Citation Nr: 18147724 Decision Date: 11/07/18 Archive Date: 11/06/18 DOCKET NO. 12-08 253A DATE: November 7, 2018 ORDER From June 18, 2010, entitlement to an initial disability rating in excess of 10 percent for residual scarring from a cesarean section (C-section) is denied. From June 18, 2010, entitlement to a separate 30 percent rating for adhesions of the uterus associated with residual scarring from a C-section is granted. FINDINGS OF FACT 1. For the entire initial rating period from June 18, 2010, the residual scarring from a C-section has been characterized by one painful scar. 2. For the entire initial rating period from June 18, 2010, the Veteran has had painful adhesions of the uterus associated with residual scarring from a C-section that continue to manifest despite treatment. CONCLUSIONS OF LAW 1. From June 18, 2010, the criteria for an initial disability rating in excess of 10 percent for the residual scarring from a C-section have not been met or more nearly approximated for any part of the initial rating period from June 18, 2010. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7804. 2. From June 18, 2010, the criteria for a separate disability rating of 30 percent for adhesions of the uterus associated with residual scarring from a C-section have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 4.3, 4.7, 4.116, Diagnostic Code 7613. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1983 to September 1993. This matter is on appeal from a November 2010 rating decision and was previously remanded by the Board of Veterans’ Appeals (Board) in October 2014. Increased Rating The Veteran claims that her residual scarring from a C-section is worse than the currently assigned 10 percent rating. The Veteran’s service treatment records reflect that she underwent two C-sections during service; in 1984 and 1992. When she underwent the second procedure, the incision was made over the excision of the scar from the first procedure Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The determination of whether an increased rating is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating 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. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. While the Veteran’s entire history is reviewed when making a disability determination, where service connection has already been established and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s residual scarring from a C-section is currently rated as 10 percent disabling under DC 7804. Under this code, a 10 percent rating is assigned for one or two scars that are unstable or painful. A 20 percent rating is assigned for three or four scars that are unstable or painful. A 30 percent rating is assigned for five or more scars that are unstable or painful. Note (2) for DC 7804 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. Note (3) for DC 7804 provides that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under diagnostic code 7804, when applicable. 38 C.F.R. § 4.118 (2018). Upon review of the record, the Board finds that an initial rating in excess of 10 percent is not warranted for the Veteran’s for residual scarring of a C-section under 38 C.F.R. § 4.118, DC 7804. The Veteran underwent a relevant VA examination in September 2010. The examiner reported that the Veteran’s one scar is the result of two C-section procedures in 1984 and 1992, respectively, with the repeat C-section scar over the first scar. The Veteran asserted that the middle portion of the scar is painful during intercourse and is itchy while wearing certain types of clothing. The VA examiner noted subjective tenderness over the middle portion of the scar, but no limitation or loss of function. There was no skin breakdown or limitations on routine daily activities due to the scar. The scar showed a low Pfannenstiel incision over the suprapubic bone, under the hairline. The scar measured 14 cm long by .3 centimeters wide. The scar was not unstable. There was no inflammation, edema, and/or keloid formation, underlying soft tissue damage, and underlying tissue loss associated with the scar. The scar was not nonlinear. There was no elevation or depression of the scar. The texture of the scarred area was normal. There was no induration or inflexibility. The scar was the same color as normal skin. The diagnosis was a well-healed C-section scar. There were no significant effects on the Veteran’s occupation. In an April 30, 2012 letter to VA, the Veteran reported that in the previous five years she had been suffering from sharp pain in the lower section of her scar. On January 2015 scars disability benefits questionnaire, the examiner identified a well-healed scar from a C-section times two with subjective tenderness over the middle portion of the scar. There was no keloid. The examiner indicated that the scar was neither painful nor unstable. The scar was linear and measured 15 cm in length. There were no superficial nonlinear or deep nonlinear scars. On review of the record, an initial rating higher than 10 percent is not warranted because it has neither been alleged nor shown that the Veteran’s scar is manifested by three or more scars that are unstable and/or painful, nor does the Veteran have one or two scars that are both unstable and painful. Id. The Board has considered the Veteran’s disability under the other diagnostic codes pertaining to scars. However, her disability is not located on her head, face, or neck to warrant consideration under DC 7800; nor are the scars shown to be deep (associated with underlying soft tissue damage) and nonlinear, or superficial and nonlinear, or cover sufficient area to warrant consideration under DC 7801 or DC 7802. The Board acknowledges that Diagnostic Code 7805 requires an evaluation of any disabling effect(s) of scars (including liner scars) not considered in a rating provided under diagnostic codes 7800-7804 under an appropriate diagnostic code. To the extent that the Veteran alleges that a higher rating for her C-section scars is warranted due to a painful gynecological disorder, a disorder manifested by excruciating pain in the upper anterior thighs, and a disorder manifested by constipation, the Board will address these contentions in further detail below. Indeed, upon review of the record, the Board finds that a separate 30 percent rating is warranted for a gynecological disorder manifested by scar tissue and painful adhesions, as a residual of in-service C-section procedures and surgical scarring, under Diagnostic Code 7613 (uterus, disease, injury, or adhesions of). Treatment records on file show that the Veteran has had a longstanding history of gynecological care, in particular for constant pelvic pain. In August 2017, the Board sent the Veteran’s claims file to a medical expert in the field of gynecology to provide an opinion as to whether any of the Veteran’s current gynecological conditions could be related to residual scarring from the Veteran’s in-service C-sections. Later that month, Dr. C.G., the Gynecology Service Chief, found that it was at least as likely as not that the Veteran had pelvic pain related to, or aggravated by repeat C-section. The Board subsequently sought a clarifying opinion in which, in April 2018, Dr. C.G. more specifically opined that the scar tissue/adhesions between the uterus and other anatomic structures at least as likely as not contributed to the Veteran’s chronic pelvic pain, and were related to her in-service repeat C-sections based on the evidence of record. Dr. C.G. added that there was no objective clinical evidence of a chronic pelvic pain condition with onset prior to the Veteran’s C-section performed twice during the Veteran’s active duty service. She explained the C-section procedure, and stated post-operatively, scar tissue may form between the bladder and uterus. Rarely, the uterus may become adherent to the anterior abdominal wall. The Board has considered the Veteran’s contentions, the medical evidence documenting ongoing pelvic pain and the presence of adhesions, as well as the expert medical opinion of Dr. C.G. Given that no treatment provider has been able to treat the Veteran’s continuous pelvic pain and other symptoms as a result of scar tissue/adhesions between the uterus and other anatomic structures that have been found to be related to her C-sections, a separate initial disability rating of 30 is warranted under Diagnostic Code DC 7613, which governs ratings of disease, injury or adhesions of the uterus. 38 C.F.R. § 4.116, DC 7613. Under DC 7613, a 30 percent rating, the maximum available, is assignable for symptoms not controlled by continuous treatment. Id. That stated, the Board finds that separate ratings are not warranted for symptoms of pain in the Veteran’s thighs or for constipation, as such have not been shown to be related to residual scarring from the Veteran’s in-service C-sections. Regarding symptoms of pain in her thighs, in April 2006, the Veteran complained of varicose veins around her knees and thigh that were worse during summer heat, with throbbing and aching. In September 2007, she reported painful varicose veins in her bilateral thighs that hurt when the weather warmed up. It was noted that she wore support stockings. In an April 2012 letter to VA, the Veteran reported that she suffered from excruciating pain in the front part of both her upper thighs. The Veteran was afforded with a VA examination in January 2015, in which the VA examiner found that there was no evidence whatsoever of any upper thigh disorder that was caused or aggravated by the Veteran’s well headed C-section scar. The Board sought an expert medical opinion, and in August 2017, Dr. C.G., the Gynecology Service Chief, reported that there was documentation regarding the pain in the Veteran’s thighs suggesting that it was due to her varicose veins and was not neuropathic in nature. Dr. C.G. opined that it did not seem likely that the thigh pain was related to or aggravated by nerve injury at the time of the C-section. The Board sought a clarifying opinion in which, in April 2018, Dr. C.G. opined that it was less likely as not that the Veteran had an iliohypogastric nerve injury or ilioinguinal nerve injury as a result of the in-service repeat C-section. The specialist attributed the excruciating pain in the upper thighs to the Veteran’s varicose veins. She clarified that it was not necessary to obtain further examination and/or information from Neurology as the evidence of record suggested the subjective complaint of excruciating pain in the upper anterior thighs was due to varicose veins. Therefore, she opined that it was less likely as not that the Veteran has a disorder manifested by excruciating pain in the upper anterior thighs caused or aggravated by residual scarring from the Veteran’s in-service C-sections as the documentation regarding the pain in her thighs suggested that it was due to varicose veins and was not neuropathic in nature. Regarding symptoms of constipation, the Veteran reported a history of her gastroenterologist telling her that “scar tissue from the scar could have involved my bowel.” Records also reflect that the Veteran has reported problems with constipation. In July 1998, for example, it was noted that her bowel movements were chronically constipated. Similarly, in November 2006, the Veteran reported having chronically hard stools. The clinical assessments included constipation and obesity. In an April 2012 letter to VA, the Veteran also alleged that her OB/GYN stated that it was possible that the Veteran’s lesions or scar tissue had overgrown and attached to her intestines and bowels, causing chronic pain and bowel obstruction VA treatment records included an August 2012 record in which the Veteran related a history of pelvic pain and uterine fibroids and reported that her OB/GYN thought her bowel was fused together and causing constipation. A subsequent pelvic ultrasound was noted to be unremarkable. In October 2012, clinical impressions of painful defecation and possible irritable bowel syndrome were recorded. In August 2013, the Veteran again reported having chronic constipation, with maybe 1 to 2 bowel movements per week. It was noted that she had had a colonoscopy the year before, with findings of scattered diverticula, but that there had been poor preparation. On repeat colonoscopy in October 2013, the provider identified three hyperplastic and adenomatous polyps, as well as internal hemorrhoids. The Veteran was afforded a VA examination in January 2015, in which the VA examiner opined that there was no competent medical opinion of record that provided an etiologic link between the veteran's claimed constipation and the C-section scar. There was no evidence of aggravation of the claimed constipation due to the C-section scar. The Board sought a medical expert opinion from a specialist. In August 2017, Dr. C.G., the Gynecology Service Chief, reported that there was documentation suggestive that the Veteran’s constipation was due to irritable bowel syndrome and it was noted that she had hard stool. Dr. C.G. opined that these findings made it less likely that the Veteran’s constipation was due to or aggravated by sequela of her C-section. Dr. C.G. added that it did not seem more likely than not that the Veteran’s constipation was due to or aggravated by adhesions from her C-section. The Board sought a clarifying opinion in which, in April 2018, Dr. C.G. attributed the Veteran’s constipation to irritable bowel syndrome and therefore opined that it was less likely as not that the Veteran had a disorder manifested by constipation that was caused or aggravated by residual scarring from the Veteran’s in-service C-section. The Board finds that the opinion of the specialist in gynecology to be the most probative and credible evidence of record addressing whether there was a relationship between the residuals of the Veteran’s C-section and her excruciating pain in the upper anterior thighs and constipation. Although the Veteran may be competent to report that she is experiencing symptoms such as excruciating pain in the upper anterior thighs and constipation, the Board is of the opinion that the August 2017 and April 2018 medical opinion by a specialist ultimately outweighs the Veteran's lay contentions as to etiology. Layno v. Brown, 6 Vet. App. 465 (1994). (Continued on Next Page) In summary, the evidence is against a finding that the Veteran’s service-connected scar is so severe as to warrant a rating higher than a 10 percent. However, it is shown by the record that adhesions of the uterus associated with residual scarring from a C-section are present, and are generally not controlled by continuous treatment. The Board will resolve all doubt in the Veteran’s favor and award a separate 30 percent rating for such scarring residuals, effective June 18, 2010. To this extent, the appeal is granted. Lisa Crohe Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Crohe, Counsel