Citation Nr: 20037571 Decision Date: 06/02/20 Archive Date: 06/02/20 DOCKET NO. 15-20 892 DATE: June 2, 2020 ORDER Entitlement to an evaluation in excess of 20 percent for left great toe disability with traumatic arthritis & hallux rigidus, prior to February 11, 2020, and in excess of 30 percent thereafter is denied. Entitlement to an evaluation in excess of 20 percent for degenerative joint disease (DJD) of the right thumb and degenerative arthritis of the right index finger, prior to February 11, 2020, and in excess of 30 percent thereafter is denied. FINDINGS OF FACT 1. Prior to February 11, 2020, the Veteran’s left great toe disability is manifested by moderately severe traumatic arthritis and severe hallux rigidus, but neither the lay nor medical evidence reflect functional impairment that more nearly reflects severe impairment at any time during the appeal period. 2. Prior to February 11, 2020, the Veteran’s disability of the right thumb and right index finger is rated at the maximum schedular level; during the appeal period, there has been no functional impairment such that no effective function remained other than that which would be equally well served by an amputation with prosthesis; and right index finger disability has not been more nearly manifested by a gap of 1 inch (2.5 centimeters) between the fingertip and the proximal traverse crease of the palm, with the finger flexed to the extent possible, or extension limited by more than 30 degrees. 3. Since February 11, 2020, the Veteran’s left great toe disability is not shown to be productive of functional impairment to the extent that there is actual loss of use of the foot. 4. Since February 11, 2020, the Veteran’s right thumb and right index finger disability has not been manifested by impairment analogous to amputation. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation in excess of 20 percent for left great toe disability, prior to February 11, 2020 and in excess of 30 percent from February 11, 2020, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.71a, Diagnostic Code 5010-5284. 2. The criteria for a disability evaluation in excess of 20 percent for right thumb and right index finger disability, prior to February 11, 2020 and in excess of 30 percent from February 11, 2020, have not been met. 38 U.S.C. § 1155; 38C.F.R. §§ 4.3, 4.71a, Diagnostic Codes 5003-5228 and 5010-5223. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the U.S. Army from April 1943 to December 1945. He received the Purple Heart, among other decorations, for this service. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in August 2018. The Veteran also had a hearing before a decision review officer in January 2016. A transcript of the hearings is of record. The Veteran’s left foot and right hand increased rating claims were previously denied in a November 2017 Board decision, which the Veteran appealed to the Court of Appeals for Veterans Claims (the Court). In March 2019, the Court set aside the November 2017 Board decision pertaining to the Veteran’s left foot and right hand increased rating claims and remanded such claims to the Board for further adjudication. The Board remanded the issues in November 2019 for further development and a new examination. In a February 2020 rating decision, the RO increased the rating for left foot to 30 percent and for the right hand to 30 percent, both effective from February 11, 2020. The February 2020 rating decision increased the Veteran's disability rating for his right thumb and left toe from 20 percent to 30 percent, effective February 11, 2020. However, because this award amounts to less than the maximum benefit available for the Veteran's service-connected right thumb and left toe disability, less than the period on appeal and because he has not indicated that he is satisfied with a 30 percent disability rating, the Veteran's increased rating claim for his service-connected right thumb and left toe disability remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39-40 (1993). Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. See 38 U.S.C. § 1115; 38 C.F.R. §§ 3.321 (a), 4.1, 4.21. Disability evaluations are based upon the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. § 4.27. VA has a duty to acknowledge and to consider all regulations that are potentially applicable to issues raised in the record and to explain the reasons and bases for its conclusions. See Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. See 38 C.F.R. §§ 3.321 (a), 4.1, 4.21. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. §§ 4.7, 4.21. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. See 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is the primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether they were raised by the Veteran, as well as the entire history of the Veteran's disability. See 38 C.F.R. § 4.1, 4.2; Schafrath,1 Vet. App. at 595. Separate evaluations may be assigned for separate periods of time, or staged, where factual findings show distinct time periods during which the Veteran's disability exhibits symptoms that warrant the application of different ratings. See Fenderson v. West, 12 Vet. App. 119, 126-28 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Additionally, the evaluation of the same disability under several Diagnostic Codes, known as pyramiding, must be avoided. See 38 C.F.R. § 4.14. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. See 38 C.F.R. § 4.40. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. See id. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. See id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. See id. The factors involved in evaluating and rating disabilities of the joints include the following: less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); weakened movement (due to muscle injury, disease, or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination and impaired ability to execute skilled movements smoothly; or pain on movement, swelling, deformity, or atrophy of disuse. See 38 C.F.R. § 4.45. Functional loss caused by pain must be rated at the same level as if that functional loss were caused by some other factor that actually limited motion, such as deformity, atrophy, adhesions, or any of the other factors cited above. See Schafrath, 1 Vet. App. at 592. Consequently, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See id. Where the veteran is diagnosed with any form of arthritis, painful motion is an important factor of disability, and facial expressions such as wincing exhibited in the presence of pressure on or manipulation of the affected joints, should be carefully noted and related to the affected joints. See 38 C.F.R. § 4.59. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. See id. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See id. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. See id. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weightbearing and, if possible, with the range of the opposite undamaged joint. See id. When adjudicating disabilities evaluated based upon limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45, pertaining to functional impairment. See DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). In applying these regulations, VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination. See id. Such inquiry was not to be limited to muscles or nerves, and, if feasible, these determinations were to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. See id. Consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis; thus, a rating based on painful motion of a joint may be appropriate regardless of whether the painful motion stemmed from joint or periarticular pathology. See Burton v. Shinseki, 25 Vet. App. 1, 4-5 (2011). However, pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination and endurance to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Although pain may cause functional loss, pain itself does not constitute functional loss and is merely one factor to be considered when evaluating functional impairment. See id. However, 38 C.F.R. § 4.40 does not require a separate rating for pain, but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194, 196 (1997). Once the evidence has been assembled in the record, it is the Board's responsibility to evaluate the evidence. See 38 U.S.C. § 7104 (a). The Board shall consider all lay and medical evidence of record, analyze the credibility and probative value of the evidence, and provide reasons for rejecting any material evidence favorable to the claimant. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In addressing lay evidence and determining its probative value, the Board must assess both its competency, a legal concept determining whether testimony may be heard and considered, and credibility, a factual determination regarding the probative value of the evidence. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall afford the claimant the benefit of the doubt. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. Where the evidence is in relative equipoise, the claimant shall prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). The preponderance of the evidence must weigh against the Veteran's claim in order for it to be denied. See Alemany v. Brown, 9 Vet. App. 518, 519-20 (1996). 1. Entitlement to an evaluation in excess of 20 percent for left great toe disability with traumatic arthritis & hallux rigidus, prior to February 11, 2020, and in excess of 30 percent thereafter. The Veteran's left foot disability is currently evaluated as 30 percent disabling under Diagnostic Code 38 C.F.R. § 4.71a, Diagnostic Code 5010-5284, since February 11, 2020. Previously, his left foot disability was evaluated as 20 percent since December 12, 2007. The Veteran filed an increase rating claim for his left foot in September 2013. Diagnostic Codes 5003 and 5010 provide that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Codes 5003 and 5010 provide a 20 percent rating for degenerative arthritis with X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Pursuant to Diagnostic Code 5284, a general rating for "other foot injuries" a severe foot injury warrants a 30 percent rating. A 40 percent disability evaluation will be assigned for actual loss of use of foot. Words such as "moderate" and "severe" 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. Regulations indicate that "loss of use of the foot" exists when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the knee with the use of a suitable prosthetic appliance. 38 C.F.R. § 4.63. This determination will be made on the basis of the actual remaining function of the foot, whether the acts of balance and propulsion, etc., could be accomplished equally well by an amputation stump with prosthesis. Id. The Veteran asserts that the rating does not accurately depict the severity of his condition. Prior to February 11, 2020 As mentioned above the Veteran’s left foot disability was rated at 20 percent since December 12, 2007. An increase from a 10 percent was granted based on evidence showing that the Veteran received injections for pain and inflammation, use of orthotics, limitation of walking and X-ray evidence of continued severe degeneration of his joints. VA treatment records show several podiatry notes where the Veteran has complained about foot pain during the period on appeal, such as in March 2013, July 2013, October 2013, August 2014, November 2014, February 2015, April 2015. The Veteran’s visits to the podiatry unit seems to have been primarily for nail debridement as he claimed he has difficulty trimming his toenail himself. Left foot X-rays from May 2011 show severe degenerative changes of the first metatarsal phalangeal joint with bony proliferative change and severe remodeling of the metatarsal head unchanged since prior exam. No fracture, dislocation, or radiopaque foreign body is seen. Severe atherosclerotic vascular calcifications of the dorsalis pedis. Alignment appears normal. No significant calcaneal spur formation is visible. VA treatment records show that in January 2013 the Veteran reported pain in the left first MTPJ and the weather makes it worse, He has tried injections, padding and inserts without relief, stated the bump is getting bigger and denied any other pedal complaints or pain. On examination, the physician noted “minimal ROM bilaterally, 1st MPJ, pt compensating with HIPJ dorsiflexion. No pain with ROM. Large medial osteophytes left 1st MTPJ that is painful with palpation.” A March 2013 orthopedic note shows that the Veteran reported that he walks a couple of miles per day, if the left foot will allow him to, he does not use any ambulation aids, and he plays a little golf. In a November 2014 statement, the Veteran claimed that his left foot has worsened, hurts constantly and the joint has grown considerably. An April 2014 VA examination reflects a diagnosis for residuals of a fractured left great toe diagnosed as moderately severe traumatic arthritis and hallux rigidus as a progression of the left great toe fracture and traumatic arthritis. Clinical findings showed severe symptoms of hallux rigidus “with function equivalent to amputation of great toe” and moderately severe traumatic arthritis of the left great toe. The examiner indicated that, due to the Veteran’s foot condition, there was not functional impairment of the lower extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The examiner described the functional impact of the condition as: “Employment tasks requiring walking and prolonged standing are limited by this condition.” Pain, weakness, fatigability, or incoordination could significantly limit functional ability either during flare-ups or when the joint is used repeatedly over a period of time. The examiner noted that limitation of range of motion cannot be estimated; however, loss of function during flare-ups or when the joint is used repeatedly over a period of time would occur with prolonged walking and prolonged standing. The Veteran did not exhibit Morton’s neuroma, hammer toe, hallux valgus, claw foot (pes cavus), malunion or nonunion of the tarsal/metatarsal bones, or bilateral weak foot. The examiner noted the Veteran’s hallux rigidus have severe symptoms. During a January 2016 hearing before a decision review officer, the appellant testified that he had constant pain in his left foot that is worst during bad weather and that he can’t bend any toes. In a December 2017 VA examination for the hips, the Veteran reported that he has constant soreness of the left foot and uses 6 Tylenol daily to ease the pain in the thumb, hip and foot. He also stated that for recreational activity, he and his wife walk one mile each night, that he was a tournament-level handball player until a few months ago and also used to enjoy golfing. At his Board hearing in August 2018, the Veteran reported his left foot have gotten worse. “I’ve got a big lump on one side right after the toe and I have no movement in that foot.” Podiatry note from April 2019 shows that the Veteran reported numbness and pain in his left foot and takes 2-4 Tylenol a day for the pain. After reviewing the relevant medical and lay evidence and applying the above laws and regulation, the Board finds that an evaluation in excess of 20 percent prior to February 11, 2020 for the left foot disability is not warranted. The objective medical evidence of record shows that the Veteran left foot, great toe disability in April 2014 showed severe symptoms of hallux rigidus “with function equivalent to amputation of great toe” and moderately severe traumatic arthritis of the left great toe and there was not functional impairment of the lower extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The record does not reflect that any VA examiner or healthcare provider has previously characterized the Veteran's left foot disability as severe. While the hallux valgus of the toe was equivalent to amputation, such a finding would warrant a 10 percent rating under Diagnostic Code 5281-5280. There is nothing in the record that suggests the overall disability of the foot would be similar to loss of use or amputation of the foot. Rather the same 2014 examiner concluded that the overall foot disability was “moderately severe.” Characterizations by healthcare providers are not dispositive, but they are probative evidence that the Board may take into consideration. Therefore, the Board finds that the Veteran is not entitled to a disability rating in excess of 20 percent for his left great toe disability prior to February 11, 2020. The Board has considered whether the Veteran's disability warrants a higher or separate rating under another diagnostic code. The evidence of record does not show that the Veteran has a separate and distinct diagnosed disability of the foot that is contemplated under the other foot diagnostic codes that would warrant a separate or higher rating. In reaching this decision, the Board has considered the Veteran's lay statements, and notes that he is competent to report his own observations with regard to the severity of his disability. See Jandreau, 492 F.3d 1372; Layno, 6 Vet. App. at 469-71. In this case the Veteran has stated his left toe disability results in pain and limitations on foot movement. For the period on appeal, however, the Veteran's lay statements do not indicate severity of symptomology that is more closely approximated by a 30 percent disability rating. Here, the specific examination findings of trained health care professionals are of greater probative weight than the Veteran’s more general lay assertions. As the preponderance of the evidence is against a finding that the Veteran's left toe disability more nearly approximates the criteria for a higher rating, a higher rating is not warranted. 38 C.F.R. §§ 4.3, 4.7, 4.71a. Since February 11, 2020 As mentioned above, the record reflects that the Veteran’s left foot has been rated at 30 percent disabling from February 11, 2020 under the provisions of Diagnostic Code 5010-5284. In February 2020, the Veteran was afforded a VA examination. The examiner diagnosed residuals of a fractured left great toe diagnosed as severe traumatic arthritis and hallux rigidus and ankylosis of all toes left foot as a progression of the left great toe fracture and traumatic arthritis and hallux rigidus and traumatic arthritis. Clinical findings showed severe symptoms of hallux rigidus “with function equivalent to amputation of great toe” and moderately severe traumatic arthritis of the left great toe. The examiner noted that there is notable pain with pain bearing and notable balance disturbance with weight bearing secondary to the previous left foot condition. The Veteran reported that he has pain in the foot all the time, that the pain is a dull ache and he can’t move the toes on his left foot any longer. The examiner noted that he uses shoe inserts with an improvement of left foot pain. The Veteran reported flare ups described as “sometimes, my foot hurts so much I can’t walk.” He reported 4 flare ups annually lasting 24 hours. He described his functional loss as “no walking than maybe one block at the most. I sued to walk a mile a day but no longer. My foot hurts too much.” The examiner remarked that all toes on left foot are ankylosed, inability to flex or extend all toes on the left foot and that this is a progression of the Veteran's previous left foot great toe fracture with severe traumatic arthritis and hallux rigidus and traumatic arthritis. The condition was noted as severe, chronically compromise weight bearing and requires custom orthotics that are worn with significant improvement of left foot symptoms which are wholly due to and a progression of his previous service-connected left foot condition. The examiner noted the following contributory factors of disability: less movement than normal due to ankylosis, weakened movement, excess fatigability, pain on movement, pain on weight bearing, pain in non-weight bearing, deformity, instability of station, disturbance of locomotion, interference with standing and lack of endurance. There are no contributing factors of disability associated with limitation of motion. The examiner described the Veteran’s functional impact of the condition as: “functional impact for all high impact activities, walking longer than 100 yards, prolonged standing, walking at incline, stair climbing, ladder climbing. Sedentary activity is possible.” The Veteran did not exhibit Morton’s neuroma, hammer toe, hallux valgus, claw foot (pes cavus), malunion or nonunion of the tarsal/metatarsal bones, or bilateral weak foot. The examiner indicated that, due to the Veteran’s foot condition, there was not functional impairment of the lower extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. As noted above, in order to warrant a disability rating higher than the maximum 30 percent rating under Diagnostic Code 5284, the evidence would need to show that there is "actual loss of use of the foot." With consideration of the evidence above, a disability rating higher than 30 percent for a left foot disability is not warranted. Specifically, the medical and lay evidence does not demonstrate that the Veteran's left foot disability is productive of functional impairment to the extent that there is actual loss of use, which, for VA purposes, is defined as having no remaining effective function other than that which would be equally well served by an amputation stump at the site of election below the knee with use of a suitable prosthetic appliance. Although he experiences severe and constant pain, he has retained the ability to stand for short periods of time, to walk for short distances, and to otherwise retain some ability to use the foot. See 38 C.F.R. § 4.63. In addition, the evidence of record does not reflect that the Veteran has suffered from any of the following: extremely unfavorable ankylosis of the knee; complete ankylosis of two major joints of an extremity; shortening of the lower extremity of 3.5 inches or more; or complete paralysis of the external popliteal nerve and consequent footdrop. See id. The Board has considered whether other potentially applicable diagnostic codes allow for a separate compensable and/or increased rating for the Veteran's left foot symptoms. However, none of the other diagnostic codes for foot disabilities contained in 38 C.F.R. § 4.71a are applicable here. These diagnostic codes are organized specifically by the type of symptoms involved in each disability. Here, the medical evidence reflects that the Veteran has complained of pain and tenderness in his left foot, but he is able to ambulate. Accordingly, as the Veteran's left foot disability does not result in total loss of the foot, a higher rating is not applicable in this case. From February 11, 2020, a rating higher than 30 percent for the left foot disability is denied. 2. Entitlement to an evaluation in excess of 20 percent for degenerative joint disease (DJD) of the right thumb and degenerative arthritis of the right index finger, prior to February 11, 2020, and in excess of 30 percent thereafter. The Veteran contends that his service-connected right thumb disability is entitled to a disability rating in excess of 20 percent, prior to February 11, 2020. The Veteran has reported constant pain of the right thumb and has asserted that he takes four to six extra strength Tylenol tables every day to ease the pain in his finger. See June 2018 Amended Informal Brief. Disabilities of the hand and thumb are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5224 and 5228. For rating purposes, no distinction is made between major (dominant) and minor (non-dominant) musculoskeletal groups. See id.; see also 38 C.F.R. § 4.69. For the index, long, ring, and little fingers (digits II, III, IV, and V), zero degrees of flexion represents the fingers fully extended, making a straight line with the rest of the hand. The position of function of the hand is with the wrist dorsiflexed 20 to 30 degrees, the metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints flexed to 30 degrees, and the thumb (digit I) abducted and rotated so that the thumb pad faces the finger pads. Only joints in these positions are considered to be in favorable position. For digits II through V, the MP joint has a range of zero to 90 degrees of flexion, the PIP joint has a range of zero to 100 degrees of flexion, and the distal (terminal) interphalangeal (DIP) joint has a range of zero to 70 or 80 degrees of flexion. See 38 C.F.R. § 4.71a, DCs 5216-5230, Note (1). When two or more digits of the same hand are affected by any combination of amputation, ankylosis, or limitation of motion that is not otherwise specified in the rating schedule, the evaluation level assigned will be that which best represents the overall disability (i.e., amputation, unfavorable or favorable ankylosis, or limitation of motion), assigning the higher level of evaluation when the level of disability is equally balanced between one level and the next higher level. See 38 C.F.R. § 4.71a, DCs 5216-5230, Note (2). For evaluation of ankylosis of the index, long, ring, and little fingers, if both the MP and PIP joints of a digit are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone, evaluate as amputation without metacarpal resection, at PIP joint or proximal thereto. If both the MP and PIP joints of a digit are ankylosed, evaluate as unfavorable ankylosis, even if each joint is individually fixed in a favorable position. If only the MP or PIP joint is ankylosed, and there is a gap of more than two inches (5.1 centimeters) between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible, evaluate as unfavorable ankylosis. If only the MP or PIP joint is ankylosed, and there is a gap of two inches (5.1 centimeters) or less between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible, evaluate as favorable ankylosis. See 38 C.F.R. § 4.71, DCs 5216-5230, Note 3. For evaluation of ankylosis of the thumb, if both the carpometacarpal (CMC) and interphalangeal joints are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone, evaluate as amputation at the metacarpophalangeal (MCM) joint or through the proximal phalanx. If both the CMC and interphalangeal joints are ankylosed, evaluate as unfavorable ankylosis, even if each joint is individually fixed in a favorable position. If only the CMC or interphalangeal joint is ankylosed, and there is a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, evaluate as unfavorable ankylosis. If only the CMC or interphalangeal joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, evaluate as favorable ankylosis. See 38 C.F.R. § 4.71, DCs 5216-5230, Note 4. If there is limitation of motion of two or more digits, evaluate each digit separately and combine the evaluations. See 38 C.F.R. § 4.71, DCs 5216-5230, Note 5. Under DC 5219, a 40 percent evaluation is warranted for unfavorable ankylosis of the thumb and any finger. Under DC 5223, a 30 percent evaluation is warranted for favorable ankylosis of the thumb and any finger. Under DC 5224, a 10 percent evaluation is warranted for favorable ankylosis of the thumb, and a 20 percent evaluation is warranted for unfavorable ankylosis of the thumb. With ankylosis, consideration is also given to whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with the overall function of the hand. See Note to 38 C.F.R. § 4.71a, DCs 5223, 5224. Diagnostic Code 5224 may also be used to evaluate the thumb where there is evidence of ankylosis and provides as follows: (1) a 20 percent rating is warranted where there is evidence of unfavorable ankylosis; and (2) a 10 percent rating is warranted where there is evidence of favorable ankylosis. See id. The Note to Diagnostic Code 5224 also requires two additional evaluations: (a) whether amputation is warranted; and (b) whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. Diagnostic Code 5228 evaluates the limitation of motion of the thumb and provides as follows: (1) a zero percent rating is warranted where there is a gap of less than one inch (2.5 centimeters) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers; (2) a 10 percent rating is warranted where there is a gap of one to two inches (2.5 centimeters to 5.1 centimeters) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers; and (3) a 20 percent rating is warranted where there is a gap of more than two inches (5.1 centimeters) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. See 38 C.F.R. § 4.71a. Degenerative arthritis must be established by X-ray findings and is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. See id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. See id. In the absence of limitation of motion, X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, will warrant a 20 percent rating. See id. X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups will warrant a 10 percent rating. See id. The 10 percent and 20 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 1. The assignment of a particular diagnostic code depends upon the facts of each particular case, and the Board is authorized to choose an appropriate diagnostic code that is supported by both the evidence of record and a sufficiently articulated rationale. See Butts v. Brown, 5 Vet. App. 532, 538-39 (1993). In this case, as stated above, the Veteran's service-connected right thumb disability is currently rated at 30 percent disabled from February 11, 2020 under Diagnostic Code 5010-5223 for arthritis and favorable ankylosis of thumb and any finger. Previously, in a June 2011 rating decision the Veteran was service connected for DJD of the right thumb and degenerative arthritis of the right finger and was rated at 10 percent disabled under Diagnostic Code 5003-5228 for limitation of motion, effective from February 16, 2001. In September 30, 2013, VA received a claim for increase. A June 2014 rating decision assigned a 20 percent evaluation effective from September 30, 2013 (date of claim). The RO issued a rating decision in February 2020 that granted 30 percent rating for degenerative joint disease, right thumb and degenerative arthritis, right index finger (claimed as right hand) based on favorable ankylosis of two digits of one hand (thumb and index finger), from February 11, 2020. For the reasons set forth below, the Board finds that a preponderance of the evidence of record weighs against an increased rating in excess of 20 percent, prior to February 11, 2020 and in excess of 30 percent, thereafter. Prior to February 11, 2020 Turning to the evidence relevant to the rating period on appeal, VA progress notes show several treatments for the Veteran’s right thumb. In August 2013, the Veteran reported pain in the right thumb and requested a joint injection. The physician noted that the right thumb demonstrates some mild tenderness to palpation of the distal interphalangeal joint. Imaging demonstrates that there is moderate arthritis of this joint and was assessed with DJD of DIP joint of right thumb. In December 2013 the Veteran was assessed with right thumb pain secondary to arthritis. In April 2014 the Veteran was afforded a VA hand and finger examination. The diagnosis was right hand DJD, right thumb and degenerative arthritis. The Veteran reported he has had worsening pain and decreased ROM on the right hand. He also indicated he was right handed and described being treated with anti-inflammatory medications without relief. He denied flare-ups during this examination. There was limitation of motion. There was no gap between thumb pad and fingers; gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips; no limitation of extension or evidence of painful motion for the index finger or long finger. Repetition did not result in additional limitation of motion. Functional loss of right thumb was described as consisting of having less movement than normal, weakened movement, pain in movement, deformity and decreased flexion of the right thumb MCP to 20 degrees. The Veteran had 4/5 hand grip strength, active movement against some resistance. He reported no use of a brace. The examiner noted carpometacarpal and interphalangeal joint ankylosis of the right thumb in extension. The ankylosis was noted not to limit motion of other digits or interfere with overall function of the hand. No functional impairment was noted. X-rays show findings of degenerative or traumatic arthritis in right thumb only. The examiner described the functional impact of the Veteran’s right thumb condition as employment tasks requiring using hand tools, gripping, grasping small objects with right hand are limited by this condition. In December 2017 the Veteran reported that he has recreational activities that includes tournament level handball player and golf. See December 2017 VA DBQ for hips. The Veteran has stated that his thumb has gotten worse and the pain drives along the bone where the shrapnel entered. He reported pain of 5/10. He also reported that the cortisone injections received has been ineffective. After careful review of the evidence of record, the Board finds that the preponderance of the evidence is against an evaluation in excess of 20 percent for the right thumb disability. The Veteran is rated at the maximum schedular level for disability of the right thumb and right index finger under Diagnostic Code 5228, and neither the lay nor the medical evidence, during this period on appeal, reflects that there is remaining function in the extremity such that no effective function remained other than that which would be equally well served by amputation with prosthesis. During this period, ankylosis has only been demonstrated in one finger, the right thumb in extension and was noted to limit motion of other digits or interfere with overall function of the hand. Therefore, 20 percent was the maximum rating for ankylosis or limitation of motion of individual digits. Consideration has also been given to the potential application of the other diagnostic codes for disabilities of the thumb; however, the Board finds no basis upon which to assign increased or additional ratings for the Veteran's right thumb disability at any point during the period before February 11, 2020, as the Veteran has never been found to have unfavorable ankylosis of multiple digits until the February 2020 VA examination. See 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5219. In addition, the evidence of record does not indicate that the amputation of the Veteran's right thumb would be warranted in this case, that other digits on the right hand manifest abnormal limitation of motion, or that there is any interference with the overall function of the right hand. See 38 C.F.R. § 4.71a, Diagnostic Code 5224, Note. Accordingly, and for the foregoing reasons, the Board finds that, for the entire period on appeal, a preponderance of the evidence of record weighs against a finding that the Veteran's right thumb disability is entitled to a disability rating in excess of 20 percent; therefore, the benefit of the doubt doctrine does not apply in this case, and the Veteran's increased rating claim prior to February 11, 2020, must be denied. See Gilbert, 1 Vet. App. at 53-54. Since February 11, 2020 The Veteran's right thumb disability has been assigned a 30 percent rating effective February 11, 2020 pursuant to DC 5010-5223. 38 C.F.R. § 4.71a, DC 5223. DC 5223 addresses favorable ankylosis of two digits of one hand. When the index and middle fingers are involved, a 20 percent disability rating is assigned. A 30 percent evaluation is assigned when there is favorable ankylosis of the thumb and any other finger. 38 C.F.R. § 4.71a. The most recent VA examination was afforded in February 2020. The examiner noted diagnoses of DJD right thumb and index finger, ankylosis of the right thumb IP joint, noted as a progression of the Veteran’s right thumb condition, and DJD, right thumb and degenerative arthritis, right index finger, ankylosis of the right index finger MCP joint with rotation of bone, also noted as a progression of the Veteran’s right thumb condition. Currently, the Veteran reports chronic pain in the right thumb and index finger. "I can't bend my thumb joint all the way. My index finger is stuck bent." Current treatment is Tylenol 3000 mg daily. His pain is aggravated by overuse and cold weather. He denied flare-ups during this examination. Functional loss of right thumb was described by the Veteran as “[n]o prolonged lifting, gripping, carrying. No handwriting. I can't play handball any longer.” On examination, the right hand was noted to be abnormal or outside of normal range. The index finger had maximum extension to 0 degrees (MCP), and to 30 degrees (PIP and DIP joint). Maximum flexion was to 30 degrees (MCP, PIP and DIP), long, ring and little fingers all had maximum extension to 0 degrees (MCP, PIP and DIP) and maximum flexion to 90 degrees (MCP) to 100 degrees (PIP) and to 70 degrees (DIP). The right thumb had a maximum extension to 0 degrees (MCP, IP) and maximum flexion to 15 degrees (MCP) and to 0 degrees (IP). There was a no gap between the pad of the thumb and the fingers. There was a 2 cm. gap (index finger) between the finger and proximal transverse crease of the hand on maximal finger flexion. The ROM itself contribute to functional loss for gripping, squeezing, handwriting, fine motor motions requiring dexterity of index and thumb fingers. Pain on finger flexion, finger extension, opposition with thumb was noted on exam causing functional loss. There is evidence of pain using the hand and objective evidence of localized tenderness on palpation of the joint described as “extreme joint TTP over MCP thumb joint and index finger joint is noted on current hand exam.” The left hand is normal. The Veteran was able to perform repetitive use testing, following which there was no additional functional loss of loss of range of motion. Pain, fatigue, weakness, and lack of endurance were factors that cause functional loss with repeated use over a period of time. In terms of ROM index finger had a maximum extension to o degrees (MCP, PIP) 30 degrees (DIP), and maximum flexion to 0 (MCP, PIP) 30 degrees (DIP). The thumb had a maximum extension and flexion to 0 degrees (MCP, IP). There is no gap between the pad of the thumb and the fingers. There is a gap of 2 cm. (index finger) and 0 cm (long finger) between the finger and proximal transverse crease of the hand on maximal finger flexion. There was less movement than normal due to ankylosis, adhesions, etc. described as ankylosis right thumb IP joint and ankylosis right index finger PIP/DIP joint. Right hand grip strength was 4/5. There was no muscle atrophy. There was ankylosis of the IP joints of the right thumb and ankylosis of the MCP and PIP of the index finger at 30 degrees flexion. The VA examiner indicated that the functioning of the Veteran's fingers was not so diminished that amputation with prosthesis would equally serve the Veteran. The Veteran right hand thumb and index finger ankylosis was noted to have difficulties involving gripping, fine motor motions such as writing, lifting, squeezing. He reported no use of a brace. After a review of all of the evidence of record, lay and medical, the Board finds that the weight of the evidence is against a disability rating in excess of 30 percent for the right thumb and index finger disability for the entire increased rating period on appeal. 38 C.F.R. § 4.71a. In the February 2020 VA examination, ankylosis has been demonstrated in the right thumb and index finger. However, the current 30 percent disability rating under DC 5223 contemplates the overall symptomology experienced by the Veteran, and adequately compensates the Veteran for the painful motion and limited function of the thumb and index fingers, including following repetitive use, as well as his flare-ups and weakened hand grip strength. Consideration has also been given to the potential application of the other diagnostic codes for disabilities of the thumb; however, the Board finds no basis upon which to assign increased or additional ratings for the Veteran's right thumb and index finger disability at any point during the period after February 11, 2020, as the Veteran has never been found to have unfavorable ankylosis. See 38 C.F.R. § 4.71a, Diagnostic Code 5219. In addition, the evidence of record does not indicate that the amputation of the Veteran's right thumb would be warranted in this case, that there is a gap of more than two inches (5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A higher evaluation in excess of 30 percent for a thumb and index finger disability requires amputation. See 38 C.F.R. § 4.71a, DCs 5155, 5156. With ankylosis, consideration must also be given to whether an additional evaluation is warranted for resulting limitation of motion of other digits or for interference with overall function of the hand. See Note following DC 5227. In order for ankylosis to be rated as amputation, the condition must manifest with extremely unfavorable ankylosis. See Note (3)(i) preceding 38 C.F.R. § 4.71a, DC 5216. In other words, in order to be evaluated as amputation, there must be ankylosis of both the metacarpophalangeal and proximal interphalangeal joints either in extension or full flexion or with rotation or angulation of a bone. Id. Note (3)(ii) explains that, if both the metacarpophalangeal and proximal interphalangeal joints of a digit were ankylosed, it should be evaluated as unfavorable ankylosis even if each joint was individually fixed in a favorable position. Note (3)(iii) indicates that if only the metacarpophalangeal or proximal interphalangeal joint were ankylosed and there was a gap of more than 2 inches (5.1 cm.) between the fingertips and the proximal transverse crease of the palm, with the fingers flexed to the extent possible, the condition should be evaluated as unfavorable ankylosis. Amputation of the index finger warrant a 10 percent rating without metacarpal resection at the proximal interphalangeal joint, or proximal thereto. A 20 percent rating is warranted with full metacarpal resection (more than one-half the bone lost). 38 C.F.R. § 4.71a, DCs 5155, 5156. The Board has considered the ankylosis of the index finger with both the MCP and IP joints ankylosed. An evaluation as amputation without metacarpal resection, at proximal interphalangeal joint or proximal thereto warrants a 20 percent rating. The ankylosis of the right thumb with only IP joint ankylosed with a gap of two inches (5.1 cm) or less between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, requires an evaluation as favorable ankylosis. The thumb and any finger warrant a 30 percent rating. Accordingly, and for the foregoing reasons, the Board finds that, for the entire period on appeal, a preponderance of the evidence of record weighs against a finding that the Veteran's right thumb and index finger disability is entitled to a disability rating in excess of 30 percent; therefore, the benefit of the doubt doctrine does not apply in this case, and the Veteran's increased rating claim must be denied. See Gilbert, 1 Vet. App. at 53-54. Extraschedular Consideration The Board has considered whether an extraschedular evaluation is warranted for the Veteran's left foot and right hand disabilities. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, 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. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321 (b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairments caused by the Veteran's left foot and right hand disabilities, including pain, limited motion, painful motion, tenderness, swelling, and numbness, are contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran has not expressly raised the matter of entitlement to an extraschedular rating. His contentions have been limited to those discussed above, i.e., that his left foot and right hand disabilities are more severe than is reflected by the assigned ratings. As was explained in the merits decision above in denying higher ratings, the criteria for higher schedular ratings were considered, but the ratings assigned were upheld because the rating criteria are adequate. In view of the circumstances, the Board finds that the rating schedule is adequate, even in regard to the collective and combined effect of all of the Veteran's service-connected disabilities, and that referral for extraschedular consideration is not warranted under the circumstances of this case. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Romero-Sanchez, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.