Citation Nr: 1642880 Decision Date: 11/08/16 Archive Date: 12/01/16 DOCKET NO. 09-42 291 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for disability of the knees. 2. Evaluation of right ring finger fracture, currently rated as noncompensable. 3. Evaluation of bilateral tinea pedis, currently rated as noncompensable. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Trickey, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from September 1973 to September 1993. The claim for entitlement to service connection for a disability of the knees is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in November 2008 of a Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The claims for increased ratings for right ring finger fractures and bilateral tinea pedis are before the Board of Veterans' Appeals (Board) on appeal of a rating decision in March 2012 of a Department of Veterans Affairs Regional Office in Waco, Texas. In July 2011, the Veteran provided testimony regarding the claim for service connection for disability of the knees at a hearing before a Veterans Law Judge that later retired. In January 2016, the Veteran provided testimony regarding the claim for service connection for disability of the knees at a hearing before the undersigned Veterans Law Judge. Transcripts of the July 2011 and January 2016 hearings are of record. Since the Veterans Law Judge (VLJ) who presided over the initial hearing is no longer employed by the Board, an additional hearing is not warranted. See Arneson v. Shinseki, 24 Vet. App. 379, 386 (2011). FINDINGS OF FACT 1. A chronic bilateral knee disability was not manifest during service and arthritis was not manifest within one year of separation. Knee pathology is not attributable to service. 2. Throughout the period on appeal, the Veteran's service-connected finger disability was manifested by pain, numbness, and stiffness. 3. The Veteran's bilateral tinea pedis has affected less than five percent of the total body area and no exposed area, and no use of topical corticosteroids. CONCLUSION OF LAW 1. A bilateral knee disability was not incurred or aggravated by service and arthritis of the knees may not be presumed to have occurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2016). 2. The criteria for a compensable evaluation for the Veteran's service-connected fifth metacarpal fracture residuals disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321 , 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5227, 5230 (2016). 3. The criteria for a compensable evaluation for bilateral tinea pedis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.31, 4.118, Diagnostic Codes 7806, 7813, 7899 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. § 3.159 (2016). The RO provided the required notice in letters sent to the Veteran in October 2008 and December 2011. In January 2016, the Veteran testified at a video-conference Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. During the January 2016 hearing, the undersigned Veterans Law Judge clarified the issues on appeal, and the VLJ conducted the hearing so as to elicit testimony from the Veteran with respect to the facts and applicable law. The actions of the VLJ supplement the VCAA and comply with any related duties owed during a hearing. 38 C.F.R. § 3.103 (2016). Regarding the duty to assist, the record contains the Veteran's service treatment records, VA medical records, VA examination reports, and statements from the Veteran's representative. The Board has carefully reviewed the Veteran's statements and concludes that he has not identified further evidence not already of record. The Board has also reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. The Board remanded the appeal in April 2016 in order for VA to obtain treatment records from the Central Texas VA Medical Center. Records from October 1994 to the present were obtained and associated with the claims file. Additionally, the Veteran was provided with VA examinations regarding his claims for increased ratings. The Veteran was also afforded a VA examination with respect to his claim for service connection for a bilateral knee disability. The Board finds that there was substantial compliance with the prior Board remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). As the Board will discuss in its analysis, the Veteran was provided with a VA examination for his disabilities in May 2016. As necessary opinions based on a review of the Veteran's past medical history, current complaints, and physical examinations have been obtained, the Board finds that further examination or medical opinion is not necessary. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and that no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claim. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and that no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claim. Service Connection Veterans are entitled to compensation from the VA if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C.A. § 1110 (wartime service), 1131 (peacetime service). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As sensorineural hearing loss and tinnitus are considered an organic disease of the nervous system which is a chronic disease, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Certain disabilities, including arthritis, may be presumed to have been incurred in service if manifested to a compensable degree within 1 year from separation from qualifying service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Analysis - Service Connection for a Bilateral Knee Disability With regard to in service incurrence, the Veteran complained of right knee pain in service December 1974. The Veteran also complained of left knee pain in September 1978. Additionally, the Veteran reported right knee pain in August 1985. The Veteran reported a history of left knee stiffness on his September 1993 Report of Medical History. However, the Veteran's lower extremities were noted as normal on his September 1993 separation examination. The Veteran's Reports of Medical Examination dated November 1982, August 1984, and September 1993 do not show evidence of right or left knee pathology. Overall, the Veteran's complaints of knee pain and stiffness show some symptomatology in service. Moreover, the Veteran has been diagnosed with a current bilateral knee disability, patellofemoral pain syndrome, at the 2013 VA examination, so he satisfies this element for service connection. The Veteran was provided with a VA examination for his disabilities in May 2012. The May 2012 VA examiner failed to diagnose a knee disability and noted that the Veteran's claimed bilateral knee disability was less likely than not incurred in active service. The examiner noted the Veteran's right and left knee injuries in service, including bruises and strain, however, the examiner found that the Veteran's current knee complaints were more likely due to the normal changes of aging and not to the acute injuries in service. The Board notes that VA x-ray reports dated May 2012 show the Veteran's right and left knee were within normal limits with no significant bone or joint abnormalities. The probative value of a medical professional's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999); see also Black v. Brown, 5 Vet. App. 177, 180 (1995). The examiner explained their conclusion and relied on supporting clinical evidence in rendering the opinion. In 2013, the Veteran underwent another VA examination, the examiner diagnosed bilateral patellofemoral pain syndrome, and determined after examination and review of the record that the Veteran's disability was not related to his complaints in service, but was more likely related to his employment as a postal carrier with the U.S. Postal Service. He addressed the Veteran's complaints and explained the basis for his findings and conclusions. To the extent that the examiner did not address the Veteran's collateral ligament strain in service specifically in his opinion, the Board remanded for another opinion to address this evidence. The Veteran was provided with another VA examination for his disabilities in May 2016. The May 2016 VA examiner noted that the Veteran's claimed bilateral knee disability was less likely than not incurred in active service. In support of their opinion, the examiner noted that the Veteran sustained contusions and strains that were self-limiting and heal within weeks or months. The examiner noted that following the contusions and strains, the Veteran performed his duties and after service was employed as a mail handler for the United States Postal Service for over twenty years. The examiner noted that the Veteran reported intermittent pain with the most pain being in the past three years. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The Board finds this opinion adequate and notes that the examiner addressed all relevant evidence and provided a rationale for the conclusions and findings rendered. In adjudicating a claim, the Board is charged with the duty to assess the credibility and weight given to evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The Veteran has submitted lay statements in support of his claim. The Veteran asserts that he has a bilateral knee disability that was incurred in service. The Veteran's statements purport to provide a nexus opinion between his bilateral knee condition and his active service. The Board finds the Veteran's statements not competent for this purpose. Although it is error to categorically reject a lay person as competent to provide a nexus opinion, not all questions of nexus are subject to non-expert opinion. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Whether a layperson is competent to provide a nexus opinion depends on the facts of the particular case. In Davidson, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) drew from its earlier decision in Jandreau v. Nicholson to explain its holding. Id. In that earlier decision, the Federal Circuit stated as follows: "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Federal Circuit provided an example, stating that a layperson would be competent to identify a simple condition such as a broken leg, but not competent to provide evidence as to a more complex medical question such as a form of cancer. Id. at n.4. Also of note is that the Veterans Court has explained that non-expert witnesses are competent to report that which they have observed with their own senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Taking Davidson, Jandreau, and Layno together, leads the Board to the conclusion that the complexity of the question and whether a nexus opinion could be rendered based on personal observation are factors in determining whether a non-expert nexus opinion or diagnosis is competent evidence. In the instant case, the question of the cause of his bilateral knee condition is not something that can be determined by mere observation. Nor is this question simple. While the Veteran is competent to report pain, the question of the cause of that pain is not an observable fact. It requires clinical testing to assess and diagnose the underlying condition and training to make the appropriate interpretations and conclusions about what the testing demonstrates in conjunction with the symptoms reported to determine the cause. Therefore, the Board finds that the Veteran's statements as to how his bilateral knee condition was caused are not competent evidence as to a nexus. In sum, the Board finds that the May 2016 VA examination is the most probative evidence of record as to the etiology of the Veteran's bilateral knee condition. Thus, the Board finds that the preponderance of the evidence is against the claim and the claim must be denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Increased Rating - Residuals of Right Fifth Metacarpal Fracture The Veteran's service-connected finger disability is rated under Diagnostic Code 5227 (Ring or little finger, ankylosis). Under Diagnostic Code 5227, a noncompensable (0 percent) disability rating is assigned for unfavorable or favorable ankylosis of the ring or little finger for both the major and minor finger; no higher disability ratings are available. 38 C.F.R. § 4.71a , Diagnostic Code 5227 (2016). A note to this diagnostic code instructs to also consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. Id. Diagnostic Code 5230 is a potentially alternative diagnostic code. Under Diagnostic Code 5230, a noncompensable (0 percent) disability rating is assigned for any limitation of motion of the ring or little finger for both the major and minor finger; no higher disability ratings are available. 38 C.F.R. § 4.71a, Diagnostic Code 5230 (2016). The Board notes that both the December 2011 and May 2016 VA examination reports noted the Veteran's right hand to be the dominant hand. The rating schedule states that, as applicable to the ring finger, the metacarpophalangeal joint (MCP) has a range of zero to 90 degrees of flexion, the proximal interphalangeal joint (PIP) has a range of zero to 100 degrees of flexion and the DIP has a range of motion of zero to 70 or 80 degrees of flexion. See 38 C.F.R. § 4.71a (2016). With respect to amputation, under Diagnostic Code 5155, disability ratings are assigned for amputation of the ring finger. 38 C.F.R. § 4.71a, Diagnostic Code 5155 (2016). When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. See 38 C.F.R. § 4.40 (2015); DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45 (2016). Pursuant to 38 C.F.R. § 4.59 (2016), it is the intention of the rating schedule to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Analysis The Board notes that both the December 2011 and May 2016 VA examination reports noted the Veteran does not manifest a limitation of motion of the right fifth metacarpal on objective testing. The December 2011 VA examination indicated that the Veteran experiences aches with cold weather. No additional functional loss or limitation of motion was present with repetitive testing. Additionally, the Veteran was noted to have no ankylosis of the fifth metacarpal, he was no prescribed medication for pain, and the Veteran reported employment as a mail handler. The May 2016 VA examination indicated that the Veteran experiences intermittent cramping, locking up, and intermittent decreased grip strength. No additional functional loss or limitation of motion was present with repetitive testing. Additionally, the Veteran was noted to have no ankylosis of the fifth metacarpal. The May 2016 examiner noted that the Veteran had an abnormal range of motion, however, this abnormality stems from his partially amputated right index finger that was injured in his post-service occupation as a mail handler for the U.S. Postal Service. The examiner noted that the Veteran did not experience functional loss from pain or from his abnormal range of motion. The examiner did note that the Veteran may experience limitation with prolonged lifting and carrying heavy weight. The Veteran's service-connected finger disability has been rated under Diagnostic Code 5227 as noncompensable (0 percent) and no higher disability ratings are available. As noted above, under Diagnostic Code 5230, a noncompensable (0 percent) disability rating is assigned for any limitation of motion of the ring finger for the minor finger and no higher disability ratings are available. As such, the Veteran has been in receipt, throughout the period on appeal, of the maximum schedular evaluation permitted under Diagnostic Code 5227 or Diagnostic Code 5230 and a compensable disability rating is therefore not warranted under these diagnostic codes. Moreover, there is no indication that his limitation is such that compensation as if it were amputated is warranted. He has essentially full motion of the finger with only intermittent symptoms. As noted above, when evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss due to pain and weakness, weakened movement, excess fatigability and incoordination and pursuant to 38 C.F.R. § 4.59 (2016), it is the intention of the rating schedule to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. However, as noted above, there is no compensable rating under either Diagnostic Code 5227 or Diagnostic Code 5230. The provisions of 38 C.F.R. §§ 4.40, 4.45 are not for consideration where the Veteran is in receipt of the highest rating based on limitation of motion and a higher rating requires ankylosis. Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). Thus, compensation for functional loss is not applicable here. In conclusion, the Board finds that the criteria for a compensable disability rating for the Veteran's service-connected residuals of a fifth metacarpal disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5227 (2016). Increased Rating - Bilateral Tinea Pedis The Veteran has been rated under Diagnostic Codes 7813 for his bilateral tinea pedis. Based on the medical evidence discussed below, the Board finds that the Veteran's foot disability has been appropriately rated under this code. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (noting that the assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case"). Under Diagnostic Code 7813, dermatophytosis (ringworm: of body, tinea corporis; of head, tinea capitis; of feet, tinea pedis; of beard area, tinea barbae; of nails, tinea unguium; of inguinal area (jock itch), tinea cruris) is rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7813 (2016). In this case, the Board finds that the predominant disability is dermatitis which is evaluated under Diagnostic Criteria 7806. Under Diagnostic Code 7806, a noncompensable rating is assigned where less than 5 percent of the entire body or less than 5 percent of exposed areas are affected, and; no more than topical therapy has been required during the past 12-month period. A 10 percent evaluation is assigned where there is involvement of at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation requires involvement of 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is assigned with involvement of more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2016). Analysis The Veteran was afforded a VA examination in December 2011 for his tinea pedis disability. The Veteran was noted to have dry skin with cracking and that he used over the counter medications such as Tinactin (anti-fungal) ointment or powder. The Veteran was not treated with corticosteroids, either systemic or topical. The December 2011 VA examiner noted that the primary symptom of the Veteran's tinea pedis disability was flaking skin between all toes of both feet. The examiner also noted that this disability does not impact the Veteran's ability to work. On VA examination in May 2016, the VA examiner noted that the Veteran's tinea pedis disability was asymptomatic. The Veteran reported that he experienced an outbreak approximately two months prior to the May 2016 examination. The May 2016 VA examiner noted that the Veteran reported 3-5 outbreaks per year, worse on the right foot than on the left. The Veteran reported that he used over the counter medications such as Tinactin and Lotrimin (anti-fungal agents) for less than 6 weeks in the last 12 month period. There was no other treatment, or debilitating or non-debilitating episodes. The Veteran's tinea pedis disability affected less than five percent of the total body area and no exposed area. There was no functional impact due to the disability. Based on the evidence, the Board finds that a compensable evaluation for tinea pedis is not warranted. The evidence indicates that the Veteran's skin disability of the foot does not involve at least 5 percent of the entire body, or at least 5 percent of exposed areas affected, or require intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the past 12-month period. Instead, the evidence demonstrates that it affects less than five percent of the total body area and there is no exposed area. Furthermore, the Veteran treats his skin disability with over-the-counter antifungal medication and not intermittent systemic therapy. The evidence also does not show that the Veteran uses topical corticosteroids. See Johnson v. McDonald, No. 14-2778 (Ct. Vet. App. Mar. 1, 2016). Therefore, a higher rating is not warranted. The Board has considered other potentially applicable diagnostic codes. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). But the evidence does not demonstrate, and the Veteran does not alleged that he has any disfigurement of the head, face, or neck, or scars. See 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. As the preponderance of the evidence is against the claim for an increased rating, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107 (b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Consideration Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, 572 F.3d 1366 (Fed. Cir. 2009). The first element requires a finding that the evidence "presents such an exceptional or unusual disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. In order to determine whether a disability is "exceptional or unusual," there "must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability." Id. "[I]f the [rating] criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, [and] the assigned schedular evaluation is, therefore adequate, and no referral is required." Id. As to the second element, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms," specifically marked interference with employment or frequent periods of hospitalization. Id.; see also 38 C.F.R. § 3.321 (b)(1) (2016). Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Id. With respect to the Veteran's service-connected finger disability, the first Thun element is not satisfied. The Veteran's service-connected finger disability was manifested by various signs and symptoms, to include pain, numbness and stiffness which are all contemplated in the schedular rating provisions. In short, there is nothing exceptional or unusual about the Veteran's service-connected finger disability because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. As such, the evidence of record does not warrant referral for an extraschedular rating. Similarly, there is nothing exceptional or unusual about the Veteran's service-connected tinea pedis disability because the rating criteria reasonably describe his disability level and symptomatology present. Thun, 22 Vet. App. at 115. As such, the evidence of record does not warrant referral for an extraschedular rating. Finally, the Board notes that a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). In this case, the Veteran has not alleged, and the evidence of record does not suggest, that his currently service-connected disabilities combine to result in additional disability or symptomatology that is not already contemplated by the rating criteria for each individual disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration is warranted under Johnson. ORDER Service connection for a bilateral knee disability is denied. A compensable rating for residuals of a right ring finger fracture is denied. A compensable rating for tinea pedis is denied. ____________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs