Citation Nr: 1807742 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 10-39 303 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUE Entitlement to a compensable evaluation for postoperative (PO) residuals of tenorrhapy and neurorrhapy of the right hand prior to January 5, 2017, and to an evaluation in excess of 10 percent thereafter. REPRESENTATION Appellant represented by: Daniel Krasnegor, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from June 1967 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) from a January 2010 rating decision by the Newark, New Jersey Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran was afforded a Travel Board hearing before the undersigned Veterans Law Judge in June 2011. A copy of the transcript has been associated with the record on appeal. A February 2014 Board decision denied an increased evaluation for PO residuals of tenorrhapy and neurorrhapy of the right hand, and denied reopening a claim of service connection for a right knee condition, and also denied service connection for a low back condition and a right foot condition, to include as secondary to a right knee condition. The Veteran appealed the 2014 Board decision to the United States Court of Appeals for Veterans Claims (Court) which in a June 2015 memorandum decision vacated the 2014 Board decision as to all claims and remanded the case to the Board. A February 2016 Board decision granted service connection for a right knee disorder, variously diagnosed to include a total right knee replacement, but remanded the remaining issues. Thereafter, the grant of service connection for a right knee disorder, status post (SP) total knee replacement (TKR) was effectuated by a September 2016 rating decision which assigned an initial 100 percent convalescent rating, all effective October 1, 2009, with a 30 percent schedular rating becoming effective March 1, 2010. The Veteran and his attorney were notified of that decision by RO letter of December 1, 2016. Thereafter, by letter in November 2017 (before the expiration of one year following the December 1, 2016 notice) the Veteran's attorney filed a Notice of Disagreement (NOD), VA Form 21-0950 to the assignment of the schedular 30 percent rating (alleging that a 60 percent rating was in order) and indicating that he had not received a copy of the December 1, 2016 notification letter. In any event, by RO letter later that month the RO informed the Veteran and his attorney that the NOD was not timely, but following receipt in December 2017 of a letter from the Veteran's attorney, by letter dated December 8, 2017, the Veteran and his attorney were notified that the December 2017 NOD was accepted as timely and acknowledged there election of the Decision Review Officer (DRO) Process. Typically, when there has been an RO adjudication of a claim and a NOD has been filed thereto, the appellant is entitled to a Statement of the Case (SOC), necessitating a remand of that matter. Manlincon v. West, 12 Vet. App. 238 (1999). However, here the RO has acknowledged receipt of the NOD, and indeed undertaken further action with respect to the DRO process, this situation is distinguishable from Manlincon, Id., where a NOD had not been recognized. As the RO is properly addressing the NOD, no action is warranted by the Board. An October 2017 rating decision granted service connection for right foot metatarsalgia and plantar fasciitis and granted service connection for spinal stenosis with degenerative arthritis of the spine, both as secondary to service-connected right knee disability, and each was assigned an initial 10 percent disability rating, all effective October 1, 2009. That decision increased the noncompensable rating for PO residuals of tenorrhapy and neurorrhapy of the right hand to 10 percent, effective January 5, 2017 (date of VA examination). That decision also granted service connection for carpal tunnel syndrome (CTS) of the right wrist and hand and assigned an initial 20 percent rating under Diagnostic Code 8515 (median nerve) effective January 5, 2017. The Veteran has not initiated an appeal as to the effective dates or ratings assigned by the October 2017 rating decision. The Veteran has been assigned a total disability rating based on individual unemployability due to service-connected disabilities (TDIU rating) effective since April 22, 2014. More recently, a January 2018 rating decision confirmed and continued a TDIU rating and entitlement to Dependents' Educational Assistance (DEA) benefits. The Veteran's attorney requested an extension of time in order to file additional evidence and argument. This was received in January 2018. This appeal was processed using the Veteran's Benefits Management System (VBMS) and, in addition there is a Virtual VA paperless claims electronic file (now described as Legacy Content Manager Documents). Accordingly, any future consideration of this appeal should take into consideration the existence of these electronic records. FINDINGS OF FACT 1. Prior to October 26, 2010, the PO residuals of tenorrhapy and neurorrhapy of the right hand were manifested by a noncompensable degree of limited finger motion and without muscle damage, symptomatic scarring, or neurologic symptoms or impairment. 2. Since to October 26, 2010, the PO residuals of tenorrhapy and neurorrhapy of the right hand have been manifested by limited and painful finger motion and less than mild neurologic impairment. CONCLUSIONS OF LAW 1. Prior to October 26, 2010, the criteria for a compensable disability rating for service-connected postoperative residuals of tenorrhapy and neurorrhapy of the right were not met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.40, 4.45, 4.59 Diagnostic Code 5229 (2017). 2. Since October 26, 2010, the criteria for no more than a 10 percent rating for PO residuals of tenorrhapy and neurorrhapy of the right hand have been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.40, 4.45, 4.59 Diagnostic Code 5229 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA imposes on VA a duty to provide notice of how to substantiate a claim and to assist in evidentiary development. VA's duty to notify was satisfied by letters in October 2009 and September 2010. See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). As to the duty to assist, this requires making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, VA medical records and relevant Social Security Administration (SSA) records. The Veteran's service treatment records (STRs), private treatment records, and VA outpatient treatment (VAOPT) records are of record. There is no indication in the claims file that the Veteran is in receipt of SSA or that any other relevant federal or private records have not been associated with the claims file. See 38 C.F.R. § 3.159(c)(2); Golz v. Shinseki, 590 F.3d 1317, 1321-23 (Fed. Cir. 2010). VA provided the Veteran with medical examinations for his hand disability in November 2009 and October 2010. Following the Board's 2016 remand the Veteran was afforded another VA examination in January 2017. Each of these examinations shows that a history was obtained from the Veteran and they addressed the functional effects caused by the Veteran's disability. The Court remand observed that there was a paucity of evidence addressing neurologic symptoms with the Veteran's right hand and this was addressed in a 2017 VA examination. Following the request of an extension of time within which to submit evidence and argument, in January 2018 the Veteran's attorney present argument that (a) the Veteran was entitled to a separate rating for neurologic impairment of the lower radicular nerve group (38 C.F.R. § 4.124a, DCs 8512, 8612, 8712); (b) that the 2017 VA examination was inadequate; and (c) that a retrospective examination was needed. As to the first argument, service connection has been granted for CTS, which involves the median nerve, and rated 20 percent disabling. As noted at DC 8512 the lower radicular group governs intrinsic muscles of the hand and some or all flexors of the wrists and fingers. These are some of the same functions governed by the median nerve. See 38 C.F.R. § 4.124a, DC 8515 (as to movements of the wrist and some of the fingers). The rating for service-connected CTS is not herein at issue. Thus, the assignment of a separate rating for neurologic impairment of the lower radicular nerve group would constitute pyramiding, i.e., double compensation, which is prohibited under 38 C.F.R. § 4.14. Indeed, the recent 2017 VA examination found that the Veteran's radial and ulnar nerves were normal and that only the median nerve was affected. The attorney offers no rationale for rating the service-connected CTS on the basis of the lower radicular group when only the median nerve is involved. In challenging the adequacy of the recent 2017 examination it was argued that when the examiner reported that there were diffuse degenerative changes throughout the Veteran's hand and not focally worsened in the area of the original injury, that the examiner had not provided a rationale for this conclusion. However, this was not a conclusion but, to the contrary, it was a statement of fact as determined by the examiner. Statements of fact do not require a rationale. It is also argued that the recent VA "examiner appears to suggest that the presence of degenerative changes to the entire hand (and not just the injured joint) [sic] means that the changes occurred because of the injury" but did not provide a rationale or explanation for this conclusion. However, read fairly, this is not what the examiner stated. Rather, the examiner explained that the degenerative changes were not localized to the injured sites and, so, the degenerative changes elsewhere in the hand did not occur because of the injury. In this connection, the additional evidence submitted in January 2018 by the Veteran's attorney consists only of a copy of an article by a rheumatologist of the Arthritis Foundation stating that "[i]n some people, traumatic joint injury can lead to OA [osteoarthritis], while in others genetics may play a role." It was also stated that "[w]hile OA can be limited to a single joint, in many cases it progresses to involve other joints, often in a sequential fashion." From this it was argued that because arthritis can spread, the examiner should have explained why degenerative changes in the hand ruled out the possibility that the arthritis had progressed. As to this, while a systemic arthritis may progress to other joints the article cited does not stand for the principle or state that arthritis from trauma is somehow transformed into a systemic process. The argument presupposes that arthritis from trauma is necessary of the same etiology as some form of systemic arthritic process, but this is not what the article states. It is also argued that the 2017 examination is inadequate because it did not cite to any relevant medical studies, as instructed in the 2016 Board remand. However, the Board's 2016 remand did not mandate that there be citation to any medical authority. Rather, the Board stated that "[a] fully articulated medical rationale for each opinion expressed must be set forth in the examination report. The examiner should discuss the particulars of this Veteran's medical history and the relevant medical sciences as applicable to this case, which may reasonably explain the medical guidance in the study of this case." In this connection, the adequacy of any examination and medical opinion is the thoroughness of the findings of the examination and explanation and rationale for any opinion reached such that Board's evaluation of the claimed disability will be a fully informed one. Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)); see also Floyd v. Brown, 9 Vet. App. 88, 93 (1996). Moreover, as set forth below, the physical examination findings in this case were observed and set forth in detail. Further, the examiner's medical conclusions were consistent with the evidentiary findings and the Veteran's clinical history, and provide sufficient guidance for the adjudication of the claim on appeal. It was also argued that because the appeal period stems from 2009 to the present and because the 2017 examiner only address findings detectable at that time that the examination is inadequate, creating a need for a "retrospective" examination. However, this overlooks the fact that the Veteran was afforded VA examinations in November 2009 and October 2010 and the wealth of clinical information set forth in VA outpatient treatment (VAOPT) records in November 2010. To the extent that it is suggested that there is a lapse of clinical findings from 2010 to the time of the 2017 VA examination, there is no rationale offered as to by what means, process or system and future examination obtained by a remand could possibly turn back the clock and reveal detailed clinical findings needed for rating purposes as opposed to unreasonably expecting a future examination to somehow determine what relevant past clinical findings might have been. In other words, any opinion attempting at this late date to ascertain the Veteran's disability level in the remote past would be speculative. Examinations are conducted to determine current clinical findings. There is no method by which an examiner can objectively find past clinical findings. Rather, an examiner could only record a history taken from past records or related by the examinee of past complaints, signs, symptoms, and treatment for a disability. These could as easily be related directly by the examinee without the expenditure of the VA resources in having to make VA medical or treating personnel available simply to perform the clerical duty of recording information that the examinee could otherwise just as easily provide by written correspondence or testimony. The duty to assist is not invoked, where "no reasonable possibility exists that such assistance would aid in substantiating the claim." 38 USCA 5103A(a)(2). As to when a retrospective VA examination may be needed it was held in Strother v. Shinseki, No. 09-2289, slip op. at 6 (U.S. Vet. App. April 18, 2011) (nonprecedential memorandum decision); 2011 WL 1643347 (Vet.App.), that as to a request for a retrospective VA examination to determine whether a Veteran was unemployable during an earlier time period for which an earlier effective date was claimed for a total disability rating based on individual unemployability (TDIU rating) "in Chotta v. Peake, the Court explained that entitlement to a retroactive medical examination 'is not automatic,' but rather 'applies only once the evidence has met the minimal threshold of indicating the existence of a medical question.' 22 Vet. App. 80, 85 (2008); see also Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992) ('In short, the 'duty to assist' is not a license for a 'fishing expedition' to determine if there might be some unspecified information which could possibly support a claim.')." The Veteran has been afforded a Travel Board hearing but neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c) as to explaining the issues and suggesting the submission of evidence, nor have they identified any prejudice in the conduct of the Board hearing. Indeed, the Memorandum Decision of the Court did not find that there was any violation of 38 C.F.R. § 3.103(c)(2) or, in fact, any violation as to the duty to assist with respect to the issue now before the Board. There is no indication in the record that additional evidence relevant to the issue decided herein is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. at 121-22. The Board finds that the duty to assist has been met. Background During service, in July 1968, the Veteran cut himself with a knife and sustained injuries to his second (2nd), third (3rd), fourth (4th) and fifth (5th) digits of his right hand. His injuries included "laceration [of the] digital nerve" and tendons in his right third finger. Surgeons repaired his tendons, and he returned to duty on September 5, 1968. Less than three weeks later he sought treatment for "loss of motion and sensation to right [third] finger of two months' duration." Range of motion testing was performed, which showed a loss of fifteen degrees of extension at the proximal interphalangeal (PIP) joint of the right middle (3rd) finger but normal range of motion throughout the remainder of the hand. His care providers discovered that he had lost sensation to the ulnar half of the finger . . . from the level of the PIP joint to the tip, with normal sensation throughout the remainder of that hand. Surgery was performed "where exploration of the ulnar digital nerve to the middle finger was carried out." The digital nerve was repaired. The surgical wound healed completely without evidence of infection. He returned to duty on October 25, 1968. The service discharge examination in March 1971 noted the Veteran's history of a tendon injury and surgery. It was found that as to his right middle (3rd) finger he had "limitation of flexion and no sensation from [his] second phalanx distally[.]" In the Veteran's original claim for service connection in December 1988 he reported that he had cut tendons in his right hand while working on a ship and had since "lost movement of [the] finger[.]" On VA examination in February 1989 physical examinations were performed and X-rays were performed, with the latter showing "a normal osseous and joint architecture" of the right hand. A February 14, 1989 VAOPT record shows that the Veteran was able to oppose his right thumb to all other fingers of the right hand and that he had pinch strength. An X-ray of the right hand revealed normal osseous and joint architecture. In April 1989, the VA RO granted the appellant entitlement to disability benefits for the residual effects of the surgeries performed on his right hand and assigned his disorder a noncompensable disability rating. The Veteran was hospitalized at the Jersey Shore University Medical Center in January 2009 for right knee disability. His past medical history included right shoulder surgery. On examination he had good strength throughout his upper extremities. Other than his right lower extremity sensation was intact in the remaining extremities. On October 1, 2009, the Veteran filed VA Form 21-526, setting forth multiple claims, including a claim for a compensable disability rating for his service-connected right hand disorder. In a statement received on October 29, 2009, the Veteran reported that he had "limited use of my [right] hand." On VA examination on November 5, 2009 it was reported that the Veteran was left hand dominant. He complained of decreased motion of the 3rd digit on the right hand since service, and difficulty gripping, and some decreased motion of the 4th digit on the right hand as well. He did not report that there were any sensation changes, incapacitating episodes, flare-ups, problems with repetitive use, or interference with job. Specifically, he reported that there were "[n]o sensation changes" in his disabled hand. He related that he had lost grip strength which interferes with daily activities. On examination the sensation in the Veteran's right third finger was "grossly intact to light touch." Range of motion testing on the third digit revealed the ability to flex the PIP and metacarpal (MCP) 90 degrees and extend 0 degrees. Extension of the distal interphalangeal (DIP) joint was to 0 degrees but he could only flex the DIP joint to 10 degrees. Sensation was grossly intact. Range of motion testing on the 4th digit revealed the ability to flex the PIP, DIP, and MCP joints to 90 degrees and extend 0 degrees. Range of motion testing on the second digit revealed the ability to flex the PIP, DIP, and MCP joints 90 degrees and extend 0 degrees. For all range of motion testing, there was no additional pain or loss of motion after repetition. Pinch and grip strength between the thumb and all fingers was 5/5. The Veteran was assessed with SP laceration to the 3rd and 4th digits of the right hand with some scar formation. On VA examination on October 26, 2010 it was again reported that the Veteran was left hand dominant. He complained of pain and soreness that has worsened for 3rd and 4th digits of his right hand since service. He also complained of decreased sensation and decreased motion of the 3rd digit of the right hand. He specifically stated that he had "decreased sensation" in his right 3rd finger. His complaints of pain and decreased sensation were observed to be new complaints which had not been reported at the 2009 VA rating examination. He indicated that it interfered with his daily activities because the condition affected his grip strength. There were no incapacitating episodes, flare-ups, problems with repetitive use, or interference with his job reported. Range of motion testing on the third digit revealed the ability to flex the PIP joint and MCP joint 90 degrees and extend 0 degrees. The Veteran could only flex the DIP joint to 15 degrees. Sensation was grossly intact, but decreased over the finger tip of the 3rd digit. Range of motion testing on the fourth digit revealed the ability to flex the PIP, DIP, and MCP 90 degrees and extend 0 degrees. Range of motion testing on the second digit revealed the ability to flex the PIP, DIP, and MCP 90 degrees and extend 0 degrees. For all range of motion testing, there was no additional pain or loss of motion after repetition. Pinch and grip strength between the thumb and fingers was 5/5. The assessment was SP laceration to the 2nd, 3rd, 4th, and 5th digits of the right hand with some scar formation of the 3rd and 4th digits. There was some sensation loss on the 3rd digit, but no change in examination findings when compared with the prior examination. However, the examiner confirmed that "[t]here is some sensation loss over digit 3." A November 10, 2010 VAOPT record noted that the Veteran had been referred for an electrodiagnostic evaluation. He reported that since service he had been unable to move the middle finger. He was able to move the index and ring fingers of right hand but he noticed there was more restriction of motion as compared to his left hand. He also described numbness of the palmar surface of the middle right finger but denies numbness in the other digits. He denied any tingling sensation. He also reported having occasional sharp pains in that middle finger, especially when the weather was bad. He had difficulty with small objects because he was unable to get as much motion out of the right sided hand, as the left side. He denied any history of diabetes, bleeding disorders, pacemaker, blood thinners. The nature of an electrodiagnostic examination, including risks and benefits, were explained and the Veteran agreed to such testing. A November 16, 2010 VAOPT record stated that damage to the digital nerves could not be evaluated by such testing, as the consult requested. However, electrodiagnostic testing of each upper extremity at the wrists and above found evidence consistent with sensorimotor median neuropathy across the wrist segment consistent with clinical diagnosis of carpal tunnel syndrome (CTS), bilaterally. The Veteran did not have clinical symptoms at that time, even though electrodiagnostic studies showed mild CTS on the left side and moderate CTS on the right side. There was no electrodiagnostic evidence of cervical radiculopathy or peripheral polyneuropathy. At the June 2011 Board hearing the Veteran testified that he had difficulty gripping items with his right hand. Page 15. He stated that he was left handed. Page 16. He felt that he had 50 percent less strength in the right hand. Page 17. He experienced pain in his right hand. Page 18. On VA rating examination on January 5, 2017, pursuant to the Board's 2016 remand, it was observed that the Veteran was left handed. The Veteran reported that he initially injured the 2nd, 3rd, and 4th fingers of the right hand with a knife during service. He had had a tendon repair of the right 3rd finger in September 1968 and then a digital nerve repair in October 1968. He reported that the hand healed well initially. However, he stated that he now has arthritis in the right hand and wrist due to this. He reported having numbness in the tips of 3rd and 4th digits of the right hand. He stated that the numbness was constant. He reported having had cortisone shots in the PIP joint of the 4th finger as well as the wrist. He reported that the most bothersome part of the hand was his 3rd and 4th fingers. Also he reported having nightly cramps in his right hand. He did not report having flare-ups of the hand, finger or thumb joints. He reported having functional loss or functional impairment due to limitation as to fine motor tasks in that it was hard to "hold screwdriver with right hand." On physical examination extension of the 1st, 2nd, 3rd, 4th, and 5th fingers was full to 0 degrees at the MCP, PIP, and DIP joints. Maximum flexion in the 2nd (index) finger was to 90 degrees at the MCP joint, to 100 degrees at the PIP joint, and to 70 degrees at the DIP joint. Maximum flexion in the long (middle, i.e. 3rd) finger was to 80 degrees at the MCP joint, to 80 degrees at the PIP joint, and to 0 degrees at the DIP joint. Maximum flexion in the ring (4th) finger was to 90 degrees at the MCP joint, to 85 degrees at the PIP joint, and to 0 degrees at the DIP joint. Maximum flexion in the little (5th) finger was to 90 degrees at the MCP joint, to 100 degrees at the PIP joint, and to 70 degrees at the DIP joint. There was a gap between the finger and proximal transverse crease of the hand on maximal finger flexion which was 2 cms. as to the index (2nd) Index finger and 5 cms. as to the long (3rd) finger. It was reported that the limitation of range of motion contribute to functional loss because it limited gripping with the right hand. However, there was no pain on examination, including pain on use. There was tenderness on palpation of the PIP joint of the right ring (4th) finger. He could perform repetitive use testing with at least three repetitions and without additional functional loss or range of motion after three repetitions. The examiner reported that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. However, pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. Right hand grip strength was 4/5, compared to 5/5 in the left hand. There was no muscle atrophy or ankylosis. The examiner reported that the Veteran was unable to actively flex the DIP joints of the 3rd and 4th fingers of the right hand. However, there was full passive range of motion of the entire right hand/fingers including those joints. There was a mild decreased sensation throughout the right 3rd and 4th fingers. There were negative carpal compression and Tinel's signs at the wrist. There was swelling of the right PIP joint of the 4th finger. As to scarring, the Veteran had 8 cm. long by 0.5 cm wide scar on the right middle (3rd) finger and also had a 4 cm. long and 1.5 cm. wide scar of the right ring (4th) finger. Both scars were well healed, nontender, and non-adherent. The examiner reported that the finger conditions did not have functional impairment such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. X-rays revealed degenerative osteoarthritis. Specifically, it was reported that X-rays in November 2009 had revealed at least 2 radiopaque foreign body noted in the second (2nd, index) finger with one measuring approximately 2 mms. along the radial aspect of the distal phalanx of the second (2nd) finger and the other less than 1 mm. along the dorsal soft tissue at the base of the middle phalanx of the second (index) finger. Also, there were multi-level degenerative osteoarthritic changes in the right hand but no definite acute displaced fracture-dislocation. The examiner reported that the finger conditions impacted the Veteran's ability to perform any type of occupational task because of limiting his ability to grip and perform fine motor tasks with right hand. There was no evidence of pain on passive range of motion testing. The January 2017 VA examiner stated that the Veteran had a tendon injury during his military service, SP repair. He continued to have loss of active range of motion of the right D3 (3rd digit). The examiner stated that tendon injuries, even if repaired, could often lead to the loss of active range of motion and his residual loss of range of motion in the right 3rd digit was likely due to the original injury, SP repair. The Veteran also had loss of range of motion of the right D4. The examiner noted that there was a report of scar contracture in the records from 1968 and it was likely his continued residual loss of range of motion was due to scarring from the initial injury. The Veteran had altered sensation in the right D3 and D4. He was treated surgically for a right ulnar sided D3 scar neuroma in October 1968. The altered sensation was currently circumferential and appeared to be from more than just an ulnar sided digital nerve injury. However, given the scars on the right D3 and D4 in the regions of the digital nerves it was felt that he likely developed further digital nerve irritation/injury due to scarring. This had likely resulted in the persistent altered sensation. Also, the Veteran had degenerative changes throughout the right hand and tenderness of the right D4 PIP joint. His original injury was to the right D3 and D4 and possibly D2. However, the mild degenerative changes noted on X-ray were diffuse throughout the hand and not focally worsened in any area of his original injury. Therefore, it is felt the Veterans degenerative changes in the right hand were likely due to age and less likely than not related to his right hand injury during military service. On VA peripheral nerve examination of October 23, 2017, the Veteran's electronic folder and electronic medical records were reviewed. It was reported that he had carpal tunnel syndrome (CTS) which had been diagnosed in 2010. He had had an inservice laceration injury of the tendon of the right middle finger and injury to right 4th finger, SP surgery of the right hand in Japan in 1967. He complained of numbness of right hand and right middle finger. An EMG of November 16, 2010 had revealed bilateral CTS, greater on the right, being moderate, than the left, being mild. He was left handed. The Veteran's symptoms attributable to his nerve injury were mild intermittent pain, and moderated numbness as well as paresthesias and/or dyesthesias. He had normal strength right wrist flexion and extension, and he had 4/5 strength in right hand grip and pinch (thumb to index finger). There was mild atrophy of the right thenar muscle. He had decreased sensation of the right hand and finger, i.e., in the C6 -8 nerve distribution but there were no trophic changes attributable to the nerve injury, i.e., characterized by loss of extremity hair, smooth, and shiny skin. For median nerve evaluation, Phalen's test was positive on the right, but Tinel's sign on the right was negative. It was reported that the Veteran's right radial (musculospiral nerve) and ulnar nerves were normal but he had incomplete paralysis of the right median nerve. The Veteran used braces as an assistive devices as a normal mode of locomotion, although occasional locomotion by other methods was possible. Due to peripheral nerve conditions, there was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. There were no other pertinent physical findings, complications, conditions, signs or symptoms. It was reported that he did not have any scarring. It was again noted that a past EMG, in November 2010, had been abnormal as to the right and left upper extremities. However, it was also reported that electrodiagnostic evidence at this time is consistent with sensorimotor median neuropathy across the wrist segment consistent with clinical diagnosis of carpal tunnel syndrome, bilaterally. The Veteran did not have clinical symptoms at this time even though electrodiagnostic studies showed mild CTS on the left side and moderate CTS on the right side. There were no other significant diagnostic test findings and/or results. The examiner opined that the peripheral nerve condition and/or peripheral neuropathy did not impact the Veteran's ability to work, commenting that there was bilateral CTS, which was moderate right, and no objective finding in the left hand. Rating Principles Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In resolving this factual issue, only the specific factors as enumerated in the applicable rating criteria may be considered. See Massey v. Brown, 7Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). 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. Musculoskeletal Impairment Degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups or painful motion is warranted an evaluation of 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5003. A 20 percent evaluation is warranted for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Id. Rating factors for a disability of the musculoskeletal system include functional loss due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion, weakness, excess fatigability, incoordination, pain on movement, swelling, or atrophy. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). In evaluating musculoskeletal disabilities, the VA must determine whether pain could significantly limit functional ability during flare-ups, or when the joints are used repeatedly over a period of time. See DeLuca, 8 Vet. App. at 206. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Court also has recently held, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. The Veteran's PO residuals of tenorrhapy and neurorrhapy of the right hand is currently evaluated under the Limitation of Motion of Individual Digits. 38 C.F.R. § 4.71a, Diagnostic Code 5229. A 0 percent 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, Diagnostic Code 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, Diagnostic Codes 5225-5227. Higher compensable evaluations can be granted for multiple favorable or unfavorable ankylosed digits when combined. 38 C.F.R. § 4.71a, Diagnostic Codes 5216-5223. Neurologic Impairment Under 38 C.F.R. § 4.124a, the schedules for rating diseases of the cranial and peripheral nerves include alternate diagnostic codes for paralysis, neuritis, and neuralgia of each nerve. See 38 C.F.R. § 4.124a, Diagnostic Codes 8205 to 8730. The diagnostic codes for paralysis of a nerve allow for multiple levels of incomplete paralysis, as well as complete paralysis. However, the ratings available for neuritis and neuralgia of the same nerves can be limited to less than the maximum ratings available for paralysis. In rating peripheral neuropathy attention is given to sensory or motor impairment as well as trophic changes (described at 38 C.F.R. § 4.104, Diagnostic Code 7115" as thin skin, absence of hair, dystrophic nails). Peripheral neuropathy which is wholly sensory is mild or, at most, moderate. With dull and intermittent pain in a typical nerve distribution, it is at most moderate. With no organic changes it is moderate or, if of the sciatic nerve, moderately severe. 38 C.F.R. § 4.124a. Neuralgia of a peripheral nerve of a lower extremity can receive a maximum rating of moderate incomplete paralysis. 38 C.F.R. § 4.124. Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, can receive a maximum rating of severe, incomplete paralysis. 38 C.F.R. § 4.123. Peripheral Nerve Ratings of the Non-Dominant (Minor) Upper Extremity Under 38 C.F.R. § 4.124a, DCs 8510 (paralysis), 8610 (neuritis), and 8710 (neuralgia) neurologic impairment of the upper radicular nerve group (5th and 6th cervical nerves) of the minor (non-dominant) upper extremity when incomplete and mild warrants a 20 percent rating; when moderate a 30 percent rating is warranted; when severe a 40 percent rating is warranted; and when complete with all shoulder and elbow movements lost or severely affected; with hand and wrist movements not affected, a 60 percent rating is warranted. Under 38 C.F.R. § 4.124a, DCs 8511 (paralysis), 8611 (neuritis), and 8711 (neuralgia) neurologic impairment of the middle radicular nerve group of the minor (non-dominant) upper extremity when incomplete and mild warrants a 20 percent rating; when moderate a 30 percent rating is warranted; when severe a 40 percent rating is warranted; and when complete with adduction, abduction and rotation of the arm, flexion of elbow, and extension of the wrist lost or severely affected, a 60 percent rating is warranted. Under 38 C.F.R. § 4.124a, DCs 8512 (paralysis), 8612 (neuritis), and 8712 (neuralgia) neurologic impairment of the lower radicular nerve group of the minor (non-dominant) upper extremity when incomplete and mild warrants a 20 percent rating; when moderate a 30 percent rating is warranted; when severe a 40 percent rating is warranted; and when complete with all intrinsic muscle of the hand, and some or all of flexors or the wrist and fingers paralyzed (substantial loss of use of the hand), a 60 percent rating is warranted. Under 38 C.F.R. § 4.124a, DCs 8513 (paralysis), 8613 (neuritis), and 8713 (neuralgia) neurologic impairment of all radicular groups of the minor (non-dominant) upper extremity when incomplete and mild warrants a 20 percent rating; when moderate a 30 percent rating is warranted; when severe a 60 percent rating is warranted; and when complete an 80 percent rating is warranted. Under 38 C.F.R. § 4.124a, DCs 8514 (paralysis), 8614 (neuritis), and 8714 (neuralgia) neurologic impairment of the musculospiral (radial) nerve of the minor (non-dominant) upper extremity when incomplete and mild warrants a 20 percent rating; when moderate a 20 percent rating is warranted; when severe a 40 percent rating is warranted; and when complete with drop of the hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity, a 60 percent rating is warranted. A note to DC 8514 provides that lesions involving only ''dissociation of extensor communis digitorum'' and ''paralysis below the extensor communis digitorum,'' will not exceed the moderate rating under DC 8514. Under 38 C.F.R. § 4.124a, DCs 8515 (paralysis), 8615 (neuritis), and 8715 (neuralgia) neurologic impairment of the median nerve of the minor (non-dominant) upper extremity when incomplete and mild warrants a 10 percent rating; when moderate a 20 percent rating is warranted; when severe a 40 percent rating is warranted; and when complete with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances, a 60 percent rating is warranted. Under 38 C.F.R. § 4.124a, DCs 8516 (paralysis), 8616 (neuritis), and 8716 (neuralgia) neurologic impairment of the ulnar nerve of the minor (non-dominant) upper extremity when incomplete and mild warrants a 10 percent rating; when moderate a 20 percent rating is warranted; when severe a 30 percent rating is warranted; and when complete with ''griffin claw'' deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened, a 50 percent rating is warranted. Under 38 C.F.R. § 4.124a, DCs 8517 (paralysis), 8617 (neuritis), and 8717 (neuralgia) neurologic impairment of the musculocutaneous nerve of the minor (non-dominant) upper extremity when incomplete and mild warrants a 0 (zero) percent rating; when moderate a 10 percent rating is warranted; when severe a 20 percent rating is warranted; and when complete with weakness but not loss of flexion of elbow and supination of forearm, a 20 percent rating is warranted. Under 38 C.F.R. § 4.124a, DCs 8518 (paralysis), 8618 (neuritis), and 8718 (neuralgia) neurologic impairment of the circumflex nerve of the minor (non-dominant) upper extremity when incomplete and mild warrants a 0 (zero) percent rating; when moderate a 10 percent rating is warranted; when severe a 20 percent rating is warranted; and when complete with abduction of arm is impossible, outward rotation is weakened; muscles supplied are deltoid and teres minor, a 40 percent rating is warranted. Under 38 C.F.R. § 4.124a, DCs 8519 (paralysis), 8619 (neuritis), and 8719 (neuralgia) neurologic impairment of the long thoracic nerve of the minor (non-dominant) upper extremity when incomplete and mild warrants a 0 (zero) percent rating; when moderate a 10 percent rating is warranted; when severe a 20 percent rating is warranted; and when complete with an inability to raise arm above shoulder level, winged scapula deformity, a 20 percent rating is warranted. A note as to rating the long thoracic nerve provides that any rating for impairment of the long thoracic nerve is not to be combined with loss motion above shoulder level. An additional note provides that combined nerve injuries should be rated by reference to the major involvement, or if sufficient in extent, consider radicular group ratings. Scars Under 38 C.F.R. § 4.118 ratings are provided under Diagnostic Code 7800 for scars of the head, face or neck which are disfiguring. Diagnostic Code 7801 provides for ratings for scar not of the head, face, or neck which are deep and nonlinear. However, in this case as the Veteran's scars do not affect his head, face or neck and, also, are neither deep nor nonlinear, DCs 7800 and 7801 are not applicable. Similarly, DC 7802 provides for a 10 percent rating for scar which are superficial and nonlinear if the affected area or areas are of 144 square inches (929 sq.cms.) or greater, but because here the total surface are of the affected fingers is not 144 square inches or greater DC 7802 is not applicable. Under DC 7804, as to scars which are unstable or painful, one or two scars warrant a 10 percent rating. Three of four scars warrant a 20 percent rating. Five or more scars warrant 30 percent rating. Notes to the criteria for rating scars provide that a superficial scar is one not associated with underlying soft tissue damage. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 to 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. DC 7805 provides that any disabling effects of scars not considered in a rating under DCs 7800 - 7804 are to be rated under an appropriate diagnostic code. Muscle Injury Under 38 C.F.R. § 4.73, DC 5307 Muscle Group (MG) VII (7) governs flexion of wrist and fingers. Muscles arising from internal condyle of humerus: Flexors of the carpus and long flexors of fingers and thumb; pronator. A slight injury of MG 7 of the nondominant upper extremity warrants a noncompensable rating. A moderate injury warrants a 10 percent rating. A moderately severe injury warrants a 20 percent rating. A severe injury warrants a 30 percent rating. Under 38 C.F.R. § 4.73, MG VIII (8) governs function of extension of wrist, fingers, and thumb; abduction of thumb. Muscles arising mainly from external condyle of humerus: Extensors of carpus, fingers, and thumb; supinator. A slight injury of MG 8 of the nondominant upper extremity warrants a noncompensable rating. A moderate injury warrants a 10 percent rating. A moderately severe injury warrants a 20 percent rating, and a severe injury also warrants a 20 percent rating. Under 38 C.F.R. § 4.73, MG IX (9) governs function of the forearm muscles which act in strong grasping movements and are supplemented by the intrinsic muscles in delicate manipulative movements. Intrinsic muscles of hand: Thenar eminence; short flexor, opponens, abductor and adductor of thumb; hypothenar eminence; short flexor, opponens and abductor of little finger; 4 lumbricales; 4 dorsal and 3 palmar interossei. A note to DC 5309 states that the hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc. Rate on limitation of motion, minimum 10 percent. 38 C.F.R. § 4.56(d) provides that ratings for muscle injuries are classified as slight, moderate, moderately severe, or severe-depending on the type of injury sustained, the history and complaints, and the objective clinical findings. For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). The criteria for a slight injury, a moderate injury, a moderately severe injury, and a severe injury are set forth at 38 C.F.R. §§ 4.56(d)(1), 4.56(d)(2), 4.56(d)(3), and 4.56(d)(4). The word used to describe the overall severity of a service-connected disorder, e.g., "moderate", "severe" and "pronounced", are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The criteria in 38 C.F.R. § 4.56(d) (previously contained in 38 C.F.R. § 4.56(c) prior to revision thereof on July 3, 1997; see 62 Fed. Reg. 30235 (1997)) are merely factors to be considered with no specific fact or single criteria establishing entitlement to a particular rating. Rather § 4.56(d) is essentially a totality-of-the-circumstances test, with no single factor is per se controlling in determining whether a muscle injury has caused slight, moderate, moderately-severe or severe disability. So, for example, simple debridement does not in itself warrant a rating for moderately severe disability. Robertson v. Brown, 5 Vet. App. 70, 73 (1993) (addressing the criteria in § 4.56(c) prior to being contained in § 4.56(d)). Similarly, the mere presence of retained metallic fragments does not per se warrant a rating for moderate muscle injury, particularly if the disability is otherwise asymptomatic. Tropf v. Nicholson, 20 Vet. App. 317, 323 - 25 (2006). 38 C.F.R. § 4.56(d)(1)(i) indicates that, as to the type of injury, slight disability of muscles will stem from a simple wound of a muscle without debridement or infection. As to history and complaints, 38 C.F.R. § 4.56(d)(1)(ii) indicates that service department record of superficial wound with brief treatment and return to duty is to be expected. Healing with good functional results and no cardinal signs or symptoms of muscle disability, as defined in 38 C.F.R. § 4.56(c). As to objective findings, 38 C.F.R. § 4.56(d)(1)(iii) requires minimal scarring, no evidence of fascial defect, atrophy or impaired tonus and no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(b) provides that a through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(d)(2)(i) indicates that, as to the type of injury, moderate disability of muscles will stem from a through-and-through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. As to history and complaints, 38 C.F.R. § 4.56(d)(2)(ii) focuses on service department records or other evidence of in-service treatment for the wound. It contemplates a record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. As to objective findings, 38 C.F.R. § 4.56(d)(2)(iii) requires looking at entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue with some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(3)(i) provides that, as to the type of injury, moderately severe disability of muscles will stem from a through-and-through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. As to history and complaints, 38 C.F.R. § 4.56(d)(3)(ii) provides that there is to be service department record or other evidence showing hospitalization for a prolonged period for treatment of the wound. Also considered is whether there have been consistent complaints of cardinal signs and symptoms of muscle disability, as defined in 38 C.F.R. § 4.56(c), and, if present, evidence of inability to keep up with work requirements. As to objective findings, 38 C.F.R. § 4.56(d)(3)(iii) provides that there is to be entrance and (if present) exit scars indicating track of missile through one or more muscle groups, indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side, and tests of strength and endurance compared with sound side demonstrating positive evidence of impairment. 38 C.F.R. § 4.56(a) provides that an open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(d)(4)(i) provides that as to the type of injury, severe disability of muscles will stem from a through-and-through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. As to history and complaints, 38 C.F.R. § 4.56(d)(4)(ii) provides that there is to be service department record or other evidence showing hospitalization for a prolonged period for treatment of the wound. Also considered is whether there have been consistent complaints of cardinal signs and symptoms of muscle disability, as defined in 38 C.F.R. § 4.56(c), worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. 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.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski 1 Vet. App. 49 (1990). Analysis Initially, the Board notes that there is no evidence that the initial in-service injury caused any bony injury and there is no competent evidence that the Veteran's arthritis in his right hand is due to or a residual of the initial in-service injury or the in-service surgery. Rather, the medical opinion addressing this matter is that of the 2017 VA examiner who opined that there was no such relationship. Similarly, the November 2009 VA X-rays found two radiopaque foreign bodies in the right 2nd finger. However, the Veteran's initial injury was a laceration and not a penetrating injury which would leave behind foreign bodies and this is particularly true since VA X-rays much earlier, in 1989 found normal osseus and joint architecture of the right hand but did not reveal the presence of any foreign bodies. Thus, there is insufficient evidence upon which to conclude that based on the current presence of foreign bodies, not detected on X-rays 20 years after service or until X-rays in 2009 about 40 years after service, that the Veteran sustained any in-service muscle injury. Likewise, there is no persuasive evidence that there was any injury of the muscles of any fingers, e.g., loss of muscle tissue or intramuscular scarring. And, it is not contended that an evaluation should be assigned on the basis of any muscle injury. In correspondence of May 3, 2017, the Veteran's attorney argued that DC 5228 should be applied since it provided for a 10 percent rating for limitation of motion when there was a gap of one to two inches (2.5 to 5.1 cms) between the thumb and the fingers. It was stated that the 2017 VA examination found that there was a gap of 2 to 5 cms. between the ring/long fingers and the thumb. However, DC 5228 specifically applied to limitation of motion of the thumb, whereas limitation of motion of the index and long fingers (2nd and 3rd) fingers is governed by DC 5229, under which the RO assigned the current and maximum 10 percent rating allowed under that DC. Limitation of motion of the ring and little (4th and 5th) fingers is governed by DC 5230 but does not provide for a compensable rating for any degree of limitation of motion in any or all planes of the ring and little (4th and 5th) fingers. In this case the 2017 VA examination found no limitation of extension but the gap between the right 2nd (index) finger and the proximal transverse crease was 2 cms., which is a noncompensable degree of limited motion. However, the gap between the right 3rd (long or middle) finger and the proximal transverse crease was 5cms. which is a compensable degree of limited motion. It was also argued that a separate 10 percent rating should be assigned under 38 C.F.R. § 4.124a, DCs 8512 - 8612 for incomplete paralysis of the lower radicular group in the hand. It was pointed out that 38 C.F.R. § 4.123 provided that neuritis was characterized by such things as loss of reflexes, pain, and sensory disturbance. It was stated that in this case the 2017 VA examination found that the Veteran had digital nerve injuries with residual altered sensation, constant numbness of the fingers, pain and tenderness to palpation, and an inability to grip. Also, the examiner noted nerve irritation and injury had resulted in persistent altered sensation. Because the Veteran had nerve damage with decreased grip, sensory disturbance, and pain a separate compensable rating should be awarded under DCs 8512 - 8612. However, the Board is persuaded by the 2017 VA examiner that the limited motion and the neurological findings are due to the residual scarring. As to this, the scarring itself, the scars were well healed, nontender, and non-adherent. Thus, a compensable rating premised upon there being unstable or painful scars, under DC 7804 is not warranted. As to a rating based on neurologic impairment of the upper radicular nerve groups, a minimum 20 percent rating for the nondominant upper extremity requires at least mild impairment. Although the 2017 VA examination indicated that the Veteran had strength in the right hand of 4/5, the report of that examination when read fairly reflects that the examiner believed that it was the Veteran's limited motion which impaired his ability to grip and perform fine motor tasks. This is because in summarizing the findings of that examination the examiner addressed the degenerative changes in the right hand, the altered sensation and the limited motion of the affected fingers of the right hand but without commenting that there was any impairment of motion function due to limited strength. Indeed, that examination found that there was no muscle atrophy, as would be expected if there were significant neurological impairment affecting motor functions. In this regard, the Board again notes that there is no evidence that the Veteran sustained an actual injury of any muscles of his fingers, as opposed to tendon and nerve injury. Rather, the Veteran's complaints have been of numbness and pain; but, the 2017 VA examination found that there was no pain, including no pain on use. Thus, the Board concludes that any impairment of the upper radicular nerves is not only wholly sensory but is, at most, slight. Or, stated in other terms any impairment of the upper radicular nerves is not only wholly sensory but is less than mild. Accordingly, entitlement to a separate compensable rating for PO residuals of tenorrhapy and neurorrhapy of the right hand is not warranted. However, the Board's inquiry does not end here. In this case, the current 10 percent rating was assigned effective the date of the January 5, 2017 VA rating examination. However, the increased rating, was premised upon the finding of limited motion of the right 3rd finger due to a gap between that finger and the proximal transverse crease which was 5cms. which is a compensable degree of limited motion. Upon a thorough review of the record, the Board finds that the Veteran's "new" complaints of pain and decreased sensation which were first related at the time of the October 26, 2010, are sufficient to premise a finding that the Veteran had a noncompensable degree of limited motion but, with the favorable resolution of doubt, also had painful motion which would warrant a minimum 10 percent rating under DC 5229. Under 38 U.S.C. § 5110 and 38 C.F.R. § 3.400 the effective date "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor," unless specifically provided otherwise. 38 U.S.C. § 5110(a). Section 5110(b)(2) provides otherwise by stating that the effective date of an increased rating "shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." Under 38 C.F.R. § 3.400(o)(1), except as provided in paragraph (o)(2), the effective date is "date of receipt of claim or date entitlement arose, whichever is later." 38 C.F.R. § 3.400(o)(2) provides that the effective date is the "earliest date as of which it is factually ascertainable that an increase in disability had occurred if a claim is received within one year from such date, otherwise date of receipt of claim." See Harper v. Brown, 10 Vet. App. 125 (1997). In this case that date as of which it was factually ascertainable that is the October 26, 2010, which was more than one year after receipt of the October 1, 2009, claim for an increased rating. Accordingly, the Board finds that a 10 percent rating for the PO residuals of tenorrhapy and neurorrhapy of the right hand is warranted as of October 26, 2010, but not prior thereto. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski 1 Vet. App. 49 (1990). ORDER Entitlement to a compensable evaluation for PO residuals of tenorrhapy and neurorrhapy of the right hand prior to October 26, 2010, is denied. Entitlement to a 10 percent evaluation for PO residuals of tenorrhapy and neurorrhapy of the right hand as of October 26, 2010, is granted, subject to applicable law and regulations governing the award of monetary benefits. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs