Citation Nr: 1341235 Decision Date: 12/13/13 Archive Date: 12/20/13 DOCKET NO. 09-16 585 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to an initial disability rating (evaluation) in excess of 10 percent for degenerative joint disease of the right ankle (hereinafter "right ankle disability). 2. Entitlement to an initial disability rating (evaluation) in excess of 10 percent for degenerative joint disease of the right wrist (hereinafter "right wrist disability"). 3. Entitlement to an initial disability rating (evaluation) in excess of 10 percent for degenerative joint disease of the left wrist (hereinafter "left wrist disability"). REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from June 1977 to June 1981 and from March 1984 to August 1985. This appeal comes to the Board of Veterans' Appeals (Board) from March 2008, April 2008 and April 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland Oregon. In the March 2008 rating decision, the RO, in pertinent part, granted service connection for degenerative joint disease of the right ankle, right wrist, and left wrist, each assigned a noncompensable rating. In the April 2008 rating decision, the RO assigned a 10 percent disability rating for each of the Veteran's service-connected wrists with an effective date of May 2007 (date of original claim for entitlement to service connection). In the April 2012 rating decision, the RO assigned a 10 percent disability rating for the Veteran's service-connected right ankle with an effective date of May 2007 (date of original claim for entitlement to service connection). The case was previously before the Board in October 2011, wherein it was, in part, remanded for additional development. As discussed below, the Board finds that there has been substantial compliance with the prior Board remand orders as the RO sent the Veteran proper notice as to what is needed to substantiate a claim for entitlement to a total disability rating based on individual unemployability (TDIU), associated additional VA treatment records with the file, and scheduled the Veteran for VA examinations to determine the current severity and impairment of his service-connected right ankle and bilateral wrist disabilities. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). The case was returned to the Board for appellate consideration and is now ready for disposition. In the October 2011 decision and remand, the Board found that entitlement to a TDIU due to service-connected disabilities had been reasonably raised by the record and, consequently, considering the issue part of the Veteran's initial rating appeal, included it among the issues listed on the first page of the October 2011 Board decision and remand. The Board subsequently remanded the issue of entitlement to a TDIU to the RO for additional development. The Board finds that this previous action was in error because the Veteran has been, and currently is, working full time during the pendency of his appeal (see January 2012 Veteran written statement, April 2012 VA examination reports, October 2012 VA psychiatric examination report); therefore, the issue of entitlement to a TDIU has not been reasonably raised by the record and is not in appellate status before the Board. The Board has amended the issues listed on the first page of this decision to reflect that entitlement to a TDIU is not currently before the Board. In reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's right ankle disability has been manifested by degenerative joint disease with loss of plantar flexion, loss of dorsiflexion, pain, stiffness, lack of endurance, fatigue, swelling, instability of station, interference with sitting, standing, and weight-bearing, and use of orthopedic boots with inserts due to instability, and more closely approximates marked limitation of motion of the right ankle. 2. For the entire period on appeal, the Veteran's right ankle disability has not been manifested by ankylosis, malunion of os calcis or astragalus, or astragalectomy. 3. For the entire period on appeal, the Veteran's right and left wrist disabilities have been manifested by degenerative joint disease with painful motion that is productive of noncompensable limitation of motion, but no evidence of ankylosis has been demonstrated. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the favor of the Veteran, the criteria for an initial rating of 20 percent, but no higher, for a right ankle disability have been met for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2013). 2. The criteria for an initial rating in excess of 10 percent for a right wrist disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5215. 3. The criteria for an initial rating in excess of 10 percent for a left wrist disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5215. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). After having carefully reviewed the record on appeal, the Board finds that the notice requirements of VCAA have been satisfied with respect to the initial rating issue decided herein. The RO sent the Veteran a letter in July 2007 that informed him, in pertinent part, of the requirements needed to establish service connection for a right ankle injury, left wrist trauma, and a right wrist injury, including information regarding the assignment of ratings and effective dates. As this case concerns initial disability ratings and comes before the Board on appeal from the decision which also granted service connection, there can be no prejudice to the Veteran from any alleged failure to give adequate 38 U.S.C.A. § 5103(a) notice for the service connection claim. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice arises from receipt of a notice of disagreement). VA satisfied its duty to assist the Veteran in the development of the claim. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include service treatment records, service personnel records, VA treatment records, VA examination reports, a copy of the October 2011 Board decision and remand, and lay statements. Second, VA satisfied its duty to obtain a medical opinion when required. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran was provided with VA examinations (the reports of which have been associated with the claims file) in February 2008 and April 2012. In October 2011, the Board remanded the claims for entitlement to initial ratings in excess of 10 percent for the service-connected right ankle and bilateral wrist disabilities, in part, to provide the Veteran with additional VA examinations to assess the current severity of the Veteran's right ankle, right wrist, and left wrist. Subsequently, the Veteran underwent VA examinations in April 2012. The Board finds the VA examinations were thorough and adequate and provide a sound basis upon which to base a decision with regard to the Veteran's claims. The VA examiners personally interviewed and examined the Veteran, fully reviewed all medical evidence of record, and specifically addressed the symptoms listed in the relevant criteria in the potentially applicable diagnostic codes. Additionally, neither the Veteran nor his representative contended that his disability has worsened since the most recent VA examination. The Veteran was offered the opportunity to testify at a hearing before the Board, but declined. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Disability Rating Criteria Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2013). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1 (2013). Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2013). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Where, as here, the question for consideration is the propriety of the initial evaluations assigned, evaluation of the evidence since the grant of service connection and consideration of the appropriateness of staged ratings is required whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). 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 that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Initial Rating for Right Ankle Disability The Veteran is in receipt of a 10 percent disability rating for a right ankle disability under Diagnostic Code (DC) 5271 for limited motion of the ankle. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limitation of ankle motion. A 20 percent (maximum) evaluation is prescribed for marked limitation of ankle motion. See 38 C.F.R. § 4.71a. Normal ankle dorsiflexion is from 0 to 20 degrees, and normal ankle plantar flexion is from 0 to 45 degrees. 38 C.F.R. § 4.71, Plate II (2013). The Veteran contends that he entitled to an initial rating in excess of 10 percent for his service-connected right ankle disability. In an April 2008 notice of disagreement, the Veteran asserted that he has instability and pain associated with the right ankle. In a May 2009 written statement, the Veteran reported that his right ankle is painful all the time with the joint aching even when not being used and that his ankles give out if he does not wear high topped leather boots. The Veteran stated that he is unable to run. In a May 2009 substantive appeal (VA Form 9), the Veteran asserted that his right ankle is arthritic, that he cannot walk without stopping, and that he has an altered gait. In a January 2012 written statement, the Veteran reported having a hard time getting on ladders, standing, or walking. The Veteran stated that, if he sits or stands too long, his ankle hurts and that he has to wear orthopedic work shoes. After review of the lay and medical evidence of record, the Board finds that, for the entire appeal period, the Veteran's right ankle disability has more nearly approximated marked limitation of ankle motion under Diagnostic Code 5271 which warrants a 20 percent (maximum) rating. 