Citation Nr: 21075373 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 17-61 514 DATE: December 20, 2021 ORDER Entitlement to a rating in excess of 10 percent for a right ankle disability is denied. Entitlement to a rating in excess of 10 percent for a left ankle disability is denied. Entitlement to a rating in excess of 10 percent for a left shoulder disability prior to August 27, 2013 is denied, and a rating in excess of 20 percent since is denied. Entitlement to a rating in excess of 10 percent for a left thumb disability is denied. Entitlement to an initial rating of 60 percent for irritable bowel syndrome (IBS) with gastroesophageal reflux disease (GERD) is granted. REMANDED Entitlement to a rating in excess of 30 percent for renal cell carcinoma, status post left partial nephrectomy with hypertension prior to August 27, 2013, and entitlement to a rating in excess of 80 percent since is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to August 27, 2013 due to service-connected disabilities is remanded. Entitlement to an initial rating in excess of 10 percent for a scar, status post left partial nephrectomy is remanded. Entitlement to service connection for a left wrist disorder is remanded. Entitlement to special monthly compensation (SMC) is remanded. FINDINGS OF FACT 1. The Veteran's left ankle disability is manifested by decreased motion and pain, characterized by marked limitation of motion, but there is no evidence of ankylosis at any point during the appeal. 2. The Veteran's right ankle disability is manifested by decreased motion and pain, characterized by marked limitation of motion, but there is no evidence of ankylosis at any point during the appeal. 3. Prior to August 27, 2013, the Veteran's left shoulder disability has been manifested by x-ray evidence of arthritis and painful motion. 4. Since August 27, 2013, the Veteran's left shoulder disability has been manifested by limitation of motion when the arm can only be lifted to shoulder level, at worst. 5. The most probative evidence does not reflect that the Veteran's left thumb disability is manifested by ankylosis of the thumb (favorable or unfavorable), a gap between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, or x-ray evidence of arthritic involvement of two or more minor joint groups with occasional incapacitating exacerbations. 6. For the entire period on appeal, the Veteran's IBS with GERD has been manifested by a combination of symptoms productive of severe impairment of health. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for left ankle disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5271 (in effect prior to and since February 7, 2021). 2. The criteria for a disability rating in excess of 10 percent for a right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DC 5271 (in effect prior to and since February 7, 2021). 3. The criteria for a rating in excess of 10 percent for a left shoulder disability prior to August 27, 2013, and in excess of 20 percent since have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.27, 4.71a, DCs 5101-5201. 4. The criteria for entitlement to a rating in excess of 10 percent for a left thumb disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5010-5224. 5. The criteria for an initial rating of 60 percent for IBS with GERD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, DCs 7319-7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1978 to June 1998. In March 2020, the Veteran presented testimony before the undersigned Veterans Law Judge. A copy of the transcript has been associated with the claims file. This appeal was previously remanded by the Board in March 2021. The requested development has been completed and the appeal is once again before the Board. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Effective February 7, 2021, VA's Schedule, 38 C.F.R. Part 4, was amended with regard to rating musculoskeletal disorders. Fed. Reg. 76453 (November 30, 2020) (codified at 38 C.F.R. § 4.71a ). When a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. VAOPGCPREC 3-2000 ; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The revised musculoskeletal regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, February 7, 2021. Hence, VA has made clear that its 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. As the Veteran's claim was pending prior to February 7, 2021, the Board will consider entitlement under the prior regulations as well as the revised regulations beginning February 7, 2021, applying the most favorable criteria for the Veteran. Here, to the extent any diagnostic codes associated with the Veteran's disabilities were impacted as a result of these changes will be discussed below. Finally, in a June 2016 statement and again during his March 2020 Board hearing, the Veteran indicated that it was his belief that his arthritis has now progressed to gout. However, a July 2021 VA medical opinion noted that gout symptomatology is distinguishable from degenerative arthritis symptoms as gout causes a joint to become red, swollen, and painful. Conversely, arthritic pain is not related to redness and swelling. Therefore, the examiner concluded that there is no association between the service-connected degenerative arthritis disabilities and the Veteran's gout. 1. Right and left ankle disabilities The Veteran submitted his increased rating claim on December 9, 2002. See December 2002 Statement in Support of Claim. Therefore, the relevant temporal focus for this issue is from December 9, 2001. 38 C.F.R. § 3.400. Here, the Veteran is rated at 10 percent pursuant to DC (Diagnostic Code) 5010 prior to August 27, 2013. Since August 27, 2013, the 10 percent rating has been continued but the DC was changed to 5003-5271. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). As a preliminary matter, the Board finds that the assignation of DC 5003-5271 is the appropriate DC for the entire period on appeal given the Veteran's right and left ankle disabilities. In this respect, Diagnostic Code 5271 requires limitation of motion of the ankles. DC 5003 requires x-ray findings of the presence of arthritis resulting in painful motion and noncompensable motion, which warrants a separate 10 percent rating under DC 5003. Therefore, the Board finds that the appropriately characterized DC for this disability is 5003-5271 and will be discussed below. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. As noted, during the pendency of this appeal, VA amended the Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020), effective February 7, 2021. Under DC 5010 in effect prior to February 7, 2021, arthritis due to trauma which is substantiated by X-ray findings is rated under DC 5003 as degenerative arthritis. 38 C.F.R. § 4.71a , DC 5010. Degenerative arthritis established by X-ray findings is rated based on limitation of motion under the appropriate DCs for the specific joint(s) involved. When the limitation of motion is noncompensable under the appropriate DCs, a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a , DC 5003. In effect since February 7, 2021, DC 5010 for post-traumatic arthritis is rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. The amended DC 5003 pertains to degenerative arthritis, other than post-traumatic. Under Diagnostic Code 5271 for the period prior to February 7, 2021, for limited motion of ankle, moderate limited motion is rated 10 percent disabling and marked limited motion is rated 20 percent disabling, which is the maximum rating under the Diagnostic Code. 38 C.F.R. § 4.71a. Under Diagnostic Code 5271 (to be codified at 38 C.F.R. § 4.71a , Diagnostic Code 5271, February 7, 2021), for limited motion of the ankle, moderate limited motion (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) is rated 10 percent disabling and marked limited motion (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) is rated 20 percent disabling, which is the maximum rating under the Diagnostic Code. 38 C.F.R. § 4.71a. Furthermore, for Diagnostic Codes 5270, and 5272, 5274, there is no change in the diagnostic criteria under the new regulations. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020), effective February 7, 2021. Also included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate ankle disabilities based on other manifestations, including Diagnostic Code 5270 (ankylosis of the ankle), Diagnostic Code 5272 (ankylosis of the subastragalar or tarsal joint), Diagnostic Code 5273 (malunion of the os calcis or astragalus), and Diagnostic Code 5274 (astragalectomy). None of the above apply to the Veteran. Factual Analysis The evidence of record includes the findings of VA examinations dated in January 2003, February 2012, April 2014, and July 2021. Further, VA treatment records for the entire appeal period are also of record and note the Veteran's continuous complaints of pain associated with his ankle disabilities. However, there are no additional objective findings included in these treatment records different from the findings as noted in the examinations discussed in detail below. In January 2003, the Veteran was scheduled for a VA examination in connection with his claim for increased ratings. At the time of this examination, the Veteran was diagnosed with degenerative joint disease of the right and left ankles, confirmed by x-ray findings. The Veteran reported experiencing pain when on his feet all day, lasting a couple of hours. Range of motion testing revealed dorsiflexion to 20 degrees, bilaterally, and plantar flexion to 45 degrees, bilaterally. There was no evidence of edema, effusion, redness, heat, abnormal movement, or guarding movement. The Veteran's gait was noted to be normal with no unusual shoe wear pattern. The February 2012 VA Gulf War Examination report noted musculoskeletal complaints of the lower legs, but no objective findings were included. The Veteran's right and left ankle disabilities were next examined by VA in April 2014. The Veteran reported constant pain exacerbated by prolonged walking or standing greater than 20 to 30 minutes. He also stated his ankles are swollen by the end of the morning. The Veteran also requires inserts in his shoes. He denied experiencing flare-ups of his right and left ankles. Range of motion testing for the right and left ankles revealed plantar flexion to 35 degrees, dorsiflexion to 15 degrees, with pain at the endpoints. The Veteran was able to perform repetitive use testing with no additional loss in range of motion. However, pain and interference with sitting, standing, and weight-bearing for both ankles was noted. The Veteran was noted to have localized tenderness or pain on palpation, bilaterally. Regarding whether pain, weakness, fatigability, or incoordination significantly limited functional ability either during flare-ups or when the joint is used repeatedly over a period of time, the examiner stated was not possible to determine without resorting to mere speculation, because there is no conceptual or empirical basis for making such a determination without directly observing function under those conditions. The Veteran was most recently examined by VA in July 2021 to ascertain the severity of his right and left ankles disabilities. During this examination, the Veteran reported mild, achy pain. He reported flare-ups occurring monthly and lasting up to 24 hours, resulting in decreased mobility. He stated the flare-ups are precipitated by running and prolonged standing. As for functional loss, the Veteran reported difficulty with lifting. He denied experiencing any instability. Upon physical examination, range of motion testing revealed dorsiflexion to 20 degrees, and plantar flexion to 45 degrees, bilaterally. It was noted that passive range of motion was the same as active range of motion for both the right and left ankles. Further there was evidence of pain on weight-bearing causing functional loss in that he has difficult with walking and standing. There was no evidence of crepitus or localized tenderness or pain on palpation, bilaterally. The Veteran was able to perform repetitive use testing with no additional loss in range of motion. Further, while the Veteran was not being examined immediately after repeated use over time or during a flare-up, the examiner found that pain significantly limited functional ability and resulted in decreased plantar flexion to 30 degrees, and dorsiflexion to 10 degrees, bilaterally. There was no evidence of muscle atrophy, ankylosis, instability, or any other physical findings associated with the right of left ankle disabilities. Finally, it was noted the Veteran has also been diagnosed with gout. The VA examiner concluded that gout is an inflammatory condition related to precipitation of uric acid crystals in the affected joint causing pain, swelling and redness of the joint. The VA examiner then concluded that the diagnosed gout is not related to degenerative arthritis or other pathology. Further, the Veteran's subjective symptoms during his flare-ups are redness, swelling and pain in the ankles. Legal Analysis Having considered the medical and lay evidence of record in light of the pertinent legal authority, the Board finds that the evidence does not warrant the assignment of a rating in excess of 10 percent each for the right and left ankles pursuant to the regulations in effect prior to February 7, 2021 or thereafter under Diagnostic Code 5271 for moderate limitation of motion. Specifically, for the regulations in effect prior to February 7, 2021, the Veteran's right and left ankle disabilities were primarily characterized by pain, with range of motion testing revealing plantar flexion limited to, at most, 30 degrees and dorsiflexion limited to 10 degrees, bilaterally. See July 2021 VA Examination. The Board finds that, while the Veteran reported pain with standing, there is no evidence of muscle atrophy or instability. See January 2003, April 2014, and July 2021 VA Examinations. Therefore, his right and left ankle disabilities are best characterized by the 10 percent rating indicative of a moderate level of severity. Similarly, for the regulations in effect since February 7, 2021, the only objective evidence of record is the July 2021 VA examination that shows range of motion limited to, at worst, plantar flexion limited to 30 degrees, and dorsiflexion to 10 degrees, bilaterally. In order to warrant the next higher 20 percent rating, the Veteran's range of motion testing must reveal less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion, neither of which is shown at any point since February 7, 2021. The Board also notes that a Veteran may be entitled to a higher disability evaluation for a musculoskeletal disability than that supported by mechanical application of the rating schedule where there is evidence that his or her disability causes additional functional loss, such as the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination[,] and endurance, including as due to pain. 38 C.F.R. § 4.40 (2020); see Lyles v. Shulkin, 29 Vet. App. 107, 117 (2017). A higher disability evaluation may also be awarded where there is a reduction of a joint's normal excursion of movement in different planes, including changes in the joint's range of movement, strength, fatigability, or coordination. 38 C.F.R. § 4.45 (2020). However, the veteran's functional loss must result in limitation of motion sufficient to satisfy the next disability rating allowable for that particular disorder to be entitled to a higher disability rating under §§ 4.40 and 4.45. See Thompson v. McDonald, 815 F.3d 781, 785-86 (Fed. Cir. 2016). Here, that is not the case, where even with pain, on repetitive use over time, or during a flare-up, the Veteran's range of motion of both the right and left ankles was still limited to, at most, plantar flexion to 30 degrees and dorsiflexion limited to 10 degrees. See Correia v. McDonald, 28 Vet. App. 158 (2016); see also Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). The Board has considered whether the Veteran may be entitled to additional ratings under other Diagnostic Codes related to disabilities of the ankle. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. No examinations or medical evidence of record has shown his ankle joint is ankylosed, which is necessary for any rating in excess of 20 percent under DCs 5270-5274. The Veteran also has not been diagnosed with any of the requisite disabilities necessary for consideration under DCs 5272-5274, as noted above. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of his right and left ankle disabilities, to include the presence of pain and the resulting functional impairment. To that end, the Board acknowledges that the Veteran, in advancing this appeal, believes that his disabilities are more severe than the assigned disability ratings reflect. Moreover, the Board notes that the Veteran is competent to report observable symptoms such as pain. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In this case, however, the competent medical evidence offering detailed, specific, and specialized determinations pertinent to the rating criteria, namely, determinations as to the characteristics of his scarring are most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The medical evidence also largely contemplates the Veteran's descriptions of his symptoms, including his reports of pain. The lay testimony, to include his Board hearing testimony, has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. As the preponderance of the evidence is against the claim for a rating in excess of 10 percent for each the right and left ankle disabilities, the benefit-of-the-doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Left shoulder disability The Veteran submitted his increased rating claim on December 9, 2002. See December 2002 Statement in Support of Claim. Therefore, the relevant temporal focus for this issue is from December 9, 2001. 38 C.F.R. § 3.400. Here, the Veteran is rated at 10 percent pursuant to DC (Diagnostic Code) 5010 prior to August 27, 2013. Since August 27, 2013, he is in receipt of a 20 percent rating pursuant to DC 5010-5201. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. As noted, during the pendency of this appeal, VA amended the Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020), effective February 7, 2021. Prior to February 7, 2021, DC 5010 pertained to traumatic arthritis which was rated as degenerative arthritis under DC 5003. Pursuant to DC 5003, degenerative or traumatic arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a , DCs 5003, 5010. Beginning February 7, 2021, under DC 5010 provides that post-traumatic arthritis is rated under limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Prior to February 7, 2021, under DC 5201 (pertaining to limitation of motion of the arm), limitation of motion at shoulder level warrants a 20 percent rating for both the major and minor arms. With limitation of the arm midway between side and shoulder level, a 30 percent rating is warranted for the major arm and a 20 percent rating is warranted for the minor arm. With limitation of the arm to 25 degrees from the side a 40 percent rating is warranted for the major arm and a 30 percent rating is warranted for the minor arm. Beginning February 7, 2021, under DC 5201, limitation of motion at shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent for both the major and minor arms. With limitation of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) a 30 percent rating is warranted for the major arm and a 20 percent rating is warranted for the minor arm. With limitation of the arm to 25 degrees from the side a 40 percent rating is warranted for the major arm and a 30 percent rating is warranted for the minor arm. For VA purposes, normal range of shoulder motion is: forward elevation (flexion) 0 to 180 degrees; shoulder abduction 0 to 180 degrees; internal rotation 0 to 90 degrees; and external rotation 0 to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. See 38 C.F.R. § 4.71, Plate I. Evidence relevant to the current level of severity of the Veteran's left shoulder disability includes VA shoulder examinations dated in January 2003, February 2012, April 2014, and July 2021. Further, VA treatment records for the entire appeal period are also of record and note the Veteran's continuous complaints of pain associated with his left shoulder. However, there are no additional objective findings included in these treatment records different from the findings as noted in the examinations discussed in detail below. During the January 2003 VA examination, the Veteran reported pain in his left arm with any range of motion movement or lifting. He stated that he noticed pain during cold weather or weather changes, and usually hurts a couple of times a week during the winter, and a couple of times a month during the summer, lasting 2 to 3 days each time. Range of motion testing revealed forward flexion to 180 degrees, abduction to 110 degrees, and external and internal rotation to 90 degrees. Pain was noted at 110 degrees abduction. There was no evidence of edema, redness, heat, abnormal movement, or instability. Finally, the Veteran stated that his left shoulder will hurt after standing on his feet all day as a correctional officer. The February 2012 VA Gulf War Examination noted musculoskeletal complaints, but no objective findings were included. The April 2014 VA Examination noted the Veteran's dominate hand was his right hand, which makes the left extremity his minor extremity for rating purposes. Degenerative arthritis was confirmed by x-ray evidence. The Veteran denied flare-ups. Upon examination, flexion and abduction were noted to be to 170 degrees, with pain at the endpoint. Internal rotation was noted to be 65 degrees and external rotation was to 75 degrees, with pain at the endpoint. The Veteran was able to perform repetitive-use testing, with no additional limitation in range of motion. However, pain on movement was noted. There was also evidence of localized tenderness or pain on palpation. Muscle strength testing was normal, with no presence of ankylosis. There was also no indication of any rotator cuff conditions, instability, dislocation, or labral pathology. Tenderness over the acromioclavicular joint was noted. Cross body adduction was negative. As for whether pain, weakness, fatigability, or incoordination significantly limit functional ability either during flare-ups or when the joint is used repeatedly over a period of time, the examiner stated that not possible to determine without resorting to mere speculation, because there is no conceptual or empirical basis for making such a determination without directly observing function under these conditions. The Veteran was most recently examined by VA in July 2021. The Veteran reported experiencing flare ups during the cold months of the year, lasting up to 24 hours, characterized by decreased mobility and precipitated reaching and pulling. The Veteran noted his functional limitations were in yard work and household chores. Upon examination, flexion and abduction were noted to be to 140 degrees, and internal and extension rotation were to 90 degrees. Pain was noted at the endpoints for flexion and abduction. Passive range of motion findings were the same as active, also with evidence of pain causing functional loss in causing difficulty with reaching, pushing, pulling, and heavy lifting. The Veteran was able to perform repetitive-use testing, with flexion to 100 degrees, abduction to 130 degrees, and internal and external rotation to 90 degrees. Following repeated use over a period time and during flare-ups, flexion and abduction were found to be to 100 degrees, and external and internal rotation to 90 degrees. Pain on movement was noted. There was also no evidence of crepitus or localized tenderness or pain on palpation. Muscle strength testing was normal, with no presence of ankylosis. There was also no indication of any rotator cuff conditions, instability, dislocation, or labral pathology. Tenderness over the acromioclavicular joint was noted. Cross body adduction was negative. There were no other physical findings noted on examination. There are two periods of time at issue here: prior to August 27, 2013, when the Veteran's left shoulder disability was evaluated as 10 percent disabling pursuant to DC 5010; and beginning August 27, 2013 to the present, while the Veteran's left shoulder disability has been evaluated as 20 percent disabling pursuant to DC 5010-5201. The Board will consider the proper evaluation to be assigned for the entire period on appeal. As for the period of time prior to August 27, 2013, the Board finds that a disability rating greater than 10 percent is not warranted for the Veteran's left shoulder disability. Significantly, the Veteran's range of motion did not meet the criteria for a compensable rating under DC 5201 for the minor extremity (which, in this case, is 20 percent) as the Veteran had full range of motion for flexion (to 180 degrees), and decreased abduction to 110. See January 2003 VA Examination. As for the period of time beginning August 27, 2013, the Board finds that a disability rating greater than 20 percent is not warranted for the Veteran's left shoulder disability. Significantly, the Board notes that the higher 30 percent rating is warranted when motion is limited to 25 degrees from the side. Here, the Veteran's flexion and abduction were limited to, at most, 100 degrees. See July 2020 VA Examination. Further, there is no evidence that the Veteran has ankylosis of the scapulohumeral articulation to warrant a higher rating under DC 5200 (ankylosis of the scapulohumeral articulation). Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992). As above, the Veteran had some limitation of motion in his left shoulder during all four VA examinations. Finally, a higher rating under DC 5202 requires recurrent dislocation of the scapulohumeral joint. However, there was no indication of such in any of the above VA examination reports. Finally, there is also no evidence of impairment of the clavicle or scapula or nonunion without loss movement. Therefore, there is no basis for a higher schedular rating under DC 5203. The Board accepts that the Veteran has functional impairment, pain, and pain on motion and finds the Veteran's own reports of symptomatology to be credible. However, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for a higher rating. The more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned ratings for each shoulder are warranted and no more. DeLuca, 8 Vet. App. At 202. The Veteran reported experiencing flare-ups during the January 2003 and July 2021 examinations. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court stated that flare-ups must be considered in providing an estimate of additional functional loss based on range of motion. The 2021 examiner gave an estimate of additional loss during flare-ups or after repeated use over time, resulting in flexion and abduction limited to 100 degrees, at its worst. However, for both the period prior to and since August 27, 2013, neither the pain on motion experienced by the Veteran nor the limitation experienced during a flare-up warrants a higher rating since the impairment is still well in excess of the requirement for a 20 percent rating and a 30 percent rating, respectively. Correia, 28 Vet. App. at 158; Sharp, 29 Vet. App. at 32. In sum, the evidence of record reflects that the Veteran's symptomatology for the left shoulder disability warrants no more than the disability ratings assigned. The Board finds that no higher rating can be assigned pursuant to any other potentially applicable diagnostic code. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 C.F.R. § 5107 (b); Gilbert, 1 Vet. App. at 49. 3. Left thumb disability The Veteran submitted his increased rating claim on December 9, 2002. See December 2002 Statement in Support of Claim. Therefore, the relevant temporal focus for this issue is from December 9, 2001. 38 C.F.R. § 3.400. Here, the Veteran is rated at 10 percent pursuant to DC 5010-5224. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. As noted, during the pendency of this appeal, VA amended the Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020), effective February 7, 2021. In this case, DC 5224 has remained unchanged by the February 7, 2021 amendments. However, DC 5010 was affected by the regulation revisions. Under the amended DC 5010, post-traumatic arthritis is rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. DC 5003 was also affected by the February 7, 2021 amendments. The amended DC 5003 pertains to degenerative arthritis, other than post-traumatic. As the pre-February 7, 2021 rating criteria for DCs 5010 and 5003 are more favorable to the Veteran, the old rating criteria will be applied for the entire period on appeal. Under Diagnostic Code 5224, governing ankylosis of the thumb, favorable ankylosis of the thumb warrants a 10 percent disability rating; unfavorable ankylosis of the thumb warrants a 20 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5224. A note to these DC instructs to 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. Id. In classifying the severity of ankylosis of the thumb, the following rules are set forth in 38 C.F.R. § 4.71a: (1) Ankylosis of both the carpometacarpal and interphalangeal joints, with either joint in extension or in full flexion or with rotation or angulation of a bone, is to be rated as amputation at the metacarpophalangeal joint or through proximal phalanx; (2) Ankylosis of both the carpometacarpal and proximal interphalangeal joints, even though each is individually in favorable position, is to be rated as unfavorable ankylosis; (3) With only the carpometacarpal or interphalangeal joint of a thumb ankylosed, and there is a gap of more than 2 inches between the thumb pad and fingers, with the thumb attempting to oppose the fingers, is to be rated as unfavorable ankylosis; and (4) With only the carpometacarpal or interphalangeal joint of a thumb ankylosed, and there is a gap of 2 inches or less between the thumb pad and fingers, with the thumb attempting to oppose the fingers, is to be rated as favorable ankylosis. See 38 C.F.R. § 4.71a. Evidence relevant to the current level of severity of the Veteran's left thumb disability includes VA examinations dated in January 2003, February 2012, April 2014, and July 2021. Further, VA treatment records for the entire appeal period are also of record and note the Veteran's continuous complaints of pain associated with his left thumb. A private treatment record received in December 2014 also confirms the presence of arthritis in the Veteran's left thumb, a fact that is not in dispute. However, there are no additional objective findings included in these treatment records different from the findings as noted in the examinations discussed in detail below. The January 2003 VA examination noted the Veteran has arthritis of the left thumb. He reported that he has pain in his finger and thumb joints and all parts of his hand and thumb. The Veteran reported that cold weather makes the hand and thumb hurt. Upon physical examination, it was noted the tip of the thumb can approximate to the fingers, and the tip of the fingers can approximate the middle transverse fold of the palm. The Veteran has grasping strength on the left equal or the same against the right. The examiner also noted that the Veteran is able to grasp, push, and pull using his left hand as a unit. The February 2012 VA Gulf War Examination noted musculoskeletal complaints, but no objective findings were included. The April 2014 VA Examination noted the Veteran's report of pain and swelling of the left thumb, with normal range of motion and strength. The Veteran stated the pain was constant and he uses Tylenol. Upon examination, it was noted that the Veteran denied flare-ups, and there was no limitation of motion or evidence of painful motion of the thumb. The examiner found repetitive use testing was not available, but there was also no function loss or impairment. There was evidence of tenderness or pain to palpation. Muscle strength was normal and there was no evidence of ankylosis. No other objective physical findings were noted on examination. The Veteran was most recently examined in July 2021. The Veteran reported flare-ups resulting in difficulty griping and holding heavy objects. Upon examination, full range of motion was noted for all digits on the left hand with the same for passive and active motion. There was no evidence of a gap between the pad of the thumb and fingers, or between the finger and proximal transverse crease of the hand on maximal finger flexion. Further, there was no evidence of localized tenderness or pain on palpation. Pain was noted for the thumb on active and passive motion resulting in difficulty grasping. There is also no evidence of ankylosis or decreased muscle strength. No other objective physical findings were noted on examination. Considering this disability under DC 5224, a higher rating in excess of 10 percent is not warranted as there is simply no evidence of ankylosis of the thumb. See January 2003, February 2012, April 2014, and July 2021 VA Examinations. In fact, the Board observes that the record only shows x-ray evidence of arthritis throughout the appeal period that is productive of noncompensable, but painful, limitation of motion. Standing alone, this evidence suffices the criteria for a 10 percent evaluation for the Veteran's service-connected thumb disability throughout the pendency of the appeal. 38 C.F.R. § 4.71a , Diagnostic Codes 5003 and 5010 (2020). In light of above, the remaining question before the Board is whether the criteria for an even higher evaluation is warranted during any point during the pendency of the appeal. Unfortunately, the record does not reflect that the symptoms associated with the Veteran's service-connected thumb disability approximates, meets, or surpasses the criteria for higher evaluations. Particularly, there is no evidence, to include from the Veteran, that the Veteran's service-connected thumb disability is productive of (1) a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers (with the thumb attempting to oppose the fingers), (2) ankylosis of the thumb (favorable or unfavorable), (3) symptoms commensurate with amputation of the thumb, or (4) arthritic involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a , Diagnostic Codes, 5003, 5010, 5152, 5224, and 5228 (2020); see also January 2003, February 2012, April 2014, and July 2021 VA Examinations. A note following Diagnostic Code 5224 indicates that VA must 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. However, the Board finds that the evidence does not demonstrate limitation of motion of the other digits of the left hand. The Board has considered the effect of pain and weakness/ difficulty gripping when rating a service-connected disability on the basis of limitation of motion, pursuant to DeLuca. However, in this case, there is no indication that pain, due to disability of the left thumb, results in functional loss greater than the aforementioned rating currently assigned. 38 C.F.R. §§ 4.40, 4.45. There is no indication that the Veteran has functional loss that most closely approximates the next level of disability for the left thumb, i.e., resulting in additional disability in other digits of the left hand. Thus, the Board finds that the currently assigned 10 percent disability rating for the thumb already contemplates any functional impairment related to pain, weakness, fatigability, on limitation of motion and does not warrant a higher rating under DeLuca. For these reasons, the Board finds that a rating in excess of 10 percent for the Veteran's left thumb disability is not warranted. Finally, the Board notes that in assessing the severity of this disability, the Board has considered the Veteran's assertions regarding his symptoms, which he is certainly competent to provide. See Layno v. Brown, 6 Vet. App. 465 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings require medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of a higher ratings pursuant to the applicable criteria. The Board has considered the applicability of the benefit of the doubt doctrine in determining the claim before it. However, the preponderance of the evidence is against the Veteran's claim of entitlement to a higher disability rating. Thus, that doctrine is not applicable in the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 4.3 ; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 4. IBS with GERD The Veteran contends that he is entitled to an initial rating in excess of 30 percent for his IBS with GERD prior to July 13, 2021, and a rating in excess of 60 percent since. The Veteran's IBS with GERD has been rated pursuant to 38 C.F.R. § 4.114, Diagnostic Codes 7319-7346. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.2. Pursuant to Diagnostic Code 7319, for irritable colon syndrome, the highest rating of 30 percent is warranted for severe symptoms, described as diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, DC 7319. Pursuant to Diagnostic Code 7346, for hiatal hernia, a 30 percent evaluation is warranted for persistently recurring epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is warranted under DC 7346 for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114. Disability ratings assigned under Diagnostic Codes 7301 to 7329 (inclusive), 7331, 7342, and 7345 to 7348 (inclusive) will not be combined with each other. Instead, a single disability rating will be assigned under the diagnostic code which reflects the predominant disability picture with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Veteran underwent a VA examination in December 2010 for digestive issues in connection with his claim for service connection. At that time, he reported abdominal pain, diarrhea 2 to 3 times a month, bloating, and heartburn a few times a week. He stated he uses over the counter medications, such as Nexium and Maalox, and a stool softener. The examiner noted the Veteran's weight is stable. He was diagnosed with irritable bowel syndrome with alternating patterns of diarrhea and constipation, and GERD. In February 2012, the Veteran was scheduled for VA Gulf War Examination. Regarding his GERD, the Veteran was experiencing infrequent episodes of epigastric distress, pyrosis (heartburn), reflux, regurgitation, and sleep disturbances. It was noted these symptoms occurred 4 or more times a year, with a duration of less than 1 day. An esophagography was performed which showed the Veteran was able to swallow without difficulty, demonstrating an unremarkable esophagus. Concerning his IBS symptomatology, the VA examiner noted the Veteran requires continuous medication during times of diarrhea. He also suffers from alternating periods of diarrhea and constipation, abdominal distension, nausea, vomiting, and frequent episodes of bowel disturbances with abdominal distress, occurring more than 7 times in the last 12 months. There was no evidence of weight loss or malnutrition. The February 2012 VA examiner also noted diagnoses of gastric ulcer and duodenal ulcer. It was found the Veteran suffers from recurring episodes of severe symptoms 4 or more times a year, lasting 1 to 9 days. He has abdominal pain at least monthly, relieved by standard ulcer therapy. The examiner concluded the Veteran did not have incapacitating episodes. The Veteran was next examined by VA in April 2014. The examiner noted the Veteran requires continuous medication for control of his symptoms. The Veteran reported experiencing frequent bouts of diarrhea and constipation, abdominal distention, nausea, and vomiting. No other physical findings were noted. The Veteran was next examined by VA in July 2017. Concerning specifically his IBS symptomology, the examiner noted the Veteran requires continuous medication for control of his symptoms. The Veteran reported experiencing frequent bouts of alternating diarrhea and constipation, abdominal distention, nightly nausea, and vomiting two times a month. No other physical findings were noted. Concerning his GERD symptomatology, the examiner noted the Veteran requires continuous medication for control of his symptoms. The Veteran reported experiencing pyrosis, reflux, regurgitation, and substernal pain. He also noted sleep disturbance caused by esophageal reflux with an average duration of 1 day; nausea, with 4 or more episodes a year, lasting less than 1 day; and, vomiting, with 4 or more episodes a year, lasting less than 1 day. No other physical findings were noted. The Veteran was most recently examined by VA in July 2021. Concerning his IBS symptomology, the Veteran reported occasional abdominal distention, occasional nausea, and constipation. His episodes or attacks result in abdominal pain, sharp in nature, with contractions and nausea. These attacks occurred 7 or more times in the past 12 months. It was also noted he lost approximately 30 pounds due to the intestinal disability. No other physical findings were noted. Concerning his GERD symptomatology, the examiner noted the Veteran requires continuous medication for control of his symptoms. The Veteran reported experiencing infrequent episodes of epigastric distress, reflux, regurgitation, and substernal pain. He also noted weight loss and nausea, with 4 or more episodes a year, lasting less than 1 day. No other physical findings were noted. The Veteran is currently in receipt of the highest rating pursuant to DC 7319 for the symptomatology related to his IBS for the period prior to July 13, 2021, which is the 30 percent rating. Therefore, the inquiry is whether he is entitled to a rating in excess of 30 percent for that period and since, pursuant to DC 7346 on account of his GERD symptomatology. Here, the Board finds that a 60 percent rating is warranted for the entire period on appeal as the Veteran has consistently complained of pyrosis, reflux, regurgitation, and substernal pain. He also noted sleep disturbance caused by esophageal reflux with an average duration of 1 day; nausea, with 4 or more episodes a year, lasting less than 1 day; and, vomiting, with 4 or more episodes a year, lasting less than 1 day. See December 2010, February 2012, April 2014, July 2017, and July 2021 VA Examinations for IBS and GERD. In fact, the only additional symptom noted ion the July 2021 VA examinations for IBS and GERD was the Veteran's noted weight loss. However, the Board finds that the combination of his symptoms is productive As noted above, disability ratings assigned under Diagnostic Codes 7319 and 7346 will not be combined with each other; instead, a single disability rating will be assigned under the diagnostic code which reflects the predominant disability picture with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. As such, the Board finds that an elevation to 60 percent is warranted for the entire period on appeals, as the Veteran's GERD symptoms warranted a higher rating as did his IBS symptoms. Accordingly, the Board finds that the Veteran's GERD with IBS warrants a 60 percent rating since August 31, 2010. The appeal is granted. REASONS FOR REMAND 1. Renal cell carcinoma, status post left partial nephrectomy with hypertension The evidence reflects the Veteran's renal cell carcinoma is currently active. Specifically, a May 2021 private treatment record notes the Veteran has been told his cancer in the kidney has come back. Further, a June 2021 statement from the Veteran's treating oncologist notes the Veteran is currently receiving treatment for his kidney cancer. However, the evidence does not include a specific date that the Veteran was either diagnosed with active kidney cancer or began receiving treatment. Renal cancer is rated under Diagnostic Code 7258, which assigns a rating of 100 percent for malignant neoplasms of the genitourinary system. 38 C.F.R. § 4.115b. A Note after Diagnostic Code 7528 provides that, following the cessation of surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105 (e). Therefore, the Board finds the date of diagnosis of the reoccurrence is necessary prior to adjudication of the increased rating claim. Thus, a remand is required so the AOJ may obtain any evidence necessary to award the Veteran the 100 percent rating from the date of reoccurrence of his kidney cancer. 2. TDIU Prior to August 27, 2013 As was previously noted in the March 2021 remand, the Veteran has consistently maintained that he is unable to work due to his service-connected disabilities, thereby making his claim for entitlement TDIU part and parcel of the increased rating claims on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). As the issue of TDIU is inextricably intertwined with the increased rating claim being remanded, it must also be remanded. 3. Scar, Status Post Left Partial Nephrectomy, Left Wrist Disorder, and SMC Regarding the issues of entitlement to a rating in excess of 10 percent for a scar, status post left partial nephrectomy, entitlement to service connection for a left wrist disorder, and entitlement to SMC, the Veteran submitted a timely notice of disagreement in July 2003 with the March 2003 rating decision, but a statement of the case with respect to these issues has not been issued. As was noted in the prior March 2021 Board remand, the Agency of Original Jurisdiction (AOJ) must issue a statement of the case as to these issues. Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). As this was not done in accordance with the prior remand directives, another remand is warranted so that the RO may comply with the prior directives of the March 2021 remand. Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. Send the Veteran and his representative a statement of the case that addresses the issues of whether the Veteran is entitled to a rating in excess of 10 percent for a scar, status post left partial nephrectomy; entitlement to service connection for a left wrist disorder; and, entitlement to SMC. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. 2. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. (continued on the next page) YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Berry, 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.