Citation Nr: 21041408 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 14-24 604A DATE: July 9, 2021 ORDER Entitlement to a 10 percent rating, but no higher, for residuals, laceration injury, left middle finger is granted effective February 15, 2010. Entitlement to an evaluation in excess of 10 percent for painful scar, left middle finger, associated with residuals of laceration injury, on or after November 13, 2019, is denied. Entitlement to an evaluation in excess of 20 percent for radiculopathy of the left upper extremity associated with residuals, laceration injury, left middle finger, on or after November 13, 2019, is denied. REMANDED Entitlement to service connection for multiple pulmonary nodules, right upper outer lung, claimed as nodules in bilateral lungs is remanded. Entitlement to service connection for left foot tendonitis is remanded. FINDINGS OF FACT 1. Prior to November 13, 2019, and throughout the remainder of the period on appeal, he Veteran's residuals, laceration injury, left middle finger, manifested as pain in throughout the left middle finger with associated functional impairments, including difficulty writing, manipulating small objects, and lifting, pushing, or pulling objects weighing 50 pounds or more. 2. As of November 13, 2019, the Veteran's painful scar, left middle finger, associated with residuals of laceration injury manifested as a painful and unstable scar. 3. As of November 13, 2019, the Veteran's radiculopathy of the left upper extremity associated with residuals, laceration injury, left middle finger, manifested as mild, incomplete paralysis of the musculospiral (radial) nerve and included symptoms of paresthesias and/or dysesthesias (e.g., sensation of itching), numbness, and left hand weakness. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 10 percent rating, but no higher, for residuals, laceration injury, left middle finger have been met throughout the appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5229. 2. As of November 13, 2019, the criteria for entitlement to an evaluation in excess of 10 percent for painful scar, left middle finger, associated with residuals of laceration injury have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7804. 3. As of November 13, 2019, the criteria for entitlement to an evaluation in excess of 20 percent for radiculopathy of the left upper extremity associated with residuals, laceration injury, left middle finger have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8714. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 1977 to October 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the multiple rating decisions of the Indianapolis, Indiana Regional Office (RO). In January 2017, the Veteran testified during a hearing before a Veterans Law Judge (VLJ), who has since retired, at the Indianapolis RO. A transcript of the hearing is of record. Via a January 14, 2021 letter, the Board informed the Veteran that the VLJ who held his January 2017 Board hearing is no longer available to decide his case. The letter explained that his appeal would be reassigned to another VLJ for a decision and that he could request another, optional Board hearing. The letter informed him that, if he did not respond within 30 days to request an optional hearing, the Board would "assume that [he did] not want another hearing and proceed accordingly." More than 30 days have elapsed and the Veteran has not responded, so the Board will proceed to the merits without another hearing. In a February 2018 Board Decision, the above-referenced claims were remanded to the RO for further evidentiary development and readjudication. The RO has substantially complied with the Board's remand instructions with respect to the above-listed claims, so the Board may proceed to their merits. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance with remand orders, rather than absolute compliance). After obtaining the requested VA examination, the RO awarded a 20 percent rating for radiculopathy, left upper extremity, and a 10 percent rating for painful scar, left middle finger, both as secondary to the service-connected disability of residuals, laceration injury, left middle finger. See June 2020 Rating Decision (also denying a compensable rating for residuals, laceration injury, left middle finger now to include scar left index finger). The June 2020 Supplemental Statement of the Case (SSOC) only addressed the noncompensable rating for residuals, laceration injury, left middle finger now to include scar left index finger. Because the remanded claim was for an increased rating for service-connected residuals, laceration, left middle finger, the Board may exercise jurisdiction over the upper left radiculopathy and painful scar components of that service-connected disability. Chavis v. McDonough, No. 18-2928, 2021 U.S.App.Vet. Claims LEXIS 660 (Vet. App. Apr. 16, 2021) (holding that, because the Veteran's "radiculopathy was part of his claim seeking higher compensation for his lumbar spine disability, the Board did not err . . . by choosing to address the appropriate evaluation for the radiculopathy component of [the Veteran's] lumbar spine condition" even though service-connection had been separately awarded for the radiculopathy and the Veteran had not filed a notice of disagreement as to the rating assigned); see also Morgan v. Wilkie, 31 Vet. App. 162, 167 (2018) (holding the duty to maximize benefits requires consideration of symptoms and effects contemplated by diagnostic codes other than and in addition to the one originally assigned in order "to ensure a veteran is appropriately compensated before resorting to § 3.321(b)'s extraschedular provision"); Bailey v. Wilkie, 33 Vet. App. 188, (Jan. 6, 2021) (holding that, pursuant to 38 C.F.R. § 3.155(d)(2), "VA is required to develop and adjudicate related claims for secondary service connection for disabilities that are reasonably raised during the adjudication of a formally initiated claim for the proper evaluation level for the primary service-connected disability"). The Board exercises its discretion to exercise jurisdiction over the increased rating claims for the upper left radiculopathy and painful scar components of the service-connected disability "residuals, laceration injury, left middle finger." While the June 2020 SSOC did not address those components of the service-connected residuals, laceration injury, the rating decision contained an explanation of the reasons and bases for the ratings assigned, so the Veteran would not substantially benefit from remand for the mere formality of issuing an SSOC restating those reasons and bases. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) ("A veteran's interest may be better served by prompt resolution of his claims rather than by further remands to cure procedural errors that, at the end of the day, may be irrelevant to final resolution and may indeed merely delay resolution."); see also Herndon v. Principi, 311 F.3d 1121, 1124 (Fed. Cir. 2002) (holding statement of the case need not specifically list an issue to be adequate, particularly where the Board must liberally construe the arguments set forth in a veteran's appeal); Bernard v. Brown, 4 Vet. App. 384, 390-91 (1993) (holding that the Board has authority "to decide all questions presented on the record before it that were necessary to its decision on the matter"); Shinseki v. Sanders, 556 U.S. 396, 407-11 (2009) (applying harmless error analysis in context of veterans benefit law). The Veteran can only benefit from the Board's consideration of allowing an increase for all components for the service-connected residuals, laceration injury, and he will have additional procedural options to protect his interests (e.g., filing a Supplemental Claim) if the Board adjudicates the claims now, whereas his time for filing a notice of disagreement with the June 2020 rating decision has almost expired. Exercising jurisdiction is veteran-friendly. See Nat'l Org. of Veterans' Advocates, Inc. v. Sec'y of Veterans Affairs, 710 F.3d 1328, 1330 (Fed. Cir. 2013) (noting the uniquely pro-claimant principles underlying the veterans' benefits system); Evans v. Shinseki, 25 Vet. App. 7, 14 (2011) (stating that the VA system is "veteran-friendly" and "non-adversarial"). The Board will exercise jurisdiction over all aspects of the increased rating claim for the service-connected residuals, laceration injury and will address their merits below. While the Board is taking jurisdiction of all aspects of the claim of entitlement to an increased rating for the service-connected residuals of the laceration injury to the left middle finger (including the painful scar rating under DC 7804 and the radiculopathy under DC 8714), the issues have been analyzed below as follows: Entitlement to a compensable rating for the service-connected residuals of the laceration injury to the left middle finger for the entire appeal period, to include any separate, compensable rating(s) for a painful scar under DC 7804 or radiculopathy under DC 8714, for the period prior to November 13, 2019. Entitlement to a rating in excess of 10 percent under DC 7804 for the service-connected painful scar for the period beginning November 13, 2019. Entitlement to a rating in excess of 20 percent under DC 8714 for the service-connected radiculopathy of the left upper extremity for the period beginning November 13, 2019. In other words, the period prior to November 13, 2019, is addressed in the first section below and the Board has considered all potentially applicable diagnostic codes for that period. Increased Rating Disability evaluations are assigned to reflect levels of current disability. The appropriate rating is determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability 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. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. When there is a question as to which of two evaluations shall be applied, the higher evaluation 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. In evaluating claims for increased ratings, VA must evaluate the veteran's condition with a critical eye toward the lack of usefulness of the body or system in question. 38 C.F.R. § 4.10. VA has considered the level of the veteran's impairment throughout the entire period on appeal, including the propriety of staged ratings. O'Connell v. Nicholson, 21 Vet. App. 89 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The factors involved in evaluating and rating disabilities of the joints include weakness, fatigability, incoordination, restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45; see also 38 C.F.R. § 4.59. In assigning disability ratings, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also VA Gen. Coun. Prec. 92004 (Sep. 17, 2004) ("[T]he key consideration in determining whether rating under more than one diagnostic code is in order is whether the ratings under different diagnostic codes would be based on the same manifestation of disability or whether none of the symptomatology upon which the separate ratings would be based is duplicative or overlapping.").. 1. Entitlement to a compensable rating for residuals, laceration injury, left middle finger The Veteran contends that he is entitled to a higher rating because he has an associated painful scar as well as additional pain that "goes from the . . . middle joint just about down across to the bottom joint." See January 2017 Board Hearing Tr. at 3-4. The Veteran's residuals, laceration injury, left middle finger is rated noncompensable under 38 C.F.R. § 4.71a, Diagnostic Code 5226 and 38 C.F.R. § , Diagnostic Code 7804. During this appeal, the Veteran was awarded a separate 10 percent rating for painful scar, left middle finger, associated with residuals, laceration injury, left middle finger now to include scar left index finger and he was also awarded a 20 percent rating for radiculopathy of the left upper extremity associated with residuals, laceration injury, left middle finger, now to include scar left index finger. Therefore, the residuals consisting of a left middle finger scar and radiculopathy of the left upper extremity are not at issue on this particular claim, but will be each be discussed in the appropriate sections below. Under Diagnostic Code 5226, ankylosis of the long finger warrants a 10 percent rating where there is ankylosis, unfavorable or favorable. A note following DC 5226 provides that the rater should 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. Limitation of motion of the middle finger is rated under Diagnostic Code 5229. Under DC 5229, a 10 percent rating is warranted for 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. A noncompensable rating is warranted with a gap of less than one inch between the finger tip 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. The Board notes that 38 C.F.R. § 4.71a was amended effective February 7, 2021, but the rating criteria under DCs 5226 and 5229 did not change. Because the November 2019 VA examiner diagnosed a left hand strain, the Board has also considered the diagnostic codes related to muscle injuries of the hand. Under 38 C.F.R. § 4.73a, Diagnostic Codes 5307 and 5308 provide for noncompensable ratings for slight injuries to Muscle Groups VII or VIII, respectively. Under DCs 5307 and 5308, a 10 percent rating is warranted for moderate injury to Muscle Groups VII or VIII, respectively. A note after DC 5309 (Goup IX) provides that the hand is so compact a structure than isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc., so "rate on limitation of motion, minimum 10 percent." Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The August 2010 VA examination noted the history of the amputation of the index finger and laceration to the left middle finger. With respect to the middle finger, the Veteran reported pain that required over-the-counter pain medication up to four times per day, with good response. He reported decreased strength and coordination as well as occasional shooting pain in the stump of the left index finger 1-2 times a month and pain in the left middle finger 1-2 times daily. There were no flare-ups. Objective examination revealed full range of motion of the left middle finger, including after repetitive use testing, with no pain, fatigue, weakness, lack of endurance, or incoordination. The examiner indicated diminished strength (3/5) in the left hand with respect to pushing and pulling and a complete loss of the ability to twist with the left hand. He was unable to twist a cap from a bottle or remove a lid from jar with the left hand, had diminished probing, difficulty writing (he is left-hand dominant), but normal touching and expression. At the November 2019 VA examination, the examiner diagnosed residuals, laceration injury, left middle finger, left hand strain, radiculopathy of the left upper extremity, and left index finger amputation at the proximal interphalangeal joint. The examiner noted the Veteran's complaints regarding "low grade pain on the entire [middle] finger, pain as if a needle is poking in it several times a day[, an] itching sensation all the time[,] cracking in two places which will flare-up and start peeling away[, and] numbness." The Veteran reported left hand weakness, numbness, and pain especially with extended use. He reported difficulty writing (he is left-hand dominant) and manipulating small objects. The Veteran reported flare-ups of the left hand lasting for several hours. Physical examination revealed normal ranges of motion of all fingers on the left hand, but pain at rest as well as objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The examiner estimated that there would be additional limitation of motion of roughly 20 degrees at each of the joints of the long (middle) finger with repeated use over time and with flare-ups. The examiner further opined that pain significantly limits functional ability with repeated use over a period of time and during flare-ups. Left hand grip was reduced (4/5), but without muscle atrophy. The Veteran did not have ankylosis of any finger joints. There were no other pertinent physical findings, complications, signs, or symptoms relevant to the diagnosed residuals, laceration injury, left middle finger, left hand strain, radiculopathy of the left upper extremity, and left index finger amputation at the proximal interphalangeal joint. The examiner noted that these were a progression of the established diagnosis of residuals, laceration injury, left middle finger. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. As discussed above, the examiner obtained this information which indicated reduced range of motion and functional impairments due to pain after repeated use over time and during flare-ups. The Board finds that the preponderance of the evidence supports a rating of 10 percent, but no higher, under DC 5229 for residuals, laceration injury, left middle finger. The evidence of record shows that the Veteran is left-handed and, at the November 2019 examination, there was limitation of motion, weakness, and functional limitations due to pain and numbness of the middle finger. While the Veteran's middle finger limitations of motion do not meet the criteria for a compensable rating under DC 5229 for limitation of motion, the Board has considered the provisions of 38 C.F.R. § 4.59 in light of the examiner's opinion that flare-ups and repeated use over time result in additional pain which "significantly limits functional ability." In awarding a 10 percent rating under DC 5229, the Board has also considered the hand sprain diagnosed by the examiner which results in some weakness of the hand. The Board finds that while the Veteran's condition does not meet the criteria for a compensable rating under DC 5307, 5308, 5309, 5226, or 5229, the combined effect of the hand sprain and the functional limitations associated with pain of the left middle finger, especially during flare-ups and after repeated use over time, a 10 percent rating is warranted in addition to the other ratings assigned for residuals (including 10 percent for scar of the left middle finger and 20 percent for radiculopathy of the left upper extremity) of the laceration injury to the left middle finger. The functional limitations are distinct from the functional limitations addressed by those separate ratings. The remaining question is when this rating should be made effective, given that the appeal period extends back to February 15, 2010, and the Board must consider the propriety of staged ratings. See O'Connell v. Nicholson, 21 Vet. App. 89 (2007); Hart v. Mansfield, 21 Vet. App. 505 (2007). The August 2010 VA examination showed full range of motion of the left middle finger, but there were daily flare-ups of pain in the left middle finger as well as significant weakness of the left hand, generally, and associated functional limitations. The Veteran's 10 percent (scar) and 20 percent (radiculopathy) ratings are both effective November 13, 2019, the date of the 2019 VA examination. Because the November 2010 VA examination supports a compensable rating for the residuals of the laceration injury to the left middle finger (either based on the pain associated with the scar or for the functional limitations including weakness of the hand), the Board finds this 10 percent rating under DC 5229 should be effective the date of the claim for increase, February 15, 2010. The Board has considered whether any other Diagnostic Codes related to disabilities of the fingers or hand would provide for a higher disability rating. 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. In conclusion, the Board finds that the preponderance of the evidence supports awarding a 10 percent rating, but no higher, under DC 5229 for service-connected residuals, laceration injury, left middle finger effective February 15, 2010. In denying any rating in excess of 20 percent, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to an evaluation in excess of 10 percent for painful scar, left middle finger, associated with residuals of laceration injury The Veteran has contended that he is entitled to an evaluation in excess of 10 percent for the painful scar, left middle finger. The Board notes that the period on appeal for this claim extends back to February 15, 2010, the date of the claim of entitlement to an increased rating for the service-connected residuals of the laceration injury of the left middle finger. The Veteran's left middle finger scar is rated under Diagnostic Code 7804 for unstable or painful scar(s) effective November 13, 2019. Prior to November 13, 2019, the Veteran had a noncompensable rating for all residuals of the laceration injury of the left middle finger. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7804 was not changed by the August 13, 2018, amendments. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under Diagnostic Code 7804 because the Veteran's scar is not manifest by three or four scars that are unstable or painful. The November 2019 VA examination noted a single scar of the left middle finger and a scar of the left index finger. The examiner noted that the Veteran had one scar of the left middle finger that was painful and unstable. The examiner noted that that scars did result in limitation of function, including lifting, pushing, or pulling more than 50 pounds due to the left middle finger. He also could not lift objects above shoulder level due to left middle finger pain. The Board notes that these functional limitations are very similar to and overlap with the functional limitations and symptoms associated with the residuals of the laceration injury to the left middle finger, hand sprain, and radiculopathy of the left upper extremity. As discussed above, the Board has awarded a separate 10 percent rating under DC 5226 for the pain, limitation of motion, and weakness due to the residuals of the laceration injury of the left hand (including hand sprain). Therefore, awarding a rating higher than the 10 percent rating under DC 7804 would constitute impermissible pyramiding. 38 C.F.R. § 4.14. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran's left middle finger scar is not of the head, face, or neck, is not deep and nonlinear, and is not associated with underlying soft tissue damage. Although it is superficial and not associated with underlying soft tissue damage, it does not cover an area or areas of 144 square inches or greater. Therefore, Diagnostic Codes 7800 through 7802, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805, other than those already awarded separate ratings under DC 5226 and 8714. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms, to include pain and occasional cracking, peeling, and numbness and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and medical records do not show, that the Veteran's left middle finger scar is manifest by three or four scars that are unstable or painful. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a disability rating in excess of 10 percent for painful scar, left middle finger. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. The Board reiterates that, for the period prior to November 13, 2019, the newly assigned 10 percent rating under DC 5229 is based on pain in the left middle finger as well as the associated functional limitations. Moreover, the November 2010 VA examiner's findings would not support an award under DC 7804. For all of these reasons, the Board declines to grant an earlier effective date for the 10 percent rating under DC 7804. See 38 C.F.R. § 4.14. 3. Entitlement to an evaluation in excess of 20 percent for radiculopathy of the left upper extremity associated with residuals, laceration injury, left middle finger The Veteran has contended that he is entitled to a higher for his residuals of a laceration injury to the left middle finger. During the pendency of this appeal, the RO awarded an additional 20 percent rating for radiculopathy of the left upper extremity as a residual of that laceration injury. The Veteran has not provided any explicit argument for a rating in excess of 20 percent for the radiculopathy, but he is presumed to be seeking the maximum possible rating. Paralysis of the musculospiral nerve (radial nerve) is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8514. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8614 and DC 8714, respectively). Under these criteria, mild incomplete paralysis is rated 20 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 percent for the major extremity and 20 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis is rated as 70 percent for the major extremity and 60 percent for the minor extremity. 38 C.F.R. § 4.124a. Complete paralysis of the musculospiral nerve is characterized by: drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border or the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity. 38 C.F.R. § 4.124a, DC 8514. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The November 2019 VA examination provides the first evidence of radiculopathy of the left upper extremity associated with the laceration injury of the left middle finger. Treatment records prior to November 2019 are silent for any diagnosis of left upper extremity radiculopathy associated with the laceration injury. Therefore, it was first ascertainable November 13, 2019, that the Veteran had an increase of the service-connected residuals of the laceration injury to the left middle finger that consisted of radiculopathy of the left upper extremity. Moreover, the November 2019 VA examination provides the best, most probative evidence regarding the severity of the radiculopathy. The November 2019 VA examination revealed mild constant pain, moderate intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness of the left upper extremity. The examiner noted reduced (4/5) strength of wrist flexion, wrist extension, and pinch (thumb to index finger) on the left. The Veteran did not have muscle atrophy and reflexes and sensation were normal throughout the left upper extremity. There were no trophic changes. The examiner indicated that the Veteran had mild, incomplete paralysis of the left musculospiral (radial) nerve. The examiner noted that there was not functional impairment of the extremity such that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms. The examiner noted that the Veteran from lifting, pushing, or pulling more than 50 pounds due to the left middle finger. The examiner indicated that the Veteran would not be able to perform work activities involving these actions. This examination supports finding that the Veteran has mild, incomplete paralysis of the musculospiral nerve on the left. This is particularly so where some of the symptoms (e.g., pain) form the basis for other ratings under DC 5229 (10 percent rating for limitation of motion and associated functional limitations based on pain) and DC 8704 (10 percent rating for painful and unstable scar of the left middle finger). A 10 percent rating is warranted, however, because the radiculopathy also results in mild paresthesias/dysesthesias, mild numbness, and reduced wrist strength, as well as pain not limited to the area of the scar but, as described by the Veteran, includes low grade pain on the entire finger, sharp pain several times a day, itching sensation all the time, and, importantly, numbness that affects ability to write and manipulate small objects. The Board finds that the evidence supports a 20 percent rating based on mild neuralgia under 38 C.F.R. §§ 4.124, 4.124a, DC 8714, due to manifestations of the nerve injury that are not fully compensated by the other, separate ratings under DCs 5229 and 8704. The Board acknowledges the lay assertions of and examiner's indication of moderate intermittent pain. However, the Board finds the medical of evidence of record to be more probative because the overall clinical significance of the incomplete paralysis of the musculospiral nerve was found to be mild. Also, as noted, the Veteran has a 10 percent rating under DC 8704 partially based on pain (painful and unstable scar). Also, the 10 percent rating assigned under DC 5229 above also involves consideration of pain and the functional impairments caused by that pain in the use of the middle finger and hand. Therefore, the reference to moderate intermittent pain does not warrant a higher rating for moderate, incomplete paralysis in addition to the other ratings assigned under DCs 5229 and 8704. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. The Board has also considered whether a rating for radiculopathy should be awarded prior to November 13, 2019. As explained above, the November 2019 VA examination provided the first evidence from which it was ascertainable that the Veteran's residuals of the laceration injury of the left middle finger had progressed to include radiculopathy of the left upper extremity. In addition, the Board notes that it has awarded a 10 percent rating for the residuals of the laceration injury of the left middle finger based on pain, left hand weakness, numbness, and associated functional limitations. A separate, additional award for radiculopathy prior to November 13, 2019, is inappropriate for the further reason that it would constitute impermissible pyramiding. 38 C.F.R. § 4.14. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for radiculopathy of the left upper extremity involving the musculospiral (radial) nerve. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for multiple pulmonary nodules, right upper outer lung, claimed as nodules in bilateral lungs is remanded. The Veteran alleges that he developed multiple pulmonary nodules in his lungs due to in-service exposure to sodium hydroxide (lye), trichloroethylene, and zinc chromate paint. See May 2019 VA Form 9. He has identified a September 1985 service treatment record that discusses diagnostic imaging of the lung with notations: "increased density within the left infraclavicular region" and "Minimal residue of previous inflammatory disease?" Id. In addition, the Veteran has noted that a treating physician noted that the alleged exposures could be related to the later-diagnosed lung nodules. See November 2014 VA Progress Note ("Assessment/Diagnosis: zinc chromate primer, paint fumes, lye vat in service and now lung nodules: repeat chest image given a smoker, return to pulmonary 12 months."). Based on this evidence, the Veteran is entitled to a VA examination and opinion regarding the etiology of his diagnosed multiple pulmonary nodules. In particular, there were abnormal (though inconclusive) findings on the in-service diagnostic imaging of the lungs and a current treating physician has suggested that alleged in-service exposures could possibly be related to the current condition. The abnormal imagines are sufficient to establish an in-service event that may be related to the current condition, so an opinion regarding whether there is a nexus between the potential in-service lung abnormalities and the current multiple pulmonary nodules. In addition, an opinion will help resolve the factual issue of whether there were in-service exposures and, if so, whether those exposures are related to the current condition. However, the Veteran and his representatives are hereby given notice that no final factual determination has been made regarding whether the alleged exposure to zinc chromate primer, paint fumes, lye vats, or other chemical exposures occurred, so they should address that issue with appropriate argument and evidence if they deem it advisable. See Smith v. Wilkie, 32 Vet. App. 332, 334 (Apr. 27, 2020) ("the principles of fair process require the Board to provide claimants notice and an opportunity to respond when it purports to reverse prior assertions that evidence is credible or otherwise satisfactory to establish a fact necessary to the claim"). This remand is to provide further factual development that will assist the Board in making a final determination on that issue. 2. Entitlement to service connection for left foot tendonitis is remanded The Veteran contends that he currently has left foot tendinitis that is related to an in-service diagnosis of left foot tendinitis or, alternatively, that his left foot tendonitis is related to an altered gait caused by the service-connected residuals, laceration injury, first toe of left foot. See May 2019 VA Form 9 (setting forth the factual basis of his claim). The Board cannot make a fully-informed decision on the issue of entitlement to service connection for left foot tendonitis because no VA examiner has opined whether the Veteran's service-connected residuals, laceration injury, first toe of left foot, has either caused or aggravated his current left foot tendonitis. Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (holding that an opinion obtained regarding secondary service connection must address both causation and aggravation of the nonservice-connected condition); 38 C.F.R. § 3.310. An adequate opinion is necessary to decide the claim. See Allen, 7 Vet. App. at 448-49; Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from February 2020 to the Present. 2. Schedule the Veteran for a VA examination for his multiple pulmonary nodules, right upper outer lung. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: a. Is there medical evidence that the Veteran was exposed to zinc chromate primer, paint fumes, or lye vats during his active service? b. Regardless of the answer to (a), assume the Veteran was exposed to zinc chromate primer, paint fumes, or lye vats during service as described in his May 2019 VA Form 9. Are his current multiple pulmonary nodules at least as likely as not related to his active service including that exposure? Please comment on the significance, if any, of the September 1985 diagnostic imaging of the lungs as well as the Veteran's history of smoking. c. Regardless of the answers to (a) or (b), assume that the Veteran was not exposed to zinc chromate primer, paint fumes, or lye vats during his active service. Are the Veteran's currently diagnosed pulmonary nodules at least as likely as not related to service, including the findings of "increased density within the left infraclavicular region" and "Minimal residue of previous inflammatory disease?" in a September 26, 1985, service treatment record? Provide a rationale to support the opinion(s). 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's left foot tendonitis is at least as likely as not proximately due to service-connected disability (particularly including the service-connected residuals of a laceration injury to the first toe of the left foot) or aggravated beyond its natural progression by service-connected disability. ROBERT C. SCHARNBERGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kerry Hubers 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.