38 C.F.R. § 4.71a. For the entire period on appeal, the Veteran's right ankle disability has been manifested by arthritis, loss of plantar flexion, loss of dorsiflexion, pain, stiffness, lack of endurance, fatigue, swelling, instability of station, interference with sitting, standing, and weight-bearing, and use of orthopedic boots with inserts due to instability, and more closely approximates marked limitation of right ankle motion required for a 20 percent rating under Diagnostic Code 5271. Id. In February 2008, the Veteran underwent a VA joints examination. The Veteran reported that his ankles are painful and stiff all the time, but are worse in cold weather as well as when moving, sitting, standing for over two hours, or walking for over two miles. The Veteran reported two days of missed work due to incapacitation. The VA examination report notes that no bed rest had been recommended by a provided in the previous 12 months. The Veteran reported subjective complaints of pain, swelling, instability, and fatigability at rest and with movement. Objective range of motion testing of the Veteran's right ankle noted plantar flexion to 40 degrees, stretch pain in the last one half of movement, and dorsiflexion to 20 degrees. The VA examiner noted limitations of pain, stiffness, lack of endurance, and fatigue that probably constitute additional limitation of motion during flare-ups. The VA examiner diagnosed soft and hard tissue degenerative joint disease of the right ankle. A June 2008 VA treatment record notes aching, tender pain in the Veteran's ankles. A July 2008 VA treatment record reflects that the Veteran reported some limitation to walking and activity because the ankles are painful to walk on. At an August 2008 VA examination in connection with the Veteran's service-connected left ankle and lumbar spine disabilities, the Veteran exhibited right ankle plantar flexion to 20 degrees and dorsiflexion to 33 degrees without pain or further loss of motion upon repetition. In April 2012, the Veteran underwent a VA ankle examination. The VA examination report notes diagnoses of tenosynovitis of the right ankle and exostosis of the right distal tibia. The Veteran reported experiencing flare-ups that impact the function of the right ankle. Specifically, the Veteran reported worse ankle pain when the weather is wet and cold, with six flare-ups per month in the winter and as few as three flare-ups per month in warmer summer months. The Veteran reported working through flare-ups of pain in his right ankle and that the pain subsides when he can take a break. Range of motion testing found decreased range of motion in the Veteran's right ankle showed plantar flexion to 25 degrees, with objective evidence of painful motion at 30 degrees, and dorsiflexion to 20 degrees, with objective painful motion at 20 degrees. Upon repetition, there was no further reduction in the Veteran's right ankle range of motion. The VA examiner noted functional loss and impairment of the right ankle of pain on movement, swelling, instability of station, interference with sitting, standing and weight-bearing, and use of orthopedic boots with inserts on both feet, due to instability, to prevent inversions and resulting sprains. The VA examiner noted that insoles are also needed due to deformity and uneven shoe wear before the inserts. The examination report indicates that the Veteran uses bilateral inserts and orthopedic boots on a regular basis. The VA examiner noted localized tenderness or pain on palpation of the joints/soft tissue of the right ankle. The VA examination report notes that anterior drawer and talar tilt tests reflected laxity in the right ankle. The April 2012 VA examination report notes no ankylosis of the ankle, subtalar, or tarsal joint. The VA examination report notes that the Veteran has "shin splints" (medial tibial stress syndrome) in both ankles with muscle cramps in the calves of both legs, usually only on one side at a time. The report notes no malunion of calcaneus (os calcis) or talus (astragalus) and that the Veteran has not had total ankle joint replacement. No scars related to the right ankle conditions were noted. The evidence shows that right ankle disability has been manifested by arthritis, loss of plantar flexion, loss of dorsiflexion, pain, stiffness, lack of endurance, fatigue, swelling, instability of station, interference with sitting, standing, and weight-bearing, and use of orthopedic boots with inserts due to instability. When viewing the disability picture as a whole, the Board finds that the evidence shows that the right ankle disability approximates marked limitation of right ankle motion. Resolving reasonable doubt in favor of the Veteran, the Board finds that a higher initial rating of 20 percent under Diagnostic Code 5271 is warranted for the entire rating period. The 20 percent rating is the maximum allowable under Diagnostic Code 5271. The Board notes that no higher or separate schedular rating is warranted under any of the other codes pertaining to the ankle. For point of explanation, ankylosis is "[s]tiffening 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) (quoting from Stedman's Medical Dictionary 87 (25th ed. 1990)). The evidence shows that the Veteran's right ankle disability is not manifested by ankylosis for any period; therefore, a higher rating is not warranted under either Diagnostic Code 5270 for ankle ankylosis or Diagnostic Code 5272 for subastragalar or tarsal joint ankylosis. 38 C.F.R. § 4.71a. Also, the evidence does not show that the Veteran's right ankle has undergone astragalectomy or is manifested by malunion of os calcis or astragalus; therefore, a rating under Diagnostic Codes 5274 or 5273 is not warranted. Id. Finally, the April 2012 VA examination report notes that the Veteran has no scars related to his right ankle disability; therefore, the Veteran is not entitled to a separate compensable rating under Diagnostic Codes 7800 through 7805. 38 C.F.R. § 4.118. Therefore, the Board finds that an initial disability rating of 20 percent, but no higher, is warranted for the Veteran's service-connected right ankle disabilities for the entire rating period. Assignment of staged ratings has been considered, but found not to be applicable in this case. 38 C.F.R. §§ 4.3, 4.7. Initial Rating for Right and Left Wrist Disabilities The Veteran is in receipt of 10 percent disability ratings for right and left wrist disabilities under Diagnostic Code (DC) 5010-5215 for degenerative joint disease with painful motion productive of noncompensable (less than 10 percent) limitation of motion. 38 C.F.R. § 4.71a. The Veteran is right hand dominant. Diagnostic Code 5010 represents arthritis due to trauma, substantiated by x-ray findings, which in turn is to be rated under Diagnostic Code 5003 as degenerative arthritis (hypertrophic or osteoarthritis). 38 C.F.R. § 4.71a. Degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Id., Diagnostic Code 5003. Notes (1) and (2) under Diagnostic Code 5003 provides the following: Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Notes (1) and (2). The Diagnostic Code 5215 focuses on limitation of motion of the wrist. Palmar flexion limited in line with the forearm warrants a 10 percent rating. Dorsiflexion less than 15 degrees warrants a 10 percent rating. Diagnostic Code 5215 does not provide for a rating in excess of 10 percent. 38 C.F.R. § 4.71a. Under Diagnostic Code 5214, a 50 percent rating is assigned for ankylosis of the major wrist when ankylosis is unfavorable, in any degree of palmar flexion, or with ulnar or radial deviation. A 40 percent rating is assigned for ankylosis of the major wrist when there is ankylosis in any other position except favorable. A 30 percent rating is assigned for ankylosis of the major wrist that is favorable in 20 degrees to 30 degrees dorsiflexion. Extremely unfavorable ankylosis will be rated as loss of use of the hands under Diagnostic Code 5125. Id. Under 38 C.F.R. § 4.71, Plate I, the standard range of motion for the wrist is extension from 0 to 70 degrees, palmar flexion from 0 to 80 degrees, forearm pronation 0 to 80 degrees, forearm supination 0 to 85 degrees, ulnar deviation from 0 to 45 degrees, and radial deviation from 0 to 20 degrees. The Veteran contends he is entitled to initial ratings in excess of 10 percent for his bilateral wrist disabilities. In an April 2008 notice of disagreement, the Veteran reported painful motion and cramping in both wrists. In a May 2009 written statement, the Veteran contended that both wrists are arthritic and that he cannot do the same work the he used to be able to do, specifically that he sometimes needs help to perform torquing. In a May 2009 substantive appeal (VA Form 9), the Veteran asserted that both wrists are arthritic and caused him to lose a position where he works. After review of the lay and medical evidence of record, the Board finds that the criteria for initial ratings in excess of 10 percent for the Veteran's right and left wrist disabilities has not been met or more nearly approximated for the entire rating period. 38 C.F.R. § 4.71a. For the entire period on appeal, the Veteran's bilateral wrist disabilities have been manifested by arthritis and painful motion that are productive of noncompensable limitation of motion. In February 2008, the Veteran underwent a VA joints examination. The Veteran reported that his wrists are painful and stiff all the time, but are worse in cold weather. The Veteran reported two days of missed work due to incapacitation. The VA examination report notes that no bed rest had been recommended by a provided in the previous 12 months. The Veteran reported subjective complaints of pain, swelling, instability, and fatigability at rest and with movement. The VA examiner noted no diffuse or localized tenderness upon palpation. Objective range of motion testing noted the Veteran's right wrist had palmar flexion to 80 degrees and dorsiflexion (extension) to 70 degrees. Range of motion testing found decreased range of motion in the Veteran's left wrist with palmar flexion to 60 degrees and dorsiflexion to 65 degrees. The examination report notes that bilateral radial deviation was to 20 degrees and bilateral ulnar deviation was to 40 degrees. The VA examiner noted that there was no additional limitation of motion or DeLuca factors upon repetition and that any attempt to determine additional limitation of motion during flare-ups would be mere speculation. The VA examiner diagnosed the Veteran with soft and hard tissue degenerative joint disease of both wrists. A June 2008 VA treatment record notes aching, tender pain in the Veteran's wrists. February 2009 VA treatment records reflect that the Veteran reported hurting his right shoulder and wrist after falling. The treatment record notes no edema, erythema, or tenderness of the right wrist, but does note pain of the right wrist. In April 2012, the Veteran underwent a VA wrist examination. The VA examination report notes diagnoses of bilateral tenosynovitis of the wrists. The Veteran reported flare-ups impacting the function of the wrist. Specifically, his bilateral wrist pain is worst in cold weather, that overuse regardless of season causes wrist pain, and that the pain is worse in the left wrist even though he is right handed. Objective range of motion testing found decreased range of motion in the Veteran's right wrist with palmar flexion to 45 degrees, with objective evidence of painful motion at 20 degrees, and dorsiflexion (extension) to 50 degrees, with objective evidence of painful motion at 30 degrees. Upon repetition, range of motion in the Veteran's right wrist was palmar flexion to 40 degrees and dorsiflexion to 55 degrees. Range of motion testing found decreased range of motion in the Veteran's left wrist with palmar flexion to 15 degrees, with objective evidence of painful motion at 55 degrees, and dorsiflexion to 50 degrees, with objective evidence of painful motion at 30 degrees. Upon repetition, range of motion in the Veteran's left wrist was palmar flexion to 55 degrees and dorsiflexion to 55 degrees. The VA examination report notes pain on movement of both wrists. The VA examiner noted no localized tenderness or pain on palpation of the joints/soft tissue of either wrist. The VA examiner noted no ankylosis or total wrist joint replacement of either wrist joint as well as no scars related to the Veteran's service-connected wrist disabilities. The VA examiner noted that, with both hands gripping and squeezing one of the examiner's fingers, the Veteran reported pain, which he rated at four to five, with hand grip. Imaging studies performed of both wrists note no documented arthritis of either wrist. Ligamentous laxity about the left thumb was noted on x-ray. Based on the above, the evidence of record does not establish that the Veteran's right and left wrist disabilities warrant evaluations in excess of 10 percent for any period on appeal. The Veteran is currently receiving 10 percent disability ratings for the right and left wrists under Diagnostic Code 5010-5215 for arthritis that is productive of painful but noncompensable limitation of motion. 38 C.F.R. § 4.71a. At worst, as noted in the April 2012 VA examination report, the Veteran's right wrist has manifested with limitation of palmar flexion to 40 (with objective evidence of painful motion at 20 degrees) and dorsiflexion to 50 degrees (with objective evidence of painful motion at 30 degrees) and the left wrist has manifested with limitation of palmar flexion to 30 degrees (with objective evidence of painful motion at 55 degrees) and dorsiflexion to 50 degrees (with objective evidence of painful motion at 30 degrees). While the limitation of motion in itself is not to such an extent that a compensable (10 percent) evaluation based solely on limitation of motion under Diagnostic Code 5215 is warranted, the rating criteria at Diagnostic Code 5003, degenerative arthritis, with painful motion that limits motion to a noncompensable degrees warrants a 10 percent disability rating, which have been assigned to both service-connected wrists. Id. The Board has considered application of 38 C.F.R. §§ 4.40 and 4.45 and DeLuca, supra for the entire appeal period, specifically the additional limitations of motion due to pain, in reaching its finding that the Veteran has limitation of motion to a noncompensable degree. Although the February 2008 and April 2012 VA examination reports note that the Veteran experienced pain, such findings do not provide for a higher disability rating than 10 percent in this case. The VA examiners specifically addressed such considerations as pain, fatigue, and weakness and the clinical findings do not show that pain on use or during flare ups results in additional functional limitation to the extent that the right or left wrist limitation of motion would warrant a higher rating under Diagnostic Code 5215. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). In this case, the Veteran's service-connected degenerative joint disease of the right and left wrists were initially rated as 10 percent disabling and a 10 percent disability rating is the maximum schedular rating provided for limitation of motion of the wrist; therefore, a higher rating in excess of 10 percent is warranted only if the evidence shows ankylosis of the wrist joint. 38 C.F.R. § 4.71a. The ranges of motion in both wrists, as documented in the February 2008 and April 2012 VA examination reports, demonstrate that the Veteran has not had ankylosis or limitation of motion akin to that of ankylosis, and VA examiners did not find the presence of ankylosis at any time. As noted above, ankylosis is "[s]tiffening 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) (quoting from Stedman's Medical Dictionary 87 (25th ed. 1990)). Thus, an initial disability rating is not warranted under Diagnostic Code 5214. Finally, the April 2012 VA examination report notes that the Veteran has no scars related to his right ankle disability; therefore, the Veteran is not entitled to a separate compensable rating under Diagnostic Codes 7800 through 7805. 38 C.F.R. § 4.118. Therefore, the Board finds that disability ratings in excess of 10 percent are not warranted for the Veteran's service-connected right and left wrist disabilities for the entire rating period. Assignment of staged ratings has been considered, but found not to be applicable in this case. The Board has also considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against this claim, the doctrine is not for application. 38 C.F.R. §§ 4.3, 4.7. Accordingly, entitlement to initial ratings in excess of 10 percent for the Veteran's right and left wrist disabilities for the entire period must be denied. Extraschedular Considerations The Board has considered whether referral for an extraschedular evaluation is warranted for the service-connected right ankle and bilateral wrist disabilities. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). 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. In the second step of the inquiry, however, 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 those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's right ankle are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's right ankle disability has been manifested degenerative joint disease with loss of plantar flexion, loss of dorsiflexion, pain, stiffness, lack of endurance, fatigue, swelling, instability of station, interference with sitting, standing, and weight-bearing, and use of orthopedic boots with inserts due to instability. The schedular rating criteria specifically provides ratings for such noncompensable limitation of motion due to painful arthritis (Diagnostic Code 5003, 38 C.F.R. § 4.59); and contemplate ratings based on limitation of motion (Diagnostic Code 5271), including motion limited to orthopedic factors such as pain and excess fatigability (38 C.F.R. §§ 4.40, 4.45, DeLuca). In this case, comparing the Veteran's disability level and symptomatology of the right ankle disability to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule and the assigned rating is, therefore, adequate. With regard to the service-connected bilateral wrist disabilities, the Board finds that the symptomatology and impairment caused by the Veteran's right and left wrist disabilities are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's left and right wrist disabilities have been manifested by degenerative joint disease with painful motion that is productive of noncompensable limitation of motion. The schedular rating criteria specifically provide ratings for based on painful arthritis (Diagnostic Code 5003, 38 C.F.R. § 4.59); and contemplate ratings based on limitation of motion (Diagnostic Code 5215), including motion limited to orthopedic factors such as pain and excess fatigability (38 C.F.R. §§ 4.40, 4.45, DeLuca). In this case, comparing the Veteran's disability level and symptomatology of the service-connected bilateral wrist disabilities to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule and the assigned rating is, therefore, adequate. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life and occupation. In the absence of exceptional factors associated with the wrist and ankle disabilities, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). (CONTINUED ON NEXT PAGE) ORDER An initial disability rating of 20 percent for a right ankle disability, but no higher, is granted. An initial disability rating in excess of 10 percent for a right wrist disability is denied. An initial disability rating in excess of 10 percent for a left wrist disability is denied. ____________________________________________ K.J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs