAA duties to notify and to assist the Veteran, and thus, no additional assistance or notification was required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard, supra. II. Factual Background The Veteran's service treatment records show that in December 1999 the Veteran underwent excision of nodules of the knuckle pads of the left middle finger and right index, middle, and ring fingers. A January 2000 separation examination report included a diagnosis of benign knuckle pads. A VA examination was conducted in March 2000. The Veteran reported that he had developed scarring over the knuckles of both hands as a result of knuckle pad nodules removed in service. In a June 2000 rating action, the RO granted service connection for dyshidrotic eczema of the bilateral hands and feet, status post excision of benign bilateral knuckle pads. A 10 percent rating was assigned under Diagnostic Codes 7806-7819, effective from February 27, 2000. Service treatment records dated during the Veteran's second period of active service show that in July 2004, he complained of skin pads on the knuckles. The examiner noted there was obvious buildup of the knuckles of the middle fingers with no pain on palpation. In correspondence dated in June 2005, the Veteran requested an increase in the rating for his service-connected benign skin growth. Private medical records submitted in support of the claim include a June 2005 report which noted hand nodules, proximal interphalangeal (PIP) joints. The examiner indicated that the nodules were slightly tender to touch and not moveable. In addition, they were cystic like in appearance and feel. A VA examination was conducted in May 2006. The examiner stated that the Veteran had a history of excision of benign knuckle pads on the bilateral hands. At present, the Veteran was developing recurrence of the knuckle pads. The only symptom was tenderness when he bumped the knuckles, such as if he knocked on a door. Upon physical examination, the Veteran had slightly raised, mildly tender pads on the extensor surface of the PIP joints of digits 2, 3, and 4 of the right hand, and digits 3 and 4 of the left hand. The pertinent diagnosis was subcutaneous fibroma/knuckle pads of the right index, middle and ring fingers, and left middle and ring fingers, with no functional impairment. The Veteran had full extension and flexion of all fingers with normal hand function and normal opposition of the thumb, with normal dexterity of both hands. In a July 2006 rating action, the RO denied the Veteran's claim for an increased rating for his service-connected dyshidrotic eczema of the bilateral hands and feet, status post excision of benign bilateral knuckle pads. The Veteran subsequently filed a timely appeal. In statements submitted with his December 2006 VA Form 9, the Veteran reported that knuckle pads had returned to his hands and were painful upon contact. He asserted the growths were similar to symptoms seen in Dupuytren's contracture. The Veteran stated the disorder was extremely painful with activities such as lifting weights, performing push-ups, of extending his fingers beyond normal range of motion. He also claimed the disorder hindered his ability to exercise and perform various forms of manual labor. The Veteran submitted copies of medical articles addressing Dupuytren's contracture. A VA skin disorders examination was conducted in July 2007. The examiner stated that according to the Veteran, his knuckle pads had returned and he had experienced stiffness in the hands and palmar contracture over the past two to three years. The examiner noted papule/nodule over the PIP on the left 3rd and 4th digits and right 2nd, 3rd, and 4th digits. There was palmar thickening on the 3rd and 4th fingers, bilaterally. The Veteran was able to open his hands fully. The pertinent diagnosis was knuckle pads acquired during active service. According to the examiner, the knuckle pads were associated with a four times risk of Dupuytren's contracture in the literature, but not causal. An orthopedic evaluation was recommended. It was noted the disorder was causing more symptoms of hand stiffness and pain to the point of requiring over-the-counter pain relief medication. In September 2007, the Veteran underwent a VA orthopedic examination. Upon physical examination, there was one centimeter (cm) by .5 cm thickening of the dorsal left hand skin that was freely moveable and only slightly tender to the PIP joints of the 2nd, 3rd, and 4th fingers on the right, and the 3rd and 4th on the left. The greatest elevation was to the left ringer finger at .5 cm above the surface. There was full range of motion of all PIP joints and distal phalangeal joints with no restriction. Examination of the palmar surfaces revealed thickening of the palmar fascia involving the 3rd left finger and 5th right finger. The band was slightly thicker on the left than the right. There was full range of motion to the metacarpophalangeal and interphalangeal joints of all fingers. The palmar thickenings were nontender. Sensation was intact, there was no evidence of muscle atrophy, and there was a full grip, bilaterally, such that the tips of all fingers could touch the palm and there was full extension. The grip was firm with no evidence of pain on maximum gripping strength testing. X-ray studies revealed no bone abnormality, and no degenerative changes. The diagnoses were the following: (1) knuckle pads involving the PIP joints of both hands, and (2) Dupuytren's contracture to both palms without finger contraction. It was noted that the Veteran had Dupuytren's disease of both palms, but that there was no loss of motion and no true contracture other than thickening of the palmar fascia. The palmar thickening was noted to produce some symptoms but it was not disabling and did not limit activity. The examiner stated that knuckle pads did not cause Dupuytren's contracture, but that they could be associated in the some patients. VAMC outpatient treatment records show that in August 2008, the Veteran underwent an orthopedic surgery consultation. The physical examination showed that the Veteran had knuckle pads that were prominent on the left ring and middle fingers with a Dupuytren's cord present at the middle finger. There was no contracture of the middle finger and range of motion was adequate. Sensation was intact to light touch and capillary fill to the middle finger was brisk. There was a Dupuytren's cord to the right middle finger with no contracture and knuckle pads prominent, but less than on the left. The examiner noted that since there were no contractures at that time observation would be continued, but that they would proceed to with surgery if the Veteran developed contractures. A VA skin examination was conducted in May 2009. The Veteran stated that he had not received any treatment for his Dupuytren's disease to both palms over the past 12 months. He had complaints of occasional pain with trauma to the knuckle pads and functional impairment due to occasional pain when he banged his knuckles. Examination of the right hand revealed a five to six millimeter papule to the PIP joints of the 3rd and 4th fingers. There was a four millimeter thin papule to the left PIP joint and the metacarpophalangeal joint. There was no tenderness to touch and no loss of motion due to the knuckle pads. There was palmar thickening over the 3rd finger tendon, bilaterally, left greater than right. There was no disfigurement. The pertinent diagnosis was benign knuckle pads with no decreased range of motion. In a June 2009 rating action, the RO granted service connection for Dupuytren's disease and determined that such disease was a part of the Veteran's already service-connected nodules of the knuckle pads of the bilateral hands. Thus, the RO recharacterized the Veteran's service-connected dyshidrotic eczema of the bilateral hands and feet, status post excision of benign bilateral knuckle pads, as two separate disabilities: (1) dyshidrotic eczema of the bilateral hands and feet, and (2) Dupuytren's disease, to include residuals of excisions of benign nodules of the knuckle pads of the hands. The RO assigned a 0 percent disability rating under Diagnostic Code 5024, effective from January 1, 2005, for the Veteran's service-connected Dupuytren's disease with nodules of the knuckle pads of the hands. VAMC outpatient treatment records show that in March 2011, the Veteran underwent a physical examination. The examiner noted that the Veteran had palmar thickening and a left ring finger contracture. The left ring metacarpophalangeal joint was flexed at 15 degrees with no proximal interphalangeal joint disease. The left ring finger knuckle pad was sensitive. In a June 2010 decision, the Board denied the claim for a disability rating in excess of 10 percent for service-connected dyshidrotic eczema of the bilateral hands and feet. However, the claim for an increased (compensable) rating for Dupuytren's disease, including residuals of excisions of benign nodules of the knuckle pads of the hands, was remanded to the RO for additional development and remained on appeal. A VA examination was conducted in April 2013. The examiner stated that the Veteran described a tightness in the right 4th palmar area with thickening of the skin, without loss of functionality. The Veteran's left hand had the same symptoms but they had progressed further along with the palmar fibrosis in the 3rd digit. Extension was minimally affected. The Veteran was right hand dominant. According to the Veteran, his pain was a 7/10 all of the time. However, the examiner noted that the Veteran's vital signs were normal and certainly not indicative of pain in that range. The Veteran indicated that cold weather increased the pain and that he took medication daily to treat his pain. The physical examination showed that the Veteran had limitation of motion or evidence of painful motion for his left thumb and long finger. All remaining digits did not have those symptoms. There was no gap between the thumb pad and the fingers. In response to the question of whether there was a gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips, the examiner responded "no." The only limitation of extension was for the left long finger; it was limited by no more than 30 degrees ( unable to extend finger fully, extension limited to between 0 and 30 degrees of flexion). There was no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions. There was no additional limitation of motion post-test and there was no gap between the thumb pad and the fingers post-test. The Veteran did not have any functional loss or any functional impairment of the fingers or the thumbs. He did not have any tenderness or pain to palpation for joints or soft tissue of either hand, including the thumb and fingers. Hand grip was 5/5, bilaterally. The Veteran did not have ankylosis of the thum and/or fingers. In response to the question of whether, due to the Veteran's hand, finger or thumb conditions, was there functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis, the examiner responded "no." X-rays of the Veteran's right hand showed an old 5th metacarpal fracture. Otherwise, the x-rays were unremarkable with no joint space narrowing. In addition, x-rays of the Veteran's left hand were reported to be unremarkable with no fractures or joint space narrowing. The diagnoses were Dupuytren's contracture and Heloderma (nodules). The examiner stated that the Veteran's hand, thumb, or finger conditions did not impact his ability to work. According to the examiner, the examination revealed bilateral palmar fibrosis; otherwise, a normal examination. III. Analysis Disability ratings are determined by applying criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations should 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. See 38 C.F.R. § 4.7. For claims for increased rating which do not rise out of an initial grant of service connection, the Board must consider the application of "staged" ratings for different periods from the filing of the claim forward, if the evidence suggests that such a rating would be appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, the RO has evaluated the Veteran's service- connected Dupuytren's disease, including residuals of excisions of benign nodules of the knuckle pads of the hands, under Diagnostic Code 5024. Under Diagnostic Code 5024, tenosynovitis shall be rated based on limitation of motion of the affected part, as degenerative arthritis under 38 C.F.R. § 4.71a, Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2012). Under Diagnostic Code 5003, degenerative arthritis established by X- ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved, with a minimum rating of 10 percent to be assigned for each major joint affected. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. The rating criteria provided for limitation of motion of the hands/fingers are found at 38 C.F.R. § 4.71a, Diagnostic Codes 5228, 5229 and 5230. Diagnostic Code 5228 provides the rating criteria for limitation of motion of the thumb and assigns a noncompensable evaluation for a gap of less than one inch (2.5 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers; a 10 percent rating for a gap of between one to two inches (2.5 cm to 5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers; and a 20 percent rating for a gap of more than two inches (5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5228 (2012). Diagnostic Code 5229 provides the rating criteria for limitation of motion of the index or long finger and assigns a noncompensable evaluation for limitation of motion of the index finger or the long finger with a gap of less than one inch (2.5 centimeters) between the fingertip and the proximal transverse crease of the palm of the hand, with the finger flexed to the extent possible and extension is limited by no more than 30 degrees; a 10 percent rating requires limitation of motion of the index finger or of the long finger with a gap of one inch (2.5 centimeters) or more between the fingertip and the proximal transverse crease of the palm of the hand, with the finger flexed to the extent possible and extension is limited by no more than 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2012). Lastly, Diagnostic Code 5230 provides noncompensable evaluations for any limitation of motion of the ring or little finger. 38 C.F.R. § 4.71a, Diagnostic Code 5230 (2012). When, as here, an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). These factors include more or less movement than normal, weakened movement, premature/excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In this case, the only limitation of motion of the thumbs and/or fingers that has been shown is in the April 2013 VA examination where limitation of motion of the Veteran's left thumb and left long finger was documented. However, those findings do not merit the assignment of a compensable rating under the applicable diagnostic criteria. This is so because any limitation of motion of the left thumb or left long finger is not compensable under the applicable Diagnostic Codes. In order to warrant a 10 percent rating under Diagnostic Code 5228 for limitation of motion of the thumb, a gap of between one to two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, must be shown. However, there is no evidence that limitation of motion of the Veteran's left thumb results in a gap of one to two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. In fact, in the April 2013 VA examination, the examiner specifically stated that there was no gap between the Veteran's thumb pad and the fingers. Thus, a compensable rating under Diagnostic Code 5228 is not warranted for the limitation of motion of the Veteran's left thumb. The Board recognizes the Veteran's complaints of pain of the thumb. However, even with pain, there is no indication that the level of functional loss approximates the level of severity required for the assignment of the next higher rating. See 38 C.F.R. §§ 4.40, 4.45; see also Deluca, 8 Vet. App. at 202. In the April 2013 VA examination, the examiner reported that the Veteran did not have any functional loss or any functional impairment of the thumb. With respect to the Veteran's left long finger, the Board recognizes that in the April 2013 VA examination, the Veteran's left long finger had limitation of extension. However, it was limited by no more than 30 degrees. In order to warrant a 10 percent rating under Diagnostic Code 5229 for limitation of motion of the long finger, extension must be limited by more than 30 degrees [emphasis added] or the limitation of extension must result in a gap of one inch or more between the fingertip and the proximal transverse crease of the palm with the finger flexed to the extent possible. In this case, there is no evidence that limitation of motion of the Veteran's left long finger results in a gap of one inch or more between the fingertip and the proximal transverse crease of the palm with the finger flexed to the extent possible, or has extension limited by more than 30 degrees. In the April 2013 VA examination, in response to the question of whether there was a gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips, the examiner responded "no." In addition, he noted that limitation of extension of the left long finger was limited by no more than 30 degrees and that there was no additional limitation of motion following repetitive-use testing. Thus, a compensable rating under Diagnostic Code 5229 is not warranted for the limitation of motion of the Veteran's left long finger. The Board recognizes the Veteran's complaints of pain of the fingers. However, even with pain, there is no indication that the level of functional loss approximates the level of severity required for the assignment of the next higher rating. See 38 C.F.R. §§ 4.40, 4.45; see also Deluca, 8 Vet. App. at 202. In the April 2013 VA examination, the examiner reported that the Veteran did not have any functional loss or any functional impairment of the fingers. The Board also notes that Diagnostic Code 5230 is not applicable because there is no evidence of record showing that the Veteran has any limitation of motion of the ring or little finger of either hand. The Board acknowledges that the Veteran has maintained that he has pain in his thumb/fingers. In this regard, painful motion is an important factor of disability from arthritis and actually painful joints are entitled to at least the minimum compensable rating for the joint under 38 C.F.R. § 4.59. However, the x-ray evidence in this case does not reveal any arthritis in either the Veteran's right hand or left hand. In the absence of x-ray evidence of arthritis in either the Veteran's right hand or left hand, the minimum compensable (10 percent) rating allowed under 38 C.F.R. § 4.59 as a result of the Veteran's pain is not for application. A compensable rating is also not warranted under any other potentially applicable Diagnostic Code. In this regard, there is no evidence showing that the Veteran has ankylosis of any thumb/digit. See 38 C.F.R. § 4.71a, Diagnostic Codes 5216 - 5227 (2012). There is also no evidence showing that the Veteran's service-connected Dupuytren's disease, with nodules of the knuckle pads of the hands, is analogous to an amputation, or that it otherwise interferes with the overall function of the hand. In light of the foregoing, the Board finds that the Veteran is not entitled to an increased (compensable) rating for Dupuytren's disease, including residuals of excisions of benign nodules of the knuckle pads of the hands, at any point in the appeal period. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply and the claim must be denied. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). IV. Extraschedular Considerations The Board has also considered whether an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See Id. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's service-connected Dupuytren's disease, including residuals of excisions of benign nodules of the knuckle pads of the hands, that would render the schedular criteria inadequate. The Veteran's symptoms, such as pain and limited motion, are contemplated by the applicable diagnostic codes. As such, it would not be found that this disability met the "governing norms" of an extraschedular rating. Accordingly, referral for consideration of an extraschedular rating is not warranted. ORDER Entitlement to an increased (compensable) rating for Dupuytren's disease, including residuals of excisions of benign nodules of the knuckle pads of the hands, is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs