Citation Nr: 0001995 Decision Date: 01/27/00 Archive Date: 02/02/00 DOCKET NO. 94-22 930 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to a rating in excess of 10 percent for residuals of a fracture of the right clavicle. 2. Entitlement to a rating in excess of 10 percent for L4-L5 disc disease. 3. Entitlement to a compensable rating for a right hip disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Carolyn Wiggins, Counsel INTRODUCTION The veteran served on active duty from March 1982 to October 1992. This appeal arises from an August 1993 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, which granted service connection for residuals of a fracture of the right clavicle, residuals of a right hip injury, hypertension and L4-L5 disc disease. The veteran disagreed with the ratings assigned for his service- connected disabilities and appealed to the Board of Veterans' Appeals (Board). The Board denied the claim for a compensable rating for hypertension in May 1996. The veteran's claims for increased ratings for his other disabilities were remanded to the RO. FINDINGS OF FACT 1. The residuals of the fracture of the right clavicle consist of a moderate degree of callous formation and a palpable bump in the right mid clavicle. There is no impairment of function of the right shoulder attributable to the healed fracture. 2. The low back disability is manifested by pain on motion of the lumbar spine which results in slight limitation of motion. 3. The veteran does not currently demonstrate any pathology of the right hip. CONCLUSION OF LAW 1. The criteria for an evaluation in excess of 10 percent for residuals of a fracture of the right clavicle have not been met. 38 U.S.C.A. §§1155 (West 1991); 38 C.F.R. §§ 4.40, 4.45 and 4.71a, Diagnostic Code 5203 (1999). 2. The criteria for an evaluation in excess of 10 percent for L4-L5 disc disease have not been met. 38 U.S.C.A. 1155 (West 1991); 38 C.F.R. §§ 4.40, 4.45 and 4.71a, Diagnostic Code 5292, 5295 (1999). 3. The criteria for a compensable evaluation for a right hip disability have not been met. 38 U.S.C.A. §§ 1155 (West 1991); 38 C.F.R. §§ 4.40, 4.45 and 4.71a, Diagnostic Code 5251, 5252, 5253 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In general, an allegation of increased disability is sufficient to establish a well-grounded claim when the veteran is seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is satisfied that all relevant facts have been properly developed. No further assistance is required to comply with the duty to assist the veteran mandated by 38 U.S.C.A. § 5107(a). Pertinent Laws and Regulations. In evaluating the severity of a particular disability, it is essential to consider its history. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1 and 4.2. The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that the rule from Francisco does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability. Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. As the veteran has perfected an appeal from the initial rating for disabilities at issue, the Board will consider the applicability of "staged" ratings to the issues on appeal. Disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the rating schedule. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be an emphasis placed upon the limitation of activity imposed by the disabling condition. The provisions of 38 C.F.R. § 4.2 require that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.10 provides that in cases of functional impairment, evaluations must be based upon lack of usefulness of the affected part or systems, and medical examiners must furnish, in addition to the etiological, anatomical, pathological, laboratory, and prognostic data required for ordinary medical classification, a description of the effects of the disability upon the person's ordinary activity. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body. Functional loss may be due to pain, supported by adequate pathology, or the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40, 4.45. When a reasonable doubt arises regarding the degree of disability such doubt should be resolved in favor of the claimant. 38 C.F.R. §§ 3.102, 4.3. Malunion of the clavicle or scapula, or nonunion without loose movement, warrants a 10 percent evaluation. A 20 percent evaluation requires nonunion with loose movement or dislocation. Impairment of the clavicle or scapula may also be rated based on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a, Diagnostic Code 5203 (1999). Severe limitation of motion of the lumbar spine is evaluated as 40 percent disabling. Moderate limitation of motion of the lumbar spine is evaluated as 20 percent disabling. Slight limitation of motion is evaluated as 10 percent disabling. 38 C.F.R. Part 4, Diagnostic Code 5292 (1999). Severe lumbosacral strain with listing of the whole spine to the opposite side, positive Goldthwaite's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion is rated as 40 percent disabling. A 20 percent evaluation is provided with muscle spasm on extreme forward bending, loss of lateral spine motion, which is unilateral in a standing position. A 10 percent evaluation is warranted for lumbosacral strain where there is characteristic pain on motion. 38 C.F.R. Part 4, Diagnostic Code 5295 (1999). Limitation of extension of the thigh to 5 degrees is rated as 10 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5251 (1999). A 30 percent evaluation is provided for limitation of flexion of the thigh to 20 degrees. Flexion limited to 30 degrees is evaluated as 20 percent disabling. Flexion limited to 45 degrees is evaluated as 10 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5252 (1999). Impairment of the thigh with limitation of rotation in which the veteran cannot toe-out more than 15 degrees on the affected leg is rated as 10 percent disabling. Impairment of the thigh where adduction is limited, and the veteran cannot cross his legs is rated as 10 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5253 (1999). Where the minimum schedular evaluation requires residuals and the schedule does not provide a noncompensable evaluation, a noncompensable evaluation will assigned when the required residuals are not shown. 38 C.F.R. § 4.31 (1999). Factual Background. The service medical records include records of treatment for back pain. In September 1983 the veteran complained of low back pain after a motor cycle accident. He had paraspinal muscle spasms of L4-L5. The assessment was that he had muscle strain. In January 1989 the veteran complained that for three years he had chronic low back pain. He had a recent exacerbation three weeks ago. The right lower back or near the right hip was the location. It was worse with heavy lifting. He denied any numbness or tingling. There was no scoliosis or kyphosis. He had full range of motion with pain on extension. The pain was located on the right side of the spinal column with a more rigid latissimus muscle. Straight leg raising was negative to 90 degrees bilaterally. Deep tendon reflexes were 2 + bilaterally. The impression was back muscle spasm on the right. Service medical records reflect that the veteran fractured his right clavicle in April 1986 when he was involved in a motorcycle accident. There was tenderness and some deformity along the course of the right clavicle. There were no neurovascular deficits. X-rays revealed a fracture of the mid-clavicle, in reasonably good position. In November 1986 the veteran had full range of motion of the right shoulder. There was a step deformity of the right clavicle with tenderness. The only reference to right hip pain appears in July 1992 service medical records. The veteran complained of right hip pain. He had been struck in the back when a nose gear collapsed. There was no edema. There was erythema of the lateral right region of the dorsal hip. There was mild to moderate point tenderness. Range of motion was intact. There was no apparent sacral or lumbar injury. He was intact neurovascularly. The assessment was contusion of the lateral right dorsal hip. Later in the month the veteran was reexamined and had minimal complaints. There was no edema or erythema. There was no point tenderness. Range of motion was intact. The Board has reviewed the service medical records to determine if the veteran's right or left shoulder is his major arm. A Report of Medical History dated in January 1987 reveals that the veteran is right handed. The veteran was examined by VA in January 1993. The examiner noted that the right clavicle fracture had healed uneventfully. It did not interfere with the veteran's activities. He had no other associated symptoms. Examination revealed a deformity of the junction of the middle and distal third of the right clavicle with a dorsal displacement of the proximal fragment. There was no acute tenderness or other acute changes. There was normal motion of the right shoulder and shoulder girdle. There was no apparent false joint at the fracture site. The assessment was status post fractured right clavicle in 1986 with residual deformity in the clavicle, but no apparent functional impairment at present. As to the right hip, the VA examiner noted that it did not interfere with the veteran's activities. There were no remarkable findings on examination of the right hip. He had full range of motion. There were no palpable abnormalities or tenderness. The assessment was: Status post right hip contusion in 1992 as