Citation Nr: 21029270 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 10-04 342 DATE: May 13, 2021 ORDER Entitlement to extraschedular rating for a right thumb condition, listed as degenerative joint disease (DJD), Bennett's fracture of right thumb, postoperative, (hereinafter right thumb condition) is denied. Entitlement to extraschedular rating for a right wrist condition associated with DJD is denied. REMANDED Entitlement to an increased rating in excess of 10 percent for a right thumb condition, listed as DJD, Bennett's fracture of right thumb, postoperative, is remanded. FINDINGS OF FACT 1. Manifestations of the Veteran's right thumb condition, listed as degenerative joint disease, Bennett's fracture of right thumb, postoperative, are considered by the schedular ratings assigned and do not present an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. 2. Manifestations of the Veteran's right wrist condition associated with DJD are considered by the schedular ratings assigned and do not present an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. CONCLUSIONS OF LAW 1. The criteria for entitlement to an extraschedular evaluation for a right thumb condition, listed as degenerative joint disease, Bennett's fracture of right thumb, postoperative, currently rated as 10 percent disabling, have not been met. 38 U.S.C. § 1155, 38 C.F.R. § 3.321. 2. The criteria for entitlement to an extraschedular evaluation for a right wrist condition associated with DJD, currently rated as 10 percent disabling, have not been met. 38 U.S.C. § 1155, 38 C.F.R. § 3.321. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1974 to December 1977. These matters come to the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision issued by the Department of Veterans' Affairs (VA) Regional Office (RO) in Waco, Texas. Procedural History By way of background, in the April 2009 rating decision, the RO granted service connection for a right wrist condition at 10 percent disabling; granted service connection for residual scar, status post open reduction internal fixation, right thumb at 10 percent disabling; and continued a 10 percent disability rating for a right thumb disability. The Veteran timely appealed requesting a hearing before the Board, which was held in June 2013. A transcript of which has been associated with the claims file and reviewed. The Board remanded the claims for additional development in a September 2014 decision. The matters returned to the Board following the additionally directed development where the Board denied an increased rating for a right thumb disability, right wrist condition, and residual scar in an April 2016 decision. Thereafter, the Veteran appealed the Board's April 2016 decision to the United States Court of Appeals for Veterans Claims (CAVC or "the Court"). The Court granted the parties' Joint Motion for Partial Remand (JMPR) in June 2017. The JMPR vacated the Board's denial of an increased rating in excess of 10 percent for a right thumb disability as well as the denial of referral for extraschedular consideration of the right thumb disability, right wrist condition, and the collective impact of the right thumb and right wrist disabilities and residual scar. All remaining matters on appeal were dismissed including an increased rating for the right wrist condition, increased rating for residual scars, and extraschedular consideration of residual scars. The claims returned to the Board for actions consistent with the terms of the JMPR. The Board again remanded in an October 2017 decision for additional development including extraschedular referral for the right thumb and wrist disabilities. The matters returned to the Board where remand was again necessary for additional development as directed in the August 2018 decision. The RO issued a June 2020 Supplemental Statement of the Case (SSOC) from which the Veteran requested a hearing before the Board. A hearing was held in March 2021, a transcript of which has been associated with the claims file and reviewed. As will be discussed in more detail below, the Board finds substantial compliance with the August 2018 remand directives has been met. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Extraschedular Considerations The Veteran contends the symptoms of his right thumb and right wrist conditions warrant extraschedular ratings. The Board finds extraschedular ratings for the Veteran's right thumb and right wrist conditions are not warranted. The Board continued separate 10 percent schedular ratings for the Veteran's service-connected right thumb and right wrist conditions in the October 2017 decision. The Board also remanded the issues of entitlement to an increased evaluation on an extraschedular basis for the right thumb and right wrist conditions in order to refer the Veteran's case to the Director of Compensation Service for consideration of whether the Veteran's right thumb and right wrist manifestations are not contemplated by the rating schedule and the collective effects of the Veteran's service-connected disabilities. In general, disability ratings are determined by applying the VA's Schedule for Rating Disabilities (Rating Schedule). See 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practicably be determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. However, in exceptional cases, schedular ratings may be inadequate. See 38 C.F.R. § 3.321(b)(1). The governing norm for an extraschedular rating is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or necessitated periods of hospitalization so as to render the regular schedular standards impractical. See id. There is a three-step inquiry for determining whether an extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for a service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability, and symptomatology and is found to be inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors, such as "governing norms." See id. at 115-16 (citing 38 C.F.R. § 3.321(b)(1) and noting that related factors include marked interference with employment and frequent periods of hospitalization). Third, if the rating schedule is inadequate to evaluate a claimant's disability picture, and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Director to determine whether, in the interests of justice, the claimant's disability picture requires the assignment of an extraschedular rating. See id. at 116. Once the Director has decided on an extraschedular rating under 3.321(b), the Board can assign an extraschedular rating. There is a judicially manageable standard limiting the Director's discretion for assignment of such a rating, namely that the extraschedular rating is commensurate with the average earning capacity impairment due exclusively to service-connected disability or disabilities. See Kupamala v. McDonald, 27 Vet. App. 447 (2015). The Board, however, is not bound by the Director's decision and, indeed, after such a determination is made by the Director, the Board is free to make a de novo decision. The Court in Smiddy v. Wilkie, further acknowledged that the standard by which the Board determined a referral is warranted is a lower threshold and does not automatically entitle the Veteran to an extraschedular grant when the matter returns for the Board. Rather, as in this case, the matter was referred to the Director based solely on factual evidence that an extraschedular rating may be warranted and further opinion was warranted because the Board was precluded from consideration of an extraschedular award in the first instance. 32 Vet. App. 350 (2020). Since the time of the Board's 2017 remand, moreover, additional evidence has been submitted, to include VA outpatient treatment records, a January 2018 VA examination, a March 2019 VA examination, and the Veteran's testimony before the Board, all of which really highlights that the Veteran's manifestations of his disabilities are all contemplated in the rating criteria. In Long v. Wilkie, the Court further elaborated that 38 C.F.R. § 3.321(b) does not provide an alternative path to compensation; extraschedular evaluations are available only where a disability is incapable of evaluation under the rating schedule. 33 Vet. App. 167 (2020) (emphasis added). The Court further held that whether the full scope of a disability is "contemplated" by a diagnostic code(s) does not turn on a mere comparison of symptoms and diagnostic criteria. Id. (emphasis added). In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). This assists in determining, among other things, entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). At the outset, the Board notes, the October 2017 decision remanded the extraschedular issues on appeal for consideration based, in-part, on the collective impact of the Veteran's conditions under Johnson v. McDonald, 762 F.3d 1362, 1366 (Fed. Cir. 2014). VA issued a Final Rule amending 38 C.F.R. § 3.321(b)(1) to clarify that an extraschedular rating is no longer available based on the combined effect of multiple service-connected disabilities. See 82 Fed. Reg. 57830 (December 8, 2017). The final rule, effective January 8, 2018, applies to all applications for benefits that received or pending before VA, the Court, or the U.S. Court of Appeals for the Federal Circuit on that date. As these issues were pending before VA on January 8, 2018, Johnson is no longer applicable and discussion of the collective impact of the Veteran's disabilities is no longer necessary or appropriate. 1. Entitlement to extraschedular rating for a right thumb condition, listed as DJD, Bennett's fracture of right thumb, postoperative, is denied. As mentioned previously, the Veteran is currently assigned a 10 percent disability rating for a right thumb condition under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5010-5228. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating, with the first code representing the underlying condition and the second code representing the residuals. 38 C.F.R. § 4.27. Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). Pre-amended DC 5010 provides arthritis due to trauma and substantiated by x-ray findings will be rated as degenerative arthritis. See 38 C.F.R. § 4.71a, DC 5010. DC 5010 instructs to rate under DC 5003 (degenerative arthritis). Under DC 5003, arthritis of a major joint or group of minor joints is to be rated under the criteria for limitation of motion of the affected joint. See 38 C.F.R. § 4.71a, DCs 5003, 5010. For the purpose of rating disabilities due to arthritis, the interphalangeal, metacarpal, and carpal joints of the upper extremities are considered a group of minor joints, ratable on parity with major joints. See 38 C.F.R. § 4.45. Where limitation of motion of the joint is noncompensable under the appropriate DC, a rating of 10 percent is for application. See 38 C.F.R. § 4.71a, DC 5003. With x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent rating is warranted. While the thumb is not a major joint, it is a collection of minor joints for the purposes of 38 C.F.R. § 4.45. Amended DC 5010 provides for post-traumatic arthritis to be rated as limitation of motion, dislocation, or other specific instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. See 38 C.F.R. § 4.71a, DC 5010. Under DC 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. Turning to the relevant evidence of record during the appeal period, the Veteran stated that he has not been able to "control" his right hand. See April 2010 Statement in Support of Claim. In 2012, the Veteran complained of right wrist and hand pain and weakness which had progressed over the past nine months. See October 2012 VA treatment records. He described being unable to hold things without dropping them, being unable to write clearly, and having difficulty opening jars or doors. Id. Upon examination, the provider noted that the Veteran was unable to abduct his thumb and had diminished grip strength. Id. The Veteran testified in April 2013 that he experiences weakness in the right thumb that impacts his grip strength. See April 2013 hearing transcript, p. 11. The Veteran explained that he is able to move his thumb, but he cannot do it all of the time. Id. at 19. He stated in the morning and evening it hurts sometimes. Id. He reported using his thumb throughout the day until it "wears out" and then he "just [doesn't] bother with it the rest of the day." Id. at 25. The Veteran reported that he stopped working as a driver following his open-heart surgery. Id. at 27. The Veteran testified in the March 2021 hearing that he is unable to write with his right hand, is limited in holding utensils while eating, and has to stop driving due to pain. See March 2021 hearing transcript, p. 3-5. The Veteran described occasional swelling and flare-ups every other day. Id. at 5. The Veteran has been afforded multiple VA examinations during the period on appeal to determine the severity of his right thumb condition. In a January 2009 examination, the Veteran reported decreased right thumb strength as well as frequent pain, weakness, and loss of function. See January 2009 C&P examination. He reported flare-ups with increased pain and loss of function that were described as severe and occurring daily for 2-4 hours. Id. Flare-ups were caused by increased activity and alleviated through rest. Id. Ankylosis was not indicated. Id. In March 2009, the examiner indicated that the Veteran is right hand dominant and experiences pain at the base of his right thumb. See January 2009 VA examination. He did not report flare-ups or use of an assistive device or brace. Id. The Veteran reported using his left hand to do most normal activities of daily living due to the pain in his right thumb and wrist. Id. Pain was noted with abduction and adduction of the thumb. Id. He was able to oppose his thumb to his fingertips. Id. There was no additional limitation with repetitive use and no effect of incoordination, fatigue, weakness, or lack of endurance. Id. Another VA examination occurred in November 2012 during which the Veteran declined experiencing flare-ups. See November 2012 VA examination. The examiner indicated there was limitation of motion or evidence of painful motion in the right thumb. Id. There was less than a one-inch gap between the right thumb pad and the fingers. Id. Pain was noted to begin at a gap of 1 to 2 inches. Id. The Veteran was able to perform repetitive use testing without additional limitation of motion. Id. Ankylosis of the thumb was found in extension. Id. Functional impact on the ability to work was not indicated. Id. During a February 2015 VA examination, the Veteran reported worsening right thumb pain. See February 2015 VA examination. He described being unable to hold a pencil or pen. Id. Pain was described as intermittent when attempting to move and extend the thumb. Id. Flare-ups were not reported. Id. There was no gap between the pad of the thumb and the fingers. Id. ROM testing revealed max extension to 5 degrees and max flexion to 100 degrees MCP and 90 degrees IP. Id. Range of motion itself contributed to functional loss because there was pain with thumb extension both actively and passively. Id. Repetitive use ROM revealed max extension to 10 degrees and max flexion to 100 degrees MCP and 90 degrees IP. Id. Ankylosis was not found. Id. Moderate to severe tenderness globally over the thumb was indicated. Id. Pain, weakness, and incoordination were noted to significantly limit functional ability with repeated use over a period of time. Id. ROM loss was estimated to be max extension to 10 degrees and max flexion to 90 degrees MCP and 70 degrees IP with a gap between the pad of the thumb and the fingers measuring 0.2 cm. Id. The Veteran reported functional impairment noting that while he did not miss work during the last year of working as a driver, he did have difficulty grasping and turning the steering wheel with his right thumb. Id. He denied avoiding any driving jobs due to the right thumb condition. Id. In December 2017, a Hand and Finger Disability Benefits Questionnaire (DBQ) was completed wherein the Veteran described his condition as worsening with tingling, swelling, stiffness, and pain that radiates to the wrist. See December 2017 DBQ. Flare-ups were noted with sharp pain and tingling, swelling, stiffness, and pain radiating to the wrist. Id. The Veteran reported functional loss or functional impairment of the joint as difficulty pushing and pulling, lifting objects, gripping, driving, and while completing daily physical activities. Id. ROM was noted to be max extension to 0 degrees and max flexion to 70 degrees MCP and 40 degrees IP. Id. A 2 cm gap was noted. Id. Pain was noted on examination that did not result in or cause functional loss. Id. Repetitive use testing was completed without additional functional loss. Id. The examiner was unable to say without resorting to speculation whether there was additional ROM loss during flare-ups. Id. Atrophy and ankylosis were not found. Id. There was no objective evidence of pain on passive ROM testing or when the joint was used in non-weight bearing. Id. Most recently, in the March 2019 VA examination, the Veteran described worsening pain and loss of ROM. See March 2019 VA examination. He reported difficulty writing, grasping, and holding objects with his right hand. Id. He noted pain with ROM. Id. Flare-ups were reported of throbbing pain with increased use of the right hand. Id. He had to stop the activity to relieve the pain. Id. Flares typically lasted one hour. Id. Functional loss was reported as difficulty lifting, holding/grasping objects, writing, and completing activities of daily living such as dressing and bathing. Id. ROM was noted to be max extension to 30 degrees MCP and 15 degrees IP with max flexion to 65 degrees MCP and 65 degrees IP. Id. A gap between the pad of the thumb and the fingers measured 2.5 cm. Id. Pain was noted on examination and causes functional loss in thumb extension and opposition. Id. The Veteran was able to perform repetitive use testing without additional functional loss or ROM loss. Id. ROM during flare-ups was estimated to be max extension to 30 degrees MCP and 15 degrees IP and max flexion to 50 degrees MCP and IP. Id. The gap measurement remained at 2.5 cm during flare-ups. Id. Ankylosis was not found. Id. There was pain with passive ROM but no evidence of pain in non-weight bearing. Id. Pain was noted to begin at 30 degrees extension of the MCP joint with both active and passive ROM. Id. Consideration of an extraschedular rating was referred to the Director of Compensation Service in April 2018. The Director conducted an administrative review and issued her findings in May 2018. The decision stated that when comparing the level of severity and symptomatology of the Veteran's DJD of the right thumb with the established rating schedule criteria, the rating criteria reasonably described the Veteran's disability level and symptomatology. See May 2018 C&P Correspondence. There was no evidence of an unusual disability picture such as frequent periods of hospitalization or marked interference with employment due to the condition. Id. Ultimately, the Director found that the established rating schedular criteria adequately described the disability level and symptomatology of the Veteran's right thumb disability. Id. Based on the lay and medical evidence of record, the Board finds that an extraschedular rating in excess of 10 percent for the Veteran's right thumb disability is not warranted. Again, in determining whether an extraschedular rating is warranted, there is a two-step inquiry: whether the disability in question is exceptional and, if so, whether the exceptional disability is manifested with symptoms that cause marked interference with employment, frequent periods of hospitalization, or other related factors. See Long, 33 Vet. App. 167. A disability is not exceptional if it can be rated under the rating schedule. Id. In this case, looking at the medical evidence and the scope of the Veteran's complaints of manifestations, the Board finds that the Veteran's disability can be rated under the rating schedule and, therefore, is not exceptional. The Veteran competently and credibly reported various manifestations, to include pain, loss of grip strength, difficulty writing, dropping objects, and other similar impacts on his activities. VA examinations noted these manifestations, to include ROM findings during flare-ups and due to functional loss as described by the Veteran. The diagnostic criteria under 5010-5228 contemplates pain, loss of range of motion, and functional impairment. The criteria contained in the Secretary's diagnostic codes are not lists of symptoms or effects meant to capture every aspect of the Veteran's disability or way in which he is personally impacted by that disability. They are metrics used to approximate disability level and serve as proxies to determine the average impairment in earning capacity caused by disabilities. That is, they are sets of defined variables chosen as the best indicators of disability level; variables from which inferences are drawn and generalizations are made about the nature and impact of a disability. The specific variables used to approximate disability level vary between the diagnostic codes based on what metric the Secretary deems to be the best indicator of disability levels that do not explicitly identify all or some of the symptoms or effects experienced by a veteran does not mean that those symptoms or effects are not contemplated by relevant percentage evaluation. Thus, in this case, the Board finds the Veteran's right thumb disability manifestations are reasonably contemplated by DC 5010-5228. While the Board has no doubt the Veteran's condition affects him personally and on a daily basis, that is part of the contemplation behind the current schedular rating. See Long, 33 Vet. App. 167 (holding that an extraschedular evaluation is not appropriate where a disability is capable of evaluation under the rating schedule and, further, how a disability specifically impacts an individual is not relevant to whether the disability is exceptional). As such, the Board finds the first element under Thun is not met, and further consideration of an extraschedular rating is not warranted. 2. Entitlement to extraschedular rating for a right wrist condition associated with DJD is denied. As mentioned previously, the Veteran is currently assigned a 10 percent disability rating for a right wrist condition under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5010-5215. Pre-amended DC 5010 provides arthritis due to trauma and substantiated by x-ray findings will be rated as degenerative arthritis. See 38 C.F.R. § 4.71a, DC 5010. DC 5010 instructs to rate under DC 5003 (degenerative arthritis). Under DC 5003, arthritis of a major joint or group of minor joints is to be rated under the criteria for limitation of motion of the affected joint. See 38 C.F.R. § 4.71a, DCs 5003, 5010. For the purpose of rating disabilities due to arthritis, the interphalangeal, metacarpal, and carpal joints of the upper extremities are considered a group of minor joints, ratable on parity with major joints. See 38 C.F.R. § 4.45. Where limitation of motion of the joint is noncompensable under the appropriate DC, a rating of 10 percent is for application. See 38 C.F.R. § 4.71a, DC 5003. With x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent rating is warranted. While the thumb is not a major joint, it is a collection of minor joints for the purposes of 38 C.F.R. § 4.45. Amended DC 5010 provides for post-traumatic arthritis to be rated as limitation of motion, dislocation, or other specific instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. See 38 C.F.R. § 4.71a, DC 5010. DC 5215 provides ratings for limitation of motion of the major wrist. A 10 percent rating is warranted for dorsiflexion less than 15 degrees of either the major or minor joint or for palmar flexion limited in line with forearm of either the major or minor joint. See 38 C.F.R. § 4.71a, DC 5215. Turning to the relevant evidence of record during the period on appeal, in 2009, the treatment records reflect tenderness on palpitation over the base of the right hand/wrist. See November 2009 VA treatment records. The Veteran stated that he has not been able to "control" his right hand. See April 2010 Statement in Support of Claim. In 2012, the Veteran complained of right wrist and hand pain and weakness which had progressed over the past nine months. See October 2012 VA treatment records. He described being unable to hold things without dropping them, being unable to write clearly, and having difficulty opening jars or doors. Id. Upon examination, the provider noted tenderness with "good ROM to right wrist" but weakness to fingers of right hand with diminished grip strength. Id. In 2016, a provider indicated the Veteran has limited ROM in the right wrist and the Veteran complained of wrist pain. See May and December 2016 VA treatment records. The Veteran testified in 2013 that he was not experiencing problems with the right wrist, but rather, pain with use. See April 2013 hearing transcript, p. 5. The Veteran described being unable to eat using his dominant right hand noting that as his pain increases in the right hand, he does more with his left. Id. at 7. He also reported dropping things that he picked up with the "wrong" hand. Id. In 2021, the Veteran testified to right wrist pain after 20 minutes of use describing tingling feelings. See March 2021 hearing transcript, p. 4. He stated that he is limited in the ability to drive, get dressed, and write. Id. at 4-5. He reported swelling that comes and goes. Id. He described problems with grasping. Id. The Veteran has been afforded multiple VA examinations during the pendency of his claim. In January 2009, the Veteran reported pain, weakness, stiffness, instability, locking, fatigability, and lack of endurance related to the right wrist. See January 2009 VA examination. Flare-ups were reported with increased pain and loss of function that were described as severe occurring daily for 4 hours. Id. Ankylosis was not found. Id. ROM testing, included repetitive use, revealed 40 degrees dorsiflexion with pain present, 30 degrees palmer flexion with pain present, 10 degrees radial deviation with pain present, and 20 degrees ulnar deviation with pain present. Id. Pain, weakness, and fatigue were present during ROM testing. Id. The examiner opined that the Veteran experiences moderate effects of the condition on usual occupation and daily activities. Id. In March 2009, the Veteran reported wrist pain when gripping or writing which he described as sharp. See March 2009 VA examinations. He declined experiencing flare-ups. Id. There was no effect on his occupation and his activities of daily living were affected in that he used his left hand to do most activities due to right wrist pain. Id. Tenderness was revealed upon examination. Id. There was minimal pain with ulnar and radial deviation of the wrist, which had full ROMs at 0 to 45 degrees and 0 to 20 degrees, respectively. Id. Nonpainful volar flexion and dorsiflexion was reported with 0 to 80 degrees and 0 to 70 degrees, respectively. Id. No additional limitations following repetitive use. Id. The examiner found no effect of incoordination, fatigue, weakness, or lack of endurance. Id. Another VA examination occurred in November 2012 during which the Veteran declined experiencing flare-ups. See November 2012 VA examination. ROM testing revealed 50 degrees palmar flexion with painful motion beginning at 25 degrees and 45 degrees dorsiflexion with painful motion at 15 degrees. Id. Repetitive use testing revealed ROM of 50 degrees palmar flexion and 45 degrees dorsiflexion. Id. Functional loss and/or impairment was noted to be less movement than normal, weakened movement, and pain on movement. Id. There was evidence of localized tenderness or pain on palpitation of the joints. Id. Ankylosis was not indicated. Id. Functional impact on ability to work was not found. Id. During a February 2015 VA examination, the Veteran described worsened right wrist symptoms with difficulty writing and using his hand. See February 2015 VA examination. He stated that wrist pain was intermittent, about every other day, lasting 30 minutes. Id. Pain increased with "playing catch" and wrist movements. Id. Flare-ups were not found. Id. Functional loss or impairment was noted to include activities of daily living in self-care, using his left hand/wrist more often for feeding himself and writing. Id. He stated he was still able to drive. Id. ROM testing revealed 15 degrees palmar flexion, 40 degrees dorsiflexion, 5 degrees ulnar deviation, and 20 degrees radial deviation. Id. Pain was noted on examination and causes functional loss. Id. There was evidence of pain with weight bearing and moderate tenderness over dorsum wrist at midline with severe tenderness over radial wrist at base of thumb. Id. Repetitive use testing was limited by pain, weakness, and incoordination which revealed ROMs of 5 degrees palmar flexion, 40 degrees dorsiflexion, 5 degrees ulnar deviation, and 10 degrees radial deviation. Id. Estimated ROM with repeated use over time revealed 5 degrees palmar flexion, 35 to 40 degrees dorsiflexion, 5 degrees ulnar deviation, and 5 degrees radial deviation. Id. The examiner found that pain, weakness, fatigability, or incoordination does not significantly limit functional ability with flare-ups. Id. Ankylosis was not found. Id. The examiner opined that the Veteran's right wrist condition does not impact his ability to perform any occupational task. Id. Most recently in March 2019, the Veteran reported pain in the right wrist that was "throbbing." See March 2019 VA examination. He also reported experiencing tingling with exacerbated pain due to increased use. Id. He reported decreased ROM over the past five years. Id. Swelling was denied. Id. The Veteran described flare-ups occurring weekly and lasting a few minutes with throbbing pain with increased use such as putting away dishes and dropping objects when lifting/carrying. Id. He reported functional loss or impairment stating that he has to stop whatever activity he is doing when the wrist pain flares. Id. He also reported needing help with dressing and showering, having difficulty sweeping and writing, and being limited in lifting. Id. ROM testing revealed 50 degrees palmar flexion, 40 degrees dorsiflexion, 30 degrees ulnar deviation, and 20 degrees radial deviation. Id. Pain was noted on examination with dorsiflexion, ulnar deviation, and radial deviation that causes functional loss. Id. There was objective evidence of pain with weight bearing and tenderness to the wrist joint. Id. Repetitive use testing was conducted without additional loss of function or ROM. Id. The examiner opined that pain significantly limits functional ability with flare-ups estimating ROM to be 45 degrees palmar flexion, 35 degrees dorsiflexion, 30 degrees ulnar deviation, and 20 degrees radial deviation. Id. Ankylosis was not found. Id. As previously mentioned, consideration of an extraschedular rating was referred to the Director of Compensation Service in April 2018. The Director conducted an administrative review and issued her findings in May 2018. The decision stated that when comparing the level of severity and symptomatology of the Veteran's right wrist condition with the established rating schedule criteria, the rating criteria reasonably described the Veteran's disability level and symptomatology. See May 2018 C&P Correspondence. There was no evidence of an unusual disability picture such as frequent periods of hospitalization or marked interference with employment due to the condition. Id. Ultimately, the Director found that the established rating schedular criteria adequately described the disability level and symptomatology of the Veteran's right wrist disability. Id. Based on the lay and medical evidence of record, the Board finds that an extraschedular rating in excess of 10 percent for the Veteran's right wrist disability is not warranted. Again, in determining whether an extraschedular rating is warranted, there is a two-step inquiry: whether the disability in question is exceptional and, if so, whether the exceptional disability is manifested with symptoms that cause marked interference with employment, frequent periods of hospitalization, or other related factors. See Long, 33 Vet. App. 167. A disability is not exceptional if it can be rated under the rating schedule. Id. In this case, looking at the medical evidence and the scope of the Veteran's complaints of manifestations, the Board finds that the Veteran's disability can be rated under the rating schedule and, therefore, is not exceptional. The Veteran competently and credibly reported various manifestations of his right wrist, to include pain, difficulty writing, difficulty feeding himself, and flare-ups with use (such as "playing catch"), which are more bothersome because his right hand is his dominant hand. The Board finds, however, that the diagnostic codes in this case (DC 5010-5215) contemplates pain and other functional loss due to loss of motion on use or during flare-ups. The diagnostic criteria, moreover, further contemplates the increased impairment if the disability affects the dominant side versus the minor side as the disability ratings are different depending on whether the affected side is "major" or "minor." See 38 C.F.R. § 4.71a, DC 5215. Again, the Board notes that the disability criteria noted in the diagnostic codes are not meant to be exhaustive lists or meant to capture every aspect of a veteran's disability or way in which he is personally impacted by that disability. They are metrics used to approximate disability level and serve as proxies to determine the average impairment in earning capacity caused by disabilities. In applying the diagnostic codes, due consideration is given to functional loss/impairments, flare-ups, and whether the disability affects the "major" or "minor" side of the specific claimant. See Long, 33 Vet. App. 167 (holding that an extraschedular evaluation is not appropriate where a disability is capable of evaluation under the rating schedule and, further, how a disability specifically impacts an individual is not relevant to whether the disability is exceptional). Thus, in this case, the Board finds the Veteran's right wrist disability manifestations are reasonably contemplated by DC 5010-5215. As such, the Board finds the first element under Thun is not met, and further consideration of an extraschedular rating is not warranted. The Board notes the Veteran is invited to file an increased (schedular) rating claim for his right wrist condition if his symptoms worsen. REASONS FOR REMAND 1. Entitlement to an increased rating in excess of 10 percent for a right thumb condition, listed as degenerative joint disease, Bennett's fracture of right thumb, postoperative, is remanded. The Veteran, during his March 2021 hearing, testified he is experiencing worsened right thumb entitling him to a higher disability rating, especially over "the past year" (from March 2021). In light of his testimony, the Board finds the evidence of record is insufficient to resolve the Veteran's claim. In particular, during the hearing, the Veteran testified that he has been experiencing worsened right thumb symptoms, to include decreased ability to write legibly, increased difficulty using utensils while eating due to pain, experiencing tingling, an inability to drive more than 20 minutes, occasional swelling, and flare-ups every other day. The Veteran was last afforded a VA examination to determine the severity of his right thumb disability in March 2019. Because the Veteran contends his condition has worsened since this time, remand is necessary to afford the Veteran a contemporaneous VA examination to determine the current severity of his symptoms. See Snuffer v. Gober, 10 Vet. App. 400 (1997); see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination before an appropriate examiner to determine the current severity of his degenerative joint disease, Bennett's fracture of right thumb, postoperative. The examiner should be provided the entire claims file and this remand for review. The examiner is directed to address and consider the Veteran's lay statements of symptom worsening during the March 2021 hearing including a decreased ability to write legibly, increased difficulty using utensils while eating due to pain, experiencing tingling, an inability to drive more than 20 minutes, occasional swelling, and flare-ups every other day. The examiner must provide a complete rationale for any opinion expressed, based on the examiner's clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 2. After the above development, and any other development deemed necessary, readjudicate the claim. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.C. Allen, 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.