Citation Nr: 1601402 Decision Date: 01/13/16 Archive Date: 01/21/16 DOCKET NO. 08-20 196 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased rating for left heel and ankle strain, currently rated as noncompensable prior to March 28, 2013 and as 10 percent disabling since March 28, 2013. 2. Entitlement to a rating higher than 10 percent for traumatic degenerative joint disease of the right elbow. 3. Entitlement to a compensable rating for right index finger laceration and dislocation. 4. Entitlement to a compensable rating for right middle finger traumatic injury. 5. Entitlement to an increased rating for right shoulder strain, currently rated as 10 percent disabling prior to March 28, 2013, and as 20 percent disabling since March 28, 2013. 6. Entitlement to an initial increased rating for left knee residuals of patellofemoral syndrome, status post arthroscopic surgery, currently rated as 10 percent disabling prior to November 19, 2014. 7. Entitlement to an initial rating higher than 30 percent for left knee total replacement arthroplasty, from January 1, 2016. 8. Entitlement to an initial increased rating for left knee instability, currently rated as noncompensable prior to March 28, 2013 and 10 percent disabling from March 28, 2013. 9. Entitlement to an increased rating for right knee strain, currently rated as 10 percent disabling prior to July 9, 2013. 10. Entitlement to an initial rating higher than 30 percent for right knee total replacement arthroplasty, from September 1, 2014. 11. Entitlement to an initial increased rating for right knee degenerative joint disease currently rated as noncompensable prior to March 28, 2013, and as 10 percent disabling from March 28, 2013 to July 9, 2013. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD L. Edwards Andersen, Counsel INTRODUCTION The Veteran had active service from August 1974 to July 1998. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran requested a hearing before the Board. The requested hearing was conducted in July 2012 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. In November 2012, the Board remanded these claims for additional development. In addition to the paper claims file, there are additional documents in Virtual VA and the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of these electronic records. The issues of entitlement to increased ratings for service connected right shoulder disability, right knee disabilities, and left knee disabilities are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to March 28, 2013, the Veteran's left heel and ankle strain was primarily manifested by pain on use. 2. From March 28, 2013, the Veteran's left heel and ankle strain is not manifested by marked limitation of motion. 3. The Veteran's traumatic degenerative joint disease of the right elbow has been manifested by pain and noncompensable limitation of motion; however, there has been no impairment of supination or pronation, elbow ankylosis, flail joint, joint facture, or impairment of the radius or ulna. 4. The Veteran's right index finger laceration and dislocation is manifested by non-compensable limitation of motion. 5. The Veteran's right middle finger traumatic injury is manifested by non-compensable limitation of motion. 6. The Veteran has demonstrated painful, limited motion, numbness, and deformity of the right index and middle fingers, and has associated degenerative changes equivalent to arthritis of two or more minor joint groups, as part and parcel of his service-connected right index finger and right middle finger. CONCLUSIONS OF LAW 1. Prior to March 28, 2013, the criteria for a 10 percent rating, but no higher, for left heel and ankle strain have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271, 5284 (2015). 2. From March 28, 2013, the criteria for a rating higher than 10 percent for left heel and ankle strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271, 5284 (2015). 3. The criteria for a rating higher than 10 percent for traumatic degenerative joint disease of the right elbow have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5205-5213 (2015). 4. The criteria for a compensable rating for right index finger laceration and dislocation have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5225, 5229 (2015). 5. The criteria for a compensable rating for right middle finger traumatic injury have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5226, 5229 (2015). 6. The criteria for a separate, 10 percent disability evaluation for associated degenerative changes equivalent to arthritis of two or more minor joint groups of the right fingers are met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.61, 4.71a, Diagnostic Code 5003 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In an increased rating claim, VA must notify the Veteran to submit evidence showing (1) a worsening or increase in severity of the disability and (2) the effect that worsening has on the claimant's employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). Appropriate notice was provided in July 2007 and August 2012 and the claims were readjudicated in an April 2013 supplemental statement of the case. Mayfield, 444 F.3d at 1333. The duty to assist has also been met and appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA and private treatment records. The Veteran was afforded adequate VA medical examinations. VBMS and Virtual VA records have been reviewed. As such, the Board finds that all records have been associated with the claims file. In Bryant v. Shinseki, the U.S. Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) requires that the "hearing officer" who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Concerning the first duty, during the hearing, the Veterans Law Judge enumerated the issues on appeal. In regard to the second duty, the duty to suggest the submission of evidence that may have been overlooked was also accomplished throughout the hearing. The Veteran was informed of the type of evidence that would be supportive of his claim. In November 2012, the Board remanded these claims to afford the Veteran VA examinations. The Veteran was afforded VA examinations in March 2013. As such, the evidence indicates that there has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). That development having been completed, the claims are now ready for appellate review. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal arises from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability of the joints is measured by abnormalities of motion, such as limitation of motion or hypermobility, instability, pain on motion, or the inability to perform skilled motions smoothly. 38 C.F.R. § 4.45. Painful motion with joint or periarticular pathology and unstable joints due to healed injury are recognized as productive of disability entitled to at least a minimal compensable rating for the joint. 38 C.F.R. § 4.59. Under section 4.59, painful motion is considered limited motion even though a range of motion is possible beyond the point when pain sets in. Hicks v Brown, 8 Vet. App. 417, 421 (1995). Examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain 'on use or due to flare-ups.' DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). A. Entitlement to an Increased Rating for Left Heel and Ankle Strain, Currently Rated as Noncompensable Prior to March 28, 2013 and as 10 Percent Disabling Since March 28, 2013 Service connection for left heel and ankle strain was granted in a January 1999 rating decision, at which time a noncompensable rating was assigned, effective August 1, 1998. In June 2007, the Veteran submitted a claim for an increased rating. In an April 2013 rating decision, the RO granted an increased evaluation of 10 percent for left heel and ankle strain, effective March 28, 2013. Despite the grant of this increased evaluation, the Veteran has not been awarded the highest possible evaluation. As a result, he is presumed to be seeking the maximum possible evaluation. The issue remains on appeal, as the Veteran has not indicated satisfaction with the 10 percent rating. A.B. v. Brown, 6 Vet. App. 35 (1993). The Veteran's left heel and ankle strain is currently rated by analogy under Diagnostic Code 5299-5271. Under Diagnostic Code 5271, a rating of 10 percent is warranted when limitation of motion of the ankle is moderate. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. The maximum rating of 20 percent disabling is available under Diagnostic Code 5271 where the limitation of motion in the ankle is marked. Id. The words "moderate" and "marked," as used in the various Diagnostic Codes, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. Normal ankle motion is dorsiflexion to 20 degrees, and plantar flexion to 45 degrees. 38 C.F.R. § 4.71a, Plate II. The Veteran was afforded a VA examination in August 2007. The Veteran reported occasional left ankle pain, lasting for a few hours. The Veteran indicated his left heel pain was asymptomatic at the time. Examination revealed the ankle had a dorsiflexion to 20 degrees and plantar flexion to 45 degrees. There was no pain on range of motion at the time. The Veteran testified in July 2012 that his ankle becomes unstable after walking and that he experiences daily pain. See July 2012 BVA Hearing Transcript, page 23. The Veteran testified that he experiences loss of motion of the ankle at times when walking, causing his toe to drop. Id. at page 25. The Veteran asserts that he experiences occasional swelling. Id. at page 26. The Veteran was afforded a VA examination in March 2013. The Veteran reported pain and having to limit his walking and standing. Examination revealed a plantar flexion to 40 degrees, with painful motion beginning at 40 degrees, and a dorsiflexion to 15 degrees, with painful motion beginning at 15 degrees. The Veteran was able to perform repetitive-use testing with three repetitions. The examiner noted that the Veteran's left ankle had less movement than normal, pain on movement and interference with sitting, standing and weight bearing. There was no localized tenderness or pain on palpation of the ankle. Muscle strength was 5/5 and there was no laxity of the joints. X-rays did not demonstrate any abnormal findings. The Board has considered all applicable statutory and regulatory provisions to include 38 C.F.R. §§ 4.40 and 4.59, as well as the holding in DeLuca v. Brown, 8 Vet. App. 202 (1995), regarding functional impairment attributable to pain, particularly in light of the fact that the Veteran contends his disability is essentially manifested by pain and instability. Under 38 C.F.R. § 4.59, painful motion is considered limited motion even though a range of motion is possible beyond the point when pain sets in. Hicks v Brown, 8 Vet. App. 417, 421 (1995). VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). Taking into account all of the evidence set out above, and resolving any reasonable doubt in the Veteran's favor, the Board finds that the evidence of record supports assigning a 10 percent rating for left heel and ankle strain, based on pain and impairment of functional use of the ankle, prior to March 28, 2013. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5271 (2015); see also 38 C.F.R. §§ 4.40, 4.45 (2015). A rating higher than 10 percent is not warranted as the evidence does not indicate that the Veteran suffered from marked limitation of motion, March 28, 2013. In fact, the evidence demonstrates that the Veteran had a normal range of motion at his August 2007 VA examination. Regarding the period of time from March 28, 2013, the Board notes that the maximum rating of 20 percent disabling is available under Diagnostic Code 5271 where the limitation of motion in the ankle is marked. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Taking into account all of the evidence set out above, the Board finds that the evidence of record does not support assigning a rating higher than 10 percent for his left heel and ankle strain, from March 28, 2013. See 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2015); see also 38 C.F.R. §§ 4.40, 4.45 (2015). A rating higher than 10 percent, from March 28, 2013, is not warranted, as the evidence does not indicate that the Veteran suffers from marked limitation of motion. The Board notes that the Veteran's range of motion was limited during the March 2013 VA examination, with a dorsiflexion of 15 degrees, and plantar flexion of 40 degrees. However, a loss of less than half the degrees of range of motion (15 out of 20 and 40 out of 45) does not constitute loss of motion that more nearly approximates marked limitation of motion. In regard to flare-ups, the examiner noted that the Veteran denied flare-ups that impacted the function of the ankle. The Board finds that the current 10 percent rating appropriately compensates the Veteran for his symptoms of pain, instability, swelling and limitation of motion. The Board also has considered whether any additional Diagnostic Codes are applicable. The March 2013 VA examination was normal with respect to the left heel. Indeed the Veteran's complaints appear to be centered on his ankle. Thus, there is no medical or persuasive lay evidence that shows that the Veteran is entitled to compensation under Diagnostic Code 5284. The Veteran is competent to report on symptoms and is credible in his belief that he is entitled to a higher rating. His competent and credible lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the ankle/heel impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment. In summary, the Board finds that the Veteran is entitled to a 10 percent rating for his left heel and ankle strain, under Diagnostic Code 5271, based on pain and impairment of functional use of ankle, prior to March 28, 2013; however, the Veteran is not entitled to a rating higher than 10 percent, from March 28, 2013. B. Entitlement to a Rating Higher than 10 Percent for Traumatic Degenerative Joint Disease of the Right Elbow Service connection for traumatic degenerative joint disease of the right elbow was granted in a January 1999 rating decision, at which time a 10 percent rating was assigned, effective August 1, 1998. In June 2007, the Veteran submitted a claim for an increased rating. The Veteran's right elbow is currently rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5010. The Veteran is right-handed. Arthritis shown by x-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (degenerative arthritis) and 5010 (traumatic arthritis). Diagnostic Code 5010 (traumatic arthritis) directs that the evaluation of arthritis be conducted under Diagnostic Code 5003, which states that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5010. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5010. In the absence of limitation of motion, x-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010, Note 1. The Veteran's primary documented symptom is pain and limitation of motion, so the Board will consider additional Diagnostic Codes for the limitation of motion of the forearm. Under Diagnostic Code 5206, for a major extremity, limitation of flexion of the forearm to 110 degrees warrants a non-compensable rating, limitation to 100 degrees warrants a 10 percent rating, limitation to 90 degrees warrants a 20 percent rating, limitation to 70 degrees warrants a 30 percent rating, limitation to 55 degrees warrants a 40 percent rating, and limitation to 45 degrees warrants a maximum 50 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Under Diagnostic Code 5207, for a major extremity, limitation of extension of the forearm to 45 degrees or 60 degrees warrants a 10 percent rating, limitation to 75 degrees warrants a 20 percent rating, limitation to 90 degrees warrants a 30 percent rating, limitation to 100 degrees warrants a 40 percent rating, and limitation to 110 degrees warrants a maximum 50 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5207. Under Diagnostic Code 5208, a 20 percent rating is warranted when forearm flexion of the major arm is limited to 100 degrees and forearm extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5208. Diagnostic Codes 5209, 5210, 5211, and 5212 are not applicable, as the evidence does not indicate the Veteran suffers from joint fracture, nonunion of the radius and ulna, impairment of the ulna, or impairment of the radius. Under Diagnostic Code 5213, a 10 percent rating is warranted for limitation of supination of the major arm to 30 degrees or less; a 20 percent rating is warranted for limitation of pronation with motion lost beyond last quarter of the arc (i.e., the hand does not approach full pronation or motion lost beyond middle of arc), and a 30 percent rating is warranted for limitation of pronation with motion lost beyond the middle of the arch. Under 38 C.F.R. § 4.71a, Plate 1 (2015), normal flexion of the elbow is 0 to 145 degrees, normal forearm pronation is 0 to 80 degrees, and normal forearm supination is 0 to 85 degrees. The Veteran was afforded a VA examination in May 2007. He reported right elbow pain with residual aching and stiffness, usually occurring once per week, lasting for a few hours. Examination revealed a flexion to 145 degrees, supination to 85 degrees, and pronation to 80 degrees. The examiner noted that the Veteran did not have pain on range of motion. X-ray of the right elbow demonstrated a large olecranon spur. The Veteran was afforded a VA examination in March 2013. The Veteran reported pain and swelling of the right elbow. He asserted he has to miss work, as he cannot move containers of mail and has difficulty twisting and turning. Examination revealed a flexion to 135 degrees, with pain beginning at 135 degrees and extension to zero with pain beginning at zero degrees. The Veteran was able to perform repetitive-use testing with 3 repetitions, with no additional loss of motion. There was no localized tenderness or pain on palpation. Muscle strength testing was 5/5. X-rays demonstrated degenerative or traumatic arthritis. He denied flare-ups. There was no additional condition of impairment of supination or pronation. As the foregoing shows, even when considering pain, the Veteran's limitation of motion has been no greater than 135 degrees of flexion and zero degrees of extension through the period on appeal. Without motion actually or functionally limited to 100 degrees or 90 degrees of flexion or 45 degrees or 75 degrees of extension, separate ratings or a rating greater than 10 percent cannot be granted under Diagnostic Codes 5206, 5207, and 5208. The 10 percent rating compensates the Veteran for pain and impairment of functional use of the right elbow. The Board has also considered whether a higher rating may be warranted under an alternative Code, but finds that one is not. In so finding the above, the Board notes that the Veteran is competent to report on symptoms and credible in his belief that he is entitled to a higher rating. His competent and credible lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the elbow impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of impairment associated with the elbow disability. Accordingly, the Board concludes that the traumatic degenerative joint disease of the right elbow disability has been 10 percent disabling throughout the rating period on appeal. As the preponderance of the evidence is against the claim, there is no doubt to be resolved. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. C. Entitlement to a Compensable Rating for Right Index Finger Laceration and Dislocation and Entitlement to a Compensable Rating for Right Middle Finger Traumatic Injury Service connection for right index finger laceration and right middle finger traumatic injury were granted in a January 1999 rating decision, at which time noncompensable ratings were assigned, effective August 1, 1998. In June 2007, the Veteran submitted a claim for an increased rating. The Veteran's right index finger laceration and dislocation is currently evaluated by analogy under the provisions of Diagnostic Code 5225, which pertains to ankylosis of the index finger. Similarly, the Veteran's right middle finger is currently evaluated by analogy under Diagnostic Code 5226, which pertains to ankylosis of the middle finger. As noted below, since the fingers in question have a range of motion, ankylosis is not shown on examination and entitlement to increased ratings based on these Diagnostic Codes is not shown. The Board has also considered Diagnostic Code 5229. Diagnostic Code 5229 contemplates limitation of motion of the index or long finger. It provides a noncompensable rating for a gap of less than one inch (2.5 centimeters) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. A 10 percent rating is afforded for a gap of one inch (2.5 centimeters) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5229. See Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). The Veteran was afforded a VA examination in August 2007. It was noted that the Veteran is right handed, and during military service, the Veteran had a laceration of his right index finger, along the medial aspect of the distal interphalangeal joint. The Veteran reported limited range of motion at the distal interphalangeal joint, but was otherwise asymptomatic. There were no effects on occupational functioning or activities of daily living. Examination revealed no ankylosis. It was noted that the Veteran's gap between the tip of the thumb and fingers, the tips of the ringers and the proximal transverse crease of the palm and between the thumb pad and the fingers with the thumb attempting to oppose the fingers were all normal; however, there was a right posttraumatic proximal interphalangeal joint middle finger injury with a flexion deformity of 5 degrees. X-rays were normal. The Veteran was diagnosed with laceration of the right index finger with limited range of motion of the distal interphalangeal joint. The Veteran was afforded a VA examination in March 2013. It was noted that the Veteran had a 2-centimeter scar on the medial finger with numbness at the tip of the joint. The Veteran reported that he has soreness and stiffness in the right middle finger. Examination revealed limitation of motion or evidence of painful motion in the index finger and long finger. There was a gap between the thumb pad and the fingers of less than 1 inch. Painful motion was noted to begin at a gap of less than 1 inch. There was also a gap between the index finger and long finger and the proximal transverse crease of the palm, or evidence of painful motion in attempting to touch the palm with the fingertips. Painful motion began at a gap of less than 1 inch. There was limitation of extension of the index finger and long finger, limited by no more than 30 degrees, with painful motion beginning at extension of no more than 30 degrees. The Veteran was able to perform repetitive-use testing without any additional limitation of motion. There was a gap between the index finger, and long finger and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips post-test of less than an inch and post-test, extension was limited to no more than 30 degrees. It was noted that the Veteran had less movement than normal, pain on movement, deformity of the index and long finger, and mild contracture of the right index and middle finger. Handgrip was 4/5. X-rays did not demonstrate any abnormal findings. The examiner noted that the Veteran's hand, thumb or finger conditions affected his ability to work in that he had difficulty lifting and carrying, and pain with opening and closing his hands. Compensable ratings for the Veteran's right index finger and right middle finger disabilities would require a gap of one inch or more between the fingertip and the proximal transverse area of the crease of the palm with the finger flexed to the extent possible, extension limited by more than 30 degrees or x-ray evidence of arthritis in one minor joint group. The evidence in this case does not show that the Veteran meets the schedular criteria for a compensable disability rating under Diagnostic Code 5229 for either the right index finger or right middle finger. Although the Veteran's motion was limited, the gap was less than one inch and extension was limited by no more than 30 degrees. However, VA policy is to compensate actually painful motion at least the minimum compensable level. 38 C.F.R. § 4.59. With any form of arthritis, painful motion is an important factor. It is the intention of the rating schedule to recognize actually painful, unstable or maligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 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. 38 C.F.R. § 4.45. The Board has carefully considered the Veteran's statements to the effect that he has functional impairment in his right hand and fingers from pain, weakness, and limitation of motion that interferes with his employment. While x-rays taken of the right hand in March 2013 were noted to be "negative", they did demonstrate spurring involving the first interphalangeal joint. Furthermore, the Board notes that the evidence reflects long-standing pain and stiffness of the Veteran's right index finger and middle finger. Limitation of motion has been objectively confirmed by findings of painful motion during the March 2013 VA examination. Furthermore, the March 2013 VA examiner noted that the Veteran had less movement than normal, pain on movement, deformity of the index and long finger, and mild contracture of the right index and middle finger. Finally, the examiner noted that the Veteran's hand, thumb or finger conditions affected his ability to work in that he had difficulty lifting and carrying, and pain with opening and closing his hands. Applying all reasonable doubt and given the findings of the VA examinations, the Veteran's complaints, and the provisions of 38 C.F.R. § 4.40, 4.45 and DeLuca, the Board finds the overall evidence supports the assignment of a separate 10 percent disability rating under Diagnostic Code 5003 based on painful limitation of motion, numbness, and deformity, and associated degenerative changes equivalent to arthritis of two or more minor joint groups of the right fingers. See 38 C.F.R. § 4.7, 4.59. There are no potential compensable residuals associated with the scars so no separate ratings are warranted under Diagnostic Codes 7801-7805. III. Extraschedular Consideration and TDIU The VA Schedule of Disability Ratings will apply unless there are exceptional or unusual factors that would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's left heel and ankle strain, right elbow, right index finger disability, and right middle finger disability are inadequate. A comparison of the level of severity and symptomatology of the Veteran's disabilities with the established criteria found in the rating schedule show that the rating criteria reasonably describe the Veteran's disability levels and symptomatology. The Veteran primarily complains of pain and limitation of functional use. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule. 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; 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; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), 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. However, in this case, there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Finally, the Board also recognizes that the Court of Appeals for Veterans Claims has clarified that a claim for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities exists as part of a claim for an increase (whether in an original claim or as part of a claim for increased rating). Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran has not raised a claim for TDIU and the evidence indicates that the Veteran is currently employed. See March 2013 VA examination. For these reasons, the Board finds that a claim for TDIU has neither been raised by the Veteran nor by the record. ORDER Prior to March 28, 2013, entitlement to a rating of 10 percent, but no higher, for left heel and ankle strain, is granted, subject to the law and regulations governing the payment of monetary benefits. From March 28, 2013, entitlement to a rating higher than 10 percent for left heel and ankle strain is denied. Entitlement to a rating higher than 10 percent for traumatic degenerative joint disease of the right elbow is denied. Entitlement to a compensable rating for right index finger laceration and dislocation is denied. Entitlement to a compensable rating for right middle finger traumatic injury is denied. A separate, 10 percent disability evaluation under Diagnostic Code 5003 for painful motion, numbness, and deformity, and associated degenerative changes equivalent to arthritis of two or more minor joint groups of the right fingers is granted, subject to the law and regulations governing the payment of monetary benefits. REMAND Right Shoulder Strain Service connection for right shoulder strain was granted in a January 1999 rating decision, at which time a noncompensable rating under Diagnostic Code 5203 was assigned, effective August 1, 1998. In June 2007, the Veteran submitted a claim for an increased rating. In a February 2008 rating decision, the Veteran was granted an increased rating of 10 percent, effective July 9, 2007 for "limitation of motion due to pain (at extremes)." The disability rating continued to be assigned to Diagnostic Code 5203. In an April 2013 rating decision, the RO granted an increased evaluation of 20 percent, effective March 28, 2013 for "limited motion of the arm at shoulder level" and "painful motion of the shoulder." The disability rating continued to be assigned to Diagnostic Code 5203. Diagnostic Code 5203 provides for a 10 percent rating for malunion of the clavicle or scapula, 10 percent rating for nonunion without loose movement, 20 percent rating for nonunion with loose movement, and 20 percent rating for dislocation of the clavicle or scapula. Diagnostic Code 5201 provides for the evaluation of limitation of motion of the shoulder. Limitation of motion of the arm at shoulder level is rated 20 percent disabling for both the major and the minor side. Limitation of the arm midway between the side and the shoulder level is rated 30 percent disabling on the major side; and limitation to 25 degrees from the side is rated 40 percent disabling on the major side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The record reflects that the Veteran was afforded a VA examination in March 2013. The VA examiner noted that the Veteran had shoulder surgery in 2012. The VA examiner also appears to indicate that the Veteran underwent a total shoulder replacement in 2011. The Board finds that the Veteran should undergo another VA examination to clarify the extent of the right shoulder disability. Additionally, the Board finds that the RO should consider whether the Veteran is entitled to application of Diagnostic Code 5051, which assigns a temporary evaluation of 100 percent for 1 year following prosthetic replacement of the shoulder joint, or entitlement to compensation under 38 C.F.R. § 4.30, which assigns a temporary evaluation of 100 percent for reasons that include surgical treatment of a service connected disability necessitating convalescence. Bilateral Knee Disabilities The Veteran was granted entitlement to service connection for right knee strain in a January 1999 rating decision, at which time a noncompensable rating was assigned under Diagnostic Code 5257, effective August 1, 1998. The Veteran submitted a claim for an increased rating in June 2007. In a February 2008 rating decision, the Veteran's rating was increased to 10 percent disabling, effective July 9, 2007, based on painful limitation of motion. See February 2008 rating decision. The disability remained assigned to Diagnostic Code 5257. Thereafter, the Veteran was granted entitlement to service connection for right knee degenerative joint disease in an April 2013 rating decision, at which time a rating of 10 percent was assigned, effective March 28, 2013 to July 9, 2013. Significantly, the RO noted the following: "At your March 28, 2013 VAMC Central Texas examination it was noted that your right knee range of motion was: flexion 110 degrees (normal 140) with painful motion, and extension 0 degrees (normal 0 degrees) with painful motion. This condition was noted in addition to the slight medial lateral instability for which your right knee is already rated. We reviewed your appeal based on General Council (GC) Opinions 23-97, 09-98 and 09-04. Collectively, these opinions provide that separate evaluations may be assigned for instability, as well as limitation of both, flexion and extension. Based on your VA examination results, including the range of motion of your knee, we have determined that separate evaluations based on limitation of motion and instability is warranted in your case. We have assigned a 10 percent evaluation for your right knee degenerative joint disease based on: • Painful motion of the knee . . . ." In an October 2013 rating decision, the Veteran was granted service connection for a right knee total replacement and assigned a rating of 100 percent, effective July 9, 2013, and a 30 percent rating, from September 1, 2014. The Board finds that the RO should reconcile its findings, assignment of diagnostic codes, and code sheets associated with the April 2013 and February 2008 determinations pertaining to the right knee disability. Additionally, the record reflects that the Veteran underwent a total knee replacement of the right knee in July 2013 and of the left knee in November 2014. The Board notes that there have been no VA examinations conducted subsequent to the total knee replacements. Furthermore, VA treatment notes indicate that the Veteran may suffer from some neurological deficits in the bilateral knees as a result of surgery. See June 2015 VA Outpatient Note. On remand, the Veteran should be afforded VA examinations of the bilateral knees to determine the current severity of his disabilities. Any updated treatment records should also be obtained. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the claims file all updated treatment records. 2. Reconcile the findings, assignment of diagnostic codes, and code sheets associated with the April 2013 rating decision with the prior findings, assignment of diagnostic codes, and code sheets associated with the February 2008 rating decision pertaining to the right knee disability. (See body of Remand for details.) 3. Afford the Veteran a VA examination to determine the current severity of his right shoulder disability, to include clarification of whether the Veteran underwent a total right shoulder replacement in 2011 as suggested in the March 2013 VA examination. The examiner should identify and completely describe all current symptomatology. The Veteran's claims folder must be reviewed by the examiner in conjunction with the examination. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The pertinent rating criteria must be provided to the examiner, and the findings reported must be sufficiently complete to allow for rating under all alternate criteria. 4. Afford the Veteran a VA examination to determine the current severity of his right and left total knee replacements. The examiner should identify and completely describe all current symptomatology, to include any neurological symptoms. The Veteran's claims folder must be reviewed by the examiner in conjunction with the examination. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. Ask the examiner to discuss all findings in terms of 38 C.F.R. § 4.71a, Diagnostic Code 5055. The pertinent rating criteria must be provided to the examiner, and the findings reported must be sufficiently complete to allow for rating under all alternate criteria. 5. After completing the above, the Veteran's claims should be readjudicated based on the entirety of the evidence to include consideration of Diagnostic Code 5051 and 38 C.F.R. § 4.30 in regard to the service connected right shoulder disability. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. 6. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs