Citation Nr: 1806519 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 13-24 124 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement for service connection for residuals of cold injury. 2. Entitlement to service connection for a psychiatric disorder to include posttraumatic stress disorder (PTSD). 3. Entitlement to a rating in excess of 10 percent for scar right index finger. 4. Entitlement to a compensable rating for residuals of laceration right index finger. REPRESENTATION Veteran represented by: Pennsylvania Department of Military and Veterans Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD B. J. Komins, Associate Counsel INTRODUCTION The Veteran had active service in the United States Army from February 1980 to April 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal of July 2012 and February 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. In March 2013, the Veteran appeared before a Decision Review Officer (DRO) at the VA RO in Boston, Massachusetts. In June 2017, the Veteran testified at a Travel Board hearing before the undersigned Veteran's Law Judge (VLJ). Transcripts of both hearings have been associated with the claims file. FINDINGS OF FACT 1. The Veteran does not have residuals of cold injury. 2. A psychiatric disorder, to include PTSD was not manifest during service and is not related to service. 3. The Veteran's scar right index finger was not manifested by three or four scars that are unstable or painful. 4. The Veteran's residuals of laceration right index finger was not manifested by limitation of motion of the index or long finger with a gap of one inch between the fingertip and the proximal transverse crease of the palm with the finger flexed or with extension limited by more than 30 degrees. 5. The Veteran did not serve in combat. CONCLUSIONS OF LAW 1. Residuals of cold injury was not incurred or aggravated by service. 38 U.S.C. §§ 1131, 5103A, 5107 (2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. A psychiatric disorder, to include PTSD was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5103A, 5107 (2014); 38 C.F.R. §§ 3.303, 3.304, 4.125(a) (2017). 3. From September 21, 2010, the criteria for a rating in excess of 10 percent for service-connected scar right index finger have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2014); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.118, Diagnostic Code 7804 (2017). 4. From September 21, 2010, the criteria for a compensable rating for service-connected residuals of laceration right index finger have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2014); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5229 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Re-characterization of Issue The Board has re-characterized the issue of entitlement to service connection for any psychiatric condition, claimed as PTSD as entitlement to service connection for a psychiatric disorder to include PTSD. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Thus, even though the AOJ adjudicated the issue as any psychiatric condition claimed as PTSD, the Board finds that the symptoms articulated by the Veteran in the evidence of record supports re-characterization as a psychiatric disorder to include PTSD. II. Duties to Assist and Notify The requirements of 38 U.S.C. §§ 5103 and 5103A (2014) have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA has a duty to notify and to assist the Veteran in the development of his claims. The AOJ satisfied its duty to notify by way of a letters dated in June 2010 and June 2011. The AOJ notified the Veteran prior to the rating decisions on appeal of the information and evidence needed to substantiate and complete the claims decided here, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, how to substantiate a claim for service connection, and how disability ratings and effective dates are determined. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Regarding the duty to assist, the Veteran's medical records, to include service treatment records (STRs) and VA treatment records have been obtained. Moreover, the Veteran underwent VA examinations during the applicable appeal period, the reports and opinions of which adequately address the issues decided here. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). During the July 2017 Travel Board hearing, the undersigned VLJ clarified the issues decided here and asked questions designed to elicit any potentially relevant evidence in the Veteran's possession. Furthermore, the VLJ described for the Veteran the type of evidence necessary to substantiate his claims. The VLJ also agreed to hold the record open for a period of 60 days to allow for additional submission of evidence. This action supplemented VA's compliance with the VCAA and satisfied 38 C.F.R. § 3.103 (2017). The Board thus finds that further action is unnecessary under 38 U.S.C. § 5103A (2014) and 38 C.F.R. § 3.159 (2017). The Veteran will not be prejudiced as a result of the Board's adjudication of the issues below. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 C.F.R. § 3.303(d) (2017). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Under 38 U.S.C. § 1154(b) (2014), the evidentiary burden for combat veterans with respect to evidence of in-service incurrence or aggravation of an injury or disease is reduced. See Collette v. Brown, 82 F.3d 389, 392 (Fed.Cir.1996). Review of the evidence of record shows that the Veteran's active service did not include combat, therefore this provision is not for application in this case. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. 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) (2017); Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (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. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be granted to the claimant. 38 U.S.C. § 5107 (2014); 38 C.F.R. §§ 3.102, 4.3 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on the merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Residuals of Cold Injury The Veteran contends that he incurred frostbite of his fingers and toes while in active service in Germany, the residuals of which manifest as present finger cramping and arthritis effects. A review of the Veteran's STRs provides a March 1981 Report of Medical History. In this report, the Veteran indicated that he suffered from colds since he arrived in Germany and foot trouble. As to the foot trouble, an examiner provided a notation of "feet, not otherwise specified (NOS)." However, in the same document the Veteran indicated that did not have lameness; skin disease; or bone, joint or other deformity. The Veteran also indicated that he had never had any illness or injury other than those specifically noted in the March 1981 Report of Medical History. The STRs are silent as to occurrences and treatment for frostbite of fingers and toes. A review of medical records from the Gainesville, Florida Veterans Affairs Medical Center (VAMC) does not show complaints or treatment for residuals of cold injury. Likewise, a review of the Veteran's medical records from the Coatesville, Pennsylvania VAMC does not reveal complaints or treatment for residuals of cold injury. The Veterans medical records from a VA facility in Northampton, Massachusetts include neither complaints nor treatment for residuals of cold injury. However, these records show his feet were addressed within the contexts of diabetes care and podiatric care. The Veteran indicated that he had decreased pulses in the feet; dry skin of the feet; tingling in the feet; and neuropathy of the feet. The Veteran was also fitted for shoes to minimize the aforementioned symptoms. Furthermore, the Veteran received treatment related to diabetes at the Miami, Florida VAMC. Reports from these VAMCs further show that the Veteran received on-going treatment for diabetes mellitus. Clinicians at these VA facilities noted that the Veteran went through periods of homelessness, which triggered concerns as to his adherence to his diabetology care and compliance. The Board notes here that the evidence of record includes approximately 20 VAMC Reports of Hospitalization, which include, in this context, admissions for gangrene of the toe; peripheral vascular disease; foot gangrene; amputation of second left toe; and, in at least two instances, homelessness itself. In December 2010 the Veteran submitted a statement, via VA Form 21-4138. Among other contentions, the Veteran wrote that he developed frostbite in Germany and was not afforded immediate medical attention, causing him to suffer for a number of days. He added that prior to this experience his toes and fingers functioned properly. In June 2011, the Veteran was afforded a VA examination. The examiner reviewed the Veteran's claims file, considered the Veteran's account of his medical history, and conducted a physical examination. The examiner noted that the Veteran indicated that he experienced "on and off" pain in the right index finger, especially during cold weather. The examiner provided neither findings nor impressions of residuals of cold injury in the Veteran's fingers. In February 2013, the Veteran was afforded a VA scar and disfigurement examination. The examiner followed VA examination protocols. In the remarks section of the examination report, he noted that the Veteran indicated that his finger scar became painful with cold weather. However, this examiner provided neither findings nor impressions of residuals of cold injury relating to the Veteran's finger scar. At the March 2013 DRO hearing, the Veteran testified that he was exposed to cold during a maneuver in Germany. Specifically, he stated that he had frostbite by the time the maneuver ended, adding that he had to take his boots and gloves off and "get around" a heater. As to symptoms, the Veteran reported that he experienced numbness in his hands and feet. At the July 2017 Travel Board hearing, the Veteran testified that by the time a maneuver on September 1980 ended, his fingers and toes had frostbite. He further stated that he was then put into a tank to thaw out, and was not afforded an opportunity to go to the infirmary. He added that he did not go to a pharmacy or a nurse, noting that he was being taught to endure it. The Veteran testified that he experienced cramping in his wedding band finger; he also stated that he was advised to get x-rays because he was told he would develop arthritis effects in the impacted finger. The Veteran did not offer testimony as to residuals of cold injury in his feet, despite a direct question on this point by the undersigned VLJ. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that service connection for residuals of cold injury is not warranted. As discussed above, the Board has reviewed the medical evidence of record and no credible evidence provides an impression of present residuals of cold injury attributable to service. In the absence of a disability, compensation may not be awarded. In the absence of evidence of a current disability, there can be no grant of service connection under the law. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, there is no competent evidence of residuals of cold injury. In reaching this conclusion, we use the definition of disability as noted in Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991) (This definition comports with the everyday understanding of disability, which is defined..., "as an inability to pursue an occupation because of physical or mental impairment"). In assessing this claim, the Board has considered the Veteran's lay assertions. He is competent to report observable symptoms such as pain. See Jandreau, 492 F.3d at 1372, 1377. However, his contentions as to residuals of cold injury are not credible. The preponderance of the evidence establishes that the Veteran does not have residuals of cold injury. As the preponderance of the evidence is against the claim to service connection, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107 (2014); 38 C.F.R. § 3.102 (2017). 2. Psychiatric Disorder to include PTSD The Veteran contends the stressful events in service, including racial animus and witnessing the death of another soldier, caused PTSD. A review of the Veteran's STRs provides a March 1981 Report of Medical History. In this report, the Veteran indicated that did not have frequent trouble sleeping; depression or excessive worry; loss of memory or amnesia; or nervous trouble of any sort. The separation examination disclosed that the psychiatric evaluation was normal. As noted above, the Veteran also indicated that he had never had any illness or injury other than those specifically noted in the March 1981 Report of Medical History. The STRs are silent as to complaints or treatment of depression, anxiety, or other psychiatric disorders. A review of medical records from the Gainesville and Coatesville VAMCs reveals a history of diagnostic impressions and treatment for alcohol dependence (ETOH), cocaine dependence, cannabis dependence, and depressive disorder. The Veteran indicated that he consumed up to 16 beers a day and used crack. He also stated that he could experience paranoia and hear voices while using cocaine. The Veteran was afforded multiple modes of in-patient and out-patient therapy, including polysubstance abuse group engagement and individualized psychotherapy. These records also include admission, discharge, and readmission reports to the VAMC's domiciliary division. Various examiners noted that the Veteran endeavored to withdraw from ETOH and polysubstance dependence. In a January 2009 psychiatry consultation, a Gainesville clinician noted that the Veteran stated that he had significant psychosocial problems due to addiction, including shame around his family. The Veteran also reported that he had a history of drug abuse. This clinician opined that the Veteran expressed a sincere desire to stop drinking, but his prior history of chronic relapse was a poor prognosticator for success. A review of 2010 VA treatment records reveals that the Veteran had a history of blackouts. The Veteran received prescriptions for psychiatric disorders. Examiners also opined as to the Veteran's accounts of childhood verbal abuse and neglect. Substance and alcohol abuse were frequently noted, including LSD and mescaline. Assessments included polysubstance and alcohol withdrawal; depression; anxiety; delusions; hallucinations; suicidal thought; homicidal thoughts; sleep disturbance; and memory loss. In June 2010, a Coatesville clinician provided a discharge summary of: ETOH; cocaine dependence, continuous use; cannabis dependence, continuous use; and mood disorder. The clinician also reported that the Veteran was unemployed, homeless, and had conflict with family members. In a September 2010 statement, the Veteran wrote about experiences with his sergeant while he was stationed in Germany. According to the Veteran, the sergeant expressed racial animus towards African-American soldiers, frequently expressed through offensive racist epithets and ridicule. Moreover, the Veteran contended that he became depressed, frustrated and confused easily because of this on-going racially charged situation; he also reported that he was prone to violent behavior. During the same month, two of the Veteran's military buddies submitted statements which, in large part, described the racially charged and discriminatory atmosphere at the base where the Veteran was stationed in Germany. In a September 2010 psychiatry consultation, a Coatesville psychiatrist opined that the Veteran has used crack cocaine, cocaine, tetrahydrocannabinol (THC), and alcohol. She indicated that she reviewed treatment records, considered the Veteran's lay accounts, and conducted a psychiatric interview and examination of the Veteran. Upon interview, she emphasized that that the Veteran reported that he grew up in a neglectful and abusive home and entered foster care at the age of 15. The Veteran also stated he was discharged after one year of service for going AWOL. He relayed his contentions as to in-service stressors, as noted above. After consideration of her fihendings and deliberation, this psychiatrist provided alternative impressions of depressive due to (d/o) NOS or substance-induced depression and polysubstance dependence. She did not provide an impression of PTSD. In September 2010, the RO issued a formal finding as to the lack of evidence to verify stressors in connection with the Veteran's PTSD claim. In pertinent part, this finding reported the actions taken thus far, concluding that all efforts to obtain the needed military information had been exhausted. Any further attempts to do so moreover would be futile. A November 2010 homeless program note in from the Northampton VA includes the Veteran's reports of experiencing auditory hallucinations, depression, and anxiety. A clinician noted that the Veteran identified that these symptoms were potentially related to his military service. In an addendum, this clinician provided impressions of: ETOH; drug abuse, dependency; depressive disorder; and PTSD from non-combat trauma. A December 2010 substance abuse progress report included a report of the Veteran's account of his racist sergeant and disparate treatment. In his December 2010 statement, the Veteran reiterated his contentions about his sergeant's disparate treatment of African-American soldiers. He added that he witnessed the death of another soldier when he was hit by a military vehicle, in which the Veteran was locked. The Veteran also wrote that he experienced nightmares and panic attacks about these events, noting that his life has "been a living hell" filled with rage, homicidal thoughts, and depression. In a January 2011 psychosocial assessment, a Northampton VA social worker wrote that the Veteran sought to remain sober and clean, regularly attending Alcoholics Anonymous (AA) meetings. She also wrote that the Veteran was hearing some negative voices, but he did not want to act on them. She provided an impression of depressive disorder, not elsewhere classified (NEC). In February 2011, a Northampton VA psychiatrist noted that the Veteran experienced frequent distressing and violent nightmares and heard voices. This psychiatrist provided impressions of depression; psychosis, not otherwise specified (NOS); and PTSD. An assessment during the same month opined that the Veteran's living situation (characterized throughout the Northampton records as either transient or homeless) and his finances played "big roles" in the Veteran's life along with PTSD and depression. In June 2011, the Veteran submitted a statement, via VA Form 21-4138. Here, he emphasized that his PTSD was related to a fatal vehicular accident in service. He also reported that he had a fight with his sergeant. In May 2012, a Northampton VA physician provided impressions of ETOH; cannabis dependence, episodic; cocaine dependence, episodic; depressive type psychosis, and PTSD. The Veteran was hospitalized when these impressions were provided. At the March 2013 DRO hearing, the Veteran testified that his sergeant "got into his face" and called him racist names. He also testified that he was locked in a turret when his military vehicle slid down a hill. Moreover, the Veteran stated that alcohol and drugs have been his solution for the aforementioned stressful situations until he entered VA treatment in 2008. This stress, according to his account, included nightmares and suicidal ideations. In March 2013, a friend submitted a statement. She wrote that she knew the Veteran for 6 months and he mentioned his PTSD evasively. She also reported that the Veteran had frequent nightmares with violent images, which led him to wake up crying. This friend further stated that the Veteran could become isolated and exhibited "snaps" of anger. A July 2015 VA Exchange of Beneficiary Information and Request for Administrative and Adjudicative Action (VA Form 10-7131) reported that the Veteran was admitted to a VA hospital for suicidal ideation and ETOH. Moreover in this context, of the approximately 20 VAMC Reports of Hospitalization, noted above, 15 are for polysubstance abuse, ETOH, or depression. At the July 2017 Travel Board hearing, the Veteran testified that his sergeant used offensive racial epithets continuously; he and his sergeant did not see eye-to eye; and they ended up in a fight. Moreover, he testified that he drank a lot when he was in Germany, adding that he left base for 6 days which prompted wage garnishment and a decision to take a discharge. The Veteran further stated that he had been in 60 private programs outside VA after his active service, noting that he had begun VA treatment 7 years earlier. These programs, according to the Veteran, helped a lot with his struggles, but his problems continually returned and he spiraled downwards. The Board recognizes that post-service treatment reports from the Gainesville, Coatesville, and Northampton VA facilities provided impressions and assessments of depressive disorder; PTSD from non-combat trauma; depressive-type psychosis; polysubstance abuse disorder; and alcohol abuse disorder. Nevertheless, these VA reports do not establish a basis for the conclusions that were reached. Moreover, the clinicians, who prepared the reports, did not mention whether any of these impressions or assessments related to the Veteran's active service. Rather, as but one example, a Northampton VA clinician opined that the Veteran's living situation (characterized as either transient or homeless) and the Veteran's finances played "big roles" in the Veteran's life along with PTSD and depression. The Board notes that multiple entries in the Veteran's VA treatment records include self-reported symptoms, without specific findings, as to a psychiatric disorder to include PTSD and the Veteran's active service. When PTSD was mentioned, it was reported as either history or a notation unsupported by examination or findings. To the extent that there is a history of preservice neglect and verbal abuse, such "stressors" do not establish that PTSD predated service or that she had PTSD during service. The presumption of soundness is not raised in such situations. The probative value of the VAMC reports and the Veteran's lay assertions are outweighed by the weight of evidence that reflects that the Veteran does not meet the applicable diagnostic criteria for PTSD. The January 2009 Gainesville VAMC clinician opined that the Veteran had significant psychosocial problems due to addiction and a history of chronic addiction relapses; he also noted that the Veteran, by his own account, had a history of drug abuse. In June 2010, a Coatesville VAMC clinician provided a discharge summary of ETOH; cocaine dependence, continuous use; cannabis dependence, continuous use; and mood disorder. The Board also notes that the RO issued a September 2010 formal finding as to a lack of evidence to verify stressors in connection with the Veteran's PTSD claim. As to a psychiatric disorder, a Coatesville VAMC psychiatrist reported that the Veteran used crack cocaine, cocaine, THC, and alcohol extensively in her September 2010 psychiatry consultation report. Through examination, interview, and records review, this psychiatrist drew no lines of continuity between her post-service diagnosis of depression, not otherwise specified vs. substance-induced depression and polysubstance dependence and the Veteran's active service. This Coatesville VAMC psychiatrist's consultation report is entitled to great probative weight. In light of the absence of any psychiatric disorder in the Veteran's STRS and absence of fully substantiated impressions and assessments with rationales in other post-service VA treatment records; this psychiatrist's conclusions are consistent with evidence of record. The Board finds the September 2010 psychiatric consultation report to be both reliable and adequate; it included references to the Veteran's file, consideration of lay statements, and examination of the Veteran, accurate findings, and a rationale for the findings. As to other diagnoses, including depressive-type psychosis, there is no probative evidence linking a diagnosis to service and there were no in-service manifestations. Prior to the Veteran's military discharge, there was no evidence of psychopathology. In fact, the psychiatric evaluation was normal. The Veteran's report of in-service depression, frustration, and confusion is inconsistent with the March 1981 Report of Medical History, in which the Veteran indicated that did not have frequent trouble sleeping; depression or excessive worry; loss of memory or amnesia; or nervous trouble of any sort. This noted inconsistency makes the Veteran's post-service report not credible. In assessing this claim, the Board has considered the Veteran's lay assertions and the other lay assertions related to the Veteran's claim. He and his buddies are competent to report what is heard, felt, seen, or smelled. See Jandreau, supra. However, their statements are of far less probative value and less credible than the evaluations and observations prepared by skilled professionals. The Veteran does not have PTSD due to service and any other psychiatric disorder was not manifest during service and is not attributable to service. The preponderance of the evidence is against the Veteran's claims and there is no doubt to be resolved. See Gilbert v. Derwinski, 1 Vet. App. at 49. Rating Claims The Veteran contents that he is entitled to a rating in excess of 10 percent for a scar on his right index finger. He further contends that he is entitled to a compensable rating for a laceration of his right index finger. Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C. § 1155 (2014). Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C. § 1155 (2014); 38 C.F.R. § 4.1 (2017). VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period 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). 1. Scar Right Index Finger Under Diagnostic Code 7804, a 10 percent evaluation may be assigned where there are one or two scars that are unstable or painful; a 20 percent rating may be assigned where there are three or four scars that are unstable or painful; and a 30 percent rating may be assigned where there are five or more scars that are unstable or painful. See 38 C.F.R. § 4.118, Diagnostic Code 7804 (2017). 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. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1) (2017). Note (2) to Diagnostic Code 7804 provides that if one or more scars are both unstable and painful, then 10 percent is added to the evaluation that is based on the total number of unstable or painful scars. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (2) (2017). Note (3) to Diagnostic Code 7804 provides that scars evaluated under Diagnostic Code 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code when applicable. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (3) (2017). The RO granted service connection for the Veteran's scar of his right index finger in February 2013, assigned a 10 percent disability rating. The Veteran was afforded a VA examination in February 2013. The examiner reviewed the claims file, considered the Veteran's accounts of his medical history, and conducted a physical examination. Upon examination, 5 or more scars were identified on the Veteran's right index finger. The Veteran indicated that his index finger scar was sporadically painful (characterized as 5, in a one to 5 scale), especially during cold weather and after prolonged periods of writing. Of the 5 scars, only one was measurable, identified as a two centimeter stable linear scar. In summary, the examiner reported that the approximate combined total area in centimeters for each characteristic of disfigurement as two centimeters on the dorsal aspect of the right index finger. The examiner noted that the Veteran indicated that this scar made it difficult to make a fist and to write as he is right-handed. Based upon review of the evidence, a rating in excess of 10 percent is not warranted for the Veteran's scar of the right index finger. The Veteran is already in receipt of the maximum under Diagnostic Code 7804. To receive a higher rating of 20 percent, there would need to be 3 or 4 scars that are unstable or painful. Here, only one scar is measurable, sporadically painful, and stable. The Board notes here that the VA examiner indicated that the total area of disfigurement was 2 centimeters, equivalent to the measurement of the one measurable scar. Therefore, the Board finds that the preponderance of evidence is against assigning a rating in excess of 10 percent for the Veteran's scar right index finger from September 21, 2010. See 38 C.F.R. § 4.118, Diagnostic 7804 (2017); Gilbert, supra. 2. Residuals of Laceration Right Index Finger The Board notes that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2017); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 (2017) and 38 C.F.R. § 4.45 (2017) are to be considered in conjunction with the Diagnostic Codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2017). For the index, long, ring, and little fingers (digits II, III, IV, and V), zero degrees of flexion represents the fingers fully extended, making a straight line with the rest of the hand. 38 C.F.R. § 4.71a (2017), Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note (1) preceding Diagnostic Code 5216. The position of function of the hand is with the wrist dorsiflexed 20 to 30 degrees, the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints flexed to 30 degrees, and the thumb (digit I) abducted and rotated so that the thumb pad faces the finger pads. Only joints in these positions are considered to be in favorable position. For digits II through V, the metacarpophalangeal joint has a range of zero to 90 degrees of flexion, the PIP joint has a range of zero to 100 degrees of flexion, and the distal (terminal) interphalangeal (DIP) joint has a range of zero to 70 or 80 degrees of flexion. The Veteran's right index finger is currently rated as noncompensable under 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2017). Under Diagnostic Code 5229, a noncompensable disability evaluation is assigned for limitation of motion of the index or long finger with a gap of less than one inch between the fingertip and the proximal transverse crease of the palm with the finger flexed or with extension limited by no more than 30 degrees. A 10 percent disability evaluation is assigned where there is limitation of motion of the index or long finger with a gap of one inch between the fingertip and the proximal transverse crease of the palm with the finger flexed or with extension limited by more than 30 degrees. Painful motion is an important factor of disability, and it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59 (2017); Burton v. Shinseki, 25 Vet. App. 1 (2011). Nevertheless, pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, functional impairment must be supported by adequate pathology. Id.; Johnson v. Brown, 9 Vet. App. 7, 10 (1996) (both citing to 38 C.F.R. § 4.40 (2017)). For the purpose of rating disability due to arthritis, the index finger is considered a minor joint. To be ratable on parity with major joints, at least two fingers of the impacted hand must be involved. See 38 C.F.R. § 4.45(f) (2017). In July 2011, the Veteran was afforded a VA examination of the hand, thumb, and fingers. The examiner considered the Veteran's statements about his medical history and conducted a physical examination of the Veterans right index finger. The examiner noted that the Veteran reported that he was doing "okay" but experienced on and off pain in his finger, especially during cold weather. The Veteran indicated that his finger was not receiving any form of treatment. Upon examination, there was objective evidence of pain. Extension of right DIP Joint was normal (0 degrees and finger aligned with hand). Extension of right PIP Joint was normal (0 degrees and finger aligned with hand). Extension of right MP Joint was normal (0 degrees and finger aligned with hand). The gap between the right index finger and proximal traverse crease of hand on maximal flexion of finger was less than one inch (2.5 centimeters). Findings as to repetitive motion revealed objective evidence of pain; however, no additional limitation of motion. X-ray imaging revealed that there was no acute fracture, dislocation, or destructive bone lesion. Furthermore bone mineralization was normal. Scattered degenerative changes were present. The examiner opined that the Veteran's right index finger condition had significant impact on the Veteran's occupational activities; namely, decreased manual dexterity created pain with lifting and carrying. As noted above, the Veteran was afforded a VA examination in February 2013. The examiner reported that the Veteran indicated that his index finger scar was sporadically painful (characterized as 5, in a one to 5 scale), especially during cold weather and after prolonged periods of writing. In February 2013, the RO granted service connection for the Veteran's laceration of right index finger and assigned a noncompensable rating. To receive a compensable rating for residuals of laceration of the right index finger, there would need to be evidence showing that there is limitation of motion of the index or long finger with a gap of one inch between the fingertip and the proximal transverse crease of the palm with the finger flexed or with extension limited by more than 30 degrees. As noted in the July 2011VA exam, range of motion in the right index finger was normal at each measurable vector. Furthermore, the July 2011 VA examiner opined that the gap between the right index finger and proximal traverse crease of hand on maximal flexion of finger was less than one inch (2.5 centimeters). These examination findings underscore that a compensable rating is not warranted under 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2017). X-ray imaging associated with the July 2011 VA examination revealed that scattered degenerative (arthritic) changes were present in the Veteran's right index finger. Nevertheless, this evidence does not meet the criteria for a compensable rating. For painful motion to be compensable, x-ray evidence must show the involvement of 2 or more major joints or 2 or more minor joint groups. See 38 C.F.R. § 4.71(a), Diagnostic Code 5003 (2017). Therefore, the Board finds that the preponderance of evidence is against assigning a compensable rating for the Veteran's residuals of laceration right index finger from September 21, 2010. See 38 C.F.R. § 4.71(a), Diagnostic Codes 5229, 5003 (2017); Gilbert, supra. The Board notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (Court) held that a claim for a total disability indicating unemployablilty (TDIU) due to service-connected disability is part and parcel of an increased rating claim when such claim is raised by the record of evidence. Here Veteran does not contend and the evidence of record does not suggest that the Veteran is unable to perform all forms of substantially gainful employment because of his scar right index finger or residuals laceration of right index finger. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Service connection for residuals of cold injury is denied. Service connection for a psychiatric disorder to include PTSD is denied. A rating in excess of 10 percent for scar right index finger is denied. A compensable rating for residuals of laceration right index finger is denied. ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs