Citation Nr: 1414763 Decision Date: 04/04/14 Archive Date: 04/11/14 DOCKET NO. 10-13 055 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to an initial compensable disability rating (evaluation) for osteoporosis. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from October 1970 to April 1972, September 1972 to December 1975, and March 1976 to October 1985. This appeal comes to the Board of Veterans' Appeals (Board) from December 2008 and April 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The December 2008 rating decision granted service connection for osteoporosis and assigned an initial noncompensable disability rating (evaluation). The April 2009 rating decision continued the initial noncompensable disability rating for the service-connected osteoporosis. A claim for a total rating based on individual unemployability due to service-connected disability (TDIU) is part of an increased rating issue when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). A January 2010 Board decision found that the issue of a TDIU had been raised by the record and remanded the issue to the RO for further development. In a November 2010 rating decision, the RO granted a TDIU effective May 26, 2010 (the last day the Veteran was employed). The Veteran has not filed a notice of disagreement with the effective date assigned the TDIU and, as such, the issue of TDIU for an earlier period is not in appellate status before the Board. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). 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. FINDING OF FACT For the entire initial rating period, the Veteran's service-connected osteoporosis has not been manifested by limitation of motion of any joint due to osteoporosis, and the Veteran's symptoms, including chronic joint pain, are not a result of osteoporosis. CONCLUSION OF LAW The criteria for an initial compensable rating for osteoporosis have not been met or more nearly approximated 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 5013 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION 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). 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 April 2007 that informed her of the requirements needed to establish service connection for osteoporosis, including information regarding the assignment of ratings and effective dates. As this case concerns an initial rating 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). Thus, the Board concludes that VA satisfied its duties to notify the Veteran. 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, VA treatment records, private treatment records, VA examination reports, and lay statements. Neither the Veteran nor the representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the appeal that has not been obtained. Thus, the Board concludes that VA has made every reasonable effort to obtain all records relevant to the Veteran's appeal. 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). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Indeed, even when the adequacy is challenged, the Board may assume the competency of any VA medical examiner, including even nurse practitioners, as long as, under 38 C.F.R. § 3.159(a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). The Veteran was provided with VA examinations (the reports of which have been associated with the claims file) in November 2008 (with an addendum opinion obtained in January 2009), July 2010, and June 2013. In a March 2010 substantive appeal (VA Form 9), the Veteran contended that she had limitation with pain in the leg and spine, that the November 2008 VA examiner knew this information, and that if the VA examiner failed to write down the information that was not the fault of the Veteran. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that a claimant challenging the expertise of a VA physician must "set forth the specific reasons . . . that the expert is not qualified to give an opinion." Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed. Cir. 2010). That has not happened in this case. While the Veteran has expressed her disagreement with the March 2008 VA examiner's findings, the Veteran, as a lay person, has not been shown to have the requisite medical knowledge, training, or experience to be able to be to differentiate symptoms of pain attributable to osteoporosis from symptoms of pain that may be due to other disorders (i.e., arthritis). See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (indicating a medical opinion as to etiology of ACL tear could include opinions as to whether the currently diagnosed disorder is consistent with an in-service injury, what type of symptoms would have been caused during service had an ACL tear occurred, and to differentiate currently diagnosed ACL tear from in-service symptoms and other diagnosis). Since the Veteran has not provided a specific argument or evidence concerning the professional competence of the VA examiner, the examiner is presumed competent. See Rizzo, 580 F.3d at 1290-1291. Further, subsequent VA examinations were obtained in July 2010 and June 2013 that are consistent with the November 2008 VA examiner's findings. As such, the Board finds that the November 2008 (with January 2009 addendum opinion), July 2010, and June 2013 VA examination reports were thorough and adequate and provide a sound basis upon which to base a decision with regard to this issue. The VA examiners personally interviewed and examined the Veteran, including eliciting a history, examination, and specifically addressed the symptoms listed in the relevant criteria in the potentially applicable diagnostic codes. Additionally, 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. Initial Rating for Osteoporosis 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. When, after careful consideration of the evidence, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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). The Board has considered whether a staged rating is warranted; however, as will discuss in more detail below, the Board finds that the assigning of staged ratings for osteoporosis is not appropriate in this case. The Board has reviewed all of the evidence in the claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the issues. The Veteran is in receipt of a noncompensable disability rating under Diagnostic Code 5013 (osteoporosis, with joint manifestations) for the entire initial rating period. Under 38 C.F.R. § 4.71a, diseases under diagnostic codes 5013 to 5024 are rated based on limitation of motion of affected parts the same as degenerative arthritis. Under Diagnostic Code 5003, 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, pursuant to Note (2) under Diagnostic Code 5003, the 10 and 20 percent ratings based on X-ray findings will not be utilized in rating Diagnostic Code 5013, relating to osteoporosis with joint manifestations. Id., Diagnostic Code 5003, Note (2). For disabilities of the musculoskeletal system, the Board also considers whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 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). The Veteran contends generally that the service-connected osteoporosis has manifested in more severe symptoms than those contemplated by the initial noncompensable disability rating assigned. In a July 2006 claim, the Veteran contended that the pain she experiences from osteoporosis is so severe that, at times, all she can do is lie down, and that she is unable to drive more than 30 to 40 minutes without stopping due to pain. The Veteran asserted that, if she takes the pain medication prescribed to her, she cannot function. In a February 2007 written statement, the Veteran contended that she has severe osteoporosis in her spine, hips, and legs that causes her a lot of pain. The Veteran contended that she cannot do any lifting, walk or sit for long periods of time, or drive a car very long due to the osteoporosis. In an April 2007 written statement, the Veteran contended that she has severe back and leg pain and is unable to stand or sit for prolonged periods due to pain. In October 2007 and January 2008 written statements, the Veteran contended that her vertebra was tearing because of the osteoporosis in the vertebra. In a December 2008 written statement, the Veteran contended that her bone density has not improved in the previous two years. In a July 2009 notice of disagreement, the Veteran contended that every doctor, book, and pamphlet as well as everything on the internet indicates that osteoporosis affects the joints. The Veteran contended that osteoporosis causes back pain because it affects the joints and that common symptoms of osteoporosis are weakness, joint pain, back pain, height loss, unsteady gait, kyphosis, and Dowagers hump. The Veteran asserted that she lives in pain in her back and left leg due to osteoporosis. In a March 2010 substantive appeal (VA Form 9), the Veteran contended that she has limitation with severe pain in her leg and spine due to osteoporosis that limits her daily activities causing her to hurt constantly if she is standing, walking, lying down, or doing nothing. The Veteran reported that, while she has not fractured any bones, she does fall a lot because of the left leg giving out on her. The Veteran reported that the pain and swelling in her knee is so bad that she cannot bend or move it without extreme pain. The Veteran further reported muscle spasms in her spine that cause severe pain. In a February 2014 appellant's brief, through her representative, the Veteran asserted that pain is a major part of the osteoporosis disability. The Veteran has consistently and credibly reported, and, as documented in the claims file, received treatment for, leg, hip, and back pain, as reflected on VA and private treatment records dated from November 2005 through June 2013. The record reflects diagnoses of (service-connected) osteoporosis and (non-service-connected) degenerative joint disease of the left knee and lumbar spine (see July 2010 VA examination report), left knee osteoarthritis (see e.g., April 2008 VA treatment record), bilateral lower extremity radiculopathy and paresthesia (see e.g., August 2006 VA treatment record), lumbar disc disease (see e.g., December 2006 VA treatment record), a left lateral annular tear at L4-L5 disc region (see November 2007 VA treatment record, June 2013 VA examination report), lumbar spondylosis (see January 2008 VA MRI report), and probable lumbar disc posterior derangement (see November 2007 VA treatment record). In November 2008, the Veteran underwent a VA examination. The Veteran reported low back pain and that the only injury she had to her back was when she pulled a small box out of her car, felt her back pop, and started having increased pain. The VA examination report notes no joint involvements, side effects from medication, periods of flare-up of bone disease, use of assistive devices, constitutional symptoms of bone disease (with no signs of anemia, weight loss, or fever), or effects on the Veteran's usual occupation and daily activities. Upon physical examination, the November 2008 examiner noted no evidence of any bone deformity, angulation, false motion, shortening of one leg, ankylosis, malunion or nonunion, painful motion, or edema. The VA examiner noted that the Veteran's complaints of right knee pain are related to the joint. In a January 2009 addendum opinion to the November 2008 VA examination, the VA examiner noted that osteoporosis and osteoarthritis are two completely different diagnoses and are not related. The VA examiner noted that osteoporosis is a disease of bone demineralization and it does not affect the joints as it causes bones to become thinner and may predispose the person to pathological fracture of a bone. The VA examiner noted that the Veteran has not had any fracture of a bone due to the osteoporosis. The VA examiner further noted that osteoporosis does not cause osteoarthritis noting that osteoarthritis is a degenerative process in the joints ("ARTHRO = joint and ITIS = inflammation") related to aging or injury of a joint that can cause pain in the joints; however, the VA examiner noted that the Veteran is not service connected for osteoarthritis. A December 2008 VA treatment record notes that the Veteran reported persistent back pain, including pain down the left leg, since falling two weeks prior and was worried about a fracture. The treatment record notes that an X-ray was ordered but that the Veteran was informed her back pain could likely be musculoskeletal in origin. In July 2010, the Veteran underwent a VA general medical examination. The Veteran reported left knee pain and back pain and stiffness in the lumbosacral spine. The Veteran reported use of a cane and walker for the low back and left knee pain. The VA examination report notes that the Veteran's gait was normal. Upon physical examination, the VA examiner noted no joint swelling, effusion, tenderness, or laxity. Range of motion testing reflects normal range of motion of the left knee with objective evidence of pain on active motion all through flexion. The VA examination report notes that the lumbosacral spine L5-S1 was tender to palpation. The VA examiner noted diagnoses of osteoporosis, degenerative joint disease of the lumbosacral spine, and degenerative joint disease of the left knee. An August 2012 VA treatment record notes that the Veteran reported hip and long-standing low back pain that worsened in December 2011. The treatment record notes that a hairline fracture of the pelvis was initially assessed; however, subsequent evaluation as well as a MRI of the pelvis did not confirm this assessment. The treatment record reflects that the Veteran was told the pain was likely due to lumbar spine disease. In June 2013, the Veteran underwent another VA examination. The Veteran reported taking calcium and Vitamin D to treat the osteoporosis with no side effects. The Veteran stated prolonged standing or prolonged sitting causes pain at the lumbar and thoracic spine that improved with lying down. The Veteran denied bilateral lower extremity pain or discomfort. The VA examination report notes no history of trauma to the bones, bone neoplasm, osteomyelitis, inflammation, fracture site motion, or deformity. The VA examination report notes no fever, general debility, or flare-ups of bone or joint disease and notes that this condition does not affect motion of a joint. Upon physical examination, the June 2013 VA examination report notes no evidence of leg shortening, bone or joint abnormality, weight bearing joint affected, evidence in the feet of abnormal weight bearing, functional limitation on standing or walking, genu recurvatum, constitutional signs of bone disease, or malunion of the os calcis or astragalus. The VA examination report notes no evidence of functional ability limited due to pain, weakness, fatigability, incoordination, flare-ups, or loss of range of motion with use. The VA examination report notes no evidence of knee, hip, thigh, or lower leg condition due to the service-connected osteoporosis. The VA examination report notes a small annular tear, L4-L5, as a separate diagnosis but does not link this diagnosis with the osteoporosis. After a review of the lay and medical evidence of record, the Board finds that a compensable disability rating is not warranted for any part of the initial rating period. The weight of the evidence does not support a finding that there is objective evidence of painful or limited motion of a major joint or group of minor joints due to the service-connected osteoporosis. 38 C.F.R. § 4.71a. Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see 38 C.F.R. § 3.159(a)(2). The Board finds that the Veteran has consistently and credibly reported, and received treatment for, leg, hip, and back pain in VA and private treatment records dated from November 2005 through June 2013 as well as in the lay statements submitted to the Board, as detailed above. However, while, as a lay person, the Veteran is competent to relate symptoms including hip, leg, and back pain, she does not have the requisite medical knowledge, training, or experience to associate the symptoms of low back, hip, and leg pain with the service-connected osteoporosis as opposed to her non-service-connected, including osteoarthritis, degenerative joint disease, lumbar disc disease, and lower extremity radiculopathy. See Kahana, 24 Vet. App. at 437 (recognizing ACL injury is a medically complex disorder that requires a medical opinion to diagnose and to relate to service or differentiate from in-service symptoms and diagnosis). The etiology of the Veteran's current symptoms of low back, hip, and leg pain are complex medical etiological question involving internal and unseen system processes unobservable by the Veteran. Further, although the Veteran has painful motion, the VA examiners have not attributed her pain to the service-connected osteoporosis. Rather, as described in detail above, the November 2008 VA examiner, in the January 2009 addendum opinion, explained that osteoporosis and osteoarthritis are two completely different diagnoses and are not related as osteoporosis is a disease of bone demineralization that does not affect the joints as opposed to osteoarthritis that is a degenerative process in the joints ("ARTHRO = joint and ITIS = inflammation") related to aging or injury of a joint that can cause pain in the joints. The VA examiner explained that osteoporosis causes bones to become thinner and may predispose the person to pathological fracture of a bone. The VA examiner noted that the Veteran has not had any fracture of a bone due to the osteoporosis. Additionally, the August 2012 VA treatment record notes that a hairline fracture of the pelvis had initially been assessed; however, subsequent evaluation as well as a MRI of the pelvis did not confirm this assessment. The treatment record reflects that the Veteran was told the pain was likely due to lumbar spine disease. Finally, the June 2013 VA examiner noted no evidence of functional ability limited due to pain, weakness, fatigability, incoordination, flare-ups, or loss of range of motion with use. The VA examiner noted no evidence of knee, hip, thigh, or lower leg condition due to the service-connected osteoporosis and, while a small annular tear, L4-L5 was noted, this separate diagnosis was not linked with the service-connected osteoporosis. The Board finds that the Veteran's opinion that her painful motion is attributable to the service-connected osteoporosis is outweighed by the VA examiners' opinions to the contrary, because their determinations are based on greater medical knowledge and experience and the Veteran has not been shown to have the requisite medical knowledge, training or experience to associate painful motion of the back, hip, and leg with the service-connected osteoporosis. See Kahana at 437. VA adjudicators are precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). However, as noted above, multiple VA examiners clearly indicated that the Veteran's reported symptoms of joint pain and painful motion were not attributable to the service-connected osteoporosis. Rather, the Veteran's current joint manifestations of the lumbar spine, hips, and legs have been differentiated - they have been attributed to non-service-connected disabilities, including osteoarthritis. The Board has also considered application of 38 C.F.R. §§ 4.40, 4.45, and 4.59 and DeLuca, supra, specifically the additional limitations of motion due to pain. None of the Veteran's painful motion is attributable to the service-connected osteoporosis, as opposed to non-service-connected disabilities. Further, the November 2008 VA examiner noted no painful motion associated with the service-connected osteoporosis and the June 2013 VA examination report notes no evidence of functional ability limited due to pain, weakness, fatigability, incoordination, flare-ups, or loss of range of motion with use. The Board finds that the weight of the evidence is against a finding that the service-connected osteoporosis has been manifested by functional loss. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 206. Based on the above, the weight of the evidence demonstrates no painful or limited motion of any joint due to the service-connected osteoporosis; therefore, the Board finds that the criteria for a compensable disability rating have not been met or more nearly approximated under Diagnostic Code 5013 for the Veteran's service-connected osteoporosis for any part of the initial rating period. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether an extraschedular evaluation would have been warranted for the osteoporosis. 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 osteoporosis are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's osteoporosis has not been manifested by pain or limitation of motion. The schedular rating criteria specifically provides that osteoporosis, under Diagnostic Code 5013, should be rated under Diagnostic Code 5003 based on limitation of motion of affected parts the same as degenerative arthritis. The schedular rating criteria specifically provide ratings for limitation of motion (Diagnostic Codes 5235 to 5242, 5251 to 5253, 5260 to 5261) including motion limited to orthopedic factors such as pain, weakness, and guarding (38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca). In this case, comparing the Veteran's disability level and symptomatology of the osteoporosis disability to the rating schedule, the degree of disability of each 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. In the absence of exceptional factors associated with the back disability, 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). ORDER A higher (compensable) initial disability rating for the service-connected osteoporosis, for the entire initial rating period, is denied. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs