Citation Nr: 21000174
Decision Date: 01/04/21	Archive Date: 01/04/21

DOCKET NO. 04-36 887
DATE: January 4, 2021

ORDER

Entitlement to a compensable rating for residuals of fracture of the right (minor) ring finger is denied.

Entitlement to a higher initial rating for hemorrhoids, rated as noncompensably disabling prior to May 5, 2017 and 20 percent thereafter, is denied.

Entitlement to a separate rating of 10 percent for pruritus ani, resulting from constant slight leakage, beginning on February 26, 2018, is granted.

Entitlement to an increased rating for tinea cruris and tinea pedis, rated as 10 percent disabling prior to February 26, 2018 and 30 percent thereafter, is denied.

Entitlement to a rating in excess of 10 percent for right foot bunion is denied.

Entitlement to a rating in excess of 10 percent for left foot bunion is denied.

Entitlement to a rating in excess of 20 percent for bony prominence of the right side of the pelvis with leg stiffness and pain is denied.

Entitlement to a higher initial rating for a gastrointestinal condition, claimed as diarrhea, stomach pain and vomiting, rated as 10 percent disabling prior to March 20, 2020 and 30 percent thereafter, is denied.

Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD), rated as 30 percent disabling prior to July 5, 2011 and 70 percent thereafter, is denied.

FINDINGS OF FACT

1.   The Veteran's residuals of a fracture of the right ring finger are not manifested by symptoms approximating an amputation of that finger, or by involvement of other fingers or the whole hand so as to warrant a compensable or separate rating.  

2.   For the appeal period prior to May 5, 2017, the Veteran's hemorrhoids were not shown to involve excessive redundant tissue; to be large, thrombotic or irreducible; to result in secondary anemia; or to involve fissures.  

3.   For the appeal period beginning on May 5, 2017, the Veteran's hemorrhoids show persistent bleeding, and the Veteran is in receipt of the maximum schedular rating available for the condition.  

4.   For the appeal period beginning on February 26, 2018, the Veteran’s hemorrhoids, with resulting pruritis ani, have been manifested by constant slight leaking without occasional involuntary bowel movements necessitating wearing of pad

5.   For the appeal period prior to February 26, 2018, the Veteran's tinea cruris and tinea pedis was not shown to involve an exposed surface or extensive area, affect 20 to 40 percent of the entire body or of exposed areas, or require systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of 6 weeks or more.  

6.   For the appeal period beginning on February 26, 2018, the Veteran's tinea cruris and tinea pedis required constant or near constant systemic therapy.  

7.   Throughout the period on appeal, the Veteran’s right foot bunions, status post bunionectomy, is manifested by no more than moderate symptoms.  

8.   Throughout the period on appeal, the Veteran’s left foot bunion, status post bunionectomy, is manifested by no more than moderate symptoms.  

9.    Throughout the period on appeal, the Veteran's bony prominence of the right side of the pelvis with leg stiffness and pain was manifested by extension limited to 10 degrees and greater than 25 degrees of flexion; limitation of motion in abduction is not beyond 10 degrees.  

10.   For the appeal period prior to March 20, 2020, the Veteran's a gastrointestinal condition manifested with moderate and frequent episodes of bowel disturbance with episodes of abdominal distress; severe diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress was not shown.  

11.   For the appeal period beginning on March 20, 2020, the Veteran's gastrointestinal condition manifested with severe diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress; the Veteran is currently at the highest scheduled rating for irritable bowel syndrome.  

12.   For the appeal period prior to July 5, 2011, the Veteran's PTSD was manifested by no more than occupational and social impairment with occasional decrease in work efficiency and reduced reliability, due to such symptoms as sleep impairment, nightmares, flashbacks, depression, anxiety, and outburst of anger.  

13.   For the appeal period beginning on July 5, 2011, the Veteran's PTSD manifested in occupational and social impairment with deficiencies in most areas without total occupational and social impairment.  

CONCLUSIONS OF LAW

1.   The criteria for a compensable rating for residuals of a fracture of the right (minor) ring finger have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5227.  

2.   The criteria for a higher rating for hemorrhoids, rated as noncompensably disabling prior to May 5, 2017 and in excess of 20 percent thereafter have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.114, Diagnostic Code 7336.  

3.   The criteria for a separate 10 percent rating for the hemorrhoids, pruritis ani with rectal seepage have been met, effective February 26, 2018.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.114 Diagnostic Code 7332.  

4.   The criteria for a rating in excess of 10 percent for tinea cruris and tinea pedis prior to February 26, 2018 have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.118, Diagnostic Code 7813-7806.  

5.   The criteria for a 30 percent rating, but no higher, for tinea cruris and tinea pedis for the period beginning on February 26, 2018 have been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.118, Diagnostic Code 7813-7806.  

6.   The criteria for a rating in excess of 10 percent for right foot bunion have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5280-5284.  

7.   The criteria for a rating in excess of 10 percent for left foot bunion have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5280-5284.  

8.   The criteria for a rating in excess of 20 percent for bony prominence of the right side of the pelvis with leg stiffness and pain have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252.  

9.   The criteria for a higher initial rating for a gastrointestinal condition, rated as 10 percent disabling prior to March 20, 2020 and 30 percent thereafter, have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.114, Diagnostic Code 7319.  

10. The criteria for a higher initial rating for PTSD, rated as 30 percent disabling prior to July 5, 2011 and 70 percent thereafter, have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.126, 4.130, Diagnostic Code 9411.  

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from March 1979 to November 1991.  

These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina.  By a rating action in February 2007, the RO increased the rating for a pelvis disability to 20 percent, effective August 17, 2005; the RO confirmed the previously assigned ratings for right ring finger fracture, tinea cruris and tinea pedis, and right and left foot bunions, status post bunionectomy.  

In August 2008, the Board remanded the case to the RO for evidentiary development.  Following the requested development, a supplemental statement of the case (SSOC) was issued in September 2008.  In October 2009, the Board again remanded the case to the RO for further evidentiary development.  By a rating action in October 2011, the RO granted service connection for PTSD and assigned a 10 percent rating, effective May 4, 2005, and 30 percent from July 5, 2011.  By a February 2014 rating action, the RO increased the rating for PTSD to 70 percent, effective February 5, 2014.  Subsequently, in a December 2017 rating decision, the RO assigned a 30 percent rating for PTSD, effective May 4, 2005 and a 70 percent rating, effective July 5, 2011.  

In March 2012, the Board remanded the case to the RO for further evidentiary development.  In that decision, the Board assigned a 20 percent rating for the right pelvis disability prior to August 17, 2005 but denied a rating in excess thereof.  The Board also denied increased ratings for tinea cruris and tinea pedis, bunions, hemorrhoids, and residuals of a fracture of the right ring finger.  The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court).  In a November 2012 Order, the Court granted the parties' Joint Motion for Partial Remand (JMPR) and vacated the Board's March 2012 decision with respect to its denials of a rating greater than 20 percent for the right pelvis disability and increased ratings for the skin disability, bunions, hemorrhoids, and residuals of a fracture of the right ring finger, and remanded these matters back to the Board for additional development consistent with the JMPR.  

In March 2013 and March 2015, the Board remanded the case to the RO for further development.  In February 2017, the Board again remanded the issues on appeal to the RO for further evidentiary development.  Following the requested development, a supplemental statement of the case (SSOC) was issued in September 2017.  By a rating action in December 2017, the RO increased the rating for hemorrhoids from zero percent to 20 percent, effective May 1, 2016; the RO also increased the rating for PTSD from 30 percent to 70 percent, effective July 5, 2011.  A February 2018 rating decision increased the rating for hemorrhoids from zero to 20 percent, effective May 5, 2017.  

In April 2018, the Board once again remanded the case to the RO for further evidentiary development.  In a Decision Review Officer’s (DRO) decision in May 2020, the RO increased the rating for the Veteran’s gastrointestinal condition from 10 percent to 30 percent, effective March 20, 2020.  An SSOC was issued in May 2020.  In July 2020, the Board once again remanded the case to the RO for still further development.  Another SSOC was issued in October 2020.  

The Veteran testified at hearings before Veterans Law Judges (VLJs) in June 2009 and in March 2016.  Transcripts of the hearing are of record.  The VLJ who conducted the June 2009 hearing held testimony on most, but not all, of the issues on appeal.  The VLJ who conducted the June 2009 hearing has since retired from the Board's employment, and the VLJ who conducted the March 2016 hearing has also retired from the Board’s employment.  By letter dated in June 2020, the Veteran was informed that the VLJs who conducted the hearings were no longer at the Board.  The Veteran was informed that his appeal was reassigned to another Veterans Law Judge and that he had the right to request an additional Board hearing within 30 days of the date of that letter.  The Veteran did not respond to the June 2020 letter.  

Finally, the Board notes the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has been in receipt of a TDIU since February 2001. As such, Rice is inapplicable in this case

Increased Rating

Disability evaluations are determined by the application of a schedule of ratings which is based upon average impairment of earning capacity.  38 U.S.C. § 1155; 38 C.F.R. Part 4.  38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history, and that there be emphasis upon the limitation of activity imposed by the disabling condition.  38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the entire recorded history, and that each disability must be considered from the point of view of the veteran's working or seeking work.  Separate diagnostic codes identify the various disabilities.  

Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating.  38 C.F.R. § 4.7.  Otherwise, the lower rating is to be assigned. Because the Veteran is appealing the original assignment of a disability rating following an award of service connection, the severity of his lumbar spine disorder is to be considered during the entire period from the initial assignment of the rating to the present.  See Fenderson v. West, 12 Vet. App. 119 (1999).  

When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing.  38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement.  See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011).  Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate.  See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.").  

When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant.  38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

1.   Entitlement to a compensable rating for residuals of fracture of the right (minor) ring finger

The Veteran essentially contends that his right finger is more disabling than reflected by the rating currently assigned.  

The Veteran is in receipt of a zero percent rating for residuals of a fracture of the right ring finger.  This rating has been assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5227.  Under Diagnostic Code 5227, a maximum noncompensable rating is assigned for unfavorable or favorable ankylosis of the ring or little finger regardless of whether the finger is on the major (dominant) or minor (non-dominant) hand.  38 C.F.R. § 4.71a, Diagnostic Code 5227.  A note accompanying Diagnostic Code 5227 provides that the Board should also consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand.  38 C.F.R. § 4.71a, Code 5227, Note.  

Turning to the evidence of record, the Veteran was afforded a VA examination in October 2010.  At that time, he reported injuring his right ring finger during a basketball game while on active duty in 1990 with immediate pain and swelling; X-ray revealed a fracture, and a splint was applied, and he was treated with pain medication.  The Veteran indicated that the fracture healed, and pain resolved only to return in 1991 without precipitating event or injury.  The Veteran indicated that he now had intermittent pain in proximal right ring finger distal 4th MC bone, aggravated by weather changes; there was no associated swelling or redness.  The examiner noted that range of motion of the finger was full and unimpaired.  There was no objective evidence of pain on active range of motion and no objective evidence of pain following repetitive motion.  No limitation of motion.  There’s no deformity, asymmetry, tenderness, swelling, erythema or weakness of right ring finger.  Remote tiny chip fracture at the base of proximal middle phalanx of right ring finger without functional impairment.  The examiner noted that today’s X-rays of the right ring finger showed no evidence of old or acute fracture or dislocation except a suggestion of an old tiny chip fracture at the base of palmar proximal middle phalanx.  No significant pathology or functional impairment of the right ring finger was noted on the examination.  

During a Disability Benefits Questionnaire (DBQ) examination in January 2014, the Veteran indicated that the fracture of the right ring finger healed, but he still had pain in the finger during cold weather months.  It was noted that the Veteran is left-handed.  He did not report any flareups that impact the function of the right hand.  There was no limitation of motion in any of the fingers or thumbs.  The Veteran was able to perform repetitive use testing with three repetitions.  There was no limitation of motion of any fingers after the test.  There was no gap between the thumb pad and the fingers post-test.  There was no functional loss or functional impairment of any of the fingers or thumb.  Muscle strength testing was normal.  No ankylosis was noted in the thumb or fingers.  No definite fracture or dislocation identified on X-ray of the right ring finger; a tiny calcific density noted adjacent to the anterior proximal middle phalanx.  The Veteran stated that he is able to use his right hand, but he had difficulty using a screwdriver to open water meters when he was employed due to pain in his right 4th finger, but he hasn't worked since April 1999.  

On the occasion of a DBQ examination in May 2017, the Veteran reported pain and cramping in the right ring finger with exposure to cold weather; he stated that he wears a glove, uses heat and water therapy for the right ring finger condition.  The Veteran reported flareups of pain with cold weather.  The examiner noted that range of motion in all fingers was normal; there was no gap between the pad of the thumb and the fingers.  There was no gap between the finger and proximal transverse crease of the hand on maximal finger flexion.  No pain was noted on examination of the fingers.  There was no evidence of pain with use of the hand.  There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.  The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional function loss or range of motion.  Muscle strength testing was normal; no muscle atrophy was noted.  No ankylosis was noted.  The examiner indicated that the Veteran uses a brace for his hand condition.  The examiner stated that the right ring finger condition does not impact the Veteran’s ability to perform any type of occupational task.  

Another DBQ examination of the fingers was conducted in February 2018, at which time the Veteran reported stiffness of the right ring finger, status post repair of fracture at the 3rd MCP proximal to finger.  The Veteran indicated that he tried many treatments, but warm water therapy and acupuncture have helped the most.  He stated that he currently experiences stiffness and aching of the knuckles of the right ring finger and distal MCP.  He is unable to squeeze anything tightly or hold unto heavy objects.  It was noted that the Veteran is left-handed.  The Veteran indicated that he experiences flareups during colder months and uses warm water or heating pad for relief.  On examination, it was noted that range of motion was normal in all fingers of both hands; no pain was noted on examination.  There was no evidence of pain with use of the hand.  There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.  Muscle strength testing was normal.  No muscle atrophy was noted.  No ankylosis was noted.  It was noted that the Veteran wears support glove during cold weather or if pain is worse.  There was no functional impairment of the right ring finger such that no effective function remained other than that which would be equally well served by an amputation with prosthesis.  X-ray study revealed a healed fracture deformity of the fourth and fifth proximal phalanges.  The examiner stated that the right ring finger condition does not impact the Veteran’s ability to perform any type of occupational task.  

During a recent DBQ examination in March 2020, the Veteran indicated that the pain in his right ring finger is worse with cold weather, and squeezing objects was painful; he now had arthritis.  The Veteran indicated that he experiences flareups with increased pain when the weather changes and he use the hand; he can’t cut up things or tie his shoes.  On examination, it was noted that range of motion was normal in all fingers of both hands; the examiner noted pain in the right hand with finger flexion and opposition with thumb.  There was no evidence of pain with use of the hand.  There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.  It was noted that the right-hand swells with flare-ups and is painful.  Muscle strength is 4/5.  No muscle atrophy was noted.  No ankylosis was noted.  It was noted that the Veteran wears a brace for arthritis of the right hand.  There was no chip fracture on the current x-ray study of the right ring finger.  The examiner indicated that any work that required lifting things or squeezing would be hard for the Veteran to accomplish; in addition, extended use of the hand would result in increased pain doing any type of occupational environment.  

Based on the above, the Board finds that the criteria for entitlement to a compensable rating for residuals of a fracture of the right ring finger have not been met.  Crucially, there has been no finding of ankylosis of the right ring finger.  Moreover, a noncompensable rating is the maximum rating allowed under Diagnostic Code 5227.  

Since the Veteran is in receipt of the maximum rating available under Diagnostic Code 5227, the Board will consider other potentially applicable Diagnostic Codes in the Rating Schedule.  Under Diagnostic Code 5230, a maximum zero percent rating is assigned for any limitation of motion of the ring or little finger (whether on the major (dominant) or minor (non-dominant) hand).  38 C.F.R. § 4.71a, Diagnostic Code 5230.  Thus, the Veteran is also in receipt of the maximum rating under Diagnostic Code 5230.  Higher schedular ratings are not available under Diagnostic Codes 5227 or 5230.  

Although the Board recognizes that the Veteran currently is in receipt of the maximum zero percent rating, the Note to Diagnostic Code 5227 states that an amputation evaluation should also be considered, particularly where ankylosis is present.  38 C.F.R. § 4.71a.  Ankylosis is defined as immobility and consolidation of a joint due to disease, injury or surgical procedure.  Lewis v. Derwinski, 3 Vet. App. 259 (1992).  

Here, there is no competent evidence suggesting that the Veteran experiences ankylosis in his right ring finger.  38 C.F.R. § 4.71a, Diagnostic Code 5227.  Specifically, ankylosis of the right ring finger was not documented at the October 2010, May 2017, February 2018, or the March 2020 examinations, nor do the VA treatment records reflect any indication of ankylosis.  While the Veteran reported increased pain with changes in weather and he experiences swelling of the finger, no evidence of record indicates that the right ring finger is so disabled by any other symptoms such that its functional impairment more nearly approximates amputation.  Thus, the Board concludes that an increased rating is not warranted via the amputation codes because the nature of the Veteran's service-connected right ring finger disability, coupled with the absence of ankylosis is not analogous to amputation.  Id.  

The Board recognizes the Veteran's lay statements of pain in his right ring finger.  In this regard, while it is the intention of the rating schedule to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, there is no compensable rating available under either Diagnostic Code 5227 or Diagnostic Code 5230.  38 C.F.R. § 4.71a.  Additionally, the provisions of 38 C.F.R. §§ 4.40, 4.45 are not for consideration where the Veteran is in receipt of the highest rating based on limitation of motion and a higher rating requires ankylosis.  Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997).  Because the Veteran is already receiving the maximum schedular rating based on symptomatology that includes limitation of motion under Diagnostic Code 5227, an increased rating under 38 C.F.R. §§ 4.40 and 4.45 is not available.  Thus, compensation for functional loss is not applicable here.  Accordingly, the Board finds that the current noncompensable rating is the appropriate rating for the Veteran's right ring finger disability.  

The Board acknowledges that the Note to Diagnostic Code 5227 states that an additional evaluation is warranted for any resulting limitation of motion of other digits or interference with the overall function of the hand due to the service-connected right ring finger.  38 C.F.R. § 4.71a.  Here, there is no competent evidence that the right ring finger has interfered with the overall function of the right hand, such that a separate evaluation is warranted under the Note to Diagnostic Code 5227.  Id.  

The Board has considered whether a staged rating under is warranted, however, the Board finds that his right ring finger fracture symptomatology has been stable throughout the period on appeal.  Therefore, assigning a staged rating is not warranted.  Hart v. Mansfield, supra. Further, 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, 69-70 (2017).

The preponderance of the evidence is against the Veteran's claim of entitlement to a compensable rating for the residuals of a right ring finger fracture.  As such, the claim is denied.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra.

2.   Entitlement to a higher initial rating for hemorrhoids, rated as noncompensably disabling prior to May 5, 2017 and in excess of 20 percent thereafter, is denied.

The Veteran seeks entitlement to a compensable rating for hemorrhoids for the period prior to May 5, 2017 and in excess of 20 percent thereafter.  

The Veteran's service-connected hemorrhoids have been evaluated as noncompensable for the period prior to May 5, 2017 and 20 percent disabling thereafter, pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7336.  According to Diagnostic Code 7336, a noncompensable rating is assigned for hemorrhoids that are mild or moderate in degree.  A 10 percent rating is assigned for hemorrhoids which are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences.  A maximum 20 percent rating is assigned for internal or external hemorrhoids with persistent bleeding and with secondary anemia, or with fissures.  Id.  

In conjunction with his claim, the Veteran was afforded a VA examination in October 2010.  At that time, it was noted that he had a colonoscopy and esophagogastroduodenoscopy (EGD) in October 2005 and was found to have internal hemorrhoids and no other significant findings.  The Veteran reported recurrent hemorrhoids three to four times a year, with the last active symptoms occurring one month ago with rectal pruritis and rectal bleeding.  The Veteran indicated that he uses rectal suppositories for treatment.  On examination, no external bleeding and no anal lesions were noted.  No rectal masses and no internal hemorrhoid were palpated.  The pertinent diagnosis was internal hemorrhoid.  

VA progress notes dated from October 2012 through July 2015 show that the Veteran received clinical attention for his hemorrhoids, including medication and suppositories.  

A DBQ examination was conducted on May 5, 2017, at which time the Veteran reported intermittent episodes of hemorrhoids and blood in his stool; he stated that he does not currently take any medication for his hemorrhoid condition.  The examiner indicated that, curing a review of the Veteran’s records, it was noted that he is anemic.  The medical literature and the gastroenterology note showed that the hematochezia is due to the hemorrhoids and can cause anemia; therefore, the Veteran’s anemia was due to his hemorrhoids.  The examiner reported findings of small or moderate external hemorrhoids.  It was noted that the Veteran had a colonoscopy in May 2016 which was normal to cecum with no evidence of neoplasia and no diverticular.  The examiner indicated that the Veteran’s condition does not impact his ability to work.  

In February 2018, a DBQ examination of the rectum reported a diagnosis of internal and external hemorrhoids.  The Veteran indicated that he currently experiences leakage of stool, and episodes of blood in stool that he attributes to hemorrhoids.  The Veteran noted that his condition caused embarrassment during episodes of leakage which occurred after every bowel movement.  The Veteran noted that his conditions limits going out to eat and requires that he has a bowel movement before he leaves and again when he returns home.  The examiner noted mild or moderate hemorrhoids, with persistent bleeding; he also noted constant slight leakage.  The examiner indicated that rectal examination revealed small or moderate external hemorrhoids, with non-thrombosed external hemorrhoid at 9 o’clock; no evidence of gross bleeding.  Normal rectal tone.  The examiner indicated that the hemorrhoids do not impact the Veteran’s ability to work.  

The Veteran was afforded another DBQ examination in March 2020; at that time, he reported worsening hemorrhoids, bleeding and itching.  He stated that he currently uses continuous medication for his hemorrhoids, including suppository and psyllium.  The examiner indicated that there were no hemorrhoids present at the time of the examination, but it comes and goes.  It was noted that the Veteran had pruritis ani after a bowel movement, especially at night.  The examiner also noted that anal tone was weak and fecal matter was evident outside of the rectum.  It was also noted that the Veteran needs to wash after each bowel movement, which maybe difficult at work.  The examiner indicated that pruritis ani is a well-known progression of the service-connected condition.  The examiner further noted that the conditions diagnosed with be an annoyance with any type of occupational setting and could be distracting during flareups.  

After reviewing the evidence discussed above, as well as all other evidence of record, the Board finds that a compensable rating is not warranted for the Veteran's hemorrhoids for the period prior to May 5, 2017.  In this regard, the October 2010 VA examination revealed no external bleeding and no anal lesions; moreover, no rectal masses and no internal hemorrhoid were palpated.  Consequently, the Veteran's hemorrhoid condition did not manifest as large or thrombotic hemorrhoids that are irreducible with excessive redundant tissue, evidencing frequent recurrences.  There was also no evidence of persistent bleeding, secondary anemia, or fissures.  Accordingly, there is no basis for assigning a compensable rating for hemorrhoids under Diagnostic Code 7336 for the period prior to May 5, 2017.  

For the appeal period beginning on May 5, 2017, the Veteran's hemorrhoids have been assigned a 20 percent rating under Diagnostic Code 7336 for mild hemorrhoids with persistent bleeding and secondary anemia.  This is the highest rating available.  Consequently, there is no basis for assigning a higher rating under this diagnostic code.

The Board acknowledges the Veteran's statement that his hemorrhoids are more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for a higher rating have been met. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for hemorrhoids. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment.

The Board has considered whether a staged rating under is warranted, however, the Board finds that his hemorrhoid symptomatology has been stable throughout each period on appeal.  Therefore, assigning a staged rating is not warranted.  Hart v. Mansfield, supra. Further, 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, supra.

Accordingly, the Board finds that a preponderance of the evidence is against the assignment of a compensable rating prior to May 7, 2017 or a 20 percent rating thereafter for hemorrhoids. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra.

3.   Entitlement to a separate rating of 10 percent for pruritus ani, resulting from constant slight leakage is granted.

As noted above, the Veteran contends that he is entitled to a higher rating for his service-connected hemorrhoids, post-operative.  The Board found that at no time during the claim period has the Veteran demonstrated large, thrombotic, or irreducible hemorrhoids; therefore, a compensable rating is not available under Diagnostic Code 7336.  However, the Board finds that the residuals of the Veteran's service-connected hemorrhoids warrant a separate compensable rating under Diagnostic Codes 7337-7332. 

Under Diagnostic Code 7337, for pruritis ani, VA is directed to rate it under the underlying condition, which is the Veteran's loss of sphincter control.  

Under Diagnostic Code 7332, a 10 percent rating is warranted for constant slight or occasional moderate leakage. A 30 percent rating is warranted for occasional involuntary bowel movements, necessitating wearing of pad. A 60 percent rating is assigned for extensive leakage due to impairment of sphincter control and fairly frequent involuntary bowel movements.  A maximum 100 percent rating is assigned under Diagnostic Code 7332 for complete loss of sphincter control.  38 C.F.R. § 4.114, Diagnostic Code 7332.  

Based on evidence in the claims file, a separate rating of 10 percent, but no higher, is warranted under Diagnostic Code 7332 beginning on beginning on February 26, 2018.  During the February 2018 DBQ examination, the Veteran noted that his condition caused embarrassment during episodes of leakage which occurred after every bowel movement.  The examiner noted mild or moderate hemorrhoids, with persistent bleeding; he also noted constant slight leakage.  Recently, in the March 2020 DBQ, the examiner noted that the Veteran had pruritis ani after a bowel movement, especially at night.  The examiner also noted that anal tone was weak and fecal matter was evident outside of the rectum.  It was also noted that the Veteran needs to wash after each bowel movement.  However, the evidence does not show that this condition results in occasional involuntary bowel movements, necessitating wearing of pad.  Accordingly, a rating in excess of 10 percent is not warranted.  

The Board has considered whether a staged rating under is warranted, however, the Board finds that his pruritis ani symptomatology has been stable throughout the period on appeal.  Therefore, assigning a staged rating is not warranted.  Hart v. Mansfield, supra. Further, 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, supra.

Accordingly, the Board finds that a separate 10 percent rating is warranted for pruritus ani beginning on February 26, 2018. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra.

4.   Entitlement to a rating in excess of 10 percent for tinea cruris and tinea pedis

The Veteran essentially contends that his skin condition is more severe than reflected by the 10 percent rating currently assigned.  

The Veteran currently receives a 10 percent rating for tinea cruris and tinea pedis under the provisions of 38 C.F.R. § 4.118, Diagnostic Code 7813-7806.  

In evaluating skin and scar residuals, the Board notes that during the appeal period, changes were made to 38 C.F.R. § 4.118, Diagnostic Code 7813.  Effective August 13, 2018, VA amended its regulations governing skin disabilities.  VA's intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. For applications filed on or after the effective date, only the new criteria will be applied.  83 Fed. Reg. 32592 (July 13, 2018).  

Under the pre-August 2018 rating criteria, Diagnostic Code 7813 provided for a zero percent rating where there is less than five percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period.  A 10 percent rating is assigned where there is involvement of at least five percent, but less than 20 percent, of the entire body or at least five percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or for dermatitis or eczema that requires systemic therapy, such as corticosteroids or other immunosuppressive drugs, for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is assigned for dermatitis or eczema, affecting more than 40 percent of the entire body or more than 40 percent of exposed areas, or for dermatitis or eczema that requires constant or near-constant systemic therapy, such as corticosteroids or other immunosuppressive drugs, during the past 12-month period.  38 C.F.R. § 4.118.  

Under the post-August 2018 rating criteria, a zero percent rating is assigned when there is no more than topical therapy required over the past 12-month period and characteristic lesions involving less than five percent of the entire body affected; or characteristic lesions involving less than five percent of exposed areas affected.  A 10 percent rating is assigned for characteristic lesions involving at least five percent but less than 20 percent of the entire body affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month.  A 30 percent rating is assigned for characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy retinoids, biologics, photochemotherapy, (psoralen with long-wave ultraviolet-A light (PUVA) or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or, constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period.  38 C.F.R. § 4.118 (August 13, 2018).  

Prior to the August 2018 amendments, the Federal Circuit distinguished between "systemic" therapy versus "topical" therapy, holding that systemic therapy means treatment affecting the whole body, whereas topical therapy means treatment pertaining to a particular surface area that affects only the area to which it is applied.  Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017).  Nevertheless, a topical corticosteroid could be administered to a large enough scale to affect the body, as a whole, thus meeting the definition of "systemic therapy.  Id.  

With the implementation of the August 2018 amendments, systemic therapy is now defined as treatment that is administered through any route (orally, injection, suppository, intranasally) other than the skin, and topical therapy is treatment that is administered through the skin.  38 C.F.R. § 4.118 (August 13, 2018).  

The Veteran’s claim for an increased rating was received in May 2005.  In conjunction with his claim, the Veteran was afforded a VA examination for evaluation for the skin in March 2006.  At that time, it was noted that he had little scaling between the fourth and fifth toes on the left and right feet; no other evidence of tinea pedis was noted.  There was no evidence of tinea cruris.  The groin area was perfectly normal.  The examiner indicated that the percentage of the exposed area involved was zero.  The examiner noted that the Veteran did not have any significant infection involved with tinea at this time; however, when he does have it, the percent of the entire body that is affected is less than two percent.  He had no scarring or disfigurement, no acne or chloracne, no scarring alopecia, and no hyperhidrosis.  The pertinent diagnoses were tinea pedis, remote, and tinea cruris, remote, without evidence of infection at this time.  

The Veteran was afforded a VA examination in October 2010.  It was noted that the Veteran had a past history of tinea cruris and tinea pedis that were treated and resolved and have not recurred.  The Veteran reported chronic course of pruritic rashes without pustules, skin thickening or associated skin infection.  The Veteran indicated that he was evaluated two years ago and given oral medication for two weeks which was helpful.  He reported constant itching.  Examination revealed scattered small noninflammatory acne on upper back.  No other skin lesions, lichenification, erythema on scalp, torso, inguinal, hands or feet were noted.  The examiner noted findings of bilateral thickening and discoloration of great toenails.  The diagnoses were mild noninflammatory acne of upper back, remote tinea cruris, resolved, and remote tinea pedis, resolved.  

A DBQ skin examination was conducted in February 2018.  At that time, the Veteran reported itching at his feet, as well as on his shoulders, back, abdomen and legs; he stated that the itching is aggravated by cold weather.  It was noted that the Veteran had been treated with oral or topical medications in the past 12 months; he uses antifungal cream for his feet.  He also uses Benzoyl peroxide daily for rash on his trunk.  He had not had any debilitating or non-debilitating episodes in the past 12 months of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis.  The examiner noted that the skin conditions do not cause scarring or disfigurement of the head, face, or neck.  He did not have any skin neoplasm.  It was noted that the infections of the skin affected 20 to 40 percent of total body area, and none on the exposed area.  The examiner noted that the Veteran had tinea pedis with dryness of feet, and tinea corporis with patches of dry flaky skin on lumbar and abdominal areas, and legs.  The examiner noted that the skin condition does not impact the Veteran’s ability to work.  

The Veteran was afforded a recent DBQ examination for evaluating the skin condition in March 2020.  The Veteran indicated that symptoms comes and goes depending on the weather.  He stated that he currently had problems with dry skin, itchiness and rash.  Current treatment included Clotrimazole, and hydrocortisone for rash and itching.  The impact of the condition is problem with working in boots or shoes.  The Veteran has been treated with medication in the past 12 months, including corticosteroids, topical, constant or near constant.  He has not had other treatments, other than systemic or topical medications in the past 12 months for any skin condition.  It was noted that he had dermatophytosis which affects five to 20 percent of total body area, but none of the exposed area.  The examiner noted that the current diagnosis was onychomycosis of both feet due to tinea infection of the toenails as a result of tinea pedis.  The examiner stated that the Veteran’s skin condition does not impact his ability to work.  

Rating for period prior to February 26, 2018 

After a thorough review of the record, the Board finds that a higher rating is not warranted for the Veteran's tinea pedis cruris under either version of Diagnostic Code 7813 prior to February 26, 2018.  Under the old regulations, the evidence does not show that the Veteran's condition affected 20 to 40 percent of the entire body or 20 percent to 40 percent of the exposed areas affect, or required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period.  

Significantly, as noted above on examination in March 2006, the examiner noted that the Veteran did not have any significant infection involved with tinea at this time; and, when he does have it, the percent of the entire body that is affected is less than two percent.  The pertinent diagnoses were tinea pedis, remote, and tinea cruris, remote, without evidence of infection at this time.  And, in October 2010, examination revealed scattered small noninflammatory acne on upper back; no other skin lesions, lichenification, erythema on scalp, torso, inguinal, hands or feet were noted.  The diagnoses were mild noninflammatory acne of upper back, remote tinea cruris, resolved, and remote tinea pedis, resolved.  

Under the amended regulations, the evidence does not show characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy retinoids, biologics, photochemotherapy, PUVA or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period.  Therefore, the preponderance of the evidence is against the Veteran's claim of entitlement to a rating in excess of 10 percent for tinea pedis cruris prior to February 26, 2018, under the old regulations or the amended regulations in effect beginning August 13, 2018.  

In sum, the Board finds that for the period prior to February 26, 2018, the Veteran's service-connected skin disorder was not shown to involve an exposed surface or extensive area, affect 20 to 40 percent of the entire body or of exposed areas, or required systemic therapy such as corticosteroids or other immunosuppressive drugs and treatment administered through any route other than the skin, for a total duration of 6 weeks or more. 

The Board acknowledges the Veteran's statement that his skin disorder is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for a higher rating have been met. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for a skin disorder. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment.

The Board has considered whether a further staged rating under is warranted, however, the Board finds that his skin disorder symptomatology has been stable throughout each period on appeal.  Therefore, assigning a staged rating is not warranted.  Hart v. Mansfield, supra. Further, 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, supra.

Thus, the criteria for a rating in excess of 10 percent have not been met for the period prior to February 26, 2018.  As the preponderance of the evidence is against the claim, and the benefit-of-the-doubt standard of proof does not apply.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra.

Rating for period beginning February 26, 2018.

After careful review of the evidence, the Board finds that for the period beginning February 26, 2018, the evidence shows that a rating of 30 percent for is warranted based on required systemic therapy for a total duration of six weeks.  

During the February 26, 2018 DBQ examination, it was noted that the infection affected 20 to 40 percent of the total body area to warrant a 30 percent rating.  Moreover, while the March 2020 DBQ examination indicated that the percentage of exposed body area affected was zero percent with five to 20 percent of the total body area that had skin infections, the record demonstrates that the Veteran required near constant systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more during a 12-month period.  Therefore, and affording the Veteran all reasonable doubt, the Board finds that the criteria for a rating of 30 percent under Diagnostic Code 7813 have been met for the appeal period beginning on February 26, 2018.  

However, a rating in excess of 30 percent is not warranted.  

In order to warrant the next higher rating of 60 percent rating (the highest available under Diagnostic Code 7806), there must be a showing that more than 40 percent of the entire body or exposed areas are affected, or that constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs was required during the past 12-month period.  

Under the new criteria, a 60 percent rating is warranted for characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period.  

As reflected above the Veteran's skin disorder at most demonstrated 5 to 20 percent of the total body area that was infected.  Additionally, there is no evidence that the Veteran's skin disability required constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over a 12-month period.  Accordingly, a rating of 30 percent but no higher is warranted for the period beginning February 26, 2018.  

The Board acknowledges the Veteran's statement that his skin disorder is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for a higher rating have been met. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for a skin disorder. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment.

The Board has considered whether a further staged rating under is warranted, however, the Board finds that his skin symptomatology has been stable throughout each period on appeal.  Therefore, assigning a staged rating is not warranted.  Hart v. Mansfield, supra. Further, 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, supra.

Thus, the criteria for a rating of 30 percent, but no higher, have been met for the period beginning on February 26, 2018 for the Veteran’s tinea cruris and tinea pedis.  As the preponderance of the evidence is against a rating in excess of 30 percent and the benefit-of-the-doubt standard of proof does not apply and the claim is denied to that extent.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra.

5.   Entitlement to a rating in excess of 10 percent for right foot bunion

6.   Entitlement to a rating in excess of 10 percent for left foot bunion

The Veteran essentially contends that his right and left foot disorder is more disabling than reflected by the 10 percent rating currently assigned.  

The Veteran’s right and left feet bunions, status post bunionectomy, have been rated under Diagnostic Code 5280-5284.   

Diagnostic Code 5280 allows for a maximum 10 percent rating for hallux valgus, unilateral, operated with resection of metatarsal head, or for severe hallux valgus, if equivalent to amputation of great toe.  38 C.F.R. § 4.73, Diagnostic Code 5280. This is the highest rating available under this diagnostic code.

Diagnostic Code 5284 states that a moderate foot injury warrants a 10 percent rating, a moderately severe foot injury warrants a 20 percent rating, and a severe foot injury warrants a maximum 30 percent rating.  However, a note states that actual loss of use of the foot warrants a 40 percent rating.  38 C.F.R. § 4.73, Diagnostic Code 5284.  

The words "mild," "moderate," and "severe" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just."  See 38 C.F.R. § 4.6.  

The Veteran was afforded a VA examination in October 2010.  At that time, it was noted that the Veteran underwent bilateral bunionectomy in March 1998; he subsequently experienced foot pain which improved postop but then similar pain returned intermittently, aggravated by prolonged walking and standing, with no swelling or redness.  There was no evidence of painful motion, swelling, tenderness, instability, weakness, or abnormal weight bearing.  No metatarsophalangeal joint (MTP) joint stiffness, swelling, redness or heat was noted.  His gait was slightly antalgic with cane, otherwise narrow and stable.  The pertinent diagnoses were status post bilateral bunionectomies, minimal degenerative joint disease (DJD) of the left first MTP joint, and bilateral pes planus.  

A DBQ examination for foot conditions was conducted in May 2017.  The Veteran reports pain in his left and right feet with prolonged standing, prolonged walking, and when the weather is cold.  He avoids wearing tight shoes.  The Veteran described the pain in his feet as throbbing.  He experiences flareups with prolonged standing and walking, as well with cold weather.  He can’t cut his grass anymore, and he can’t handle the grandchildren because they move too fast.  It was noted that the Veteran has pain in both feet on the use of the feet; the pain accentuated on use of both feet.  He did not have pain on manipulation of the feet, nor did he have swelling on use or characteristic callouses on the feet.  The Veteran did not have extreme tenderness of plantar surfaces on one or both feet; however, he did have decreased longitudinal arch height of both feet on weight bearing.  There was no objective evidence of marked deformity of one or both feet, and he did not have marked pronation of the feet.  The Veteran did not have inward bowing of the achilles tendon, nor did he have marked inward displacement and severe spasm of the achilles tendon.  The examiner noted mild or moderate symptoms of hallux valgus in both feet.  The Veteran reports a throbbing pain at his left and right foot with prolonged standing and prolonged walking.  There was no functional loss during flareups or when feet are used repeatedly over a period of time.  The examiner indicated that the Veteran uses a cane for his foot condition, a brace for his back condition, and a brace for his ankle condition, a brace for his hand condition.  Mild arthrosis in the left and right feet.  

The Veteran was afforded a DBQ examination of his feet in February 2018.  He reported constant aching and popping of great toe joints.  The Veteran also described sharp pain at the soles of his feet, worse during cold weather.  The Veteran stated that his symptoms are aggravated by walking or standing for longer than 10 minutes.  The Veteran has pain on use of the feet, the pain is accentuated on use of both feet.  The Veteran also has pain on manipulation of the feet.  The pain is accentuated on manipulation of both feet.  It was noted that there is indication of swelling on use of both feet.  He also has characteristic callouses on both feet.  It was noted that the Veteran uses arch supports for both feet but remained symptomatic.  He does not have extreme tenderness of plantar surfaces on one or both feet.  The Veteran has decreased longitudinal arch height of both feet on weight bearing.  There was no objective evidence of marked deformity of the feet.  No marked pronation of the feet.  The Veteran has alteration of the weight bearing line caused by bunions.  He had d bowing of the achilles tendon of both feet.  He had metatarsalgia on both feet.  He had mild or moderate hallux valgus on both feet.  He had bunionectomy, metatarsal osteotomy of the right foot in March 1998; he had bunionectomy on the left foot in August 1999.  He does not have any residual symptoms due to the surgeries.  The Veteran had pain on both feet that contributed to functional loss.  It was noted that he had pain on weight bearing, pain on non-weight bearing, disturbance of locomotion and interference with standing.  It was noted that the Veteran is unable to walk or stand for prolonged periods of time due to pain in both feet.  He uses a cane for ambulatory support for right hip and feet.  X-ray of the left foot revealed prior bunionectomy and mild arthrosis; x-ray of the right foot stable postoperative changes and mild arthrosis.  The Veteran can perform physical labor that precludes climbing or walking or standing for prolonged periods of time.  

In March 2019, a DBQ examiner noted that she reviewed DBQ foot examinations in May 2017 and February 2018, which did not reveal any neurological complaints and there were no neurological findings both examinations.  This was reiterated in an email from the examiner who conducted the May 2017 examination; she noted that there were no neurological findings associated with the Veteran’s service-connected bunionectomies of the foot.  The examiner stated that she also reviewed podiatry notes in the electronic record which showed a normal neurological examination of the feet.  

After careful review of the evidentiary record, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's bunions with valgus deformity of each foot.  The Board acknowledges the Veteran's reports of symptoms and that there was functional loss in that there was difficulty standing for longer than 15 minutes or walking. However, even considering the Veteran's lay reports of symptoms and functional loss, the degree of limitation would not result in symptoms more nearly approximating moderately severe foot injuries.  

The Board has considered whether a higher or separate rating is warranted under other diagnostic codes. The Veteran has not alleged, and the record does not show, weak foot, hallux rigidus, acquired pes cavus or malunion or nonunion of tarsal or metatarsal bones. Therefore, a higher or separate rating under Diagnostic Codes 5277, 5281, 5278 or 5283 is not warranted. Although the clinical evidence shows that the Veteran also suffers from pes planus, plantar fasciitis and Morton’s neuroma, the March 2020 VA examiner noted that the Veteran's service connected bunions do not cause pes planus, plantar fasciitis or Morton's neuroma as they are common problems but unrelated. A higher or separate rating under diagnostic codes 5276 or 5279 is not warranted. Finally, the March 2020 VA examiner found that the Veteran’s third, fourth and little toes were hammertoes on both the right and left feet.  However, a separate or higher rating under Diagnostic Code 5282 requires that all toes of one foot must be hammertoes. Therefore, a higher or separate rating is not warranted.

The Board acknowledges the Veteran's statement that his left and right feet are more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for a higher rating have been met. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for his feet. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment.

The Board has considered whether a staged rating under is warranted, however, the Board finds that his right and left foot symptomatology has been stable throughout the period on appeal.  Therefore, assigning a staged rating is not warranted.  Hart v. Mansfield, supra. Further, 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, supra.

Accordingly, the Board finds that a preponderance of the evidence is against the assignment of a rating in excess of 10 percent for right or left foot bunions. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra.

7.   Entitlement to a rating in excess of 20 percent for bony prominence of the right side of the pelvis with right leg stiffness and pain

The Veteran contends that he is entitled to a higher rating for his service connected bony prominence of the right side of the pelvis with right leg stiffness and pain. Specific argument in support of this appeal has not been submitted.

The Veteran’s right hip disability has been assigned a 20 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5252.  Under Diagnostic Code 5252, for limitation of flexion of the thigh, a 10 percent rating is warranted for flexion limited to 45 degrees.  A 20 percent rating is warranted for flexion limited to 30 degrees.  A 30 percent rating is warranted for flexion limited to 20 degrees.  A maximum 40 percent rating is warranted for flexion limited to 10 degrees.  38 C.F.R. § 4.71a, Diagnostic Code 5252.  

Limitation of extension of the thigh to 5 degrees warrants the assignment of a 10 percent evaluation under Diagnostic Code 5251.  

Under Diagnostic Code 5253, where there is limitation of rotation of the thigh, cannot toe-out more than 15 degrees; or there is limitation of abduction and cannot cross legs, a 10 percent evaluation is assigned.  Where there is limitation of abduction with motion lost beyond 10 degrees, a 20 percent rating is assigned.  

On the occasion of a VA examination in October 2010, the Veteran reported onset of right groin pain in service, with no associated trauma or injury; he stated that he was evaluated and given pain medications and rest.  The Veteran indicated that the pain has remained localized to the right groin area; he denied radiation into the right leg.  He underwent surgery for removal of a large exostosis of the right pelvis in 1992; he noted that groin pain resolved postop but has returned gradually and has become constant since 2005.  The Veteran reported pain and stiffness in the right hip; he denied any episodes of dislocation, locking or effusion.  The right hip problem causes difficulty with prolonged standing and walking.  On examination, it was noted that the Veteran’s gait was antalgic.  There were no abnormal findings of hip joint.  Range of motion of the right hip revealed a flexion to 114 degrees, extension to 21 degrees, and abduction to 28 degrees; he was able to cross his right leg over the left.  X-ray of the right hip revealed questionable exostosis arising from the right pubis; otherwise, normal examination.  The pertinent diagnosis was large exostosis of the right superior pubic ramus, recurrent.  

On the occasion of a DBQ examination in January 2014, the Veteran indicated that he currently has pain in the right pelvis when he lays on his right side and with sitting and prolonged standing; he reported increased pain in cold weather.  The Veteran did not report any flareups that impact the function of the right hip or thigh.  Range of motion of the right hip revealed a flexion to 115 degrees, with extension greater than 5 degrees.  Adduction was not limited such that the Veteran cannot cross his legs.  Rotation was not limited such that the Veteran cannot toe-out more than 15 degrees.  The Veteran was able to perform repetitive use testing with three repetitions.  There was no change in range of motion post-test.  After repetitive use testing, the Veteran had less movement than normal, pain on movement and disturbance of locomotion.  It was noted that the Veteran had pain on palpation of the right hip.  Muscle strength was 4/5 in the right hip.  No ankylosis was noted.  It was noted that, due to the arthroscopic surgery, the Veteran now had intermittent pain with movement of the hip joint or direct pressure on the right pelvic bone.  The Veteran stated that he uses a cane for his right hip condition.  

The Veteran was afforded another DBQ examination for evaluation of the right pelvis in February 2018.  The Veteran reported aching, popping and stiffness in the right pelvis; he stated that he currently experiences aching pain with stiffness of his right groin.  He also has popping sensation and sound when he moves his right leg or foot.  He noted that the bone appears prominent when lying down.  He stated that he is unable to twist or make sudden movements, lift, or walk or stand for prolonged periods of time.  Flares occur during cold weather, or from prolonged walking or standing.  Flexion in the right hip was to 50 degrees, extension to 20 degrees, abduction to 30 degrees, and adduction to 25 degrees.  Adduction was not limited such that the Veteran cannot cross his legs.  External rotation and internal rotation were 20 degrees.  The Veteran states he limits external and internal rotation for reasons unrelated to hip condition.  No pain was noted on examination.  There was no evidence of pain with weight bearing.  There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.  There was no objective evidence of crepitus.  The Veteran was able to perform repetitive use testing with at least three repetitions, and there was no additional loss of function or range of motion after three repetitions.  Functional loss caused by pain and lack of endurance.  He also has disturbance of locomotion and interference with standing.  Muscle strength testing was normal.  No muscle atrophy was noted.  No ankylosis was noted.  As a result of the surgery, he now has stiffness, aching and popping.  Regularly uses a cane for ambulatory support for right hip and feet.  The veteran can perform physical labor that precludes heavy lifting, climbing, prolonged standing, or walking long distances.  Passive range of motion could not be performed or was not medically appropriate for hip examination.  

On a more recent DBQ examination in March 2020, the Veteran indicated that he started experiencing pain in his feet about 6 months ago and the pain came up to his hip; he went to urgent care and got a shot and given a walker for 2 to 3 months.  The Veteran indicated that he is unable to cup his grass, sweep, or stand up long enough to fix his food; he is only able to stand for 10 to 15 minutes at most before his feet start hurting.  The Veteran reported that he is in constant pain and can’t lay on his right side to sleep; he can’t get up quickly from a chair.  Range of motion in the right hip revealed flexion to 45 degrees, extension to 20 degrees, abduction to 15 degrees, adduction to 20 degrees, external rotation to 45 degrees, and internal rotation to 40 degrees.  Adduction was not limited such that the Veteran could not cross his legs.  Pain was noted on examination and caused functional loss.  There was objective evidence of localized tenderness and pain on palpation of the joint in the inguinal region.  There was evidence of pain with weight bearing.  The examiner noted that the Veteran was able to perform repetitive use testing with at least three repetitions.  After repetitive use testing, the right hip had flexion to 25 degrees, extension to 10 degrees, abduction to 10 degrees, adduction to 10 degrees, external rotation to 10 degrees, and internal rotation to 10 degrees.  It was noted that post-test adduction was limited such that the Veteran could not cross his legs.  The right hip disability resulted in difficulty standing and walking.  No ankylosis was noted.  The Veteran did not have malunion or nonunion of the femur, flail hip joint or leg length discrepancy.  The examiner indicated that the Veteran uses a cane and walker for his knee, feet and bony prominence of the right side of the pelvis with right leg stiffness and pain.  X-ray study of the right hip revealed mild osteoarthritis of the right hip with presumed old trauma for the right inferior pubic rami.  There was no objective evidence of pain on non-weight bearing.  The examiner noted that Veteran would have difficulty standing for longer than 15 minutes or walking and this would affect work requiring ambulation but not sedentary work.  

In light of the foregoing clinical findings, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for right hip disability based on limitation of the thigh.  The record reflects that the Veteran’s right hip disability manifests as pain, stiffness, and limitation of flexion to 25 degrees, limitation of adduction that prevented the crossing of his legs, noncompensable limitation of extension, noncompensable limitation of external rotation, and noncompensable limitation of abduction.  This is consistent with the criteria for the current 20 percent rating under Diagnostic Code 5252 for limitation of flexion to 30 degrees.  VA treatment records have also been reviewed, but do not show evidence that the Veteran's right hip disability more nearly approximates flexion limited to 20 degrees, the criteria for a higher rating under Diagnostic Code 5252.  

The Board acknowledges the Veteran’s lay reports of symptoms, including an inability to twist or make sudden movements, lift, or walk or stand for prolonged periods of time.  However, even considering this, the Veteran’s symptoms do not more nearly approximate limitation of extension to 5 degrees, limitation of flexion to 20 degrees, and/or require limitation of abduction to 10 degrees.  Thus, a rating in excess of the currently assigned 20 percent is not warranted.  The Board has also considered the other Diagnostic Codes pertaining to the hip and thigh.  Here, the record does not show hip flail joint, impairment of the femur, or ankylosis of the hip.  Thus, separate ratings under Diagnostic Code 5250, Diagnostic Code 5254, or Diagnostic Code 5255 are not warranted.  

The Board acknowledges the Veteran's statement that his right hip is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for a higher rating have been met. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for his right hip. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment.

The Board has considered whether a staged rating under is warranted, however, the Board finds that his right hip symptomatology has been stable throughout the period on appeal.  Therefore, assigning a staged rating is not warranted.  Hart v. Mansfield, supra. Further, 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, supra.

In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating higher than 20 percent for bony prominence of the right side of the pelvis with right leg stiffness and pain under Diagnostic Code 5252.  In denying the claim, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra.

8.   Entitlement to an initial rating in excess of 10 percent for a gastrointestinal condition prior to March 20, 2020 and in excess of 30 percent thereafter is denied.

The Veteran contends that a higher rating is warranted for his gastrointestinal condition.  He contends that after returning from the Gulf War, he experienced symptoms of constant abdominal distress.  

The Veteran's gastrointestinal condition has been rated under 38 C.F.R. § 4.114, Diagnostic Codes 7319, as 10 percent prior to March 20, 2020; and a 30 percent thereafter.  Diseases of the digestive system, particularly within the abdomen, which while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Thus, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System" do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14.  38 C.F.R. § 4.113.  

The Schedule of Ratings-Digestive System directs that ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other.  A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation.  38 C.F.R. § 4.114.  

Under Diagnostic Code 7319, a 10 percent rating is warranted for moderate irritable colon syndrome with frequent episodes of bowel disturbances with abdominal distress.  A maximum 30 percent rating is warranted for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation, with more or less constant abdominal distress.  38 C.F.R. § 4.114, Diagnostic Code 7319.  The words "mild," "moderate" and "severe" are not defined in the rating schedule, and the Board must evaluate all of the evidence to the end that its decisions are equitable and just.  See 38 C.F.R. § 4.6.  

The Veteran was afforded a VA examination in October 2010.  At that time, he indicated that he used to have recurrent abdominal pain and periodic diarrhea in 1990s, but these have improved over the years.  It was noted that the medical records show no documented complaint of diarrhea or need for its treatment at least since 2008.  It was also noted that the Veteran’s gastrointestinal symptoms have improved along with medical treatment for his reflux esophagitis and depression/anxiety.  The Veteran was described as a well-nourished, well developed male with normal color tone and in no acute distress.  The abdomen was soft, nontender, with no abnormal masses or hernia.  No hepatosplenomegaly was noted.  The examiner noted that EGD & colonoscopy with biopsies in October 2005 revealed mild distal esophagitis and internal hemorrhoid.  The diagnosis was IBS.  

The Veteran was afforded a DBQ examination for evaluation of intestinal conditions in January 2014.  It was noted that the Veteran was diagnosed with a bowel condition based upon subjective reports of diarrhea alternating with constipation.  The examiner noted that a colonoscopy in 2005 did not confirm IBS, and biopsies taken were negative for any pathology; and, the Veteran does not have a currently diagnosed bowel condition, nor is he receiving treatment for a bowel condition.  It was further noted that he was not required to take continuous medication for control of his intestinal condition.  The Veteran does not have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition.  The Veteran does not have malnutrition, serious complications or other general health effects attributable to the intestinal condition.  The pertinent diagnosis was irritable bowel syndrome.  The examiner reiterated that the Veteran does not have a currently diagnosed bowel condition, nor is he receiving treatment for a bowel condition.  

In May 2017, the Veteran also underwent a DBQ examination for intestinal conditions.  It was noted that the Veteran requires continuous medication for control of his intestinal condition; that includes Polyethylene Glycol for constipation, and Lactobacillus tablet.  The Veteran has a bowel movement three times a day which varies from formed to loose; he indicated that he sometimes has to strain to have a bowel movement.  The Veteran reported that after a bowel movement he experiences leakage of stool.  He also reported that he loses control of his bowels with passing of gas.  It was noted that the Veteran was diagnosed with irritable bowel syndrome in 2014, at which time he was referred for a colonoscopy and advised to increase fiber in his diet; he has been prescribed MiraLax, Benefiber, lactobacillus tablets and FODMP diet.  It was also noted that he is anemic.  The Veteran’s irritable bowel symptoms include constipation; and, it was determined that the Veteran’s anemia is due to his hemorrhoids and his IBS.  The examiner noted that the Veteran did not have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition.  He did not have malnutrition, serious complications or other general health effects attributable to the intestinal condition.  The examiner noted that the intestinal condition does not impact the Veteran’s ability to work.  

A DBQ examination for Intestinal conditions was conducted in February 2018.  At that time, the Veteran reported problems with diarrhea stools occur about two to three times per day, and episodes of constipation occur about two times per week.  He also reported problems with bloating and lower abdominal pain which is described as feeling he is too full and can't breathe.  He described episodes of nausea when he is experiencing bloating; he also reported episodes of vomiting accompanied by nausea when he is experiencing bloating.  It was noted that the Veteran experiences more or less constant abdominal distress.  He described episodes of abdominal pain, with a sense of abdominal fullness; he reported approximately seven or more attacks in the past 12 months.  No weight loss, no serious complications or other general health effects attributed to the gastrointestinal condition.  No tumors or neoplasms related to the gastrointestinal condition.  The examiner indicated that the Veteran can perform in an occupational capacity that allows time for rest breaks and access to bathroom facilities.  

On the occasion of a recent DBQ examination in March 2020, the Veteran indicated that he currently had problems with diarrhea, constipation, abdominal pain and bloating; he uses psyllium and polyethylene Glycol.  It was noted that he experiences diarrhea about three to four times a day every day; he noted that it is difficulty to have a bowel movement and, after five minutes, he experiences alternating diarrhea.  The Veteran also indicated that he experiences bloating after eating; it is hard to sit or lay down.  It was also noted that he had problems with nausea.  Another reported symptom was vomiting; he sometimes throws up a lot of food or water.  It was noted that the Veteran had frequent episodes of bowel disturbance with abdominal distress; he also reportedly had episodes of exacerbations and/or attacks of the intestinal condition, with abdominal distention, bloating and cramping, relieved with bowel movements.  The examiner indicated that frequent stooling and abdominal pain would affect him at work be it sedentary or physical occupations.  

After a review of all the evidence, lay and medical, the Board finds that a rating in excess of 10 percent, prior to March 20, 2020, is not warranted.  During the October 2010 examination, it was noted that the medical records showed no documented complaint of diarrhea or need for its treatment at least since 2008.  In January 2014, the examiner indicated that the Veteran does not have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition.  At the time of the DBQ examination in May 2017, the Veteran did not report any diarrhea; and, while it was noted that the Veteran experiences constipation, the examiner noted that the Veteran did not have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition.  On examination in February 2018, the Veteran reported problems with diarrhea stools occur about two to three times per day, and episodes of constipation occur about two times per week.  

Based on this evidence, the Veteran's gastrointestinal condition has not reflected a severity to warrant higher rating than 10 percent.  The Board finds a 30 percent rating is not warranted as the Veteran has not shown severe symptoms with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress.  While the Veteran reported that he experienced more or less constant abdominal distress; the medical evidence does not support a finding of severe symptoms with diarrhea and constant abdominal distress.  Therefore, a rating in excess of 10 percent is not warranted.  

Since March 20, 2020, the Veteran's service-connected irritable bowel syndrome has been assigned a disability rating of 30 percent under 38 C.F.R. § 4.114, Diagnostic Code 7319.  The Board notes that 30 percent is the highest scheduled rating for gastrointestinal condition and a rating higher than 30 percent is not permitted.  For the Veteran's gastrointestinal condition no other diagnostic codes apply, other than Diagnostic Code 7319.  

In summary, the Board finds that a higher rating for the Veteran's service-connected gastrointestinal condition prior to and after March 20, 2020 is not warranted.  

The Board acknowledges the Veteran's statement that his gastrointestinal condition is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for a higher rating have been met. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for his gastrointestinal condition. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment.

The Board has considered whether a staged rating under is warranted, however, the Board finds that his gastrointestinal symptomatology has been stable throughout the period on appeal.  Therefore, assigning a staged rating is not warranted.  Hart v. Mansfield, supra. Further, 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, supra.

In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating greater than a 10 percent rating prior to March 20, 2020 and in excess of 30 percent thereafter for his gastrointestinal condition. In denying the claim, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra.

9.   Entitlement to an initial rating in excess of 30 percent for PTSD prior to July 5, 2011 and in excess of 70 percent thereafter is denied.

The Veteran essentially contends that his PTSD is more disabling than reflected by the currently assigned ratings.  

The rating for the Veteran's PTSD is determined by application of 38 C.F.R. § 4.130, Diagnostic Code 9411.  Under that code, a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).  

A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships.  

A 70 percent rating requires occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); or the inability to establish and maintain effective relationships.  

A 100 percent rating requires total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for the names of close relatives, own occupation, or own name.  

When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission.  38 C.F.R. § 4.126(a).  The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination.  Id.  The rating agency shall also consider the extent of social impairment, but not assign an evaluation solely on the basis of social impairment.  38 C.F.R. § 4.126(b).  

The United States Court of Appeals for the Federal Circuit (Federal Circuit) has emphasized that the list of symptoms under a given rating is a non-exhaustive list, as indicated by the words "such as" that precede each list of symptoms.  Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013).  In Vazquez-Claudio, the Federal Circuit held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration.  Id. at 118.  Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating.  Id. at 116.  

Post service VA progress notes show that the Veteran received clinical attention and treatment for a psychiatric disorder, diagnosed as PTSD and depressive disorder.  In March 2006, it was noted that the Veteran was currently being treated for PTSD, chronic and depressive disorder not otherwise specified; he denied any worsening of depression and is able to sleep well most of the time.  The Veteran indicated that he continued to have nightmares and flashbacks; he denied any suicidal or homicidal ideas.  The pertinent diagnosis was PTSD, chronic and depressive disorder not otherwise specified.  During a group therapy session in April 2006, the Veteran talked about problems with anger and anger style.  A mental health note, dated in December 2008, reported that the Veteran had a diagnosis of PTSD, depression and dysthymia.  It was noted that depression and anxiety were under control on medication; he denied mood swings, irritability or thought disorder.  The Veteran denied suicidal ideation or homicidal ideation or intention to harm others.  

During a VA Persian Gulf examination in October 2010, it was noted that the most likely clinical explanation for the Veteran’s subjective complaints of sleep disturbance, loss of energy and fatigue, and sweating is a combination of factors including a long history of cocaine and alcohol abuse, depression, anxiety and PTSD.  It was noted that he has been treated for insomnia, nightmares and anxiety.  

On the occasion of a DBQ examination in February 2014, it was noted that the Veteran’s condition was manifested by depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, flattened affect, circumstantial speech, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene.  The examiner noted that the Veteran was fully oriented.  The Veteran's thought processes were grossly within normal limits; however, he reported distraction from intrusive memories of traumatic events as well as disturbing flashback experiences and disturbing dreams.  Thought content was grossly normal.  No delusions were reported or noted during the examination.  Judgment was fair, and insight was good.  Memory was grossly intact.  The Veteran reported passive thoughts of suicide but denies any past suicide attempts or current plan or intent for self-harm.  The examiner noted that the Veteran was generally able to maintain personal hygiene but reports having periods of intense depression when he does not attend to personal hygiene needs.  At the current interview, he was dressed appropriately but his clothes were mildly soiled and there was some body odor.  The examiner noted that the Veteran’s psychiatric disorder resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.  

The Veteran was afforded a DBQ examination in May 2017.  It was noted that the Veteran currently lives with his wife of 35 years, and they have three adult children.  The Veteran indicated that his children are doing well, though he and his wife have minimal contact with them, due to children’s busy schedules.  The Veteran denied any social life outside of his marriage; he denied any hobbies or past times.  The Veteran reported ongoing problems with depression and anxiety.  He endorsed continued sleep problems, including nightmares 3 to 4 times per week, despite taking medications for sleep.  The examiner indicated that the Veteran’s disorder is manifested by depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting.  On examination, the Veteran was well groomed.  He presented with appropriate eye contact; he was alert, and oriented times three.  Speech was normal, and he was cooperative during the exam.  No psychomotor agitation was noted.  The Veteran denied any delusional thinking.  He denied auditory or visual hallucinations.  The Veteran denied any current suicidal or homicidal ideation.  His thought process was logical.  His mood was depressed, with a restricted affect.  He presented with no apparent attention or memory difficulties.  Insight and judgment were adequate.  The Veteran did not endorse feelings of hopelessness about the present or future at this time.  The examiner noted that the Veteran denied history of suicide attempt, and no history of suicidal attempt found in records reviewed.  The examiner noted that the Veteran was diagnosed with PTSD, and major depressive disorder, recurrent, moderate.  The examiner stated that the diagnoses of PTSD and major depressive disorder are mutually aggravating and symptoms and degree of impairment in functioning cannot be delineated without resorting to mere speculation.  The examiner indicated that the Veteran’s PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.  

On the occasion of a recent DBQ examination in March 2020, the Veteran indicated that he has been receiving ongoing treatment with therapy and medication management for his symptoms; he is currently on sertraline, prazosin, Trazodone and buspirone.  He reported ongoing problems with chronic pain and depression.  The Veteran reported a better sleep pattern, somewhat improved nightmares and suicidal thinking.  Lately, he has been averaging 3 hours of sleep with trouble staying asleep; has ongoing problems with anxiety, trouble relaxing and restless feelings.  He notes having ongoing issues with depression, low motivation, worries about losing childhood home and decreased interests.  His depression is further exacerbated due to chronic pain.  He notes having occasional and passive suicidal ideation but denies active suicidal ideation, intent or plans.  He did not have inpatient psychiatric hospitalizations.  He denies manic symptoms or psychotic symptoms.  He denies active suicidal ideation/ homicidal ideation/intent or plans.  It was noted that the Veteran has been married for 37 years, he has one daughter and two sons; he reported having a better relationship with his wife and a fair relationship with his children.  His PTSD was currently manifested by depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and inability to establish and maintain effective relationships.  The pertinent diagnoses were PTSD and major depressive disorder.  The examiner indicated that the Veteran’s disabilities resulted in occupational and social impairment with reduced reliability and productivity.  

For the appeal period prior to July 5, 2011, the Board finds that the Veteran's PTSD symptoms most nearly approximated the 30 percent rating.  The specific symptoms associated with the Veteran's PTSD are considered by the 30 percent criteria.  Significantly, a VA treatment note dated in March 2006 indicated that the Veteran was currently being treated for PTSD, chronic and depressive disorder not otherwise specified; he denied any worsening of depression and is able to sleep well most of the time.  The Veteran indicated that he continued to have nightmares and flashbacks; he denied any suicidal or homicidal ideas.  A Persian Gulf examination in October 2010 noted that the Veteran had been treated for insomnia, nightmares and anxiety.  There is no indication of symptoms associated with a 50 percent rating during this period, to include panic attacks, impaired judgment, and impaired thinking.  Nor does the evidence show symptoms of like kind to those listed for higher ratings.  

Moreover, occupational and social impairment with deficiencies in most areas was not demonstrated. Impairment to mood was demonstrated as the Veteran reported depression and anxiety. The Veteran maintained a relationship with his wife and children; impairment to family relations was not demonstrated. Impairment to thinking was not demonstrated as hallucinations, delusions, paranoia, ideas of reference, flight of ideas or loose associations were not demonstrated. Judgment was consistently found to be good or intact. School was not attempted during the appeal period and the Veteran was not employed during the appeal period.  Therefore, a 70 percent rating is not warranted for the appeal period prior to July 5, 2011.

Moreover, the Board finds that the criteria for a 100 percent rating under the General Rating Formula are not met at any time during the appeal period. In this regard, the evidence does not show that the Veteran has total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In this regard, there was no evidence of perceptual disturbances such as hallucinations, mania or psychosis found on mental status examination. While the Veteran was noted to experience mild memory loss, there is no evidence or allegation that he experienced memory loss for names of close relatives, own occupation or his own name. The Veteran's thought processes were found to not be impaired while his thought content was not found to include delusions or hallucinations. Although the Veteran reported passive suicidal ideations, there is no evidence or allegation that he is a persistent danger of hurting himself or others. Moreover, the Veteran has consistently been found to have appropriate hygiene and appearance and he has not alleged being unable to maintain minimal personal hygiene. The Veteran maintained a long-term marriage, relationships with his children and attended church occasionally.  Thus, total social impairment was not demonstrated.  In addition, the Veteran did not work during the appeal period. Therefore, total social and occupational impairment has not been demonstrated.

The Board acknowledges the Veteran's statement that his PTSD is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for a higher rating have been met. The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for his PTSD. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment.

The Board has considered whether a staged rating under is warranted, however, the Board finds that his PTSD symptomatology has been stable throughout the period on appeal.  Therefore, assigning a staged rating is not warranted.  Hart v. Mansfield, supra. Further, 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, supra.

In conclusion, the Board finds that the preponderance of the evidence is against the claim for a rating higher than 30 percent prior to July 5, 2011 and 70 percent thereafter for PTSD.  In denying the claim, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra.

 

 

KRISTY L. ZADORA

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Suzie S. Gaston, Counsel

The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.