Citation Nr: 21025787 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 08-31 728 DATE: April 29, 2021 ORDER Entitlement to a rating in excess of 10 percent for right hallux valgus with hammer toe is denied. Entitlement to a rating in excess of 10 percent for left hallux valgus with hammer toe is denied. Entitlement to a rating in excess of 10 percent for tinea unguium is denied. Entitlement to a 10 percent rating for a right wrist fracture for the appeal period prior to March 20, 2013 is granted. Entitlement to a rating in excess of 10 percent for a right wrist fracture is denied. REMANDED Entitlement to a total rating based on individual unemployability is remanded. FINDINGS OF FACT 1. The Veteran has been awarded the maximum 10 percent rating each for left and right foot hallux valgus. 2. Throughout the period on appeal, the Veteran’s tinea unguium affects less than five percent of the entire body and less than five percent of exposed areas and has not involved treatment from corticosteroids or other immunosuppressive drugs approximating systemic therapy. 3. For the appeal period prior March 20, 2013, the Veteran’s right wrist fracture manifested was dorsiflexion that was limited to 40 degrees and plantar flexion that was limited to 15 degrees without ankylosis. 4. For the appeal period beginning on March 20, 2013, the Veteran’s right wrist fracture manifested as limitation of motion without ankylosis. CONCLUSIONS OF LAW 1. The criteria for a rating excess of 10 percent for the Veteran’s right foot hallux valgus have not been met. 38 U.S.C. §§ 1155, 5017; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.71a, Diagnostic Code 5282. 2. The criteria for a rating in excess of 10 percent for the Veteran’s left foot hallux valgus have not been met. 38 U.S.C. §§ 1155, 5017; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.71a, Diagnostic Code 5282. 3. The criteria for entitlement for a rating in excess of 10 percent for tinea have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.118, Diagnostic Codes 7806. 4. The criteria for a 10 percent rating for a right wrist fracture for the appeal period prior to March 20, 2013 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.59, 4.71a, Diagnostic Code 5215. 5. The criteria for a rating higher than 10 percent for a right wrist fracture have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.59, 4.71a, Diagnostic Code 5215. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from August 1983 to December 1991. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a May 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in May 2016, January 2019 and December 2020, at which times the issues currently on appeal was remanded for additional development. Specifically, the claims were remanded to obtain updated VA treatment notes, private treatment notes and VA examinations. Updated VA treatment records have been associated with the record and the Veteran was asked to complete appropriate authorization to obtain private treatment records in a January 2021 letter. A VA foot examination was conducted in October 2020, a VA skin examination was conducted in October 2020 and a VA wrist examination was conducted in June 2018. The Board therefore determines that there has been substantial compliance with its previous remands. The case has now been returned to the Board for further appellate action. INCREASED RATING CLAIMS Disability ratings are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as “staged” ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA’s determination of the present level of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased-rating claim has been pending. Hart v. Nicholson, 21 Vet. App. 505, 509 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”).] The Board notes that effective February 7, 2021, the criteria for schedule of ratings for the musculoskeletal system was revised. See 86 Fed. Reg. 8142 (Feb. 4, 2021) (codified at 38 C.F.R. pt. 4). In the instant case, the applicable rating period occurred before the implementation of these revised diagnostic criteria and there is no evidence submitted after the effective date. Moreover, the diagnostic criteria applicable to this case, namely Diagnostic Codes 5282 and 5215, were unchanged by this revised criteria. Therefore, the February 2021 musculoskeletal criteria do not apply to the Veteran’s claims on appeal; and the appropriate criteria is discussed below. Hallux Valgus with Hammertoe The Veteran generally asserts that he should have ratings in excess of 10 percent for his right and left foot hallux valgus with hammer toe disabilities, respectively, as each is worse than contemplated by the currently assigned ratings. The Board notes that relevant examination findings are discussed above. During the period on appeal, the Veteran’s right and left foot hallux valgus with hammertoe disabilities are rated 10 percent, respectively, under 38 C.F.R. § 4.71a, Diagnostic Codes 5282, governing hammer toe. Diagnostic Code 5282 provides ratings for hammer toes. A noncompensable rating is warranted when single toes are affected. A 10 percent rating is warranted when all toes are affected unilaterally without claw foot. 38 C.F.R. § 4.71a. Under Diagnostic Code 5280, a 10 percent rating is warranted for: (1) hallux valgus that has been operated on with resection of the metatarsal head; or, (2) severe hallux valgus that is equivalent to amputation of the great toe. 38 C.F.R. § 4.71a, Diagnostic Code 5280. There is no higher rating available under this Diagnostic Code. Under Diagnostic Code 5284, for other foot injuries, a 10 percent rating is assigned for moderate injury, a 20 percent rating is assigned for moderately severe injury, and a 30 percent rating is assigned for severe injury. With actual loss of use of the foot, a 40 percent rating is assigned. The terms “mild,” “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 arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. At a March 2007 VA examination, the examiner noted that the Veteran experienced bilateral foot hammer toe and hallux valgus. The Veteran reported that he experienced bilateral foot pain and stiffness, and he denied redness and fatiguability. The Veteran indicated that he experienced pain at rest and with ambulation. The Veteran reported that he experienced flare-ups of bilateral foot pain approximately once per week that typically lasted 3-5 hours in duration. On examination, the examiner noted that the Veteran experienced bilateral foot hammer toe on digits 2 through 5. At an April 2011 VA examination, the examiner reported that the Veteran’s bilateral foot hallux valgus and hammer toe disabilities were productive of pain, redness, fatiguability and weakness. The examiner indicated that the Veteran was unable to stand for more than 15-30 minutes without pain and that he was unable to walk more than a quarter mile. On examination, there was no evidence of swelling, instability or weakness. The examiner reported that the Veteran experienced bilateral foot 2nd toe hammer toe and that no claw foot was present. At a March 2013 VA examination, the examiner reported that the Veteran experienced bilateral foot hallux valgus, but there was no evidence of hammertoe. The examiner reported that the Veteran’s hallux valgus was productive of mild to moderate symptomatology. The examiner reported that the Veteran did not use any devices for assistance with ambulation. No other pertinent findings were noted. At a June 2018 VA examination, the examiner reported that the Veteran experienced bilateral foot hallux valgus and hammertoe. The Veteran reported that he was unable to stand or walk for more than 15 minutes without experiencing bilateral foot pain. The Veteran indicated that he experienced flare-ups of bilateral foot pain approximately once per week that required the Veteran to sit or lay down. On examination, the examiner reported that the Veteran experienced right and left foot hammertoe on the little, second, third and fourth toes. There was evidence of pain on movement and with weight-bearing, as well as tenderness. The examiner indicated that the Veteran’s bilateral hallux valgus and hammertoe disabilities were productive of moderate symptomatology. The examiner reported that the Veteran’s bilateral foot disabilities did not compromise weight-bearing, and that the Veteran did not require arch supports, custom orthotics, or shoe modifications. There was no evidence of additional function loss during flare-ups. With regard to functional impairment, the examiner reported that the Veteran’s bilateral foot hallux valgus and hammertoe disabilities impacted his ability to work in that he was unable to walk or stand for prolonged periods of time. At an October 2020 VA examination, the examiner reported that the Veteran experienced bilateral foot hallux valgus and hammertoe. The Veteran reported that he experienced daily flare-ups of moderate bilateral foot pain. The Veteran indicated that he experienced difficulty with prolonged walking and standing. On examination, the examiner noted that the Veteran experienced right foot hammer toe of the second, third and fourth toe, as well as left foot hammertoe of the second, third, fourth and little toe. The examiner indicated that the Veteran’s bilateral hallux valgus and hammertoe disabilities were productive of moderate symptomatology. The examiner reported that the Veteran’s bilateral foot disabilities were productive of pain on movement and pain with weight-bearing, as well as pain with active and passive movement. With regard to functional impairment, the examiner reported that the Veteran’s bilateral foot hallux valgus and hammertoe disabilities impacted his ability to work in that he was unable to walk or stand for prolonged periods of time. A review of the Veteran’s clinical records does not show that the Veteran has complained of symptoms not reflected in the above-mentioned examination reports. The Veteran is currently assigned a 10 percent rating, which contemplates severe overall disability, equivalent to the amputation of the toe. As the Veteran is already in receipt of the maximum allowable rating for hallux valgus for the right and left foot, respectively, and increased schedular ratings are not possible in this case. The Board notes that the Veteran has reported, and the medical evidence shows, that the right and left foot hallux valgus is manifested by pain on use, passive and active motion, and weightbearing and non-weightbearing. The Veteran has also reported that the pain results in difficulty walking and standing for prolonged periods. However, the currently assigned 10 percent ratings are for hallux valgus that is severe overall. As the currently assigned ratings are based on the overall severity of the disabilities, the assigned ratings inherently contemplate any and all manifestations of the disabilities and the resulting overall level of impairment resulting therefrom. As such, the diagnostic criteria contained in Diagnostic Code 5280 contemplate all of the Veteran’s reported symptoms, and referral for extraschedular consideration is not warranted. Thun v. Peake, 22 Vet. App. 111, 116 (2008); Chudy v. O’Rourke, 30 Vet. App. 34 (2018). The Board has considered whether a higher rating is available under other diagnostic codes but finds that it is not. In this regard, the Veteran is service connected for right foot hallux valgus, which is specifically covered by Diagnostic Code 5280. As such, it would be inappropriate to rate his right foot hallux valgus disability by analogy to any other Diagnostic Codes. Copeland v. McDonald, 27 Vet. App. 333, 336-37. Thus, consideration of whether higher ratings may be assigned under alternative Diagnostic Codes is not warranted in this case. Based on a review of the evidence, the Board finds that the preponderance of the evidence is against a compensable rating under Diagnostic Code 5282. The evidence of record reflects that only the Veteran’s second, third, and fourth toes bilaterally are affected. While the medical evidence of record supports worsening of the Veteran’s bilateral hammer toes during the appeal period, at no point during the appeal period did the Veteran’s bilateral hammer toe affect all of his toes unilaterally. As such, a compensable rating is not warranted under Diagnostic Code 5282. Moreover, the evidence of record does not show a diagnosis of weak foot, pes planus, claw foot, Morton's disease, hallux rigidus or malunion and/or nonunion of the tarsal or metatarsal bones. Therefore, a higher or separate rating under Diagnostic Code 5275, 5276, 5277, 5278, 5279 or 5283. In reaching its conclusion, the Board acknowledges the Veteran’s belief that his right and left foot hallux valgus is more severe than as reflected by the currently assigned disability rating. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, supra. Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than his reports regarding the severity of his right foot hallux valgus. The Board has also considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran’s right and left foot hallux valgus; however, the Board finds that his symptomatology has otherwise been stable throughout the period on appeal. Therefore, assigning staged ratings is not warranted. Further, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the rating claim adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to a rating in excess of 10 percent for right and left foot hallux valgus is not warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Tinea Unguium The Veteran asserts that he should have a higher rating for his tinea unguium because his disability is worse than contemplated by the currently assigned rating. The rating for the Veteran’s tinea unguium has been assigned a 10 percent rating pursuant to Diagnostic Code 7806. A noncompensable rating is assigned for less than five percent of the entire body or less than five percent of exposed areas affected, and; no more than topical therapy is required during the past 12-month period. A 10 percent rating contemplates at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immuno-suppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating contemplates more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. The Federal Circuit Court has held that systemic therapy means “treatment pertaining to or affecting the body as a whole,” whereas topical therapy means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied, and that nothing in Diagnostic Code 7806 displaces the accepted understandings of systemic therapy and topical therapy to permit a topical therapy that affects “only the area to which it is applied” to count as a systemic therapy under the Code. However, the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case and does not automatically mean systemic therapy because Diagnostic Code 7806 distinguishes between systemic and topical therapy. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). On August 13, 2018, the VA adopted new regulations for skin disorders. Under the new regulations systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 83 Fed. Reg. 32,592 (July 13, 2018). The new regulations create a bright-line definition of topical and systemic treatment therapies. Prior to this change, the regulations did not define topical or systemic treatment and the determination of whether a Veteran received topical or systemic treatment was based on the factual circumstances of each case. Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017). As the Veteran filed a claim for service connection prior to August 13, 2018 and his appeal for an increased rating was pending on August 13, 2018, the Board will consider both the new and old regulations and apply the most favorable. The Federal Circuit also held that a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, and the use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. In Burton v. Wilkie, 30 Vet. App. 286 (2018), the Court held that there are at least two other potential ways of showing that a topical corticosteroid is systemic: the method by which the treatment works and its side effects. An April 2011 VA examination reflected the Veteran's reports of an intermittent fungal inguinal groin condition. The Veteran reported that he had treated the condition with a topical cream that was not a corticosteroid or immunosuppressive. The examiner noted that this condition did not impact any exposed areas and impacted greater than five percent but less than 20 percent of the total body area. At a November 2017 VA examination, the Veteran reported that he had a long history of bumps on his face, as well as burning with shaving. The Veteran reported that he used antibacterial medication, to include topical clindamycin, benzoyl peroxide, and tretinoin to treat his pseudofolliculitis barbae. The Veteran reported that he did not experience pain, pruritus or bleeding. On examination, the examiner noted that the Veteran experienced scarring on his cheeks above his beard line. The examiner reported that the scars were neither painful nor unstable, and that they did not have a total area equal to or greater than six square inches. Rather, the examiner noted that the Veteran had bilateral cheek scars that each measured 0.25 cm x 0.25 cm. There was no evidence of skin neoplasms or systemic manifestations due to any skin diseases. The examiner reported that the Veteran’s pseudofolliculitis barbae required constant/near-constant use of clindamycin, benzoyl peroxide, desonide and tretinoin. The examiner indicated that the Veteran’s pseudofolliculitis barbae had a total body area and total exposed area each of less than five percent. The examiner reported that the Veteran’s pseudofolliculitis barbae did not impact his ability to work. A May 2018 VA examination indicated that the Veteran had not been treated with oral or topical medications in the past 12 months for any skin condition and that he did not have visible skin condition. An October 2020 VA examination reflected the Veteran's complaints of discoloration and thickening of toe nails, that he had not been treated with medication in the past 12 months for any skin condition and that tinea unguium involved less than five percent of the Veteran's total body area. A review of the Veteran’s clinical records does not show that the Veteran has complained of symptoms not reflected in the above-mentioned examination reports. The Veteran currently receives a 10 percent rating for tinea unguium under 38 C.F.R. § 4.118, Diagnostic Code 7806. The Board agrees that this is the appropriate diagnostic code, as there is no noted disfigurement of the head, face, neck. Moreover, the Board has considered assigning a separate rating for the bilateral check scars. However, the November 2017 VA examiner indicated that the Veteran’s scars was less than six square inches, stable, and not productive of functional impairment. Moreover, there was no evidence that either scar was painful. Moreover, the Board has reviewed the various medical records and finds no indication that the Veteran’s scars are either painful or unstable. Thus, with no other disabling effects of the scar, a separate compensable rating for bilateral check scars is not warranted. 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. As noted above, to receive a 10 percent rating, the Veteran must show that his tinea unguium covers five to 20 percent of the entire body; covers five to 20 percent of exposed areas (to include the hands, face and neck); or, requires the use of intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than six weeks during the last 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. The Board must thus consider two questions, in any order, when determining whether topical treatment for a skin disorder constitutes “systemic therapy such as corticosteroids or other immunosuppressive drugs” under the pre-August 13, 2018 version of Diagnostic Code 7806: a) Whether the topical treatment operates by affecting the body as a whole in treating a veteran’s skin condition; and b) Whether the given treatment is “like” a corticosteroid or other immunosuppressive drug. Only the second question needs to be considered if the treatment is clearly systemic. Here, the Veteran uses multiple topical medication to treat his tinea unguium during the appeal period. However, the Veteran reported that he had not been treated with medication in the past 12 months for any skin condition. The evidence shows that these topical medications pertain only to a particular surface area, the face, and there is no evidence that these medications affect other areas outside of the locations to which they are applied. Moreover, there is no evidence that the Veteran’s tinea unguium affects more than five percent of his body. In this regard, the November 2017 VA examiner noted that only a small area on his cheeks were affected and the October 2020 VA examination found that it impacted less than five percent of the Veteran's total body area. The May 2018 VA examination found that there was no visible skin condition. Although the April 2011 VA examination found five percent but less than 20 percent of the total body area, the condition was consistently found affect less than five percent of the body thereafter. Accordingly, a compensable rating under Diagnostic Code 7806 is not warranted at any time during the appeal period. 38 C.F.R. § 4.118. In reaching its conclusions, the Board acknowledges the Veteran’s belief that his tinea unguium symptoms are more severe than the current rating reflects. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert, 21 Vet. App. 456. The Board finds the medical evidence in which professionals with medical expertise examined the Veteran’s toenails and feet, acknowledged his reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than his own reports regarding the severity of such conditions. The Board has considered whether a staged rating under Hart v. Mansfield, supra is warranted, however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning a staged rating is not warranted. Further, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. Accordingly, the Board finds that a rating in excess of 10 percent for tinea unguium is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Right Wrist Fracture The Veteran generally asserts that he should have a rating in excess of 10 percent for his right wrist disorder as it is worse than contemplated by the currently assigned rating. Specific argument in support of this appeal has not been submitted. This appeal stems from a claim dated in January 2007. During the period on appeal, the Veteran’s right wrist fracture was rated as noncompensable prior to March 20, 2013 and 10 percent thereafter under 38 C.F.R. § 4.71a, Diagnostic Codes 5215. Diagnostic Code 5215 is applicable for limitation of wrist motion. Full wrist motion is to 70 degrees of dorsiflexion (extension), 80 degrees of palmar flexion, 45 degrees of ulnar deviation, and 20 degrees of radial deviation. 38 C.F.R. § 4.71, Plate I. A 10 percent rating is for assignment under 38 C.F.R. § 4.71a, Diagnostic Code 5215 when motion in either the dominant or non-dominant hand is limited to palmar flexion being in line with the forearm or less than 15 degrees of dorsiflexion. A 10 percent rating is the only assignable rating under Diagnostic Code 5215. The Veteran is right-hand dominant. Normal range of motion of the wrist includes dorsiflexion (extension) from zero to 70 degrees, palmar flexion from zero to 80 degrees, ulnar deviation from zero to 45 degrees, and radial deviation from zero to 20 degrees. See 38 C.F.R. § 4.71a, Plate I. At a March 2007 VA examination, the examiner reported that the Veteran experienced a right wrist fracture in 1991. At an August 2009 VA examination, the Veteran reported that he experienced decreased right wrist strength, mobility and fatigue. He indicated that he experienced flare-ups that were caused by overuse and were approximately 30 minutes in duration. The Veteran reported that he was employed as an auditor and that he routinely required break to tend to his wrist. The Veteran indicated that he did not use any assistive devices or take medication to treat pain. On examination, the Veteran demonstrated right wrist dorsiflexion to 40 degrees, palmar flexion at 15 degrees, and radial deviation and ulnar deviations were zero to five times three iterations. There was no evidence of ankylosis. At an August 2016 VA examination, the Veteran reported that he experienced right wrist numbness and tingling. The Veteran reported flare-ups that occurred approximately four times per week and resulted in an inability to move heavy objects. On range of motion testing, the Veteran demonstrated right wrist palmar flexion to 40 degrees, dorsiflexion to 50 degrees, ulnar deviation to 40 degrees, and radial deviation to 15 degrees. Following repetitive-use testing, the Veteran demonstrated right wrist palmar flexion to 35 degrees, dorsiflexion to 30 degrees, ulnar deviation to 25 degrees, and radial deviation to 25 degrees. The examiner reported that the flare-ups resulted in less movement than normal, as well as increased pain, weakness, fatigue and incoordination. The Veteran indicated that he regularly used a brace. There was no evidence of ankylosis. With regard to functional impairment, the examiner commented that the Veteran was unable to perform moderate to heavy lifting, pushing and pulling. At an August 2019 VA examination, the Veteran reported that he experienced right wrist pain and stiffness. The Veteran indicated that he constantly used a brace, and that he also used over-the-counter medication to treat pain. The Veteran reported that he experienced flare-ups that impaired his ability to carry, grasp or perform repetitive activities. The Veteran reported flare-ups that occurred approximately four times per week and resulted in an inability to move heavy objects. On range of motion testing, the Veteran demonstrated right wrist palmar flexion to 0 degrees, dorsiflexion to 20 degrees, ulnar deviation to 5 degrees, and radial deviation to 10 degrees. Pain was noted on all range of motion testing. The examiner indicated that the baseline was too great to allow performance of repetitive-use testing. The examiner reported that pain resulted in functional loss. There was no evidence of ankylosis. The examiner reported that the Veteran did not experience functional impairment as a result of his right wrist. For the appeal period prior to March 20, 2013, the Veteran’s right wrist fracture manifested as right wrist dorsiflexion to 40 degrees and palmar flexion at 15 degrees with pain, at worst, at the August 2009 VA examination. In light of the limitation of motion and painful motion, the Board finds that a 10 percent rating is warranted for the appeal period prior to March 20, 2013. For the appeal period beginning on March 20, 2013, the Veteran’s right wrist fracture is rated as 10 percent rating which is the maximum schedular rating. As a 10 percent rating is the highest assignable rating under Diagnostic Code 5215, and the only other diagnostic code pertaining to the wrist (Diagnostic Code 5214) requires ankylosis, which is not demonstrated or claimed, a schedular rating in excess of 10 percent is not warranted for the right wrist for any portion of the appeal period under consideration. Moreover, while VA must in some circumstances consider functional impairment in addition to limitation of motion due to factors such as pain, weakness, premature or excess fatigability, and incoordination, see DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); 38 C.F.R. §§ 4.40, 4.45, this rule does not apply where, as here, the Veteran is receiving the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis. See Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997). Similarly, Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) and Correia v. McDonald, 28 Vet. App. 158 (2016) are not for application because those decisions pertain to the adequacy of examinations as they relate to range of motion findings, but range of motion findings are not relevant here because they cannot result in a higher rating. The Board acknowledges the Veteran’s statement that his right wrist fracture is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds, however, that neither the Veteran’s statement nor medical evidence demonstrates that the criteria for a higher rating have been met. The Board also acknowledges that the Veteran’s VA treatment records note complaints of and treatment for his right wrist disorder. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. The Board has considered whether a further staged rating under Hart, supra, is warranted, however, the Board finds that her symptomatology has been stable throughout each period on appeal. Therefore, assigning a staged rating is not warranted. Further, neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. In this case, the Board finds that a 10 percent rating is warranted for a right wrist fracture for the appeal period prior to March 20, 2013. However, the preponderance of the evidence is against a rating in excess of 10 percent for his right wrist fracture and the claim must, accordingly, be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND The Board finds that additional development is required before the remaining claim on appeal is decided. Entitlement to a TDIU The Veteran has alleged that he is unable to obtain and maintain employment as a result of his service connected right wrist fracture on his Application for Increased Compensation Based on Unemployability (VA Form 21-8940). Specifically, the Veteran has alleged that he is no longer able to be employed as a biomedical technician as a result of limitations associated with his right wrist fracture. As no point during the appeal period as of March 8, 2011 has the Veteran had a single disability rated at 60 percent disabling, or a disability rated at least 40 percent disabling with a combined total of 70 percent or more. As such, the rating percentage criteria for consideration of a TDIU under 38 C.F.R. § 4.16(a) have not been not met at any point during the pendency of the appeal as of March 8, 2011. Although the Veteran does not meet the rating requirements for consideration of a TDIU on a schedular basis under 38 C.F.R. § 4.16(a), a TDIU may be granted alternatively on an extraschedular basis under § 4.16(b) if it is established that the Veteran is indeed unemployable on account of his service-connected disabilities. However, the Board is precluded from granting a TDIU on an extraschedular basis in the first instance, and must refer the matter to the Director of Compensation Service for the initial adjudication. See 38 C.F.R. § 4.16(b); Barringer v. Peake, 22 Vet. App. 242 (2008). If and only if, the Director of the Compensation Service or designee determines that an extraschedular TDIU is not warranted does the Board then have jurisdiction to decide the issue on its merits. To date, the issue of entitlement to a TDIU as of March 8, 2011 has not been considered on an extraschedular basis under 38 C.F.R. § 4.16(b). Thus, because there is evidence that the Veteran may have been unemployable during the appeal period due to service-connected disabilities, referral of the issue for entitlement to a TDIU as of March 8, 2011 to the Director of the Compensation Service is warranted. The matter is REMANDED for the following action: 1. Refer the issue of entitlement to a TDIU as of March 8, 2011 to the Director of Compensation Service for consideration of an extraschedular rating pursuant to 38 C.F.R. § 4.16(b). 2. Then, readjudicate the claim. If the benefit sought on appeal remains denied, then a fully responsive SSOC should be furnished to the Veteran and his representative, and they should be afforded a reasonable opportunity for response. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher O'Donnell, 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.