Citation Nr: 21025938 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 14-37 193 DATE: April 29, 2021 ORDER Service connection for hemorrhoids is denied. Entitlement to a compensable rating for residuals of a service-connected left-hand injury prior to October 2, 2019 is denied. Entitlement to a rating in excess of 10 percent for residuals of the left-hand injury from October 2, 2019 and thereafter is denied. FINDINGS OF FACT 1. The Veteran’s hemorrhoids were not incurred in or aggravated during service. 2. Entitlement to a compensable rating for residuals of a service-connected left-hand injury prior to October 2, 2019 is denied because the October 2019 VA examination was the first to show objective pain on motion of multiple joints in the hand. 3. Entitlement to a rating in excess of 10 percent for residuals of the left-hand injury from October 2, 2019 and thereafter is denied due to the fact that the residuals of the left-hand injury more nearly approximate a 10 percent rating. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hemorrhoids have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107, 7104; 3811 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for entitlement to a compensable rating for residuals of a service-connected left-hand injury prior to October 2, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 §§ 4.40, 4.45, 4.59, 4.71a. 3. The criteria for entitlement to a rating in excess of 10 percent for residuals of the left-hand injury from October 2, 2019 and thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 §§ 4.40, 4.45, 4.59, 4.71a. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from November 1998 to November 2002. This matter originated from February 2012 and November 2014 rating decisions issued by the Department of Veterans Affair (VA) Regional Office (RO). The Veteran appealed the issues to the Board of Veterans’ Appeals (Board), and the issues were remanded in an April 2018 Board decision for further development and new VA examinations. Caffrey v. Brown, 6 Vet. App. 377 (1994); 38 C.F.R. § 3.327(a). The Board has now determined that the remand directives were fully satisfied, and is now ready to fully adjudicate the issues before it. In November 2017, the Veteran had a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the electronic claims file. 1. Entitlement to service connection for hemorrhoids The Veteran contends that he is entitled to service connection for his internal and external hemorrhoids. 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. §§ 1110, 1131. 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). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Veteran’s service treatment records (STRs) show diagnoses of internal and external hemorrhoids in-service. The Veteran was diagnosed with hemorrhoid inflammation in March 2000. The Veteran was again seen and treated for hemorrhoids in March 2001 after the Veteran noticed blood in his stool. In a November 2014 VA exam, the Veteran denied having current hemorrhoids but did report that he had a flare up six months ago that he treated with dietary changes and Preparation H. The examiner also conducted an examination and found no evidence of current hemorrhoids. At the November 2017 Board hearing the Veteran reported he still dealt with hemorrhoids but opted for self-treatment rather than any professional medical treatment. The April 2018 Board decision remanded the issue for another VA examination to be performed. In October 2019, the Veteran attended a new VA exam. However, the Veteran claimed no hemorrhoids were present and therefore no examination was necessary. Here, the Veteran had a clear diagnosis of hemorrhoids in-service. However, on both the November 2014 and October 2019 examinations, the Veteran claimed he had no current disability of hemorrhoids and that he had treated his hemorrhoids with dietary changes and Preparation H. In the absence of a current disability, the Veteran can not establish a direct service connection for his in-service disability. Even assuming a current diagnosis in light of the Veteran’s lay testimony that he continued to have hemorrhoids that he self-treated, the evidence does not reflect a nexus to service. The 2019 VA examiner concluded that he was unable to determine the cause of the rectal bleeding and advised that further testing would best be performed by gastroenterology. Another October 2019 examination of the intestine concluded that the service treatment records and military treatment records were silent for complaints, treatment, or diagnoses of ulcer, digestive or gastrointestinal condition. That examiner was unable to make a formal diagnosis due to lack of objective evidence confirming a diagnosis, testing or treatment. To the extent to which the Veteran attempts to link the current rectal bleeding to service, as a layperson, he is not competent to opine as to the etiology of rectal bleeding, as that medical question requires imaging studies and other complex diagnostic examinations. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions); see also Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (reiterating this axiom in a claim for rheumatic heart disease). In fact, testing such as flexible sigmoidsocopy, rigid anoscopy, rectal examination, and colonoscopy may be essential in evaluating and diagnosing rectal bleeding. See Merck Manual 91 and 165 (18th ed. 2006) (noting that flexible sigmoidoscopy and rigid anoscopy may be all that is required for symptoms of hemorrhoidal bleeding but other patients with hematochezia should have colonoscopy). In discussing hemorrhoids, the Merck Manual explains that while most hemorrhoids are seen on inspection of the anus and rectum, anoscopy is essential in evaluating painless or bleeding hemorrhoids. Id. at 165. It further notes that rectal bleeding should be attributed to hemorrhoids only after more serious conditions are excluded. Id.; 38 C.F.R. § 19.9 (a remand or referral to the AOJ is not necessary when supplementing the record with a recognized medical treatise). Accordingly, the totality of the record fails to reflect a nexus between the rectal bleeding during service and the current hemorrhoids. The Board has further considered the benefit of the doubt rule in this case, but as the preponderance of the evidence is against the claim, the evidence is not in equipoise, and there is no basis to apply it. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, service connection for hemorrhoids is denied. 2. Entitlement to a compensable rating for residuals of a service-connected left-hand injury prior to October 2, 2019 The Veteran also contends that he is due a rating in excess of 0 percent for his service-connected left-hand injury prior to October 2, 2019. The Veteran was first granted service connection for the left-hand injury in February 2012 with an effective date of September 14, 2010. Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be “staged.” Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran’s condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. The Veteran’s left hand condition was evaluated under Diagnostic Code 5010-5229. Diagnostic Code 5010 which determines a disability rating for arthritis due to trauma, substantiated by X-ray, defers to DC 5003, which rates disability based on limitation of motion under the appropriate diagnostic code. Diagnostic Code 5229 states that for limitation of motion of the index or long finger, a noncompensable rating is warranted when there is a gap of less than one inch between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension limited by no more than 30 degrees. A 10 percent rating is warranted when there is a gap of one inch 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. Under the limitation of thumb motion provisions of DC 5228, a noncompensable rating is warranted if there is 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 rating is warranted when there is a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers; and a 20 percent rating is warranted if 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. 38 C.F.R. § 4.71a , DC 5228. Under DC 5230 for the little finger, the little finger warrants a disability rating of 0% for having any limitation of motion. In fact, under DC 5227, unfavorable or favorable ankylosis of the little finger also warrants a noncompensable evaluation. In October 2011 the Veteran underwent a VA examination on the residuals of his left-hand injury. The examiner noted that there was no limitation of motion or objective pain on motion during the examination. The examiner only noted excessive fatigability and pain on movement of the left little finger. In the November 2017 hearing, the Veteran claimed that his hand has gotten worse as he noticed gripping had become more difficult, he was dropping things more consistently, he could not hold on to things for long periods of time, and the pain was now being felt in the top of his hand as well as his middle, ring, and little fingers. The April 2018 Board decision remanded the issue back to the RO to obtain another VA examination of the Veteran’s left-hand injury to see if there is objective pain on motion, weakness, excessive fatigability, and/or incoordination. In the October 2019 VA exam of the Veteran, limitation of motion was shown in all the fingers of the Veteran’s left hand. No gap was shown between the pad of thumb and the fingers and no gap was shown between the fingers and the proximal transverse crease of the hand on maximal finger flexion. In the October 2019 exam, the Veteran exhibited painful motion during the range of motion testing and therefore, he was granted a 10 percent rating. 38 C.F.R. § 4.59 provides for a minimum compensable rating for disabilities manifested by painful motion, even if the criteria for a compensable rating under the applicable diagnostic code are not met. In the 2011 VA examination, only the little finger was shown to have pain on movement and the little finger did not show any objective pain on motion during the range of motion testing. The October 2019 exam showed pain and limitation of motion on the middle, ring and little finger. Therefore, under 39 C.F.R. § 4.59, the Veteran was found to be rated at the minimum compensable rating of 10 percent due to the painful motion in his fingers on the range of motion testing performed in October 2019. For the period prior October 2019, there is no evidence in the file to support a minimum compensable rating. Specifically, the Veteran’s VA examinations during this period show normal range of motion for the fingers and no gaps between the pad of the thumb and the fingers or between the finger and the proximal transverse crease of the hand on maximal finger flexion. The absence of gaps is substantial, as a rating in excess of 0 percent is generally given when gaps between the pad of the thumb and fingers is noted, or when a gap between the fingers and the proximal transverse crease of the palm is noted. 38 C.F.R. § 4.71, Diagnostic Codes 5228, 5229, 5230. Even considering pain, the record does not reflect that pain resulted in functional impairment that more nearly approximated the requisite limitation of motion for a compensable rating. Therefore, under the rating criteria of diagnostic code 5229, a compensable rating is not available. 3. Entitlement to a rating in excess of 10 percent for residuals of the left-hand injury from October 2, 2019 and thereafter The Veteran contends that after the October 2019 examination, he is due a rating in excess of his current 10 percent rating. The Board finds no evidence on the record to support this contention. The October 2019 VA examination showed limited motion in all fingers of the left hand and reported pain on motion in the left hand. The examiner also noted that the imaging studies show no other abnormalities of the hand. There is no finding of degenerative arthritis on the x-ray images, and no diagnosis of posttraumatic arthritis to increase the Veteran’s rating. 38 C.F.R. § 471a, Diagnostic Codes 5003, 5010. Additionally, a higher evaluation of 20 percent is not warranted for limitation of motion of the index or long finger unless the evidence shows amputation of any finger with metacarpal resection, amputation of the index finger without metacarpal resection, amputation of the long and little fingers, or amputation of the long and ring fingers. Additionally, there is also no evidence of favorable or unfavorable ankylosis of any of the fingers, either alone, or combined with other fingers of the left hand. 38 C.F.R. § 4.71, Diagnostic Codes 5216, 5217, 5218, 5219, 5220, 5221, 5222, 5223. There is simply no evidence in the October 2019 VA examination, or evidence of the record after the October 2019 examination to support a rating in excess of 10 percent for the Veteran. The Veteran is at the maximum schedular rating under Diagnostic Code 5229. A higher 20 percent rating, necessitates a gap of more than two inches, or 5.1 centimeters, between the thumb pad and fingers, with the thumb attempting to oppose the fingers. No such finding has been made here, and as such, 20 percent ratings are not warranted. Significantly, a 10 percent evaluation is also the maximum evaluation for unfavorable or favorable ankylosis of the index or long finger. The evidence does not reflect any ankylosis and even factoring in the functional impairment from pain, the condition does not more nearly approximate ankylosis of the long finger. Likewise, as the Veteran still has his long finger and still has significant motion of the finger, albeit painful, it does not more nearly approximate a finding of amputation of the long finger with metacarpal resection required for a higher rating under Diagnostic Code 5154. (Continued on the next page)   Therefore, a rating in excess of 10 percent for the residuals of the left-hand injury is denied. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E.L. Aumiller, Associate 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.