Citation Nr: 1334348 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 07-34 461 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial disability rating greater than 10 percent for service-connected residuals of a lumbar strain injury prior to September 21, 2011; and greater than 20 percent thereafter. 2. Entitlement to an initial compensable disability rating for service-connected hyperhydrosis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The Veteran had active service from April 1983 to April 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Waco, Texas. In that decision, the RO, in pertinent part, granted service connection for residuals of a lumbar strain injury, assigning an initial 10 percent disability rating; and granted service connection for hyperhydrosis, assigning an initial zero percent disability rating. The RO also denied service connection for hypertension. The Veteran expressed disagreement with the respective initial disability ratings and with the denial of service connection, and perfected a substantive appeal. This matter was previously before the Board in April 2011 at which time it was remanded for additional development. It is now returned to the Board. As will be discussed further herein, the Board finds that the agency of original jurisdiction substantially complied with the remand orders, and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). During the pendency of this appeal, by rating action dated in June 2012 the RO determined that the Veteran's low back disability warranted a 20 percent disability rating, effective as of September 21, 2011. Applicable law provides that absent a waiver, a claimant seeking a disability rating greater than assigned will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and that a claim remains in controversy where less than the maximum available benefits are awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran has not withdrawn the appeal as to the issue of a disability rating greater than assigned, therefore, the issue remains in appellate status. By rating action dated in October 2012, service connection for hypertension was granted by the RO. As this represents a complete grant of the benefit sought on appeal, the issue is no longer before the Board. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file indicates that there is relevant information to the Veteran's current claims and such evidence has been considered accordingly. FINDINGS OF FACT 1. Prior to September 21, 2011, the Veteran's lumbar spine disability has not been manifested by 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 spasms or guarding severe enough to result in abnormal gait or abnormal spinal contour such as scoliosis, reverse lordosis, or abnormal kyphosis. 2. From September 21, 2011, the Veteran's lumbar spine disability has not been manifested by forward flexion of the thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. 3. The Veteran's hyperhydrosis is manifested by moisture on the hands which does not disable him from handling paper and tools. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating greater than 10 percent for service-connected residuals of a lumbar strain injury prior to September 21, 2011; and greater than 20 percent thereafter, have not been met. 38 U.S.C.A. § 1155, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5237 (2013). 2. The criteria for an initial compensable disability rating for hyperhydrosis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.118, Diagnostic Code 7832 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. This is an appeal arising from a grant of service connection in a February 2007 rating decision; and as the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify the Veteran in this case has been satisfied. See Hartman v. Nicholson, 483 F.3d 1311 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Nevertheless, in correspondence provided by the RO, the Veteran was notified of the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Next, the VCAA requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The Veteran's relevant service, VA, and private medical treatment records have been obtained. There is no indication of any additional, relevant records that the RO failed to obtain. The Veteran has been medically evaluated. The Board further observes that this case was remanded in April 2011 in order to obtain outstanding treatment records and afford the Veteran VA examinations so as to assess the severity of his asserted disabilities. Thereafter, additional private medical record, to specifically include those requested from Dr. R. J., were associated with the claims file, and the Veteran was afforded the requested VA examinations in September 2011. Therefore, the Board finds that the agency of original jurisdiction has substantially complied with the April 2011 remand directives such that no further action is necessary in this regard. See D'Aries, supra. In sum, the Board finds that the duty to assist and duty to notify provisions of the VCAA have been fulfilled and no further action is necessary under the mandates of the VCAA. Increased disability ratings Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Veteran is appealing the initial assignment of disability ratings, as such, the severity of each disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (2013). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). It is possible for a Veteran to have separate and distinct manifestations from the same injury that would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14 (2013) (precluding the assignment of separate ratings for the same manifestations of a disability under different diagnoses). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45 (2013). VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board observes that when rating spine disabilities, any additional limitation of motion that a Veteran has due to pain, weakness, or fatigue must be discussed. See Cullen v. Shinseki, 24 Vet. App. 74, 85 (2011). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The guidance provided under DeLuca must be followed in adjudicating claims where a rating under the diagnostic code provisions governing limitation of motion should be considered. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the diagnostic code provisions predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2013). Initially, the Board notes all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal, has been reviewed. Although there is an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Residuals of a Lumbar Strain Injury Disabilities of the spine are evaluated under a General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). The criteria of the General Rating Formula are applied with and without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Associated objective neurologic abnormalities, including but not limited to bowel or bladder impairment, are evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). The General Rating Formula pertinent to the lumbosacral spine provides a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is 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 and guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is from zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion is zero to 30 degrees, and left and right later rotation is zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. General Rating Formula, Note (2). Intervertebral disc syndrome is rated either under the General Rating Formula or alternatively under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, pursuant to Diagnostic Code 5243, whichever method results in a higher disability rating. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent disability rating is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the preceding 12 months. A 20 percent disability rating is warranted for incapacitating episodes having a total duration of at least two week but less than four weeks during the preceding 12 months. A 40 percent disability rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the preceding 12 months. The maximum 60 percent disability rating is warranted for incapacitating episodes having a total duration of at least six weeks during the preceding 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. VA regulations provide that an incapacitating episode is 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. See Note (1). Ankylosis is immobility and consolidation of a joint due to disease, injury, surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992) (memorandum decision); Nix v. Brown, 4 Vet. App. 462, 465 (1993); and Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). An April 2006 VA examination report shows that while still on active duty, the Veteran reported low back pain. There was no radiation, and the pain was not debilitating. He was able to function and perform daily activities. He was occasionally treated by a chiropractor. There were no flare-ups reported. There was no abnormal or fixed deformity. There were no reported incapacitating episodes within the prior 12 months. The Veteran used no mechanical aids to ambulate. Physical examination revealed the range of motion of the thoracolumbar spine was flexion to 70 degrees; extension to 20 degrees; right and left lateral flexion to 20 degrees; and, right and left rotation were to 40 degrees. The lumbar spine had normal curvature. There was tenderness to palpation. There was no pain, fatigue, weakness, lack of endurance, or incoordination with repetition. No diagnosis was established. A September 2011 VA examination report shows that the examiner noted the last VA examination had been in 2006. The Veteran was said to have had continued lumbar pain since that time. He denied any trauma to the lumbar spine since that time but had been treated with two cortisone injections. He reported working as an assistant engineer, and missing work for one week due to his lumbar strain. He added that he experienced at least one flare-up per month related to standing for a long time or from bending forward. These were alleviated by rest and over-the-counter pain medication. Physical examination of the back revealed range of motion of the thoracolumbar spine of flexion to 60 degrees, extension to 20 degrees, right side flexion to 30 degrees, left side flexion to 30 degrees, right rotation to 30 degrees, and left rotation to 25 degrees. The examiner noted objective evidence of pain on active range of motion and following repetitive motion. No additional limitation of motion, function, or impairment was noted. There was localized tenderness to palpation of the thoracolumbar spine. There was some guarding and muscle spasm present. Muscle strength was 5/5. There was no intervertebral disc syndrome found. The Veteran used no assistive devices to walk. X-rays of the lumbar joints revealed scoliosis, but were otherwise normal. There was no pain, fatigue, weakness, lack of endurance, or incoordination with repetition. After careful review of the evidence of record, the Board finds no basis for the assignment of an increased disability rating for either period on appeal. In this regard, incapacitating episodes of disc disease are neither shown, nor have such been alleged at any time. Thoracolumbar forward flexion has consistently been greater than 30 degrees. In fact, forward flexion was 70 degrees at on VA examination in April 2006, and 60 degrees in September 2011. Moreover, there was no additional loss of function with repetitive motion. The VA examiner was specifically asked to consider whether the Veteran would likely experience additional loss of function during periods of flare-up, and the examiner found that there would not be any such additional loss. Further considering the relevant rating criteria, muscle spasm and guarding was shown on examination, but abnormal gait or contour of the thoracolumbar spine has not been shown. The spine is not ankylosed. The schedule provides for a separate disability rating for any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). The medical evidence of record has not shown evidence of bladder complaints or bowel complaints. The evidence did not reveal any additional separately ratable neurological symptoms. As such, there is no other provision under which an additional separate disability rating may be assigned for the Veteran's disability. For the above reasons, the disability picture presented does not warrant a rating in excess of 10 percent prior to September 21, 2011; or a rating in excess of the currently assigned 20 percent thereafter under any applicable criteria. The Board has considered the statements of the Veteran as to the extent of his current symptoms. He is certainly competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. As noted above, consideration has been given to whether any additional staged ratings would be warranted. However, there appears to be no identifiable period over the course of this claim that any additional staged rating for the manifestations of the lumbar spine disability is warranted. Accordingly, the Board finds that the preponderance of the evidence is against the claim for a disability rating higher than 10 percent prior to September 21, 2011; and higher than 20 percent thereafter. Therefore, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Hyperhydrosis. Service connection for hyperhydrosis was granted in a February 2007 rating decision, and an initial noncompensable disability rating was assigned under the provisions of 38 C.F.R. § 4.118, Diagnostic Code 7832. Under Diagnostic Code 7832, a noncompensable disability rating is warranted where, after therapy, the Veteran is able to handle paper and tools. The maximum 30 percent disability rating is warranted where the Veteran is unable to handle paper or tools because of moisture, and the disability is unresponsive to therapy. The April 2006 VA examination report shows that it was noted that while the Veteran was still on active duty, he had been diagnosed with hyperhydrosis and had been successfully treated with Botox injections. A September 2011 VA examination report shows that the Veteran reported being given different antiperspirants and subsequently being treated with Botox injections which he noted had helped a lot. No other treatment was indicated. The examiner noted no scarring or disfigurement. There was no benign or malignant skin tumor; or any debilitating episodes in the preceding 12 months. There was no visible skin condition noted. The examiner concluded that the Veteran was able to handle paper or tools after treatment. He had no residual effects from the treatment. The examiner added that the Veteran's skin condition did not impact on his ability to work. The Board finds that the September 2011 VA examination report reveals symptomatic hyperhydrosis which was treated with Botox injections that were said to have helped. The Veteran did not indicate that the disability caused excoriations, rashes, lesions, vesicles, or night time symptoms. In the conclusion of the report, the examiner stated that the Veteran's hyperhydrosis did not impact his ability to work. After careful review of the evidence of record, the Board finds no basis for the assignment of an increased disability rating for the service-connected hyperhydrosis under the criteria set forth in Diagnostic Code 7832. The medical and lay evidence of record indicates that the Veteran has symptomatic hyperhydrosis in his hands that may be alleviated by therapy or medication. The evidence does not support a conclusion that the symptoms disable him from handling paper or tools. Despite the symptoms, the evidence is clear that he is able to handle paper and tools. His disability may cause him embarrassment, discomfort, inconvenience, or perhaps even reported difficulty in handling paper and tools. Nevertheless, he has retained the ability to handle such objects. The Board has considered the statements of the Veteran as to the extent of his current symptoms. He is certainly competent to report that his symptoms are worse. Layno, 6 Vet. App. at 470. However, in evaluating a claim for an increased schedular rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Consideration has also been given to whether any staged rating would be warranted. However, there appears to be no identifiable period over the course of this claim that any additional staged rating for the manifestations of the hyperhydrosis is appropriate. Accordingly, the Board finds that the preponderance of the evidence is against the claim for an initial compensable disability rating higher for the service-connected hyperhydrosis. Therefore, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert, 1 Vet. App. at 53-56. Extra-schedular Consideration Finally, the Board finds that the Veteran's low back disability and hyperhydrosis do not warrant referral for extra-schedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extra-schedular disability rating is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular disability rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board finds that the evidence does not warrant referral of the Veteran's claim for extra-schedular consideration. The level of severity of the Veteran's low back disability and hyperhydrosis are adequately contemplated by the applicable diagnostic criteria. The criteria provide for higher ratings, but as has been thoroughly discussed above, the ratings assigned herein are appropriate. In view of the adequacy of the disability rating assigned under the applicable diagnostic criteria, consideration of the second step under Thun is not for application in this case. Accordingly, the claim will not be referred for extra-schedular consideration. ORDER An initial disability rating greater than 10 percent for service-connected residuals of a lumbar strain injury prior to September 21, 2011; and greater than 20 percent thereafter, is denied. An initial compensable disability rating for service-connected hyperhydrosis is denied. ____________________________________________ DEMETRIOS G. ORFANOUDIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs