Citation Nr: 0007119 Decision Date: 03/16/00 Archive Date: 03/23/00 DOCKET NO. 95-24 118A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased evaluation for a low back disability (degenerative disc disease), currently evaluated as 40 percent disabling. 2. Entitlement to an increased (compensable) evaluation for degenerative joint disease of the left hand. 3. Entitlement to an increased (compensable) evaluation for degenerative joint disease of the left foot. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Christopher P. Kissel, Counsel INTRODUCTION The appellant was honorably discharged from the United States Army in March 1992 with over twenty years of active duty service. This case comes before the Board of Veterans' Appeals (the Board) on appeal from a June 1995 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO). The record reflects that the appellant appeared at a hearing before the undersigned Member of the Board on December 7, 1999. A transcript of that hearing has been associated with the record on appeal. The issue of an increased rating for the low back disability will be the subject of the remand portion of this decision. FINDINGS OF FACT 1. The medical evidence of record does not show any clinical findings of functional impairment as a result of the degenerative joint disease in the appellant's left hand or left foot under the schedular criteria. 2. The evidence in this case does not reflect that the appellant has an exceptional or unusual disability picture as to render impractical the application of the regular schedular disability rating standards for his left hand and left foot disabilities. CONCLUSIONS OF LAW 1. The appellant's degenerative joint disease of the left hand is no more than noncompensably disabling pursuant to the schedular criteria. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. Part 4, Diagnostic Code 5010-5220 (1999). 2. The appellant's degenerative joint disease of the left foot is no more than noncompensably disabling pursuant to the schedular criteria. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. Part 4, Diagnostic Code 5284 (1999). 3. Application of extraschedular provisions for the left hand or left foot disability is not warranted in this case. 38 C.F.R. § 3.321(b) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background The appellant was most recently evaluated on a VA joints examination conducted in December 1998. Prior to 1998, the appellant's service-connected left hand and left foot disabilities were evaluated on a VA compensation examination conducted in January 1995. The balance of the medical evidence consists of service medical records, the reports of VA examinations conducted in June 1991 (general medical) and December 1992 (joints), and outpatient records from the Daytona Beach VA outpatient clinic dated in August 1992. Service department records disclosed that the appellant was honorably discharged from the Army in March 1992 with over twenty years of active duty service. He filed his original claim for VA disability compensation benefits in April 1992, and by rating decision in July 1992, service connection was granted for the low back, left hand and left foot disabilities at issue here on appeal. These conditions were described as a single disability, degenerative joint disease, lumbar spine, left hand and left foot with history of fracture of left hand and left foot (without limitation of motion), and assigned a 10 percent rating under Diagnostic Code 5010, effective from the date of claim, April 1, 1992. Service medical records revealed that the appellant was treated for numerous minor joint injuries over the course of his lengthy service, which included the rigorous duties of a paratrooper occupational specialty. These injuries included a fractured left thumb and multiple ankle sprains and blunt- force trauma to the feet associated with parachute drops. An x-ray of the left hand taken in November 1991 showed mild degenerative joint disease at the first metacarpophalangeal (MCP) joint. An x-ray of the left foot taken in August 1989 showed degenerative joint disease and a bone spur. The report of June 1992 VA general medical examination noted that appellant's complaints of pain on the plantar surface of both with periodic swelling. He also complained of numbness in both arms, especially the right arm, which seemed to start in the region of the wrist and extended out to the hands and arms. Notwithstanding these complaints, clinical findings on examination revealed no evidence of abnormal pathology of the feet or arms: Arms: No evidence of abnormality along with the hands. The pulse is entirely within normal limits as well as temperature and color of the hands and arms. He does describe some fleeting discomfort described as numbness in the thumb and index and middle fingers of both hands. Feet: There is no evident abnormality noticed, there being no swelling or any other abnormality, no circulatory disturbances. The plantar surface of the feet is normal in appearance. Based on these findings, diagnosis of possible carpal tunnel syndrome and "no pathologic evidence of abnormality of the feet" were reported. The August 1992 outpatient report detailed treatment for complaints of tendinitis in the elbows. No complaints referable to the left hand or left foot were reported. The report of the December 1992 VA joints examination noted the appellant's complaints of pain in his elbows and left shoulder. Objectively, he had no limitation of motion of any joints and, specifically, no limitation of motion of the elbows or left shoulder. Based on his complaints, x-rays were taken only of the elbows. No diagnoses referable to the left hand or left foot were reported on this examination. The appellant's claim seeking increased ratings for the disabilities in question was filed in November 1994. In connection with this claim, his left hand and left foot disabilities were evaluated on a VA joints examination in January 1995. Subjectively, he complained of pain in the elbows, knees and back. He indicated that the pain in these joints had become progressively worse, requiring medication for pain relief. Objectively, there was no evidence of any joint swelling, deformity or other impairment. Based on his complaints, range of motion testing was limited to his knees, ankles and elbows. X-rays taken on this examination of his left hand and left foot were interpreted by the examiner as showing no evidence of abnormality, although the report of the left foot x-ray noted a minimal hypertrophic change in the left talonavicular joint. Based on these findings, the examiner recorded a pertinent diagnosis of "[h]e denies problems with the left hand or the left foot." As noted previously, the appellant was most recently examined on a VA joints examination in December 1998. The appellant's reported medical history was significant for a left hand fracture that was treated with casting and bracing while he was stationed at Fort Bragg, North Carolina, and for a history of injuring his left foot during training exercises in 1973, also at Fort Bragg. He was treated with light duty and immobilization at that time. The appellant's employment history since service was significant for unemployment since July 1998. He had worked in the past as a truck driver for the Postal Service, but was awaiting re-employment in another capacity due to his orthopedic problems. His past medical history was reported as significant for status post right carpal tunnel release in 1992. Subjectively, the appellant complained of occasional tingling and stiffness in his left hand. With regard to his left foot, he indicated that he did not bother him that much. Objectively, examination of his left hand showed no evidence of swelling or gross pain on palpation, and he had full range of motion of the fingers to the distal palmar crease. Grip strength was actually greater on the left (137 pounds) than on the right (128 pounds). The appellant was also able to demonstrate an 8 millimeters 2 point discrimination in the median, radial and ulnar distribution. As far as the left foot was concerned, the examiner noted mild swelling over the dorsal aspect of this foot, but he had a normal medial longitudinal arch, good capillary refill, 2+ dorsalis pedis pulse, and no pain on palpation. X-rays taken in November 1998 of the left hand and left foot were interpreted by the examiner as showing early osteoarthritic degenerative changes in the first carpal metacarpal (CMC) joint of the left hand and early mid foot arthritis in the left foot. Based on these findings, the examiner's clinical impression was "[f]irst CMC arthritis, left hand" and [m]ild foot arthritis, left foot." In the comments section of the report, the examiner offered the following remarks: This patient has good grip strength of his left hand and with testing it's felt by this examiner that his disability from his first CMC arthritis is mild and would give him only difficulty with occasional heavy material handling. In reference to the patient's left foot, he has mild mid foot arthritis that can be adequately treated with arch supports and should not give him any difficulties because it's asymptomatic at the present time. Additional evidence submitted with the appellate record included a letter addressed to the appellant and dated in January 1999 from the Postal Service manager of the In-Plant Support. The appellant was notified therein that he was found medically unsuitable for a Casual position based on a review of his medical records and the evaluation by the Postal Service's medical officer (the report of which is dated in September 1998 and is of record) who advised that the appellant could not perform or withstand the following conditions of employment: heavy lifting over 25 pounds; prolonged standing; walking over 45 minutes per hour while lifting and carrying over 10 pounds; repetitive motion work with wrists/hands/fingers; repeated bending, twisting, pushing, or pulling while lifting or carrying over 10 pounds; heavy manual labor; or, exposure to excessive heat or cold. On the basis of the above, the RO issued a rating decision in March 1999 which recharacterized the appellant's original multiple joints disability and awarded separate disability ratings for the low back, left hand, and left foot disabilities, assigning a 40 percent rating for the low back disability (lumbar degenerative disc disease) and noncompensable evaluations for the left hand (osteoarthritis degenerative changes (minor)) and left foot (early mid foot arthritis), effective from December 2, 1998. In April 1999, the RO received additional argument from the appellant in the form of a handwritten statement. He stated that his left hand was constantly numb with little or no use, even during periods of non-use (rest), and that his left foot ached, even with "very minimal" use. At his Travel Board hearing before the undersigned in December 1999, the appellant testified that while he was receiving no current treatment for his left hand and left foot disabilities, other than taking anti-inflammatory medications for his left foot, he continued to experience numbness and moderate stiffness in his left hand, particularly the index finger, and pain in the ball of his left foot with prolonged standing or walking. He denied any related swelling in his left hand, but indicated that he had pain in the fingertips which limited his grip strength, although he admitted that his left hand grip strength was better than his right hand. He further testified that his left hand was his minor extremity (making him right-hand dominant). He also testified with respect to the left foot that he could move all of his toes and experienced no numbness per se in the left foot, but that he could not work in a job that required prolonged standing. The appellant also testified that he could ascertain no relationship between his back pain complaints, which involved radicular symptoms into the lower extremities, and his pain complaints attributable to his left foot disability. Analysis The appellant's claims are well grounded. 38 U.S.C.A. § 5107(a) (West 1991) and Murphy v. Derwinski, 1 Vet. App. 78 (1990). This finding is based on the appellant's contentions regarding the increased severity of his service-connected left hand and left foot disabilities. See Jones v. Brown, 7 Vet. App. 134 (1994); Proscelle v. Derwinski, 2 Vet. App. 629 (1992). A merits-based review of the appellant's claims requires the Board to provide a written statement of the reasons or bases for its findings and conclusions on material issues of fact and law. 38 U.S.C.A. § 7104(d)(1) (West 1991). The statement must be adequate to enable a claimant to understand the precise basis for the Board's decision, as well as to facilitate review by the United States Court of Appeals for Veterans Claims (the Court). See Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Masors v. Derwinski, 2 Vet. App. 181, 188 (1992). To comply with this requirement, the Board must analyze the credibility and probative value of the evidence, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the appellant. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Moreover, as the Court has pointed out, the Board may not base a decision on its own unsubstantiated medical conclusions but, rather, may reach a medical conclusion only on the basis of independent medical evidence in the record or adequate quotation from recognized medical treatises. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Moreover, the Board has the duty to assess the credibility and weight to be given to the evidence. See Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997), and cases cited therein. Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. See also Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Further, with respect to the rating of musculoskeletal joint disabilities (as in this case), the Court has held that the Board must consider the application of 38 C.F.R. § 4.40 (1999) regarding functional loss due to joint pain on use or during flare-ups, and 38 C.F.R. § 4.45 (1999) regarding weakness, fatigability, incoordination, or pain on movement of a joint. See DeLuca v. Brown, 8 Vet. App. 202, 203 (1995). (Title 38, Code of Federal Regulations, Sections 4.40 and 4.45 make clear that pain must be considered capable of producing compensable disability of the joints) and Quarles v. Derwinski, 3 Vet. App. 129, 139-40 (1992) (Board's failure to consider section 4.40 was improper when that regulation had been made potentially applicable through assertions and issues raised in record). Accordingly, the Court's holding in DeLuca requires the Board to consider whether increased schedular or separate (multiple) ratings for the appellant's left hand and left foot disabilities may be in order on three independent bases: (1) pursuant to the relevant schedular criteria, i.e., notwithstanding the etiology or extent of his pain complaints, if the medical examination test results reflect findings which support higher ratings pursuant to the delineated schedular criteria; (2) pursuant to 38 C.F.R. § 4.40 on the basis of additional functional loss due specifically to complaints of pain on use or during flare-ups; and (3) pursuant to 38 C.F.R. § 4.45 if there is additional functional loss due specifically to any weakened movement, excess fatigability, or incoordination. Additionally, with regard to assigning an evaluation for degenerative or traumatic arthritis under Diagnostic Codes 5003 or 5010, the General Counsel has held that the Board must consider whether an increased schedular or separate rating may be in order pursuant to 38 C.F.R. § 4.59 on the basis of painful motion "with joint or periarticular pathology." See VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). With respect to the above, the General Counsel held the Board's consideration of sections 4.40, 4.45 and 4.59 depended on whether the musculoskeletal disability was rated under a specific diagnostic code that did not involve limitation of motion and where another diagnostic code based on limitation of motion was potentially applicable to the particular disability under consideration. Id. However, the General Counsel cautioned that the applicability of a separate or multiple rating for a musculoskeletal disability was subject to the limitations of 38 C.F.R. § 4.14, which prohibits "the evaluation of the same manifestation [of a disability] under different diagnoses." Id. After review of all material issues of fact and law, the Board concludes that a preponderance of the evidence found probative to these claims is against entitlement to compensable or higher disability ratings for the appellant's left hand and left foot disabilities. As stated above, the appellant's degenerative arthritis of multiple joints disability was recharacterized by the RO in March 1999, deleting the prior 10 percent rating under Diagnostic Code 5010 and assigning a 40 percent rating under Diagnostic Code 5010-5295 for the low back disability and noncompensable ratings for the left hand and left foot under, respectively, Diagnostic Codes 5010-5220 and 5284. The RO determined that these ratings were effective from December 2, 1998, on a facts found basis (the results of the December 1998 VA joints and spine examinations). Hence, as the now- deleted 10 percent rating was effective from a later period, April 1, 1992 to December 1, 1998, there was no reduction in the total amount of compensation payable that would give rise to a rating reduction issue. See VAOPGCPREC 71-91, 57 Fed. Reg. 2316 (1992) (where evaluation of a specific disability is reduced but the amount of compensation is not reduced because of a simultaneous increase in the evaluation of one or more other disabilities, 38 C.F.R. § 3.105(e) is not applicable). Left Hand: Diagnostic Code 5220 applies to favorable ankylosis of the five fingers of one hand and provides a single rating of 40 percent for the minor extremity. However, the appellant's disability is presently rated by under Diagnostic Code 5010 for arthritis due to trauma, as it is shown by the evidence that his residuals are manifested only by arthritic changes in the first CMC joint of the left hand. See 38 C.F.R. §§ 4.20, 4.27 (1999). Code 5010 specifies that traumatic arthritis is to be rated under the criteria for degenerative arthritis. Degenerative arthritis, if substantiated by x-ray findings, is rated pursuant to the criteria given under Diagnostic Code 5003 which provides for rating the disability on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of ratable limitation of motion, a 10 percent rating applies where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent evaluation requires x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. The ratings based on x-ray findings are not to be combined with ratings based on limitation of motion. Left Foot: A 10 percent disability rating for a foot injury is warranted in cases where the evidence supports a finding of moderate impairment of function of the foot. A 20 percent disability rating is applicable when the evidence supports a finding of moderately severe impairment of function of the foot. A maximum rating of 30 percent may be assigned if there is evidence of severe impairment. 38 C.F.R. Part 4, Diagnostic Code 5284 (1999). Words such as "moderate" and "severe" are not defined under these schedular criteria and therefore, the use of terminology such as "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decision is "equitable and just." 38 C.F.R. §§ 4.2, 4.6 (1999). Notwithstanding the above-cited schedular criteria, 38 C.F.R. Part 4 provides that in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (1999). After having reviewed all of the relevant medical evidence, the Board concludes that the appellant is entitled to no more than the currently assigned zero percent evaluations for the left hand and left foot. His complaints of numbness with occasional impairment caused by stiffness in the index finger of his left hand and pain in the ball of his left foot with prolonged standing or walking, noted by the record in this case, have been considered; however, the Board assigns the greater weight of probative value to the objective medical evidence, in particular, the recent VA examination conducted in December 1998. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (while evaluation of a service-connected disability requires review of the veteran's medical history, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern). Clinical findings on the 1998 VA examination were essentially negative except for some mild swelling over the dorsal aspect of the left foot. With regard to his left hand, the examiner found no evidence of swelling or gross pain on palpation and moreover, he had full range of motion of the fingers. In addition, his grip strength was actually greater on the left than on the right. And, other than the aforementioned mild swelling in the left foot, the appellant had a normal arch, good capillary refill, 2+ dorsalis pedis pulse and no pain on palpation. X-rays showed only early degenerative changes in the left hand (first CMC joint only) and left foot (mid foot arthritis). Based on these findings, the examiner opined that his left hand arthritis in the CMC joint was "mild" and would only give him difficulty with occasional heavy material handling, and that his left foot, notwithstanding the early mid foot arthritis, was ". . . asymptomatic at the present time." The clinical findings noted on the December 1998 VA examination are not unlike those noted previously in the record. As detailed above, when the appellant was examined for compensation purposes by VA in January 1995, he reported no specific complaints referable to his left hand and left foot. Moreover, the examiner found no evidence of any joint swelling, deformity or other impairment, which would necessarily include the joints of his hands and feet. In addition, x-rays taken at that time of the 1995 examination showed no specific abnormalities in the left hand and left foot; this negative finding therefore consistent with the more recent 1998 x-rays which showed "early" degenerative changes in these joints. Further, the clinical findings reported on the 1992 VA general medical and joints examinations are similarly negative for any abnormalities of the left hand and left foot. Objectively, he had no limitation of motion of any joints on the December 1992 joints examination. On the June 1992 general medical examination, he described some fleeting discomfort manifested by numbness in the thumb and index and middle fingers of both hands, which the examiner diagnosed as possible carpal tunnel syndrome. Hence, it appears that this finding of neurological impairment, which was noted in both hands, was attributed by the examinser as possibly resulting from a disabililty not here at issue. In any event, the medical evidence does not provide any medical opinion which attributes any neurological impairment to the veteran's service-connected left hand disability. By reason of the above findings, the Board concludes that the disability picture presented does not support a compensable or higher ratings under any of the potentially applicable diagnostic codes for the left hand and left foot. In the absence of clinical evidence of same as shown on the VA examinations of record, the appellant's left hand disability is not entitled to a compensable or higher rating pursuant to Diagnostic Codes for impairment/limitation of motion of the fingers manifested by favorable or unfavorable ankylosis (Codes 5216-5227). There is simply no medical evidence which shows that the appellant's left hand disability has any limited impairment caused by ankylosis. Moreover, as it is presently shown by the medical evidence that the appellant's left foot is "asymptomatic," entitlement to a compensable rating under Code 5284 is not warranted. 38 C.F.R. § 4.31. There is also no clinical- medical evidence which would support a compensable or higher rating for any of the other Diagnostic Codes for the foot; it is not shown that his disability is manifested by flatfoot (Code 5276), claw foot (Code 5278), Morton's disease (Code 5279), hallux valgus (Code 5280), hallux rigidus (Code 5281), hammer toe (Code 5282), or malunion or nonunion of the tarsal or metatarsal bones (Code 5283). With regard to the Code 5277, weakness of the foot, bilateral, clinical findings must show that the condition is symptomatic to warrant the 10 percent rating under that code. In this case, the appellant has neither a bilateral service-connected disability nor a symptomatic condition of the left foot, and hence, a rating under Code 5277 would not be in order. In addition, although the recent x-rays substantiate that he has some early degenerative changes in the left hand CMC (thumb) joint and in the mid foot area of the left foot, compensable ratings under Code 5003-5010 are not otherwise in order because it is not shown that such degenerative changes involve 2 or more major joints or 2 or more minor joint groups as defined under 38 C.F.R. § 4.45(f) (1999). According the definition given under section 4.45(f), the joints affected by the degenerative changes in the left hand and left foot would only represent one minor joint group in each extremity, which therefore, would not warrant entitlement to a 10 percent rating for either disability under Code 5003. In any case, as the examiner stated on the December 1998 examination that these disabilities were essentially asymptomatic for purposes of actual functional impairment, application of 38 C.F.R. § 4.31 would preclude entitlement to increased ratings. Further, as there is no evidence that the appellant has sought in/outpatient treatment for the left hand and left foot disabilities in the recent or remote past following service, entitlement to an increased rating for either disability is not otherwise shown pursuant to the general rating policy under 38 C.F.R. § 4.10 which contemplates that disabilities impair the individual's ability to function under the ordinary conditions of life. With respect to above, the Board notes that the diagnostic impressions noted on the 1998 VA examination did not include any comments regarding employment difficulties the appellant would likely experience due to his left foot disability. However, the Board would like to make clear that the description of his disability in these terms is not the only evidence to be considered that will determine the outcome of this claim. What matters is that the medical findings of record are insufficient to warrant greater than a zero percent evaluation for the left foot under the schedular standards. 38 C.F.R. § 4.31. Thus, for purposes of entitlement to Government benefits, VA recognizes that his left foot disability does not involve any impairment of earning capacity of what he could earn in civilian occupations. See 38 C.F.R. § 4.1 (1999). With respect to the left hand, the examiner in 1998 commented that his disability would only give him difficulty with occasional heavy material handling and hence, a compensable rating solely on such grounds is clearly not warranted given that he does not meet any of the schedular standards for a compensable rating. In effect, the schedular criteria mandate that his disability in the left hand must produce greater functional impairment than is presently shown to be considered as causing earning capacity impairment under section 4.1. The Board has considered the Postal Service examination of September 1998 in this regard, but it is clear from review of that report in light of the other medical evidence of record that the appellant's impairment was attributed to his low back disability. In summary, the Board finds that entire record on appeal, aside from his contentions, does not reflect actual impairment of earning capacity as a result of the left hand and left foot disabilities. As alluded to above, the Board must also address whether an increased rating for either the appellant's left hand or left foot disabilities is warranted under 38 C.F.R. §§ 4.40, 4.45. The regulation for musculoskeletal system functional loss in section 4.40 provides: Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursions, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, which respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity[,] or the like. Section 4.45 provides that factors of disability involving a joint reside in reductions of its normal excursion of movements in different planes of motion and therefore, inquiry will be directed to such considerations as movement abnormalities, weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; and incoordination (impaired ability to execute skilled movements smoothly). The appellant's general joint pain complaints noted in the record do not warrant an increased rating under 38 C.F.R. §§ 4.40 and 4.45 for either the left hand or left foot because the medical evidence does not substantiate additional range-of-motion loss in these joints due to pain on use or during flare-ups, or due to weakened movement, excess fatigability, or incoordination. As noted above, the examiner who conducted the 1998 VA examination observed that the appellant only had some mild swelling over the dorsal aspect of the left foot. When viewed together with the fact that he does not have any findings which support a compensable evaluation under the schedular standards, the Board is of the opinion that he does not actually have any "additional" functional impairment of the left hand or left foot. Moreover, regarding section 4.45, the Board notes that at the time of the 1998 VA examination it was not reported that the appellant was using any medical support devices or claiming experiencing any episodes of instability. There is also no evidence of recent outpatient care, physical therapy, or current medication use for the left hand or left foot. These findings preponderate against a finding that he has any additional functional loss due to movement abnormalities, weakened movement, or incoordination. Thus, as the record currently stands, there is no objective medical evidence which confirms the presence of additional functional loss in the appellant's left hand and left foot disabilities. There is also no evidence of any impairment under 38 C.F.R. § 4.59 caused specifically to painful motion "with joint or periarticular pathology" In summary, the recent clinical findings do not reflect a significant level of impairment caused by these disabilities that would support higher schedular ratings under any applicable criteria found in 38 C.F.R. Part 4. With respect to the above, it appears that the exact degree or "extent" of functional loss due pain complaints, expressed either in mathematical or medically certain terminology, is an elusive concept from a medical standpoint. As the Court has stated, "[m]edicine is more art than exact science" and therefore, mere reliance on pain complaints is insufficient to establish an increased level of disability, especially where the clinical findings are not remarkable. Lathan v. Brown, 7 Vet. App. 359, 366 (1995). Accordingly, the Board finds that a preponderance of the evidence is against a finding of "additional functional loss" in his left hand or left foot that is evidently caused by his pain complaints. Consequently, the benefit-of-the- doubt doctrine under 38 U.S.C.A. § 5107(b) is not for application in this case as the evidence for and against the claim is clearly not in equipoise. Cf. Williams (Willie) v. Brown, 4 Vet. App. 270, 273-74 (1993) (citing Gilbert, supra, 1 Vet. App. at 54, the Court found "significant" evidence in support of veteran's claim). In this case, for the reasons stated, the Board finds that a preponderance of the evidence to be against the claim. See Gilbert and Alemany. Moreover, although the Board is required to consider the effect of pain when making a rating determination, which has been done in this case, it is important to emphasize that the rating schedule does not provide a separate rating for pain. See Spurgeon v. Brown, 10 Vet. App. 194, 196 (1996). In view of the above, the Board concludes that an increased disability rating for the left hand or left foot disabilities is not warranted, based on the application of 38 C.F.R. §§ 4.40, 4.45, and 4.59. The Board has considered the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they were raised by the appellant. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, for the reasons discussed above, the Board concludes that the currently assigned ratings for the appellant's service-connected left hand and left foot disabilities adequately reflect the level of impairment pursuant to the schedular criteria. It should be emphasized that the diagnoses and clinical findings of record are essentially uncontradicted by any other medical evidence of record. There is no evidence of record showing that the appellant is qualified to render a medical diagnosis or opinion. Hence, the medical evidence of record cited above specifically outweighs his views as to the etiology of his complaints and/or the extent of functional impairment caused by his service-connected disabilities. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992) (lay assertions will not support a finding on questions requiring medical expertise or knowledge). It is noted that the RO did not consider referral of these claims for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b) (1999) when it last adjudicated the claim by supplemental statement of the case in April 1999. Nevertheless, the Board does not find that a remand is in order with respect to extraschedular consideration as it has not been claimed by the appellant or inferred by his contentions, and it does not appear from review of the medical evidence, that referral for consideration of an extraschedular rating is indicated. In Floyd v. Brown, 9 Vet. App. 88 (1996), the Court held that the Board does not have jurisdiction to assign an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. However, the Board is obligated to seek out all issues that are reasonably raised from a liberal reading of documents or testimony of record and to identify all potential theories of entitlement to a benefit under the law and regulations. In Bagwell v. Brown, 9 Vet. App. 337 (1996), the Court clarified that it did not read the regulation as precluding the Board from affirming an RO conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1) or from reaching such a conclusion on its own. Moreover, the Court did not find the Board's denial of an extraschedular rating in the first instance prejudicial to the appellant, as the question of an extraschedular rating is a component of an increased rating claim and the appellant had full opportunity to present the claim before the RO. Bagwell, 9 Vet. App. at 339. Consequently, the Board will consider whether this case warrants the assignment of an extraschedular rating. In exceptional cases where schedular evaluations are found to be inadequate, the RO may refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1). "The governing norm in these exceptional cases is: A finding that 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." Id. In this regard, the schedular evaluations assigned for the left hand and left foot disabilities in this case are not inadequate. As fully detailed above, the medical evidence does not reflect that these disabilities are severe enough to warrant a compensable or higher schedular rating and hence, it does not appear that the appellant has an "exceptional or unusual" disability. Moreover, the Board finds no evidence of an exceptional disability picture as manifested by related factors such as marked interference with employment or frequent hospitalizations. It is not shown by the evidence that the appellant has ever required inpatient hospitalization for his left hand or left foot disability in the years after service. In addition, there is no recent record of outpatient treatment for either disability. With respect to employment, it is noted that the appellant has been unemployed since July 1998, however, as detailed above, the VA medical records which describe his employment history do not in any implicate his left hand or left foot disability as a factor. Thus, the overall picture presented by the evidence in the claims folder does not actually reflect "marked interference" in employment due specifically to these service-connected disabilities. In the absence of any evidence which actually shows that either disability is exceptional or unusual such that the regular schedular criteria are inadequate to rate it, an extraschedular rating on the basis of employment handicap is not in order. Finally, and for the reasons discussed above, the evidence in this case is not so evenly balanced so as to allow application of the benefit of the doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). ORDER An increased (compensable) rating for the left hand hip disability is denied. An increased (compensable) rating for the left foot disability is denied. REMAND The Board notes that additional medical records, not currently associated with the record on appeal, may be pertinent to the proper adjudication of the appellant's claim seeking an increased rating for his low back disability. Specifically, at his hearing before the undersigned Board Member in December 1999, the appellant testified that he had been recently treated at the VA outpatient clinic in Orlando for his back disability, at which time a CAT scan was taken of his lumbar spine and he was provided a TENS unit. In light of the appellant's testimony, there appear to be additional medical records available. The requisition and consideration of all available medical records that are clearly relevant to an issue on appeal is necessary for the adjudication of the case. Decisions of the Board must be based on all of the evidence that is known to be available. 38 U.S.C.A. §§ 5103(a), 7104(a) (West 1991 & Supp. 1999); see also Franzen v. Brown, 9 Vet. App. 235 (1996) (VA's obligation under sec. 5103(a) to assist claimant in filing his claim pertains to relevant evidence which may exist or could be obtained). Moreover, as this increased rating claim is well grounded, the duty to assist in the development of his claim includes the duty to request information which may be pertinent to the claim. 38 U.S.C.A. §§ 5106, 5107(a) (West 1991). The duty to assist is particularly applicable to records which are known to be in the possession of the Federal Government. See Counts v. Brown, 6 Vet. App. 473 (1994). The Board has carefully reviewed the appellate record and finds that additional medical development to evaluate the service-connected low back disability would prove useful in this case, and is consistent with VA's duty to assist the appellant. The appellant was most recently examined for compensation purposes in December 1998, which in light of the more recent outpatient treatment of his back disability, noted above, merits additional and up-to-date medical evaluation. The duty to assist includes the duty to develop the pertinent facts by conducting a current and thorough medical examination. See 38 C.F.R. § 3.159 (1999); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (citing Allday v. Brown, 7 Vet. App. 517, 526 (1995), "where the record does not adequately reveal the current state of the claimant's disability and the claim is well grounded, the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination," particularly if there is no additional medical evidence which adequately addresses the level of impairment of the disability since the previous examination). In addition to the above, the Board notes that claims for service connection for a bilateral shoulder disorder and entitlement to a total disability evaluation on the basis of individual unemployability (TDIU) were raised by the appellant in his personal statement dated April 25, 1999. Accordingly, as these claims are not presently on appeal, they are referred to the RO for appropriate development and adjudication. Accordingly, this case is REMANDED to the RO for the following development: 1. The RO should contact the VA Outpatient Clinics in Daytona and Orlando and request complete, legible copies of all medical reports which these facility have in their possession pertaining to treatment provided to the appellant since August 1992. Efforts to obtain these records should be documented and any evidence received in response to this request should be associated with the claims folder. 2. Next, the RO should schedule the appellant for a VA compensation examination to determine the nature and extent of impairment caused by his low back disability. All appropriate diagnostic tests and studies deemed necessary by the examiner to render the opinions requested, and to assess the severity of this disability, to include neurological testing and x-rays, if appropriate, should be conducted. All pertinent symptomatology and medical findings should be reported in detail. The physician should be specifically requested to proffer an opinion as to the specific extent and severity of the appellant's low back disability, to include a complete and detailed discussion of all functional limitations associated with this condition, precipitating and aggravating factors (i.e., movement and activity), effectiveness of any pain medication or other treatment for relief of pain, functional restrictions from pain on motion, and the effect the disability has upon daily activities. In that the examination is to be conducted for compensation rather than for treatment purposes, the physician should be advised to address the functional impairment of the appellant's lumbar spine in correlation with the criteria set forth in the VA Schedule for Rating Disabilities, 38 C.F.R. Part 4 (1999). The physician should address the degree of severity and medical findings that specifically correspond to the criteria listed in the Rating Schedule for traumatic arthritis, limitation of motion, ankylosis, etc., and other impairments of the lower back pursuant to the applicable diagnostic codes found under 38 C.F.R. § 4.71a, as well as for any existing neurological impairment, if appropriate. The examiner must conduct range of motion (ROM) testing, and should report the exact ROM of the lumbar spine. The ROM results should be set forth in degrees, and the report should include information as to what is considered "normal" range of motion. If the appellant does not cooperate in such testing, this fact should be specifically noted and the examiner should provide a discussion explaining how the appellant's failure to fully cooperate with ROM testing impacts the validity of the medical examination. The examiner should further address the extent of functional impairment attributable to any reported pain. The report should include a detailed account of all lumbar spine pathology, including arthritis or neurological disorder, found to be present. Moreover, in accordance with DeLuca, supra, the examination report must cover any weakened movement, including weakened movement against varying resistance, excess fatigability with use, incoordination, painful motion, and pain with use in the joints of the lumbar spine, and provide an opinion as to how these factors result in any limitation of motion and/or function of the affected joint or joints. If the appellant describes flare-ups of pain, the examiner should offer an opinion as to whether there would be additional limits on functional ability during flare-ups, and if feasible, express this in terms of additional degrees of limitation of motion during the flare-ups. If the examiner is unable to offer an opinion as to the nature and extent of any additional disability during a flare-up that fact should be so stated. Finally, the examiner should render an opinion as to the severity of the low back disability and the impact it has on the appellant's employability. The examiner should provide complete rationale for all conclusions reached. The claims folder and a copy of this remand must be made available to and reviewed by the examining physician in conjunction with the requested examination. 3. The appellant must be given adequate notice of the requested compensation examination described above, which includes advising him of the consequences of failure to report for a scheduled examination. If he fails to report for an examination, this fact should be documented in the claims folder. A copy of all notifications must be associated with the claims folder. 4. Subsequently, the RO should review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the examination report to ensure that it is in compliance with the directives of this REMAND. The RO should specifically review the examination reports to determine if they meet the requirements specified above. If a report is deficient in any manner or fails to include adequate responses to the specific clinical findings/opinions requested, it must be returned to the examiner for corrective action. 38 C.F.R. § 4.2 (1999); Stegall v. West, 11 Vet. App. 268 (1998). 5. Following completion of the above, the RO should readjudicate the increased rating claim for the low back disability, with consideration of all the evidence of record, to include any evidence obtained as a result of this remand. The readjudication of the low back disability must be within the analytical framework provided by the Court in DeLuca, supra, and by the General Counsel in VAOPGCPREC 9-98, supra. In so doing, the RO must consider alternative diagnostic criteria that may be applicable for this disability, to include separate ratings for any additional functional loss caused by arthritic or neurologic/sensory impairment as well as for additional functional loss caused by weakened movement against varying resistance, excess fatigability with use, incoordination, painful motion, and pain with use in the joints of the lower back. In addition to the above, the RO is advised to consider carefully and with heighten mindfulness the benefit of the doubt rule. 38 U.S.C.A. § 5107(b) (West 1991). If the evidence is not in equipoise the RO should explain why. See Cartwright v. Derwinski, 2 Vet. App. 24, 26 (1991). 6. The RO must develop and adjudicate the appellant's claims seeking service connection for a bilateral shoulder disorder and the TDIU benefits, as alluded to above. All contentions, arguments, theories of entitlement raised by the appellant should be fully addressed by the RO. Notice of the RO's decision regarding these claims, to include notice of appellate rights attaching thereto if the decision is in any way adverse to the appellant, should be furnished in accordance with established claims processing procedures. However, these issues should not be certified to the Board unless all applicable appellate procedures are followed, including the completion of the appeal. Thereafter, the case should be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. Steven L. Keller Member, Board of Veterans' Appeals