Citation Nr: 0810959 Decision Date: 04/03/08 Archive Date: 04/14/08 DOCKET NO. 04-37 345 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an increased initial rating greater than 10 percent for hypertension. 2. Entitlement to an increased initial rating greater than 10 percent for left elbow epicondylitis. 3. Entitlement to an initial compensable rating for diverticulosis. 4. Entitlement to an initial compensable rating for hemorrhoids. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD John Francis, Associate Counsel INTRODUCTION The veteran served on active duty from August 1977 to August 1981 and from May 1983 to May 2003. This appeal comes before the Board of Veterans' Appeals (Board) from an April 2003 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection and noncompensable ratings for hypertension, left elbow epicondylitis, diverticulosis, and hemorrhoids. In January 2006, the RO granted 10 percent ratings for hypertension and left elbow epicondylitis. FINDINGS OF FACT 1. The veteran's hypertension is manifested by diastolic blood pressure predominantly less than 110 mm Hg and systolic blood pressure predominantly less than 200 mm Hg. The veteran's blood pressure is controlled with medication. 2. The veteran's left elbow tendinitis with olecranon spurs is manifested by 135 degrees flexion (110 degrees against resistance) with pain at the limit of motion and zero degrees extension without pain. There is no limitation of motion or pain in pronation or supination. Pain flare-ups occur every three to four months lasting up to four hours and interfere with gripping and pulling aircraft fueling hoses on the job. There is no locking, giving way, fatigability, or use of support devices. 3. In service, the veteran was diagnosed with sparsely scattered diverticular outpouchings in the left descending colon but with no evidence of ulceration, polyp, or tumor mass. The veteran uses a stool softener to aid bowel function. His symptoms are not moderate. 4. The veteran has external hemorrhoids and experiences occasional soreness and intermittent bleeding. The hemorrhoids are not large or thrombotic, irreducible, or with excessive redundant tissue or evidencing frequent recurrences. There are no residuals of an anal fissure or impairment of sphincter control or leakage. CONCLUSIONS OF LAW 1. The criteria for an initial rating greater than 10 percent for hypertension have not been met. 38 U.S.C.A. § 1155(West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7101 (2007). 2. The criteria for an initial rating greater than 10 percent for left elbow epicondylitis have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.69, 4.71a, Diagnostic Codes 5015, 5024, 5206, 5207, 5208 (2007). 3. The criteria for an initial compensable rating for diverticulosis have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.114, Diagnostic Codes 7301, 7319, 7323, 7327 (2007). 4. The criteria for an initial compensable rating for hemorrhoids have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7336 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the veteran is challenging the initial evaluation assigned following the grant of service connection. The RO provided notice in November 2002 that did not address the assignment of ratings and effective dates. In Dingess, the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Furthermore, additional notice was provided in March 2006 that addressed the assignment of a rating and effective date with an opportunity to respond. No additional evidence was received. The Board notes that in his March 2004 notice of disagreement and in his August 2004 and October 2004 substantive appeals, the veteran described his then-current symptoms and their effects on his employment. In addition, VA has obtained all relevant, identified, and available evidence and has notified the appellant of any evidence that could not be obtained. VA has also obtained medical examinations. Thus, the Board finds that VA has satisfied both the notice and duty to assist provisions of the law. The veteran served in armored units in the U.S. Army, retiring at the rank of Sergeant First Class. He contends that the disabilities on appeal are more severe than are contemplated by the initial ratings. Ratings for service-connected disabilities are determined by comparing the symptoms the veteran is presently experiencing with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based as far as practical on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. VA must take into account the veteran's entire medical history and circumstances. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Since the veteran timely appealed the rating initially assigned for the disabilities, the Board must consider entitlement to "staged" ratings to compensate for times since filing the claim when the disabilities may have been more severe than at other times during the course of the appeal. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Hypertension The veteran filed a claim for service connection for hypertension in November 2002. Regulations pertaining to the ratings for hypertension were changed during the pendency of the appeal. See 71 Fed. Reg. 52,457-60 (Sept. 6, 2006). Effective October 6, 2006, a note was added after the rating criteria of Diagnostic Code 7101 concerning separate evaluations of hypertension and other heart diseases. However, the basic criteria for rating hypertension have not changed during the entire period of the veteran's appeal. Because the appellant had not been diagnosed or petitioned for service connection any other cardiovascular disease, this change to the regulation is inapplicable to this appeal. Hypertensive vascular disease (hypertension and isolated systolic hypertension) is evaluated based on blood pressure measurements expressed in millimeters of mercury (mm Hg). A 10 percent rating is warranted when diastolic pressure predominantly is 100 or more, or; systolic pressure predominantly 160 or more, or; a minimum evaluation for a history of diastolic blood pressure of predominantly 100 or more with continuous medication for control. A 20 percent rating is warranted for diastolic pressure of predominantly 110 or more; or systolic pressure predominantly 200 or more. Higher ratings are provided for higher predominant blood pressure measurements. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2007). Service medical records showed that the veteran's blood pressure was noted on physical examinations in January 1988 and November 1988 as 138/100 and 130/102 respectively. However, measurements taken several times per day for five days in November 1988 were all less than 100 diastolic or 160 systolic. In a July 1992 follow-up examination, the veteran's blood pressure was 138/94. He was diagnosed with borderline hypertension and prescribed medication. Measurements taken several times per day for five days in August 1995 were all less than 100 diastolic or 160 systolic. The diagnosis of hypertension and control with medication were noted on physical examinations in November 1998 and November 1999, on an incomplete examination in November 2002, and on a pre-discharge VA examination in January 2003. However, the measurements were all less than 100 diastolic or 160 systolic. In a March 2004 notice of disagreement, the veteran stated that he took prescribed medication to regulate blood pressure and that he had not been hired for some jobs because he would not be covered by health insurance as a result of the disorder. In June 2005, a VA examiner did not review the claims file but noted the veteran's history of hypertension and continued regular use of medication that is consistent with the record. The veteran did not report nor is there evidence of medical follow-up examination or treatment other than the continued use of medication since discharge in 2003. The veteran did not report any observable symptoms that he attributed to high blood pressure. The examiner obtained three blood pressure measurements, all less than 100 diastolic or 160 systolic. The Board concludes that an initial rating greater than 10 percent for hypertension is not warranted at any time covered by this appeal. The Board notes that confirmation of a diagnosis of hypertension requires at lease two measurements taken over at least three days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. However, here the veteran has been diagnosed with hypertension and uses medication regularly to control the disorder. Service medical records and post-service examinations contain many blood pressure measurements on different days that show the veteran's blood pressure has never been 110 diastolic or more or 200 systolic or more on any occasion. Further, the Board notes that there is also no indication that the disorder necessitated frequent periods of hospitalization or otherwise rendered impractical the application of the regular schedular standards. In the absence of evidence of these factors, the Board concludes that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) have not been met. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Left Elbow Epicondylitis 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 with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage and the functional loss with 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 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. Codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, 4.59. Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). A finding of dysfunction due to pain must be supported by, among other things, adequate pathology. 38 C.F.R. § 4.40. "[F]unctional loss due to pain is to be rated at the same level as the functional loss when flexion is impeded." Schafrath, 1 Vet. App. at 592. Evaluating the disability under several diagnostic codes, the Board considers the level of impairment of the ability to engage in ordinary activities, including employment, and assesses the effect of pain on those activities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Ratings for disability of the elbow are, in part, dependent on a determination of the veteran's dominant hand. Only one hand is considered dominant which will be determined by the evidence of record or by VA testing. 38 C.F.R. § 4.69. The veteran indicated that his right hand is dominant on several service medical record history questionnaires. Right hand dominance was also observed by a VA examiner in June 2005. Therefore, rating criteria for a non-dominant left elbow is for application in this case. Epicondylitis is inflammation of tissues adjoining an eminence of the bone. Dorland's Illustrated Medical Dictionary, 564, 28th Ed.(1994). There is no specific rating provided for epicondylitis. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 CFR § 4.20. The veteran's epicondylitis of the left elbow is currently rated as 10 percent disabling under the diagnostic code for tenosynovitis, an inflammation of the tendon sheath. Dorland's at 1668. As there is X-ray evidence of olecranon spurs, the diagnostic code 5015 for benign new growths of bone is also appropriate. Both diagnostic codes provide for rating for limitation of motion of the affected part, as for arthritis. 38 C.F.R. § 4.71a, Diagnostic Codes 5015, 5024. The Board concurs that rating under these identical analogous diagnostic codes is appropriate because the criteria addresses closely related anatomical localization and symptomatology of pain and limitation of motion of the elbow and because the most recent medical examiner diagnosed tendonitis and olecranon spurs. Limitation of flexion of the non-dominant forearm warrants a 10 percent rating if flexion is limited to 100 degrees, a 20 percent rating limited to 90 degrees, a 30 percent rating if flexion is limited to 55 degrees, and a 40 percent rating if limited to 45 degrees. There is no higher rating. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Limitation of extension of the non-dominant forearm warrants a 10 percent rating if extension is limited to 45 degrees, a 20 percent rating if limited to 75 degrees, a 30 percent rating if limited to 100 degrees, and a 40 percent rating if limited to 110 degrees. There is no higher rating. 38 C.F.R. § 4.71a, Diagnostic Code 5207. A 20 percent rating is warranted if flexion is limited to 100 degrees and extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5208. As there is no medical evidence of ankylosis, fracture, impairment of the major bone structure, or limitation of pronation or supination, these criteria do not apply. 38 C.F.R. § 4.71a. Diagnostic Codes 5205, 5209-5213. The normal range of motion for the elbow is from full extension at zero degrees to 145 degrees flexion. 38 C.F.R. § 4.71, Plate I. Service medical records contain a partial, unsigned military discharge physical examination with some information dated in November 2002. In the attached medical history questionnaire, the veteran reported pain in his left and right wrist but no symptoms related to the left elbow. Military outpatient records showed that the veteran was treated for recurrent right wrist pain in September and October 1997 and for injuries to his left hand after a fall in March 2000. There is no record of any symptoms or treatment of the left or right elbows. In January 2003, prior to retirement, the veteran underwent a VA examination. The examiner noted that the veteran provided his service medical records for review and noted his reports of a fall and injury to his left elbow in service in 2000. The veteran reported that he currently experienced flare-up elbow pain three to four times per year. A pain episode lasted for a week and included a reduction of grip strength. The examiner noted no tenderness on palpation over the olecrandon or epicondyle with no fatigue, swelling, laxity, effusion, or muscle atrophy. There was full range of motion without pain and a normal grip. The examiner noted only a history of episodic left elbow epicondylitis. In November 2002, the RO received the veteran's claim for service connection for epicondylitis of the "LT" elbow. The RO granted service connection and a noncompensable rating for epicondylitis of the left elbow in April 2003. In a March 2004 notice of disagreement, the veteran stated that the rating decision was in error and that his claim was for service connection for his right elbow. However, he also expressed disagreement with the assigned rating (presumably for the left elbow) because he experienced stiffness and soreness that interfered with his work and required the use of over-the-counter pain medication. In an August 2004 substantive appeal, the veteran indicated a desire to appeal the rating assigned for the left elbow disability but again stated that his right elbow was the location of the discomfort and functional limitation. The Board notes that a claim for service connection for the right elbow has been adjudicated separately and is not before the Board on appeal. In July 2005, a VA examiner noted that the claims file was not available for review but noted the veteran's reports of repeated bumping of his elbows while performing his duties as a tank crewmember throughout the 1990s. The veteran stated that he did not seek treatment at any time in service. However, the veteran reported episodes of flare-up pain every three to four months lasting up to four hours that interfered with gripping and pulling aircraft fueling hoses in his workplace. He obtained relief with rest, topical cream, and over-the-counter medication. He did not use support devices and denied any locking, giving way, or fatigability. On examination, the examiner noted some tenderness in the olecranon area and minor loss of strength but no heat, redness, or swelling. Strength was 4/5. Flexion was 135 degrees (110 degrees against resistance) with pain at the limit of motion. Extension was to zero degrees without pain, and there was no limitation of motion or pain in pronation or supination. X-rays showed the presence of olecranon spurs. The examiner diagnosed tendinitis of left elbow. In January 2006, the RO granted an initial rating of 10 percent, effective the day following discharge from service. The Board concludes that an initial rating greater than 10 percent for tendinitis and olecranon spurs of the left elbow is not warranted at any time during the period covered by this appeal. Examiners prior to retirement noted no limitation or pain on motion. On the most recent examination, flexion of the left elbow was slightly greater than the 100 degree criteria for a 10 percent rating, and there was no limitation in extension, pronation, or supination. However, the veteran reported some episodic discomfort and reduction in strength in the performance of his work, and X-rays showed the presence of bone spurs. A higher rating is not warranted because flexion is not limited to less than 90 degrees and limitation of extension is not shown. The veteran's episodes occur only three to four times per year, and he obtains prompt relief with over-the-counter products. Although he experiences some loss of strength during an episode, he did not report an inability to perform his employment duties or any lost time from work. In July 2007, the veteran's representative contended that the July 2005 VA examination was inadequate because the claims file was not available for review and therefore the disability was not evaluated in relation to its history. The Board concludes that the examination was adequate because the medical history available in the claims file contained no evidence of any previous symptoms, injury, or disorder of the left elbow. Service records were silent for any left elbow injury and the veteran contended on two occasions that examination and adjudication of a left elbow disorder was in error. The VA examiner in January 2003 noted no current disability and only a history of epicondylitis which was not confirmed in the service records. The veteran provided a description of the circumstances of elbow injuries in service for the first time to the examiner in July 2005. As the file contained no supportive clinical evidence, the veteran was not prejudiced by the examiner's lack of review. In fact, the examiner relied on a symptomatic history provided by the veteran. In addition, the examiner conducted a thorough physical examination which provided the information necessary to assess the severity of the condition. Further, the Board notes that there is also no indication that the disorder has necessitated frequent periods of hospitalization or has otherwise rendered impractical the application of the regular schedular standards. In the absence of evidence of these factors, the Board concludes that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) have not been met. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Diverticulosis and Hemorrhoids Diverticulitis is rated as for irritable colon syndrome, peritoneal adhesions, or ulcerative colitis depending on the predominant disability picture. 38 C.F.R. § 4.114, Diagnostic Code 7327 (2007). Adhesions of the peritoneum warrant a noncompensable rating for mild disability. A 10 percent evaluation is warranted for moderate disability manifested by pulling pain on attempting work or aggravated by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or abdominal distension. 38 C.F.R. § 4.114, Diagnostic Code 7301 (2007). Higher evaluations of 30 percent and 50 percent are provided for moderately severe and severe disability, respectively. A 10 percent evaluation is warranted for moderate ulcerative colitis with infrequent exacerbations. A 30 percent evaluation is warranted for moderately severe disability with frequent exacerbations. Evaluations of 60 percent and 100 percent are provided for severe and pronounced disability, respectively. 38 C.F.R. § 4.114, Diagnostic Code 7301. Irritable colon syndrome warrants a noncompensable rating if symptoms are mild with disturbances of bowel function and with occasional episodes of abdominal distress. A 10 percent rating is warranted if symptoms are moderate with frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating, the highest available, is warranted if symptoms are severe with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. Internal or external hemorrhoids warrant a noncompensable rating if the symptoms are mild or moderate. A 10 percent rating is warranted if the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue and evidencing frequent recurrences. 38 C.F.R. § 4.114, Diagnostic Code 7336. Anal fistulas are rated as for impairment of sphincter control. A noncompensable rating is warranted if the fissure is healed or slight without leakage. A ten percent rating is warranted if the fissure is constant, slight, or with occasional moderate leakage. 38 C.F.R. § 4.114, Diagnostic Codes 7332, 7335. Service medical records showed that the veteran sought treatment in February 1998 for bleeding on bowel movements. The veteran was prescribed topical medications. The symptoms persisted and in April 1998, an examiner noted a positive blood in stool test, diagnosed an anal fissure, and prescribed antibiotic medication. A consulting surgeon prescribed a stool softener and deferred any surgical procedure pending additional observation. A barium enema study was performed in December 1998 to investigate colonic pathology. The radiologist noted a few sparsely scattered diverticular outpouchings in the left descending colon but no evidence of ulceration, polyp, or tumor mass. The radiologist also made conditional comments regarding possible bone density on the fifth sacral segment of the spine. He recommended a check for point tenderness but also stated that the veteran's reports of rectal pain could be related to the prostate. The service medical records contain only a partial, unsigned military discharge physical examination. In the attached medical history questionnaire, the veteran did not report any history of abdominal distress or rectal disease. There is no record of any surgical procedures. In January 2003, prior to retirement, the veteran underwent a VA examination. The examiner noted that the veteran provided his service medical records for review and summarized the treatment noted above. The examiner noted the veteran's reports of mild rectal pain two or three times per year especially after sitting on hard surfaces, but he denied bleeding and did not report abdominal distress. The examiner noted that diverticulosis was an incidental finding of the barium study and was normal for the veteran's age. The examiner also noted that the veteran continued to have external hemorrhoids and that the anal fissure resolved without residuals. In March 2004 notice of disagreement and in an August 2004 substantive appeal, the veteran stated that he continued to use a stool softener and experienced rectal soreness and episodic rectal bleeding. In July 2005, a VA examiner noted the veteran's reports of tailbone soreness and constipation for which he regularly used a stool softener. He denied any rectal bleeding or abdominal pain. The examiner noted good sphincter control with no leakage. The rectal area was normal with no fissures and no signs of anemia. The examiner noted the presence of external hemorrhoids but no thrombosis or bleeding. The veteran declined to undergo another barium study. The Board concludes that compensable ratings for diverticulosis, residuals of an anal fissure, and hemorrhoids are not warranted for any time covered by this appeal. Although a barium study in service identified diverticula in the left descending colon, there was no diagnosis of inflammation, infection, or other colonic disease during service or at any time after service. Although the veteran does continue to use a stool softener to aid bowel function, a compensable rating is not warranted because he has not experienced moderate symptoms with episodes of frequent bowel disturbance with abdominal distress or moderate symptoms similar to ulcerative colitis with infrequent exacerbations. Ulcerative colitis is defined as chronic, recurrent ulceration in the colon, chiefly of the mucosa and submucosa, of unknown cause; it is manifested clinically by cramping and abdominal pain, rectal bleeding, and loose discharges of blood, pus, and mucus with scanty fecal particles. Complications include hemorrhoids, abscesses, fistulas, perforation of the colon, pseudopolyps, and carcinoma. Dorland's Illustrated Medical Dictionary 357 (27th ed. 1988). Such symptoms to a moderate degree have not been demonstrated by the evidence of record. Nor have moderate symptoms under Diagnostic Code 7301, such as pulling pain, colic pain, nausea, abdominal distension or constipation, been demonstrated. The veteran has reported constipation for which he takes stool softeners, however, this symptom alone does not result in a disability that is more than mild in degree. Symptoms of tailbone pain were noted in service to be possibly related to the prostate, and the Board notes that the veteran has service connection and a rating for degenerative disease of the lower spine. Moreover, rectal discomfort and occasional bleeding were attributed to hemorrhoids. Concerning the compensable rating for hemorrhoids and residuals of an anal fissure, there is no record of a continuity of symptoms in service after 1998, and the veteran reported no rectal disease on his retirement physical examination history. No examiner after service noted any residuals of the anal fissure. There is no evidence of impairment of sphincter control or leakage. The veteran continues to have external hemorrhoids and experiences soreness and intermittent bleeding. However, a compensable rating is not warranted because the hemorrhoids are not large or thrombotic, irreducible, with excessive redundant tissue and evidencing frequent recurrences. Further, the Board notes that there is also no indication that the condition has necessitated frequent periods of hospitalization or has otherwise rendered impractical the application of the regular schedular standards. In the absence of evidence of these factors, the Board concludes that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) have not been met. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). (CONTINUED ON NEXT PAGE) ORDER An increased initial rating greater than 10 percent for hypertension is denied. An increased initial rating greater than 10 percent for left elbow epicondylitis is denied. An initial compensable rating for diverticulosis is denied. An initial compensable rating for hemorrhoids is denied. ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs