Citation Nr: 1339754 Decision Date: 12/03/13 Archive Date: 12/18/13 DOCKET NO. 08-12 818 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to a rating in excess of 10 percent for residuals of a partial amputation of the middle finger of the left (minor) hand with degenerative changes. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from July 1969 to July 1971 and May 29, to May 30, 2000. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which increased the Veteran's rating for his left finger disability from 0 to 10 percent disabling, effective May 3, 2006, the date of receipt of his claim for an increased rating. The case was remanded for additional development in April 2012 and now returns to the Board for final appellate review. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the Virtual VA claims file reveals VA treatment records dated from August 2006 to April 2012 and unrelated VA examination reports dated in January 2007 and July 2013. VA treatment records dated through April 2010 were considered by the agency of original jurisdiction (AOJ) in the April 2010 supplemental statement of the case. While records dated through April 2012 were subsequently associated with Virtual VA the same month, the November 2012 supplemental statement of the case did not explicitly consider them. However, such newly associated records do not contain findings referable to the Veteran's left middle finger disability and, therefore, are not relevant to the instant claim. Moreover, in a November 2012 response to the most recent supplemental statement of the case, the Veteran's representative waived AOJ consideration of any additional evidence. Therefore, there is no prejudice to the Veteran in the Board proceeding with a decision at this time. FINDINGS OF FACT 1. The Veteran is right handed. 2. For the entire appeal period, the Veteran's residuals of a partial amputation of the middle finger of the left hand with degenerative changes have been manifested by complaints of numbness and decreased sensation of the distal tip of the finger, mild atrophy, stiffness, pain, decreased range of motion, and inability to straighten to zero degrees of flexion, without metacarpal resection such that more than one-half of the bone is lost, ankylosis of more than one finger, symptomatic scarring or scarring of such a size so as to warrant a separate compensable rating, or neurological impairment that more nearly approximates mild incomplete paralysis of the median nerve. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for residuals of a partial amputation of the middle finger of the left hand with degenerative changes are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5229-5154 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's 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; 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1)Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Regarding claims for increased ratings such as that on appeal in the instant case, the VCAA requirement is generic notice, that is, 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. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. Sept. 4, 2009). In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a September 2006 letter, sent prior to the initial unfavorable decision issued in March 2007, advised the Veteran of the evidence and information necessary to substantiate his increased rating claim as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records and post-service treatment records. Moreover, the Veteran's statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. Additionally, the Veteran was afforded VA examinations in October 2006, February 2010, and June 2012 to evaluate the severity of the service-connected finger disability on appeal. Neither the Veteran nor his representative has alleged that the examinations are inadequate for rating purposes. Moreover, the Board finds that these examinations are adequate to evaluate the Veteran's service-connected finger disability as they reflect an interview with the Veteran, a review of the record, and a full physical examination addressing the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's increased rating claim and no further examination is necessary. As noted in the Introduction, in April 2012, the Board remanded the case for additional development, to include affording the Veteran an opportunity to identify any healthcare provider who treated him for his left finger disability since 2005, obtaining updated VA treatment records, and affording the Veteran a VA examination so as to determine the nature and severity of his left finger disability. As discussed in the preceding paragraphs, VA treatment records dated through April 2012 have been obtained and the Veteran was afforded a VA examination in June 2012 so as to determine the nature and severity of his left finger disability. Additionally, he was sent a letter in June 2012 in which he was requested to identify any healthcare provider who treated him for his left finger disability since 2005; however, he did not respond to such inquiry. Therefore, the Board finds that the AOJ has substantially complied with the April 2012remand directives such that 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). In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose with respect to the matter adjudicated in this decision. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case with respect to the claim adjudicated herein, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Ratings Schedule) found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the appellant's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating an appellant's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for an appellant to have separate and distinct manifestations from the same injury which 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). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is 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. When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). The service connected disability at issue is rated under DC 5229-5154. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With diseases, preference is to be given to the number assigned to the disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27. The hyphenated diagnostic code in this case indicates that limitation of motion of the index or long finger under Diagnostic Code 5229 is the service-connected disorder and amputation of the long finger under Diagnostic Code 5154 is a residual condition. In this regard, the Board notes that DC 5229 was not added to the Veteran's service-connected disability until the issuance of a code sheet in connection with the adjudication of unrelated claims in an August 2013 rating decision. Under DC 5229, a noncompensable rating is warranted for limitation of motion of the long major or minor finger with a gap of less than 1 inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. A 10 percent rating is warranted for limitation of motion of the major or minor long finger with a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. 38 C.F.R. § 4.71a, DC 5229. The highest assignable rating for limitation of motion of the longer finger under DC 5229 is 10 percent. Under DC 5154, an amputation of the major or minor middle finger, without metacarpal resection, at the proximal interphalangeal joint or proximal thereto warrants a 10 percent evaluation. Amputation of the major or minor long finger with metacarpal resection (more than one-half of the bone lost) warrants a 20 percent evaluation. 38 C.F.R. § 4.71a DC 5154. With respect to other potentially applicable diagnostic codes, the diagnostic codes pertaining to range of motion of the fingers are found in 38 C.F.R. § 4.71a, DCs 5216 to 5230. Note (1) under the criteria for Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand indicates that, for digits 2 through 5, zero degrees of flexion represents the fingers fully extended, making a straight line with the rest of the hand. The position of function of the hand is with the metacarpophalangeal and proximal interphalangeal joints flexed to 30 degrees; only joints in these positions are considered to be in favorable position. For digits 2 through 5, the metacarpophalangeal joint has a range of 0 to 90 degrees of flexion, the proximal interphalangeal joint has a range of 0 to 100 degrees of flexion, and the distal interphalangeal joint has a range of 0 to 70 or 80 degrees of flexion. Note (2) indicates that, when two or more digits of the same hand are affected by any combination of amputation, ankylosis, or limitation of motion that is not otherwise specified in the rating schedule, the evaluation level assigned will be that which best represents the overall disability (i.e., amputation, unfavorable or favorable ankylosis, or limitation of motion), assigning the higher level of evaluation when the level of disability is equally balanced between one level and the next higher level. Note (3), for evaluation of ankylosis of the index, long, ring, and little fingers states as follows: (i) If both the metacarpophalangeal and proximal interphalangeal joints of a digit are ankylosed, and either is in extension or full flexion, or there is rotation or angulations of a bone, evaluate as amputation without metacarpal resection, at proximal interphalangeal joint or proximal thereto; (ii) If both the metacarpophalangeal and proximal interphalangeal joints of a digit are ankylosed, evaluate as unfavorable ankylosis, even if each joint is individually fixed in a favorable position; (iii) If only the metacarpophalangeal or proximal interphalangeal joint is ankylosed, and there is a gap of more than two inches (5.1 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, evaluate as unfavorable ankylosis; (iv) If only the metacarpophalangeal or proximal interphalangeal joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, evaluate as favorable ankylosis. (iv) If only the metacarpophalangeal or proximal interphalangeal joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, evaluate as favorable ankylosis. (5) If there is limitation of motion of two or more digits, evaluate each digit separately and combine the evaluation. DC 5149 addresses amputation of the middle and ring fingers, and provides for a 30 percent rating for the major hand and a 20 percent rating for the minor hand. The rating for multiple finger amputations applies to amputations at the proximal interphalangeal joints or through proximal phalanges. See Note (a). Under DC 5219, a 20 percent rating is the only, and maximum, rating for unfavorable ankylosis of two fingers of the hand, without thumb involvement, regardless of whether the hand is dominant or non-dominant. A note following DC 5219 also provides that VA should consider whether an evaluation for amputation is warranted. Under DC 5226, a 10 percent rating is warranted for unfavorable or favorable ankylosis of the long finger of the dominant (major) or non-dominant (minor) hand. A note following DC 5226 provides that VA should also consider whether an evaluation for 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. Degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. DC 5003 provides that when limitation of motion due to arthritis is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Summarizing the pertinent evidence with the above criteria in mind, the Board notes that, during a period of National Guard Service in May 2000, the Veteran cut the middle finger of his left hand. The reports from surgery performed after this injury noted that such injury included an open fracture of the distal phalanx of the left middle finger with partial amputation of the fingertip. This surgery resulted in the reapproximation of the tuft fragments from the finger that was severed. As the Veteran is right handed (see eg., June 2012 VA examination reports), this injury involves the minor (non-dominant) hand, and service connection for a disability listed as a partial amputation of the tip of the middle finger of the (non-dominant) left hand was granted by an August 2000 rating decision. A noncompensable rating was assigned under DC 5154. Also of record are reports from a VA examination in June 2004, at which time the Veteran complained of stiffness and some numbness in the left middle finger. It was noted on these reports that the tip of the finger had been successfully reattached by surgery. On examination, there was no swelling or deformity. There was a scar around the mid-portion of the distal phalanx, which appeared to be healed. The range of motion was normal, and the diagnosis was traumatic amputation of the left middle finger tip with successful replantation. An August 2005 Board decision found that a 10 percent staged rating on the basis of ankylosis was warranted for the left middle finger from May 31, 2000, to August 8, 2000, for the period of time this finger was in a splint. This decision was effectuated by a November 2005 rating decision. The August 2005 Board decision also denied a compensable rating for the period beginning August 8, 2000, and the November 2005 rating decision also effectuated this decision. Thereafter at an October 2006 VA examination, the Veteran reported problems with straightening the finger in question due to pain and stiffness and indicated that disability associated with this finger had become progressively worse. Also described was decreased dexterity in the left hand and limitation of motion. It was noted that there was no amputation, ankylosis, or deformity of one or more digits. There was no gap between the thumb pad and tips of the fingers on attempted opposition of the thumb to the fingers and no gap between the finger at issue and the proximal transverse crease of the hand on maximal flexion of the finger. There was no decrease in strength for pushing, pulling, and twisting, and there was no decrease in dexterity for twisting, probing, writing, touching, and expression. Motion in the distal interphalangeal joint of the left middle finger at the October 2006 VA examination was from 10 to 30 degrees of active flexion and 0 to 60 degrees of passive flexion with no pain, to include after repetitive flexion. Repetitive flexion also resulted in no additional loss of motion. Also demonstrated in the distal interphalangeal joint of the left middle finger was active extension (mislabeled as "flexion) from 30 to 10 degrees and passive extension from 60 to 10 degrees. There was no pain with active or passive extension, to include after repetitive extension, and repetitive extension also resulted in no additional loss of motion. Also at the October 2006 VA examination, the distal phalanx was said to be mildly atrophic and sensation to light touch and pinprick was significantly decreased therein. X-rays of the left middle finger showed mild degenerative changes with marginal osteophytes at the metacarpophalangeal joint; and probable "very minimal" degenerative changes at the distal interphalangeal joint with no acute fractures or other significant osseus abnormalities noted. It was indicated the Veteran was employed full time and had lost less than one week of work during the previous 12 months. Following the October 2006 VA examination, the diagnosis was mild degenerative joint disease of the left third finger. This condition was said by the examiner to result in no significant effects on occupational functioning but mildly effect the ability to perform chores, exercise, play sports, or exercise. Following the October 2006 VA examination, the March 2007 rating decision increased the rating for the service connected left middle finger to 10 percent under DC 5154, effective from the date of claim of May 3, 2006. At a February 2010 VA examination, the Veteran described numbness, an aching sensation, and an inability to grip tightly due to his left middle finger disability. It was noted that the Veteran had not worked in "some time," but that the left finger disability did not impact his occupational functioning or the activities of daily living. He also reported no flareups, although he did report some increased discomfort with weather changes and cold weather. Upon physical examination, there was some numbness at the tip of the finger in question. Motion of the metacarpophalangeal joint of the left middle finger at the February 2010 VA examination was from 0 to 90 degrees, and the proximal interphalangeal joint was held in flexion at 15 degrees and the Veteran was unable to straighten it to 0 degrees of flexion. He was able to move this joint to 90 degrees such that the range of motion was from 15-90 degrees with discomfort. The distal interphalangeal joint was also held in slight flexion at 15 degrees, and the Veteran was unable to straighten this joint to 0 degrees. Flexion in this joint was from 15 to 40 degrees. There was a gap of .5 cm when the Veteran attempted to oppose his thumb due to discomfort as reported by the Veteran. The Veteran was able to touch the tip of his middle finger to the base of his thumb but not to the crease of his palm. Repetitive motion did not result in increased instability, pain, or weakness, although it was reported the Veteran's complaints were "consistent" and that he described increased discomfort with motion of a moderate degree. The diagnosis was sequelae of the left middle finger of the left hand with degenerative changes. An X-ray was recommended to ascertain whether there was "further" degenerative disease. Reports from the most recent VA examination of the left finger conducted in June 2012 reflect the Veteran's description of the circumstances of the in-service injury to the left middle finger and his report of residual pain with movement and use of this finger. Activity and weather were said to worsen the condition, and the Veteran also described numbness over the tip of the finger. No flareups were described. Motion testing of the left middle finger was said to not reveal a gap between the thumb pad and fingers; no gap between the fingertip and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips; and painful motion such that the finger could not be extended fully and that there was painful extension beginning between 0 and 30 degrees of flexion. No other fingers were said to be affected in terms of loss of motion Repetitive (three times) motion resulted in no additional loss of motion but some excess fatigability, pain on movement, and "very mild" loss of sensation over the distal tip of the left index finger. The examiner stated there was no functional loss or impairment of any other finger or the thumb. Tenderness but no loss of grip strength or ankylosis was demonstrated. Scarring, but not greater than 39 square centimeters (6 square inches), was noted, and the examiner stated that it was not the case that functioning was so diminished that the Veteran would be equally well served by an amputation with prosthesis. An X-ray was said to have shown degenerative or traumatic arthritis in multiple joints. The examiner stated that the condition at issue did not affect the Veteran's ability to work and remarked that the arthritis was located in fingers/locations other than the location of the trauma to the left middle finger. The examiner remarked that this arthritis was not due to the [in-service] trauma but to aging and the physical nature of the Veteran's post-service employment. The only neurologic finding was very mild loss of sensation over the very tip of the left middle finger that "does not affect the overall/use function of the left hand in any way." The examiner concluded by noting that grip and strength in the left hand were intact. Review of the VA outpatient treatment reports does not reflect any pertinent disability that differs significantly in kind or degree from that described on the VA examination reports set forth above. Based on the foregoing, the Board finds that, for the entire appeal period, the Veteran's residuals of a partial amputation of the middle finger of the left hand with degenerative changes have been manifested by complaints of numbness and decreased sensation of the distal tip of the finger, mild atrophy, stiffness, pain, decreased range of motion, and inability to straighten to zero degrees of flexion, without metacarpal resection such that more than one-half of the bone is lost, ankylosis of more than one finger, symptomatic scarring or scarring of such a size so as to warrant a separate compensable rating, or neurological impairment that more nearly approximates mild incomplete paralysis of the median nerve. Therefore, he is not entitled to a rating in excess of 10 percent for such disability. Specifically, applying the pertinent criteria to the facts summarized above, the Board notes initially that left middle finger was only partially amputated and that the fingertip was not completely severed. Rather, it was completely reattached. Thus, as there has not been a metacarpal resection such that more than one-half of the bone was lost, an increased (20 percent) rating is not warranted under 38 C.F.R. § 4.71a, DC 5154. A rating in excess of 10 percent is also not warranted under any other potentially applicable diagnostic code. In this regard, the Board has considered the February 2010 examination finding that the proximal interphalangeal joint was held in flexion at 15 degrees and the Veteran was unable to straighten it to zero degrees; however, he was capable of movement of such joint. Moreover, subsequent examination found no ankylosis of the joint. Even so, if such were to be considered ankylosed, such would warrant only a 10 percent rating under DC 5226. Furthermore, the Veteran is already in receipt of a 10 percent rating based on limitation of motion and, thus to assign a separate rating based on the same symptomatology, would result in pyramiding. 38 C.F.R. § 4.14; Esteban, supra. As there is no resulting limitation of motion of other digits or interference with overall functioning of the hand, an evaluation for amputation is not warranted pursuant to the note following DC 5226. In addition, as a 20 percent rating under DC 5219 would require ankylosis of another finger in addition to the left middle, and no such ankylosis of another finger is demonstrated, increased compensation cannot be assigned under DC 5219. With respect to the loss of motion shown, the highest compensable rating for limitation of motion under DC 5229 is 10 percent; as such, a rating in excess of 10 percent cannot be assigned for the loss of motion shown in the left middle finger. As disability due to arthritis is rated on the basis of limitation of motion, a rating in excess of 10 percent also may not be assigned for any disability attributable to arthritis in the left middle finger (despite the June 2012 VA examiner's finding that such is not related to the service connected disability). 38 C.F.R. § 4.71a, DC 5003. With regard to giving proper consideration to the effects of pain in assigning a disability rating, as well as the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca and Mitchell, supra, the reports from the examinations conducted above document consideration of these principles, and there is no indication that increased compensation would be warranted under these principles. Moreover, while the evidence reveals that the Veteran has scarring associated with his left middle finger disability, such is not shown to be symptomatic or of a size so as to warrant a separate compensable rating under the Diagnostic Codes pertaining to the rating of skin disabilities set forth at 38 C.F.R. § 4.118. Finally, the Board notes that the evidence shows that the Veteran has complaints of numbness and decreased sensation of the distal tip of the finger. Additionally, while such was described as mildly atrophic in October 2006, such impairment is specifically contemplated in his assigned 10 percent rating pursuant to functional loss based on limitation of motion pursuant to 38 C.F.R. § 4.40 (requiring consideration of functional loss, including the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, pain, weakness, and atrophy). Moreover, there is no evidence of decrease in strength, dexterity, or grip strength. In fact, the June 2012 VA examiner noted that grip and strength in the left hand were intact, and specifically determined that the only neurologic finding was very mild loss of sensation over the very tip of the left middle finger that "does not affect the overall/use function of the left hand in any way." Based on the determination that such neurologic impairment results in only "very mild" symptomatology, the Board finds that such does not more nearly approximately mild incomplete paralysis of the median nerve so as to warrant a separate compensable rating. In short and based on the analysis above, the rating criteria for compensation in excess of 10 percent for a partial amputation of the middle finger of the left finger of the left hand with degenerative changes are not met. In this regard, entitlement to increased compensation on the basis of a staged rating for discrete periods of times has been considered but has not been demonstrated. See Hart, supra. In making its rating determinations above, the Board has also carefully considered the Veteran's contentions with respect to the nature of his service-connected left middle finger disability and notes that his lay testimony is competent to describe certain symptoms associated with this disability. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability rating that has been assigned for his left middle finger disability. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability addressed above. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected finger disability at issue. The Board has also contemplated whether the case should be referred for consideration of an extra-schedular rating. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, 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. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected finger disability with the established criteria found in the rating schedule. The Board finds that this disability is fully addressed by the rating criteria under which the Veteran's left finger disability is rated. In this regard, the specific diagnostic criteria adequately address the whole of the Veteran's symptoms referable to his service-connected left middle finger disability. There are no additional symptoms of this disability. In this regard, a wide range of signs and symptoms are contemplated in the applicable rating criteria for the Veteran's left middle finger disability. This service-connected disorder requires application of the holding in Deluca, supra, and Mitchell, supra, which, in turn, requires consideration of 38 C.F.R. §§ 4.40 and 4.45. 38 C.F.R. § 4.40 requires consideration of functional loss, including the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, pain, weakness, and atrophy. Likewise, 38 C.F.R. § 4.45 requires consideration of, in part, incoordination, impaired ability to execute skilled movements, painful motion, swelling, deformity, disuse atrophy, instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing. Also, 38 C.F.R. § 4.59 requires consideration of such matters as unstable or mal-aligned joints, and crepitation as well as any painful arthritic motion. Moreover, to the extent that the Veteran has residual scarring and numbness, while such do not currently warrant separate ratings, the Rating Schedule does provide criteria for evaluating such additional disabilities. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology associated with the service-connected disability addressed above. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating for the service-connected disability for the time periods addressed above is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, the Court has held that, if the claimant or the record reasonably raises a question of whether the Veteran is unemployable due to the disability for which a higher rating is sought, then part and parcel to that claim for a higher rating is the matter of whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this regard, there has been no assertion that the Veteran's service-connected left middle finger has rendered the Veteran unemployable, and it was specifically noted at the June 2012 VA examination that this condition has not impacted the Veteran's ability to work. There is otherwise no specific evidence that the Veteran's service-connected finger disability renders him unable to secure or follow a substantially gainful occupation. As there is no suggestion of actual or effective unemployment due solely to the service-connected left middle finger disability, consideration of a TDIU in connection with the higher rating claim on appeal is not warranted. In sum, Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for residuals of a partial amputation of the middle finger of the left hand with degenerative changes; as such, the benefit of the doubt doctrine is not applicable and entitlement to such an increased rating must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. ORDER A rating in excess of 10 percent for residuals of a partial amputation of the middle finger of the left (minor) hand with degenerative changes is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs