Citation Nr: 1336582 Decision Date: 11/08/13 Archive Date: 11/22/13 DOCKET NO. 05-31 662 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an evaluation higher than 40 percent for degenerative arthritis, lumbar spine. 2. Entitlement to an evaluation higher than 10 percent for osteochondritis of the left fifth metacarpal with Dupuytren's Contracture. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION The Veteran served on active duty from June 1966 to June 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. Two hearings have been conducted in this case, one in May 2006 before a local Decision Review Officer (DRO), and another a February 2010 Travel Board hearing at the RO before the undersigned Veterans Law Judge (VLJ). Transcripts of the proceedings are of record. During pendency of the appeal, claims previously on appeal, for service connection for major depressive disorder and anxiety (originally claimed as posttraumatic stress disorder (PTSD)) and for entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) have been granted by the RO, and consequently are no longer on appeal. The Board has remanded this case twice before - most recently in January 2013 to ensure that the Veteran received an updated Supplemental Statement of the Case (SSOC) at his existing home address, and to ensure that the results of a prior March 2011 VA Compensation and Pension examination were properly supported by clinical findings made with a goniometer (for assessing joint range of motion). These development objectives having been completed, the case has been returned to the Board for an appellate disposition. Through correspondence of June 2013, the Veteran raised the additional claim for service connection for bilateral foot disorder. As this matter has not been addressed by the RO as the Agency of Original Jurisdiction (AOJ), the claim is being referred there for initial review and adjudication. FINDINGS OF FACT 1. The Veteran does not experience any joint ankylosis involving the thoracolumbar spine. There is also no indication of separate compensable neurological disability, or any recognized incapacitating episodes of Intervertebral Disc Syndrome (IVDS) 2. The condition of osteochondritis of the left fifth metacarpal with Dupuytren's Contracture, to the extent involving limitation of motion and/or joint ankylosis, cannot be compensated on this basis pursuant to the VA rating schedule, including in excess of the 10 percent rating previously assigned when this condition was rated as analogous to a finger joint amputation under 38 C.F.R. § 4.71a, Diagnostic Code 5156, as there is not attendant symptomatology or severe functional limitation to warrant any higher analogous rating under Diagnostic Code 5156. CONCLUSIONS OF LAW 1. The criteria are not met to establish an evaluation higher than 40 percent for degenerative arthritis, lumbar spine. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71; 4.71a, Diagnostic Code 5242 (2013). 2. The criteria are not met to establish an evaluation higher than 10 percent for osteochondritis of the left fifth metacarpal with Dupuytren's Contracture. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71; 4.71a, Diagnostic Codes 5156, 5227, 5230 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist the Claimant The Veterans Claims Assistance Act, codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2002 & Supp. 2013), prescribes several requirements as to VA's duty to notify and assist a claimant with the evidentiary development of a pending claim for compensation or other benefits. Implementing regulations were created, codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2013). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must inform the claimant of any information and evidence (1) that is necessary to substantiate the claim; (2) that the claimant is expected to provide; and (3) that VA will seek to provide on the claimant's behalf. See also Pelegrini v. Principi, 18 Vet. App. 112, 120-121 (2004) ("Pelegrini II"). A regulatory amendment effective for claims pending as of or filed after May 30, 2008 removed the requirement that VA specifically request the claimant to provide any evidence in his or her possession that pertains to the claim. 73 Fed. Reg. 23,353-56 (Apr. 30, 2008), later codified at 38 CFR 3.159(b)(1) (2013). Through December 2004 VCAA correspondence the RO has informed the Veteran of what evidence would substantiate his claims for increased rating as to each element of satisfactory notice. The VCAA notice further indicated the joint obligation between VA and the Veteran to obtain pertinent evidence and information, including that VA would undertake reasonable measures to assist in obtaining further VA medical records, private treatment records and other Federal records. See Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). The relevant notice information must have been timely sent. The U.S. Court of Appeals for Veterans Claims (Court) in Pelegrini II prescribed as the definition of timely notice the sequence of events whereby VCAA notice is provided in advance of the initial adjudication of the claim. See also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In this instance, the VCAA notice correspondence was issued prior to the March 2005 RO rating decision adjudicating the increased rating claims being decided, and therefore met the criteria for timely notice. The RO (including through the Appeals Management Center (AMC)) has taken appropriate action to comply with the duty to assist the Veteran through obtaining VA outpatient treatment records. There is no indication of relevant private treatment records to obtain. The Veteran has also undergone several VA Compensation and Pension examinations. See 38 C.F.R. §4.1 (for purpose of application of the rating schedule accurate and fully descriptive medical examinations are required with emphasis on the limitation of activity imposed by the disabling condition). In furtherance of his claim, the Veteran has provided several personal statements. He has testified during DRO and Travel Board hearings. The record as it stands includes sufficient competent evidence to decide the claims. Under these circumstances, no further action is necessary to assist the Veteran. In sum, the record reflects that the facts pertinent to the claims being decided have been properly developed and that no further development is required to comply with the provisions of the VCAA or the implementing regulations. That is to say, "the record has been fully developed," and it is "difficult to discern what additional guidance VA could [provide] to the appellant regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F. 3d. 1369 (Fed. Cir. 2004). Accordingly, the Board will adjudicate the claims on the merits. Background and Analysis Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. § 4.1 (2013). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating a musculoskeletal disability based upon a range of motion, consideration is given to the degree of any additional limitation upon motion due to functional loss. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). This includes the analysis of additional functional impairment above and beyond the limitation of motion objectively demonstrated involving such factors as painful motion, weakness, incoordination, and fatigability, etc., particularly during times when these symptoms "flare up," such as during prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. Id. See also 38 C.F.R. §§ 4.40, 4.45 and 4.59. In this regard, manifestation of pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). A. Lumbar Spine Degenerative Arthritis The Veteran's service-connected lumbar spine disability is rated at 40 percent disabling under provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5242, for degenerative arthritis. Under applicable rating criteria, the Veteran's condition is to be evaluated in accordance with VA's General Rating Formula for Diseases and Injuries of the Spine. This rating formula provides for the assignment of a 10 percent rating when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range 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 of more of the height. A 20 percent rating is for assignment upon a showing of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or a 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. The next higher available 40 percent rating is made for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation requires unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating may be assigned due to unfavorable ankylosis of the entire spine. Under notes to the rating formula: Note (1) Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which 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 (0 degrees) always represents favorable ankylosis. Upon VA Compensation and Pension examination of January 2005, the Veteran indicated that due to a lumbar spine condition he had experienced lower back pain for 12 years. The pain occurred constantly, and traveled up and down the spine and legs. The pain was crushing in nature, squeezing, burning, aching, oppressing, sharp, sticking and cramping. On a scale of 1 to 10, pain level was estimated at 10. At the time of pain he could function with use of medication. The condition reportedly did not cause incapacitation. The functional impairment was that he could only walk half a block, carry only 35 pounds, and sit for 30-60 minutes. Gait was abnormal, and the Veteran walked with a limp and using a cane. Physical examination of the thoracolumbar spine revealed no complaints of radiating pain on movement. Muscle spasm was absent. There was tenderness noted on examination. There was positive straight leg raising on the right and left. Range of motion testing revealed thoracolumbar spine flexion to 90 degrees; extension to 30 degrees, right and left lateral flexion to 30 degrees; and right and left rotation 30 degrees. Range of motion of the spine was additionally limited after repetitive use by pain, fatigue, weakness, lack of endurance, and incoordination, with incoordination having the major functional impact. There was no ankylosis of the spine. There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement. The peripheral nerve examination was within normal limits. Neurological evaluation of the lower extremities revealed the findings of motor function within normal limits. Sensory function was within normal limits. Right and left lower extremity reflexes revealed knee jerk 1+ and ankle jerk absent. A lumbar spine x-ray report showed degenerative arthritis. The diagnosis was lumbar strain. Records of VA outpatient treatment from June 2005 reflect that the Veteran complained of pain throughout several regions, including pain in the lower back, worse right than left side, which had worsened over the last couple of years and was constant, but worse with walking and moving. Occasionally the pain radiated to the bilateral knees, causing the knees to buckle. He also stated that he had non-painful numbness on the lateral portions of both legs. Lumbosacral spine range of motion was measured at flexion to 100 degrees, extension to 10 degrees, right and left lateral bending to 15 degrees, and right and left lateral rotation 35 degrees. Neurologically, there was decreased sensation throughout the lower extremities bilaterally. X-ray imaging showed multi focal degenerative disease changes of the lumbar spine, most focal at L3-4 where there was a small far lateral left sided disc protrusion. There was no apparent associated nerve root compression. The impression was in part, myofascial pain syndrome. Upon VA re-examination of May 2008, the Veteran described pain in his lower back, as well as pain in his legs, though not radicular pain. He also would get numbness in his legs; however, this was global numbness, that occurred primarily when he was sitting and was consistent with meralgia paresthetica. This was because of his obese abdomen placing pressure on the femoral artery and the femoral aspect of the nervous system which caused a global type of paresthesia in the legs. It was not related to his lumbar spine. He did have a back brace but did not use it as it was uncomfortable. He did use a cane. He had no incapacitating events. There was no bowel, bladder or sexual dysfunction. He did get flare-ups primarily with pain with prolonged walking. He had had no specific injury and no surgery. Daily activities were affected in limited walking and standing. Objectively, the Veteran had normal gait and normal posture. He had no indication of spinous or paraspinous tenderness, or of muscle spasm. He was capable of flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion of 30 degrees, and right and left lateral rotation 30 degrees. There was no indication of pain, weakness or fatigue on repetitive motion. There was negative straight leg raising on both the right and left sides. He had no indication of lower extremity radiculopathy or sensory deprivation of the left or the right. There was no indication of quadriceps or hamstring muscle atrophy or loss of strength bilaterally. He had normal and equal patella and Achilles tendon and deep tendon reflexes bilaterally. An x-ray of the lumbar spine showed spine alignment was normal, and intervertebral disc spaces were preserved and vertebral body heights maintained. The diagnosis given was "normal lumbar spine without indication of degenerative disc disease." The VA examiner further commented that the majority of the Veteran's symptoms were not due to degenerative disc disease of the lumbar spine, but were due to his morbid obesity. This was a large contributing factor to the Veteran's disability and not his lumbar spine degenerative disc disease since degenerative disc disease did not appear on his spine x-rays. On further examination of March 2011, he described continued back pain, helped in part by use of a brace and TENS unit. He had undergone physical therapy in the past, but never any injections, surgery or hospitalization for the back. He stated he had mild intermittent incontinence at night and not during the day. He stated he had tried some cervical traction on the past which helped the lower back. Objectively, straight leg raising was negative bilaterally, and motor function was 5/5 in all muscle groups of the lower extremities. There was slight increased lumbar lordosis due to the obesity but there was no tenderness to palpation or spasms noted. He had a slow non-antalgic gait. Range of motion was flexion to 90 degrees, extension to 25 degrees, right and left lateral bending to 30 degrees, and right and left lateral rotation 30 degrees. There was no pain, fatigue, weakness or incoordination with repetitive motion in any plane. X-rays of the lumbar spine showed vertebral bodies were normal height and anatomically aligned, disc spaces were normal and there was faint