Citation Nr: 18147879 Decision Date: 11/07/18 Archive Date: 11/06/18 DOCKET NO. 16-31 569 DATE: November 7, 2018 ORDER The claim for service connection for an acquired psychiatric disorder, to include a bipolar disorder and posttraumatic stress disorder, claimed as manic depression and anxiety, is denied. The claim for an initial rating in excess of 10 percent for a scar of the nose, as a residual of an injury, is denied. The claim for an initial rating in excess of 10 percent for a right hand strain with painful motion of the thumb and index finger is denied. The claim for an initial compensable rating for a right hand strain with painful motion of the right 5th finger is denied. The claim for an initial compensable rating for a right hand strain with painful motion of the right 4th finger is denied. The claim for an initial compensable rating for scars, as residuals of a right hand injury, is denied. FINDINGS OF FACT 1. An acquired psychiatric disorder is first shown many years after active service and is unrelated to his military service; and posttraumatic stress disorder (PTSD) is not shown. 2. The Veteran has a small scar on the bridge of his nose which is not significantly disfiguring, and while depressed is otherwise asymptomatic and does not cause any functional impairment. 3. Due to an inservice injury of the right hand, the Veteran’s dominant upper extremity, he has painful but unlimited motion of the right thumb and index finger and opposition of the thumb to the other fingers is not limited by more than 2 inches. 4. The Veteran has painful but unlimited motion of the right 5th finger. 5. The Veteran has painful but unlimited motion of the right 4th finger. 6. The Veteran’s surgical scars on the medial and lateral aspects of his right hand and wrist are asymptomatic and not productive of functional impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include a bipolar disorder, claimed as manic depression and anxiety, are not met. 38 U.S.C. §§ 1110, 1112, 1137, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304(f), 3.307, 3.309 (2017). 2. The criteria for an initial rating in excess of 10 percent for a scar of the nose, as a residual of an injury, are not met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.118, Diagnostic Code 7800 (2017). 3. The criteria for an initial rating in excess of 10 percent for a right hand strain with painful motion of the thumb and index finger are not met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.71a, Diagnostic Codes 5228 – 5229 (2017). 4. The criteria for an initial compensable rating for a right hand strain with painful motion of the right 5th finger are not met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.71a, Diagnostic Code 5230 (2017). 5. The criteria for an initial compensable rating for a right hand strain with painful motion of the right 4th finger are not met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.71a, Diagnostic Code 5230 (2017). 6. The criteria for an initial compensable rating for scars, as residuals of a right hand injury, are not met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.71a, Diagnostic Code 7801 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1977 to November 1978 and was discharged under honorable conditions. This matter comes before the Board of Veterans’ Appeals (Board) from a March 2013 decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran’s October 2013 Notice of Disagreement (NOD) expressed dissatisfaction with the adjudications in the March 2013 rating decision, and all eleven (11) issues were addressed in the June 2016 Statement of the Case (SOC). However, in his June 2016 VA Form 9, Appeal to the Board, he limited his appeal to the issues as stated on the title page. This was confirmed by the RO’s letter to the Veteran of July 11, 2016. In the VA Form 9, he also requested a videoconference hearing. By another letter of July 11, 2016, the RO notified the Veteran that he was placed on a list of those that desired a Board videoconference but it could not predict when the hearing would be held. In response, the Veteran withdrew his request for a Board hearing. Background In October 1997 it was noted that the Veteran had a laceration over his nose and on his nose, after he fell that morning. He was sent to the emergency room to have stiches for a laceration of his forehead and the bridge of his nose. A July 1978 clinical record noted that the Veteran had lacerated his right wrist when he hit a glass window with his fist. Service personnel records show that in October 1978 the Veteran received an Article 15 for possession of marijuana and for striking, with his fist, his superior non-commissioned officer. A November 1978 document shows that it was to be recommended that the Veteran be discharged from military service because of his poor attitude, lack of self-discipline, inability to adapt emotionally, inability to accept instructions and directions, and his clearly substandard performance. It was noted that he had been counseled five (5) times concerning his deficiencies. The November 1978 examination for service separation revealed that the Veteran’s psychiatric status was normal. Specifically, his behavior and thought content were normal. He was fully alert and fully oriented. His mood was not depressed, his thinking process was clear, and his thought content was normal. His memory was good. The impression was that he had no significant mental illness. He had a 1-centimeter (cm.) scar across his nose, and he had a 5 cms. semicircular scar on the dorsum of his right hand. In an adjunct medical history questionnaire, he denied frequent trouble sleeping, depression or excessive worrying, loss of memory or amnesia, nervous trouble of any sort, and having periods of unconsciousness. He reported that he was right handed. The Veteran applied for VA education benefits in January 1979. In a February 2011 VA Form 21-4138, Statement in Support of Claim, the Veteran reported that during service he had received four Article 15s for fighting, disobeying an order, drunk on duty, and drug possession. He stated that he had gotten into a lot of trouble during service because of a bipolar disorder. While in a manic phase he had cut his hand and face, causing discomfort and leaving permanent scars. Then, and now, he could not get along with others, and over the years his depression had escalated. Since 1977 he had had bouts of manic depression, as well as drug and alcohol abuse, for which he had sought rehabilitation four times. In VA Form 21-4142, Authorization and Consent to Release Information, the Veteran reported having been treated at VA facilities since 2000 for manic episodes, anxiety, bipolar disorder, and alcoholism. A March 2003 decision by an Administrative Law Judge (ALJ) of the Social Security Administration (SSA) reflects that the Veteran was awarded SSA disability benefits, having been disabled since June 2000 due to left shoulder rotator cuff pain, mechanical low back pain, bipolar disorder with psychotic features in 1997 but without psychotic features since 1997, and polysubstance abuse, especially alcohol, marijuana, and cocaine. He had been hospitalized in 1988 for alcoholism; again in 1993 when, although a bipolar disorder was suspected, a diagnosis was not possible due to alcohol, cocaine, and marijuana use. He was hospitalized in 1996 due to an “LSD” overdose. Thereafter, he had had VA treatment for depression and substance abuse. The ALJ decision noted that the Veteran was hospitalized in March 1997 at a private facility and diagnosed with a bipolar disorder, manic, with psychotic features. At discharge he had a psychotic disorder with manic features that could have been drug induced. In July 1998 a private physician reported that the Veteran was followed for a well-established bipolar disorder, active cannabis dependence, and alcohol dependence, in sustained remission. A June 2000 VA clinical source had reported in June 2000 that his substance abuse, of alcohol, cocaine, and cannabis, was inactive but when hospitalized for an exacerbation of bipolar disorder in November 2000 he reported having smoked marijuana on the day of VA hospital admission. When later hospitalized in October 2001 he was diagnosed with encephalopathy, which was suspected to be due either to overdosing of prescribed medication or drug interaction. He thereafter continued to have depression and anxiety, and underwent electroshock therapy (ECT). The ALJ stated that the Veteran had a medically documented history of a chronic affective disorder of at least 2 years duration. SSA records include a June 1998 report from Dr. R. Cantor who stated that in the past the Veteran had had a large laceration of the dorsal aspect of the right wrist, after his hand had gone through a window, which cause him pain, and limitation secondary to pain. However, it was also reported that the Veteran had no deficits in the range of motion of his hands. On physical examination he had 5/5 motor strength in all muscles. Grasp, manipulation, pinch and fine coordination were normal, bilaterally. His well healed scar on the dorsum of the right wrist, from the proximal ulnar to the distal lateral radial aspect, was tender to palpation. He was right handed, with dynametric readings of: on the right 38/40/24, and on the left 24/40/50. There were no deficits in the ability to pick up and manipulate large and small objects. Ranges of motion of the wrists and hands were within normal limits. There were no sensory deficits in the upper extremities to light touch, and no atrophy. A discharge summary of the Veteran’s VA hospitalization in November and December 2000 shows that he was admitted for treatment of cannabis problems, having used marijuana for 28 years. It was noted that he had difficulty controlling his anger, and this was likely due to borderline personality traits. The discharge diagnoses were cannabis dependence, bipolar disorder, nicotine dependence, and borderline personality traits. The Veteran underwent an evaluation in March 2001 for back pain. On physical examination he had 5/5 motor strength in both upper extremities. All joints of the upper extremities were stable, without effusion, warmth or erythema. Neurovascular examination was completely within normal limits, and he was without numbness, paresthesias or tingling. He had normal vibratory and position sense and well as normal sensation to pin prick. Reflexes were all within normal limits. His ability to grasp and manipulate with each hand was “certainly within normal limits.” VA outpatient treatment (VAOPT) records show that in December 2006 the Veteran reported having been in a car accident the week before, when he was not wearing a seat belt, and hit the right side of his head on the wind shield on the passenger side. There was no loss of consciousness but he had had headaches since then. The assessment was chronic recurrent headache, probably migraine, and the Veteran reported that his usual headache was recurrent more often since the head injury in the car accident. VAOPT records include a June 20, 2006, Psychiatric Nursing Intake record show that a PTSD screening was positive, because of the Veteran’s responses endorsing having had an experience that was so frightening, horrible or upsetting, that in the past month he had had nightmares about it or thought about it when you did not want to; he had tried hard not to think about it or went out of your way to avoid situations that reminded you of it; he was constantly on guard, watchful or easily startled; and he felt numb or detached from others, activities or his surroundings. There was no actual description of the putative stressful event. On VA examination on January 31, 2013, of the Veteran’s hands and fingers his claim file was reviewed. The examiner reported that the diagnosis was a right hand strain. It was reported that the Veteran had injured his right hand during service when he punched a window. He sustained a deep laceration, including severing the tendon, which was surgically repaired, followed by physical therapy. Surgical scars were on the dorsum of and hand and wrist. Since that time, he had had intermittent moderate pain in the right hand which occurred daily, and was aggravated by prolonged use and when he bumped it. He denied wrist pain. He reported some weakness of right hand grip and numbness of the dorsum of the right hand and 4th and 5th fingers. He currently took Vicodin for generalized pains, including pain in the right hand, with relief of right hand pain and no side effects. He wore a brace on right hand during sleep with moderate relief of pain. The Veteran was right handed and did not report having flare-ups. It was reported that he had limitation of motion or painful motion of all the fingers of the right hand. As to his ability to oppose his thumb, there was no gap between the thumb pad and the fingers, and no painful motion. There was no gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips, and no evidence of painful motion. There was no limitation of extension or evidence of painful motion of the index finger or long finger and no evidence of painful motion. The Veteran was able to perform repetitive-use testing with 3 repetitions without additional limitation of motion for any fingers. On repetitive flexion of the fingers there was no gap between any fingertips and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips. After repetitive extension there was no limitation of motion of any finger. He did not have additional limitation in range of motion of any of the fingers or thumbs following repetitive-use testing but did have functional loss or functional impairment because he had painful and weakened movement of all fingers of the right hand. As to all fingers of the right hand he did not have limitation of motion, excess fatigability, incoordination or impaired ability to execute skilled movements smoothly, atrophy of disuse, or deformity. He did not have tenderness or pain to palpation for joints or soft tissue of either hand, including the thumb and fingers. The Veteran’s right hand grip was 4/5. There was no ankylosis of the thumb or any fingers. His surgical scar was not painful and/or unstable, and the total area of all related scars was not greater than 39 square cms. (6 square inches). He regularly used a right wrist brace. His condition was not such that no effective function remained other than that which would be equally well served by amputation with prosthesis. X-rays in January 2013 of the Veteran’s right hand and wrist revealed contour abnormalities suggestive of posttraumatic deformities involving the distal radius and ulna. There were possible sutures overlying the radial styloid. A lucency associated with the ulnar styloid was suspected to reflect either posterior matter change, or possible subchondral geode related to degenerative changes. There was a similar lucency within the lunate with adjacent sclerosis, which might also be degenerative in nature. The examiner reported that the Veteran’s condition of the right hand and fingers impacted his ability to work in that employment tasks requiring prolonged use of right hand was limited by this condition. In the presence of chronic narcotic use, operation of equipment was prohibited. On VA scar examination on January 31, 2013, the Veteran’s claim file was reviewed. The Veteran had scars of his right hand due to a deep laceration in 1978 and, also, a scar on the bridge of his nose due to a deep laceration ih 1977. None of the Veteran’s scars were painful, unstable, or had frequent loss of covering of skin over the scar. He had a scar on the medial aspect of the right hand and wrist, and on the lateral aspect of the right hand and wrist. Of these deep, non-linear scars, the first (on the medial aspect) was 9.5 cms.by 0.5 cms. and the scar on the lateral aspect was 6.5 cms. by 0.7 cms. The approximate total area of both scars was 9.3 cms. The Veteran also had a scar on the bridge of his nose from a deep laceration in 1977. The scar was not painful, unstable and did not have frequent loss of covering of skin over the scar. The scar measured 2.5 cms. by 0.3 cms. The scar was depressed but not adherent to underlying tissue, and there was no abnormal pigmentation, induration or texture. There was no gross distortion or asymmetry of facial features or visible or palpable tissue loss. The scar did not result in limitation of function. A photograph was attached to the report of the examination. On VA peripheral nerve examination on January 31, 2013, it was reported that since the Veteran’s inservice injury he had had intermittent moderate pain in the right hand which occurs daily, aggravated by prolonged use and when he bumps it. He denied wrist pain. He reported having some weakness of the grip with the right hand and numbness of dorsum of hand and 4th and 5th fingers. He currently took Vicodin for generalized pains, including pain in the right hand, with relief of right hand pain and without any side effects. He wore a brace on right hand during sleep with moderate relief of pain. It was reported that the Veteran had mild numbness of the right upper extremity but no paresthesias or dysesthesias. Strength in right wrist flexion and extension was 5/5, and pinch strength (thumb to index finger) was 5/5 but right hand grip was 4/5. The was no muscle atrophy. There was decreased sensation in the right hand and fingers but no trophic changes. It was reported that he had mild incomplete paralysis of the right ulnar nerve. The functional impairment was not such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The Veterans peripheral nerve condition and/or peripheral neuropathy did not impact his ability to work. On VA scar examination on March 9, 2016, the Veteran’s electronic records were reviewed. The Veteran had scars of the nose and forehead and scars of the right hand and right wrist. None of the scars of the extremities were painful or unstable. The scar on the medial aspect of the right and wrist was 9.5 cms. by 0.5 cms. The scar on the lateral aspect of the right hand and wrist was 6.5 cms. by 0.7 cms. The total area of involvement was 9.3 cms. As to the scars of the nose and forehead, these were from a fall in 1977 which had required suturing. The scars were not painful or unstable. The scar on the bridge of the nose was 2.5 cms. by 0.5 cms. The scar on the forehead was 1.5 cms. by 0.5 cms. The scar on the bridge of the nose was depressed upon palpation but otherwise no abnormality of the scars was noted. The scars did not cause any limitation of function and did not impact his ability to work. Principles of Service Connection Establishing entitlement to service connection generally requires having probative (meaning competent and credible) evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a correlation ("nexus") between the disease or injury in service and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009). A rebuttable presumption of service connection exists for chronic diseases, specifically listed at 38 C.F.R. § 3.309(a) (and not merely diseases which are “medically chronic”), including psychoses, if the chronicity is either shown as such in service which requires sufficient combination of manifestations for disease identification and sufficient observation to establish chronicity (as opposed to isolated findings or a mere diagnosis including the word ‘chronic’), or manifests to 10 percent or more within one year of service discharge (under § 3.307). 38 C.F.R. § 3.384 states that a psychosis means any of the following disorders listed in the Diagnostic and Statistical Manual of Mental Disorders – (a) brief psychotic disorder;(b) delusional disorder;(c) psychotic disorder due to general medical condition;(d) psychotic disorder NOS;(e) schizoaffective disorder; (f) schizophrenia;(g) schizophreniform disorder; (h) shared psychotic disorder; and (i) substance-induced psychotic disorder. However, a bipolar disorder of any type is not listed at 38 C.F.R. § 3.384 as being a psychotic disorder. 79 Federal Register 45099 (effective August 4, 2014). Personality disorders are not considered diseases or injuries for which service connection is available. 38 C.F.R. §§ 3.303(c), 4.9, 4.127. The Board must determine whether the weight of the evidence supports each claim or is in relative equipoise, with the appellant prevailing in either event. However, if the weight of the evidence is against the appellant’s claim, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990). 1. The claim for service connection for an acquired psychiatric disorder, to include a bipolar disorder, claimed as manic depression and anxiety Analysis In the Veteran’s VA Form 9 of June 30, 2016, he made reference to his facial scarring bring back “PTSD” of the circumstances of how his injury occurred. However, the STRs show that the injury occurred in a simple fall and there is nothing to suggest that the Veteran was involved in any event that placed his life or well-being in jeopardy. Indeed, the Veteran did not come into contact with hostile military or terrorist activity; he served in peacetime and, so, he did not participate in combat and was not a prisoner-of-war; and PTSD was not diagnosed during service. Accordingly, the Veteran’s uncorroborated allegation that he sustained a stressor which could cause PTSD is insufficient. See 38 C.F.R. § 3.304(f). Rather, there must be corroboration of any such putative stressor. In this case, not only is there is no corroboration, the Veteran has never identified any putative stressor, much less provided any specifics as to any possible stressor. In fact, he has not even provided a broad-brushed suggestion as to what, if any, event might have been a stressor. Consequently, the Board finds no merit to the Veteran’s vague suggestion that he may have PTSD. In the Veteran’s NOD he indicated that he had had manic episodes due to his military service which, in turn, had led to years of drug and alcohol abuse. However, the STRs are negative for a psychiatric disability. In fact, the Veteran’s psychiatric status at discharge from active service was normal and he had no complaints of a psychiatric nature. The earliest evidence of a psychiatric disorder is at a time many years after the Veteran discharge from active service and, significantly, after many years of postservice abuse of alcohol and a variety of drugs. There is no evidence that he had any manic episodes, as he alleges, during active service. Rather, there is postservice evidence that his abuse of alcohol and drugs may be due to personality traits. This suggests that he has a personality disorder. Personality disorders are not considered diseases or injuries for which service connection is available. 38 C.F.R. §§ 3.303(c), 4.9, 4.127. A personality disorder is defined in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDER (4th ed.) 629, as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture ... and leads to distress or impairment. Wilkins v. Brown, 8 Vet. App. 555, 556 (1996). Thus, to the extent that the Veteran may have a personality disorder which may have contributed to his abuse of alcohol and drugs, it does not serve as a basis for granting service connection for an acquired psychiatric disorder. Although the Veteran may well believe that his current psychiatric disorder, often described in recent years as a bipolar disorder, had it onset during active service, he is not competent to render an opinion as to the etiology of any current acquired psychiatric disorder. Sometimes laypersons are competent to identify a condition, i. e., when simple, such as a broken leg, and sometimes not, e.g., a form of cancer. See Jandreau, 492 F.3d at 1377 n.4. A psychiatric disorder is not necessarily accompanied by observable symptoms, and for that reasons alone is more akin to cancer than a broken leg. See Tyrues v. Shinseki, 26 Vet. App. 31 (2012) (nonprecedential memorandum decision). Similarly, “PTSD is not the type of medical condition that lay evidence, standing alone, is competent and sufficient to identify.” Young v. McDonald, 766 F.3d 1348 (Fed.Cir. Sept. 8, 2014). Accordingly, for these reasons and bases the Board must conclude that the preponderance of the evidence is against the claim for acquired psychiatric disorder, to include a bipolar disorder, claimed as manic depression and anxiety. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990). General Rating Principles Ratings for a service-connected disability are determined by comparing current symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which is based as far as practical on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Disabilities are viewed, and examinations are interpreted, historically, to accurately reflect the elements of disability present. 38 C.F.R. §§ 4.1, 4.2. A higher rating is assigned if it more nearly approximates such rating. 38 C.F.R. §§ 4.7, 4.21. Separate ratings may be assigned either initially or during any appeal for an increased rating for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119 (1999) (initial staged ratings). Also, the alleviating effects of medication may not be considered in schedular ratings unless explicitly provided in the applicable schedular rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69. 2. The claim for an initial rating in excess of 10 percent for a scar of the nose, as a residual of an injury 38 C.F.R. § 4.118, Diagnostic Code 7800 provides that scars of the head, face, or neck from burns or other causes, or other disfigurement of the head, face, or neck when manifested by one characteristic of disfigurement warrant a 10 percent rating. Thirty (30) percent is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. Fifty (50) percent is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. With visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement an 80 percent rating is assigned. Note 1 to DC 7800 provides that for rating purposes the 8 characteristics of disfigurement are (1) a scar 5 or more inches (13 or more cm.) in length; (2) a scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.) (effective as to claims file on or after October 23, 2008). Note 4 to DC 7800 provides for separately evaluating disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply § 4.25 to combine the evaluation(s) with the evaluation assigned under this diagnostic code (effective as to claims file on or after October 23, 2008). Note 5 to DC 7800 provides that the characteristic(s) of disfigurement may be caused by one scar or by multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation (effective as to claims file on or after October 23, 2008). Analysis In this case, the Board has reviewed the entire evidentiary record, including the photograph taken of the scar of the bridge of the Veteran’s nose. Although the Veteran has reported being very self-conscious about the scarring, the Board does not concur that it is significantly disfiguring. The pigmentation of the scar is not significantly different than the surrounding skin. The length and width of the scar do not meet the requirements of the 8 characteristics of disfigurement and while the scar is somewhat depressed it is not adherent to underlying tissue and is not indurated and is not manifested by a loss of underlying soft tissue in an area exceeding six square inches. Significantly, the scar is not shown to cause any functional impairment of the Veteran’s nose or, in fact, any functional impairment of any kind. Accordingly, the preponderance of the evidence is against finding that an initial rating in excess of 10 percent for a scar of the nose, as a residual of an injury is warranted at any time during the appeal. Ratings for Fingers Under 38 C.F.R. § 4.71a, DC 5228 a noncompensable evaluation is warranted for limitation of motion of a thumb of the major or minor extremity when there is a gap of less than one (1) inch (2.5 cms.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 10 percent rating is warranted for limitation of motion of a thumb of the major or minor extremity when there is a gap of one (1) to two (2) inches (2.5 to 5.1 cms.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 20 percent rating is warranted for limitation of motion of a thumb of the major or minor extremity when there is a gap of more than two (2) inches (5.1 cms.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Under DC 5229 a noncompensable evaluation is warranted for a limitation of motion of the index or long finger with a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. Id. A 10 percent evaluation is warranted for a limitation of motion of the index or long finger with a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. Id. A zero (0) percent evaluation is granted for any limitation of motion in the ring or little finger. 38 C.F.R. § 4.714a, DC 5230. Also, a 10 percent evaluation is granted for ankylosis that is shown to be favorable or unfavorable for the index and longer fingers, while a 0 percent evaluation is granted for ankylosis that is shown to be favorable or unfavorable for the ring and little fingers. 38 C.F.R. § 4.71a, DC 5225 - 5227. Higher compensable evaluations can be granted for multiple favorable or unfavorable ankylosed digits when combined. 38 C.F.R. § 4.71a, DCs 5216 - 5223. 3. The claim for an initial rating in excess of 10 percent for a right hand strain with painful motion of the thumb and index finger In this case, the Veteran does not have any actual limitation of motion of either the thumb or the index finger of the right hand. The current rating is assigned on the basis of painful motion. To warrant a higher evaluation the evidence must establish that the Veteran has some actual functional impairment which is beyond that encompassed by the current 10 percent rating. In this regard, the schedular criteria to not provide for an evaluation greater than 10 percent for limitation of motion of the index finger and there is no ankylosis, or such impairment as to approximate ankylosis, of either the index finger or the thumb of the right hand. For a higher rating for limitation of motion of the thumb, there must be such limitation of motion of the thumb such that the thumb can come to less than two inches of the other fingers when attempting opposition. The rating examination in this case clearly demonstrates that the Veteran does not have such a degree of limitation of motion of the right thumb. Accordingly, the preponderance of the evidence is against finding that an initial rating in excess of 10 percent for a right hand strain with painful motion of the thumb and index finger is warranted at any time during the appeal. 4. The claim for an initial compensable rating for a right hand strain with painful motion of the right 5th finger The schedular rating criteria for the evaluation of limited motion of the little, i.e., 5th, finger of either the dominant or nondominant upper extremity do not provide for a compensable disability rating on the basis of any limitation of motion of that finger. Consequently, a compensable rating is not warranted even if there is full, but painful, motion in the absence of affirmative evidence of some actual functional impairment, and here there is none. Accordingly, the preponderance of the evidence is against finding that an initial compensable rating is warranted for a right hand strain with painful motion of the right 5th finger any time during the appeal. 5. The claim for an initial compensable rating for a right hand strain with painful motion of the right 4th finger The schedular rating criteria for the evaluation of limited motion of the ring, i.e., 4th, finger of either the dominant or nondominant upper extremity do not provide for a compensable disability rating on the basis of any limitation of motion of that finger. Consequently, a compensable rating is not warranted even if there is full, but painful, motion in the absence of affirmative evidence of some actual functional impairment, and here there is none. Accordingly, the preponderance of the evidence is against finding that an initial compensable rating is warranted for a right hand strain with painful motion of the right 4th finger any time during the appeal. 6. The claim for an initial compensable rating for scars, as residuals of a right hand injury Under 38 C.F.R. § 4.118 Diagnostic Code 7801 provides for ratings for scar not of the head, face, or neck which are deep and nonlinear. Scars not of the head, face, or neck from burns or other causes that are deep and nonlinear when involving an area of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrant a 10 percent rating. Scars not of the head, face, or neck from burns or other causes that are deep and nonlinear when involving an area of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) warrant a 20 percent rating. Scars not of the head, face, or neck from burns or other causes that are deep and nonlinear when involving an area of area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.) warrant a 30 percent rating. Here, the Veteran’s surgical scars of the right hand and wrist do not involve an area of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). Consequently, a minimum 10 percent rating is not warranted. Moreover, the scars are not shown to cause any limitation of motion, painful motion or significant functional impairment. Accordingly, the preponderance of the evidence is against finding that an initial compensable rating for scars, as residuals of a right hand injury, is warranted at any time during the appeal. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs