Citation Nr: 1502541 Decision Date: 01/20/15 Archive Date: 01/27/15 DOCKET NO. 10-14 547 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an increased disability rating in excess of 20 percent for L4-L5 disc bulge with residual low back pain [herein low back disability]. 2. Entitlement to an increased disability rating in excess of 10 percent for tenosynovitis, right hand (major) [herein right hand disability]. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD S. Hoopengardner, Associate Counsel INTRODUCTION The Veteran had active duty service from October 1989 to October 1999. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Veteran was scheduled for a videoconference hearing before the Board in July 2011; however, he failed to appear. Under the applicable regulation, if an appellant fails to appear for a scheduled hearing and a request for postponement has not been received and granted, the case will be processed as though the request for a hearing had been withdrawn. 38 C.F.R. § 20.702 (d) (2014). Accordingly, the Veteran's request for a hearing is considered withdrawn. A review of the electronic records maintained in Virtual VA and Veterans Benefits Management System (VBMS) was conducted. FINDINGS OF FACT 1. The Veteran's service-connected low back disability is manifested by pain (that occasionally radiates into the lower extremities), limitation of motion, painful motion and limitation of standing and walking. His forward flexion is limited to no less than 60 degrees, and his combined range of motion is 180 degrees. 2. The Veteran's service-connected low back disability has not resulted in physician-prescribed bed rest; nor is there objective evidence of a neurological disability associated with the low back disability. 3. The Veteran's service-connected right hand disability is manifested by pain, subjective complaints of numbness, and his hand locking up. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for the Veteran's service-connected low back disability have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5243 (2014). 2. The criteria for a disability rating in excess of 10 percent for the Veteran's service-connected right hand disability have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5024, 5214-5230 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist The Veteran was provided with adequate notice in a March 2009 letter, prior to the June 2009 decision on appeal. The duty to assist includes assisting the Veteran in the procurement of relevant records. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c) (2014). The RO obtained the Veteran's VA treatment records. As discussed below, while some test results, such as x-ray and MRI, were referenced in VA treatment records and the May 2009 VA examination, the actual reports of such tests are not of record. However, as the medical providers included detailed references to the results of these tests, and the Veteran's increased rating claims depend primarily on range of motion findings that the tests in question would likely not provide information on, remand is not required to obtain these records. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). As such, the Board finds that VA has satisfied its duty to assist with the procurement of records. The duty to assist also includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on a claim, as defined by law. See 38 C.F.R. § 3.159(c) (4) (2014). With respect to the issues on appeal, the Veteran was provided with a VA examination in May 2009. In a May 2009 statement, the Veteran appeared to question the adequacy of the VA examination and referenced it as being "the quickest exam that I have ever seen." After review, however, the Board finds the VA examination report to be thorough, complete, and sufficient bases upon which to reach a decision on the Veteran's claim. See Rodriguez-Nieves v. Peake, 22 Vet. App. 295, 302-05 (2008); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). There is no evidence of a worsening of symptoms since the examination. Therefore, the Board finds it adequate. In sum, VA has met all statutory and regulatory notice and duty to assist provisions with respect to the Veteran's claim. II. Low Back Disability Legal Criteria When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. See 38 C.F.R. § 4.40 (2014); DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45 (2014). The Veteran's service-connected low back disability is rated under Diagnostic Code 5243 for intervertebral disc syndrome. The June 2009 rating decision on appeal continued a 20 percent disability rating based on forward flexion limited to 60 degrees. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). The General Rating Formula for Diseases and Injuries of the Spine provides a 20 percent disability rating for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2014). A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. These criteria are to be applied irrespective of whether there are symptoms such as pain (whether or not it radiates), stiffness, or aching in the affected area of the spine. Id. The term "combined range of motion" refers to "the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation." 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2) (2014). Note (1) under the General Rating Formula for Diseases and Injuries of the Spine also states to "[e]valuate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code." 38 C.F.R. § 4.71a General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2014). Spine conditions rated under Diagnostic Code 5243, for intervertebral disc syndrome, may be rated alternatively based on the General Rating Formula for Diseases and Injuries of the Spine discussed above or based on the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2014). A 20 percent rating is assigned where incapacitating episodes have a total duration of at least two weeks but less than four weeks during the past twelve months. A 40 percent rating is assigned where incapacitating episodes have a total duration of at least 4 weeks but less than six weeks during the past twelve months. An "incapacitating episode" is defined in Note (1) of Diagnostic Code 5243 as a "period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1) (2014). Analysis In his February 2009 claim, the Veteran stated that "[t]he pain continues to increase in my back; my physical activity is limited due to the pain in my back and the shooting pain in my right leg which becomes numb more frequently now." Under 38 C.F.R. § 3.400(o)(2) (2014), an effective date of up to one year prior to a claim for increased rating may be assigned where evidence indicates an increase in severity of the disorder during that one year period. The Veteran filed his increased rating claim on February 23, 2009. As such, evidence dating to February 23, 2008 will be considered. A February 2008 VA treatment note showed that the Veteran complained of low back pain. An August 2008 VA treatment note showed that the Veteran continued to complain of low back pain, that it goes down his right leg, and that he gets numbness. The assessment noted that the CT scan was normal, and since the Veteran was complaining of radicular symptoms, an MRI would be ordered. A January 2009 VA treatment record noted that the MRI did not show any spondylosis or stenosis. A neurology consult was ordered. A February 2009 VA neurology consult noted that the Veteran complained of intermittent numbness down his right leg since 1992 and that he only noticed the numbness when he has a lot of activity like running. Deep tendon reflexes were noted to be 2+ (normal) and symmetrical in the lower extremities, and Babinski, Hoffmann's and Tromner's signs were reported as absent. An impression was noted of complaints of intermittent numbness right leg. The Veteran was afforded a VA examination in May 2009. The examination report stated that the Veteran said his back pain can range from a 5 or a 6 to a 10 (out of 10), depending on what he is doing. The pain was reported to be mainly in the lower back, but that it also occasionally radiated down his legs at times. It was noted that the Veteran used a back brace, which provided minimal relief. Some weakness secondary to pain in his legs was also reported. It was noted that the Veteran could walk for about 10 or 15 minutes before he started to have a fairly significant amount of back pain. The back pain was reported to be worse with any repetitive activities, such as bending or lifting. Difficulty was also reported with activities, like mowing the lawn or doing work around the house, which required prolonged walking. It was noted that increased pain occurred with prolonged sitting. Beyond this, no specific flare-ups were noted. The examination report noted that the Veteran's activities of daily living and job are affected with repetitive activities or especially with prolonged sitting. No physician-ordered bed rest in the last 12 months was reported. Physical examination noted no tenderness to palpation of the lumbar spine. Forward flexion was noted to 60 degrees, extension to 20 degrees, right and left lateral bending to 20 degrees and right and left lateral rotation to 30 degrees. This is a combined range of motion of 180 degrees. Moderate pain throughout each of these "arcs of motion" was noted. No alteration in pain or "arc of motion" was reported with repetitive motion. A mildly antalgic gait was noted. Neurologically, sensation to light touch was intact throughout both lower extremities. Patella and Achilles reflexes were noted to be 2+ (normal) bilaterally. Bilateral straight leg raises were negative, with no clonus, and Babinski was negative bilaterally. This is a normal neurological examination. MRI results were referenced of "very minimal L4-5 disk bulge without any spinal or foraminal stenosis or degenerative changes." An assessment was noted of "[l]umbar spine minimal L4-5 disk bulge without foraminal or spinal canal stenosis. No signs of degenerative joint disease or degenerative disk disease." The examination report further noted that while the Veteran has a very small disk bulge, the examiner did not think that this should be causing all of his back pain and that the examiner was unsure of the etiology of his back pain. The examination report also noted, with respect to the DeLuca provisions, that "there was pain on range of motion testing at this time. It is conceivable that pain could further limit function as described particularly after being on his feet...It is not feasible, however, to attempt to express any of this in terms of additional limitation of motion as these matters cannot be determined with any degree of medical certainty." In a May 2009 statement, the Veteran noted that he wore a back brace at all times, that his chronic lower back pain was unbearable, that he could not sit for long periods or walk for long distances without shooting pain and numbness in his right leg. He reported having to constantly get up during the day and that his day to day activities were limited. The Veteran reported that between his back, right leg and hands, he was unable to perform the necessary functions of his last job in a timely manner and that he is "just hanging on barely" at his current job. The Veteran referenced taking medication prescribed by VA and that this "keeps me up all through the night and has killed my sex drive." The Veteran further reported impairment at work from his back pain and reported impairment in his personal life, such as in doing things around the house or picking