Citation Nr: 21006316 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 16-22 035 DATE: February 3, 2021 ORDER Entitlement to an initial 20 percent rating for ankylosis, left thumb, with angulation of the joint, prior to October 7, 2020, is granted. Entitlement to an initial rating greater than 20 percent for ankylosis, left thumb, with angulation of the joint, from October 7, 2020, is denied. REMANDED The claim of entitlement to a separate rating for neurological residuals of a fractured first left metacarpal, left hand, is remanded. FINDINGS OF FACT 1. The Veteran is right-handed. 2. The Veteran’s left thumb disability was as severe prior to October 7, 2020 as it has been since that date, resulting in no actionable use of the joint. 3. The Veteran’s left thumb has not been amputated. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial 20 percent rating for ankylosis, left thumb, with angulation of the joint, prior to October 7, 2020, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.40, 4.45, 4.59, 4.71A, Diagnostic Codes (DCs) 5003, 5224, 5228. 2. The criteria for entitlement to an initial rating greater than 20 percent for ankylosis, left thumb, with angulation of the joint, from October 7, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.40, 4.45, 4.59, 4.71A, DCs 5003, 5224, 5228. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1950 to June 1954. His claims come before the Board of Veterans' Appeals (Board) on appeal of an April 2014 rating decision, in which the Agency of Original Jurisdiction (AOJ) granted the Veteran service connection for residuals of a fractured first left metacarpal, degenerative arthritis, left hand, and assigned that disability an initial 0 percent rating from September 30, 2009. In a March 17, 2020 rating decision, the AOJ increased the rating assigned that disability to 10 percent from February 12, 2020. In a March 31, 2020 rating decision, the AOJ increased the rating assigned that disability to 10 percent from September 30, 2009. In a November 2020 rating decision, the AOJ recharacterized the disability as ankylosis, left thumb, with angulation of the joint, and increased the rating assigned that disability to 20 percent from October 7, 2020. The Board remanded this case to the AOJ in January 2020 and June 2020. Entitlement to an initial rating greater than 10 percent for ankylosis, left thumb, with angulation of the joint, prior to October 7, 2020 Entitlement to an initial rating greater than 20 percent for ankylosis, left thumb, with angulation of the joint, from October 7, 2020 The AOJ initially rated the Veteran’s left thumb disability 10 percent disabling under 38 C.F.R. § 4.71a, DCs 5003 and 5228, based on limited motion secondary to arthritis. Most recently, the AOJ rated the left thumb disability 20 percent disabling under 38 C.F.R. § 4.71a, DC 5224, based on a deformity akin to ankylosis. The Veteran seeks higher initial ratings for his left thumb disability. He contends that this disability progressed over the years, first resulting in a lump and then enlarging and causing an angulation deformity. He claims the weakness, intermittent, dull, achy pain, occasional tingling, and reduced range of motion associated with this disability interferes with his ability to use his left thumb. He further claims that physical therapy and the use of a brace have been ineffective in improving his left thumb symptoms. He reportedly has difficulty gripping, opening bottles, lifting, holding objects and buttoning his shirts, has to hire a handyman for yard work and can no longer hunt, fish or shovel snow. He asserts that his disability is more appropriately rated under DC 5224 than DC 5228, based on ankylosis. The evidence supports this claim for the time period preceding October 7, 2020. For the time period beginning October 7, 2020, the preponderance of the evidence is against the assignment of an initial rating greater than 20 percent. The Veteran, who is right-handed, has x-ray evidence of arthritis in his left thumb. Under DC 5003, VA must rate such arthritis based on limitation of motion of the specific joint or joints involved, in this case, the thumb. 38 C.F.R. § 4.71a, DC 5003. DC 5228, which governs ratings of limitation of motion of the thumb, provides that a 10 percent rating is assignable when there is a gap of one to two inches (2.5 to 5.1 cm.) between the major or minor thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 20 percent rating, the maximum available under this DC, is assignable when there is a gap of more than two inches (5.1 cm.) between the major or minor thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71A, DC 5228. DC 5224 provides that a 10 percent rating is assignable for favorable ankylosis of the minor or major thumb. A 20 percent rating, the maximum available under this DC, is assignable for unfavorable ankylosis of the minor or major thumb. 38 C.F.R. § 4.71A, DC 5224. The adjudicator is also to consider whether an evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with the overall function of the hand. 38 C.F.R. § 4.71A, DC 5224, Note. Under DC 5152, which governs thumb amputations, a 20 percent rating is assignable when there is amputation at the major or minor distal joint or through the major or minor distal phalanx, or at the minor metacarpophalangeal joint or through the minor proximal phalanx. A 30 percent rating is assignable for amputation at the major metacarpophalangeal joint or through the major proximal phalanx, or with minor metacarpal resection. 38 C.F.R. § 4.71A, DC 5152. Here, the evidence is clear that the Veteran’s left thumb disability was as severe prior to October 7, 2020, the effective date of the 20 percent rating, as it has been since that date, resulting in no actionable use of the joint. The Veteran filed his claim for service connection for a left thumb disability in 2009, and since then, treatment providers and VA examiners have noted that the disability has progressed in deformity and severity of symptomatology. During treatment visits dated from 2015 to 2016, such providers described the Veteran’s left thumb deformity as severe and significant (stiff adduction contracture that is difficult to reduce with compensatory hyperextension of the metacarpophalangeal), causing tenderness, pain, swelling, severely limited range of motion, and progressively increasing weakness and decreasing grip strength, particularly over the past few years. They noted that the Veteran had used a thumb brace, but it caused discomfort and, due to its bulk and compressive nature, hindered functional use; he also had physical therapy but without improvement in strength. They discussed surgery, including a trapeziectomy, a ligament reconstruction and tendon interposition using the flexor carpi radialis, a metacarpophalangeal arthrodesis and possible adductor lengthening, but indicated that, due to the deformity’s severity, it was unclear whether it could be corrected surgically. During a December 2009 VA examination, a VA examiner described the Veteran’s left thumb disability as an angulation deformity at the metacarpophalangeal joint, noted some associated limitation of motion, but not ankylosis, indicated that the deformity mildly affected certain activities of daily living and significantly affected the Veteran’s usual occupation. During a subsequent VA examination, the examiner referred to this angulation in a manner that raised a question of whether angulation is akin to ankylosis. In March 2020, a VA examiner who initially answered this question unfavorably, changed his opinion. He indicated that, after further reviewing the Veteran’s claim, the angulation may be regarded as similar to ankylosis with respect to the severity of limitation to perform tasks. He explained that the Veteran’s deformity, which is inoperable, hinders him from gripping, holding or grabbing objects, dysfunction for which the Veteran compensates by using his other fingers to perform the tasks. The examiner concluded that, like ankylosis, the angulation results in no actionable use of the left thumb joint. Prior to October 7, 2020, including during treatment visits and December 2009 and February 2020 VA examinations, no medical professional specifically noted that the Veteran had left thumb ankylosis. However, as the angulation was evident since the Veteran filed his 2009 claim, and a VA examiner has found the angulation to be like ankylosis (resulting in no actionable use of the joint), the 20 percent rating is assignable for the left thumb disability prior to October 7, 2020, under DC 5224. As this case does not involve an amputation, a rating greater than 20 percent is not assignable under DC 5152. To the extent the Veteran’s left thumb disability results in limitation of motion or ankylosis of any other finger on his left hand or interferes with the overall function of such hand, that matter is addressed below, in the REMAND section of this decision. The criteria for entitlement to an initial 20 percent rating for ankylosis, left thumb, with angulation of the joint, prior to October 7, 2020, are met. The criteria for entitlement to an initial rating greater than 20 percent for ankylosis, left thumb, with angulation of the joint, from October 7, 2020, are not met. REASONS FOR REMAND Entitlement to a separate rating for neurological residuals of a fractured first left metacarpal, left hand During treatment visits from 2015 to 2016, the Veteran reported tingling in his left thumb and pain radiating from his thumb to his wrist. Given these complaints, which the ratings discussed above do not contemplate, a neurological examination is needed to determine whether a separate rating should be assigned for neurological involvement. This matter is REMANDED for the following action: 1. Afford the Veteran a VA neurology examination for the purpose of determining whether he has neurological residuals of his fractured first left metacarpal. The examiner should review all pertinent evidence of record, including treatment records dated from 2015 to 2016. The examiner should record the Veteran’s history of tingling in and radiating pain from his left thumb. After conducting any necessary testing and considering as competent the Veteran’s reports of lay-observable left thumb symptoms, the examiner should identify and describe the severity of any neurological residuals of the fractured first left metacarpal. The examiner should conduct range of motion testing of the four fingers on the Veteran’s left hand and indicate whether any such finger is limited in motion and/or ankylosed. The examiner should offer an opinion as to whether and to what extent the Veteran’s left thumb disability interferes with the overall function of his left hand. The examiner should provide rationale for all findings and opinions. 2. Adjudicate whether a separate rating is assignable for neurological involvement, limitation of motion or ankylosis of any finger on the left hand and/or overall dysfunction of the left hand. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. N. 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.