described above, resolved, with periodic discomfort in the region, but no remarkable findings on examination and no functional impairments apparent. When questioned about his back the veteran indicated that he had no restrictions in his activities. There was no radiculopathy or other associated symptoms. He used caution when exerting his back. Examination revealed full range of motion. There were no changes in the paraspinal musculature. He had no neurological abnormalities in the low back. The assessment was intermittent low back pain occurring about once a week since 1983, as described above, suggestive of low back strain. There were no remarkable findings on examination. The veteran appeared at a hearing at the RO in September 1994. The veteran described his back pain as a tightness in his muscles that came and went. It was mostly tight in the afternoon. He always had pain in the afternoon and first thing in the morning. Both legs were affected by it. He always had pain in his back. Whether or not he was bending or sitting he had pain in his back. Bending made it worse. It bothered him at night when he lay down. He was employed as a boat mechanic. He wore a back brace at work. The pain interfered with his work a little bit. He did not lift things by himself. He asked for help or used the proper equipment. He had never been totally incapacitated by his back. He always had pain in his hip. It felt as if there was a burning and a tightness. He had not had surgery on his back. The fracture of the clavicle had not affected his ability to lift. If he had to lift the arm above shoulder height he noticed a weakness. He had a loss of sensation and a tingling in one area due to breaking his collar bone. He thinks that it healed incorrectly. When he had to work over his head for period of time it irritated him quite a bit. He worked beneath him and at a bench doing Marine mechanic work. That had been recommended to him due to his back and shoulder problems. VA records from June 1995 revealed that the veteran had low back pain after chopping wood. He had tingling in both lower extremities. The examiner noted that the veteran was walking in slight flexion. He moved slowly. Motor strength was 5/5. Sensations was intact. Deep tendon reflexes were one plus and symmetrical. Babinski was downgoing. He had decreased range of motion. Straight leg raising was less than 15 degrees on the right and to 30 degrees on the left. A VA examination was performed in July 1995. The veteran reported that he had a bump over the distal clavicle. He had some numbness in the anterior shoulder. He described rather full range of motion. He could not hold his arm out with any weight for any length of time. The veteran reported numbness and pain in his back. Some of the pain went down the back of both of his legs to his knees and occasionally down to his heels. The examiner noted that it was not classic radicular symptomatology. Recently he had torn a muscle in his back. The impression was lumbosacral sprain, chronic low back pain. X-ray reports revealed disk space narrowing at L4-5. Examination of the right shoulder showed a prominent step-off deformity of the distal one-third of the clavicle. There was full internal and external rotation of the right shoulder. There was minimal wasting of the right deltoid. Flexion and abduction were from 0-170 degrees. The impression was: Fracture of the right clavicle with minimal right shoulder girdle wasting and decreased range of motion compatible with some chronic bursitis of the shoulder. Examination of the lower back showed no abnormal curvatures. The veteran moved and turned when he got up off the table in a way which suggested he had chronic back pain. Forward flexion was to 90 degrees, extension backwards was to 20 degrees, lateral flexion was to 40 degrees and lateral rotation was 35 degrees to the right and left. He could heel-toe walk. Straight leg raising gave him some back pain bilaterally without radicular symptoms. Deep tendon reflexes were hypoactive. There was some numbness over the right lumbosacral area compared to the left. The impression was: Chronic lower back pain. The examiner could not define whether or not this was diskogenic or a chronic strain in nature. Examination of the hip revealed that hip motion was normal. There was no leg length discrepancy. The impression was: I cannot make any diagnosis of pathology of right hip. There is no pain to the groin or to the anterior thigh to suggest right hip disease. The Board remanded the veteran's claims to the RO in May 1996 based on DeLuca v. Brown, 8 Vet. App. 202 (1995). In October 1996 a VA examination was performed. Subjectively the veteran reported some numbness along his right side. He had difficulty sleeping on his right side as a consequence of his right clavicle fracture. A year and a half ago he began chiropractic treatments for his back. He had been receiving weekly adjustments for a period of six months. The veteran had soreness in his lower back. He did not take any medications. Examination revealed asymmetry of the right shoulder. He had a healed mid-shaft right clavicular fracture in bayonet apposition. He had unrestricted shoulder abduction, adduction, flexion and extension. Adduction was measured as 170 degrees on the right and left. Flexion was 170 degrees right and left. Extension was 35 degrees right and left, in a seated position. The veteran had external rotation of both shoulders up to 75 degrees right and left. Internal rotation was 30 degrees to the right and left. He had full elbow extension, flexion, pronation and supination. He had full wrist flexion and extension. Upper extremity circumference was 35 centimeters for the upper right and left arms. Forearm circumference was 33 centimeters on the right and left. Reflexes in the biceps, triceps and brachial radialis were trace with reinforcement. Motor strength testing revealed strong shoulder adduction, abduction, flexion, extension, internal/external rotation, 5/5. The veteran had strong elbow flexion, extension, pronation and supination. Wrist extension and flexion was strong. Extrinsic and intrinsic movements of the hand were strong. Sensation in the upper extremities was intact to light touch, to pinprick and temperature. The diagnosis was healed fracture of the right clavicle. Examination of the back revealed forward lumbar flexion to 80 degrees. Lumbar extension was to 30 degrees. Lateral bending was to 25 degrees. Straight leg raising was negative to 75 degrees. Patella and ankle jerks were trace with rein- forcement. The veteran had strong hip flexors. His extensors were strong. Ankle dorsiflexion, plantar flexion, toe dorsiflexors and plantar flexors were strong. Sensation in the lower extremities was intact to light touch, to pinprick and temperature. The veteran's gait was normal in appearance. He could easily walk on his toes and heels. He could easily perform a deep knee bend. His pain was localized not in the area of the right hip, but in the area of the sacroiliac joint. There was localized tenderness to palpation of the sacroiliac joint on the right and none on the left. X-rays taken in June of 1995 showed normal height and alignment of the vertebral bodies, disk spaces by this examiner's review appeared normal. There was no evidence of scoliosis and no facet changes. The examiner reported that Dr. J. Marley in June 1995, reported his interpretation that the X-rays documented mild L4-5 disk narrowing. The examiner did not see that on plain films as reported after review. The diagnosis was chronic low back pain. Examination of the hips revealed no restriction of movement. There was no pain on movement. Circumference of the right thigh four finger breadths above the patella was 46 centimeters on the right and left. Calf circumference was 41 centimeters on the right and left. The diagnosis was reported right hip numbness. In his discussion the examiner stated that it was his opinion that there was no impairment to the right shoulder and right upper extremity secondary to the healed right clavicle. It was the opinion of the examiner that the veteran had normal range of motion of the back. The veteran was able to perform range of motion without reports of pain. His right hip pain was localized to the right sacroiliac joint. There was no increased pain on compression of the sacroiliac joint. The examiner reported that there was no pain on movement. There was no evidence of swelling. There was no evidence of muscle spasm. There was no documentation in the medical record or with the claimant of recurring attacks resulting in weakened movement or excess fatigability. The examiner felt that the veteran did have pain in the sacroiliac joint area. The hip, knee and ankle joint were otherwise normal. The examination of the right shoulder was normal. There was no evidence of right hip pathology. There was no evidence of right shoulder pathology or impairment. The veteran had reported that he worked full time. He had not lost additional time because of flare-ups. The only treatment he had sought were chiropractic treatments in late 1996. In October 1998 the RO received copies of treatment records from the veteran's chiropractor, Dr. Jennifer Hess. In a November 1994 letter, she reported that the veteran had active flexion and extension in the lower back which was full, but both were painful in the lumber region and right sacroiliac joint. Palpation revealed moderate hypertonicity of the right sided erector spinae muscles from T6 to L5 as well as bunching of the right sided gluteus maximus and medius muscles. Motion palpation indicated restriction of the right sacroiliac joint, L5 and T7-T8. Derefield's Test was positive for right sacroiliac joint dysfunction and misalignment. Additionally, there was marked shortening of bilateral hamstring muscles, causing a posterior tilt of the pelvis, decreased lumbar lordosis, and increased stress on the lumbar musculature. This also contributed to a decrease in the thoracic kyphosis. Dr. Hess noted decreased transverse arches, bilaterally, which further contributed to the veteran's biomechanical imbalances. Deep tendon reflexes were +2 and symmetric for the patellar and Achilles reflexes. Lasegue's Straight Leg Raise and Braggart's Tests were negative for disc herniation, though the leg pains suggest evidence of disc involvement. Sensory motor exams were unremarkable. The diagnosis was vertebral subluxation at the right sacroiliac joint, L5, T7 and T8; altered biomechanics of the lumbar and thoracic spine causing repeated strain of the lumbar musculature, sprain of the right sacroiliac joint, weakened back extensors, hypertonic hip extensors and dropped transverse arches. Additionally, Dr. Hess reported that his symptoms were suggestive of mild disc degeneration. A VA examination was performed in December 1998. The veteran perceived that his residuals of fracture of the right clavicle included numbness in the right anterior shoulder. In fact, objective examination revealed global numbness about the right anterior shoulder, distal to the clavicle fracture. The veteran reported back and low back pain. At one time it was radiating down the leg. Currently, it was not radiating into the leg. Examination revealed an entirely symmetrical lumbar spine. There was no evidence of kyphosis or scoliosis. There was no hypertonicity, no spasm, no sacroiliac joint or sciatic notch tenderness. The veteran reported subjectively that the pain was in a strip at the lumbosacral junction. He had 90 degrees of lumbar forward flexion. It was measured with an inclinometer. He had 10 degrees of extension. He had 30 degrees of lateral bending. He had 60 degrees of rotation to the right and left of the thoracolumbar spine. Even with reinforcement the veteran had trace reflexes, including patellar and ankle jerks. They were just trace, without reinforcement, no other reflexes could be elicited. Sensation was intact in both lower extremities, dermatomes to light touch and pinprick. The diagnosis was chronic low back pain. Right buttock contusion related to work activity in the summer of 1992 was noted. Examination revealed a prominence in the mid-clavicle on the right. There was some overriding with some moderate degree of callous formation. The clavicle was clinically healed. The veteran had unrestricted passive range of motion. Unrelated to the clavicle fracture, the claimant did have some subacromial crepitus of the right shoulder. It caused some discomfort with overhead reaching, namely abduction and flexion. The veteran had full passive range of motion. He did limit abduction on the right to 155 degrees under active control, while abduction on the left was to 180 degrees. Flexion was likewise reduced to 140 degrees on the right while it was 150 degrees on the left. Extension was to 35 degrees on the right and left. External rotation was 90 degrees on the right and 95 degrees on the left. Internal rotation was 30 on the right and 40 degrees on the left. Elbow and wrist motions were normal. Motor strength was intact. His shoulder abductors, adductors, flexors and extensors were strong. Over the right anterior chest wall, the veteran did have some global discomfort of a non dermatome distribution. It was multilevel. It began up 10 centimeters above the right nipple of the breast and extended up to the clavicle. The diagnoses were: Right clavicle fracture, healed with a prominent callous formation. Reduced sensation anterior chest wall, unrelated to diagnosis #1, on a more probable than not basis. The numbness does not conform with residual clavicle fracture. Right shoulder impingement syndrome unrelated to service activity. Examination of the lower extremities revealed hip flexion of 105 degrees on the right and left. Abduction was to 60 degrees on the right and left measured with a goniometer, adduction was 40/40. External rotation was 40/40. Internal rotation was 15/15. Straight leg raising was 8 negative to 85 degrees right and left. X-rays were entirely normal. The disk heights were well maintained, vertebral bodies and joints looked normal. The examiner disagreed with the report of Dr. J. Harley of mild narrowing of L4, 5. In his discussion the examiner indicated that the claims folder had not been available for his review. He stated that there was restricted range of motion of the shoulder. In all probability it was secondary to an impingement syndrome. It was not specifically related to, nor was it caused by the clavicle fracture. The lower back was unremarkable on examination. There was documentation on Form 212507 that the veteran might have cystic lesions in the right hip area. X-rays of the right hip were ordered. Another VA examination was performed in June 1999. The examiner noted that the veteran's claims folder had been reviewed. The veteran had been working as a boat mechanic since 1993. He was working full time without any formal restrictions. The veteran reported that he perceived soreness and numbness in the area of the right hip. He reported lower back discomfort. He reported no numbness or weakness in either arm or leg. He did feel soreness in the right shoulder. Examination revealed a palpable bump on the right mid clavicle. He had a mid shaft clavicle fracture. It was clinically united. He sensed some numbness about the site. Upper and lower extremities were well muscled. His hands were well callused and stained. Upper extremity circumference was 35 centimeters on the right and left. Forearm circumference on the right and left was to 34 centimeters. He had full passive range of motion of both shoulders without restrictions. There was no subacromial crepitance. On palpation the veteran reported some tenderness over the acromion, this was away from the clavicle fracture. The shoulder soreness prevented him from actively abducting fully. He lacked 5 degrees of complete adduction on the right measurably. Adduction was 165 on the right and 170 on the left. It was the examiner's opinion that it was in no way connected with the clavicle fracture. Shoulder flexion measured with the goniometer was 150/150. Extension was 40/40. External rotation was to 85 degrees on the right and 90 degrees on the left. Internal rotation was 40/40. Upper extremity motor strength was excellent. He had strong shoulder abductors, adductors, flexors, extensors and internal and external rotators. Flexors extensors were strong. Hand and intrinsic strength was strong. Sensation about both upper extremities was intact to light touch, pinprick, vibration and temperature. Examination of the lower back revealed some localized right sacroiliac joint tenderness. There was no visible asymmetry of the lumbar spine. There was no palpable hypertonicity or spasm. There was no lumbar tenderness, no sacroiliac joint tenderness, no greater trochanteric tenderness. He had unrestricted back motion. He was able to forward flex to 85 degrees measured with an inclinometer. Extension was to 20 degrees, lateral bending was to 35/35. In the seated position rotation was to 45/45 measured with a goniometer. He had a symmetrical gait as he walked. He could walk on his toes and heels. In the supine position he had symmetrical hip flexion actively. He could flex both hips to 120 degrees measured with goniometer. With his own assistance, grabbing his knees and pulling them forward he could get flexion to 135 degrees right and left. Abduction measured with a goniometer was 45 degrees on the right and left. Adduction was to 25 degrees on the right and left. Internal rotation was 40 degrees on the right and left. External rotation was 40 degrees on the right and 45 degrees on the left. Supine straight leg raising was negative to 85 degrees. It was difficult to elicit reflexes either at the patellar, patellar jerks or ankle jerks even with reinforcement. Sensation was intact to light touch, pinprick, vibration and temperature. X-rays of the right hip taken in December 1998 were normal. Lumbosacral films were normal. The vertebral bodies were normal. Disk spaces were well maintained. The diagnoses were: (1) The claimant reports residual tenderness of right sacroiliac joint; (2) Normal musculoskeletal neurologic examination today; and (3) Right clavicle fracture sustained, healed without sequelae. He had a palpable bump from the fractured callus in the healing process. He had a contusion of the right hip on July 1992 and continued to report right sacroiliac tenderness. In his discussion the examiner stated that the veteran did not have any impairment of his back, upper extremity, or lower extremities. He had an unremarkable examination. Clinically, he had a healed fracture with a bump over the right mid clavicle, but otherwise the examination was normal. There was no documentation of loss of motion due to pain, no pain behaviors noted on examination. Ranges of motion were performed actively and the veteran was advised not to exceed his own pain tolerance. There was no evidence of recurring attacks, and no history of such. There is no history of muscle spasms, swellings or particular sense of stiffness in the right shoulder. Pain was not supported by adequate pathology. The objective examination was unremarkable. There was no current pathology discernible to support subjective complaints in the area of the low back, right shoulder or right hip. The examiner noted that the claims folder had been reviewed. Analysis. As a preliminary matter the Board noted that the veteran's claims were remanded to the RO in May 1996. In Stegall v. West, 11 Vet. App. 268 (1998) the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, "the Court") held a remand by the Court or the Board of Veterans' Appeals (Board) confers on the veteran as a matter of law, the right to compliance with the remand orders. It imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand. In the remand the RO was ordered to request that the veteran identify any physicians who had treated him in the recent past. In September 1998 the RO sent the veteran a letter requesting that he notify them of any treatment he had received for his service-connected disabilities. The veteran responded that he had been treated by Dr. Jennifer Hess. Records of treatment of the veteran by Dr. Hess were obtained and associated with the claims folder. The RO was also ordered to afford the veteran an orthopedic examination which addressed 38 C.F.R. § 4.40 and 4.45. The veteran was examined by VA for disability evaluation purposes in October 1996, December 1998, and again in June 1999. The reports of those examinations address the issues of impairment due to pain as per DeLuca v. Brown, 8 Vet. App. 202 (1995). Residuals of Fracture of the Right Clavicle The residuals of the fracture of the right clavicle are currently evaluated as 10 percent disabling. The service medical records reveal that the veteran is right handed. The Schedule for Rating Disabilities provides a 20 percent rating for the major arm when there is dislocation of the shoulder or nonunion of the clavicle with loose motion. 38 C.F.R. § 4.71a, Diagnostic Code 5203. There is no evidence of record which demonstrates that the veteran has dislocated his shoulder. The VA examiners have all reported that the veteran's fracture of the clavicle was healed. There is no evidence of nonunion or loose motion. A higher evaluation than 10 percent based on Diagnostic Code 5203 is not warranted. Impairment of the clavicle may also be rated based on impairment of function of the contiguous joint. Examination of the shoulder has demonstrated that the veteran does have some decreased range of motion as reported in the July 1995 VA examination. The examiner attributed it, not to the fracture of the clavicle, but to bursitis. In December 1998 the VA examiner also noted global numbness about the right anterior shoulder. The examiner diagnosed right shoulder impingement syndrome which he noted was unrelated to the fracture of the clavicle. A review of the claims folder indicates that no impairment of the right shoulder has been attributed to the residuals of the fracture of the right clavicle. An increased rating based on impairment of function of the right shoulder is not warranted. The Board has also considered whether an evaluation under 38 C.F.R. § 4.40 and 4.45 as outlined in DeLuca v. Brown, 8 Vet. App. 202 (1995) is appropriate. The regulation requires that functional loss due to pain be supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Limitation of the shoulder, due to pain, has been attributed to pathology of the shoulder itself such as bursitis and impingement syndrome. There is no indication that the residuals of the fractured clavicle have caused pain or functional impairment. For that reason an increased rating based on 38 C.F.R. § 4.40 and 4.45 is not warranted. L4-L5 Disc Disease The first question to be addressed in this case is which Diagnostic Code is appropriate for evaluating the veteran's low back disorder. The veteran was initially service connected for what the RO described as disc disease. The RO evaluated the veteran under Diagnostic Code 5293 for rating intervertebral disc syndrome. After reading the record in its entirety, the Board concluded that the veteran has not been diagnosed with degenerative disc disease. Recently the veteran has denied having any radicular symptoms. For that reason the Board has considered the application of other Diagnostic Codes. Based on the medical record in this case, described above, the Board does not believe that any other rating codes are as appropriate as Diagnostic Codes 5292 for rating limitation of motion of the lumbar spine and 5295 for rating lumbosacral strain. These diagnostic codes incorporate both the pain on motion and strain complained of by the veteran. See Butts v. Brown, 5 Vet. App. 532, 537-540 (1993) and Tedeschi v. Brown, 7 Vet. App. 411, 413-4 (1995). The Board first considers whether or not the veteran meets the criteria for a 20 percent rating based on moderate limitation of motion. In January 1993 the veteran had full range of motion of the back. The veteran described his back pain as a constant tightness in September 1994. VA examination in July 1995 revealed flexion to 90 degrees. After an injury in June 1995 the veteran had decreased range of motion. In October 1996 the veteran was able to flex to 80 degrees. The examiner described the veteran as having normal range of motion of the back in October 1996. He did note that the veteran had pain in the area of the sacroiliac joint. The veteran's, chiropractor, Dr. Hess, also reported active flexion and extension that was full, but painful. In December 1998 the VA examiner described the examination as unremarkable. In June 1999, the examiner reported that he was able to forward flex to 85 degrees. Extension was to 20 degrees and lateral bending was to 35/35. In the seated position rotation was to 45/45. Based on the evidence of record the veteran has not demonstrated moderate limitation of motion of the lumbar spine. An increased rating based on limitation of motion is not warranted. The Board next considers whether or not the veteran demonstrated muscle spasm on extreme forward bending. A higher evaluation to 20 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5295 requires more than characteristic pain on motion, it requires evidence of muscle spasm on forward bending. There is no indication in the claims folder that the veteran has back spasms. VA examiners have specifically stated that no spasm was noted. A higher evaluation under Diagnostic Code 5295 is not warranted. The Board also considered an evaluation under 38 C.F.R. § 4.40 and 4.45 for the low back. The examiner in June 1999 stated unequivocally that the veteran's complaints of pain were not supported by adequate pathology. In his discussion the examiner stated that the veteran did not have any impairment of his back. The pathology demonstrated by the veteran is insufficient to support a higher evaluation than 10 percent. An increased evaluation for the veteran's service-connected low back disability is not warranted. Right Hip A review of the claims folder indicates that no pathology of the right hip was demonstrated on examination. It was noted by the VA examiner in June 1999 that the veteran suffered a contusion of the right hip in 1992. No disorder of the right hip was diagnosed. The examiner stated that the veteran's complaints of right hip pain actually referred to pain over the sacroiliac joint and not the hip joint. There is no evidence of limitation of motion. The veteran's gait was noted to be normal. The veteran had demonstrated full range of motion of the right hip on examination. The VA examiner in June 1999 stated that there was no impairment of the lower extremities. Based on the evidence of record a compensable evaluation for disability of the right hip is not warranted. 38 C.F.R. § 4.31. In Conclusion In exceptional cases where the schedular evaluations are found to be inadequate, an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be approved provided the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321 (1999). The Board finds that the above evaluations contemplate the symptomatology and resulting impairment demonstrated in the medical evidence of record for the right clavicle, the back, and the right hip disabilities. The veteran has testified that he works full time. He has not indicated any marked interference with employment. His complaints are not unusual. Consequently, the Board concurs with the RO that there are no unusual or exceptional factors such as to warrant referral of this case for consideration of an extra-schedular evaluation. There is no evidence of arthritis affecting the low back, right clavicle or right hip. For that reason application of 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010 are not applicable. The Board further notes that in making the above determinations it has taken into consideration the applicability of "staged ratings," pursuant to Fenderson, supra. However, the record does not contain any evidence showing any distinctive periods for which the severity of any of the disabilities met or nearly approximated the criteria necessary for an increased disability rating. ORDER An increased rating for residuals of a fracture of the right clavicle is denied. An increased rating for L4-5 disc disease is denied. An increased rating for a right hip disability is denied. Gary L. Gick Member, Board of Veterans' Appeals