up his son. In his July 2009 Notice of Disagreement (NOD), the Veteran referenced the June 2009 rating decision, denied saying his pain was 5 or 6 out of 10 and stated that he would rate his back pain as a 9 out of 10 and that it "is constant and has been for quite some time." He listed his pain as unbearable. The Veteran also denied having said he had no incapacitating episodes during the past 12 months. On his April 2009 VA Form 9 (Appeal to Board of Veterans' Appeals), the Veteran referenced his daily pain and that he cannot bathe his son because bending over results in unbearable pain. The Veteran further referenced that his service-connected low back disability limited his activities. He stated that a 50 percent disability rating would satisfy him because he is only able to do 50 percent of things he used to do due to his disability. Following a review of the available evidence in this case, and the applicable laws and regulations, the Board concludes that the evidence does not warrant a rating greater than the 20 percent currently assigned for the Veteran's service-connected low back disability. The May 2009 examination report contained the only required range of motion findings for a rating under the General Rating Formula for Diseases and Injuries of the Spine during the appeal period and the Veteran's forward flexion was noted to be to 60 degrees, with moderate pain. Notably, this is the upper limit of forward flexion warranting a 20 percent evaluation. Additionally, his combined range of motion of 180 degrees exceeds that allowable for the 20 percent. Higher disability ratings require limitation of forward flexion to 30 degrees or less, or ankylosis of the entire thoracolumbar spine, neither of which have been approximated. Thus, a rating in excess of 20 percent is not warranted. As noted above, under the General Rating Formula for Diseases and Injuries of the Spine, associated objective neurologic abnormalities are to be rated separately. 38 C.F.R. § 4.71a General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2014). In this case, the Veteran has reported subjective symptoms of numbness in his lower extremities, particularly his right leg. However, the symptoms have not resulted in an objective diagnosis of a neurological disability. Specifically, neurological testing demonstrated normal reflexes and a negative straight leg raise test, which is an objective indicator of radiculopathy. Therefore, no separate rating is warranted at this time. Turning to whether a higher rating is warranted alternatively under the criteria for IVDS, the May 2009 examination report noted that no physician-ordered bed rest in the last 12 months was reported. In the July 2009 NOD, the Veteran denied having said he had no incapacitating episodes during the past 12 months. However, an "incapacitating episode" is defined in Note (1) of Diagnostic Code 5243 as a "period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1) (2014). The evidence in this case does not demonstrate that a physician has ever confined the Veteran to bed due to his back disability. As such, a disability rating in excess of 20 percent is not warranted under Diagnostic Code 5243. In adjudicating this decision, the Board has considered the Veteran's statements with regard to his service-connected low back disability symptomatology and functional impairment. In evaluating the Veteran's level of disability, functional loss was considered. 38 C.F.R. §§ 4.40, 4.45 (2014). Again, the May 2009 examination report noted, with respect to the DeLuca provisions, that "there was pain on range of motion testing at this time. It is conceivable that pain could further limit function as described particularly after being on his feet...It is not feasible, however, to attempt to express any of this in terms of additional limitation of motion as these matters cannot be determined with any degree of medical certainty." The Board finds that any functional impairment reflected by the manifestations of the Veteran's service-connected low back disability, to include pain (that occasionally radiates into the lower extremities), limitation of motion, painful motion and limitation of standing and walking, are fully contemplated by the 20 percent rating currently assigned to his service-connected low back disability. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2014). Staged ratings are not warranted in this case, as the Veteran has had a stable level of symptomatology throughout the period on appeal. All potentially applicable diagnostic codes have been considered and there is no basis to assign an increased disability rating in excess of 20 percent for the Veteran's service-connected low back disability. As such, entitlement to an increased rating in excess of 20 percent for the Veteran's service-connected low back disability is denied. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5243 (2014). III. Right Hand Disability Legal Criteria The Veteran's service-connected right hand disability is rated under Diagnostic Code 5099-5024. The June 2009 rating decision on appeal continued a 10 percent disability rating based on painful or limited motion of a major joint or group of minor joints. The hyphenated code is intended to show that the Veteran's service-connected right hand disability is rated analogously to tenosynovitis. See 38 C.F.R. § 4.20 (2014) (an unlisted condition may be rated under a closely related disease or injury in which the functions affected, anatomical localization, and symptomatology are closely analogous); 38 C.F.R. § 4.27 (2014) (unlisted disabilities rated by analogy are coded first by the numbers of the most closely related body part and then "99"). Diagnostic Code 5024, for tenosynovitis, provides ratings based on limitation of motion