Citation Nr: 1615861 Decision Date: 04/19/16 Archive Date: 04/26/16 DOCKET NO. 08-25 788 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts THE ISSUE Entitlement to a rating in excess of 10 percent for residuals, status post left wrist fusion, from January 1, 2007 through December 3, 2008. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD B. Elwood, Counsel INTRODUCTION The Veteran served on active duty from March 1988 to March 1990. This appeal to the Board of Veterans' Appeals (Board) arose from a May 2007 rating decision in which the RO granted a temporary total (100 percent) rating for the service-connected left wrist disability for the period from October 11, 2006 through December 31, 2006, and denied entitlement to a rating in excess of 10 percent for the left wrist disability from January 1, 2007. In November 2007, the Veteran filed a notice of disagreement (NOD) with the May 2007 decision. A statement of the case (SOC) was issued in July 2008 and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veteran's Appeals) in August 2008. After receipt of additional evidence, in a June 2009 rating decision, the RO granted a temporary total (100 percent) rating for the service-connected left wrist disability for the period from December 4, 2008 through January 31, 2009, and granted an increased (20 percent) rating for the left wrist disability, from February 1, 2009. The RO continued to deny the claim for an increased rating for the left wrist disability (as reflected in a February 2010 supplemental statement of the case (SSOC)). In August 2011, the Veteran testified during a Board video-conference hearing before the undersigned Veterans Law Judge; a copy of the transcript is of record. In October 2011, the Board characterized the appeal as encompassing the separate issues of entitlement to a rating in excess of 10 percent for the service-connected left wrist disability, from January 1, 2007 through December 7, 2008, and entitlement to a rating in excess of 20 percent for the left wrist disability, from February 1, 2009 (consistent with Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) and AB v. Brown, 6 Vet. App. 35, 38 (1993)) and remanded these claims to the RO, via the Appeals Management Center (AMC) in Washington, DC, for further action, to include additional development of the evidence. After attempting to complete the requested development, in a July 2012 rating decision (issued in August 2012), the RO/AMC granted an increased (30 percent) rating for the left wrist disability, from February 1, 2009. The RO/AMC continued to deny the claims for higher ratings for the left wrist disability (as reflected in a September 2012 SSOC) and returned the two matters then on appeal to the Board for further consideration. In February 2014, the Board again remanded the two matters then on appeal to the agency of original jurisdiction (AOJ) for consideration of the newly submitted evidence, as well as further development. After accomplishing further action, the AOJ continued to deny the increased rating claims (as reflected in a July 2014 SSOC) and again returned the matters to the Board for further appellate consideration. In July 2015, the Board denied the claims for a rating in excess of 10 percent for the service-connected left wrist disability from January 1, 2007 through December 3, 2008, and for a rating in excess of 30 percent for the left wrist disability from February 1, 2009. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In February 2016, the Court set aside the Board's July 2015 decision, in part, and remanded the case for readjudication in compliance with directives specified in a February 2016 Joint Motion filed by counsel for the Veteran and VA. In the Joint Motion, the parties specified that a remand was sought only as to that portion of the July 2015 decision in which the Board denied a rating in excess of 10 percent for the service-connected left wrist disability from January 1, 2007 through December 3, 2008. As the Joint Motion did not address the Board's denial of a rating in excess of 30 percent for the left wrist disability from February 1, 2009, the Court , dismissed the appeal with respect to that issue. The matter set forth on the title page has been returned to the Board for further appellate consideration. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim herein decided have been accomplished. 2. As the Veteran is right-handed, his service-connected eft wrist disability involves his minor extremity for evaluation purposes. 3. For the period from January 1, 2007 through December 3, 2008, the Veteran's left wrist disability was manifested by dorsiflexion and palmar flexion limited to no less than 10 degrees, including as a result of pain or other functional impairment. There was no evidence showing the Veteran's left wrist was manifested by ankylosis in any position during the applicable time period. 4. The applicable schedular criteria are adequate to evaluate the Veteran's left wrist disability at all pertinent points, and no claim of unemployability due to the left wrist disability has been raised in conjunction with the claim for an increased rating. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for residuals, status post left (minor) wrist fusion, from January 1, 2007 through December 3, 2008, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5214, 5215 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). The notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim, as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his or her possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 - 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Id. Furthermore, with respect to claims for increase, the VCAA notice requirements include notice to provide, or ask VA to obtain, medical or lay evidence of increased severity and the impact thereof on employment to substantiate the claim; and providing examples of types of medical or lay evidence that may be submitted, or that VA can be asked to obtain, which are relevant to establishing an increased rating. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), affirmed in part by Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ (here, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this case, a pre-rating letter dated in December 2006 provided notice to the Veteran regarding the information and evidence needed to substantiate his increased rating claim. The letter also informed the Veteran of what information and evidence must be submitted by him, and what information and evidence would be obtained by VA. The letter further advised the Veteran of general information pertaining to VA's assignment of disability ratings and effective dates. The May 2007 rating decision reflects the RO's initial adjudication of the increased rating claim after the issuance of the December 2006 letter. Thereafter, a July 2008 statement of the case (SOC) set forth the specific criteria for higher ratings for limitation of motion of the wrist (the timing and form of which suffices, in part, for Dingess/Hartman). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file consists of the reports of VA examinations and VA outpatient treatment records. Also of record and considered in connection with the appeal is the transcript of the August 2011 Board hearing, along with various written statements provided by the Veteran and his representative. The Board finds that no further AOJ action to develop the claim herein decided, prior to appellate consideration, is required. As for the August 2011 Board hearing, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties: (1) to fully explain the issues and (2) to suggest the submission of evidence that may have been overlooked. In this case, the Board finds that there has been substantial compliance with the duties set forth in 38 C.F.R. 3.103(c)(2), and that Board hearing was legally sufficient. Here, the hearing transcript reflects that the undersigned identified the issue on appeal and solicited information regarding the severity of the Veteran's service-connected left wrist disability, including information regarding the effect the disability has on his ability to work. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Although the undersigned did not explicitly suggest the submission of any additional evidence, on these facts, the Veteran is not prejudiced by any such omission. In fact, the hearing discussion revealed that there were outstanding VA treatment records needed for consideration in conjunction with the claim on appeal, and those records were requested in the subsequent remand. The Board further notes that the purposes of the October 2011 and February 2014 remands were fulfilled, as all outstanding VA treatment records were obtained and associated with the record and the Veteran was given an opportunity to identify any outstanding, relevant private treatment records. Also, VA examinations were conducted to obtain information as to the severity of the Veteran's service-connected left wrist disability. Therefore, the Board also finds that there has been substantial compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) and Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that substantial, not strict, compliance is required). In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran was notified and made aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the matter on appeal. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 539, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505 (2007). While the Veteran's left wrist disability was initially rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5215, for limitation of motion of the wrist, his disability has been rated under DC 5214, for ankylosis of the wrist, since February 1, 2009. In evaluating the propriety of the ratings assigned for the left wrist disability throughout the appeal, the Board will consider all applicable diagnostic codes, including DCs 5214 and 5215. The Veteran is right-hand dominant; thus, his service-connected left wrist disability involves his minor extremity. With respect to the minor extremity, DC 5215 provides that a 10 percent disability rating is warranted where there is limitation of motion of the wrist manifested by dorsiflexion limited to less than 15 degrees and palmar flexion limited in line with the forearm. This is the maximum possible schedular rating under DC 5215. 38 C.F.R. § 4.71a, DC 5215. For the minor extremity, under DC 5214, a 20 percent rating is warranted where there is favorable ankylosis of the wrist in 20 to 30 degrees of dorsiflexion. A 30 percent rating is warranted where there is ankylosis of the wrist in any other position, except favorable, and a 40 percent rating is warranted where there is unfavorable ankylosis in any degree of palmar flexion, or with ulnar or radial deviation. A note following DC 5214 states that extremely unfavorable ankylosis will be rated as loss of use of hands under DC 5125. 38 C.F.R. § 4.71a, DC 5214. Normal range of motion of the wrist includes dorsiflexion (extension) from zero to 70 degrees, palmar flexion from zero to 80 degrees, ulnar deviation from zero to 45 degrees, and radial deviation from zero to 20 degrees. See 38 C.F.R. § 4.71a, Plate I (2015). When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2015); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). In the present case, the Veteran underwent a left wrist fusion on October 11, 2006, for which he was awarded a temporary total (100 percent) rating from October 11, 2006 through December 31, 2006. A 10 percent rating was awarded for residuals of left wrist scaphoid fracture under DC 5215 from January 1, 2007 (see the May 2007 rating decision). The report of a January 2007 VA examination documents the Veteran's report of left wrist discomfort, limitation of movement, deformity, giving way, instability, pain, stiffness, weakness, and redness. There was no history of any neoplasm and the Veteran did not experience any constitutional symptoms or incapacitating episodes of arthritis, functional limitations on standing or walking, episodes of dislocation or subluxation, locking episodes, effusion, or flare ups of joint disease. Examination revealed that a weight bearing joint was not affected and that there was no evidence of abnormal weight bearing, but that range of motion testing of the left wrist was very limited because the Veteran had undergone surgery and there were multiple pins in articulation. The ranges of left wrist motion were recorded as palmar flexion to 10 degrees (with pain beginning at 10 degrees and ending at 0 degrees), dorsiflexion (extension) to 15 degrees (with pain beginning at 15 degrees and ending at 5 degrees), and ulnar and radial deviation both to 15 degrees (with pain beginning at 15 degrees and ending at 0 degrees). The examiner noted that there was no additional limitation of palmar flexion or dorsiflexion following repetitive use, but there was an additional loss of motion from 0 to 15 degrees of both ulnar and radial deviation due to pain. There was loss of a bone or part of a bone and left wrist edema, tenderness, painful movement, weakness, and guarding of movement. There was no inflammatory arthritis or joint ankylosis. X-rays of the left wrist revealed postoperative changes, including a small amount of heterotopic bone in the operated field, mild irregularity in the distal radius, and focal tenting of the skin due to a K wire. There was normal mineralization and no significant soft tissue swelling. The Veteran was diagnosed as having status post left wrist scaphoid excision and degenerative joint disease. This disability prevented exercise, sports, and recreation and had mild to moderate effects on other activities of daily living (including chores, feeding, bathing, dressing, and toileting). VA treatment records dated from January 2007 to November 2008 and the Veteran's November 2007 notice of disagreement reflect reports of left wrist pain while typing (the Veteran used a padded splint), extreme pain with both flexion and extension of the wrist, and a "cold" sensation of the ulnar side of the wrist. Focal pain was worst near the distal ulna and central dorsum of the wrist and the pain was described as being sharp in nature and 4/10 in intensity at the time of a February 2007 VA nursing consultation. During an August 2007 VA occupational medicine consultation, the Veteran reported that any movement of the wrist was excruciating, that the pain was "way worse" than it was before he underwent surgery, that it was 5/10 in intensity at rest and 10/10 in intensity with movement; that it was sharp/jabbing/stabbing in nature; , and that he had a burning sensation radiating up the arm. He also reported a "freezing cold pain sensation" just distal to the ulnar styloid process. On September 2007 VA occupational therapy evaluation, the pain was noted to be 5/10 in intensity at rest and with light activity when wearing a splint and 10/10 in intensity with grasping when not wearing a splint. During an October 2007 VA occupational therapy evaluation the Veteran reported that the severity of the pain ranged from 3-4/10 when at rest to 10/10. Random pains occurred even during periods of rest and this pain was located on the medial aspect of the hand and was intensely sharp in nature. Also, there was a ripping sensation on the dorsum of the hand with and without grasping. Moreover, during a February 2008 VA evaluation, the Veteran reported that the wrist pain was 10/10 before medication use and 6/10 after medication use. It was noted that the Veteran's left wrist pain compromised his ability to do any work or manual activities and was alleviated when the wrist did not move. Reportedly, he was unable to perform many daily activities, such as mowing the lawn, riding a bike, playing bass, playing video games, and driving his stick shift truck. He regularly used a computer, but there was pain with resting the hypothenar eminence on the table during typing. He was able to bathe, brush his teeth, and shave because he was right hand dominant. He used medication (Percocet) on a daily basis to treat the pain and wore a wrist brace. Pins had been surgically placed in the wrist during the October 2006 surgery and were later removed in February 2007. The Veteran continued to experience symptoms following the February 2007 surgery. For example, his hand was edematous and red during the months following the surgery and the wrist pain was worse. He indicated that he had lost more than eighty percent of left wrist flexion and extension, that he only had approximately 10 to 15 percent mobility, that he took medication (Percocet) on a daily basis, that he constantly used a wrist splint, and that an additional wrist surgery was scheduled for some time in 2008 to fuse the entire wrist joint. He attended occupational therapy sessions, but the therapist determined that the therapy was providing little to no benefit, the exercises caused a great deal of pain, and the Veteran's grip strength and range of motion remained stagnant. Therefore, the occupational therapy was terminated. Examinations revealed left wrist stiffness, tenderness to palpation over the entire wrist and the pisiform, discomfort with forearm rotation, guarded and painful movement, occasional minimal edema, hyperesthesia with light touch to the ulnar side of the wrist/hand, a dark scar, sensitivity about the dorsal wrist scar, dulled sensation around the dorsal aspect of the wrist where there were incisions (although this had also been present prior to the wrist surgery), coldness/mottling of the hand, and decreased and painful left hand grip. The surgical incisions were well healed, there was no soft tissue swelling, cellulitis, crepitus, skin discoloration, or erythema, and motor strength and sensation were otherwise intact. The ranges of left wrist motion were recorded as being flexion to between 10 and 45 degrees, extension to between 10 and 30 degrees, radial deviation to between 10 and 12 degrees, and ulnar deviation to between 15 and 18 degrees. X-rays and CT scans of the wrist revealed evidence of prior surgery, including resection of the distal aspect of the navicular bone and partial fusion of the carpal bones. There was also heterotopic bony formation and some mild degenerative changes at the base of the second and third metacarpal bone as it articulated with the adjacent body carpus, but there was no superimposed acute injury or abnormal calcification. The Veteran was diagnosed as having status post four corner fusion with scaphoid excision. There were some signs and symptoms suggestive of reflex sympathetic dystrophy/complex regional pain syndrome (i.e., mottled skin, parathesias, extreme cold, and burning pain). Considering the evidence of record in light of the applicable diagnostic criteria and rating considerations delineated above, the Board finds that a rating in excess of 10 percent is not warranted for the service-connected left wrist disability at any time during the period from January 1, 2007 through December 3, 2008. During this period, the Veteran's service-connected left wrist disability was manifested by pain, discomfort, painful and limited wrist motion, deformity, giving way, instability, stiffness, weakness, redness, edema, tenderness, guarding of movement, and decreased grip strength in the left hand. The Veteran is already in receipt of a 10 percent rating under DC 5215 based on these symptoms and this is the maximum possible schedular rating under this diagnostic code for limitation of wrist motion. In the Joint Motion, the parties indicated that the Veteran contends that he is entitled to a rating in excess of 10 percent under 38 C.F.R. § 4.40 on the basis of functional impairment caused by symptoms such as pain and weakness. The Board acknowledges that the Veteran experienced wrist symptoms such as pain and weakness during the period from January 1, 2007 through December 3, 2008. Nevertheless, where a veteran is in receipt of the maximum schedular rating based on limitation of motion of the wrist (i.e., a 10 percent rating under DC 5215) and a higher rating requires ankylosis, the regulations pertaining to functional impairment (38 C.F.R. §§ 4.40, 4.45, 4.59) are not for application. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). There is no lay or medical evidence of any wrist ankylosis during the period from January 1, 2007 through December 3, 2008 and the January 2007 VA examiner specifically indicated that there was no joint ankylosis. A 10 percent rating has been assigned under DC 5215 on the basis of limitation of left wrist motion. As the evidence does not reflect that there was any ankylosis of the left wrist any point from January 1, 2007 through December 3, 2008, a rating in excess of 10 percent for the service-connected left wrist disability under DCs 5214 and 5215 is not warranted at any time during this period. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, DCs 5214, 5215. The Board has also considered the applicability of alternative diagnostic codes for rating the left wrist disability, but finds that no other diagnostic code provides a basis for a higher rating at any point during the period from January 1, 2007 through December 3, 2008. Although the Board acknowledges that there is evidence of left wrist arthritis, both degenerative and traumatic arthritis are rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. See 38 C.F.R. § 4.71a, DCs 5003, 5010 (2015). As the Veteran is already in receipt of a 10 percent rating under DC 5215 on the basis of limitation of wrist motion, a separate rating on the basis of wrist arthritis would constitute prohibited pyramiding and is not warranted. 38 C.F.R. § 4.14 (2015). Further, the Board has considered whether the scar/incision associated with the Veteran's service-connected left wrist disability warrants a separate, compensable disability rating. The Board notes that two amendments were made to the criteria for rating the skin, effective August 30, 2002, and October 23, 2008. See 67 Fed. Reg. 49,596 (July 31, 2002) (codified at 38 C.F.R. § 4.118, DCs 7800 to 7833 (2002); 73 Fed. Reg. 54,708 (September 23, 2008) (codified at 38 C.F.R. § 4.118, DCs 7800 to 7805 (2012)). Generally, in a claim for an increased rating, the Board considers both the former and current schedular criteria where the rating criteria are amended during the course of an appeal. However, the amendments to the rating criteria in 2002 occurred before the Veteran filed his increased rating claim, and the amended regulations effective in October 2008 are only applicable to claims received on or after October 23, 2008, or if the claimant expressly requests consideration under the new criteria, which has not been done in this case. Therefore, the rating criteria in effect prior to August 2002 and the amended regulations effective in October 2008 will not be addressed in the present decision. To warrant a compensable rating under the applicable criteria, a scar would need to involve the head, face or neck and have at least one character of disfigurement (DC 7800); be deep or cause limited motion and affect an area or areas exceeding at least 6 square inches (39 square centimeters) (DC 7801); be superficial and affect an area or areas of 144 square inches (929 square centimeters) or greater (DC 7802); be superficial and unstable (DC 7803); be superficial and painful on demonstration (DC 7804); or cause some limitation of the function of the part affected (DC 7805). 38 C.F.R. § 4.118 , DCs 7800-7805 (2006). In this case, the left wrist scarring does not involve the head, face, or neck and there is no evidence that such scarring is deep, causes any limitation of motion or function, affects an area exceeding at least 6 square inches (39 square centimeters), or is unstable. A July 2007 addendum to a July 2007 VA orthopedic outpatient progress note reflects that there was some "sensitivity about the dorsal wrist scar." However, there is no evidence that the scar itself was painful on demonstration and there is no other lay or medical evidence of any painful wrist scarring. Hence, a separate, compensable rating for left wrist scarring is not warranted at any time during the period from January 1, 2007 through December 3, 2008. The Board further notes that the service-connected left wrist disability is not shown to involve any other factors warranting evaluation under any other provision of VA's rating schedule. In this regard, the Board points out that, although records document neurological symptoms associated with the left upper extremity during the time frame in question-to include a cold sensation in the area of his wrist/hand, a burning sensation radiating up his arm, hyperesthesia with light touch to the ulnar side of the wrist/hand, a dulled sensation around the dorsal aspect of the wrist (also present prior to the wrist surgery), and coldness/mottling of the hand-such symptoms, have never been attributed to the Veteran's service-connected left wrist disability; but, rather, have been identified as signs and symptoms suggestive of separate and distinct reflex sympathetic dystrophy/complex regional pain syndrome. See August 2007 VA occupational medicine consultation report. In evaluating the Veteran's increased rating claim, the Board has considered his own assertions and those of his representative advanced submitted in support of his claim. However, as the findings needed to support a higher rating requires clinical findings, the lay assertions made in support of the Veteran's claim for a higher rating are not entitled to more weight than the objective findings rendered by trained medical professionals in evaluating his left wrist disability. See 38 C.F.R. § 3.159 (a)(1); see also Bostain v. West, 11 Vet. App. 124, 127 (1998). Indeed, as explained in detail above, the most persuasive evidence indicates that the left wrist disability does not warrant a higher schedular rating during the period under consideration. The above determinations are based upon consideration of applicable pertinent provisions of VA's rating schedule. Additionally, the Board finds that, at no point pertinent to the period under consideration did the Veteran's service-connected left wrist disability reflect so exceptional or so unusual a picture as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b). There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun, supra. In this case, the parties to the Joint Motion agreed that the Board had not sufficiently addressed whether all of the symptoms associated with the Veteran's service-connected left wrist disability during the period from January 1, 2007 through December 3, 2008 are adequately contemplated by the applicable schedular criteria. In this regard, the parties explained that the January 2007 VA examination report includes evidence of deformity, giving way, instability, pain, stiffness, weakness, and inflammation related to the service-connected left wrist disability and indicates that this disability would prevent the Veteran from exercising and participating in sports and recreation and that they would cause impairment in toileting, dressing, bathing, performing chores, and feeding. The parties also identified the August 2007 VA occupational therapy note and the February 2008 VA physician note which indicate that the Veteran's left wrist pain was occasionally 10/10 in intensity, which was reduced to 6/10 in intensity with medication; that any movement of the wrist was painful ("excruciating") and guarded; and that he was unable to mow the lawn, ride a bike, or drive a stick shift. As explained above, the symptoms associated with the Veteran's service-connected left wrist disability during the period from January 1, 2007 through December 3, 2008 included pain, discomfort, painful and limited wrist motion, deformity, giving way, instability, stiffness, weakness, redness, edema, tenderness, guarding of movement, and decreased grip strength in the left hand. These symptoms are all contemplated by the appropriate rating criteria as set forth above (i.e., the criteria in DCs 5214 and 5215). Specifically, 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, 25 Vet. App. at 37. For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse, disturbance of locomotion, interference with sitting, standing, and weight-bearing, instability, and crepitation. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Hence, the 10 percent rating assigned for the service-connected left wrist disability during the period from January 1, 2007 through December 3, 2008 contemplates all of the Veteran's reported and observed symptoms during that period, as set forth above, and the Veteran has not demonstrated any symptomatology that falls outside the scope of the applicable criteria. Further, the Board notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. Here, however, the Veteran's left wrist disability is appropriately rated as a single disability and there is no additional functional impairment in the left wrist, including associated with the left wrist scar, that has not been attributed to or considered in conjunction with a service-connected disability. Accordingly, this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. Under these circumstances, the Board concludes that the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met, and that referral of this claim for extra-schedular consideration is not warranted. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, the Board notes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which a higher rating is sought, then part and parcel to that claim for a higher rating is the matter of whether a total disability rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Although, the Veteran has consistently asserted that his left wrist disability has interfered with his ability to work-to include his July 2007 report that his worsening left wrist pain compromised his ability to work and do manual activities and his August 2007 and December 2007 reports that he experienced pain typing on a computer keyboard at work-there is no evidence or assertion that his left wrist disability has actually or effectively rendered him unable to secure and follow all substantially gainful employment at any pertinent point. Under these circumstances, no claim for a TDIU due to the left wrist disability has been raised, and need not be addressed in conjunction with the current claim for increase. For all the foregoing reasons, the Board finds that there, for the period in question, there is basis for staged rating of the left wrist disability, pursuant to Hart, and that the increased rating claim remaining on appeal must be denied. In reaching the conclusions to deny this claim, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of any higher rating at any pertinent point, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (2014). ORDER The claim for a rating in excess of 10 percent for residuals, status post left wrist fusion, from January 1, 2007 through December 3, 2008, is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs