Citation Nr: 21015069 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 14-36 364 DATE: March 16, 2021 ORDER Entitlement to an effective date earlier than April 29, 2014 for the assignment of a 10 percent rating for degenerative joint disease of the right hand, to include the ring finger and thumb, is denied. Entitlement to an initial compensable rating for degenerative joint disease of the right hand, to include the ring finger and thumb, prior to April 29, 2014 is denied. Entitlement to a 20 percent rating, but no higher, for degenerative joint disease of the right hand, to include the ring finger and thumb, from to April 29, 2014 is granted. Entitlement to a total disability rating based on individual unemployability (TDIU), to include on an extraschedular basis, is denied. FINDINGS OF FACT 1. The Veteran has continuously prosecuted his claim since the date he first filed for service connection in February 2011; there is no probative evidence that supports a 10 percent rating at any time prior to April 29, 2014 for his right-hand disability, to include the ring finger and thumb. 2. Prior to April 29, 2014, the Veteran’s right-hand disability, to include his right ring finger and thumb, was manifested by right ring finger limitation of motion, pain, weakness, and cramping. 3. For the period from April 29, 2014, the Veteran’s degenerative joint disease of the right hand, to include ring finger and thumb, was manifested by a gap of one to two inches between the thumb pad and the fingers on the right, with an additional loss of 1 inch when opposing thumb or during finger flexion due to pain on use or during flare-ups. 4. The Veteran does not meet the schedular criteria for TDIU, and he is not precluded from securing and following substantially gainful employment due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to April 29, 2014, for the award of a 10 percent disability rating for degenerative joint disease of the right hand, to include the ring finger and thumb, have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.114(a), 3.400. 2. The criteria for an initial compensable rating for degenerative joint disease of the right hand, to include ring finger and thumb, prior to April 29, 2014 have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71, Diagnostic Code 5010-5228, 5230. 3. The criteria for a 20 percent rating, but no higher, from April 29, 2014 for degenerative joint disease of the right hand, to include the ring finger and thumb, have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71, Diagnostic Codes 5010-5228. 4. The criteria for entitlement to a rating of total disability based on individual unemployability (TDIU), to include on an extraschedular basis, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1984 to April 1986. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an October 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. In June 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript is of record. In October 2019, the Board remanded these issues for further development. Specifically, the Board instructed that, after verifying the Veteran’s mailing address, the Veteran should be provided VA Forms 21-8940 and 21-4192, as well as a 38 U.S.C. § 5103(a)-compliant notice letter pertaining to his TDIU claim. Additionally, any outstanding VA and private treatment records should be obtained, and the Veteran should be afforded a VA examination to ascertain the current severity of the service-connected right hand DJD, including an opinion addressing the impact of the Veteran’s service-connected right hand disabilities on his employability. Finally, after further developing the Veteran’s right-hand disability claim, if the schedular criteria for a TDIU are not met, the Board instructed that the claim should be referred to the Director of Compensation Services for consideration of assignment of a TDIU on an extraschedular basis. In a December 2019 correspondence, the Veteran verified his current mailing address and indicated that all of his medical treatment had been through VA. Additional VA treatment records, dated through November 2020, have been obtained and associated with the claims file. The requested VA Form 21-8940 has been received, and a 38 U.S.C.§5103(a)-compliant notice letter was sent to the Veteran in December 2019. Regarding the VA Form 21-4192, VA attempted to request employment information from the Veteran’s former employer; however, this information was unavailable. The Veteran was then afforded the requested VA examination in October 2020, which included an opinion regarding the effect of his right-hand disability on his ability to work. Finally, the case was referred to the Director of Compensation Services, and in January 2021, an advisory opinion was rendered, and a Supplemental Statement of the Case was issued thereafter, addressing each issue on appeal. Thus, the Board finds that there has been substantial compliance with the October 2019 remand. Stegall v. West, 11 Vet. App. 268 (1998). This appeal has been advanced on the Board’s docket pursuant to 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.900(c). Increased Rating Determining an appropriate effective date for an increased rating involves an analysis of the evidence to determine (1) when a claim for an increased rating was received and, if possible (2) when the increase in disability actually occurred. 38 C.F.R. §§ 3.155, 3.400(o)(2); see also Hazan v. Gober, 10 Vet. App. 511 (1997). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. See also 38 U.S.C. § 1155. 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. 38 C.F.R. § 4.21. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly 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. §§ 4.3, 4.7. The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1995). VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Earlier effective date and increased rating for degenerative joint disease of the right hand, to include ring finger and thumb (formerly evaluated as broken right hand to include ring finger and thumb) The Veteran was awarded service connection for his broken right hand, to include his right ring finger and thumb, effective February 18, 2011; at this time, his disability was rated as noncompensable pursuant to Diagnostic Code 5299-5230. The Veteran filed a timely notice of disagreement with the rating assigned, and, in a September 2014 rating decision, he was awarded a 10 percent disability rating for degenerative joint disease of the right hand (previously evaluated as broken right hand to include right ring finger and thumb condition under code 5299-5230), effective April 29, 2014 pursuant to Diagnostic Code 5010-5228. Following the issuance of a statement of the case (SOC), the Veteran filed a timely substantive appeal to the Board. The Board finds that the Veteran has continuously prosecuted his claim since the date he first filed for service connection in February 2011. As noted above, the effective date of a rating is established by the date the Veteran’s claim for increased rating was received, or the date in which the disability rose to the level in which the increased rating is based, whichever is later. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). If later evidence indicates that the degree of disability increased or decreased following the assignment of the rating, staged ratings may be assigned for separate periods of time. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). Here, as the Veteran has continuously prosecuted his claim since the date that he first filed for service connection in February 2011, the question is whether the Veteran’s disability rose to the level of severity as to warrant a 10 percent rating at any time prior to April 29, 2014. As the issue of whether an increased rating is warranted at any time throughout the period on appeal for degenerative joint disease of the right hand, to include ring finger and thumb, is also on appeal, the Board will address both of these issues together below. Although not on appeal, the September 2014 rating decision awarded service connection for muscle Group VII injury to right hand, assigning a 30 percent evaluation effective April 29, 2014 for moderately severe muscle impairment, and peripheral neuropathy of the right upper extremity, assigning a 10 percent evaluation effective April 29, 2014 for mild, incomplete paralysis of the median nerve. As these issues are not currently before the Board, the Board will not address whether higher ratings are warranted for any symptoms associated with his right-hand muscle injury or peripheral neuropathy. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes “to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities.” Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran’s claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, Diagnostic Code 5010 provided that arthritis, due to trauma, substantiated by X-ray findings, should be rated as degenerative arthritis, instructing that the rating should be based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5010 (2018). Pertinent to the application of Diagnostic Code 5010 under the pre-amended regulations, the pre-amended Diagnostic Code 5003 for degenerative arthritis provides that when limitation of motion due to arthritis is noncompensable under the appropriate diagnostic code, a rating of 10 percent 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. In the absence of limitation of motion, Diagnostic Code 5003 provides for a 10 percent rating with x-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent rating under Diagnostic Code 5003 requires involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5010 (2018). As of February 7, 2021, under the amended criteria, Diagnostic Code 5010, changes the title of the regulation to posttraumatic arthritis, distinguishing between joint conditions arising from traumatic causes and joint conditions resulting from systemic processes, and instructs that the disability should be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are two or more joints affected, each rating shall be combined in accordance with § 4.25. 85 Fed. Reg. 76453, 76454 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5010. Diagnostic Code 5228 remains unchanged, however. Under the General Rating Formula, under Diagnostic Code 5228, a noncompensable disability evaluation is assigned for limitation of motion of the thumb with a gap of less than one inch (2.5 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 10 percent disability evaluation is assigned for a gap of one to two inches (2.5 to 5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 20 percent disability evaluation is assigned for a gap of more than two inches (5.1 cm) between the thumb and fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, DC 5228. Also relevant, Diagnostic Code 5230 provides the assignment of a noncompensable disability rating for any limitation of motion of the ring and little finger, which has not been affected by the recent amendments. 38 C.F.R. § 4.71a, DC 5230. A June 2011 SSA evaluation notes that the Veteran had no evidence of joint deformity in his hands. His finger approximation was intact; he was able to make a fist and oppose the thumbs; his hand could be fully extended. He did have some mild bilateral finger tenderness. An associated SSA Physical Residual Functional Capacity Assessment notes, in pertinent part, that the Veteran was able to occasionally lift and carry 50 pounds; frequently lift and carry 25 pounds; was unlimited in his ability to push or pull. There was no manipulative limitation, including reaching and fine and gross manipulation. In an August 2011 correspondence, the Veteran reported radiating pain and numbness, trouble grasping, and trouble making a fist due to his right-hand disability. A September 2011 VA examination notes that the Veteran fractured the 4th metacarpa1 of right hand in service. He had a current diagnosis of healed fracture with osteophyte and 4th right finger strain. He received no further treatment for this condition. He was currently a crane operator and felt pain from the right 4th metacarpa1 to the wrist to the elbow. The Veteran reported that he was right hand dominant, and he had a decrease in right hand strength. He denied experiencing flare-ups, and there was no limitation of motion or objective evidence of pain on active range of motion. There was no objective evidence of pain or additional functional loss following repetitive motion. The examination notes that the Veteran did not have decreased strength for pushing, pulling, or twisting, and there was no decreased dexterity for twisting, probing, writing, touching, and expression. The examination report indicates that the Veteran had been unemployed for the last one to two years, which the Veteran attributed to back pain and diabetes. Upon physical examination, the examiner noted a normal examination apart from slightly decreased strength of the right 4th finger; there was no elbow or wrist tenderness. The examiner indicated only a moderate impact on his ability to do chores, but there was no other impact on his activities of daily living. A June 2012 medical consultation performed at the request of the Department of Social Services indicates that the Veteran complained of severe numbness and tingling in his bilateral hands and feet. He additionally reported that his right hand sometimes got “struck” and he had to use his other hand to open his right hand. Physical examination revealed a reduced grip strength in the right, and flexion of the “MCE” joints was noted as 60/90 degrees on the right, with decreased flexion of the PIP and DIP joints, without specifically identifying which fingers were affected. The report notes that he had pain and decreased range of motion in the right wrist and suffered some kind of nerve damage. In pertinent part, the provider opined that the Veteran was limited in his ability to push, pull, lift, or carry 50 pounds occasionally and 25 pounds frequently. A July 2012 VA treatment record notes that the Veteran complained of right ring finger locking, and right-hand numbness and tingling. In April 2014, the Veteran reported that he was right hand dominant but had to use his left hand to eat. He reported impairment in his ability to work as a crane operator, since he could not grasp the crane levers necessary to perform his job. He reported that he was unable to firmly grip a steering wheel while driving due to his right-hand injury. He also experienced pain in the right hand that radiated to his right arm. An April 2014 VA examination notes a diagnosis of degenerative joint disease of the right hand, which was a progression of his service-connected disability. The Veteran reported that his disability had worsened as his right arm muscles weakened and he had poor coordinating skills. The Veteran endorsed flare-ups of his right-hand disability described as difficulty holding and handling. The examination revealed limitation of motion or evidence of painful motion for the right thumb and right ring finger. There was a gap of one to two inches between the thumb pad and the fingers on the right; pain began at the same. There was also a gap of one inch or more between the ring finger and the proximal transverse crease of the palm, and evidence of painful motion in attempting to touch the palm with the ring finger fingertip at a gap of less than one inch. The Veteran declined repetitive testing due to severe pain. The Veteran had functional loss or functional impairment of the ring finger and thumb in the form of less movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. He additionally had swelling and deformity of the right ring finger, and atrophy of disuse in all right-hand fingers and thumb. Pain, weakness, fatigability, and incoordination limit functional ability during flare-ups or when the joint is used repeatedly over time, which the examiner described as additional loss of 1 inch when opposing thumb or during finger flexion due to pain on use or during flare-ups. He had tenderness or pain to palpation for joints or soft tissue of the right hand. His right-hand grip strength was noted as 3/5, noted as overall poor strength. No ankylosis was noted. The examiner indicated that, due to his right-hand disability, the Veteran had limitations with prolonged handling, gripping, grasping, holding, carrying, and pinching; the Veteran could perform his activities of daily living except from the referenced limitations. A January 2019 x-ray of the right hand revealed mild humeral ulnar joint osteoarthritis. An assessment notes loss of sensation in the fourth and fifth digits of right hand, acute, with likely nerve involvement due to placement of acupuncture needles. Also, mild osteoarthritis of the humeral ulnar joint, chronic. Recent imaging did not have alarming findings. An April 2019 VA treatment record notes that the Veteran sought treatment for numbness of the right fourth and fifth digits. The Veteran reported that he was disposing of drywall while working construction and developed numbness in the right fourth and fifth digits that started about three to four weeks ago. He reported that he had been dropping items from his hands recently. Examination revealed normal bilateral upper extremity muscle strength, except that right finger abduction was noted as 4/5. A nerve conduction study revealed electrodiagnostic evidence of right moderate median sensorimotor mononeuropathy at the wrist of demyelinating nature and a subclinical left moderate median sensorimotor mononeuropathy at the wrist of demyelinating nature, consistent with right carpal tunnel syndrome and subclinical left carpal tunnel syndrome. The provider indicated that, given the Veteran’s history of uncontrolled diabetes and electrodiagnostic study, there is likely peripheral polyneuropathy underlying his bilateral median and right ulnar mononeuropathies. A January 2020 private evaluation notes review of the Veteran’s VA treatment records and a telephone interview; an in-person examination was not conducted. The Veteran reported that he had constant pain and numbness in the right hand and indicated that he could barely use it. He reported that he was unable to use a knife or type because of the weakness, numbness, and pain of the right hand. The Veteran indicated that he was able to move his hand but it was painful; his pinky finger was numb; he indicated that he could not use his pinky, ring, or middle fingers and he had limited range of motion and weakness in his wrist. The evaluation notes that the Veteran reported working for three or four years after service as a pipe fitter, requiring constant grasping of tools; he indicated that he was laid off. He was also a crane operator for 10 years but because of his right-hand injury, he was not able to operate it very well and was laid off. He has not worked since 2014. The provider indicted that he sustained a fracture of his fourth metacarpal as well as the base of his proximal fourth phalanx resulting in deformity of the fourth right metacarpal with subsequent right carpal tunnel syndrome as well as right ulnar neuropathy complicated by peripheral neuropathy of the median and ulnar nerve. As a result of these injuries, the Veteran had severe lack of use of the right hand between the deformity of his hand with limited range of motion as well as his nerve entrapment of the median and ulnar nerve of the right hand. An October 2020 VA examination notes a diagnosis of right-hand degenerative arthritis. The Veteran reported that his current symptoms were pain and tightness radiating up and down the right arm to the fingers, making carrying groceries, opening doors, and doing normal daily activities difficult. The Veteran endorsed experiencing flare-ups of his right hand, occurring two to three times per week, manifested by moderate pain lasting a couple of days. He indicated that his flare-ups are precipitated by performing normal activities of daily living and were alleviated by hot showers. He indicated that he had functional impairment manifested by loss of grip, impacting all activities of daily living. Upon physical examination, the Veteran’s range of motion was noted as normal on the right; there was no gap between the pad of the thumb and the fingers or between the finger and proximal transverse crease of the hand on maximal finger flexion. No pain was noted on examination, but there was mild tenderness or pain on palpation along the fourth and fifth metacarpal joint. No additional functional loss or range of motion was noted after three repetitions. With repeated use over time or during flare-ups, the examiner indicated that the Veteran’s range of motion remained largely unchanged, except that flexion of his ring and little finger MCP, PIP, and DIP measurements were noted as 80 degrees, a loss of 10 degrees, as a result of pain and fatigue. No additional contributing factors were indicated. No muscle atrophy or ankylosis was noted, and there was no functional impairment such that no effective function remained other than that which would be equally well served by amputation with prosthesis. Due to his right-hand disability, the examiner indicated that the Veteran was unable to use right hand to write, use tools, hold objects more than a piece of paper; however, being sedentary is not affected. After a review of the evidence, the Board finds that a higher rating is not warranted for the Veteran’s broken right hand, including his ring finger and thumb, prior to April 29, 2014 pursuant to Diagnostic Code 5299-5230. The Board finds that the Veteran’s broken right hand, to include his ring finger and thumb, has been assigned the appropriate rating for limitation of motion of the ring finger, with pain, weakness, and cramping. In making this determination, the Board notes that 38 C.F.R. § 4.59 provides that actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. However, there is no compensable rating for limitation of motion of the ring finger under DC 5230. As explained by the United States Court of Appeals for Veterans Claims (CAVC) in Sowers v. McDonald, 27 Vet. App. 472, 480 (2016), “[r]eading § 4.59 in conjunction with [Diagnostic Code] 5230” would not result in a compensable rating, as “there is no minimum compensable rating available under [Diagnostic Code] 5230, that is, any level of disability warrants a [noncompensable] rating.” Hence, “[b]ecause no impairment of motion warrants a compensable rating under [Diagnostic Code] 5230, reading § 4.59 in conjunction with [Diagnostic Code] 5230, [the Veteran] is not entitled to a compensable rating under” this Diagnostic Code. Id. Therefore, a compensable rating is not warranted for loss of range of motion of the ring finger. Furthermore, the Board finds that a higher rating is not warranted pursuant to Diagnostic Code 5228 at any time prior to April 29, 2014. As noted above, Diagnostic Code 5228 addresses limitation of motion of thumb. However, there is no evidence of any pain or limitation of motion of the thumb at any time during this period. In this regard, the Board has considered the June 2012 SSA consultation which reflects complaints of pain, cramping or sticking of his right hand, and notes limited range of motion of the finger joints. However, there is no indication at any time during this period that the Veteran had a gap of one to two inches (2.5 to 5.1 cm), or greater, between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, or that he otherwise complained of thumb pain. Indeed, the only medical evidence during this period mentioning the Veteran’s thumb is the April 2011 record, which notes that the Veteran was able to make a fist and oppose the thumbs. See 38 C.F.R. §§ 4.71a, 4.59. Therefore, the Board finds that a compensable rating is not warranted under DC 5228. Moreover, the Board notes that there was no finding of arthritis in the Veteran’s right hand, including the ring finger or thumb, prior to April 29, 2014. As noted above, during this period, Diagnostic Code 5010 provided that arthritis, due to trauma, substantiated by X-ray findings, should be rated as degenerative arthritis. Diagnostic Code 5003 rates degenerative arthritis and provides that degenerative arthritis 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 (e.g., DCs 5228 to 5230), provided the limitation of motion is compensable; however, when limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic codes, DC 5003 provides that a rating of 10 percent is for application for each such major joint or two or more minor joint groups affected by limitation of motion. 38 C.F.R. § 4.71a. Here, arthritis was not found in the Veteran’s fingers or joints in the hand itself at any time prior to April 29, 2014. Therefore, the weight of the evidence is against finding that the service-connected right-hand disability, to include the ring finger and thumb, warrants consideration for a rating under DCs 5003 or 5010. Id. The Board has additionally reviewed other diagnostic codes to determine if the Veteran may be entitled to a compensable disability rating pursuant to other schedular criteria during this period. Diagnostic Code 5229 is not for application because there is no evidence indicating that the Veteran experienced impairment of his index or long fingers. Although the Board acknowledges that the June 2012 SSA consultation record notes limitation of motion of the finger joints, as noted above, there is no indication which fingers were affected. Thus, the Bard does not find that this record is probative evidence of limited range of motion of the index or long fingers. Diagnostic Code 5227 addresses ankylosis of the individual digits. However, there is no evidence of record that the Veteran had ankylosis in any of his fingers. A note following DC 5227 allows for consideration as to whether an 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. Although the evidence demonstrates that the his right hand finger had limited range of motion and that his right hand had decreased grip strength, pain, and sometimes got “stuck”, the evidence does not demonstrate that the disability manifested functional impairment such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. In this regard, although the Veteran reported trouble grasping and making a fist, the medical evidence reflects that the Veteran was able to make a fist, and while there was some limitation of range of motion and decreased strength, there was no manipulative limitation, including reaching and fine and gross manipulation. The Board finds that this medical evidence outweighs the assertions of the Veteran regarding the severity of his disability. Therefore, DC 5227 is not for application. 38 C.F.R. § 4.71a. The Board recognizes the Veteran’s reports of numbness, tingling, and weakness during this period, as well as the Veteran’s contention that he had peripheral neuropathy and muscle injury symptoms in his right hand since the date that he initially filed his claim for a right hand disability in 2011, well before the date that those disabilities were service connected in 2014. However, the Veteran was awarded service connection for his right-hand muscle injury and peripheral neuropathy as secondary to his degenerative joint disease of the right hand in a September 2014 rating decision, and, as noted above, these issues are not currently on appeal. To the extent that the Veteran believes that an earlier effective date or higher rating is warranted for these disabilities, he is free to file such a claim with his local Regional Office. Therefore, based on the foregoing, the Board finds that the Veteran’s right-hand disability, to include his right ring finger and thumb, is most consistent with a noncompensable rating evaluation for the period prior to April 29, 2014. Thus, the preponderance of the evidence is against the claim for entitlement to a rating in excess of zero percent for the Veteran’s right-hand disability, to include his ring finger and thumb, for the period prior to April 29, 2014. 38 C.F.R. § 4.71a, DC 5230. Additionally, the Board finds that April 29, 2014 is the earliest evidence of record demonstrating a worsening of the Veteran’s service-connected disability. In this regard, the April 29, 2014 VA examiner found that the Veteran had a diagnosis of degenerative joint disease of the right hand, which was a progression of his service-connected disability, with right thumb limitation of motion. As noted above, the evidence prior to April 29, 2014 reveals symptoms that more closely approximate a noncompensable evaluation for the Veteran’s service-connected right-hand disability, to include the ring finger and thumb. Accordingly, the Board finds that the evidence does demonstrate worsening right-hand symptoms warranting an increased evaluation occurred prior to April 29, 2014, and an effective date prior to April 29, 2014 for the award of a 10 percent disability rating is not warranted. Turning to whether an increased evaluation is warranted for the period from April 29, 2014, the Board finds that a rating of 20 percent is warranted for this period. In this regard, the Board notes that although the evidence reflects that the Veteran had a gap of one to two inches between the thumb pad and the fingers on the right, which is consistent with a 10 percent disability rating, the April 2014 VA examiner indicated that with flare-ups or when the joint is used repeatedly over time, the Veteran had an additional loss of 1 inch when opposing thumb or during finger flexion due to pain on use or during flare-ups, which the Board finds more closely approximates a 20 percent disability rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5228; see also DeLuca, 8 Vet. App. at 202-06. While the Board recognizes that the October 2020 VA examination seems to suggest improvement in the Veteran’s disability, affording the Veteran the benefit of the doubt, the Board finds that a 20 percent disability rating is warranted throughout the period from April 29, 2014. 38 C.F.R. § 4.71a, DC 5228. The Board has considered whether a higher evaluation was warranted under a different diagnostic code, as a 20 percent rating represents the maximum statutory rating for the subject disability under DC 5228. Under Diagnostic Code 5003 and 5010, a 10 percent evaluation is the highest possible evaluation for the Veteran’s right-hand disability, as the right-hand joint is a single major joint; thus, a higher rating is not available under these diagnostic codes. Further, a rating under DC 5229 is not warranted as the weight of the probative evidence does not indicate that the Veteran had limited range of motion of the index or long fingers. Although the Board acknowledges that the Veteran has reported impairment of his right-hand long finger, the Board notes that no clinician has indicated that the Veteran experienced any functional impairment of the long finger. Indeed, neither VA examiner indicated that the Veteran experienced any limitation of motion or functional loss, to include with repetitive use and/or during flare-ups, of the right long finger, and treatment records only note complaints or treatment of the fourth and fifth fingers. The Board finds the probative value of the Veteran’s statements regarding his long finger impairment is outweighed by the medical evidence of record. Thus, a rating under DC 5229 is not warranted. In this case, a higher rating would only be applicable if the Veteran’s disability warranted amputation or could be evaluated consistent with amputation under 38 C.F.R. § 4.71a. However, the record does not indicate that amputation of his right hand or any right hand fingers was warranted or suggested at any time during the period on appeal or that the symptomology of the Veteran’s right hand disability, to include his ring finger and thumb, would allow evaluation consistent with amputation. Similarly, the record does not indicate that an additional evaluation is warranted for interference with the overall function of the hand during this time. In this regard, the Board acknowledges that the January 2020 private evaluation notes that the Veteran reported that he could barely use his right hand. The provider indicated that the Veteran had severe lack of use of his right hand due to his right-hand disability and nonservice-connected carpal tunnel syndrome on the right. The Board has considered this private evaluation and affords the evaluation minimal probative value. Specifically, this was not an in-person examination, and thus, no testing was performed to determine range of motion of his hand and fingers, and the January 2020 assessment regarding functional impairment appears to be based, in part, on a nonservice-connected disability. The April 2014 and October 2020 VA examinations were based on in-person evaluations and considered only the Veteran’s service-connected right-hand degenerative arthritis. The Board affords more probative value to the findings noted in the VA examinations which indicate that, while limited, the Veteran was not completely unable to use his right hand or that his right hand was useless such that amputation with prosthesis would equally serve the Veteran. 38 C.F.R. § 4.71a, Diagnostic Code 5125. Moreover, there is no indication that the Veteran had ankylosis, and therefore, ratings under DCs 5216 through 5227 are not applicable. Specifically, as noted above, there is no evidence that the Veteran’s right hand or fingers are in a fixed position and cannot be moved. Rather, the evidence throughout the period on appeal reveals only decreased range of motion affecting his ability to perform certain activities, which does not support a finding that his right-hand disability, including the ring finger and thumb, more closely approximates ankylosis of the right hand or fingers. Nevertheless, the Board has considered the Veteran’s statements that he was unable to use his pinky, ring, or middle fingers on his right hand. As noted above, the Board finds that the weight of the probative evidence does not establish that the Veteran had impairment of the long finger associated with his service-connected right-hand disability, and while the Veteran experienced weakness and decreased range of motion of the ring finger and little finger, the evidence does not reflect that he was unable to use these digits. However, even if the Veteran was unable to use the ring and little finger of his right hand because they were in a fixed position, the Board notes that the highest rating available under DC 5223 for favorable ankylosis of the ring and little finger of the dominant or nondominant hand is 10 percent; as such, a higher rating is not available for his right hand disability pursuant to the DCs for ankylosis. 38 C.F.R. § 4.71a, DC 5216-5227. To the extent that the Veteran also experienced symptoms of muscle weakness, tingling, and numbness, these symptoms are already accounted for under DCs 5307 and 8515. Assigning other ratings based on the same symptoms that are already accounted for would be tantamount to pyramiding. 38 C.F.R. § 4.14. Furthermore, although the record reflects that the Veteran may also have carpal tunnel syndrome, the Veteran is not service connected for carpal tunnel syndrome. Additionally, since the Veteran has been awarded the maximum schedular rating for his right-hand disability for limitation of motion of the right thumb, entitlement to an extraschedular rating is for consideration. The Board finds, however, that a referral for extraschedular evaluation of his disability is not warranted. Although the Veteran has reported an increase in right hand pain, limited motion of his ring finger and thumb, and difficulty gripping, grasping, and holding objects, there is no indication from the record that this symptomatology has restricted his range of motion or functional abilities to the point that the schedular criteria are inadequate to describe the severity of the disability. The Board finds that the Veteran’s currently assigned 20 percent disability rating contemplates his right hand, to include his ring finger and thumb, symptoms of pain, limitation of motion, and functional ability, to include his difficulty gripping or holding objects. These symptoms only allow for a maximum 20 percent evaluation under the available diagnostic codes absent a showing of amputation or the functional equivalent of amputation of the right thumb. Furthermore, the evidence does not present such unusual or exceptional circumstances which would render the schedular criteria inadequate. In this regard, the Veteran has not described experiencing any exceptional or unusual features of his right hand, to include his ring finger and thumb, disability, and there is no objective evidence of any such manifestations. Accordingly, the Board finds that referral for extraschedular consideration of a higher rating is not warranted. See 38 C.F.R. § 3.321(b)(1); Thun v. Peake, 22 Vet. App. 111, 115-116 (2008). Finally, the Board has also considered the Veteran’s right hand degenerative joint disease, to include the ring finger and thumb, under the revised rating criteria effective February 7, 2021. However, as noted above, the only pertinent changes made were with regard to Diagnostic Code 5010, and there is no evidence suggesting that the Veteran had dislocation or other specified instability under the affected joint. As such, the amended criteria do not provide a more favorable rating. The Board has considered the Veteran’s statements regarding his right hand and finger symptoms. The Veteran is competent to report symptoms, such as pain and decreased motion, because these symptoms require only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disability has been provided by the VA examiners who examined the Veteran during the current appeal and who rendered pertinent findings in conjunction with the evaluations. The medical findings directly address the criteria under which the disability is evaluated. As such, to the extent that the Veteran believes that his hand disability is worse than currently reflected in the assigned ratings, the Board finds that this medical evidence outweighs the assertions of the Veteran. In summary, the Board finds that preponderance of the competent and credible evidence supports a rating of 20 percent, but no higher, for right hand degenerative joint disease, to include the ring finger and thumb, for the period from April 29, 2014. 38 C.F.R. § 4.71a, DC 5228. Entitlement to a TDIU, to include on an extraschedular basis The Veteran seeks entitlement to a TDIU based on extraschedular consideration under 38 C.F.R. § 4.16(b). Specifically, the Veteran contends that he was no longer able to work as a crane operator because he could not grasp the crane levers necessary to perform his job. Total disability ratings for compensation may be assigned where the schedular rating is less than total and when the veteran is unable to secure or follow a “substantially gainful” occupation (i.e. work which is more than marginal, that permits the individual to earn a “living wage,” 38 C.F.R. § 4.16(b); Moore v. Derwinski, 1 Vet. App. 356 (1991), as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Under VA regulations, when a claimant fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), the RO may submit such case to the Director, Compensation and Pension Service (“Director”), for extraschedular consideration. 38 C.F.R. § 4.16(b). The Board may not grant a total rating in the first instance, and when there has been a review by the Director, that determination is subject to review by the Board on appeal. See Floyd, 9 Vet. App. at 95; Anderson, 22 Vet. App. at 277-28. At no point during the period on appeal does the Veteran meet the minimal schedular criteria for a TDIU. 38 C.F.R. § 4.16(a). However, since he submitted statements alleging that he was unemployable due to his service-connected right hand, to include records from the Social Security Administration (SSA) showing the award of disability benefits, his claim was referred to the Director for consideration. The Director provided an administrative decision in January 2021. This decision denied entitlement to TDIU on an extraschedular basis. Since the Director has denied entitlement to a TDIU on an extraschedular basis in the first instance, the Board now has the authority to consider, and if appropriate, award TDIU on an extraschedular basis for this period. Entitlement to TDIU requires the presence of an impairment so severe that it precludes the average person from following a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In April 2011, the Veteran filed for SSA disability, indicating that that he was disabled due to chronic low back pain and spinal pain; pain in the bilateral knees and feet; problems standing for long periods; headaches; bilateral hand and feet cramps; lumbar sprain; and diabetes. His application indicates that he worked as a construction worker or crane operator from 1987 to December 2009; he stopped working in December 2009 due to his “conditions.” He reported that he completed one year of college education, and he completed specialized job training in landscaping, crane operating, and truck driving. An SSA mental examination notes that the Veteran reported that he stopped working in March 2011 as a crane operator because he could not pass the physical examination due to high blood pressure. A June 2011 SSA evaluation notes that the Veteran had no evidence of joint deformity in his hands. His finger approximation was intact; he was able to make a fist and oppose the thumbs; his hand could be fully extended. An associated SSA Physical Residual Functional Capacity Assessment notes, in pertinent part, that the Veteran was able to occasionally lift and carry 50 pounds; frequently lift and carry 25 pounds; was unlimited in his ability to push or pull. There was no manipulative limitation, including reaching and fine and gross manipulation. The September 2011 VA examiner found that the Veteran did not have decreased strength for pushing, pulling, or twisting, and there was no decreased dexterity for twisting, probing, writing, touching, and expression. The examination report indicates that the Veteran had been unemployed for the last one to two years, which the Veteran attributed to back pain and diabetes. Upon physical examination, the examiner noted a normal examination apart from slightly decreased strength of the right fourth finger. The examiner indicated only a moderate impact on his ability to do chores, but there was no other impact on his activities of daily living. The April 2014 VA examiner indicated that, due to his right-hand degenerative joint disease, neuropathy, and muscle injury, the Veteran had limitations with prolonged handling, gripping, grasping, holding, carrying, and pinching; the Veteran could perform his activities of daily living except from the referenced limitations. A June 2018 VA mental health record notes that the Veteran had medical issues, including high blood pressure and diabetes, and was unable to work at this time due to his inability to get medical clearance to work as a crane operator. At his June 2018 Board hearing, the Veteran’s representative indicated that the Veteran was right hand dominant and used his right hand to control the crane, and due to the severe pain and the nature of the disability he incurred in the service, he was unable to continue with his job. After making numerous mistakes, he was fired from his job. He was unable to find another job even though that was his specialty and where he was specifically trained to work as a crane operator. The Veteran reported that he re-injured his right hand at work, and since then, his employer no longer trusted his ability to operate the crane and he was let go. A July 2018 Rehabilitation Needs Inventory indicates that the Veteran worked as a crane operator from 1989 to 2013. He reported that he left this position due to medical reasons. The Veteran indicated that he had a high school education. SSA records, received in December 2019, indicate that the Veteran was determined to be disabled due to diabetic neuropathy since December 2009. The SSA decision indicates that the Veteran had severe impairment due to chronic lumbar pain, upper and lower extremity pain, poorly controlled non-insulin dependent diabetes mellitus with peripheral neuropathy and retinopathy, and mental impairments due to depressive disorder and posttraumatic stress disorder. The decision further notes that, due to peripheral neuropathy of the upper and lower extremities, the Veteran was able to lift and carry 10 pounds occasionally; the ability to stand and walk 10 minutes at a time less than two hours per day; and the ability to sit 30 minutes a time but less than 6 hours per day. The ability to use his hands for fine and gross manipulation is less than occasional secondary to decreased grip strength and range of motion of the bilateral upper extremities. In February 2019, VA records reflect that the Veteran sought assistance finding a job from VA’s Vocational Rehabilitation Services. The Veteran reported that he worked from 1987 to 2012 as a crane operator. He also worked for two years in security in the 1980s, eight years driving in the 1980s and 1990s, and six years in a warehouse in the 1990s. The record notes that the Veteran last worked in 2012, except that he worked for one week in 2014 as a crane operator but had to cease work due to hand neuropathy. He indicated that he was available to work full time, with moderate physical labor. The assessment notes that the Veteran had a consistent, complete work history, however, injury related to work caused the Veteran to have to leave his career field, which had caused a seven-year absence from the competitive workspace ever since that time. The Veteran had a fairly decent skill set, with some areas of skill, knowledge, and experience in the construction and refinery trades; his competitive skill set is, however, offset by injury and medication to treat his injuries. He had a history of chronic homelessness and experiences pre-vocational barriers (e.g. clothing, transportation, training, etc.). The Veteran also experienced significant medical issues, which the Veteran states was having an especially impactful effect on his mental health as it pertains to his ability to re-enter his chosen/preferred career choice (crane operator). April 2019 VA records note that the Veteran was completing paperwork to begin a worksite assignment through VA Vocational Rehabilitation Service’s Compensated Work Therapy (CWT)-Transitional Work (TW) program. However, before he was permitted to begin his work placement, he needed to complete the required paperwork and enroll in mental health services. In a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, received by VA in November 2019, the Veteran reported that he last worked full time in 2011 as a crane operator, and his broken hand and depression prevented him from working. He reported that he completed one year of college education. The January 2020 private evaluation, as noted above, indicates that the Veteran sustained a fracture of his fourth metacarpal as well as the base of his proximal fourth phalanx resulting in deformity of the fourth right metacarpal with subsequent right carpal tunnel syndrome as well as right ulnar neuropathy complicated by peripheral neuropathy of the median and ulnar nerve. The provider opined that the Veteran would be unable to perform the jobs that he was trained to do and has done, which includes a crane operator and pipe repairman, as these jobs require manual dexterity and the use of tools. It was the provider’s opinion that the Veteran’s hand disabilities would render him unable to perform these work duties due to his lack of strength, limitation of movement, and lack of sensation. As noted above an October 2020 VA examination notes that the Veteran reported that his current symptoms were pain and tightness radiating up and down the right arm to the fingers, making carrying groceries, opening doors, and doing normal daily activities difficult. He indicated that he had functional impairment manifested by loss of grip, impacting all activities of daily living. Due to his right-hand disabilities, the examiner indicated that the Veteran was unable to use his right hand to write, use tools, or hold objects more than a piece of paper. The Board notes that, for a Veteran to prevail on a claim for TDIU on an extraschedular basis, it is necessary that the record reflect some factor which places the case in a different category than other Veterans with an equal rating of disability. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The pertinent question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. Id. This is because a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The Board does not find that the record demonstrates the Veteran is precluded from securing or following substantially gainful employment solely by reason of his service-connected disabilities or that he is incapable of performing the mental and physical acts required by employment due solely to his service-connected disorders, even when his disabilities are assessed in the context of subjective factors such as his occupational background and level of education. While the Veteran has said he can no longer work, these statements must be weighed against the objective medical evidence of record. The Board notes a TDIU rating is not warranted where a veteran is unable to continue a chosen profession but, as already noted, the determinative question for purposes of TDIU is whether the Veteran’s level of disability, given his education, training, and experience, renders it impossible for the average person to obtain or retain substantially gainful employment of some type. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Simply stated, while perhaps the Veteran cannot work in his prior job or even in his prior vocation, the question is whether he can, in fact, work. This finding can, unfortunately, not take into consideration the Veteran’s age or his nonservice-connected disabilities. At the outset, the Board acknowledges that the Veteran contends, and the evidence supports, that he has functional impairment or other limitations that impact his ability to work. However, the weight of the probative evidence indicates that his functional impairment is due to, not only his service-connected right-hand disabilities, but also numerous nonservice-connected disorders. In this regard, the Board notes that the record reflects that the Veteran has reported that he was no longer able to work due to his right hand disability; depression; back pain; pain in the bilateral knees and feet; problems standing for long periods; headaches; bilateral hand and feet cramps; and diabetes. He further indicated that he was unable to find employment because he was unable to pass a medical clearance/physical due to high blood pressure and/or diabetes. Moreover, SSA found that the Veteran was disabled due to diabetic neuropathy, noting that the Veteran had severe impairment due to chronic lumbar pain, upper and lower extremity pain, poorly controlled non-insulin dependent diabetes mellitus with peripheral neuropathy and retinopathy, and mental impairments due to depressive disorder and posttraumatic stress disorder. However, of these noted disabilities, the only disabilities for which service connection is in effect are those related to his right hand, specifically, right hand degenerative joint disease, right hand muscle injury, and right upper extremity peripheral neuropathy; he is not service connected for these other mentioned disabilities. Although the January 2020 private evaluator opined that the Veteran would be unable to work due to his right upper extremity impairment, the evaluator’s opinion did not indicate that the Veteran was precluded from all forms of employment due to his disabilities. Rather, the opinion was specific to the jobs he had trained to do or the jobs he had done, such as a pipe fitter and crane operator. Additionally, as noted above, this private opinion appears to have considered the Veteran’s nonservice-connected carpal tunnel syndrome. Thus, to the extent that the evaluator provided an opinion regarding the Veteran’s employability, the Board affords this opinion minimal probative value and finds that it is outweighed by the remaining evidence of record. The weight of the probative evidence does not reflect that the Veteran’s right hand degenerative joint disease, neuropathy, or muscle injury render him unable to work. To the extent that the medical evidence of record, including the VA examinations, address functional impairment due to the right hand, the Board notes that there is no probative medical opinion of record indicating that the Veteran was unable to work due to solely his service-connected disabilities, and the Board does not find that these limitations would prevent all forms of employment. The record reflects that the Veteran has had specialized training in landscaping, truck driving, and crane operating, and while his physical limitations may prevent his ability to engage in the same or similar employment to his previous work, there is no probative evidence of record indicating that the Veteran would be unable to secure and maintain work consistent with his education and occupational background. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In this regard, the Board acknowledges that the Veteran’s right-hand disabilities result in difficulty with gripping, grasping holding, carrying, and pinching. However, the Board finds that these symptoms have been adequately considered under his currently assigned disability ratings. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1. Although the Board recognizes that the Veteran believes that his service-connected disabilities have rendered him unable to work, as noted above, the Veteran’s description of his service-connected disabilities must be considered in conjunction with the clinical evidence of record, as well as the pertinent rating criteria. Here, after considering the evidence of record, both lay and medical, the Board finds that the preponderance of the competent and credible evidence does not reflect that the Veteran is unable to secure or follow substantially gainful employment due solely to his service-connected disabilities. The Board is sympathetic to the Veteran’s physical limitations, and acknowledges that the Veteran’s service connected disabilities will cause him problems, and may cause him not to be able to function in some jobs; however, this fact, in and of itself, does not provide the basis to grant this case. Based on the foregoing, the Board finds that the weight of the probative lay and medical evidence does not demonstrate that the Veteran is precluded from securing or following substantially gainful employment solely by reason of his service-connected disabilities or that he is incapable of performing the mental and physical acts required by employment due solely to his service-connected disorders, even when his disability is assessed in the context of subjective factors such as his occupational background and level of education. As the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable, and his claim for entitlement to a TDIU on an extraschedular basis must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Hite, 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.