Citation Nr: 1622140 Decision Date: 06/02/16 Archive Date: 06/13/16 DOCKET NO. 09-32 094 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an evaluation in excess of 40 percent for degenerative joint disease (DJD) of L3-L5, with degenerative disc disease (DDD). 2. Entitlement to an evaluation in excess of 30 percent for cervical fusion, C3-C6, with DJD. 3. Entitlement to a compensable evaluation for DJD of the right great toe with hallux valgus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Mullins, Counsel INTRODUCTION The Veteran had active service from June 1977 to June 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado, denying the Veteran's claims for increased evaluations. In October 2012, the Veteran provided testimony at a video conference hearing before the undersigned. A written transcript of this hearing has been prepared and associated with the Veteran's electronic record. In July 2014, the issues on appeal were remanded by the Board for further evidentiary development. This appeal was processed using the Veteran Benefits Management System (VBMS) and Virtual VA paperless claims file systems. FINDINGS OF FACT 1. The Veteran's lumbar spine disability is manifested by forward flexion limited to as much as 30 degrees; it is not manifested by ankylosis. 2. The Veteran's cervical spine disability has been manifested by forward flexion to 15 degrees or less; it is not manifested by ankylosis. 3. The Veteran's right great toe disability has been diagnosed as degenerative joint disease and results in pain on motion. 4. The Veteran's right great toe disability is not associated with claw foot, malunion or nonunion of the tarsal or metatarsal bones or other foot injuries. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to an evaluation in excess of 40 percent for a lumbar spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5242-5243 (2015). 2. The criteria for establishing entitlement to an evaluation in excess of 30 percent have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5242-5243 (2015). 3. The criteria for establishing entitlement to a 10 percent evaluation, and no higher, for a right great toe disability have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5280 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). Proper notice from VA must inform the Veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For an increased disability rating claim, VA is required to provide the Veteran with generic notice - that is, the type of evidence needed to substantiate the claim. This includes evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In the current appeal, the Veteran was provided with the above information in letters dated August 2008 and March 2012. The August 2008 letter was provided prior to the initial decision on appeal and notified the Veteran of the evidence he needed to submit, how VA establishes a disability rating and how VA determines an effective date. Under these circumstances, the Board finds that the notification requirements have been satisfied as to both timing and content. Adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board that complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA obtained the Veteran's service treatment records. Also, the Veteran received VA medical examinations in September 2008, April 2012, June 2012, October 2014 and January 2016, and VA has obtained these records as well as the records of the Veteran's outpatient treatment with VA. The Board finds that the relevant VA examinations are well-supported by clinical findings and a full rationale. Each examination report reflects a review of the claims file, a pertinent history and all clinical findings and opinions necessary for proper adjudication of the Veteran's claims, and are therefore adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Additionally, the Board finds there has been substantial compliance with its July 2014 remand directives. The Board notes that the Court has held that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand). The record indicates that the Appeals Management Center (AMC) obtained additional records and scheduled the Veteran for additional VA examinations. The AMC later issued a Supplemental Statement of the Case (SSOC). Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remand. See Stegall, supra, (finding that a remand by the Board confers on the appellant the right to compliance with its remand orders). As previously noted, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned Veterans Law Judge in October 2012. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that a Veterans Law Judge who chairs a hearing to 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. Here, the undersigned noted the issues on appeal and solicited information regarding the nature of his symptomatology as well as the functional impact the claimed disabilities have on his daily life and employment. The Veteran was advised of the reasons for the previous denials and of the type of evidence that could be identified or submitted to further substantiate the claims. 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. Moreover, the hearing discussion did not reveal any evidence that might be available that has not since been obtained. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claims. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him 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). Analysis Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings will be applied, the higher rating will be assigned if the disability picture more closely approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7 (2015). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). See also 38 C.F.R. §§ 4.1, 4.2 (2015). As such, the Board has considered all of the evidence of record. However, the most probative evidence of the degree of impairment consists of records generated in proximity to and since the claim on appeal. Lumbar Spine The Veteran contends that he is entitled to an evaluation in excess of 40 percent for his service-connected lumbar spine disability. For historical purposes, the Veteran was originally granted service connection for a lumbar spine disability in an April 2000 rating decision. An evaluation of 10 percent was assigned, effective as of June 4, 1999. The Veteran's evaluation was increased to 40 percent, effective July 5, 2002, in a January 2003 rating decision. In July 2008, the Veteran submitted a claim for an increased rating for his lumbar spine disability which was denied in an October 2008 rating decision. Thereafter, the Veteran perfected an appeal as to this decision. Evidence relevant to the current level of severity of the Veteran's lumbar spine disability includes VA examination reports dated in September 2008, April 2012, October 2014 and January 2016 as well as VA treatment records dated through October 2014 and private treatment records dated through October 2015. During the September 2008 VA spine examination, it was noted that the Veteran had missed more than 30 days of work in the past year due to either his low back or his neck. The Veteran reported that his low back pain had been getting progressively worse. His pain was increased when he had to stand over the sink washing dishes. It ranged in intensity from 0 to 9 out of 10 and was accompanied by stiffness. The pain was in the midline lower lumbar region "like the joints" but also into the bilateral paraspinal muscles to the posterior thighs bilaterally where there is a pulling sensation. He did have numbness and tingling in his feet and arms in the past. This recurred whenever he lifted anything heavy. He felt it involved all of his toes. He had trouble holding his neck up if he was lying on his back for more than a minute. He noted that when his back flared up he had to walk more slowly and bend over or sit down to try and relieve the pain. He frequently wore a back brace. He had not experienced any flare-ups in the last year. He did have 2 days off of work ordered by a physician, although bedrest was nor ordered. Examination revealed the Veteran's lumbar range of motion to be consistently diminished throughout all portions of the examination, although he held himself even more stiffly during the official portion of the examination. There was tenderness to palpation over the bilateral lumbar paraspinals. Right extensor halluces longus was 4+ but otherwise 5/5 in the bilateral upper and lower extremities. Deep tendon reflexes were 2+ and symmetric and sensation was intact. Thoracolumbar forward flexion was to 30 degrees with pain at 30 degrees, extension was to 20 degrees with pain at 20 degrees, left lateral flexion was to 20 degrees with pain at 20 degrees, right lateral flexion was to 30 degrees with pain at 30 degrees, and bilateral lateral rotation was to 25 degrees with pain at 25 degrees. Magnetic resonance imaging (MRI) revealed spondylosis at L4-5. There was no significant change in active or passive range of motion following repeat testing so no additional losses of range of motion were recommended for the lumbar spine due to painful motion, weakness, impaired endurance, incoordination, instability or acute flares. In fact, the Veteran was noted to be flared at the time of examination so it was recommended that his thoracolumbar forward flexion on average be considered to be 50 degrees. A November 2008 private treatment note reflects that the Veteran suffered from chronic low back pain. Based on the examination, the author opined that it was most likely with muscle spasms of the lower back. During the April 2012 VA spine examination, the Veteran was noted to be suffering from degenerative joint disease of the lumbosacral spine with L3-4 disc disease and L4-5 spinal canal stenosis. The Veteran reported pain in the lower lumbar area and side that radiated down into both hamstring areas. He described his pain at a 7 to 8 out of 10. By the end of the day it was noted to be a 4 to 5 out of 10. It was noted that the Veteran was placed on 3 to 4 days of bedrest by his physician in January 2012. The Veteran's flare-ups were noted to not impact the function of the thoracolumbar spine. Physical examination revealed forward flexion to 90 degrees or greater with pain at 65 degrees, extension to 30 degrees or greater with pain at 30 degrees, right lateral flexion to 15 degrees with pain at 15 degrees, left lateral flexion to 20 degrees with pain at 20 degrees, and bilateral lateral rotation to 30 degrees with pain beginning at 30 degrees. The range of motion remained the same after 3 repetitions. It was noted that the Veteran had functional loss and impairment of the lumbar spine due to less movement than normal and pain on movement. Strength testing was normal, as was a reflex examination and a sensory examination. It was determined that there was no radiculopathy and no other neurological abnormalities. The Veteran did have intervertebral disc syndrome with prescribed bedrest of less than 1 week in the past 12 months. The condition was noted to impact the Veteran's employment. He had missed 6 to 7 days of work due to back pain because he had problems with lifting more than 25 pounds and bending. He currently worked using a bar code reader to scan inventory. According to an October 2012 MRI, the lesion to the Veteran's spine appeared to be stable and did not appear to be causing any problems at this time. A May 2013 VA treatment note reflects that the Veteran was seen with an acute onset of low back pain for the past 10 days. He reported that the pain had been more in his right buttock and at times radiated down his right leg. There were no problems with bowel or bladder function or numbness or weakness. Another May 2013 VA treatment note reflects pain in the right SI joint area. MRI revealed no change in the size of a small mildly enhancing lesion anterior to cauda equine. L4-5 degenerative disc disease and central canal stenosis was also noted. A July 2013 VA note confirms a small 4 by 4 millimeter (mm) nodular lesion along the ventral aspect of cauda equina at L2, but it was noted that there were no signs of radiculopathy. A July 2013 VA treatment note reflects that while the Veteran had complained of pain occasionally radiating down his bilateral posterior thighs, his pain was mostly localized to his low back and felt like "tightness" in the hamstrings which improved with stretching in the morning. There was no weakness, parasthesias or bowel/bladder dysfunction. He felt like he could control his pain if he stretched and did "the right things." According to a February 2014 MRI, there was no change in the size of the small mildly enhancing lesion anterior to cauda equina. L4-5 degenerative disc disease and central canal stenosis were again noted. In June 2014, the Veteran was seen with complaints of pain radiating into the bilateral lower extremities. He stated that he could only stand for about 10 minutes prior to having to "stoop over" to get relief. When going to the store, he also would use a cart to hold onto to allow him to bend over. He also reported tingling and numbness in the bilateral feet when walking. This would get better with sitting. A private treatment note dated July 2014 reflects that the Veteran was seen for an evaluation of low back pain and leg pain. The Veteran reported pain with standing and walking in his buttock and posterior leg, which was improved with sitting and laying down, as well as using a grocery cart. He also described mechanical back pain with lifting and twisting. When he stood he reported left foot parasthesias improved by sitting. Physical examination showed that he was tender to palpation of the lumbar spine. He had buttock and posterior thigh pain with lumbar extension. He noted top of foot tingling upon standing but he was deemed to be neurologically intact. Radiographic imaging revealed multiple levels of degeneration and spondylophytes off the anterior and posterior aspects of the vertebral body. It was explained to the Veteran that the likely treatment needed would be a fusion and decompression, likely from L4-S1, perhaps extending to L3. An August 2014 note reflects that the Veteran did not seek surgery as there was a concern about recovery time. During the October 2014 VA spine examination, the Veteran was noted to be suffering from degenerative joint disease and degenerative disc disease of the lumbar spine with spinal stenosis. He was also noted to be suffering from bilateral sciatica without objective evidence of radiculopathy. The Veteran reported daily baci pain that he rated as a 4 out of 10. His pain increased to a 10 out of 10 with increased activity 7 to 10 days per month and lasted for about half of the day. He stated that his symptoms improved with massage, heat pad, pain medications and TENS unit. He denied going to his medical provider for care during a flare-up and he had not been formally prescribed bedrest. He stated that he had missed 10 to 15 days of work in the last 12 months due to either his back or his neck. He was not on modified duty. He could stand for 20 minutes and sit for 20 minutes, he could climb unlimited stairs at his own pace and he could lift or carry 30 pounds. He used a cane infrequently but this was mostly due to his right foot. Physical examination revealed range of motion to be forward flexion to 70 degrees with pain at 60 degrees, extension to 20 degrees with pain at 20 degrees, bilateral lateral flexion to 20 degrees with pain at 20 degrees, and bilateral lateral rotation to 30 degrees with pain at 30 degrees. The Veteran was able to perform 3 repetitions with no further decrease in range of motion. The Veteran did have functional loss to the lumbar spine due to symptoms such as less movement than normal and pain on movement. Muscle strength, reflex and sensory testing were all normal. It was noted that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. The Veteran did not suffer from ankylosis. The Veteran was noted to have intervertebral disc syndrome, but he did not have any incapacitating episodes over the past 12 months. It was noted that this condition impacted the Veteran's ability to work in that he was limited to lifting no more than 30 pounds, no squatting or kneeling, no prolonged standing and a need for frequent position changes. The examiner noted that the Veteran's pain in the buttock to the back of both thighs bilaterally was representative of a sciatica condition (referred myofascial pain) rather than a radicular condition as his motor/sensory/reflex examinations were all normal. Also, although the Veteran admitted to missing 10 to 15 days of work in the past year, he admitted to managing his flares on his own and not seeking medical care. He had not been formally prescribed bed rest. While there was a lesion at the L2 level, this was stable compared to earlier studies. This was felt to be a Schwannoma. At this time, it did not appear to be causing any functional or clinical effects. The examiner concluded that pain could limit the Veteran's range of motion further, resulting in a loss of 10 degrees - flexion to 60 degrees and extension to 20 degrees. An October 2014 private medical note following the October 2014 VA examination report indicates that there was no real change in the Veteran's disability at that time. He was able to cope and was not at the point of wanting surgery. However, an October 2015 private treatment note reflects that the Veteran underwent a posterior lumbar pedicel screw instrumentation, a lumbar laminectomy/decompression, a posterior lumbar interbody fusion, a posterior spinal fusion and a fluoroscopy. In light of the October 2015 procedure, the Veteran was afforded an additional VA examination in January 2016. At that time, the Veteran was noted to be suffering from degenerative joint disease at L3-5 with degenerative disc disease. The Veteran continued to report constant low back pain and stiffness. He rated his pain now as a 3 or 4 out of 10, all the time, every day. He also complained of intermittent low back pain every day that he rated as a 6 or 7 out of 10 for 4 to 5 hours per day. He could not sit or stand for more than 30 minutes at a time, and after walking one block, he would develop numbness in the feet. He was unable to bend down to tie his shoes. The Veteran also reported flare-ups occurring if he accidentally bumped his back or moved the wrong way. His pain during a flare-up was noted to be a 10 out of 10 according to the Veteran. This would last for 3 to 4 hours and occur 1 to 2 times per week. Physical examination revealed forward flexion to 30 degrees, extension to 5 degrees, bilateral lateral flexion to 5 degrees and bilateral lateral rotation to 5 degrees. Pain was noted in all fields of motion but there was no further decrease in range of motion after 3 repetitions. The examiner was unable to say whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time without resort to mere speculation. Functional loss was noted due to less movement than normal, disturbance of locomotion, interference with sitting and interference with standing. Muscle strength, reflex and sensory testing were all deemed to be normal. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. The Veteran did not suffer from ankylosis of the thoracolumbar spine. It was determined that the Veteran did not suffer from intervertebral disc syndrome of the thoracolumbar spine at this time. It was noted that the Veteran had functional impairment, including an inability to stand or sit for more than 30 minutes, an inability to bend or twist, an inability to lift more than 5 pounds since his surgery, and when he develops severe low back pain, he needs to lie down for 2 hours to rest his back before he can walk. This occurred 1 to 2 times per week. The preponderance of the above evidence demonstrates that the Veteran is not entitled to an evaluation in excess of 40 percent for a lumbar spine disability at any time during the pendency of this claim. 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). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The disabilities of the spine that are rated under the General Rating Formula for Diseases and Injuries of the Spine include vertebral fracture or dislocation (Diagnostic Code 5235), sacroiliac injury and weakness (Diagnostic Code 5236), lumbosacral or cervical strain (Diagnostic Code 5237), spinal stenosis (Diagnostic Code 5238), spondylolisthesis or segmental instability (Diagnostic Code 5239), ankylosing spondylitis (Diagnostic Code 5240), spinal fusion (Diagnostic Code 5241), and degenerative arthritis of the spine (Diagnostic Code 5242) (for degenerative arthritis of the spine, see also Diagnostic Code 5003). The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 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. A 30 percent disability rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent disability rating is assigned for unfavorable ankylosis of the entire cervical spine; or, 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. 38 C.F.R. § 4.71a. An evaluation in excess of 40 percent requires evidence of ankylosis of the entire thoracolumbar spine. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury or surgical procedure. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 94 31st ed., 2007). The Veteran has clearly demonstrated that he still has mobility of the lumbar spine. Significantly, the Veteran had lumbar flexion to 30 degrees in September 2008, 90 degrees (with pain at 65 degrees) in April 2012, 70 degrees (with pain at 60 degrees) in October 2014, and 30 degrees in January 2016. As such, there is no evidence of ankylosis during the appeal period and a higher evaluation is not warranted under the rating schedule. In DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court discussed the applicability of 38 C.F.R. §§ 4.40 and 4.45 to examinations of joint motion. 38 C.F.R. § 4.40 listed several factors to consider in evaluating joints including inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss due to pain was a consideration, as well as weakness, which was an important consideration in limitation of motion. 38 C.F.R. § 4.40 (2012). As regards the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal; (b) more movement than normal; (c) weakened movement; (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; (f) pain on movement, swelling, deformity or atrophy of disuse; instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are related considerations. 38 C.F.R. § 4.45 (2015). The Board recognizes that the Veteran has functional impairment due to painful and limited motion. However, there is no evidence, medical or lay, to suggest that the Veteran suffers from such a degree of functional impairment as to rise to the level of ankylosis. While the Board is not ignoring the Veteran's functional impairment, it does not find that it rises to the level of ankylosis - or immobility and consolidation of the spine. The Board has also considered whether a separate evaluation is warranted for neurological impairment. See 38 C.F.R., § 4.71a, Note (1) (Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code). In the present case, there is no objective evidence of any neurological abnormality associated with the Veteran's service-connected lumbar spine disability. While the Veteran has reported symptoms of pain and numbness, neurological evaluations, including the most recent evaluation of January 2016, have been found to be normal. As such, a separate evaluation for a separate neurological condition is not warranted. The Board has also considered whether a higher evaluation may be warranted because of the Veteran's intervertebral disc syndrome. Under 38 C.F.R. § 4.71a, Diagnostic Code 5243, a higher evaluation of 60 percent is warranted if the Veteran suffers from intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. In the present case, there is no evidence of bedrest having been prescribed due to incapacitating episodes for a period of 1 week or more. As such, a higher evaluation is not warranted based on incapacitating episodes. The Board recognizes that the Veteran and his representative believe that an evaluation in excess of 40 percent is warranted. In November 2009, the Veteran's representative argued that the Veteran's back pain had worsened since his 2002 VA examination and that he had stiffness and bilateral paraspinal muscle pain to the posterior thighs, bilaterally. It was also noted that the Veteran had reported numbness and tingling in the feet. Finally, his representative noted in October 2015 that the Veteran appeared to continue to have ongoing exacerbations that required continued treatment. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to an evaluation in excess of 40 percent for a lumbar spine disability must be denied. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. In this regard, to accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The provisions of 38 C.F.R. § 3.321(b) state as follows: Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service- connected disability or disabilities. The governing norm in these exceptional cases is: 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 as to render impractical the application of the regular schedular standards. In Thun v. Peake, 22 Vet. App. 111 (2008), the Court specified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. VA's General Counsel has stated that consideration of an extra-schedular rating under 3.321(b)(1) is only warranted where there is evidence that the disability picture presented by the Veteran would, in that average case, produce impairment of earning capacity beyond that reflected in the rating schedule or where evidence shows that the Veteran's service-connected disability affects employability in ways not contemplated by the rating schedule. See VAOPGCPREC 6-96 (Aug. 16, 1996). In Thun, the Court further explained that the actual wages earned by a particular Veteran are not considered relevant in the calculation of the average impairment of earning capacity for a disability, and contemplate that Veterans receiving benefits may experience a greater or lesser impairment of earning capacity than average for their disability. The Thun Court indicated that extraschedular consideration cannot be used to undo the approximate nature of the rating system created by Congress. The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. However, the Board is not precluded from raising this question, see Floyd v. Brown, 9 Vet. App. 88 (1996), and addressing referral where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board is aware of the Veteran's complaints as to the effects of his service-connected lumbar spine disability on his activities of work and daily living. In the Board's opinion, all aspects of this disability are adequately encompassed in the assigned schedular ratings. The Veteran has primarily complained of symptoms such as pain, limitation of motion and impairment on his activities of daily living such as lifting heavy objects. However, the rating criteria are specifically designed to address this symptomatology. His assigned rating contemplates these symptoms. Furthermore, 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 condition fails to capture all of the symptoms associated with the service-connected disabilities experienced. However, even after affording the Veteran the benefit of the doubt, there is no additional impairment that has not been attributed to a specific rated disability. As such, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and the rating schedule is adequate to evaluate his lumbar spine disability. Therefore, the Board need not proceed to consider the second factor, i.e.; whether there are attendant related factors such as marked interference with employment or frequent periods of hospitalization. The record does not reflect that the Veteran is unemployed as a result of his service-connected disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for his service-connected disability. Consequently, the Board concludes that referral of this case for consideration of an extraschedular rating is not warranted. See Thun, 22 Vet. App. at 114-15; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Cervical Spine The Veteran also contends that he is entitled to an evaluation in excess of 30 percent for his cervical spine disability. For historical purposes, the Veteran was originally granted service connection for a cervical spine disability in an April 2000 rating decision. An evaluation of 30 percent was assigned, effective June 1999. In July 2008, the Veteran submitted a claim for an increased rating for his cervical spine disability which was denied in an October 2008 rating decision. Thereafter, the Veteran perfected an appeal as to this decision. Evidence relevant to the current level of severity of the Veteran's cervical spine disability includes VA examination reports dated in September 2008, April 2012, and October 2014 as well as VA treatment records dated through October 2014 and private treatment records dated through October 2015. During the September 2008 VA spine examination, the Veteran complained of left neck pain that was intermittent in nature. He was concerned because he had recently had 3 episodes where something in his neck locked up when he rotated his neck. It was noted that he had undergone an anterior C3 to C5 fusion around November 1997 (it was noted that prior to this surgery the Veteran had decreased sensation in his legs and this resolved postoperatively). The pain was noted to range from a 0 out of 10 to a 9 out of 10. It was intermittent in nature and accompanied by stiffness. This had not triggered any flares or incapacitating episodes. Lifting more than 20 pounds did increase his neck pain. Examination revealed his cervical spine range of motion to be consistently diminished throughout all portions of the examination, although he held himself even more stiffly during the official portion of the examination. There was tenderness to palpation over the bilateral cervical paraspinals. Right extensor halluces longus was 4+ but otherwise 5/5 in the bilateral upper and lower extremities. Deep tendon reflexes were 2+ and symmetric and sensation was intact. Cervical range of motion was forward flexion to 30 degrees with pain at end range, extension to 25 degrees with pain at end range, bilateral lateral flexion to 15 degrees with pain at 15 degrees, left lateral rotation to 45 degrees with pain at end range and right lateral rotation to 60 degrees with pain at end range. He also complained of a grinding in the neck with these maneuvers but the range of motion did not change after 3 repetitions. MRI revealed the Veteran to be status post anterior fusion C3 through C5. There was no significant change in active or passive range of motion following repeat testing, and as such, no additional losses of range of motion was recommended due to painful motion, weakness, impaired endurance, incoordination, instability or acute flares. According to a November 2011 private treatment note, the Veteran was experiencing worsening neck pain. An MRI revealed postsurgical fusion of C3-5, abnormal marrow signal and irregularity of the C6 vertebral body, a moderate amount of bone indents at C5-6 and multilevel degenerative changes. A December 2011 private treatment note also reflects cervical stenosis worst at C5-6 status-post fusion in 1997 without evidence of myelopathy. During an April 2012 VA spine examination, the Veteran was noted to be suffering from residual degenerative joint disease at C3-7 with pain and decreased motion, status post cervical fusion. The Veteran noted a lot of popping of the joints and grinding. The pain hurt him at the base of his neck to his strapezius. There was no radiation down the arms. He was noted to get tingling in his hands but this has been diagnosed as carpal tunnel syndrome. The Veteran reported flare-ups noting that lifting things above his head caused marked increased pain which he rated as a 6 or 7 out of 10, as well as heavy legs, tingling and tenderness with movement of the neck. The last episode of this was noted to be approximately 6 months earlier. His current pain was rated as a 4 to 5 out of 10. Physical examination revealed forward flexion to 30 degrees with pain at 30 degrees, extension to 15 degrees with pain at 15 degrees, right lateral flexion to 15 degrees with pain at 15 degrees, left lateral flexion to 20 degrees with pain at 20 degrees, and bilateral lateral rotation to 45 degrees with pain at 45 degrees. There was no reduction in range of motion after 3 repetitions. The Veteran did have functional loss and impairment due to less movement than normal and pain on movement. Muscle strength, reflex and sensory testing were all normal. There was no evidence of radicular pain or other symptoms. There was no evidence of intervertebral disc syndrome of the cervical spine. This condition was noted to impact the Veteran's employment. He missed 10 days of work due to this condition and he had difficulty with lifting things above his head. He also has to turn his whole upper body for driving. During an October 2014 VA examination of the cervical spine the Veteran was noted to be suffering from degenerative joint disease of the cervical spine status-post cervical fusion without radiculopathy. The Veteran reported that since his surgery, he has done well with a 0 out of 10 pain rating increasing to 7 or 8 out of 10 with certain activities. He described his pain as a deep ache and point to the circumference of the neck area. He reported decreased rotational movement during these flares. These would resolve within 3 days with medication. He denied numbness, tingling or weakness. He stated that between his neck and back condition he missed 10 to 15 days of work per year. He denied going to his medical provider for care during a flare and had not been formally prescribed bedrest. Physical examination revealed forward flexion to 30 degrees with pain at 30 degrees, extension to 30 degrees with pain at 30 degrees, bilateral lateral flexion to 20 degrees with pain at 20 degrees and bilateral lateral rotation to 30 degrees with pain at 30 degrees. The Veteran was able to perform 3 repetitions with no additional limitation of motion. The Veteran did have functional impairment due to less movement than normal and pain on movement. Muscle strength, reflex and sensory testing were all normal. It was noted that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. It was further noted that the Veteran did not suffer from ankylosis. It was noted that it was at least as likely as not that pain could significantly limit functional ability during flare-ups or when the joint was used repeatedly over a period of time. Therefore, the examiner assigned an additional range of motion loss of 10 degrees of cervical lateral rotational movement due to pain on use or during flare-ups. This would result in right and left 20 degrees of lateral rotation during a flare-up. Other range of motion measurements would remain the same. The preponderance of the above evidence demonstrates that the Veteran is not entitled to an evaluation in excess of 30 percent for his service-connected cervical spine disability at any time during the pendency of this claim. Under 38 C.F.R. § 4.71a, a higher evaluation of 40 percent is warranted when there is evidence of unfavorable ankylosis of the entire cervical spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Significantly, the Veteran had cervical flexion to 30 degrees in September 2008, 30 degrees in April 2012, and 30 degrees in October 2014. As such, there is no evidence of ankylosis during the appeal period and a higher evaluation is not warranted under the rating schedule. As previously noted, evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca, 8 Vet. App. at 202. However, the Veteran has not provided any evidence, and the medical evidence of record, fails to reflect that the Veteran suffers from a degree of impairment so significant as to warrant a rating on par with ankylosis of the cervical spine. Even during periods of flare-ups, he is able to move his neck to some degree. As such, the higher rating of 40 percent is not warranted based on limitation of function. The Board recognizes that the Veteran and his representative believe that an evaluation in excess of 30 percent is warranted for his cervical spine disability. In November 2009, the Veteran's representative noted that the Veteran had experienced numbness and tingling in the arms. The Veteran also reported intermittent neck pain and 3 recent episodes where "something in his neck locked when [he] rotated it." The Veteran also described stiffness in the neck. Finally, his representative noted in October 2015 that the Veteran appeared to continue to have ongoing exacerbations that required continued treatment. While the Board has considered this testimony, it does not suggest that the Veteran's current disability warrants a higher rating - requiring ankylosis of the cervical spine. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to an evaluation in excess of 30 percent for a cervical spine disability must be denied. The Board has again considered whether the case should be referred for extra-schedular consideration. See Thun, 22 Vet. App. at 111. The Board is aware of the Veteran's complaints as to the effects of his service-connected cervical spine disability on his activities of work and daily living. In the Board's opinion, all aspects of this disability are adequately encompassed in the assigned schedular ratings. The Veteran has primarily complained of symptoms such as pain, limitation of motion and impairment on his activities of daily living such as driving. However, the rating criteria are specifically designed to address this symptomatology. His assigned rating contemplates these symptoms. Furthermore, the Board notes that under Johnson, 762 F.3d at 1362, 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 condition fails to capture all of the symptoms associated with the service-connected disabilities experienced. However, even after affording the Veteran the benefit of the doubt, there is no additional impairment that has not been attributed to a specific rated disability. As such, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and the rating schedule is adequate to evaluate his lumbar spine disability. Therefore, the Board need not proceed to consider the second factor, i.e.; whether there are attendant related factors such as marked interference with employment or frequent periods of hospitalization. The record does not reflect that the Veteran is unemployed as a result of his service-connected disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for his service-connected disability. Consequently, the Board concludes that referral of this case for consideration of an extraschedular rating is not warranted. See Thun, 22 Vet. App. at 114-15; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Right Great Toe Finally, the Veteran contends that he is entitled to a compensable evaluation for his right great toe disability. For historical purposes, the Veteran was originally granted service connection for degenerative arthritis of the right great toe in an April 2000 rating decision. A noncompensable (0 percent) evaluation was assigned, effective June 1999. In July 2008, the Veteran submitted a claim for an increased rating for his right great toe disability which was denied in an October 2008 rating decision. Thereafter, the Veteran perfected an appeal as to this decision. Evidence relevant to the current level of severity of the Veteran's right great toe disability includes VA examination reports dated in September 2008, May 2012, and October 2014 as well as VA treatment records dated through October 2014 and private treatment records dated through October 2015. During the September 2008 VA foot examination, the Veteran reported that his right great toe problem caused him to limp. Specifically, when he went to the mall with his family he usually sat in the lobby and waited for them. He reported that he hated standing, primarily because of the low back pain and neck stiffness, but also because of the feet. He had increased pain at the right great toe with wearing leather shoes. He reported that his pain was constant and ranges in intensity from 3 out of 10 to 8 or 9 out of 10. His symptoms generally occurred with walking. The Veteran was noted to be a little tangential and somewhat vague about how far he could walk so it was difficult for the examiner to clarify this further than indicating that he had trouble walking all the way through the mall. The Veteran used a cushion on the top of his toe. Examination was remarkable for deformity of the right great toe with enlargement and hallux valgus of 30 degrees present. There was tenderness to palpation at the first metatarsophalangeal joint on the right but no other tenderness in the right foot. Weight bearing was normal and there were no abnormal callosities. His shoes showed normal signs of lateral heel and uniform toe wear. The Achilles tendon was nontender to palpation without varus or valgus alignment during weight-bearing. There was tenderness over the right MTP joint. Range of motion of the right first MTP joint was 55 degrees of dorsiflexion and 25 degrees of plantar flexion. X-rays revealed a hallux valgus angle of 20 degrees (which does not match the 30 degrees noted in the report) and there was mild joint space narrowing at the first MTP joint and lateral subluxation of the sesamoids which also demonstrated degenerative change. Degenerative changes were also present at the dorsum of the midfoot. Mineralization was maintained. There was no significant change in active or passive range of motion following repeat testing so no additional losses of range of motion were recommended for the feet due to painful motion, weakness, impaired endurance, incoordination, instability or acute flares. During the May 2012 VA foot examination, it was noted that the Veteran was suffering from metatarsalgia and hallux valgus. The Veteran reported that since service, he had had periods where the right great toe was better, but at times, it had been worse. It would swell up and hurt depending on the type of shoe he was wearing. He reported that he would get right great toe pain when he wore leather shoes or boots. It would also swell on hot days when wearing leather shoes. He rated his pain as a 6 or 7 out of 10 lasting for 1 to 2 days. The pain and swelling occurred once per week. It improved with an ice pack and heat, and if he accidentally bumped it, it would hurt for 2 to 3 days. He was able to stand for 30 to 45 minutes before the toe hurt, walk 1 mile, run or jog for 20 to 30 minutes, climb stairs (no limitation) and lift 20 to 30 pounds. Physical examination revealed that the Veteran did not have Morton's neuroma, hammer toe, hallux rigidus, pes cavus (claw foot), malunion or nonunion of tarsal or metatarsal bones, bilateral weak foot or other pertinent findings. He did have hallux valgus resulting in mild or moderate symptoms to the right foot. It was also noted that the Veteran's right great toe was reddened and enlarged. It was noted that this condition did not impact the Veteran's ability to work. During the October 2014 VA foot examination, the Veteran was noted to be suffering from degenerative joint disease of the right foot. Specifically, he was noted to have hallux valgus and degenerative arthritis. It was noted that surgery was recommended in 2010 but the Veteran has deferred. He reported daily pain as a 0 out of 10 with an increase to 9 out of 10 when he wears dress shoes or some tennis shoes. He reported that the area would become red and swollen during the warm summer months. This occurred about 2 times per month with no loss of work. The Veteran reported that during flare-ups his mobility was limited due to pain. Physical examination revealed that the Veteran did not suffer from flat foot (pes planus), Morton's neuroma and metatarsalgia, hallux rigidus, pes cavus (clawfoot), malunion of the tarsal or metatarsal bones or other foot injuries. He suffered from hallux valgus with mild or moderate symptoms of the right foot. Pain was noted on physical examination but it was not found to contribute to functional loss. However, functional loss was noted during flare-ups because the Veteran's mobility was limited and he would use a cane for ambulation during these times. The Veteran was noted to have functional loss due to an inability to perform prolonged walking. The examiner concluded that due to all of the Veteran's conditions, he could work with limitations primarily related to his low back and foot. He is limited to no prolonged walking, no standing greater than 20 minutes without the ability to change positions as needed, no squatting or kneeling, no overhead lifting and no lifting items in excess of 20 pounds. Some absenteeism would occur. The Veteran was noted to be currently working as of this time. In light of the above evidence, the Board finds that the Veteran is entitled to a 10 percent evaluation for his right great toe disability under Diagnostic Code 5003. Diagnostic Code 5003, pertaining to degenerative arthritis, provides that when the limitation of motion of the joint or joints under consideration is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be granted for each relevant major joint or group of minor joints affected by limitation of motion. The evidence clearly reflects that the Veteran suffers from degenerative joint disease with pain of the right great toe. Therefore, he is entitled to a 10 percent evaluation under Diagnostic Code 5003. See 38 C.F.R. § 4.71a. As to whether the Veteran's right great toe disability rating warrants either a higher or separate rating under any other diagnostic code, the Board notes that Diagnostic Code 5280 specifically pertains to hallux valgus. Specifically, under Diagnostic Code 5280, a 10 percent rating is warranted for either severe hallux valgus equivalent to amputation of the great toe, or operated hallux valgus with resection of the metatarsal head. In this case, there is no evidence of severe hallux valgus equivalent to amputation of the great toe or operated hallux valgus with resection of the metatarsal head. As above, the May 2012 VA examiner noted that the Veteran's hallux valgus resulted in mild or moderate symptoms to the right foot and during the October 2014 VA examination, the Veteran indicated that, while surgery had been recommended in 2010, he declined. As such, a separate rating under Diagnostic Code 5280 for the Veteran's hallux valgus is not warranted. The Board has considered the application of other diagnostic codes referable to feet. None are applicable in this case. In particular, there is no evidence of pes planus, weak foot, claw foot, metatarsalgia, hallux rigidus, hammer toe, or malunion/nonunion of the tarsal or metatarsal bones. With regard to metatarsalgia, while the May 2012 VA examiner noted a diagnosis of metatarsalgia, the Veteran is not currently service connected for metatarsalgia and the October 2014 VA examiner found no evidence of metatarsalgia. It could be argued that Diagnostic Code 5284 (foot injuries, other) may be applied because it is a "catch-all" provision encompassing various foot disabilities. However, this argument fails in light of the fact that there are specific diagnostic codes which are applicable to the Veteran's degenerative arthritis and hallux valgus. See Zimick v. West, 11 Vet. App. 45, 51 (1998) ("'a more specific statute will be given precedence over a more general one . . . . ")(quoting Busic v. United States, 446 U.S. 398, 406 (1980)); see also Kowalski v. Nicholson, 19 Vet. App. 171, 176-7 (2005). The Board again recognizes that the Veteran and his representative believe that a compensable evaluation is warranted for the right great toe. In November 2009, the Veteran's representative noted that the Veteran described continuing, constant pain in the right great toe and especially noticed pain when standing and walking. Finally, his representative noted in October 2015 that the Veteran appeared to continue to have ongoing exacerbations that required continued treatment. However, no evidence has been presented to suggest that the Veteran is entitled to an evaluation in excess of 10 percent for this disability at any time during the pendency of this claim. Having resolved all reasonable doubt in favor of the Veteran, the Board finds that an evaluation of 10 percent is warranted for the residuals of a right great toe injury. See 38 U.S.C. § 5107(b). However, the preponderance of the evidence of record demonstrates that an evaluation in excess of 10 percent is not warranted at any time during the pendency of this claim. The Board has again considered whether the case should be referred for extra-schedular consideration. See Thun, 22 Vet. App. at 111. The Board is aware of the Veteran's complaints as to the effects of his service-connected right great toe disability on his activities of work and daily living. In the Board's opinion, all aspects of this disability are adequately encompassed in the assigned schedular ratings. The Veteran has primarily complained of symptoms such as pain and limited mobility and impairment on his activities of daily living such as standing or walking. However, the rating criteria is specifically designed to address this symptomatology. His assigned rating contemplates these symptoms. Furthermore, the Board notes that under Johnson, 762 F.3d at 1362, 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 condition fails to capture all of the symptoms associated with the service-connected disabilities experienced. However, even after affording the Veteran the benefit of the doubt, there is no additional impairment that has not been attributed to a specific rated disability. As such, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and the rating schedule is adequate to evaluate his lumbar spine disability. Therefore, the Board need not proceed to consider the second factor, i.e.; whether there are attendant related factors such as marked interference with employment or frequent periods of hospitalization. The record does not reflect that the Veteran is unemployed as a result of his service-connected disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for his service-connected disability. Consequently, the Board concludes that referral of this case for consideration of an extraschedular rating is not warranted. See Thun, 22 Vet. App. at 114-15; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, as to all three claims adjudicated above, a claim for increased rating includes a claim for a finding of total disability based on individual unemployability (TDIU) where there are allegations of worsening disability and related unemployability. Rice v. Shinseki, 22 Vet. App. 447 (2009). As the Veteran is currently working and has not alleged unemployability, no TDIU claim is inferred. ORDER An evaluation in excess of 40 percent for a lumbar spine disability is denied. An evaluation in excess of 30 percent for a cervical spine disability is denied. An evaluation of 10 percent, and no higher, for a right great toe disability is granted. ______________________________________________ APRIL MADDOX Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs