Citation Nr: 0841243 Decision Date: 12/01/08 Archive Date: 12/09/08 DOCKET NO. 02-12 773A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to an initial rating greater than 10 percent for gastroesophageal reflux disease (GERD). 2. Entitlement to an initial rating greater than 10 percent for testalgia. 3. Entitlement to an initial rating greater than 10 percent for residuals of a right inguinal hernia repair with scar. 4. Entitlement to an initial rating greater than 10 percent for recurrent dislocation of the left index finger. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The veteran had active service from March 1998 to March 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a June 1999 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California, which granted, in pertinent part, the veteran's claims of service connection for GERD, testalgia, residuals of a right inguinal hernia repair with scar, and for recurrent dislocation of the left index finger, assigning a 10 percent rating to each of these disabilities effective April 1, 1999. This decision was issued to the veteran and his service representative in July 1999. In March 2000, the veteran moved to the jurisdiction of the RO in Portland, Oregon. The veteran disagreed with the June 1999 rating decision in May 2000, seeking higher initial ratings for his service-connected GERD, testalgia, residuals of a right inguinal hernia repair with scar, and for recurrent dislocation of the left index finger. He perfected a timely appeal in September 2002. In January 2006, the Board remanded the veteran's appeal to the RO via the Appeals Management Center (AMC) in Washington, D.C., for additional development. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained. 2. The veteran's service-connected GERD is manifested by, at worst, episodes of mild regurgitation and moderately well- controlled daily acid reflux; it is not productive of considerable or severe health impairment. 3. The veteran's service-connected testalgia is manifested by, at worst, complaints of intermittent pain and discomfort. 4. The veteran's service-connected residuals of a right inguinal hernia repair with scar are manifested by, at worst, tenderness from chronic scar impingement on nerves in the area with no evidence of hernia recurrence and no instability, adherence to underlying tissue, ulceration, or underlying soft tissue damage. 5. The veteran's service-connected recurrent dislocation of the left index finger is manifested by, at worst, occasional instability typical of recurrent subluxation of the left index finger, a full range of motion in all digits of the left hand, complaints of left index finger pain, and no interference with the overall function of the left hand. CONCLUSIONS OF LAW 1. The criteria for an initial rating greater than 10 percent for GERD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.114, Diagnostic Code (DC) 7346 (2008). 2. The criteria for an initial rating greater than 10 percent for testalgia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.115a, 4.115b, DC 7525 (2008). 3. The criteria for an initial rating greater than 10 percent for residuals of a right inguinal hernia repair with scar have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, DC 7804-7338 (effective before and after August 30, 2002). 4. The criteria for an initial rating greater than 10 percent for recurrent dislocation of the left index finger have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, DC 5225 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. The veteran's higher initial rating claims are "downstream" elements of the RO's grant of service connection for GERD, testalgia, residuals of a right inguinal hernia repair with scar, and recurrent dislocation of the left index finger in the currently appealed rating decision issued in July 1999. For such downstream issues, notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159 is not required in cases where such notice was afforded for the originating issue of service connection. See VAOPGCPREC 8-2003 (Dec. 22, 2003). For an increased compensation claim, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). In May 2001 and in July 2005, VA notified the veteran of the information and evidence needed to substantiate and complete these claims, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187. To the extent that Dingess requires more extensive notice as to potential downstream issues such as disability rating and effective date, because the July 1999 rating decision was fully favorable to the veteran on the issues of service connection for GERD, testalgia, residuals of a right inguinal hernia repair with scar, and recurrent dislocation of the left index finger, and because all of the veteran's higher initial rating claims are being denied in this decision, the Board finds no prejudice to the veteran in proceeding with the present decision and any defect with respect to that aspect of the notice requirement is rendered moot. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In Dingess, the United States Court of Appeals for Veterans Claims (Court) 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. See Dingess, 19 Vet. App. at 490-91. The Board notes that the Court, in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) clarified VA's notice obligations in increased rating claims. The appeal for higher initial ratings for GERD, testalgia, residuals of a right inguinal hernia repair with scar, and for recurrent dislocation of the left index finger originates, however, from the grant of service connection for these disabilities. Consequently, Vazquez-Flores is inapplicable. With respect to the timing of the notice, the Board points out that the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the RO could not have provided pre-adjudication VCAA notice as the July 1999 rating decision was issued prior to the VCAA's enactment. Because all of the veteran's higher initial rating claims are being denied, any question as to the appropriate disability rating or effective date is moot and there can be no failure to notify the veteran. See Dingess, 19 Vet. App. at 473. There has been no prejudice to the appellant, and any defect in the timing or content of the notices has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328; see also Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). The Board also finds that VA has complied with the VCAA's duty to assist by aiding the veteran in obtaining evidence and affording him the opportunity to give testimony before the RO and the Board, although he declined to do so. It appears that all known and available records relevant to the issues here on appeal have been obtained and are associated with the veteran's claims file; the veteran does not contend otherwise. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. An examination or opinion shall be treated as being necessary to make a decision on the claim if the evidence of record, taking into consideration all information and lay or medical evidence (including statements of the claimant) contains competent evidence that the claimant has a current disability, or persistent or recurring symptoms of disability; and indicates that the disability or symptoms may be associated with the claimant's act of service; but does not contain sufficient medical evidence for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). VA has provided the veteran with examinations to determine the current nature and severity of his service-connected GERD, testalgia, residuals of a right inguinal hernia repair with scar, and recurrent dislocation of the left index finger. In summary, VA has done everything reasonably possible to notify and to assist the veteran and no further action is necessary to meet the requirements of the VCAA. The veteran contends that his service-connected GERD, testalgia, residuals of a right inguinal hernia repair with scar, and recurrent dislocation of the left index finger all are more disabling than currently evaluated. In general, disability evaluations are assigned by applying a schedule of ratings that represent, as far as can be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria that must be met for specific ratings. The regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history. 38 C.F.R. § 4.2; see also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). The veteran's service-connected GERD currently is evaluated as 10 percent disabling under 38 C.F.R. § 4.114, DC 7346 (hiatal hernia). See 38 C.F.R. § 4.114, DC 7346. Under DC 7346, a 10 percent rating is assigned for a hiatal hernia with 2 or more of the symptoms for the 30 percent rating of less severity. A 30 percent rating is assigned for a hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, and productive of considerable health impairment. A maximum 60 percent rating is assigned for a hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia or other symptoms combinations productive of severe health impairment. See 38 C.F.R. § 4.114, DC 7346. The veteran's service-connected testalgia currently is evaluated as 10 percent disabling under 38 C.F.R. § 4.115b, DC 7525 (chronic epididymo-orchitis). DC 7525 provides that chronic epididymo-orchitis will be rated as a urinary tract infection. A urinary tract infection is rated under 38 C.F.R. § 4.115a. See 38 C.F.R. §§ 4.115a, 4.115b, DC 7525. A 10 percent rating is assigned under 38 C.F.R. § 4.115a for a urinary tract infection with long-term drug therapy, 1-2 hospitalizations per year, and/or requiring intermittent intensive management. A 30 percent rating is assigned for a urinary tract infection with recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than 2 times/year) and/or requiring continuous intensive management. A urinary tract infection manifested by poor renal function should be rated as renal dysfunction. See 38 C.F.R. § 4.115a. The veteran's service-connected residuals of a right inguinal hernia repair with scar currently is evaluated as 10 percent disabling by analogy to 38 C.F.R. §§ 4.114, 4.118, DC 7804- 7338 (superficial scar-inguinal hernia). See 38 C.F.R. §§ 4.114, 4.118, DC 7804-7338. Although the regulations for evaluating skin disabilities were revised effective August 30, 2002, the Board notes that DC 7804 was not changed. See 67 Fed. Reg. 49596 (July 31, 2002). A 10 percent rating is assigned under DC 7804 for superficial scars which are painful on examination. Note (1) to DC 7804 defines a superficial scar as one not associated with underlying soft tissue damage. See 38 C.F.R. § 4.118, DC 7804. A 10 percent rating is assigned under DC 7338 for a postoperative recurrent inguinal hernia that is readily reducible and well supported by a truss or a belt. A 30 percent rating is assigned under DC 7338 for a small postoperative recurrent inguinal hernia or an unoperated irreducible inguinal hernia that is not well supported by a truss or not readily reducible. A maximum 60 percent rating is assigned for a large postoperative recurrent inguinal hernia that is not well supported under ordinary conditions and not readily reducible when considered inoperable. See 38 C.F.R. § 4.114, DC 7338. Finally, the veteran's service-connected recurrent dislocation of the left index finger currently is evaluated as 10 percent disabling by analogy to 38 C.F.R. § 4.71a, DC 5225 (ankylosis of index finger). See 38 C.F.R. § 4.71a, DC 5225. A 10 percent rating is assigned under DC 5225 for unfavorable or favorable ankylosis of the index finger for either the major (dominant) or minor (non-dominant) side. A Note to DC 5225 provides that raters should consider whether an evaluation as an amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with the overall function of the hand. Id. A review of the veteran's service medical records indicates that, in a "Summary of Care," the veteran's significant health problems included a right inguinal hernia in March 1998, testicle pain in May 1998, and a right inguinal hernia repair in September 1998. At the veteran's enlistment physical examination in February 1998, he denied any relevant medical history. Clinical evaluation was normal except for a surgical scar. On outpatient treatment on June 10, 1998, the veteran complained of a 5-day history of steadily worsening right testicle pain and swelling. He denied any trauma or history of similar symptoms. His pain radiated up to the right lower abdomen and in to the right thigh. Objective examination showed edema in the scrotum on the right side, tenderness to palpation in the scrotum, a slightly/moderately enlarged right testicle, no inguinal lymphadenopathy, and a negative hernia examination. The assessment was pain/edema to the scrotum of questionable etiology. On June 13, 1998, the veteran complained of right hemi- scrotal pain. Objective examination showed bilaterally descended testes. The assessment included testalgia, possibly symptomatic. On June 25, 1998, the veteran complained of a dull ache, swelling, and bulging in the right inguinal area that had lasted for 3 weeks and was reduced by rest. Objective examination showed no swelling or deformity in the right inguinal area and widening of the inguinal ring. The assessment was right indirect inguinal hernia. On July 14, 1998, the veteran reported that his right indirect inguinal hernia was not bothering him much. Physical examination showed no swelling in the right inguinal area and no symptoms related to the hernia. On July 21, 1998, the veteran reported no new symptoms. Objective examination showed no significant change from the last examination and a palpable hernia on coughing which was reducible at rest. The assessment was reducible right inguinal hernia. On outpatient treatment on August 10, 1998, the veteran complained of left hand soreness and left third MCP pain secondary to an injury first sustained about 5 weeks earlier when he fell on his left hand and experienced immediate swelling and pain. The veteran's pain and swelling resolved and then he re-injured his left hand when he tripped and fell. Physical examination of the left hand showed a full range of motion, no crepitus, deformity, swelling, ecchymosis, or erythema, 5/5 motor strength limited by pain, and a mild resting tremor bilaterally. X-rays of the left hand were normal. The assessment included mechanically induced tendonitis in the left third MCP. On August 21, 1998, the veteran complained of pain in the left lower quadrant of the abdomen and left hand pain. The veteran's history of a right inguinal hernia was noted. The veteran was right hand dominant. Physical examination showed a benign abdomen, no palpable hernia bilaterally, a full range of motion in the second and third MCP joints, and laxity of the radial collateral ligament of the second MCP joint. The assessment included a right inguinal hernia and a left second MCP radial collateral ligament tear. On September 1, 1998, the veteran received right inguinal hernia repair. On outpatient treatment on September 10, 1998, the veteran complained of a left index finger injury which had occurred around July 15th. Physical examination showed hyperextension to 35 degrees without subluxation or dislocation. X-rays of the left index finger were normal. The assessment was healing left index finger dorso-radial dislocation. On September 21, 1998, the veteran complained of right testicular pain "that is worse now than before the surgery." His pain was constant sharp and radiated up in to the groin. He also noted a small amount of red discharge in the corner of the surgical wound. Physical examination of the surgical wound showed no erythema, mild expected edema, a single suture noted at the lateral wound margin with serous discharge, tenderness to palpation consistent with being 3 weeks post-operative, bilateral descended testes, tenderness to palpation in the right epididymis without enlargement, no testicular edema, mild testicular erythema, and mild bilateral tenderness to palpation in the testes. The assessment was that the veteran was doing well post-operative from right inguinal hernia with the exception of testicular pain/epdidymal pain consistent with epididymitis. On September 24, 1998, the veteran complained of continued pain and tenderness in the right groin area and continued right testicular pain. Physical examination of the surgical wound showed erythema with tenderness to palpation and yellow/green thick pus expressed from wound at a small opening in the right end of the wound, tenderness to palpation at the right epidydmis, and bilaterally descended testes without masses. The assessment was status-post right inguinal hernia and epididimytis. On September 29, 1998, the veteran complained of a left hand injury. His history included dislocated PIP and MCP joints. Objective examination of the left hand showed no ecchymosis, edema, ulcerations, or erythema, no pain on passive range of motion testing of the dorsal interphalangeal (DIP) joint, the PIP joint, or the MCP joint, an intact flexor digitorum profundus, flexor digitorum superficialis, and extensor digitorum, and interosseous, tenderness to palpation on the volar surface of the PIP joint of the index finger, tenderness to palpation in the interosseous between the first and second digit (index and long fingers), and intact light touch. The assessment was digit nerve stretch injury versus inner MCP ligament sprain. A testicular/scrotal ultrasound in October 1998 showed a probable vascular injury in the mid-right testis but otherwise was normal. On outpatient treatment on October 2, 1998, the veteran complained of bilateral testalgia, right worse than left, right groin pain, and left index finger dorso-radicular dislocation. Physical examination showed a soft, non-tender abdomen without distention or masses, a palpable hernia in the left groin, a well-healed incision on the right groin, an old cut down scar on the right groin, and a questionable right spermatocele. The assessment included testalgia, bilateral inguinal hernias of questionable etiology versus a symptomatic spermatocele, and a left index finger dorso- radicular dislocation. On October 5, 1998, the veteran complained of right testicular pain. Physical examination showed a non- distended, non-tender abdomen with no active bowel sounds present, a well-healed scar in the right inguinal region, bilaterally descended testes, and tenderness to palpation in the right testis/epididymis. The impressions included right testalgia. On October 23, 1998, the veteran complained of pain on activity on the lateral aspect of the second metacarpophalangeal (MCP) joint of the left index finger and partial dislocation and locking that had lasted for 1 week. The veteran was status-post volar plate injury to the left index finger consistent with dorsal-radial dislocation. He also was left-hand dominant. The veteran had been in a cast for 3 weeks until it was removed 10 days earlier. Physical examination showed that he was unable to make a fist with his left hand, tenderness both at the volar plate and at the metacarpophalangeal and proximal interphalangeal joints with no subluxation. The assessment was status-post volar plate injury to left finger consistent with dorsal-radial dislocation. His left hand was casted again. On October 28, 1998, the veteran complained of a volar plate injury. Physical examination of the left hand showed that his cast was in good condition. The assessment was left volar plate injury. On November 5, 1998, the veteran complained of increasing left testicular pain and bilateral testalgia. Objective examination showed that the right testicle was restricted consistent with a vascular injury. The assessment was bilateral chronic testalgia consistent with a right testicular infarct following a right inguinal hernia repair. On November 17, 1998, the veteran complained of decreased range of motion in the left index finger following dislocation/volar plate injury in July 1998, pain in the back of his left hand with movement, and pain from a right testicular infarction. The assessment was volar plate injury and dislocation. On December 1, 1998, the veteran complained of repeated dislocation of the left first MCP and left first MCP and proximal interphalangeal (PIP) joint pain and instability. His history included dislocation but he denied any dislocations since his cast was removed on November 24, 1998. Physical examination of the left hand showed no deformities, crepitus in the first MCP with no laxity, laxity in the first PIP to lateral and medial ligaments, positive volar plate laxity in the first PIP when compared to the right PIP, and mild tenderness to palpation at the first MCP and PIP. Range of motion testing of the left hand showed flexion to 70 degrees in the first MCP, flexion to 67 degrees in the first PIP, and an inability to make a fist. The assessment was resolving left first MCP and PIP volar plate injury. On December 2, 1998, the veteran complained of intermittent pain that was 5/6 out of 10 on a pain scale in left lower quadrant of his abdomen. Physical examination of the abdomen showed no masses, normal active bowel sounds, vague tenderness to palpation in the left lower quadrant, and no suprapubic tenderness to palpation. The assessment included post-operative right groin pain/testalgia status-post right inguinal hernia repair with intermittent/concurrent muscular injury. On December 7, 1998, the veteran complained of an upset stomach with hematemesis and stomach pain and pressure. He reported that, one week earlier, he had vomited "lots of blood" five times. His history included a right inguinal hernia repair and right testicular vascular injury. Physical examination of the abdomen showed no masses, positive bowel sounds, tenderness to palpation on the right side secondary with scarring, tenderness to palpation on the left side with no rebound, and no hematemesis in the rectal area. Genitourinary examination showed testalgia, right greater than left. The assessment included likely gastritis. On December 10, 1998, the veteran complained of continuous pain in the right testicle which extended up to the right groin incision and post-prandial "queasiness" and hematemesis. A urology workup had showed a right wedge- shaped infarct in the right testicle. The veteran denied any bloody stool. Physical examination showed a well-healed groin scar with a healing ridge and tenderness to palpation along the wound, tenderness to palpation of the bilateral testes, right greater than left, and no numbness or decreased sensation in groin. The assessment was chronic testalgia with an unclear relationship to a right inguinal hernia repair. In a Medical Evaluation Board (MEB) report dated on December 10, 1998, it was noted that the veteran had experienced worsening testicular pain following a right inguinal hernia repair. The veteran continued to complain of continuous bilateral testicle pain exacerbated by physical activity. He had regular bowel movements and no nausea, vomiting, fever, chills, or sweats. The veteran's small infarct of the right testicle and diagnosis of testalgia were noted. The veteran had developed an upper GI hemorrhage consistent with non-steroidal use which was discontinued. The veteran's pain did not allow him to perform training or other duties. Physical examination showed a well-healed right groin crease incision with mild tenderness along the wound, the pubic tubercle was not especially tender, no palpable hernia, mild to moderate tenderness to palpation in both testicles, and no surrounding fluid or reducible hernia on either side. Because the veteran's groin pain had worsened, he was unlikely to be able to continue his training or assume his duties for an indeterminate period. The diagnoses were testalgia and right groin pain. In a December 17, 1998, addition to the MEB report, the veteran's separation from active service was recommended based on his debilitating chronic testalgia which had been unresponsive to conservative therapy. An upper gastrointestinal (GI) series on December 30, 1998, showed a grossly normal stomach and gastroesophageal reflux to the upper esophagus. At a separation physical examination in December 1998, the veteran's medical history included GERD versus stress gastritis, which was being evaluated, and a right inguinal hernia repair with post-operative groin pain and testalgia. The veteran's MEB for a small infarct of the right testis causing chronic testalgia was noted. Clinical evaluation showed status-post right inguinal hernia repair without recurrence, no hematemesis, slight left testis atrophy, and left greater than right testicular tenderness with no masses. On January 20, 1999, the veteran complained of reflux symptoms and breakthrough pain. He denied any hematemesis or bright red blood per rectum. Physical examination showed positive bowel sounds in the abdomen with no tenderness or distention. The assessment was severe GERD with no evidence of ulcer on upper gastrointestinal series. A February 1999 testicular/scrotal ultrasound show a probable ischemic injury of the right testicle. The post-service medical evidence shows that, on VA outpatient treatment in December 1999, the veteran complained of persistent pain in the right groin area and persistent testicular pain. Physical examination showed a soft abdomen, a right inguinal scar, and some tenderness in the right testicle. The impression included right testalgia by history, status-post right inguinal hernia surgery and mesh implant with transection of ilioinguinal nerve, hiatal hernia by history with vomiting blood, and a history of recurrent inguinal hernia. VA upper endoscopy in March 2000 showed a hiatal hernia and gastritis. On VA outpatient treatment in November 2000, the veteran complained of GERD and chronic pain from a previous inguinal hernia surgery. The assessment was GERD. On VA examination in March 2001, the veteran complained of continuing groin pain and a painful scar. He reported that his activities "are quite limited by his incisional pain." Physical examination showed a well-healed inguinal hernia scar on the right that was quite tender with palpable scarring noted under it in the soft tissue. The diagnosis was surgical scar over the ilioinguinal nerve with groin pain and testicular pain which were related to the veteran's in- service surgery On VA hand examination in May 2001, the veteran complained of left hand, right lower abdominal quadrant, and right hip problems. The veteran's left hand problems included pain and some instability at the MCP joint of the index finger, subluxation, and instability episodes. The veteran also experienced weakness at the left index finger and easy fatigue in the right lower quadrant of the abdomen, some impairment of coordination at the left index finger, right testicle pain, and stomach distress. He reported multiple closed reductions for instability of the MCP joint of the left index finger. The VA examiner reviewed the veteran's claims file, including his service medical records. Objective examination showed a well-healed hernia scar on the right of 3 inches, just proximal to the inguinal ligament area, which was very tender and without numbness, "a bit of tenderness" in the right scrotum area, little tenderness in the groin area just distal to the scar, full extension of all digits in both hands, full flexion of 8 fingers, full opposition and flexion of 2 thumbs, moderate pain with movements of the left hand at left index finger MCP joint only, normal sensation in both hands, a questionable slight weakness and atrophy of the first interosseous muscle of the left hand, no redness or swelling in either hand, tenderness in the MCP joint of the left index finger, and no instability at the MCP joint of the left index finger. The assessment included a history of acute dislocation of the left index finger MCP joint, reduced satisfactorily, with continued occasional instability, chronic synovitis secondary to lax ligaments and recurring episodes of subluxation, referred pain from the right lower quadrant scar as well as some pain from the portion of the scar that is closest to the hip joint, and evidence of nerve injury at this scar with some pain at the right hip. On VA genitourinary examination in May 2001, the veteran complained of constant pain secondary to a painful hernia repair scar and right testicle pain. The VA examiner reviewed the veteran's claims file, including his service medical records. Physical examination showed no abnormal testicular masses, moderate tenderness to palpation over the right testicle, a healed surgical scar in the right inguinal area approximately 8 centimeters in length with marked tenderness to palpation over the medial aspect of the scar, no signs of a recurrent inguinal hernia, and no testicular atrophy. The diagnoses included a history of treatment for epididymitis on the right side, chronic pain of the right testicle (testalgia), and status-post right inguinal hernia repair with intentional transection of the right ilioinguinal nerve. On VA esophagus and hiatal hernia examination in May 2001, the veteran complained of continued regurgitation (2 to 3 times per day). The VA examiner reviewed the veteran's claims file, including his service medical records. The veteran denied any dysphagia, pyrosis, or epigastric pain. His only episode of hematemesis occurred in November 1998. He also denied any nausea or actual vomiting. Physical examination showed generally good health without anemia, good nutrition, and stable weight. An esophagogastroduodenoscopy (EGD) in March 2000 showed a hiatal hernia and gastritis. The diagnoses were GERD with hiatal hernia, secondary to high doses of Motrin while on active service, and a continued problem with regurgitation (2 to 3 episodes per day). On VA outpatient treatment in December 2001, the veteran complained, "I have a hiatal hernia and I want to get it fixed." His history included gastroesophageal reflux symptoms for three years and a 3-4 centimeter hiatal hernia in early 2000. His reflux symptoms were not controlled adequately with medical therapy. He regurgitated food in to his mouth 30-45 minutes after every meal. Physical examination showed a flat, soft, non-distended, non-tender abdomen with present bowel sounds. The assessment was GERD and hiatal hernia with symptoms not adequately controlled on medical treatment. Following VA outpatient treatment in May 2002, the assessment was GERD with mild esophagitis on EGD but no Barrett's esophagus. In September 2002, the veteran complained of daily GERD and regurgitation after eating. Physical examination showed a well-healed scar in the right inguinal area which was tender to light touch, no inguinal hernia, and normal testicles with no masses. The assessment was GERD. Following VA outpatient treatment in October 2002, the assessment was chronic right inguinal based pain. The veteran was hospitalized for one day in November 2002 at a VA Medical Center for surgical treatment of his reflux. He had a laparoscopic nissen fundiplication procedure. VA endoscopy in July 2004 showed a prolapsing hiatal hernia. An upper GI series and esophagogram in August 2004 showed no evidence of gastroesophageal obstruction, post-fundoplication with possible small hernia at the gastroesophageal junction versus soft tissue from the fundoplication, and no reflux. On VA outpatient treatment in August 2004, the veteran complained of feelings of heartburn and regurgitation. The assessment was status-post Nissen in 2002 with stable heartburn and regurgitation. On VA examination in June 2006, the veteran's complaints included chronic testalgia of the right testicle, chronic residual tenderness of the hernia repair surgical scar, and some ilioinguinal nerve impingement, discomfort, and daily acid reflux. The veteran denied any melena or hematochezia. The VA examiner reviewed the veteran's claims file, including his service medical records. Physical examination showed a non-distended, non-tender abdomen with present bowel sounds and no palpable organomegaly or masses, a well-healed hernia surgery scar which was 7 centimeters in length by 1 centimeter in width just proximal to the right inguinal canal area, some pain on deep palpation of the scar but no ulceration or evidence of malnourishment, no adherence to underlying tissue, and no keloids or contractures, no evidence of recurrent inguinal hernia, and some discomfort radiating from the scrotum up to the scar on palpation of the testicle and hernia. The diagnoses were a well-healed surgical scar from the right inguinal hernia repair with some tenderness from chronic scar impingement on nerve in the area with associated testalgia and intermittent right testicle pain on a daily basis and gastroesophageal reflux On VA examination in July 2006, the veteran complained of flare-ups of left index finger pain about 1 time per week. The VA examiner reviewed the veteran's claims file, including his service medical records. The veteran did not experience loss of motion, strength, or endurance in the left hand. He experienced a sensation of subluxation at the index MCP joint with flare-ups and pain extending down the dorsum along the extensor tendon and the palmar aspect along the flexor tendon in to his palm. Physical examination of the left hand showed a full equal range of motion in the left index finger at the MCP, PIP, and DIP joints including full extension and flexion, the ability to make a full fist and oppose index and thumb, no pain on range of motion testing, no tenderness over the PIP joint, some tenderness over the dorsum and lower aspect of the MCP joint, increasing pain across the dorsum and lower aspect of the index finger down in to the palm and dorsum of the hand on repetitive motion, normal sensation, and normal strength and musculature. X-rays of the left hand were within normal limits. The VA examiner commented that, with repetitive activity, the veteran was likely to have increased pain but no loss of motion, strength, or endurance. The examiner also stated that the veteran's condition did not affect his ability to work as a computer specialist. The diagnosis was status-post PIP joint dislocation of the left index finger. In a September 2006 addendum to this examination report, the VA examiner stated that, because there was a full range of motion in the left index finger, there was no ankylosis. The VA examiner also stated that there were no other limitation in the veteran's left hand and the veteran experienced only occasional flare-ups and no loss of motion, loss of endurance, or loss of function during a flare-up of pain. In an October 2006 addendum to the June 2006 VA examination report, the VA examiner who saw the veteran in June 2006 stated that he had reviewed the veteran's claims file extensively along with electronic VA medical records. This examiner reiterated his prior conclusions contained in the June 2006 report. The Board finds that the preponderance of the evidence is against the veteran's claim for an initial rating greater than 10 percent for GERD. The veteran's service medical records show that he was diagnosed as having severe GERD following outpatient treatment in January 1999 when positive bowel sounds and no tenderness in the abdomen were noted. The post-service medical evidence indicates that the veteran experiences, at worst, regurgitation of food following meals. Endoscopy in March 1999 showed a hiatal hernia. At his VA gastrointestinal examination in May 2001, the veteran denied any history of dysphagia, pyrosis, or epigastric pain and reported regurgitation, stable weight, and good nutrition. The diagnoses included GERD with a hiatal hernia secondary to high doses of Motrin while on active service and continued regurgitation. The veteran again complained of regurgitation on outpatient treatment in December 2001, when physical examination noted positive bowel sounds and no abdominal tenderness. The diagnosis was GERD with mild esophagitis in May 2002. In September 2002, the veteran complained of daily GERD and regurgitation; the assessment was GERD. A UGI in August 2004 showed no evidence of reflux or gastrointestinal obstruction. On outpatient treatment in August 2004, the veteran's heartburn and regurgitation were stable. Finally, VA examination in June 2006 showed no melena and tenderness to palpation in the abdomen; the assessment included gastroesophageal reflux. Because the veteran's service- connected GERD is not manifested by multiple symptoms productive either of considerable or severe health impairment (i.e., a 30 or 60 percent rating), the Board finds that an initial rating greater than 10 percent is not warranted. See 38 C.F.R. § 4.114, DC 7346 (2008). The Board also finds that the preponderance of the evidence is against the veteran's claim for an initial rating greater than 10 percent for testalgia. Initially, the Board notes that, although the veteran's service-connected testalgia is rated by analogy to a urinary tract infection, he was not treated for a urinary tract infection during or after active service. See 38 C.F.R. §§ 4.115a, 4.115b, DC 7525 (2008). There is no evidence that the veteran's testalgia is manifested by recurrent symptomatic urinary tract infection requiring drainage, frequent hospitalization, or continuous intensive management, or was manifested by poor renal function such that a higher initial rating than 10 percent is warranted. Id. Instead, the veteran's service medical records show repeated treatment for testalgia beginning in June 1998. In September 1998, physical examination showed tenderness to palpation in the right epididymis without enlargement, mild testicular erythema and mild tenderness to palpation of the testes. The diagnosis was testicular pain/epididymal pain consistent with epididymitis. A testicular ultrasound in October 1998 showed a probable vascular injury in the mid-right testis but otherwise was normal. Following outpatient treatment in October 1998, the diagnosis was right testalgia. The diagnosis was changed in November 1998 to bilateral chronic testalgia consistent with right testicular infarct following right inguinal hernia repair. The diagnosis was changed again in December 1998 to chronic testalgia with an unclear relationship to the right inguinal hernia repair. The MEB concluded in December 1998 that the veteran had testalgia which was chronic and debilitating and necessitated his discharge from active service. The veteran's separation physical examination showed left greater than right testicle tenderness to palpation with no masses. The post-service medical evidence shows that a probable ischemic injury to the right testicle was noted on February 1999 ultrasound. The VA examiner related the veteran's testicular pain to his in-service inguinal hernia repair in March 2001. Physical examination in May 2001 showed moderate tenderness to palpation in the right testicle without masses or atrophy. The VA examiner diagnosed chronic testalgia. The veteran's testicles were normal without masses on VA outpatient treatment in September 2002. Finally, following VA examination in June 2006, the diagnoses included testalgia and intermittent right testicular pain on a daily basis which was associated with the veteran's in-service right inguinal hernia repair. Without evidence that the veteran's service- connected testalgia is manifested by recurrent symptomatic urinary tract infections requiring frequent hospitalization or continuous intensive management or by poor renal function, the Board finds that an initial rating greater than 10 percent is not warranted. Id. The Board also finds that the preponderance of the evidence is against an initial rating greater than 10 percent for residuals of a right inguinal hernia repair with scar. The veteran was treated surgically for a right inguinal hernia during active service. The service medical records and post- service VA treatment records all show that the veteran's surgical repair resulted in a surgical scar and other residuals, including right groin pain. Following his in- service surgical repair in September 1998, he did well post- operatively. In October 1998, physical examination showed a well-healed right groin incision and an old right groin scar. There was no numbness or decreased sensation in the right groin on physical examination in December 1998. The veteran's MEB in December 1998 showed a well-healed right groin incision with mild tenderness to palpation along the wound, no hernia, and no reducible hernia. The veteran's separation physical examination in December 1998 also noted no recurrent right inguinal hernia. The post-service medical evidence shows that the veteran complained of persistent right groin pain in December 1999; physical examination showed a right inguinal scar and the diagnoses included status-post surgery and a history of recurrent inguinal hernia. The veteran complained of limited activities due to incisional pain on VA examination in March 2001. Physical examination showed a well-healed inguinal hernia scar which was quite tender with palpable scarring underneath it. On VA examination in May 2001, physical examination showed a healed right inguinal hernia scar with marked tenderness to palpation but no recurrent inguinal hernia. On VA examination in June 2006, physical examination showed a well-healed hernia surgery scar with some pain on deep palpation of the scar but no ulceration or evidence of malnourishment, no adherence to underlying tissue, and no keloids or contractures, and no evidence of recurrent inguinal hernia. The diagnoses were a well-healed surgical scar from the right inguinal hernia repair with some tenderness from chronic scar impingement on nerve in the area with associated testalgia and intermittent right testicle pain on a daily basis. Without evidence that the veteran's service-connected residuals of a right inguinal hernia repair with scar include a post-operative recurrent hernia which is not readily reducible or a scar that is associated with underlying soft tissue damage (i.e., not a superficial scar which is painful on examination), the Board finds that an initial rating greater than 10 percent is not warranted. See 38 C.F.R. §§ 4.114, 4.118, DC 7804-7338 (2008). The veteran also is not entitled to additional compensation for his service-connected residuals of a right inguinal hernia repair with scar under other potentially applicable rating criteria for evaluating scars. DC 7801 provides in part a 20 percent rating for scars that are deep or cause limited motion and exceed 12 square inches (77 square centimeters). DC 7805 provides that other scars will be rated based on the limitation of motion of the affected body part. Although DC's 7801 and 7805 were revised effective August 30, 2002, see 67 Fed. Reg. 49596 (July 31, 2002), the Board notes that there is no medical evidence that the veteran's scar is deep, causes limited motion, and exceeds 77 square centimeters (DC 7801) or is manifested by limitation of motion (DC 7805) such that additional compensation is warranted under other potentially applicable rating criteria for evaluating scars. See 38 C.F.R. §§ 4.118, DC's 7801 and 7805 (2008). The Board finally finds that the preponderance of the evidence is against the veteran's claim for an initial rating greater than 10 percent for recurrent dislocation of the left index finger. As noted above, the veteran's service- connected recurrent dislocation of the left index finger is rated under DC 5225 and a 10 percent rating is the maximum disability rating available under this DC. See 38 C.F.R. § 4.71a, DC 5225 (2008). The veteran's service medical records show that he dislocated his left index finger on several occasions and received a cast. On August 10, 1998, the veteran complained of left hand pain secondary to an earlier injury. Physical examination showed a full range of motion in the left hand, no erythema, edema, or ecchymosis, and full strength. X-rays also were normal. The assessment included mechanically induced tendonitis in the left third MCP. On August 21, 1998, physical examination showed laxity in the second MCP joint and the diagnosis was a tear of the second radial collateral ligament. On September 10, 1998, physical examination showed hyperextension of the left index finger without subluxation or dislocation. The diagnosis was a healing left index finger dislocation. On September 29, 1998, there was no erythema, edema, or ecchymosis in the left hand, and the diagnosis was an MCP ligament strain. The veteran's left index finger was casted again. The diagnosis following outpatient treatment on October 2, 1998, was a left index finger dislocation. The veteran was unable to make a fist with his left hand on outpatient treatment on October 23, 1998, and his left index finger was casted again. In December 1998, after the cast was removed, there was no left hand deformity and laxity in the first MCP joint although crepitus was present in that joint. There also was laxity in the first PIP joint, positive volar plate laxity in the first PIP joint, mild tenderness to palpation in the first MCP and PIP joints, limited flexion in the PIP and MCP joints, and the veteran again was unable to make a fist with his left hand. The diagnosis was a resolving left index finger injury. The post-service medical evidence shows that, on VA examination in May 2001, the veteran had full extension of all digits in both hands, full flexion of 8 fingers, full opposition and flexion of 2 thumbs, moderate pain with movements of the left hand at left index finger MCP joint only, normal sensation in both hands, a questionable slight weakness and atrophy of the first interosseous muscle of the left hand, no redness or swelling in either hand, tenderness in the MCP joint of the left index finger, and no instability at the MCP joint of the left index finger. The assessment included a history of acute dislocation of the left index finger MCP joint, reduced satisfactorily, with continued occasional instability, chronic synovitis secondary to lax ligaments and recurring episodes of subluxation. On VA examination in July 2006, physical examination of the left hand showed a full equal range of motion in the left index finger at the MCP, PIP, and DIP joints including full extension and flexion, the ability to make a full fist and oppose index and thumb, no pain on range of motion testing, no tenderness over the PIP joint, some tenderness over the dorsum and lower aspect of the MCP joint, increasing pain across the dorsum and lower aspect of the index finger down in to the palm and dorsum of the hand on repetitive motion, normal sensation, and normal strength and musculature. X- rays of the left hand were within normal limits. The VA examiner commented that, with repetitive activity, the veteran was likely to have increased pain but no loss of motion, strength, or endurance. The diagnosis was status- post PIP joint dislocation of the left index finger. In a September 2006 addendum to this examination report, the VA examiner stated that, because there was a full range of motion in the left index finger, there was no ankylosis. The VA examiner also stated that there were no other limitations in the veteran's left hand and the veteran experienced only occasional flare-ups and no loss of motion, loss of endurance, or loss of function during a flare-up of pain. As the veteran already is in receipt of the maximum disability rating available under DC 5225, the Board must consider whether he is entitled to a separate rating for amputation or for limitation of motion of other digits or interference with the overall function of the left hand. See 38 C.F.R. § 4.71a, DC 5225 (2008). See also 38 C.F.R. § 4.71a, DC 5153 (2008) (amputation of index finger). The Board also must consider whether the veteran is entitled to additional compensation under other potentially applicable rating criteria for evaluating orthopedic disabilities. In this case, however, there is no evidence that the veteran is entitled to a separate rating for amputation of the left index finger. The VA examiner noted in September 2006 that there were no other limitations in the veteran's left hand and the veteran experienced only occasional flare-ups and no loss of motion, loss of endurance, or loss of function during a flare-up of left index finger pain; thus, the veteran is not entitled to an additional evaluation for limitation of motion of other digits or interference with overall left hand function. Finally, as there is no medical evidence that the veteran experiences occasional incapacitating exacerbations and as his left hand x-rays are within normal limits, he is not entitled to additional compensation under other potentially applicable rating criteria. See, for example, 38 C.F.R. § 4.71a, DC 5003 (2008) (arthritis). The potential application of various provisions of Title 38 of the Code of Federal Regulations have been considered whether or not they were raised by the veteran as required by Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991), including the provisions of 38 C.F.R. § 3.321(b)(1). The evidence of record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." See 38 C.F.R. § 3.321(b)(1) (2008). There has been no showing by the veteran that his service-connected disabilities have resulted in marked interference with his employment or necessitated frequent periods of hospitalization beyond that contemplated by the rating schedule. For example, the VA examiner concluded in July 2006 that the veteran's service- connected recurrent dislocation of the left index finger did not affect his ability to work as a computer specialist. In the absence of such factors, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, the Board notes that the evidence of record from the day the veteran filed these claims to the present also supports the conclusion that he is not entitled to additional increased compensation for his service-connected disabilities at any other time within the appeal period. As the preponderance of the evidence is against the veteran's claims, the benefit-of- the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App 49, 55-57 (1990). ORDER Entitlement to an initial rating greater than 10 percent for GERD is denied. Entitlement to an initial rating greater than 10 percent for testalgia is denied. Entitlement to an initial rating greater than 10 percent for residuals of a right inguinal hernia repair with scar is denied. Entitlement to an initial rating greater than 10 percent for recurrent dislocation of the left index finger is denied. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs