Citation Nr: 21005402 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 12-14 973 DATE: February 1, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. Entitlement to an initial rating in excess of 10 percent for residuals of fracture of middle finger left hand, postoperative, excision of tumor, is denied. FINDINGS OF FACT 1. A chronic psychiatric disorder, to include PTSD, was not manifest during active service, or within one year of service discharge; and, the preponderance of the evidence fails to establish that any current acquired psychiatric disorder is etiologically related to service. 2. The Veteran’s service-connected residuals of fracture of middle finger left hand, postoperative, excision of tumor, are manifested by no more than unfavorable ankylosis of that single digit. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1131, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 2. The criteria for entitlement to an initial rating in excess of 10 percent for residuals of fracture of middle finger left hand, postoperative, excision of tumor have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5226. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from June 1975 to July 1976. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision by the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA). In April 2015, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. The transcript is of record. The case was remanded for additional development in November 2014, December 2015, and July 2018. The Board notes that an April 2020 rating decision granted an increased 10 percent rating for the Veteran’s left middle finger disability, effective from the date of the claim (November 10, 2011). The issue remaining on appeal as to this matter has been accordingly revised. The April 2020 rating decision also established separate evaluations for a painful scar to the left middle finger, for a surgical scar to the left middle finger, and for left middle finger digital neuropathy, median nerve. The Veteran has expressed no disagreement with the assigned ratings or effective dates as to these matters and they have not been developed for appellate review. Additional VA records were added to the claims file after the RO last considered the appealed matters in a July 2020 supplemental statement of the case. Those records are either cumulative or not relevant to the appeals. There is no prejudice in proceeding with appellate review. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303(a). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The term “disability” for VA compensation purposes refers to the functional impairment of earning capacity rather than the underlying cause of the impairment and it is noted that pain alone may be a functional impairment. See Saunders v. Wilkie, 887 F.3d 1356, 1364-68 (Fed. Cir. 2018). VA regulations provide that service connection for PTSD requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). During the course of this appeal VA revised its regulations to reflect that mental disorder diagnoses are based upon the criteria provided in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association. 38 C.F.R. § 4.125(a). If a PTSD claim is based on in-service personal assault, evidence from sources other than a veteran’s service records may corroborate the veteran’s account of the stressor incident. 38 C.F.R. § 3.304(f)(5).   Certain chronic diseases, including psychoses, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Psychoses are qualifying chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). VA may favor one medical opinion over another, provided an adequate basis is provided. Owens v. Brown, 7 Vet. App. 429 (1995). In determining whether evidence submitted by a claimant is credible, VA may consider internal consistency, facial plausibility, and consistency with other evidence. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). A medical opinion based upon an inaccurate factual premise may be discounted entirely. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102. The Veteran contends that he has an acquired psychiatric disorder, to include PTSD, as a result of active service. He asserts has PTSD due to in-service stressors including having been assaulted by his sergeant and having been struck in the face with a shotgun when he went to assist a neighbor.   Service treatment records are negative for complaint, treatment, or diagnosis of an acquired psychiatric disorder, including PTSD. A March 1976 report shows that the Veteran sustained three small abrasions in his right cornea and a laceration to his eyebrow and nose apparently due to shattered glass fragments. His July 1976 separation examination revealed a normal clinical psychiatric evaluation. VA treatment records include a February 2008 report noting a PTSD screen was negative. A May 2008 psychiatric evaluation revealed normal mood and affect and noted he was oriented to person, place, and time. A January 2009 report noted he stated he had been laid off from work due to a positive urine screen but that he did not think his alcohol and past cocaine use were current problems. An initial psychiatric evaluation in May 2012 included diagnoses of cocaine dependence and alcohol and opiate overuse. Subsequent treatment records noted a history of PTSD and depression without opinion as to etiology. VA examination in June 2019 included diagnoses of other specified bipolar and related disorder and alcohol use disorder. It was noted the Veteran did not have a diagnosed traumatic brain disorder (TBI). The examiner found that it was less likely that PTSD was incurred in or caused by the alleged incident where his sergeant assaulted him or by the alleged incident where he was hit in the face with a shotgun in 1975. It was noted that the symptoms reported did not meet the criteria for a diagnosis of PTSD and that his clinical presentation was better explained by the diagnosis of other specified bipolar and related disorder and alcohol use disorder. The examiner noted that a July 1976 letter indicated the Veteran was separated because of poor attitude, lack of self-discipline, and inability to adapt socially or emotionally. He added that the Veteran was shown to have been counseled with no evidence of the reason for these encounters. A history of alcohol and illicit substances abuse was also shown, including a December 2012 report indicating diagnoses of alcohol dependence, cocaine dependence, substance-induced mood disorder, and ruled-out poor impulse control disorder. The examiner acknowledged the Veteran’s report that the onset of his polysubstance abuse occurred in service. However, he observed that there was no evidence of substance use treatment in service nor evidence supporting the onset of the diagnosed alcohol use disorder in service. The mental health symptoms reported by the Veteran, such as fluctuations in mood and behavior, as well as, periods of anger and irritability, were better explained by the diagnosis of other specified bipolar and related disorder. The examiner stated that it was well known that prolonged exposure to alcohol and illicit drugs causes changes in the brain neurochemistry within the reward system that led to compulsive drug seeking. This behavior affects the individual’s ability to remain sober and compliant with psychiatric and medical treatments. Drug abuse causes changes in the brain that can lead to bipolar related disorder. Based upon the Veteran’s military and medical records, the examiner found there was no evidence that support the etiology of the diagnosed conditions having occurred during service nor could the disorders be attributed to the reported stressors alleged to have occurred in service. Based upon the evidence of record, the Board finds that a chronic psychiatric disorder, to include PTSD, was not manifest during active service. There is likewise no evidence of a psychosis manifesting within one year of service. It is again noted that service treatment records are negative for complaints, treatment, or diagnosis of any psychiatric disorder, and that there is no documented post-service evidence of the same until many years thereafter. The preponderance of the evidence fails to establish that an acquired psychiatric disorder is etiologically related to service. The June 2019 VA opinions are found to be persuasive and to have been based upon adequate rationale. The examiner is shown to have reviewed the evidence of record and to have adequately considered the credible lay statements and reported symptom manifestation history of record. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). There is no competent opinion to the contrary. Consideration has been given to the medical reports of record indicating diagnoses of PTSD and other acquired psychiatric disorders. The Board finds, however, that those reports provided no information as to the basis for such diagnoses nor comments as to etiology. The Board finds such reports warrant a lesser degree of probative weight. Indeed, by contrast, the June 2019 VA opinion provided a comprehensive and detailed explanation for its findings. The June 2019 opinion also included testing that ruled out a diagnosis of PTSD with an explanation of why the record did not support a PTSD diagnosis. The records that list PTSD as a diagnosis do just that – list PTSD as a diagnosis. There are no findings that support that diagnosis. The Board acknowledges that the Veteran is competent to report observable symptoms, but there is no indication that he is competent to etiologically link any such symptoms to a diagnosis of an acquired psychiatric disorder. He is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise in evaluating such disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. Consideration has also been given to the Veteran’s personal assertions that he has an acquired psychiatric disorder, to include PTSD, as a result of service. However, while lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The disability at issue is not a matter that is readily amenable to lay diagnosis or probative comment regarding etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). 2. Entitlement to an initial rating in excess of 10 percent for residuals of fracture of middle finger left hand, postoperative, excision of tumor. Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. This Rating Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran’s disability claim may require re-ratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). VA regulations under 38 C.F.R. § 4.71 a provide evaluations for ankylosis or limitation of motion of single or multiple digits of the hand. It is noted that: (1) for the index, long, ring, and little fingers (digits II, III, IV, and V), zero degrees of flexion represents the fingers fully extended, making a straight line with the rest of the hand. The position of function of the hand is with the wrist dorsiflexed 20 to 30 degrees, the metacarpophalangeal and proximal interphalangeal joints flexed to 30 degrees, and the thumb (digit I) abducted and rotated so that the thumb pad faces the finger pads. Only joints in these positions are considered to be in favorable position. For digits II through V, the metacarpophalangeal joint has a range of zero to 90 degrees of flexion, the proximal interphalangeal joint has a range of zero to 100 degrees of flexion, and the distal (terminal) interphalangeal joint has a range of zero to 70 or 80 degrees of flexion; (2) when two or more digits of the same hand are affected by any combination of amputation, ankylosis, or limitation of motion that is not otherwise specified in the rating schedule, the evaluation level assigned will be that which best represents the overall disability (i.e., amputation, unfavorable or favorable ankylosis, or limitation of motion), assigning the higher level of evaluation when the level of disability is equally balanced between one level and the next higher level; (3) evaluation of ankylosis of the index, long, ring, and little fingers:(i) if both the metacarpophalangeal and proximal interphalangeal joints of a digit are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone, evaluate as amputation without metacarpal resection, at proximal interphalangeal joint or proximal thereto, (ii) if both the metacarpophalangeal and proximal interphalangeal joints of a digit are ankylosed, evaluate as unfavorable ankylosis, even if each joint is individually fixed in a favorable position, and (iii) if only the metacarpophalangeal or proximal interphalangeal joint is ankylosed, and there is a gap of more than two inches (5.1 cm.) between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible, evaluate as unfavorable ankylosis(iv) If only the metacarpophalangeal or proximal interphalangeal joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible, evaluate as favorable ankylosis; (4) evaluation of ankylosis of the thumb: (i) if both the carpometacarpal and interphalangeal joints are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone, evaluate as amputation at metacarpophalangeal joint or through proximal phalanx, (ii) if both the carpometacarpal and interphalangeal joints are ankylosed, evaluate as unfavorable ankylosis, even if each joint is individually fixed in a favorable position, (iii) if only the carpometacarpal or interphalangeal joint is ankylosed, and there is 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, evaluate as unfavorable ankylosis, and (iv) if only the carpometacarpal or interphalangeal joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, evaluate as favorable ankylosis; and (5) if there is limitation of motion of two or more digits, evaluate each digit separately and combine the evaluations. A zero percent (noncompensable) rating is provided for ankylosis of the long finger which is either favorable or unfavorable. 38 C.F.R. § 4.71a, Diagnostic Code 5226. It is noted that 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 must be considered. A zero percent (noncompensable) rating is provided for limitation of motion of the index or long fingers with a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. A 10 percent rating is assigned with a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5229. For amputation of the long finger a 10 percent rating is assigned without metacarpal resection, at proximal interphalangeal joint or proximal thereto, and a 20 percent rating with metacarpal resection (more than one-half the bone lost). 38 C.F.R. § 4.71a, Diagnostic Codes 5154. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. However, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. The Veteran contends, in essence, that a higher rating is warranted for his service-connected residuals of fracture of middle finger left hand, postoperative, excision of tumor. Service treatment records include a January 1976 report noting he had a tumor removed from his left middle finger and that an X-ray study revealed some irregularity about the proximal interphalangeal joint involving the proximal and middle phalanges that was probably post-surgical in nature. His original service connection claim was received on November 10, 2011.   VA examination in December 2011 included a diagnosis of residuals of tumor excision left long finger. The examiner noted the Veteran reported increasing pain and stiffness in the finger. It was noted that no flare-ups impacting the function of the hand were reported. There was limitation of motion or painful motion to the left thumb and long finger. There was no limitation of extension and no ankylosis of the thumb or fingers. There was no functional impairment such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. VA examination in June 2019 included a diagnosis of residual fracture left middle finger postoperative tumor excision. It was noted the Veteran reported current symptoms of his finger staying in a certain position when he used his cane and that he had shooting pain in the finger if he grabbed things incorrectly. He described having moderate flare-ups two to three times per day that lasted from 15 to 20 minutes and that were precipitated by banging the finger while trying to grasp things. The examiner noted that range of left finger motion was abnormal or outside the normal range. Range of motion studies revealed limited long finger flexion without limitation of motion to the other digits of the left hand. There was a five-centimeter gap between the long finger and the proximal transverse crease of the hand on maximal finger extension. There was no evidence of pain on motion, but there was objective evidence of moderately severe localized tenderness or pain on palpation radial along the scar. There was additional functional loss or range of motion of the left long finger after repetitive use and with flare-ups. There were additional contributing factors of disability including less movement than normal due to ankylosis, adhesions, etc. It was noted that the finger and scar interfered with grasping things and that he had pain, limitation of motion, and decreased sensation. There was ankylosis to the left long finger, in extension, without ankylosis to the thumb or other fingers of the left hand. There were no other pertinent physical findings, complications, conditions, signs or symptoms related to the diagnosed condition. The examiner also noted that the Veteran had decreased use of the finger in terms of grip and grasping which would be analogous to a partial amputation.   Based upon the evidence of record, the Board finds the Veteran’s service-connected residuals of fracture of middle finger left hand, postoperative, excision of tumor, are manifested by no more than unfavorable ankylosis of that single digit. It is noted that the assigned 10 percent rating is the highest schedular rating available for individual long or middle finger limitation of motion or ankylosis, and that separate evaluations have been established for left long finger scars and nerve disability that are not in dispute. The June 2019 VA examination findings are persuasive that there are no other pertinent physical findings, complications, conditions, signs, or symptoms related to the service-connected disability at issue. The overall evidence further demonstrates that an additional evaluation is not warranted for any resulting limitation of motion of other digits nor for any interference with overall function of the hand attributable to this service-connected disability as opposed to other service-connected or nonservice-connected disabilities. It is noted that the June 2019 VA examiner found the Veteran had decreased use of the finger in terms of grip and grasping that would be analogous to a partial amputation. As such, a higher, alternative rating for a left long finger disability analogous to an amputation must be considered. The Board finds, however, that the evidence does not indicate a disability analogous to an amputation with metacarpal resection and more than one-half the bone lost as required for a higher rating under Diagnostic Code 5154. The term metacarpal resection under these criteria is construed as requiring involvement of the metacarpal bone rather than the phalanges of the middle finger. Upon comprehensive review of the overall findings of the June 2019 examination report, the examiner’s reference to an analogous partial amputation due to decrease use of the finger in terms of grip and grasping is found to be indicative of no more than an analogous phalangeal impairment. Therefore, a rating in excess of 10 percent is not warranted. The Board acknowledges that the Veteran is competent to report observable symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he is not competent to identify a specific level of disability. Competent evidence concerning the nature and extent of the Veteran’s service-connected disability, however, has been provided by VA medical professionals who have examined him. The June 2019 VA findings directly address the criteria under which the disability is evaluated, including whether a specific symptom caused a level of impairment required for a higher disability rating. The Board accords these medical findings greater weight than any subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The preponderance of the evidence in this case is against the claim for a higher rating. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Douglas 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.