of affected parts, as arthritis, degenerative. Under Diagnostic Code 5003, degenerative arthritis is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Diagnostic Code 5003 further provides that, when the limitation of motion of the joint involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. For purposes of rating arthritis, major joints include the wrist and multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities are considered groups of minor joints, ratable on parity with major joints. See 38 C.F.R. § 4.45 (2014). Limitation of motion of the individual fingers is rated under Diagnostic Codes 5228, 5229, and 5230 and the disability ratings for such codes are the same for both major and minor digits. Under Diagnostic Code 5228, for limitation of motion of the thumb, a 10 percent disability rating is warranted when there is a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A maximum 20 percent disability rating is warranted when there is a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Under Diagnostic Code 5229, for limitation of motion of the index or long finger, a maximum 10 percent disability rating is warranted when there is 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. Diagnostic Code 5230 provides for a maximum noncompensable disability rating for any limitation of motion of the ring or little finger. Diagnostic Codes 5216-5227 also provide various ratings for ankylosis of multiple and individual digits. Analysis As noted above, evidence dating to February 23, 2008 will be considered in evaluating the Veteran's claim for an increased rating. A February 2008 VA treatment note indicated that the Veteran complained of pain and locking of the right middle finger. An assessment was noted of hand problem, with x-ray normal. An April 2008 VA orthopedic consult noted complaints of right hand pain. No trauma was reported to the hand and no abnormality was noted on x-ray. The Veteran reported frequent use of the hands at work with writing and typing. The note stated that the pain was more probable the result of overuse. On physical exam it was noted that there was full range of motion of all phalanges of the hand without difficulty, no swelling and no bony abnormality. Light touch and two point discrimination was within normal limits bilaterally. No snuff box tenderness was noted, opposition was full and within normal limits, dexterity was within normal limits and grip strength was strong and equal bilaterally. Negative Phalen's and negative Tinel's were noted. An impression was noted of right hand pain, with occupational therapy ordered. A May 2008 VA occupation therapy treatment note indicated that the Veteran reported pain in the mid palm that is generally worse during working hours and on work days and that the Veteran has less tolerance for typing and writing activities at work. Active range of motion was noted to be within normal limits. Strength was noted to be decreased on the right side compared to the left. Sensation was noted to be intact in the upper extremities, fine motor coordination was noted to be good and no locking was noted in any finger joints. A summary section stated overuse syndrome from work activities (extensive typing and writing required at job). In his February 2009 claim, the Veteran stated that his right hand continued to lock up more and affected his job and physical activities. He referenced being "unable to do small things with my hands" and referenced being unable to hold his son for long periods due to pain in his hand. He stated that his job required him to write and type all day and that his right hand hinders his job. The Veteran was afforded a VA examination in May 2009. The examination report stated that the Veteran reported he was right hand dominant and that he did not remember a specific injury to his right hand. Pain was reported to be mainly in the palmar area in the mid palm substance. The pain was reported to range from 1-2 out of 10 up to about 10 out of 10. The Veteran reported using a hand splint at times, which gives minimal if any relief. The Veteran denied flare-ups, but noted he had increased pain with any sort of repetitive activity of the right hand (specific examples were provided and included typing). It was noted that there was no numbness, tingling and shock like sensations and that it does not ever feel like his hand is asleep. It was reported that the Veteran's activities of daily living and job are affected with repetitive activity with his right hand, which causes pain in the palmar area of the hand that does not radiate to the finger tips or out to the wrist at all. Physical examination noted that the right hand moves as a unit, that the Veteran is able to open up his hand all the way and make a fist all the way without a gap between the finger tips to the proximal crease and that there is no gap when opposing the thumbs to the finger tips with each of the fingers. Range of motion findings were reported for the thumb and other digits and the range of motion was noted to not be painful. No alteration in pain or "arc of motion" was reported upon repetition. No swelling, warmth or erythema was reported about the right hand. Very mild tenderness to palpation near the palmar crease in the middle of the palm was noted. No swelling of the tendons or signs of trigger fingering was found. Grip strength was noted to be normal. The examination report noted intact sensation to light touch and negative Tinel and Phalen's in the hand. X-rays of the right hand were noted to be normal (though the results were not included). An assessment was provided of right hand pain of unknown etiology. The examiner noted that the Veteran's right hand carries a previous diagnosis of tenosynovitis, but that this does not usually last 10 years and no signs of this was found during the examination. The examiner further noted that while he does not have a good etiology of the Veteran's right hand pain, that the Veteran does have pain and limitations of activities. The examination report also noted, with respect to the DeLuca provisions, that "[i]t is conceivable that pain could further limit function as described particularly after...using his hand all day. It is not feasible, however, to attempt to express any of this in terms of additional limitation of motion as these matters cannot be determined with any degree of medical certainty." In a May 2009 statement, the Veteran reported that between his back, right leg and hands, he was unable to perform the necessary functions of his last job in a timely manner and that he is "just hanging on barely" at his current job. The Veteran referenced taking medication prescribed by VA and that this "keeps me up all through the night and has killed my sex drive." The Veteran reported wearing a hand brace at all times. The Veteran further reported impairment at work from his hands locking up with pain and reported impairment in his personal life, such as in doing things around the house or picking up or feeding his son. The Veteran also referenced the May 2009 VA examination and stated that the examiner told him that he should see a hand doctor to see what his hand was doing. In his July 2009 NOD, the Veteran referenced the June 2009 rating decision and stated that the pain in his right hand is always there and that it increases severely with activity. The Veteran denied saying he did not have numbness, tingling or sock type sensations and flare-ups of hand pain and reported that his hand is constantly going numb and tingling. On his April 2009 Form 9, the Veteran referenced his right hand impacting him in a variety of different ways and noted dealing with his son, driving a car and repetitive action. The Veteran further reported pain in his hand and it locking up. Following a review of the available evidence in this case, and the applicable laws and regulations, the Board concludes that the evidence does not warrant a rating greater than the 10 percent currently assigned for the Veteran's service-connected right hand disability. The May 2009 examination report noted that the Veteran is able to open up his hand all the way and make a fist all the way without a gap between the finger tips to the proximal crease and that there is no gap when opposing the thumbs to the finger tips with each of the fingers. Accordingly, an increased disability rating greater than 10 percent is not warranted under Diagnostic Code 5228, as the required limitation of motion of the thumb has not been shown (a 20 percent disability rating is warranted when there is a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers). Additionally, Diagnostic Codes 5229 and 5230 do not provide disability ratings in excess of 10 percent, and the evidence of record does not show that there is limitation of motion of the index, long, ring or little fingers of the Veteran's right hand as contemplated under those codes. Also, ankylosis has not been noted for any of the Veteran's digits on the right hand and therefore an increased disability rating under Diagnostic Codes 5216-5227 is not warranted. Also potentially applicable are Diagnostic Codes 5214 (ankylosis of the wrist) and 5215 (limitation of motion of the wrist); however no limitation of motion or ankylosis of the wrist has been shown and thus a higher rating is not warranted under these codes. With respect to the Veteran's complaints of numbness and tingling in his hand, no neurological diagnosis has been provided with respect to his right hand and thus the Board finds that no evaluation is warranted for any neurological complaints. Under Diagnostic Code 5003, degenerative arthritis is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Diagnostic Code 5003 further provides that, when the limitation of motion of the joint involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. As noted above, the June 2009 Rating Decision on appeal assigned a 10 percent disability rating for painful or limited motion of a major joint or group of minor joints. For purposes of rating arthritis, major joints include the wrist and multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities are considered groups of minor joints, ratable on parity with major joints. See 38 C.F.R. § 4.45 (2014). Based on the evidence of record, the Board concludes that there is no basis for a disability rating in excess of 10 percent, or additional disability rating, under Diagnostic Code 5003 and that the 10 percent disability rating assigned adequately reflects the Veteran's right hand symptomatology. In adjudicating this decision, the Board has considered the Veteran's statements with regards to his service-connected right hand disability symptomatology and functional impairment. In evaluating the Veteran's level of disability, functional loss was considered. 38 C.F.R. §§ 4.40, 4.45 (2014). Again, the May 2009 examination report noted, with respect to the DeLuca provisions, that "there was pain on range of motion testing at this time. It is conceivable that pain could further limit function as described particularly after...using his hand all day. It is not feasible, however, to attempt to express any of this in terms of additional limitation of motion as these matters cannot be determined with any degree of medical certainty." The Board finds that any functional impairment reflected by the manifestations of the Veteran's service-connected right hand disability, to include pain and his hand locking up that results in functional limitations, are fully contemplated by the 10 percent rating currently assigned to his service-connected right hand disability. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2014). Staged ratings are not warranted in this case, as the Veteran has had a stable level of symptomatology throughout the period on appeal. All potentially applicable diagnostic codes have been considered and there is no basis to assign an increased rating in excess of 10 percent for the Veteran's service-connected right hand disability. As such, entitlement to an increased rating in excess of 10 percent for the Veteran's service-connected right hand disability is denied. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5024, 5214-5230 (2014). IV. Extraschedular Consideration Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, 572 F.3d 1366 (Fed. Cir. 2009). The first element requires a finding that the evidence "presents such an exceptional or unusual disability picture that the available schedular evaluations for that service-connected disability are inadequate." See id. at 115. In order to determine whether a disability is "exceptional or unusual," 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." Id. "[I]f the [rating] criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, [and] the assigned schedular evaluation is, therefore adequate, and no referral is required." Id. Neither the first nor second Thun element is satisfied here. The Veteran's service-connected low back disability is manifested by pain (that occasionally radiates into the lower extremities), limitation of motion, painful motion and limitation of standing and walking. The Veteran's service-connected right hand disability is manifested by pain, subjective complaints of numbness, and instances of his hand occasionally locking up that results in functional limitations. These signs and symptoms, and their resulting impairment, are specifically contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to disabilities of the low back and hand provide disability ratings on the basis of limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5024, 5214-5230 (applicable to the hand); 5235-5243 (applicable to the low back) (2014). For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40 (2014); Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; swelling; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59 (2014); Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture. In short, there is nothing exceptional or unusual about the Veteran's service-connected low back or right hand disabilities because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. With respect to the second Thun element, the evidence does not suggest that any of the "related factors" are present. In particular, the Veteran does not contend, and the evidence of record does not suggest, that his service-connected low back and right hand disabilities has caused marked interference with employment or resulted in frequent hospitalizations. 38 C.F.R. § 3.321(b)(1) (2014). While the Veteran has stated that these service-connected disabilities impacted his work performance and that he had to change jobs, the evidence has not shown that they have caused marked interference with employment. Thus, even if his disability picture was exceptional or unusual, referral for an extraschedular evaluation would not be warranted. The schedule of rating criteria contemplates some level of impairment in occupational functioning. Additionally, in a May 2009 statement the Veteran referenced taking medication prescribed by VA and that this "keeps me up all through the night and has killed my sex drive." Providing the Veteran the benefit of the doubt and assuming (without deciding) that these symptoms are attributable to medication taken for his service-connected disabilities, it does not appear that difficulty sleeping and decreased sex drive are contemplated by the rating criteria discussed above. In any event, under the second Thun element, the evidence of record does not indicate that these particular symptoms (difficulty sleeping and decreased sex drive) have caused marked interference with employment or resulted in frequent hospitalizations and as such, referral for an extraschedular evaluation is not warranted. Finally, the Board notes that a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, F.3d 1362 (Fed. Cir. 2014). In this case, the Veteran or his representative have not alleged that his currently service-connected disabilities combine to result in additional disability or symptomatology that is not already contemplated by the rating criteria for each individual disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration is warranted under Johnson. V. Total Disability Rating Based on Individual Unemployability (TDIU) Finally, the Board is cognizant of the ruling of the United States Court of Appeals for Veterans Claims in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran or his representative have not argued and the record does not demonstrate that his service-connected low back and right hand disabilities have resulted in an inability to secure or follow a substantially gainful occupation. Again, while the Veteran has stated that these service-connected disabilities impacted his work performance and that he had to change jobs, the evidence does not show that the Veteran was unable to secure or follow a substantially gainful occupation. Accordingly, the Board concludes that a claim for entitlement to a TDIU has not been raised. ORDER Entitlement to an increased disability rating in excess of 20 percent for L4-L5 disc bulge with residual low back pain is denied. Entitlement to an increased disability rating in excess of 10 percent for tenosynovitis, right hand (major) is denied. ____________________________________________ Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs