Citation Nr: 21025559 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 20-13 736 DATE: April 28, 2021 ORDER Entitlement to a rating in excess of 10 percent for left middle finger osteoarthritis with ankylosis is denied. Entitlement to a rating in excess of 20 percent for residuals of left index finger amputation is denied. Entitlement to a compensable rating of 10 percent for a residual surgical scar of left index finger amputation is granted. REMANDED Entitlement to service connection for a right-hand disability is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s left middle finger disability is manifested by osteoarthritis with ankylosis of the metacarpophalangeal and proximal interphalangeal joints, there is no evidence of that his middle finger disability resulted in limitation of motion of other fingers or interference of the overall function of the left hand. 2. The Veteran’s left index finger was amputated at the proximal diaphysis and is characterized by metacarpal resection. 3. The competent and probative evidence is at least in equipoise as to whether the Veteran’s residual surgical scar associated with left index finger amputation is painful. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for left middle finger osteoarthritis with ankylosis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5226. 2. The criteria for a rating in excess of 20 percent for residuals of left index finger amputation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5153. 3. The criteria for a compensable disability rating of 10 percent for a residual surgical scar associated with left index finger amputation have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118 Diagnostic Codes 7804, 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1955 to October 1957. In March 2021, the Veteran testified at a Board hearing before the undersigned. A transcript of the hearing is in the record. Increased Ratings Ratings for service-connected disabilities are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 (2009). The assignment of a particular diagnostic code to evaluate a disability is “completely dependent on the facts of a particular case.” See 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, the diagnosis, and demonstrated symptomatology. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. §§ 4.59; see Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). Moreover, when evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202 (1995); Burton, 25 Vet. App. at 5. The Court also held in Correia v. McDonald, 28 Vet. App. 158 (2016) that the final sentence of 38 C.F.R. §§ 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the “pain must affect some aspect of ‘the normal working movements of the body’ such as ‘excursion, strength, speed, coordination, and endurance,” as defined in 38 C.F.R. §§ 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while “pain may cause a functional loss, pain itself does not constitute a functional loss,” and, is therefore, not grounds for entitlement to a higher disability rating). 1. Entitlement to a rating in excess of 10 percent for left middle finger osteoarthritis with ankylosis 2. Entitlement to a rating in excess of 20 percent for residuals of left index finger amputation The Veteran seeks higher ratings for his left index infer and middle finger disabilities. The Board notes that the Veteran is right-handed. On VA examination in October 2017, the examiner noted diagnoses of left middle finger osteoarthritis and left index finger status post amputation. The Veteran endorsed flare ups of left hand symptoms with extended use of strain resulting in very limited use of the middle finger. Reportedly, the condition had worsened and the middle finger could not bend. There was no gap between the pad of the thumb and fingers. There was no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. There was no pain noted on examination. There was no localized tenderness to palpation of the soft tissues. There was no additional loss following repetitive use, repeated use over time, or during flare-ups. There were additional contributing factors including less movement than normal and deformity. Muscle strength was 4/5 on the left and 5/5 on the right. There was muscle atrophy of the middle finger with the normal right side of 6 cm. and the left side of 4 cm. There was no ankylosis of the thumb, index, ring or little fingers. There was ankylosis of the middle finger at the proximal interphalangeal (PIP) joint in full extension and there was angulation of the bone, but there was no rotation of the bone. There was no ankylosis of the middle finger at the metacarpophalangeal (MCP) joint. The functional loss was chronic associate of traumatic injury/amputation as the development of osteoarthritis. The Veteran did not use any assistive devices for his left hand. Due to his hand or finger condition, there was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Occupationally, the amputation affected the Veteran’s left hand dexterity with handgrip and manipulation of objects. He did not require assistive devices. On VA examination in January 2018, the Veteran endorsed flare ups of left hand symptoms with extended use of strain resulting in very limited use of the middle finger. Examination showed a 3cm gap between the pad of the thumb and fingers. There was no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. There was pain noted on examination affecting finger flexion, extension and opposition with thumb. There was localized tenderness to palpation of the soft tissues. The Veteran was unable to utilize remaining fingers and thumb for gripping objects due to the immobility of the long finger being in the way. The Veteran was unable to perform repetitive use testing due to immobility and ankylosis of the long finger. There were additional contributing factors including less movement than normal and deformity. Muscle strength was 2/5 on the left and 5/5 on the right. There was no muscle atrophy. There was no ankylosis of the thumb, index, ringer, or little fingers. There was ankylosis of the middle finger at the PIP and MCP joints in full extension and there was angulation of the bone with rotation of the bone. The examiner noted inability to utilize ring and little finger to check thumb to finger grip due to ankylosed middle finger. There was a scar on the left index finger at the site of amputation measuring 7cm, not painful or unstable. The Veteran did not use any assistive devices for his left hand. Due to his hand or finger condition, there was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Occupationally, the Veteran was unable to manipulate tools and to grasp objects with the left had due to the missing digit and the immobility of the remaining proximal digit, or to hold objects when utilization of both hands was required. Therefore, manual labor would be difficult as he was unable to manipulate tools or hold object with the left hand, and typing in a sedentary position would also be difficult. A VA examiner in January 2018, noted a linear scar on the left index finger at the site of amputation measuring 18cm by 0.5cm. It was not painful or unstable. The scar did not result in limitation of function and did not impact his ability to work. The Veteran is currently assigned a 10 percent evaluation for left middle finger osteoarthritis with ankylosis pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5226. 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. 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note (1) preceding Diagnostic Code 5216. The position of function of the hand is with the wrist dorsiflexed 20 to 30 degrees, the MCP and PIP 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 MCP joint has a range of zero to 90 degrees of flexion, the PIP joint has a range of zero to 100 degrees of flexion, and the distal (terminal) interphalangeal (DIP) joint has a range of zero to 70 or 80 degrees of flexion. Id. 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 disability is equally balanced between one level and the next higher level. Id. at Note (2). Under Diagnostic Code 5226, a 10 percent evaluation is assigned for favorable or unfavorable ankylosis of the long finger and is the maximum the schedular evaluation available under that diagnostic code. Nevertheless, a higher rating may be assigned if the Veteran’s service-connected middle finger disability results in limitation of motion of other digits of the same hand or interference with overall function of the hand. Under Diagnostic Code 5228 for limitation of motion of the thumb, a non-compensable evaluation is assigned for a gap of less than one inch (2.5 cm) between the thumb pad and the fingers with the thumb attempting to oppose the fingers. A 10 percent evaluation is assigned when the gap is one to two inches (2.5 to 5.1 cm); a 20 percent evaluation is assigned when the gap is more than two inches (5.1 cm). The same ratings apply for either hand. Under Diagnostic Code 5229, a maximum 10 percent rating is warranted with a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the fingers flexed to the extent possible, or; with extension limited by more than 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5229. Under Diagnostic Code 5230, a 0 percent disability evaluation is assigned for any limitation of motion of the ring or little finger of either hand. Loss of use of a hand is present when no effective function remains other than that which could be equally well served by an amputation stump at the site of election below elbow with use of a suitable prosthetic appliance. 38 C.F.R. § 3.350 (a)(2). Here, the Board finds that a rating higher than 10 percent is not warranted for any time period on appeal. This is the maximum schedular rating under the diagnostic code pursuant to which the Veteran’s left middle finger is rated, Diagnostic Code 5226. Moreover, a higher rating is not warranted under any other potentially applicable diagnostic codes. For example, limitation of motion of the long finger with a gap of one inch or more between the fingertip and the palm warrants a maximum 10 percent rating under Diagnostic Code 5229. However, as both Diagnostic Codes 5226 and 5229 contemplate limitation of motion, a separate rating under either of these Diagnostic Codes would violate the rule against pyramiding. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261 (1994). While higher ratings are warranted for ankylosis of multiple digits and limitation of motion of the thumb, other than the service-connected residuals of left index finger amputation, there is no evidence of limitation of the remaining digits in this case. Finally, there is no indication of interference with overall function of the hand to allow for assignment of an additional compensable rating. While the Veteran has reported problems with gripping objects in his left hand and muscle strength was reduced, the Veteran retained function of his left hand and the VA examiners indicated that due to the Veteran’s hand condition, there was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Although the evidence shows impaired dexterity of the left hand, such as difficulty manipulating tools and grasping objects, due to his left long finger disability, these functional limitations, including functional loss in the form of weakened movement, excess fatigability, incoordination or pain on examination, have already been used to support the 10 percent rating assigned above, thus, they cannot be used again. In other words, given that he is in receipt of the highest rating available based on loss of motion of the finger involved, further compensation is not available for these symptoms. 38 C.F.R. §§ 4.14, 4.40, 4.45. The Board has considered the Veteran’s statements regarding the difficulty he has with his left hand as well as his subjective symptoms, including pain, and stiffness. However, the Board concludes that the medical findings on objective examinations are of greater probative value than the lay allegations regarding the severity of the Veteran’s left finger disability. Thus, although considered, the Veteran’s own assertions are not considered more persuasive than the examination results and pertinent clinical findings of record which, as indicated, do not warrant any higher schedular rating for the disability under consideration. The January 2018 VA examiner noted findings of bone angulation and rotation associated with the ankylosis of the metacarpophalangeal and proximal interphalangeal joints. As such, consideration of a rating based on amputation without resection is warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5226, Note (3). Regardless, rating the Veteran’s long finger based on amputation without metacarpal resection would still only warrant a 10 percent rating under the relevant diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5154. Thus, a higher evaluation is not warranted under Diagnostic Code 5154. Diagnostic Code 5003 also authorizes a rating where, as here, there is x-ray evidence of arthritis. Under Diagnostic Code 5003, degenerative arthritis established by x-ray evidence of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, warrants a 20 percent rating. The Veteran’s osteoarthritis is limited to one minor joint group-his left middle finger. As such, the Veteran is not entitled to a rating in excess of 10 percent under Diagnostic Code 5003 for any portion of the period on appeal. Next, the Veteran is currently service connected for residuals of left index finger amputation, rated as 20 percent disabling. The Veteran is also claiming a separate compensable rating for a left index finger scar, nothwithstanding the amuputation evaluation. The 20 percent rating is assigned pursuant to 38 C.F.R. § 4.73, Diagnostic Code 5153. Under Diagnostic Code 5153, a 20 percent rating is warranted for amputation of the minor index finger with metacarpal resection, or of either index finger without metacarpal resection at the proximal interphalangeal joint or proximal thereto. A maximum rating of 30 percent is warranted for amputation of the major index finger with metacarpal resection. 38 C.F.R. § 4.71a, Diagnostic Code 5153. As the left hand is the Veteran’s non-dominant hand, the currently assigned 20 percent rating is the highest available schedular rating. Moreover, the governing regulations state that the single finger amputation ratings are the only applicable ratings for amputations of whole or part of single fingers. 38 C.F.R. § 4.71a, Diagnostic Codes 5152-56, Note. Although VA must generally consider “functional loss” of a musculoskeletal disability, the applicable Diagnostic Code rating criteria do not provide for a disability rating in excess of 10 percent for loss of range of motion. The Veteran is competent to describe his observable symptoms, including pain resulting in limitation of motion. Layno v. Brown, 6 Vet. App. 465 (1994). However, to the extent that his reported symptoms are inconsistent with the objective medical evidence of record, such statements are afforded less probative value, as the Veteran does not possess the medical or orthopedic expertise to assess the severity of a complex musculoskeletal or orthopedic condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The medical findings directly address the criteria under which the disabilities on appeal are evaluated. The Board accords the objective records greater weight than the Veteran’s subjective complaints. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Therefore, the claims for increased schedular or additional separate ratings for residuals of left index finger amputation and left middle finger osteoarthritis with ankylosis must be denied. In sum, the preponderance of the evidence weighs against the Veteran’s claim of entitlement to a disability rating higher than 20 percent for residuals of left index finger amputation. Additionally, the evidence does not support an evaluation higher than the currently assigned 10 percent for left middle finger osteoarthritis with ankylosis. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board now turns to whether referral for extraschedular consideration is necessary in this case. Consideration of an extraschedular rating requires a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, whether the schedular rating criteria adequately contemplate the veteran’s disability picture. See Yancy v. McDonald, 27 Vet. App. 484 (2016); Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances); Sowers v. McDonald, 27 Vet. App. 472, 478 (2016) (“[t]he rating schedule must be deemed inadequate before extraschedular consideration is warranted”). Second, if the schedular rating does not contemplate the veteran’s level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran’s disability picture exhibits other related factors such as marked interference with employment, social functioning, and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16; see also Doucette, 28 Vet. App. at 371 (requiring the Board to explain whether the rating criteria contemplates functional effects such as social isolation due to difficulties communicating). Third, if the first two Thun elements have been satisfied, refer the case to the Director of Compensation and Pension Service to determine whether an extraschedular rating is warranted. Thun, 22 Vet. App. at 116. A review of the relevant medical and lay evidence and application of the above laws and regulations demonstrates the Veteran is not entitled to extraschedular ratings. Regarding the first Thun element, a comparison of the Veteran’s symptoms, associated functional impairment, and testimony does not show that the rating criteria are inadequate to describe his disability picture. The schedular criteria contemplates the effects of pain, weakness and limited motion. See Doucette, 28 Vet. App. at 369-70. The Board recognizes the Veteran’s assertions regarding the impact of his left index finger amputation and left middle finger osteoarthritis with ankylosis on his daily life as noted above. Martinak v. Nicholson, 21 Vet. App. 447 (2007). The rating criteria for fingers contemplate the functional effects of stiffness, pain and limitation of motion which make it difficult to perform activities, such as holding or griping and manipulating tools. The Board finds there are no reported symptoms related to the service-connected finger disabilities which cannot be properly evaluated by the rating schedule. As the symptoms related to the fingers do not present an exceptional disability picture, extraschedular consideration is not warranted. The Board observes that the Veteran believes that, if he were still working his left index finger amputation, surgical scarring and left middle finger osteoarthritis with ankylosis would have adversely impacted his ability to work; however, throughout the duration of the appeal the Veteran has been retired. Most significantly, the preponderance of the evidence reflects that the Veteran’s left index finger amputation, surgical scarring and left middle finger osteoarthritis with ankylosis has not resulted in either marked interference with employment or frequent periods of hospitalization. In light of the above, the Board concludes that neither of the first two Thun elements are satisfied during the appeal period and thus, referral for an extraschedular rating is not warranted. Yancy v. McDonald, 27 Vet. App. 484, 494-95 (2016) (“If either [Thun] element is not met, then referral for extraschedular consideration is not appropriate”); Anderson v. Shinseki, 22 Vet. App. 423, 427 (2009) (noting that the Thun ”steps are, in fact, elements that must be established before an extraschedular rating can be awarded”). Accordingly, higher disability ratings than those currently assigned for a compensable disability rating for left index finger amputation and left middle finger osteoarthritis with ankylosis are not warranted on either a schedular or extraschedular basis. 3. Entitlement to a compensable rating for a residual surgical scar associated with left index finger amputation The left index finger scar is rated as noncompensable pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 7805. During the pendency of this appeal, the Schedule for Rating Disabilities that addresses 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7805, and 7806 was amended, and this went into effect on August 13, 2018. 83 Fed. Reg. 32592 (July 13, 2018). However, with both the former and new rating criteria, other scars and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 are rated under 38 C.F.R. § 4.118, Diagnostic Code 7805. Diagnostic Code 7805 under both the old and new rating criteria provides a rating for disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04. 38 C.F.R. § 4.118. The Board notes that Diagnostic Code 7800 pertains to disfigurement of the head, face, or neck, and thus is not for application here. The Board also acknowledges that the July 13, 2018 amendments to the Schedule for Rating Disabilities revised the portion of the schedule addressing deep scars under Diagnostic Code 7801 and superficial scars under Diagnostic Code 7802. 83 Fed. Reg. 32592 (July 13, 2018). In publishing this revised rule VA stated that the amendment applied to claims pending prior to the effective date, such that both the old and the new rating criteria would be considered and whatever criteria was more favorable to the Veteran would be applied. However, under both the old and the new regulations, Diagnostic Codes 7801 and 7802 are not applicable as they pertain to nonlinear scars and scars associated with underlying soft tissue damage, neither of which is reflected in the available medical evidence. Id. Finally, under Diagnostic Code 7804, scar(s), unstable or painful, warrant a rating of 10 percent for one or two scars that are unstable or painful; 20 percent for three or four scars that are unstable or painful; and a maximum rating of 30 percent for five or more scars that are unstable or painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this Diagnostic Code, when applicable. See 38 C.F.R. § 4.118, Diagnostic Code 7804. On VA examination in January 2018, the examiner noted a scar on the left index finger at the site of amputation measuring 7cm, not painful or unstable. A VA examiner in January 2018, noted a linear scar on the left index finger at the site of amputation measuring 18cm by 0.5cm. It was not painful or unstable. The scar did not result in limitation of function and did not impact his ability to work. VA examination reports throughout the appeal, noted that the scar was not painful or unstable, nor covering a total area greater than 39 square cm. See 38C.F.R. §4.118, Diagnostic Codes 7801, 7802, 7804. Additionally, there are indeed is no indication of any disabling effects not considered by Diagnostic Codes 7800, 7801, 7802, 7805 for the scar. The Veteran has not reported any such effects, and VA medical examinations do not indicate that there is any limitation of function resulting from it. Thus, a compensable rating pursuant to Diagnostic Code 7805 is also not warranted. See 38C.F.R. §4.118, Diagnostic Code 7805. At the Board hearing the Veteran reported vague complaints of pain associated with the scar. Although the VA examiners opined that the scar was not painful, the Veteran is competent to report that his scar is painful as this requires only personal knowledge that comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The competent and probative evidence is at least in equipoise as to whether the left finger scar is painful. Accordingly, a rating of 10 percent, but no higher, is warranted for one painful scar of the left index finger. See 38 C.F.R. § 4.118, Diagnostic Code 7804. A higher rating is not warranted under Diagnostic Code 7804 because the weight of the competent and probative evidence is against finding that the scar is unstable. Resolving all reasonable doubt in the Veteran’s favor, a rating of 10 percent for the scar of the left index finger is granted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND 1. Entitlement to service connection for a right-hand disability is remanded. The Veteran contends that he is entitled to service connection for a right-hand disability manifested by pain and limitation of motion. He asserted that his right-hand disability was secondary to overuse as a result of his service-connected left index finger and left middle finger disabilities. The VA treatment records and examination reports throughout the appeal fail to document a right-hand disability, and on VA examination in October 2017 and January 2018, he denied any right hand symptoms and no functional impairment or limitation of motion findings were reported. In support of his claim, the Veteran submitted a private medical treatment report dated March 2021. Examination revealed decreased range of motion of the right shoulder, pain noted to palpation over the humeral head and decreased hand grip. The clinician noted pain with decreased grip and strength in the right hand due to overuse secondary to deformity of the left hand. The Board notes while the Veteran’s right hand pain alone may not constitute a disability, such symptomatology may rise to a level of functional impairment that impacts earning capacity, which would then qualify right hand pain as a disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In this case, there is competent evidence of right hand pain and therefore the potential presence of a disability under Saunders. In light of Saunders and a plausible nexus to service or potential causation on a secondary basis, the Board finds that the “low threshold” requirement under McLendon v. Nicholson, 20 Vet. App. 79 (2006) is met, and the Veteran should be afforded VA examination, to include consideration of functional impairment in the absence of other diagnosis. 2. Entitlement to a TDIU is remanded. The Veteran asserts that he is entitled to a TDIU due to his service-connected left finger disorders, as well as the claimed right-hand disability. In support of his claim, he submitted an April 2019 private independent vocational assessment report that concluded that the Veteran’s chronic symptoms of left hand injury and resulting painful overuse of the right hand rendered the Veteran unable to obtain or maintain substantially gainful employment. The claim for entitlement to a TDIU is inextricably intertwined with the claim being remanded as the outcome of such could have bearing on whether the Veteran meets the criteria for a TDIU. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Therefore, the adjudication of such claim must be deferred pending the outcome of the Veteran’s service connection claim. The matters are REMANDED for the following action: 1. Obtain all relevant ongoing VA treatment records or any private records the VA does not have. If possible, the Veteran himself should submit any pertinent new evidence regarding the condition at issue in order to expedite the appeal. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any disability affecting the right upper extremity. Based on the review of the record and examination of the Veteran, the examiner should state a medical opinion as to the following: a. Identify any disability that has been present at any point during the period on appeal with respect to the right upper extremity. If no specific disability is identified upon examination, the examiner is reminded that pain alone can be considered a disability if there is associated functional loss. If the only identified disability is reported pain, the examiner is to identify and describe any and all functional loss associated with this reported pain. b. For any identified disability, opine as to whether it is at least as likely as not (i.e., whether there is a 50 percent or better probability) that any right upper extremity disability was caused or aggravated by his service connected left index finger and left middle finger disabilities, to include as due to overuse? (Continued on the next page)   The examiner is advised that the Veteran is competent to report symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. All opinions expressed must be accompanied by a complete rationale. John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Azizi, T. 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.