atherosclerotic calcification of the abdominal aorta and paravertebral soft tissues were normal. There was no spondylolysis or spondylolisthesis. The radiologist read it as no significant change from the prior examination, and unremarkable lumbar spine. The VA examiner summarized that the Veteran really had minimal symptoms associated with the lumbar spine. There was no evidence of ankylosis of the lumbar spine, he had completely normal x-rays and he had significant comorbidities with morbid obesity, heart failure, a previous cerebrovascular accident, ulcers, anemia and a pituitary adenoma. Through a May 2013 addendum, the 2011 VA examiner clarified that a goniometer had not been used on the previous examination of the spine, however, the Veteran did have then excellent range of motion considering his morbid obesity. He was able to flex past 90 degrees. The ranges observed were accurate to within 5 degrees of any measurement with a goniometer, and testing with a goniometer would not have changed the previously recorded range of motion. Having reviewed the entire array of medical evidence in this case since the November 2004 date of claim for increased rating, the Board will continue the assigned 40 percent disability evaluation for lumbar spine degenerative arthritis, thereby denying the claim for increased compensation. Viewing the evidence objectively and comprehensively, the Veteran does not meet the requisite rating standard for an award of any higher evaluation. To begin with, he does not manifest joint ankylosis, which is absolutely necessary to warrant the next higher available 50 percent evaluation under the General Rating Formula for Diseases and Injuries of the Spine, found under 38 C.F.R. § 4.71a. Joint ankylosis, including with regard to the lumbosacral spine, requires total absence of joint mobility. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) and Lewis v. Derwinski, 3 Vet. App. 259 (1992) (indicating that ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable). Here, the Veteran plainly has retained joint mobility of the lumbosacral spine. Fortunately there is enough retained mobility that he has at or near normal range of motion. At least one VA examiner has commented that the lumbosacral spine, both on physical examination and x-ray study, has a minimal level of disability. Nor for that matter would the lack of availability of a goniometer during the Veteran's most recent examination have any tangible impact on this claim -- indeed, on the March 2011 exam the Veteran demonstrated normal forward flexion to 90 degrees, not remotely near joint ankylosis, and as the VA examiner subsequently explained, a goniometer might add 5 degrees of accuracy to joint range of motion measurements, but clearly no more that would substantially change the outcome in this instance. The aforementioned does not completely rule out a higher schedular evaluation for lumbar spine degenerative arthritis, inasmuch as the Veteran could potentially demonstrate entitlement under provisions pertaining to Intervertebral Disc Syndrome. Rated under 38 C.F.R. § 4.71a, Diagnostic Code 5243, IVDS is evaluated pursuant to the relative frequency and severity of characteristic "incapacitating episodes," episodes requiring physician prescribed bedrest. Here, however, there is no indication of any such incapacitating episodes, much less of a complex of orthopedic with neurological symptomatology approximating IVDS in its manifestations. Nor for that matter is there any basis for assignment of a separate compensable evaluation due to neurological manifestations of the Veteran's lumbar spine disorder, apart from the existing 40 percent assigned due to orthopedic symptomatology. To this effect, the Veteran does not have sciatic neuropathy or similar disability of the lower extremities, resultant from radiation of lower back pain. Inasmuch as there is some pain and numbness experienced in the bilateral lower extremities, this has been attributed to the condition of meralgia parethetica from pressure placed upon the femoral artery, due to underlying causes wholly separate from a service-connected back disorder. Consequently, overall the Board cannot ascertain any tenable basis upon which to assign an evaluation in excess of 40 percent for lumbar spine degenerative arthritis. B. Osteochondroma of the Left Fifth Metacarpal The Veteran left fifth finger condition is presently assigned a 10 percent evaluation under provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5227-5156, for ankylosis of the little finger, rated by analogy to a partial amputation of the little finger. See 38 C.F.R. § 4.27 (permitting application of an analogous diagnostic code where an unlisted disease, injury, or residual condition is encountered). Under Diagnostic Code 5227, for ankylosis of the ring or little finger, a noncompensable rating is assigned whether there is unfavorable or favorable ankylosis. A note to the rating criteria provides for consideration also of whether evaluation as amputation is warranted, and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. Diagnostic Code 5156 applies to amputation of the little finger. A 20 percent disability rating is assigned where there is metacarpal resection (more than one-half the bone lost) in the major hand, and a 10 percent disability rating is assigned where the amputation occurs at the proximal interphalangeal joint or proximal thereto, without metacarpal resection. A Note to the Diagnostic Code provides that single finger amputation ratings are the only applicable ratings for amputations of whole or part of single fingers. Also potentially applicable is Diagnostic Code 5230, under which any limitation of motion of the ring or little finger warrants assignment of a noncompensable (0 percent) rating. On VA examination of January 2005, the Veteran reported that the symptoms of his left fifth finger condition consisted of numbness, tingling, trembling and much pain, which all occurred constantly. The treatment consisted of pain medication. The functional impairment was not being able to lift more than 35 pounds with his left hand. On physical examination, the Veteran had difficulty tying shoelaces with the left hand, as well as difficulty fastening buttons, and picking up a piece of paper and tearing it. Hand dexterity examination revealed the left hand fingertips could approximate the proximal transverse crease of the palm. Left hand strength was within normal limits. Range of motion of the left hand little finger was DIP flexion to 90 degrees, PIP flexion to 100 degrees, and MP flexion to 10 degrees. A left hand x-ray showed degenerative changes to the PIP joints. The diagnosis was confirmed of osteochondroma of the left fifth metacarpal with Dupuytren's Contracture. Pursuant to the May 2008 VA examination, the Veteran did have a boutonnihres deformity. He had no pain in his finger, thought there was limited flexion which frustrated him, because of the inability to use his hand adequately. He did not have any medications for this. He had no flare-ups. He had had no further injury. He had had no surgery. Daily activities were affected primarily in decreased grip. A physical examination revealed that the left fifth finger was at 60 degrees of flexion at the proximal interphalangeal joint. He did have full flexion to 100 degrees; however, he could not extend his finger beyond 60 degrees of flexion at the PIP joint. The MP joint did flex to 90 degrees and the DIP joint flexed to 80 degrees. He had no gap between the finger and the palm with full flexion. Repetitive range of motion of the joints of the finger did not produce pain, weakness or fatigue. The disability was the boutonnihres contraction at 60 degrees of flexion. An x-ray revealed deformity PIP joint fifth digit most likely posttraumatic. There were no other significant osseus, joint or soft tissue abnormalities. The diagnosis was fixed boutonniher's deformity of the left fifth finger at the PIP joint. Upon an April 2011 VA examination, of the hand, thumb and fingers, the Veteran described difficulty post-surgery in service with ability to extent the PIP joint of the left fifth finger. He stated that the condition now would occasionally bother him. He had had no treatment or evaluation for his hand since discharge from service. He described no limitations on activities of daily living. He had had no flare-ups or incapacitating events. He used no braces or other aids from his left hand. He stated he occasionally had difficulties with activities that caused his finger to be straight. He had had no reinjury and had had no further surgery or hospitalization. Upon examination, the Veteran had a diamond-shaped skin graft overlying the PIP joint of the left small finger. It was very hyperpigmented compared to the rest of the skin of the hand. It was well-healed, nontender and not adherent to underlying tissues. He had decreased sensation in the skin graft itself. The remainder of the finger was neurovascularly sensory intact. He had 50 degrees flexion contracture at the PIP joint. Range of motion was 50 to 90 degrees both active, passive against resistance. There was no pain, fatigue, weakness, or incoordination with repetitive motion. He had full motion of the PIP joint 85 degrees, MCP joint to 95 degrees. There was no pain, fatigue, weakness or incoordination with repetitive motion. He was able to bring the fingertips to the palm. He had good grip strength. He did have tremors in his hand with any resisted motion. He was otherwise neurovascularly sensory intact. X-rays of the left hand showed findings grossly unchanged, with flexion deformity of the fifth PIP joint when compared to prior examinations. There was no osseous erosion. Soft tissues were unremarkable. According the VA examiner, the Veteran did not have ankylosis. The Veteran did have flexion contracture due to soft tissues. There were no functional limitations due to pain, weakened movement, excessive fatigability, pain on use, or incoordination. Through a May 2013 addendum, the 2011 VA examiner clarified that a goniometer had been used on the previous examination of the hand, thumb and fingers, but in any event, the VA examiner was aware did not make a difference in this case, given that flexion contracture of the small or ring finger was not ratable. Given review of the evidence, and particularly in light of the inherent restrictions of the applicable rating criteria, the Board must deny the instant claim for increased evaluation beyond 10 percent for a left fifth finger condition. It is clearly provided under the VA rating schedule that both orthopedic limitation of motion, and joint ankylosis (which as indicated, is the total absence of mobilitity) are entirely noncompensable manifestations. A factual history of this left fifth finger condition it is observed, shows no signs of ankylosis, given the retained joint mobility, and for that matter, limitation of motion of the left fifth finger was not that pronounced. Regardless, any such limitation of motion, in and of itself, is noncompensable pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5230. Indeed, the existing assigned 10 percent evaluation, for disability approximating the level of severity of an amputation of the right fifth finger, appears to have little grounding in objective fact given the relatively minimal nature of symptomatology shown, including retained strength, grip, and functionality following recent surgery -- the Board raises this point not to call into question the existing 10 percent rating, as that at present is a settled matter, but merely to indicate that there is clearly no basis for any higher evaluation than 10 percent. That is, there is nothing approaching the level of severity of disability affecting the left fifth finger that is equivalent to metacarpal resection (more than one-half the bone lost) in the major hand, as to suggest the propriety of assignment of a 20 percent evaluation. See Diagnostic Code 5156. Consequently, no higher evaluation than 10 percent for the service-connected left fifth finger condition is warranted pursuant to the provisions of the rating schedule. C. Conclusion Apart from the VA rating schedule, the potential application of other provisions of Title 38 of the Code of Federal Regulations has also been considered, including 38 C.F.R. § 3.321(b)(1), which provides procedures for assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). In Thun v. Peake, 22 Vet. App. 211 (2008), the Court articulated a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation is found inadequate because it does not contemplate the claimant's level of disability and symptomatology, the Board must determine whether the claimant's disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, there is no basis to find that the Veteran's service-connected lumbar spine and left fifth finger conditions present such an exceptional disability picture that the applicable schedular criteria are inadequate, particularly as the rating criteria are thorough, and he does not manifest or describe symptomatology outside of those criteria. See also 38 C.F.R. §§ 4.40, 4.45. The rating criteria premised upon limitation of motion in each case fairly encompasses the extent of symptomatology shown. To the extent there is any sign of neurological impairment involving the lumbar spine condition, this has been considered under different schedular rating criteria, and duly ruled out as the basis for compensation when taking into account the verified etiology of symptomatology. Thus, the Board cannot conclude that the Veteran's conditions are consistent with an exceptional disability picture as to render the schedular rating criteria inadequate. The first stage of the standard for determining availability of an extraschedular rating not having been met, the potential application of the next two steps becomes a moot issue. In the absence of the evidence of such factors, the Board is not required to remand this case to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For these reasons, the Board is denying the claims for an increased rating for lumbar spine degenerative arthritis, and a left fifth finger condition. This determination takes into full account the potential availability of "staged rating" based upon incremental increases in severity of service-connected disability during the pendency of the claim under review. The preponderance of the evidence is against the claims, and under these circumstances, the benefit-of-the-doubt doctrine is inapplicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. See also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER An evaluation higher than 40 percent for degenerative arthritis, lumbar spine is denied. An evaluation higher than 10 percent for osteochondritis of the left fifth metacarpal with Dupuytren's Contracture is denied. ____________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs