Citation Nr: 1753030 Decision Date: 11/17/17 Archive Date: 11/22/17 DOCKET NO. 11-16 714 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to increases in the staged ratings (of 10 percent prior to September 29, 2009, and 20 percent since) for a lumbar spine disability. 2. Entitlement to a rating in excess of 10 percent for a right knee disability. 3. Entitlement to a rating in excess of 10 percent for a left knee disability. 4. Entitlement to a rating in excess of 10 percent for a cervical spine disability. 5. Entitlement to a rating in excess of 10 percent for a fracture of the right tibia with bilateral shin splints. 6. Entitlement to a rating in excess of 10 percent for a right foot disability. 7. Entitlement to a rating in excess of 10 percent for a left foot disability. 8. Entitlement to a compensable rating for tinea cruris. 9. Entitlement to a compensable rating for tinea pedis of the right foot. 10. Entitlement to a compensable rating for residuals of boxer's fracture to the right 5th metacarpal. 11. Entitlement to a compensable rating for onychomycosis of the 2nd and 5th toenails on the right foot. 12. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Adam Neidenberg, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jarrette A. Marley, Counsel INTRODUCTION The Veteran served on active duty in the United States Marine Corps from March 2000 to January 2002. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the St. Petersburg, Florida Department of Veterans Affairs (VA) Regional Office (RO). In May 2014, a video conference hearing was held before the undersigned. These matters were before the Board in August 2014 when, in part, the matters were remanded for additional development. During the appeal, a June 2016 rating decision granted an increased (10 percent) rating for the Veteran's service-connected left knee disability, effective November 14, 2011 (date of claim), and a separate rating for left lower extremity radiculopathy, rated 10 percent disabling, effective January 20, 2016 (associated with the service-connected lumbar spine disability). The left knee disability has been characterized in accordance with the June 2016 rating decision. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of entitlement to an increased rating for a lumbar spine, cervical spine, and right and left knee disabilities, and entitlement to TDIU, are addressed in the REMAND portion of the decision below and REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's fracture of the right tibia with bilateral shin splints has been manifested by pain, tenderness, and difficulty with prolonged standing and walking. 2. For the period prior to August 24, 2012, the Veteran's right foot disability was manifested by moderate residual impairment. 3. For the period prior to August 24, 2012, the Veteran's left foot disability was manifested by moderate residual impairment. 4. For the period since August 24, 2012, the Veteran's bilateral foot disability has met the criteria for pronounced bilateral pes planus, due to severe pain, extreme tenderness of the feet, marked pronation, swelling on use, not improved by orthopedic shoes or appliances. 5. Throughout the appeal period, the Veteran's tinea cruris is not shown to have affected at least 5 percent of the entire body, or at least 5 percent of exposed areas, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during a 12-month period. 6. Throughout the appeal period, the Veteran's tinea pedis of the right foot is not shown to have affected at least 5 percent of the entire body, or at least 5 percent of exposed areas, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during a 12-month period. 7. Throughout the appeal period, the Veteran's residuals of boxer's fracture to the right 5th metacarpal has been manifested by discomfort when gripping objects tightly, and pain with weather changes. 8. Throughout the appeal period, the Veteran's onychomycosis of the 2nd and 5th toenails of the right foot has been manifested by thick, discolored nails, and pain. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for fracture of the right tibia with bilateral shin splints have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.56, 4.71a, 4.73, Diagnostic Codes 5262, 5312 (2017). 2. For the period prior to August 24, 2012, the criteria for a rating in excess of 10 percent for right foot disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, Diagnostic Codes 5276, 5284 (2017). 3. For the period prior to August 24, 2012, the criteria for a rating in excess of 10 percent for left foot disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, Diagnostic Codes 5276, 5284 (2017). 4. Since August 24, 2012, the criteria for a 50 percent rating for a bilateral foot disability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, Diagnostic Codes 5276 (2017). 5. The criteria for a compensable rating for tinea cruris are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.118, Diagnostic Codes 7806, 7813 (2017). 6. The criteria for a compensable rating for tinea pedis of the right foot are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.118, Diagnostic Codes 7806, 7813 (2017). 7. The criteria for a compensable rating for residuals of boxer's fracture to the right 5th metacarpal are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.59, 4.71a, Diagnostic Codes 5156, 5227, 5230 (2017). 8. Throughout the appeal period, the criteria for a 10 percent rating, but no higher, for onychomycosis of the 2nd and 5th toenails of the right foot, rated by analogy as a painful scar, has been approximately met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.118, Diagnostic Codes 7804, 7813 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). Fracture of the Right Tibia with Bilateral Shin Splints The Veteran contends that he is entitled to a rating in excess of 10 percent for a right tibia fracture with bilateral shin splints. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Historically, a March 2002 rating decision granted service connection for the Veteran's right tibia fracture, rated 10 percent. The instant claim was filed on September 29, 2009. "Shin splints" refers to nonspecific pain that occurs in the lower legs during running. It has also been defined as a strain of the flexor digitorum longus muscle occurring in athletes, with pain along the shin. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1753 (32nd ed. 2012). The Veteran's right tibia fracture is rated under Diagnostic Codes 5312 and 5262 (for muscle injuries of Group XII (leg and foot) of the musculoskeletal system and impairment of the tibia and fibula). Hyphenated diagnostic codes will be used where a disability is rated on the basis of its residuals. 38 C.F.R. § 4.27. Under Diagnostic Code 5312, a 0 percent rating is given for slight disability. A 10 percent rating is warranted for moderate injury. A 20 percent disability rating is assigned when the disability is moderately severe. A maximum evaluation of 30 percent is in order when the disability is severe. 38 C.F.R. § 4.73, Diagnostic Code 5312. The words "moderate" and "severe" as used in the various diagnostic codes are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Under Diagnostic Code 5262, a 10 percent rating is warranted for malunion with slight knee or ankle disability. A 20 percent rating is warranted for malunion with moderate knee or ankle disability. A 30 percent rating is warranted for malunion with marked knee or ankle disability. A 40 percent rating is warranted for nonunion with loose motion, requiring brace. 38 C.F.R. § 4.71a. At the outset, the Board notes that the Veteran has also established service connection for right and left knee disabilities, which are remanded below for additional development. Accordingly, the Board's analysis of the Veteran's service-connected right tibia fracture with bilateral shin splints will be limited to Diagnostic Codes 5262 and 5312, as the remaining diagnostic codes pertaining to the knee will be considered in the evaluation of his right knee disability in a future decision. At the outset, the Board notes that there is no evidence of malunion or nonunion of the tibia or fibula during any period of the appeal. Accordingly, Diagnostic Code 5262 is not applicable in this case and is of no benefit to the Veteran. During the appeal period, post-service treatment records and VA examination reports show complaints of pain, tenderness, and difficulty with prolonged standing and walking. See, e.g., October 2009 VA bones, feet examinations; August 2012 VA knee and lower leg conditions examination; January 2016 VA knee and lower leg conditions, foot conditions examinations. A record of consistent complaints of muscle pain and/or fatigue is a characteristic of a moderate muscle disability. 38 C.F.R. § 4.56(c), (d)(2). The Board finds that the record contains such consistent complaints throughout the appeal period. As such, the Veteran's right tibia fracture with bilateral shin splints is consistent with the currently assigned 10 percent rating based on the moderate nature of the disability. 38 C.F.R. §§ 4.3, 4.7, 4.56(d)(2), 4.73. There is no evidence of muscle atrophy or other findings to reflect, or approximate, moderately severe impairment so as to warrant an increased (20 percent) rating. 38 C.F.R. § 4.56(d). Right and Left Foot Disabilities The Veteran contends that he is entitled to a rating in excess of 10 percent for his right and left pes planus with hind foot valgus and fasciitis with bunion formation of the first metacarpal phalangeal joint (MP). See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Historically, a March 2002 rating decision granted service connection for the Veteran's right and left foot disabilities, rated 10 percent each. The instant claim was filed on September 29, 2009. The Veteran's right and left foot disabilities are rated under Diagnostic Codes 5276 and 5284 (for pes planus and other foot injuries). Hyphenated diagnostic codes will be used where a disability is rated on the basis of its residuals. 38 C.F.R. § 4.27. Pes planus is rated under Diagnostic Code 5276, which provides that a 10 percent rating is warranted for moderate pes planus evidenced by the weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, or pain on manipulation and use of the feet (bilateral or unilateral). A 30 percent rating is warranted if the disability is manifested by severe pes planus evidenced by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A 50 percent rating is assigned for bilateral pes planus that is pronounced with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. Under Diagnostic Code 5284, a 10 percent rating is warranted for moderate foot injury, a 20 percent rating is warranted for a moderately severe foot injury, and a 30 percent rating is warranted for a severe foot injury. The words "moderate" and "severe" as used in the various diagnostic codes are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. After a review of the evidence of record, for the period prior to August 24, 2012, the Board finds that the preponderance of the evidence is against a finding the Veteran's right and left foot disabilities warrant a rating in excess of 10 percent. On October 2009 VA feet examination, the Veteran's primary complaint was pain of both feet. Physical examination of both feet revealed tenderness to the plantar area and mild valgus angulation. However, there was no evidence of abnormal weight bearing, pronation, midfoot or forefoot malalignment, pain on manipulation, swelling, painful motion, instability, weakness, or other symptomatology to reflect or approximate severe pes planus. The overall functional impairment is not consistent with that of severe pes planus, as manifested by the Veteran's denial of flare-ups, and the mild (except for sports, which was moderate) restriction of daily activities, even with consideration of the criteria indicated in DeLuca v. Brown, 8 Vet. App. 202 (1995). See also Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Consequently, a rating in excess of 10 percent under Diagnostic Code 5276 is not warranted for the period prior to August 24, 2012. As to other Diagnostic Codes for rating the Veteran's right and left foot disabilities, even with consideration of Code 5284, the Board finds that the preponderance of the evidence is against a finding his disabilities warrant a rating in excess of 10 percent. The symptomatology and functional impairment associated with the Veteran's right and left foot disabilities at no point during the period prior to August 24, 2012, were consistent with, or approximated the criteria for an increased (20 percent) rating for moderately severe foot injuries. As noted above, the Veteran's primary complaint was pain, although tenderness to the plantar area and mild valgus angulation were also found on October 2009 VA examination. There is no indication that such symptomatology and physical findings are consistent with or approximate the severity so as to be characterized as moderately severe, and there is no medical evidence to the contrary. Inasmuch as there are no additional diagnostic codes that would be of benefit to the Veteran as they are not applicable in this Veteran's case because there is no evidence of such disabilities (e.g., claw foot, malunion or nonunion of the tarsal or metatarsal bones), there is no need for the Board to consider further alternative schedular criteria. For the period since August 24, 2012, the Board finds that the Veteran's right and left foot disabilities warrant a (maximum) 50 percent rating for pronounced bilateral pes planus, due to a combination of symptoms, including severe pain, marked pronation, pain on use, swelling on use, extreme tenderness of the plantar surfaces of the feet, not improved by orthopedic shoes or appliances. See August 24, 2012 VA pes planus, January 2016 VA foot conditions examinations. Tinea Cruris The Veteran contends that he is entitled to a compensable rating for his tinea cruris. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Initially, it should be noted that tinea cruris is not a listed disability under the Rating Schedule. 38 C.F.R. Part 4. In this case, the RO has rated tinea cruris, by analogy, under 38 C.F.R. § 4.118, Diagnostic Code 7813, for dermatophytosis. Historically, a March 2002 rating decision granted service connection for tinea cruris, rated noncompensable. The instant claim was filed on November 14, 2011. Diagnostic Code 7813 provides ratings for dermatophytosis (or ringworm) in various locations on the body, including the body (tinea corporis), the head (tinea capitis), the feet (tinea pedis), the beard (tinea barbae), the nails (tinea unguium), and the inguinal area, also known as jock itch (tinea cruris). Diagnostic Code 7813 provides that dermatophytosis is to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. 38 C.F.R. § 4.118. Based on the Veteran's symptoms, the Board finds that the Veteran's tinea cruris is properly rated under Diagnostic Code 7806. Diagnostic Code 7806 provides that a noncompensable rating is warranted if less than five percent of the entire body or less than five percent of exposed areas are affected, and; no more than topical therapy was required during the past 12 month period. A 10 percent rating is warranted if at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas are affected, or; if intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12 month period. A 30 percent rating is warranted if 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; if systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12 month period. A 60 percent rating is warranted if more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12 month period. In this case, the Board finds that the preponderance of the evidence is against a finding a compensable rating is warranted for the Veteran's service-connected tinea cruris. The medical evidence during the appeal period fails to show the Veteran's tinea cruris is manifested by at least five percent of the entire body or of exposed areas. In addition, there is no evidence that his tinea cruris has required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. See, e.g., August 2012 VA skin diseases examination (noting no treatment with oral or topical medications in the past 12 months for any skin condition, less than 5 percent of the total body area affected, and 0 percent of the exposed area affected); January 2016 VA skin diseases examination (noting no treatment with oral or topical medications in the past 12 months for any skin condition, less than 5 percent of the total body area affected, and 0 percent of the exposed area affected). In summary, the Board finds no distinct period of time during the appeal period when symptoms of the Veteran's tinea cruris were of, or approximated, such nature and gravity as to warrant an increased compensable rating. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal, and his claim must be denied. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Tinea Pedis Right Foot The Veteran contends that he is entitled to a compensable rating for his tinea pedis of the right foot. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Initially, it should be noted that tinea pedis is not a listed disability under the Rating Schedule. 38 C.F.R. Part 4. In this case, the RO has rated tinea pedis, by analogy, under 38 C.F.R. § 4.118, Diagnostic Code 7813, for dermatophytosis. Historically, a March 2002 rating decision granted service connection for tinea pedis, rated noncompensable. The instant claim was filed on November 14, 2011. Diagnostic Code 7813 provides ratings for dermatophytosis (or ringworm) in various locations on the body, including the body (tinea corporis), the head (tinea capitis), the feet (tinea pedis), the beard (tinea barbae), the nails (tinea unguium), and the inguinal area, also known as jock itch (tinea cruris). Diagnostic Code 7813 provides that dermatophytosis is to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. 38 C.F.R. § 4.118. Based on the Veteran's symptoms, the Board finds that the Veteran's tinea pedis is properly rated under Diagnostic Code 7806. Diagnostic Code 7806 provides that a noncompensable rating is warranted if less than five percent of the entire body or less than five percent of exposed areas are affected, and; no more than topical therapy was required during the past 12 month period. A 10 percent rating is warranted if at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas are affected, or; if intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12 month period. A 30 percent rating is warranted if 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; if systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12 month period. A 60 percent rating is warranted if more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; if constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12 month period. In this case, the Board finds that the preponderance of the evidence is against a finding a compensable rating is warranted for the Veteran's service-connected tinea pedis. The medical evidence during the appeal period fails to show the Veteran's tinea pedis is manifested by at least five percent of the entire body or of exposed areas. In addition, there is no evidence that his tinea pedis has required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. See, e.g., August 2012 VA skin diseases examination (noting no treatment with oral or topical medications in the past 12 months for any skin condition, less than 5 percent of the total body area affected, and 0 percent of the exposed area affected); January 2016 VA skin diseases examination (noting no treatment with oral or topical medications in the past 12 months for any skin condition, less than 5 percent of the total body area affected, and 0 percent of the exposed area affected). While the Board acknowledges that on January 2016 VA skin diseases examination the Veteran exhibited scaling, sloughing skin on the upper half of the bottom of both feet, such symptomatology does not warrant, or approximate, the criteria for a compensable rating for his tinea pedis under any criteria for skin disabilities, to include under Diagnostic Codes 7800 through 7805. In summary, the Board finds no distinct period of time during the appeal period when symptoms of the Veteran's tinea pedis were of, or approximated, such nature and gravity as to warrant an increased compensable rating. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal, and his claim must be denied. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Residuals of Boxer's Fracture to the Right 5th Metacarpal The Veteran contends that he is entitled to a compensable rating for residuals of a boxer's fracture of the right little finger. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board notes that the rating criteria that are applicable to the Veteran's right little finger disability are identify for the major (dominant) extremity and the minor (non-dominant) extremity. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Under Diagnostic Code 5230, limitation of motion of the ring or little finger, any limitation of motion is noncompensable. 38 C.F.R. § 4.71a. Under Diagnostic Code 5227, ankylosis (favorable or unfavorable) of the ring or little finger is noncompensable. 38 C.F.R. § 4.71a. Degenerative or traumatic arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joints involved. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. When, however, the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic codes, a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. For the purpose of rating disabilities from arthritis, major joints include the shoulders and wrists; the interphalangeal, metacarpal and carpal joints of the upper extremities are considered groups of minor joints. 38 C.F.R. § 4.45(f). After reviewing all of the evidence of record, the Board finds that the preponderance of the evidence is against a compensable rating for the Veteran's boxer's fracture of the right little finger. Initially, there is no evidence of any limitation of motion or ankylosis of the right little finger, and, notwithstanding, under the applicable diagnostic criteria, any limitation of motion or ankylosis of the little finger is noncompensable. See August 2012, January 2016 VA hand and finger conditions examinations; 38 C.F.R. § 4.71a, Diagnostic Codes 5227, 5230. Moreover, although 38 C.F.R. § 4.59 and Burton v. Shinseki, 25 Vet. App. 1 (2011), provide that actual painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint, there is no compensable rating for limitation of motion or ankylosis of the little finger. Therefore, application of 38 C.F.R. § 4.59 does not assist the Veteran in this case. See Sowers v. McDonald, 27 Vet. App. 472 (2016). Thus, no compensable rating is available under these criteria. Alternatively, the Veteran's residuals of a boxer's fracture of the right little finger may be evaluated as an amputation under 38 C.F.R. § 4.71a, Diagnostic Code 5156. On both August 2012 and January 2016 VA hand and finger conditions examinations, the examiner found no functional loss or functional impairment of any of the fingers or thumb, and opined that there was no functional impairment such that no effective function remained other than that which would be equally well-served by an amputation with prosthesis. Hence, the Board finds that the Veteran's severity of symptomatology is not sufficient to find the severity of his right little finger disability is equivalent to an amputation. As to rating the Veteran's right little finger disability under any other diagnostic code used to rate finger disabilities and/or as a wrist disability, the Board finds that, given the nature and location of his service-connected disability, it is not ratable under any of the other criteria to rate finger disabilities and/or the wrist because those other criteria do not deal with his right little finger. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.71a, Diagnostic Codes 5215 to 5230; Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of Diagnostic Code should be upheld so long as it is supported by explanation and evidence). In summary, the Board finds no distinct period of time during the appeal period when symptoms of the Veteran's residuals of a boxer's fracture of the right little finger were of, or approximated, such nature and gravity as to warrant an increased compensable rating. The Board acknowledges the Veteran's symptoms of occasional discomfort when gripping objects tightly, and pain with weather changes, but such symptomatology does not warrant or approximate the criteria for a compensable rating for his disability. See August 2012 and January 2016 VA hand and finger conditions examinations. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal, and his claim must be denied. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Onychomycosis of the 2nd and 5th Toenails on the Right Foot The Veteran contends that he is entitled to a compensable rating for his onychomycosis of the 2nd and 5th toenails of the right foot. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Initially, it should be noted that onychomycosis is not a listed disability under the Rating Schedule. 38 C.F.R. Part 4. In this case, the RO has rated onychomycosis, by analogy, under 38 C.F.R. § 4.118, Diagnostic Code 7813, for dermatophytosis. Historically, a March 2002 rating decision granted service connection for onychomycosis of the 2nd and 5th toenails of the right foot, rated noncompensable. The instant claim was filed on November 14, 2011. Diagnostic Code 7813 provides ratings for dermatophytosis (or ringworm) in various locations on the body, including the body (tinea corporis), the head (tinea capitis), the feet (tinea pedis), the beard (tinea barbae), the nails (tinea unguium), and the inguinal area, also known as jock itch (tinea cruris). Diagnostic Code 7813 provides that dermatophytosis is to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. 38 C.F.R. § 4.118. Scars, other than those on the head, face, or neck, are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7801 through 7805. Rating the Veteran's onychomycosis under either Diagnostic Code 7801 or 7802 would be inappropriate in this case as the disability is not shown to be deep (associated with underlying tissue damage) or cause limitation of motion, and it is not shown that it is a superficial scar that encompasses an area of 144 square inches. Hence, these Diagnostic Codes will not be addressed further. A 10 percent rating is authorized for unstable or painful scars. 38 C.F.R. § 4.118, Diagnostic Code 7804. Note (1) following this diagnostic code provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Here, the record reflects that the Veteran's onychomycosis of the 2nd and 5th toenails of the right foot is most appropriately rated by analogy under Diagnostic Code 7804 (for painful scars). The Veteran has reported pain throughout the appeal period, and VA examination reports note that his toenails are thick, discolored, and manifested by cracking and being brittle. See August 2012, January 2016 VA skin diseases examinations. Therefore, based on the Veteran's competent and credible report of painful toenails, along with objective evidence of thick and disfigured toenails, the Board finds that a 10 percent rating is warranted throughout the appeal. In order for the Veteran to satisfy the criteria for a rating in excess of 10 percent, the evidence would need to show that he has three or more painful scars, or that his scar is both unstable and painful. Inasmuch as the Veteran's onychomycosis is rated by analogy to Diagnostic Code 7804, and the toenails as a whole are considered as a single painful scar, and there is no evidence or contention that his onychomycosis is unstable, the Board finds that a rating in excess of 10 percent for the Veteran's onychomycosis, 2nd and 5th toenails of the right foot, is not warranted. ORDER A rating in excess of 10 percent for fracture of the right tibia with bilateral shin splints is denied. For the period prior to August 24, 2012, a rating in excess of 10 percent for right foot disability is denied. For the period prior to August 24, 2012, a rating in excess of 10 percent for left foot disability is denied. Subject to the applicable laws and regulations governing the payment of monetary benefits, effective August 24, 2012, a 50 percent rating for the Veteran's bilateral foot disability is warranted. A compensable rating for tinea cruris is denied. A compensable rating for tinea pedis of the right foot is denied. A compensable rating for residuals of boxer's fracture to the right 5th metacarpal is denied. Subject to the applicable laws and regulations governing the payment of monetary benefits, a 10 percent rating, but no higher, throughout the appeal period for onychomycosis of the 2nd and 5th toenails of the right foot, is warranted. REMAND Regarding the claims for increased ratings for a cervical spine disability, a lumbar spine disability, and a right and left knee disability, the Veteran was most recently afforded VA examinations in January 2016. During these appeals, the United States Court of Appeals for Veterans Claims (Court) made a precedential finding that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158 (2016). In a separate decision, the Court held that before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare-up, the examiner must "elicit relevant information as to the veteran's flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran's functional loss due to flares based on all the evidence of record, including the veteran's lay information, or explain why she could not do so." Sharp v. Shulkin, 29 Vet. App. 26 (2017). In light of these decisions, the Board finds that new VA examinations should be provided regarding the Veteran's claims for increased ratings for a cervical spine disability, a lumbar spine disability, and a right and left knee disability. See Barr v. Nicholson, 21 Vet. App. 21 Vet. App. 303, 312 (2007). Additionally, because the Veteran's TDIU claim is inextricably intertwined with the claims remaining on appeal, appellant consideration of entitlement to TDIU is deferred pending resolution of the remaining claims on appeal. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); see also Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The RO should associate with the claims file updated VA treatment records dated since May 2016. 2. Provide the Veteran an Application for Increased Compensation Based on Unemployability, VA Form 21-8940, and request that he provide information as to his employment since August 2015. 3. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of the nature, extent and severity of his low back, cervical spine and knee symptoms and the impact of the conditions on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. Schedule the Veteran for appropriate VA examination(s) to determine the current nature and severity of his cervical spine, lumbar spine, and right and left knee disabilities. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. All findings should be reported in detail. The examiner should identify all cervical spine, lumbar spine, and right and left knee pathology found to be present. The examiner(s) should conduct all indicated tests and studies, to include range of motion studies. The joints involved should be tested in both active and passive motion, in weight-bearing and nonweight-bearing. If the examiner(s) is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner(s) should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. The examiner should also identify the nature and severity of any right upper extremity, left upper extremity, right lower extremity and/or left lower extremity neuropathy or radiculopathy found to be present. The examiner(s) should also state whether the examiner is taking place during a period of flare-up. If not, the examiner(s) should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or repeated use over time. Based on the Veteran's lay statements and the other evidence of record, the examiner(s) should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner(s) cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner(s) (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 5. Then readjudicate the appeal, to include whether entitlement to TDIU is warranted. If the benefits sought on appeal are not granted in full, the Veteran and his attorney should be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs