Citation Nr: 18143502 Decision Date: 10/23/18 Archive Date: 10/19/18 DOCKET NO. 13-30 716 DATE: October 23, 2018 ORDER Entitlement to service connection for right ear hearing loss is denied. Entitlement to a higher disability rating for service-connected residuals of fracture of the left wrist, currently evaluated as 10 percent for fracture, radial side, left wrist, and 10 percent for limitation of motion of the left thumb, is denied. Entitlement to a separate disability rating of 10 percent for trigger finger, left index finger, is granted, subject to controlling regulations governing the payment of monetary benefits. Entitlement to a disability rating in excess of 30 percent for service-connected sarcoidosis is denied. Entitlement to a compensable disability rating for service-connected scar, left first metacarpal (thumb), is denied. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current right ear hearing disability for VA compensation purposes. 2. The preponderance of the evidence of record is against finding that the Veteran’s service-connected fracture, radial side, left wrist, were productive of ankylosis. 3. The preponderance of the evidence of record is against finding that the Veteran’s service-connected limitation of motion of the left thumb was productive of a gap of more than 2 inches (5.1 cm.) between the thumb pad and the fingers with the thumb attempting to oppose to the fingers, to include consideration of whether the episodes of spasms and locking due to A1 pulley with triggering of the left thumb cause increased limitation of motion. 4. The preponderance of the evidence of record is in favor of finding that the Veteran has trigger finger of the left index finger that is a residual of his service-connected left wrist fracture and is productive of noncompensable painful limitation of motion consistent with a 10 percent disability rating under 38 C.F.R. § 4.59. 5. The preponderance of the evidence of record is against finding that the Veteran’s service-connected sarcoidosis is productive of pulmonary involvement requiring the use of systemic high dose (therapeutic) corticosteroids for control, cor pulmonale, cardiac involvement with congestive heart failure, or progressive pulmonary disease with fever, night sweats and weight loss despite treatment. 6. The preponderance of the evidence of record is against finding that the Veteran’s scar on the left first metacarpal (thumb) is unstable and/or painful; is deep and nonlinear; is superficial and nonlinear and covers an area of 144 square inches (929 sq. cm.) or greater; is associated with underlying soft tissue; or causes any other disabling effect such as limitation of function of the affected body part. CONCLUSIONS OF LAW 1. The criteria for service connection for right ear hearing loss are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for disability rating in excess of 10 percent for service-connected fracture, radial side, left wrist, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Codes 5214, 5215. 3. The criteria for disability rating in excess of 10 percent for service-connected limitation of motion of the left thumb have not been met. 38 U.S.C. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Codes 5003, 5010, 5024, 5228. 4. The criteria for disability rating of 10 percent, but no higher, for trigger finger, left index finger, have been met. 38 U.S.C. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Codes 5003, 5024, 5229. 5. The criteria for a disability rating in excess of 30 percent for service-connected sarcoidosis have not been met. 38 U.S.C. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, and 4.97, Diagnostic Code 6846. 6. The criteria for a compensable disability rating for service-connected scar, left first metacarpal (thumb), have not been met. 38 U.S.C. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, and 4.118, Diagnostic Codes 7801-7805; 38 Fed. Reg. 32592. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active military service with the U.S. Air Force from January 1956 to February 1960, and with the U.S. Marine Corps from February 1960 to March 1964. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from May 2010 and December 2014 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2016, the Veteran appeared and testified at a video-conference hearing before the undersigned Veterans Law Judge. Thereafter, in May 2017, the Board reopened the Veteran’s previously denied claim for service connection for defective hearing, and remanded all his claims on appeal for further development. In an October 2017 rating decision, service connection was granted for left ear hearing loss, which represents a full grant of the benefits sought on appeal as to that disability. Therefore, only service connection for right ear hearing loss remains on appeal for the Board to consider as to the Veteran’s claim for service connection for hearing loss. The Board finds that substantial compliance with the prior remand has been accomplished. Substantial compliance with a remand order, not strict compliance, is required. See Donnellan v. Shinseki, 24 Vet. App. 167, 176 (2010); Dyment v. West, 13 Vet. App. 141, 147 (1999). Therefore, the Board may proceed forward with adjudicating the Veteran’s claim without prejudice to him. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 1. Entitlement to service connection for right ear hearing loss The Veteran contends that his bilateral hearing loss is related to noise exposure in service. As previously discussed, service connection has recently been awarded for left ear hearing loss, but remains denied for right ear hearing loss. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of right ear hearing disability pursuant to 38 C.F.R. § 3.385 subject to service connection, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). With respect to hearing loss, VA has specifically defined what is meant by a “disability” for the purposes of service connection: “[I]mpaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent.” 38 C.F.R. § 3.385. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). On VA examination in January 2006, audiometric testing demonstrated pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 20 20 30 Speech audiometry revealed speech recognition ability of 94 percent in the right ear. On VA examination in July 2017, audiometric testing demonstrated pure tone thresholds, in decibels, were as follows:   HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 20 20 30 Speech audiometry revealed speech recognition ability of 96 percent in the right ear. Based on the above audiometric test results, the Veteran’s auditory threshold levels in the right ear do not meet the required definition in 38 C.F.R. § 3.385 to establish that he has a hearing disability in the right ear. The Board acknowledges that the July 2017 VA examiner diagnosed the Veteran to have sensorineural hearing loss in the right, as well as the VA treatment records showing such a diagnosis. However, in order for hearing loss to be considered a disability, the requirements set forth in 38 C.F.R. § 3.385 must be met. In the present case, the objective medical evidence fails to demonstrate such is the case and, therefore, the Board gives more probative weight to such evidence. Increased Rating Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Separate diagnostic codes identify the various disabilities. Id. Evaluation of a service-connected disorder requires a review of the veteran’s entire medical history regarding that disorder. 38 C.F.R. §§ 4.1 and 4.2. It is also necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the veteran’s favor, 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to the veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 38 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When analyzing lay evidence, the Board should assess the evidence and determine whether the disability claimed is of the type for which lay evidence is competent. See Davidson, 581 F.3d at 1313; Kahana v. Shinseki, 24 Vet. App. 428 (2011). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). 2. & 3. Entitlement to a higher disability rating for service-connected residuals of fracture of the left wrist, currently evaluated as 10 percent for fracture, radial side, left wrist, and 10 percent for limitation of motion of the left thumb and separate rating for left index trigger finger Veteran contends that his service-connected residuals of left wrist fracture should be evaluated as at least 20 percent disabling due to debilitating pain that contributes to limitation of motion, recurrent episodes of locking of fingers and visible disfigurement of wrist due to calcification. See February 2015 Notice of Disagreement. In June 2013, the Veteran filed a new claim seeking a higher disability rating for his service-connected left wrist fracture. The RO initially only certified the issue of a disability rating higher than 10 percent for service-connected fracture, radial side, left wrist was warranted. However, in its May 2017 remand, the Board broadened the Veteran’s claim and characterized it as an increased disability rating for all residuals of his in-service fracture of the left wrist to include both the 10 percent rating for fracture, radial side, left wrist, and the 10 percent rating for the limitation of motion of the left thumb. Service treatment records show the Veteran sustained a fracture to the left first metacarpal joint in March 1961. In developing the Veteran’s initial claim for service connection, the examiner who conducted the initial VA examination in June 1967 did not have the Veteran’s service records and the Veteran reported fracturing his left wrist on the radial side in service. The examiner diagnosed the Veteran to have a fracture, radial side, left wrist, and, therefore, that is the disability that was granted service connection. This disability was initially evaluated as non-disabling (zero percent) but, effective November 16, 2004, a 10 percent rating was assigned for painful motion of the wrist. See June 2005 rating decision. Furthermore, in an August 2007 rating decision, the RO granted service connection for arthritis of the carpometacarpal joint of the left thumb (limitation of motion of the left thumb) as secondary to the service-connected fracture, radial side, left wrist, which was evaluated as 10 percent disabling for painful and limited motion of the thumb under Diagnostic Code (DC) 5228 effective May 16, 2007. Consequently, as of May 16, 2007, the Veteran’s service-connected residuals of the left wrist fracture have been evaluated as 20 percent disabling, which is the evaluation the Veteran is seeking. Nevertheless, the Board will consider whether the evidence of record provides any further higher rating. The Veteran’s service-connected fracture, radial side, left wrist, is currently evaluated as 10 percent disabling under DC 5299-5215. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. When a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be built-up as follows: The first 2 digits will be selected from that part of the schedule most closely identifying the part, or system, of the body involved; the last 2 digits will be 99 for all unlisted conditions. 38 C.F.R. § 4.27. Under DC 5215, limitation of motion of the wrist is rated as 10 percent disabling, for either a major or minor extremity, when there is dorsiflexion less than 15 degrees or palmar flexion is limited in line with the forearm. 38 C.F.R. § 4.71a. The current 10 percent rating is the maximum schedular rating under DC 5215. For a higher disability rating, there must be ankylosis of the wrist. Favorable ankylosis of the wrist in 20 degrees to 30 degrees of dorsiflexion warrants a 20 percent rating for a minor extremity and a 30 percent rating for a major extremity. 38 C.F.R. § 4.71a, DC 5214. If a wrist is ankylosed in any other position except favorable, a 40 percent rating for the major extremity, and a 30 percent rating for a minor extremity, is warranted. Id. The highest rating (50 percent for the major extremity and 40 percent for the minor extremity) is warranted for unfavorable ankylosis of the wrist in any degree of palmar flexion or with ulnar or radial deviation. Id. The Veteran is also service-connected for limitation of motion of the left thumb associated with the fracture, radial side, left wrist, which is currently evaluated as 10 percent disabling under DC 5228-5010. DC 5228 evaluates disabilities due to loss of motion of the thumb and provides a 10 percent rating where loss of thumb motion results in a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a. A maximum schedular 20 percent disability rating is assigned for loss of thumb motion that causes a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Id. Ratings under DC 5228 are the same, regardless of whether the disability in question involves the thumb on the major (dominant) or minor hand. Id. DC 5010 evaluates traumatic arthritis established by X-ray findings and advises the evaluator to rate as degenerative arthritis under DC 5003. Under DC 5003, arthritis established by X-ray findings is rated on the basis of limitation of motion of the affected joints. When, however, the limited motion of the specific joint or joints involved would be noncompensable under the appropriate diagnostic codes, a 10 percent rating is assigned for each involved major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (degenerative arthritis) and 5010 (traumatic arthritis). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, however, arthritis is rated as 10 percent disabling when shown by X-ray evidence of the involvement of two or more major joints or two or more minor joint groups, or as 20 percent disabling when show by x-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Id. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Pain may be taken into consideration when rating “functional loss.” However, pain on motion is not, itself, “functional loss,” but “may result in functional loss...only if it limits the ability ‘to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.’” Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). A finding of functional loss due to pain, however, must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Finally, it is the intention of the VA rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. Consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. Burton v. Shinseki, 25 Vet. App. 1 (2011). In March 2013, the Veteran called into VA requesting referral to the Hand Clinic due to having more pain and intermittent throbbing in his left wrist. Although he wore a wrist splint, he reported it was not effective and he did not use pain medications. Instead he was referred to his primary care physician whom he saw in April 2013 at which time he reported his left thumb would stiffen, lock up and be painful. He reported still using the thumb splint, icing and over-the-counter medications, which helped. On examination, the left carpometacarpal (CMC) joint was swollen and tender to palpation. X-rays continued to show advanced degenerative changes of the CMC joint at the base of the thumb with fragmentation of the bone and marked narrowing of the triscaphe joints with subcortical sclerosis. It was noted that there was some progression since the previous examination, particularly in the triscaphe joint. The assessment was left thumb/wrist pain likely secondary to CMC joint arthritis. In May 2013, he was seen by his private physician for complaints of left wrist pain. It was noted he played golf every Monday and is physically active. He reported he usually has mild pain but recently has been having more pain and stiffness and has problems with his golf clubs when it is cold. On examination, there was no swelling but signs of osteoarthritis at the base of the thumb. The assessment was sprain of wrist. In December 2013, the Veteran underwent a VA examination at which he reported pain at the base of the left thumb, which has gradually worsened his last evaluation in 2007. He also complained of spasms and locking of the left thumb and index finger and spasm in the forearm many times during the day lasting several minutes alleviated by stretching his fingers (these were reported as flare-ups). Because of the pain, he reported he could not use the left hand for significant maneuvering and bimanual tasks that require more than a little assistance from the left hand. He reported having some swelling at the base of the left thumb along with pain, stiffness, grinding and popping. Because of guarding due to pain, it was noted he limits the motions of the left wrist and forearm. Grip strength was very weak. By being very careful, the Veteran is able to avoid long-lasting incapacitating flare-ups of left thumb, hand and wrist pain. On examination, range of motion testing of the left wrist demonstrated 60 degrees of palmar flexion with objective evidence of painful motion beginning at 45 degrees (normal 80 degrees) and 70 degrees of dorsiflexion with objective evidence of painful motion beginning at 65 degrees (normal 70 degrees). Radial deviation and ulnar deviation were normal at 20 and 45 degrees, respectively, and were pain free. These ranges of motion remained unchanged after three repetitions. Furthermore, left forearm supination was 80 degrees (normal) and pronation was 80 degrees (normal 85 degrees), was essentially pain free and remained unchanged with three repetitions. The Veteran was able to oppose the left thumb to the tips of all other fingers and to the palmar crease but had pain in doing so. The pain increased with repetitions of these motions, but no loss of range of motion is noted with three repetitions of motion. Range of motion of the joints of the fingers is normal. Motions of the left CMC joint are painful and range is less than the opposite side. The VA examiner remarked that pain on movement contributes to functional loss and/or functional impairment. There is localized tenderness or pain on palpation of the left wrist. Muscle strength was 4/5 in the left wrist compared to 5/5 in the right. Grip strength in the left hand was 4/5. In February 2014, the Veteran again complained to his private primary care physician that his left wrist pain had not significantly improved and he was referred to an orthopedist. In March 2014, he underwent an orthopedic consultation at which he complained of painful snapping of the thumb and index finger for which he wore a splint most of the time. Examination of the left wrist showed it was swollen and stiff lacking full extension and flexion. There was swelling and tenderness of the thumb and index finger as well. The Veteran had A1 pulley with triggering in the thumb only. X-rays showed loss of joint space in the CMC, trapezium scaphoid, trapezoid scaphoid and trapezium trapezoid joints. The assessment was long standing carpal arthrosis as well as trigger thumb and index finger. The Veteran was given a steroid injection into the A1 pulley thumb. Surgical treatment for the left wrist was also discussed, which would be a fusion. Follow up note from two weeks later shows the injection into the thumb was very effective. The Veteran requested that range of motion be documented for VA, and the physician noted that he had 20 to 30 degrees of dorsiflexion and volar flexion in both wrists although the left was somewhat painful. He was seen by his VA primary care physician in September 2014. He reported that he saw his private physician for chronic left wrist/base left thumb pain and discomfort and was told that X-ray was okay, and they gave him an analgesic balm to use four times a day and a glove for his thumb. He complained that his wrist affects his golf game (reported he played every Monday). No specific assessment or plan was specified in the treatment note. In September 2014, the Veteran underwent a VA examination for his left wrist at which he reported constant mild pain in his left wrist that worsened with gripping with the left hand. He reported using his wrist brace and Thera-gesic pain reliever for pain relief. He denied having flare-ups or that flare-ups impact the function of his left wrist. The only function loss or impairment he reported was that he could not grip with his left hand. On physical examination, range of motion of the left wrist was limited to 20 degrees of palmar flexion (normal 80 degrees), 25 degrees of dorsiflexion (normal 70 degrees), 15 degrees of ulnar deviation (normal 45 degrees), and 15 degrees of radial deviation (normal 20 degrees). The examiner remarked that this abnormal range of motion contributed to the Veteran’s functional loss. There was no change in range of motion after three repetitions. There was objective evidence of pain on all ranges of motion on testing and when the joint is used in weightbearing and non-weightbearing. There was moderate tenderness to palpation over the radial, volar and dorsal aspects of the wrist consistent with degenerative joint disease. The examiner noted that contributing factors of disability included less movement than normal, weakened movement, pain on movement and swelling, but this was not due to limitation of motion. The examiner further noted that there was no functional loss or impairment during flare-ups or when the joint is used repeatedly over time. Muscle strength was 4/5 in the left wrist compared to 5/5 in the right. It was noted the Veteran wore a wrist brace on the left constantly. X-rays showed advanced arthritis at the base of the thumb on the left and much lesser degenerative joint disease on the right. The diagnosis was osteoarthritis, left wrist, and left wrist fracture – status post ORIF – residuals. The Veteran was seen next in February 2016 at VA Urgent Care complaining of a flare-up of left wrist pain radiating to his left elbow for five to six days. He denied recent injury to the area. Examination did not reveal any erythema or significant tenderness to palpation. He reported the wrist had been swollen and painful but that he could use the hand. He was referred back to the VA Hand Clinic and was seen in March 2016 and noted to have poor range of motion at the CMC joint with the joint subluxed and positive thumb grind. He was given a Kenalog injection. Since then, the Veteran has had repeat Kenalog injections approximately every three months without further complaints of severe pain in the left wrist or thumb. In June 2017, the Veteran underwent a VA examination, which was ordered at the request of the Board to evaluate all possible residuals he may have related to his service-connected left wrist fracture, including any that may involve the fingers of his hand and his forearm given his earlier reports of pain, spasms and locking in those areas. On examination of the wrist, it was noted that the Veteran complained of pain in his left wrist that is constant, which he rated as 7 out of 10 in intensity on average. He reported having flare-ups of pain and limitation of motion with repetitive lifting of five pounds. He described functional loss and/or impairment as decreased strength in the wrist (weakness and pain with use). On physical examination, range of motion of the left wrist was limited to 35 degrees of palmar flexion (normal 80 degrees) and 20 degrees of dorsiflexion (normal 70 degrees). Ulnar and radial deviation were both normal at 45 and 20 degrees, respectively. There was no additional limitation of motion on three repetitions. The examiner remarked that range of motion contributed to functional loss of the left wrist in that there was limited range of motion, difficulty with doing chores and using tools, it produces pain and there is associated weakness with use. The examiner further remarked that there was objective evidence of pain on range of motion testing that causes functional loss and pain with weightbearing and non-weightbearing of the left wrist. There was also moderate pain to palpation in the dorsal and palmar areas of the left wrist and objective evidence of crepitus. The examination was not conducted during a flare-up or immediately after repetitious use over time; however, the examiner noted that the examination was consistent with the Veteran’s report of functional loss during flare-ups and immediate after repetitious use over time. Furthermore, the examiner remarked that pain and weakness significantly limit the functional ability of the left wrist with reported use over time and flare-ups but, when describing this in terms of range of motion, the examiner did not provide any change in the ranges of motion for the left wrist. Muscle strength in the left wrist was 4/5 as compared to 5/5 in the right. There was no atrophy or ankylosis. The diagnosis was old fracture of the first CMC joint, radial side, left wrist with residual traumatic degenerative joint disease and pain. On examination of the Veteran’s hand and fingers, he complained of decreased range of motion of the left thumb as well as weakness and pain. He especially has aching in cold weather, pain on repetitive range of motion and is unable to lift using the left thumb. He wears a thumb brace due to limitation of motion, pain and weakness. He denied flare-ups specific to the left thumb. As to functional loss and/or impairment, he reported that he cannot use it or lift with it and, especially during cold weather, he has pain and it feels weak. On physical examination, the Veteran had full range of motion of fingers two through five (the index, long, ring and little fingers) on the left hand. (Full range of motion of the joints of fingers two through five is 0 to 90 degrees of flexion of the metacarpophalangeal joints, 0 to 100 degrees of the proximal interphalangeal joints, and 0 to 70 or 80 degrees of the distal interphalangeal joints. See 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note (1).) In addition, the left thumb’s range of motion of the metacarpophalangeal joint was 60 degrees and the interphalangeal joint was 45 degrees and there was a 3-cm. gap between the pad of the thumb and the fingers. There was no gap between the fingers and the proximal transverse crease of the hand on maximal finger flexion. Pain was noted objectively on examination during flexion and extension of the thumb, opposition of the thumb and use of the hand. There was also objective evidence of tenderness to palpation of the left thumb. The examiner stated that the limitation of motion of the left thumb was associated with the fracture, radial side, left wrist. The 10 percent disability rating provided under DC 5215 for the fracture, radial side, left wrist is the maximum available. For a higher rating to be warranted, the evidence must show the Veteran has ankylosis of the left wrist, which it does not. All three VA examiners clearly indicate that the Veteran does not have ankylosis of the left wrist. Consequently, evaluation under DC 5214 for a higher disability rating based upon ankylosis of the wrist is not warranted. As for a higher rating for the arthritis in the left thumb, the Board notes that the initial 10 percent disability rating was actually awarded under 38 C.F.R. § 4.59 for painful noncompensable limitation of motion as the evidence in 2007 did not show the Veteran’s left thumb had limitation of motion that met the 10 percent rating criteria under DC 5228. However, as of the last VA examination conducted in June 2017, the medical evidence shows there is a 3-cm. gap between the Veteran’s left thumb pad and the fingers, which meets the 10 percent rating criteria under DC 5228 that there be a 2.5 to 5.1 cm. gap. A higher 20 percent rating is not warranted unless the gap between the thumb pad and the fingers is more than 5.1 cm. (or 2 inches), which the evidence clearly does not show as, at most, the gap was 3 cm. The Board has considered the Veteran’s other symptoms and functional loss/impairment when considering whether a higher rating is warranted for either the fracture, radial side, left wrist or limitation of motion of the left thumb. The Veteran’s main complaint is of pain but he also complains of spasms and locking in the fingers of his left hand and spasms in the left forearm. Despite complaints of spasms and pain in the left forearm, no treating or examining physician has provided any objective findings of any disorder to explain the Veteran’s complaints. Therefore, such complaints are most likely related to pain from the Veteran’s left wrist and are considered as part of the evaluation of the service-connected fracture, radial side, left wrist. Since this disability is currently evaluated at the highest schedular evaluation available based upon limitation of motion, then a higher rating based on functional loss/impairment under 38 C.F.R. §§ 4.40, 4.45, and 4.59 is not warranted. See Johnston v. Brown, 10 Vet. App. 80 (1997). The medical evidence shows, however, that the spasms and locking he complains of in the left hand and fingers are most likely due to trigger finger of the left thumb and left index finger. The Board finds that the separately diagnosed conditions of trigger finger of the left thumb and left index finger are residuals of the left wrist fracture. In this regard, it is noted that, except as otherwise provided in the rating schedule, all disabilities, including those arising from a single disease entity, are to be rated separately unless the conditions constitute the same disability or the same manifestation. See Esteban v. Brown, 6 Vet. App. 259 (1994). The critical inquiry in making such a determination is whether any of the symptomatology is duplicative or overlapping. The appellant is entitled to a combined rating where the symptomatology is distinct and separate. Esteban, 6 Vet. App. at 262. There is no DC specific for “trigger finger.” However, “trigger finger” is also called “stenosing flexor tenosynovitis” and is caused when the flexor tendon catches when it attempts to glide through a relatively stenotic sheath, resulting in an inability to smoothly flex or extend the finger. See UpToDate, Jun. 4, 2018. Thus, such condition should be rated as tenosynovitis under DC 5024. Tenosynovitis is rated on limitation of motion of the affected part, as arthritis, degenerative, under DC 5003. 38 C.F.R. § 4.71a, DC 5024. As the rating criteria for DC 5003 was previously set forth above in discussing the criteria for DC 5010, it will not be restated here. As to the Veteran’s left thumb, he is already evaluated as 10 percent disabling based upon limitation of motion for arthritis under DC 5228-5010 as previously discussed. Therefore, a separate rating for limitation of motion under DC 5024 would be impermissible pyramiding under 38 C.F.R. § 4.14. However, it must be considered whether they tenosynovitis would warrant a higher 20 percent rating under DC 5228. The most detailed medical note relating to his complaints is the February 2014 private orthopedic consultation note, which indicates he only reported painful snapping of the thumb rather than locking. Physical examination indicated his thumb was swollen and tender with A1 pulley with triggering in the thumb only. It did not identify any locking of the thumb. Nor did any of the other examinations at which the Veteran complained of having locking of the thumb. The Veteran himself has not provided a detailed description of what occurs during these episodes of locking. At most he has stated he has pain, spasms and locking that are in his “fingers” (without specifying which ones) and wrist and that cause him to be unable to bend them much or to be able to use his hand or fingers making it completely incapacitated. These episodes last a few minutes and he has to manipulate his fingers to unlock them. At the December 2013 VA examination, he reported these episodes occurred many times during the day. At the December 2016 Board hearing, he testified he still has them but they occur several times per month. However, after he received the steroid injection into the left thumb in March 2014, there has been no further complaint seen in the medical records or medical findings that the Veteran has these episodes. At the September 2014 and June 2017 VA examinations, the Veteran failed to report continuing to have such symptoms and nothing was found on physical examination of the fingers in June 2017 (the September 2014 examination was only of the left wrist). The evidence is against finding that any additional limitation of motion is consistent with the rating criteria for a 20 percent disability rating under DC 5228. The Veteran’s left thumb had noncompensable limitation of motion during most of the rating period. In other words, there was a gap of less than 2.5 cm between the thumb pad and the fingers when opposing the thumb thereto. As previously discussed, it was only since the June 2017 VA examination that the evidence shows he has compensable limitation of motion of the left thumb under DC 5228 in that he now has a gap of 3 cm, which is consistent with a 10 percent disability rating. The Board finds it unlikely that the Veteran’s limitation of motion of the left thumb exceeded 5.1 cm. during the appeal period such that a 20 percent disability rating is warranted. However, the Board finds that a 10 percent disability rating for trigger finger of the left index finger is warranted under DC 5024. The Board acknowledges that the medical evidence does not show that the Veteran’s index finger has limitation of motion generally. Nevertheless, given that UpToDate indicates that locking usually occurs during flexion, the Board resolves reasonable doubt and finds that the index finger would be limited in motion during an episode of locking. The Board finds that a 10 percent disability rating can be assigned under 38 C.F.R. § 4.59 for painful limited motion. As for the effective date of this rating, the Board finds that the VA treatment records show evidence of triggering of the left index finger as early as July 2005 when an Occupational Therapy note indicates that sometimes the left index metaphalangeal joint seemed to lock in flexion. However as the Veteran’s present claim for an increased rating was filed in June 2013. Consequently, the effective date of this separate 10 percent disability rating for trigger finger of the left index finger is June 19, 2013, the date of the Veteran’s claim for an increased disability rating. See 38 C.F.R. § 3.400. Additional reference to the Veteran’s disabilities are presented in additional evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. The additional evidence of record does not present findings concerning the Veteran’s disabilities that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. 4. Entitlement to a disability rating in excess of 30 percent for service-connected sarcoidosis The Veteran contends that a higher disability rating is warranted for his service-connected sarcoidosis as he has been prescribed a higher dose of corticosteroids to control his cough. See VA Form 21-4138 received May 9, 2009; see also, December 2016 Board hearing transcript, p. 6. At his Board hearing in December 2016, the Veteran testified that he was given oral systemic treatment for his service-connected sarcoidosis for approximately six months about one to one and a half years prior to the hearing. See December 2016 Board hearing transcript, p. 9. After reviewing the evidence, the Board finds that the preponderance of the evidence fails to establish that a disability rating in excess of 30 percent is warranted. The Veteran’s sarcoidosis is currently evaluated as 30 percent rating under DC 6846, which is warranted when there is pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids. A 60 percent rating is warranted for pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control merits. A 100 percent rating is warranted for cor pulmonale, cardiac involvement with congestive heart failure, or progressive pulmonary disease with fever, night sweats, and weight loss despite treatment. 38 C.F.R. § 4.97. DC 6846 also provides that sarcoidosis may alternatively be rated as chronic bronchitis under DC 6600, or as extra-pulmonary involvement under the specific body system involved. Under DC 6600, a 10 percent rating is warranted for FEV-1 of 71 to 80 percent of the predicted value, FEV-1/FVC of 71 to 80 percent of the predicted value, or DLCO (SB) of 66 to 80 percent of the predicted value. A 30 percent rating is warranted for FEV-1 of 56 to 70 percent of the predicted value, FEV-1/FVC of 56 to 70 percent of the predicted value, or DLCO (SB) of 56 to 65 percent of the predicted value. A 60 percent rating is warranted for FEV-1 of 40 to 55 percent of the predicted value, FEV-1/FVC of 40 to 55 percent of the predicted value, DLCO (SB) of 40 to 55 percent of the predicted value, or maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). A 100 percent rating is warranted for FEV-1 less than 40 percent of the predicted value, FEV-1/FVC less than 40 percent of the predicted value, DLCO (SB) less than 40 percent of the predicted value, a maximum exercise capacity of less than 15 ml/kg/min in oxygen consumption (with cardiac or respiratory limitation), cor pulmonale (right heart failure), right ventricular hypertrophy, pulmonary hypertension (shown by echocardiogram or cardiac catheterization), or an episode or episodes of acute respiratory failure, or if outpatient oxygen therapy is required. Id. Post-bronchodilator results are to be used unless the results are poorer than pre-bronchodilator results. 38 C.F.R. § 4.96(d)(5). A review of the medical evidence of record, which includes VA treatment records from 2005 through 2018, private treatment records from 2005 to 2017, and VA examination reports from October 2009, February 2016 and July 2017, shows the Veteran is diagnosed to have quiescent sarcoidosis that has been, at most, manifested by an intermittent, generally non-productive cough. Except for the cough (which has been questioned to be related to his sarcoidosis versus asthma), the Veteran’s sarcoidosis has been a stable for many years manifested solely by hilar and mediastinal lymphadenopathy shown on radiographic study without pulmonary parenchymal involvement or functional limitations. See e.g., VA treatment notes dated October 22, 2008 and September 25, 2013. VA treatment records show the Veteran’s cough was initially treated with Albuterol, a corticosteroid, and steroid inhalers. See e.g., March 1, 2006 Chest Clinic note. However, sometime within the next year or so, the Veteran quit taking the steroid inhaler and continued using only the Albuterol inhaler as when he was next seen in 2008 he had quit taking the steroid inhaler. Thereafter, he continued to use only the Albuterol inhaler to help control his cough until September 2013 when he was prescribed Symbicort, which is also an inhaled corticosteroid. Since September 2013, the Veteran has used both Symbicort and Albuterol. The Veteran was also prescribed a nasal steroid inhaler for allergic rhinitis, along with loratadine (an antihistamine), in hopes of improving his cough symptoms, which it did according to the Veteran’s report. Also prescribed because it was thought it might help the Veteran’s cough (but not given to directly treat the Veteran’s sarcoidosis) was Omeprazole (a proton pump inhibitor) for treatment of gastroesophageal reflux disease (GERD). Consequently, a review of the Veteran’s treatment records does not demonstrate that his sarcoidosis has ever been treated using systemic high dose corticosteroids. Rather, they only show treatment with inhaled corticosteroids. In 2006, he was treated with Flunisolide and Mometasone and, in September 2013, he was prescribed Symbicort, which he has continued to use to the present. Consistent throughout the Chest Clinic notes is the evaluation that his sarcoidosis has remained stable and has not required steroids. Despite the Veteran’s testimony at the December 2016 Board hearing that he was tried on oral steroids but was unable to tolerate them and, therefore, was placed back on Symbicort about one to one and a half years prior to the hearing, there are no VA treatment records showing any such treatment. An April 8, 2015 Chest Clinic note shows he was stable with his cough well-controlled on Symbicort and he was to continue his current medication regimen, which included Symbicort, Albuterol, Flunisolide nasal spray and Loratadine. An October 2015 Primary Care note also did not indicate any problems with, or that the Veteran was taking steroids for, his sarcoidosis. The Veteran was not seen again in the Chest Clinic until March 2016 at which time he was noted to be doing well without new symptoms except for intermittent cough well-controlled by as-needed Guaifenesin. Furthermore, the Veteran’s private treatment records fail to show any treatment for his sarcoidosis and the VA examination reports from February 2016 and June 2017 fail to show the examiners reported the Veteran’s sarcoidosis required the need for steroids within the 12 months preceding the examinations. Consequently, as the medical evidence fails to demonstrate that the Veteran’s service-connected sarcoidosis has required the use of systemic high dose corticosteroids, a disability rating of 60 percent under DC 6846 is not warranted. Furthermore, the Board acknowledges that the VA and private treatment records show that the Veteran has a heart disorder. However, there is no indication in the records that this is related to the Veteran’s service-connected sarcoidosis or that the specific cardiac criteria listed in DC 6846 are present such that a 100 percent disability rating is warranted. Moreover, there is no evidence to demonstrate that the Veteran has progressive pulmonary disease with fever, night sweats, and weight loss despite treatment. As discussed above, the evidence shows that his primary symptom is an intermittent cough. Otherwise his sarcoidosis has been stable and quiescent. It has been noted that he has a good exercise tolerance level. See e.g., March 23, 2016 Chest Clinic note. Although he reported night sweats at an October 2009 VA examination, he also reported walking over four miles three times per week and denied fevers and weight loss. Moreover, VA treatment records around the same time fail to note any report of night sweats or other such symptoms. The VA examiner only noted his symptom of cough having worsened since the last VA examination in May 2007. As such, the criteria for a 100 percent rating under DC 6846 are not met. Moreover, the Board finds that a higher rating is not warranted under DC 6600. Pulmonary function testing (PFTs) performed on VA examination in October 2009 showed FEV-1 of 128 percent and FEV-1/FVC of 121 percent post-bronchodilator. DLCO was not reported. PFTs performed on VA examination in June 2017 showed FEV-1 of 128 percent and FEV-1/FVC of 121 percent post-bronchodilator. DLCO was again not reported. Clearly, these findings are not consistent with the next higher rating of 60 percent, which requires the FEV-1 or the FEV-1/FVC to be between 40 to 55 percent of the predicted value. The Board acknowledges that the DLCO was not provided on the PFTs, but it was noted this is because it is not indicated for the Veteran’s condition. Additional reference to the Veteran’s disabilities are presented in additional evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. The additional evidence of record does not present findings concerning the Veteran’s disabilities that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. 5. Entitlement to a compensable disability rating for service-connected scar, left first metacarpal (thumb) At the December 2016 Board hearing, the Veteran testified that his scar on his thumb is painful. Service connection for the left thumb scar was awarded in an April 2006 rating decision and an initial noncompensable disability rating was assigned under DC 7805. The Veteran filed his current claim for an increased disability rating in March 2014. The Board notes that, effective August 13, 2018, VA has revised 38 C.F.R. § 4.118. These revisions apply to all claims filed on or after August 13, 2018. As to claims filed prior to and pending on August 13, 2018, they are to be considered under both the old and new rating criteria and whatever criteria is more favorable to the veteran will be applied. 83 Fed. Reg. 32592. As the Veteran’s disability to be evaluated as a scar on his left thumb, the Board finds that only DCs 7801 through 7805 are for potential application in rating his disability. A review of the newly revised rating criteria for scars shows that only DCs 7801 and 7802 were revised. Under the old rating criteria, DC 7801 provided that burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrants a 10 percent rating. A 20 percent rating requires an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A 30 percent rating requires an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.). A 40 percent rating requires an area or areas of 144 square inches (929 sq. cm.) or greater. A qualifying scar is one that is nonlinear and deep, and is not located on the head, face, or neck. Note (1) to Diagnostic Code 7801 provides that a deep scar is one associated with underlying tissue damage. 38 C.F.R. § 4.118. The revised criteria change the requirement that the scar be “deep and nonlinear” to “associated with underlying soft tissue damage.” Otherwise, the rating criteria remain the same. 83 Fed. Reg. at 32598. Under the old criteria, DC 7802 provided that burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent evaluation. Note (1) to Diagnostic Code 7802 provides that a superficial scar is one not associated with underlying soft tissue damage. Note (2) to Diagnostic Code 7802 provides that if multiple qualifying scars are present, a separate evaluation is assigned for each affected extremity based on the total area of the qualifying scars that affect that extremity. 38 C.F.R. § 4.118. The new rating criteria requires the scar be “not associated with underlying soft tissue damage” rather than be “superficial and nonlinear.” 83 Fed. Reg. at 32598. The only other revisions to DCs 7801 and 7802 are the notes were revised. Note (1) now defines six zones of the body as each extremity, anterior trunk, and posterior trunk; and states that the midaxillary line divides the anterior trunk from the posterior trunk. Note (2) states that a separate evaluation may be assigned for each affected zone of the body under this DC if there are multiple scars, or a single scar, affecting multiple zones of the body. Separate evaluations should be combined under 38 C.F.R. § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under the DC. Id. The rating criteria under DCs 7804 and 7805 were not changed in the new revisions (only the header of DC 7805 was revised). DC 7804 provides a 10 percent rating for 1 or 2 scars that are unstable or painful. A 20 percent rating is warranted for 3 to 4 scars that are unstable or painful and a 30 percent disability rating assigned for 5 or more scars that are unstable or painful. Note (1) to Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. DC 7805 provides that other scars (including linear scars) and other effects of scars evaluated under DCs 7800-04 require the evaluation of any disabling effect(s) not considered in a rating provided under DCs 7800-04 under an appropriate diagnostic code. Id. VA examination of the Veteran’s left wrist in December 2013, October 2014 and June 2017 demonstrate that he has a scar located on the left first metacarpal that is a residual of the surgery (open reduction, internal fixation) that he had during service to repair the fracture he sustained in service. All examinations indicate that, objectively, the scar is not painful or unstable. The June 2017 examiner also found that the scar is superficial and linear along the medial side of the left hand at the base of thumb and measures six centimeters. The examiner further noted that the scar is non-adherent, non-tender, well-nourished, non-ulcerated, non-keloidal and does not limit the function of the affected area. VA treatment records do not show any complaints of pain related to the scar. The only notation seen relating to the scar is in a July 2008 Occupational Therapy evaluation note in which it is commented that the Veteran reported having tried to obtain compensation for keloid scarring on the wrist and the evaluator’s notation in parentheses that none is present. Private treatment records are silent as to a scar on the left thumb. Based on this evidence, the Board finds that the preponderance of the evidence is against finding that a compensable disability rating is warranted for the Veteran’s left thumb scar under either the old or new rating criteria. The Board finds the objective medical evidence provided in the VA examinations to be more probative for rating purposes than the Veteran’s statements as to whether his scar is painful. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Additional reference to the Veteran’s disabilities are presented in additional evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. The additional evidence of record does not present findings concerning the Veteran’s disabilities that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S.M. Kreitlow