Citation Nr: 1331810 Decision Date: 10/03/13 Archive Date: 10/07/13 DOCKET NO. 10-05 983 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Evaluation of lumbar spine strain, initially rated as 20 percent disabling. 2. Evaluation of pterygium, initially rated as noncompensable. 3. Evaluation of residuals of a crush injury to the 1st, 2nd, and 3rd digits of the left hand, initially rated as noncompensable. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran had service from February 1986 to February 2006. This appeal comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which granted service connection for the Veteran's lumbar spine strain, pterygium, and residuals of a crush injury of the left hand. Noncompensable disability evaluations were assigned, effective March 1, 2006. Subsequently, in an April 2013 rating decision, the RO granted an increased, 20 percent disability evaluation for lumbar spine strain also effective from March 1, 2006. The Veteran continued to disagree with the rating assigned; therefore, the grant of a higher rating is not a full grant of the benefit sought on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). The Virtual VA claims file has been reviewed. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims held that a TDIU claim is part of an increased rating claim when such claim is reasonably raised by the record. In this case, however, the Veteran has not reported or testified that he cannot work due to his service-connected disabilities. Therefore, TDIU claim is not raised by the record in this case. FINDINGS OF FACT 1. Lumbar spine strain is manifest by pain and spasm without abnormal gait or spinal contour. Functional flexion is to 60 degrees and the combined range of motion is better than 120 degrees. 2. Pterygium is manifest by corrected vision of 20/40 or better at distance and near, without conjunctivitis or disfigurement. 3. Residuals of a crush injury of the 1st, 2nd, and 3rd digits of the left hand are manifest by complaints of weakness and reduced dexterity, without decreased range of motion or ankylosis. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for lumbar spine strain are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2013). 2. The criteria for a compensable disability rating for pterygium are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.84a, Diagnostic Codes 6034, 6079 (2008); 38 C.F.R. § 4.79, Diagnostic Codes 6034, 6066 (2013). 3. The criteria for a compensable disability rating for residuals of a crush injury to the 1st, 2nd, and 3rd digits of the left hand are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5222, 5228-5229 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the agency of original jurisdiction (AOJ) issued a notice letter, dated in August 2006, to the Veteran. This letter explained the evidence necessary to substantiate the Veteran's initial claims for service connection and the downstream issues of an increased rating, as well as the legal criteria for entitlement to such benefits. The letter also informed him of his and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The claims file contains the Veteran's available service treatment records, reports of VA and private post-service treatment, and the Veteran's own statements in support of his claims. The Veteran was afforded VA examinations responsive to the initial claims for service connection and the subsequent claims for increased ratings. The Board has reviewed the examination reports, and finds that they are adequate for the purpose of deciding the issues on appeal. The examination reports contain all the findings needed to rate the Veteran's service-connected lumbar spine strain, pterygium, and residuals of a crush injury of the left hand, including history and clinical evaluation. The Veteran's appeal for higher evaluations, is distinguished from the facts in Proscelle v. Derwinski, 2 Vet. App. 629, 633 (1992), where no VA examination was provided during the rating claim, and a veteran specifically stated that his disability "has increased in severity [such] that I rate a higher disability," constituting at least both some assertion by the veteran and some evidence of worsening of disability since the last VA examination. Proscelle, 2 Vet. App. at 632. In the Veteran's case currently on appeal to the Board, there is no evidence of worsening of the Veteran's disability since the 2012 VA examinations, including no assertion by the Veteran of worsening since the last VA examination. The Veteran here does not assert that his lumbar spine strain, pterygium, and residuals of a crush injury of the left hand have worsened since the December 2012 VA examinations; he merely asserts entitlement to a higher disability evaluation. The Veteran has not submitted evidence of worsening, and the evidence of record, including the medical evidence reflecting on the severity of the disability on appeal, does not suggest that these disabilities worsened since the most recent VA examinations, or since the most recent VA treatment records. As there is no evidence of worsening since the last VA examination, a remand for a new VA examination is not warranted, and is not required by the VCAA. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination); VAOPGCPREC 11-95 (interpreting that a new examination is appropriate when there is an assertion of an increase in severity since the last examination). The Veteran has been afforded adequate examinations on the issue decided herein. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, the Veteran has not alleged that any examination is inadequate to decide the claims being adjudicated herein, so the examinations are presumed to have been adequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of the opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Legal Criteria for Increased Disability Evaluation Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disability has not significantly changed and a uniform evaluation is warranted. In addition, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Analysis for Increased Disability Evaluation Lumbar Spine Lumbosacral and cervical spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine ("general rating formula"). 38 C.F.R. § 4.71a, DCs 5237-5242. Intervertebral disc syndrome (IVDS) is rated under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. See 38 C.F.R. § 4.71a, DC 5243. According to the general rating formula, a 20 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is to be assigned for unfavorable ankylosis of the entire thoracolumbar spine. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, entire thoracolumbar spine, or entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 68 Fed. Reg. 51,443, Note (5) (Aug. 27, 2003). The Formula for Rating IVDS Based on Incapacitating Episodes provides for ratings from 10 to 60 percent based on the frequency and duration of incapacitating episodes, defined in Note 1 as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. The maximum 60 percent schedular rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the previous 12 months. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note 1 provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note 2 provides that, for VA compensation purposes, the combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. Note 4 provides that range of motion measurements are to be rounded to the nearest five degrees. Note 5 defines unfavorable ankylosis as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note 6 provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The Veteran's lumbar spine strain is evaluated as 20 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237. The Veteran was initially afforded a VA examination in August 2006. According to the examination report, the Veteran complained of a constant dull aching pain, without radiation or flare-up. The Veteran does not use a brace or aid to ambulate. He denied incapacitating episodes and limitation of daily activities; he can walk up to 4 to 5 miles. Examination of the spine did not show any deformity; there was mild tenderness of L4-5. Range of motion showed flexion to 90 degrees and 30 degrees extension; right lateral flexion was to 50 degrees, left lateral flexion was to 40 degrees, and rotation was normal bilaterally. There was no weakness, fatigue, incoordination, or lack of endurance upon repetitive range of motion. Strength was 5/5 in all extremities, with intact sensation and normal deep tendon reflexes. X-rays showed mild straightening of the lumbar spine. The Veteran was most recently afforded a VA examination in December 2012. According to the report, the Veteran complained of intermittent pain, spasm, weakness, left lower extremity radiculopathy, and limited motion. He reported treatment with physical and chiropractic therapy. The Veteran related that he experiences flare-ups involving "general debility" until his pain ebbs, with occasional bed rest and minimal activity. Range of motion testing showed forward flexion to 60 degrees, with pain at 30 degrees; extension to 10 degrees, with pain at 5 degrees; lateral flexion to 25 degrees bilaterally, with pain at 10-15 degrees; and rotation to at least 30 degrees bilaterally, with pain at 20 degrees. The Veteran was able to perform repetitive use testing, with additional limitation of motion and pain, as indicated, upon such testing. The Veteran did not have localized tenderness or pain to palpation of the spine, but he did have guarding and/or muscle spasm without abnormal gait or spinal contour. Strength testing was 5/5 for hips, knees, ankles, and toes; there was no muscle atrophy and deep tendon reflexes were 2+ bilaterally. Sensory testing was normal and straight leg testing was negative. The Veteran had intermittent, mild radiculopathy of pain and paresthesias of the left lower extremity; there was involvement of L4-5, S1-3. The Veteran did not have intervertebral disc syndrome or incapacitating episodes; he does not use any assistive devices. X-rays did not show arthritis or vertebral fracture. The VA examiner noted that the Veteran cannot participate in activities involving moderate to high impact due to his lumbar spine pain and decreased range of motion. The Veteran has been assigned a 20 percent evaluation for his lumbar spine strain. The 20 percent evaluation contemplates pain on motion. 38 C.F.R. § 4.59 (2013). It is also consistent with flexion to 60 degrees, with muscle spasm and guarding, albeit without abnormal gait or spinal contour. In order to warrant a higher evaluation, there must be the functional equivalent of limitation of flexion to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Here, the Veteran has complained of pain and limitation of motion. After a review of the lay and medical evidence, the Board finds that an evaluation in excess of 20 percent is not warranted. 38 C.F.R. § 4.7. The evidence of record indicates that the Veteran's lumbar spine strain was productive of pain with combined range of motion of the thoracolumbar spine of 180 degrees at the December 2012 VA examination; this is much better than motion limited to 120 degrees. The Veteran's thoracolumbar strain was productive of no worse than forward flexion to 60 degrees at his December 2012 VA examination; extension was to 10 degrees and lateral rotation and flexion were to at least 25 degrees. Likewise, he had normal gait and negative straight leg testing. Reflexes and strength testing were normal. X-rays did not show arthritis or vertebral fracture. Clearly, this examination demonstrated that he did not have abnormality of gait or the spinal contour. He had pain on motion, spasm, and guarding, with some additional limitation of motion due to pain, but without tenderness to palpation. Thus, applying the facts to the criteria set forth above, the Veteran remains entitled to no more than a 20 percent evaluation for his service-connected lumbar spine strain under the General Rating Formula for Diseases and Injuries of the Spine. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. The Board finds that the Veteran's subjective complaints of pain and spasm have been contemplated in the current rating assignment. The August 2006 and December 2012 VA examination reports indicate that the Veteran complained of pain and spasm, but physical examination did not demonstrate any additional limitations in response to pain, including incoordination, weakness, or fatigability. Even when we consider the pleadings regarding pain and spasm as credible, neither the lay nor medical evidence suggests that flexion is functionally limited to 30 degrees or that the combined range of motion is functionally equivalent to favorable ankylosis. The Board accepts that he has pain at 30 degrees of flexion. However, the evidence establishes that his pain does not actually restrict motion. See Mitchell, supra. His reports of pain, limitation of motion, and spasm are credible, but do not provide a basis for a higher evaluation. In essence, the Board finds that the lay and medical evidence are not significantly dissimilar. However, neither the lay nor medical evidence provide a basis for a higher evaluation. Rather, the evidence establishes that remaining functional flexion is 60 degrees, the remaining combined range of motion is better than 120 degrees and that there is no abnormality of gait or spinal contour. Further, the evidence does not show favorable or unfavorable ankylosis of the entire thoracolumbar spine during the rating period on appeal. The evidence establishes that the Veteran's lumbar spine strain has not been productive of incapacitating episodes. Although the Veteran reported experiencing flare-ups at the VA examinations, there is no indication that the flare-ups required bed rest by a physician and treatment by a physician. Moreover, although the Veteran reported that he occasionally treats his flare-ups with bed rest and minimal activity, the Board observes that the Veteran did not report any incapacitating episodes requiring bed rest by a physician and treatment by a physician. With consideration of the provisions of Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, the neurological examinations at these examinations showed decreased strength and sensation in the left lower extremity due to his service-connected lumbar spine strain; the Veteran was granted service connection for radiculopathy of the left lower extremity in an April 2013 rating decision, and assigned a separate 10 percent disability evaluation, effective December 18, 2012. As the Veteran is separately evaluated for his neurological deficits of his left lower extremity, it is not for consideration here. Pterygium The schedular criteria for evaluating disabilities of the eye have undergone revision during the pendency of this appeal. At the time of the Veteran's claim and initial disability evaluation, in March 2006, he was rated in accordance with 38 C.F.R. § 4.84a, Diagnostic Code 6034 for pterygium, which was to be rated for impairment of central visual acuity. Under the applicable rating criteria, impairment of central visual acuity is evaluated from noncompensable to 90 percent disabling based on the degree of the resulting impairment of visual acuity. See 38 C.F.R. § 4.79, Diagnostic Codes 6061-6066. A disability rating for visual impairment is based on the best distance vision obtainable after the best correction. See 38 C.F.R. § 4.75. The rating criteria at that time called for a noncompensable disability rating where there was vision of 20/40 bilaterally. An increased, 10 percent disability rating whether there was vision in one eye of 20/100 and vision in the other eye of 20/40. See 38 C.F.R. § 4.84a, Diagnostic Code 6079 (2008). The rating criteria was amended in 2008. 73 Fed. Reg. 66,550 (Nov. 10, 2008). According to the revised Code, the Veteran's pterygium is rated in accordance with in accordance with 38 C.F.R. § 4.79, Diagnostic Code 6034, which calls for rating pterygium for impairment of central visual acuity, disfigurement (Diagnostic Code 7800), or conjunctivitis (Diagnostic Code 6018), depending on findings. Impairment of visual acuity is rated noncompensable where there is vision of 20/40 bilaterally. A 10 percent disability rating is warranted where there is vision in one eye of 20/50 to 20/100 and vision in the other eye is 20/40. An increased, 20 percent evaluation is warranted for vision in one eye of 20/70 to 20/100 and vision in the other eye of 20/50. See 38 C.F.R. § 4.79, Diagnostic Code 6066 (2013). The Veteran was initially afforded a VA eye examination in September 2006. That report, the Veteran complained of discomfort and burning, not alleviated with drops. He denied current treatment. Upon evaluation, visual acuity uncorrected was 20/20, near and distance, bilaterally. The Veteran does not wear corrective lenses and there was no diplopia; pupils were 6mm in the dark and 4mm in the light. Slit lamp examination was normal. He had pterygium nasally with cornea encroachment in both eyes and pinguecula temporally in both eyes, without interference in vision. No treatment was recommended. Treatment records from Effingham Ophthalmology, dated April 2007, indicate that the Veteran complained of worsening pterygium, with dryness of the eyes. Treatment records from Adams Family Eye Care show that the Veteran complained of burning of the eyes and red pterygium. Conjunctiva were clear. Red and inflamed nasal pterygium were noted. The Veteran was most recently afforded a VA examination in December 2012. According to the report, visual acuity testing showed uncorrected distance vision of 20/40 bilaterally, uncorrected near vision of 20/100 bilaterally, and corrected near vision of 20/40. Pupils are 4mm, round, and reactive to light; there was no afferent papillary defect. There was no anatomical loss, light perception only, extremely poor vision, or blindness of either eye. There was no corneal irregularity resulting in astigmatism or diplopia. Tonometry showed pressure of 18 bilaterally; slit lamp examination and conjunctiva were normal. Examination of the cornea showed nasal pterygium of 3mm in the right eye and 2mm in the left eye. The iris, lens, anterior chamber, and fundus were normal. There was no visual field defect. There was no evidence of scarring or disfigurement, corneal irregularity, or incapacitating episodes. The Veteran's pterygium does not impact the Veteran's ability to work. After a review of all the evidence, the Board finds against an increased, compensable evaluation for the Veteran's pterygium, for the entire rating period on appeal. At the September 2006 VA examination, the Veteran had uncorrected visual acuity of 20/20 bilaterally, near and at distance. Pupils were 4mm, with positive reaction. His pterygium were 2mm on the right and 1.5mm on the left. At the December 2012 VA examination, the Veteran had corrected visual acuity at near of 20/40 bilaterally; uncorrected distance visual acuity was 20/40 or better in both eyes. The Veteran's pupils were round and reactive to light; there was no evidence of corneal irregularity, diplopia, or visual field defects. Slit lamp and external eye examinations were normal. There was no disfigurement or scarring and conjunctiva were normal. Thus, applying the facts to the criteria set forth above, the Veteran is not entitled to an increased, compensable evaluation for his service-connected pterygium for the entire rating period on appeal under either the previous or current General Rating Formula for Diseases of the Eye. Further, the evidence does not show that the Veteran anatomical loss of an eye, no more than light perception in one eye, poor vision or blindness of the eye. As previously stated, there is also no demonstration diplopia, disfigurement or conjunctivitis. For these reasons, the Board finds that the Veteran's current noncompensable disability rating for his pterygium most appropriately represents the impairment of his visual acuity under either the previous or current rating criteria. Residuals of Crush Injury The Veteran was initially assigned a noncompensable evaluation for residuals of a crush injury to the 1st, 2nd, and 3rd fingers of the left hand pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5222, which provides for a 20 percent evaluation for favorable ankylosis of three digits of one hand. However, as discussed below, the Veteran does not have ankylosis of the left hand. Diagnostic Codes 5228-5229 are also for consideration. A noncompensable disability evaluation is assigned for limitation of motion of the thumb with a gap of less than one inch (2.5cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 10 percent disability evaluation is assigned for a gap of one to two inches (2.5 to 5.1 centimeters) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Under Diagnostic Code 5229, a noncompensable disability evaluation is assigned for limitation of motion of the long finger with a gap of less than one inch between the fingertip and the proximal transverse crease of the palm with the finger flexed or with extension limited by no more than 30 degrees. A 10 percent disability evaluation is assigned where there is limitation of motion with a gap of one inch between the fingertip and the proximal transverse crease of the palm with the finger flexed or with extension limited by more than 30 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2013). The Veteran was initially afforded a VA examination in August 2006. The report indicates that the Veteran is right hand dominant. He complained of numbness of the 2nd and 3rd digits of the left hand, as well as the left thumb; he denied weakness and pain. Examination of his left hand showed normal flexion and extension of the carpometacarpal, proximal interphalangeal, and distal interphalangeal joints of the 2nd and 3rd digits of the left hand. He also had normal range of motion of the left thumb, and can approximate his left thumb to the tips of the 2nd through 5th digits of the left hand. The most recent, December 2012 VA examination report states that the Veteran complained of reduced dexterity and weakness from pain and numbness during flare-ups; he also complained of decreased motion of the fingers in the winter. The Veteran is right hand dominant. Upon examination, there was no limitation of motion or painful motion, even after repetitive motion testing. The Veteran did not have any functional loss or impairment of the left hand, fingers, or thumb; there was no weakness, excess fatigability, pain on movement, incoordination, swelling, or deformity. There was also no pain on palpation, hand grip was 5/5, and there was no ankylosis. X-rays did not show acute fracture or dislocation; there was deformity at the distal phalangeal tuft of the 2nd and 3rd digits, but soft tissue was normal. The competent evidence of record does not support a compensable evaluation under Diagnostic Code 5228 or 5229. Although the Veteran had complaints of pain and reduced dexterity with flare-ups at the December 2012 VA examination, there was no limitation of motion of the thumb or the 1st through 5th fingers; the Veteran had full grip strength, and there was no functional loss or weakened movement of his left hand. There was no evidence of incoordination, atrophy, or ankylosis. See 38 C.F.R. § 4.71a, Diagnostic Codes 5222, 5228-5229. Although he complained of numbness, he is separately rated for carpal tunnel syndrome. The Board has also reviewed the competent evidence of record and finds no basis for a higher evaluation under the rating criteria for scars. A scar was noted at the December 2012 VA examination, but it was not greater than 6 square inches (39 sq. cm), painful, or unstable. As such, that Diagnostic Code cannot serve as a basis for a higher rating. Therefore, a higher, compensable rating is not warranted. Here, the most probative evidence consists of the medical evidence prepared by skilled examiners. That evidence establishes that there is minimal, if any, functional impairment. The preponderance of the evidence is against the claim and there is no doubt to be resolved. Lay Pleadings One function of the Board is to consider the lay evidence and pleadings. However, other than that recorded during medical evaluations, the record is remarkably lacking in substantive pleadings from the Veteran or the representative. Under the circumstances, the medical evidence is more probative than any implied pleadings or lay evidence. The Board has considered the statements by the Veteran. We accept as credible that pain reduces range of motion of his lumbar spine, that he experiences difficulty in focusing due to his pterygium, and that he has reduced usefulness and numbness due to residuals of a crush injury of the left hand. However, neither the lay nor medical evidence suggests that these disabilities functionally limit the Veteran. Extraschedular Considerations As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's lumbar spine strain, pterygium, and residuals of a crush injury of the left hand are fully contemplated by the applicable rating criteria. As shown above, the criteria include symptoms, each of which were addressed in the VA examination reports and treatment records and which provided the basis for the disability ratings that were assigned. The Veteran has no complaints other than discomfort due to a burning sensation regarding his eyes, which was considered as part of determining his evaluation; however, such complaints had no impact on his vision, and did not cause disfigurement or conjunctivitis. With regard to his lumbar spine and left hand, he complains of pain and reduced motion as a result of each disability, which was clearly considered in the range of motion testing that was carried out and which serves as the basis for his assigned disability rating for his lumbar spine strain and residuals of a crush injury of the left hand. In any event, the evidence does not reflect that there has been marked interference with employment, frequent hospitalization, or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. The Veteran alleged that lumbar spine strain interferes with his ability to work, but he did not indicate that he had to miss any time from work due to his lumbar spine strain, pterygium, or residuals of a crush injury of the left hand. According to the Veteran, his lumbar spine strain, pterygium, and residuals of a crush injury of the left hand prevent high energy activity, but have no other impact on his employment. Therefore, referral for consideration of extraschedular ratings for the Veteran's lumbar spine strain, pterygium, and residuals of a crush injury of the left hand is not warranted. 38 C.F.R. § 3.321(b)(1). In the absence of exceptional factors associated with lumbar spine strain, pterygium, and residuals of a crush injury of the left hand, the Board finds that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to a disability evaluation in excess of 20 percent for lumbar spine strain is denied. Entitlement to a compensable disability evaluation for pterygium is denied. Entitlement to a compensable disability evaluation for residuals of a crush injury to the 1st, 2nd, and 3rd digits of the left hand is denied. ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs