Citation Nr: 1752452 Decision Date: 11/15/17 Archive Date: 11/22/17 DOCKET NO. 12-11 265A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUE Entitlement to an increased rating for residuals of a fractured left first metacarpal, currently rated 10 percent. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Thaddaeus J. Cox, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1995 to May 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico. In March 2013, the Veteran testified in a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The Board remanded this matter in January 2013 for a Board hearing, and in August 2016 for a VA examination. FINDINGS OF FACT The Veteran's left metacarpal disability was manifested by pain and decreased grip strength, with motion limited at most to 40 degrees of wrist dorsiflexion, and 45 degrees of palmar flexion. There was no objective evidence of ankylosis, muscle injury, or neurological deficit of the left hand or wrist. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for a left wrist disability have not been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. § 4.59, 4.69, 4.71a, Diagnostic Codes (DCs) 5010, 5214, 5215 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has a duty to notify a claimant of any information necessary to substantiate a claim, and to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim, to include requesting records and providing an examination. 38 U.S.C.A. § 5103, 5103A (West 2014). VA provided the Veteran that notice in November 2009, obtained the Veteran's service records, and provided examinations for the Veteran. The Veteran has not referred to any additional, unattained, relevant, or available evidence. Thus, the Board finds that the duties to notify and assist the Veteran have been fulfilled. Disability ratings are based on VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2017). Separate Diagnostic Codes identify various disabilities and the criteria for a specific percentage rating to be assigned for that disability. The percentage ratings represent as far as practicably can be determined the average impairment in earning capacity due to a service-connected disability. 38 U.S.C.A. § 1155 (West 2014). A rating is assigned by comparing the extent to which a Veteran's service-connected disability impairs the ability to function under the ordinary conditions of daily life, as demonstrated by the Veteran's symptomatology, with the criteria for the percentage ratings. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.10 (2017); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2017). Examination reports must be interpreted, and if necessary reconciled, into a consistent picture so that the evaluation rating may accurately compensate the elements of disability present. 38 C.F.R. § 4.2 (2017). If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). However, any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). Consideration must be given to whether staged ratings are warranted. Where the evidence contains factual findings that demonstrate distinct time periods in which a disability exhibited symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of a different rating for each time period is warranted. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2017). Functional loss in the form of limitation of motion may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion, or weakness. 38 C.F.R. § 4.40, 4.59 (2017). It also may be due to excess fatigability or incoordination. 38 C.F.R. § 4.45 (2017). A higher rating for functional loss, to include during flare ups, due to those factors accordingly may be assigned under Diagnostic Codes predicated on limitation of motion. 38 C.F.R. § 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). Diagnostic Code 5215 is used to rate limitation of motion of the wrist and provides that a 10 percent rating is warranted when there is less than 15 degrees of dorsiflexion of the wrist or palmar flexion limited in line with the forearm. A higher rating is available if the evidence establishes ankylosis, unfavorable or favorable, of the wrist. 38 C.F.R. § 4.71a, Diagnostic Code 5215 (2017). Normal range of motion of the wrist includes dorsiflexion from 0 to 70 degrees, palmar flexion from 0 to 80 degrees, ulnar deviation from 0 to 45 degrees, and radial deviation from 0 to 20 degrees. 38 C.F.R. § 4.71a, Plate I (2015). When, however, the limitation of motion of the specific joint or joints affected by service-connected arthritis warrants a 0 percent rating under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion, to be combined, not added. Ratings under Diagnostic Code 5003 cannot be combined with ratings for limitation of motion of the same joint.38 C.F.R. § 4.71a, Diagnostic Code 5003 (2017). Limitation of more than one interphalangeal joint is required to be considered a group of minor joints. Spicer v. Shinseki, 752 F.3d 1367 (Fed. Cir. 2014). The Board has reviewed all the evidence of record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all of the evidence submitted by the Veteran or obtained on their behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence was needed to substantiate the claim and what the evidence in the claim file shows, or does not show, with respect to the claim. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). On October 22, 2009, the Veteran contended that his left wrist disability had worsened since the initial grant of service connection in November 1998. In a November 2009 VA examination, the Veteran had dorsiflexion from 0 to 70 degrees with pain and stiffness at 50 degrees, and palmar flexion from 0 to 75 degrees with pain and stiffness at 50 degrees. Ulnar deviation was from 0 to 30 degrees with pain and stiffness at 15 degrees, and radial deviation was from 0 to 20 degrees with pain and stiffness at 10 degrees. Pain was also noted with repetitions, but there was no swelling, muscle atrophy, deformities, or erythema present. The Veteran also had interphalangeal joint flexion from 0 to 20 degrees with pain and stiffness at 10 degrees. Locking and stiffness were present in the thumb after repetitions. Despite difficulty, the Veteran was able to touch the thumb with the tip of the fingers. The examiner estimated a 30 to 50 degree limitation in interphalangeal extension, and moderate impairment on flare ups or repetitive motion. The Veteran reported the ability to perform daily living activities and drive, but also that he missed three days of work in the last year due to pain. However, the examiner did not provide an opinion on any occupational impairment present. Another VA examination in August 2016 noted abnormal range of motion in the Veteran's left hand. The Veteran reported weakened grip strength and pain with typing or writing. The Veteran presented pain on palpation along the dorsum of the thumb, but exhibited good grip strength with a 4 out of 5 score. The examiner noted no ankylosis or muscle atrophy. The examiner only indicated single finger range of motions, but not the range of motion for the wrist. Index and long finger ranges of motion were within normal limits. There were no gaps between the finger and the pad of the thumb or the proximal transverse crease of the hand noted on examination. The examiner opined that the Veteran's weakened grip strength would cause occupational impairment in writing, typing, or gripping. The examiner also opined that the left wrist disability at least as likely as not affected the Veteran's thumb. The Veteran's most recent VA examination in January 2017 noted abnormal range of motion in the left wrist. Dorsiflexion was from 0 to 40 degrees, and palmar flexion was from 0 to 45 degrees. Ulnar deviation was from 0 to 35 degrees and radial deviation was from 0 to 15 degrees. Strength on flexion and extension was 5 out of 5. Pain was noted on examination, but it did not cause functional loss. No ankylosis or muscle atrophy was noted. Repetitive use did not cause pain, weakness, incoordination, or limit functional ability. That examiner also noted finger ranges of motion. The index and longer finger ranges of motion were within normal limits. The examiner also noted no gaps between the finger and the pad of the thumb or the proximal transverse crease of the hand. Additionally, finger extension was not limited by 30 degrees or more. The examiner noted hand grip strength was 4 out of 5. The examiner opined that the decreased grip strength would cause mild occupational impairment. The Board finds that all of the VA examinations adequately indicated the Veteran's level of disability. Ranges of motion for the wrist and fingers were recorded, and pain on motion and palpation were noted. The examiners opined the wrist disability caused mild occupational impairment. The examinations continuously and consistently identified the presence of abnormal and painful range of motion in the left wrist. Although the Veteran's wrist range of motion was not limited to the extent contemplated in the rating schedule on any examination, since pain was objectively noted on motion, a 10 percent rating was warranted. Additionally, since no wrist ankylosis was present in any examination during the appeal period, consideration of a higher rating under Diagnostic Code 5214 was not warranted. The Board has also considered whether a higher rating could be assigned based on the criteria for rating finger disabilities. However, the examinations did not find a gap between the thumb pad and the fingers due to limitation of motion of the thumb, a gap between the fingertips and the transverse crease of the palm of the index finger, or any ankylosis or loss of any part of any finger. Therefore, the Board finds that the criteria for any increased or separate rating based on finger disability are not met. 38 C.F.R. § 4.71a, Diagnostic Codes 5126-5156, 5216-5230 (2017). The Board has considered whether the claim for increased rating should be referred for consideration of an extraschedular rating. 38 C.F.R. § 3.321(b)(1) (2017). The Board concludes referral is not warranted. The Veteran's limited range of motion and pain on motion are fully contemplated by the schedular rating criteria. There is nothing in the record to suggest that the disability picture is so exceptional or unusual as to make impractical the application of the regular schedular standards. Although the Veteran reported, and the examiners noted, mild impairment in typing and tying, and three missed work days in a year, that evidence did not show marked interference with employment. Furthermore, there was no evidence of frequent hospitalization due to the disability. Therefore, the Board finds that referral for consideration of the assignment of an extraschedular rating is not warranted. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating higher than 10 percent for a left metacarpal disability. Therefore, the claim for increase must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2017). ORDER Entitlement to a rating in excess of 10 percent for residuals of a fractured left first metacarpal is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs