Citation Nr: 22019720 Decision Date: 04/02/22 Archive Date: 04/02/22 DOCKET NO. 18-06 295 DATE: April 2, 2022 ORDER Entitlement to an initial compensable rating prior to November 12, 2021 for painful motion of the right third finger (right third finger disability), is denied. Entitlement to an initial rating in excess of 10 percent from November 12, 2021 for a right third finger disability is denied. Entitlement to an initial compensable rating prior to and from November 12, 2021 for painful motion of the right fourth finger (right fourth finger disability), is denied. Entitlement to a compensable rating for right fifth digit, partial flexor tendon rupture (right fifth finger disability), is denied. A separate 10 percent, but no higher, rating from July 1, 2018 for right fifth finger disability based on interference with overall function of the right hand, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to an effective date of October 15, 2021, but no earlier, for Dependents' Educational Assistance (DEA) benefits is granted, subject to regulations governing the payment of monetary awards. FINDINGS OF FACT 1. The Veteran is right hand dominant. 2. Prior to November 12, 2021, the Veteran's right third finger disability was manifested by no gap between the fingertip and proximal transverse crease of the palm, with full range of motion without pain, and without favorable or unfavorable ankylosis. 3. From November 12, 2021, the Veteran's right third finger disability has been manifested by no gap between the fingertip and proximal transverse crease of the palm, with reduced range of motion with pain, and without favorable or unfavorable ankylosis. 4. The Veteran's right fourth finger disability has been manifested by reduced range of motion with pain, but without favorable or unfavorable ankylosis. 5. Throughout the appeal period, there has been no amputation of all or part of the right fifth finger and his right fifth finger disability has resulted in symptoms most nearly approximating ankylosis of the joint of the right fifth finger. 6. From July 1, 2018, the Veteran's right fifth finger disability has resulted in symptoms most nearly approximating ankylosis of the joint of the right fifth finger, which has interfered with the overall function of the hand, including his grip ability and grip strength. 7. The Veteran met basic eligibility for DEA on October 15, 2021, the date he is in receipt of a combined 100 percent rating, as a result of the instant decision. CONCLUSIONS OF LAW 1. Prior to November 12, 2021, the criteria for an initial compensable rating for a right third finger disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5226, 5229 (2021). 2. From November 12, 2021, the criteria for an initial rating in excess of 10 percent for a right third finger disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5226, 5229 (2021). 3. Throughout the appeal period, the criteria for an initial compensable rating for a right fourth finger disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5227, 5230 (2021). 4. Throughout the appeal period, the criteria for a compensable rating for a right fifth finger disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5227, 5230 (2021). 5. From July 1, 2018, the criteria for a separate 10 percent, but no higher, rating for a right fifth finger disability, based on interference with overall function of the right hand, are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, 4.73, Diagnostic Codes 5227, 5309 (2021). 6. The criteria for an effective date of October 15, 2021 for the award of basic eligibility for Dependents' Educational Assistance benefits are met. 38 U.S.C. §§ 3500, 3501, 3510 (2012); 38 C.F.R. § 21.3021 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from June 1992 to June 1995. These matters are before the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the Board at a hearing held by the undersigned in February 2020. A transcript of the hearing is of record. This case was previously before the Board in September 2020 and October 2021 when the Board remanded it for further development. In a November 2021 rating decision, the Agency of Original Jurisdiction (AOJ) awarded a separate noncompensable rating for a right fourth finger disability and a 10 percent rating for a right third finger disability, both effective November 12, 2021. The Veteran's third and fourth finger disability ratings under Diagnostic Codes 5229 and 5230 are part and parcel of the Veteran's December 2015 claim seeking an increased rating for his right fifth finger disability. Therefore, all applicable finger and hand ratings throughout the entirety of the appeal period are currently before the Board. The issues are characterized as such on the title page. In addition, in the November 2021 rating decision, the AOJ awarded entitlement to DEA benefits effective November 12, 2021 based on the award of a combined 100 percent rating. As entitlement to DEA benefits prior to November 12, 2021 is inextricably intertwined with the award of the 10 percent rating for the right fifth finger disability based on interference with overall function of the right hand herein, the Board will address entitlement to an effective date prior to November 12, 2021 for DEA benefits herein. Increased Rating Right Hand and Finger Disabilities The Veteran and his representative contend the Veteran is entitled to increased ratings for his right finger disabilities. See January 2022 Informal Hearing Presentation. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The AOJ has assigned the Veteran's right third finger disability a 10 percent rating from November 12, 2021 under Diagnostic Code 5229. The AOJ has assigned the Veteran's right fourth finger a noncompensable rating from November 12, 2021 under Diagnostic Code 5230. The AOJ has assigned the Veteran's right fifth finger disability a noncompensable rating throughout the appeal period under Diagnostic Code 5230. Under Diagnostic Code 5229, a 10 percent evaluation is assigned 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. A gap of less than one inch is noncompensable. Under Diagnostic Code 5230, a noncompensable rating is assigned for any limitation of motion of the ring or little finger regardless of whether the affected hand is dominant or minor. Diagnostic Code 5230 does not provide for a compensable rating. 38 C.F.R. § 4.71a. Diagnostic Codes 5154, 5155, 5156 evaluates amputation of the third, fourth, and fifth fingers. The record contains no evidence of an amputation of the right third, fourth, or fifth fingers. Although there is evidence that the Veteran has had reduced strength in the right hand at times during the appeal period; the March 2016, December 2020, and January 2021 VA examiners found that the Veteran would not be equally well served by amputation, and there is no other evidence to indicate such. Therefore, the Veteran's right hand and finger disabilities are not equivalent to amputation. Therefore, these Diagnostic Codes are not applicable and will be discussed no further. Diagnostic Code 5226 evaluates ankylosis of the third finger and provides a 10 percent rating for unfavorable or favorable ankylosis. Diagnostic Code 5227 evaluates ankylosis of the fourth and fifth fingers and provides a noncompensable evaluation for favorable or unfavorable ankylosis. Notes following the Codes instruct that it should be considered whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with the overall function of the hand. 38 C.F.R. § 4.71a. Limitation of motion of the thumb is rated under Diagnostic Code 5228. 38 C.F.R. § 4.71a. Under Diagnostic Code 5228, a 10 percent evaluation is assigned when there is a gap of one to two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 20 percent evaluation is assigned when there is a gap of more than two inches between the thumb pad and fingers, with the thumb attempting to oppose the fingers. For the second, third, fourth, and fifth digits of the hand, the metacarpophalangeal (MCP) joint has a range of 0 to 90 degrees of flexion, the proximal interphalangeal (PIP) joint has a range of 0 to 100 degrees, and the distal interphalangeal joint (DIP) has a range of 0 to 70 or 80 degrees. 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, (1). In rating disabilities of the musculoskeletal system, VA may, in addition to applying the schedular criteria, consider functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. DeLuca v. Brown, 8 Vet. App. 202 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Lastly under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis, and Diagnostic Code 5010, traumatic arthritis, arthritis established by X-ray findings will be rated because of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined not added. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating will be assigned where there is X-ray evidence of involvement of 2 or more minor joint groups and a 20 percent rating where there is X-ray evidence of involvement of 2 or more minor joint groups, with occasional incapacitating exacerbations. Note (1) provides that the 10 and 20 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. For the purpose of rating disability from arthritis, the shoulder, elbow, wrist, hip, knee, and ankle are considered major joints; multiple involvements of the interphalangeal, metacarpal, and carpal joints of the upper extremities, the interphalangeal, metatarsal, and tarsal joints of the lower extremities, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae, are considered groups of minor joints, ratable on a parity with major joints. 38 C.F.R. § 4.45(f). The Board notes that the rating criteria for arthritis under Diagnostic Code 5003 were revised during the Veteran's appeal, effective February 7, 2021. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76,453, 76,463 (Nov. 30, 2020) (codified at 38 C.F.R. § 4.71a, Diagnostic Code 5003). However, the changes to Diagnostic Code 5003 are in name only in that the amended criteria encompass any degenerative arthritis, other than posttraumatic arthritis. Thus, the amended rating criteria have not affected any applicable rating for the Veteran's finger disabilities. Turning to the medical evidence of record, the Veteran attended a VA examination in March 2016 for an evaluation of his right fifth finger disability. The examiner diagnosed the Veteran with right fifth digit partial flexor tendon rupture. The Veteran had full range of motion in the thumb and all digits in the right hand. The examiner noted that the DIP joint of the fifth finger lacked 10 degrees of full extension; however, there was no functional impairment noted due to the abnormality. The Veteran had no gap between the thumb pad and fingers bilaterally. The Veteran had no gap between the finger and proximal transverse crease of the hand on maximal finger flexion bilaterally. The Veteran had no pain with range of motion or with finger opposition. The Veteran had no pain with use of his right hand and no pain on palpation in the right hand. The Veteran performed repetitive use testing without additional functional loss or range of motion. He had normal grip strength in the right hand, no muscle atrophy, and no ankylosis in the right hand. The Veteran's right fifth finger disability did not cause such functional impairment that no effective function remained other than that which would be equally well served by amputation with prosthesis. The examiner noted the Veteran's right fifth finger disability caused no functional impact. The Veteran reported having chronic pain in the lateral fifth finger. Furthermore, he reported that he works in information technology (IT) on the computer all day and finds it hard to type with his finger due to pain. He reported no further functional loss or functional impairment. A July 20, 2018 VA treatment record reflects that the Veteran reported a three-week history of a sore and stiff right fifth finger. He reported that his finger ached all the time. X-ray results of the right hand were normal. At a June 2019 VA appointment, the Veteran reported continued stiffness in the right fifth finger, and he reported constant discomfort. Furthermore, the Veteran reported difficulty with flexion and extension at times. The treatment note reflects that recent X-rays were normal. The Veteran attended an additional VA examination in December 2020 for an evaluation of his right hand. The examiner diagnosed the Veteran with right fifth digit partial flexor tendon rupture and degenerative arthritis. Range of motion testing revealed the Veteran had limitation of motion in the PIP and DIP joints of the right fifth finger, but he had no limitation of motion in any other finger or the thumb. The examiner noted the Veteran had pain with flexion in the right fifth finger that caused functional loss, but he had no pain with any other range of motion. The Veteran had no gap between the thumb pad and fingers. The Veteran had no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. The Veteran had pain with use of the right hand. The Veteran had localized tenderness or pain on palpation in the right fifth finger that radiated into the interspace of the third and fourth fingers. He also had pain in the metacarpals. The Veteran performed repetitive use testing without additional functional loss or range of motion loss. With repeated use, the examiner noted that pain, fatigue, and lack of endurance significantly limited functional ability and caused reduced range of motion. The examiner estimated that the Veteran's right fifth finger flexion of the DIP joint would be reduced by five degrees compared to his initial range of motion. There were no further reductions in his range of motion upon repeated use. The examiner noted that an additional factor contributing to disability was deformity, and the examiner described it as the Veteran's right fifth digit remained contracted and was not functional for use. The Veteran had reduced grip strength to 4/5 in the right hand. He had no muscle atrophy and no ankylosis. The ankylosis section of the examination report reflects that the right fifth finger could be moved with passive motion and the movement was limited. The Veteran's right fifth finger disability did not cause such functional impairment that no effective function remained other than that which would be equally well served by amputation with prosthesis. The examiner noted the disability caused functional impact in the form of constant pain, he is unable to use the finger for functioning, and the finger remains contracted. Furthermore, the pain radiates to the lateral and metacarpal area, so he limits activity with the right hand and relies mainly on the left hand to complete work. Gripping, holding, and steering are impaired with the right hand and fifth finger. In addition, gripping, holding, and steering aggravate the right hand and fifth finger pain. The Veteran reported that the condition was worsening and that he had pain in the fifth finger that radiates into the lateral side of the hand and travels across the interspace of the third and fourth fingers. He reported his fifth finger remains contracted and does not assist with hand gripping. He described the pain as a constant 8 out of 10 in the fifth finger. The right hand was noted to be his dominant hand. December 2020 X-rays of the right hand and right fifth finger showed mild degenerative changes. A January 2021 right hand X-ray showed persistent mild flexion deformity of the right fifth finger at the proximal interphalangeal joint level. The Veteran attended a VA examination in November 2021 for an evaluation of his right hand. The examiner diagnosed the Veteran with right fifth digit partial flexor tendon rupture, degenerative arthritis, and right-hand strain. Range of motion testing revealed the Veteran had limitation of motion in the PIP and DIP joints of the right second, third, fourth, and fifth fingers. He also had reduced range of motion in the MCP joint of the fifth finger. He had no limitation of motion in the thumb. The examiner noted that the range of motion itself contributed to functional loss in the form of it limits his ability to type and limitation of grip. The examiner noted the Veteran had pain in the fourth and fifth fingers with range of motion that caused functional loss. The Veteran had no gap between the thumb pad and fingers. The Veteran had no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. Passive range of motion testing was the same as the active range of motion testing. The Veteran had mild localized tenderness or pain on palpation in the third, fourth, and fifth fingers. The Veteran performed repetitive use testing without additional functional loss or range of motion loss. With repeated use and during flare-ups, the examiner noted that pain, fatigability, weakness, lack of endurance, or incoordination would not significantly limit functional ability. The examiner noted that there were no additional factors contributing to disability. The Veteran had normal grip strength, no muscle atrophy, and no ankylosis. The Veteran's right fifth finger disability did not cause such functional impairment that no effective function remained other than that which would be equally well served by amputation with prosthesis. The examiner noted the disability caused functional impact in the form of pain in the fifth finger and area of the third, fourth, and fifth metatarsals that impacts his ability to do required typing tasks for work. Furthermore, there is some impairment of grip. The examiner also noted that the Veteran's diagnosed hand strain is related to his initial right fifth finger disability, and the examiner noted that the mild degenerative changes noted on the hand X-ray are likely not related to his fifth finger disability. In addition, the examiner noted that the reduced range of motion and pain in the third, fourth, and fifth fingers impacts his grip capacity and use of the hand for many daily activities. The Veteran reported right fifth finger pain that radiates to the third, fourth, and fifth metatarsal areas. He reported limited range of motion, it is hard to type, and that the pain increases when doing typing for his job. He relieves the pain with rest and ice. The Veteran reported moderate flare-ups causing increased difficulty gripping tools and objects that occur a few times a year and last three to four days. He reported the flare-ups are precipitated by yard work and gripping activities, and he alleviates them with ice, medication, and rest. A November 2021 right hand MRI was normal. In addition to the Veteran's reports at the VA examinations addressed above, the Veteran also provided reports at his April 2020 Board hearing and in January 2017, January 2018, and January 2021 written statements regarding his right hand. In those written statements and Board hearing testimony, the Veteran consistently reported that he is unable to bend his right fifth finger without pain, his finger disability impacts his job due to difficulties with typing, and it affects his daily activities. For example, he reported difficulties doing yard work, playing with his daughter, hunting, and fishing. See April 2020 Board Hearing Transcript, at 8-9. Furthermore, in a February 2019 written brief, the Veteran's representative noted that the Veteran's right fifth finger disability makes it difficult to type all day, and his representative noted that it causes functional loss. Regarding the Veteran's 10 percent rating for his right third finger disability under Diagnostic Code 5229 effective November 12, 2021, the maximum schedular rating available under Diagnostic Code 5226 for ankylosis or Diagnostic Code 5529 based on range of motion is 10 percent. 38 C.F.R. § 4.71a. As there is no legal basis upon which to award a higher schedular rating, the appeal for a higher rating since November 12, 2021 must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). For the period prior to November 12, 2021, the evidence persuasively weighs against a finding of 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 that he had extension limited by more than 30 degrees. See March 2016 and December 2020 VA Examination Reports. Furthermore, the March 2016 and December 2020 VA examination reports reflect that the Veteran did not have pain with range of motion of the right third finger. Although 38 C.F.R. § 4.59 and Burton provide that actual painful, unstable, or malaligned joints, due to healed injury are entitled to at least the minimum compensable rating for the joint, a review of the medical and lay evidence of record illustrates that there are no reports of pain with range of motion of the right third finger prior to November 12, 2021. As such, a separate rating under Diagnostic Code 5229 is not warranted for the Veteran's right third finger disability. The Board has considered whether the Veteran is entitled to a separate rating at any point during the appeal period under Diagnostic Code 5226 for ankylosis of the third finger. However, the evidence does not show evidence of ankylosis or the functional equivalence of ankylosis at any point during the appeal period. See March 2016, December 2020, and November 2021 VA Examination Reports. Notably, the Veteran's flexion in the PIP and DIP joints has been limited by at most 10 degrees. See November 2021 VA Examination Report. In addition, the Veteran has had full range of motion in the MCP joint. Id. Thus, a separate compensable rating under Diagnostic Code 5226 is not warranted. See Chavis v. McDonough, 34 Vet. App. 1 (2021). Regarding the Veteran's noncompensable ratings for his right fourth and fifth fingers under Diagnostic Code 5230, as indicated above, the applicable diagnostic criteria provide that any limitation of motion of the fourth and fifth fingers is noncompensable. 38 C.F.R. § 4.71a. Moreover, although 38 C.F.R. § 4.59 and Burton provide that actual painful, unstable, or malaligned joints, due to healed injury are entitled to at least the minimum compensable rating for the joint; there is no compensable rating for limitation of motion of the fourth and fifth fingers. Therefore, application of 38 C.F.R. § 4.59 does not assist the Veteran in this case. See Sowers v. McDonald, 27 Vet. App. 472 (2016). As such, even with consideration of 38 C.F.R. § 4.59, compensable ratings are not warranted under Diagnostic Code 5230 for the right fourth finger disability and the right fifth finger disability at any point throughout the appeal period. The Board has considered whether the Veteran is entitled to a separate rating at any point during the appeal period under Diagnostic Code 5227 for ankylosis of the fourth finger. However, the evidence does not show evidence of ankylosis or the functional equivalence of ankylosis at any point during the appeal period. See March 2016, December 2020, and November 2021 VA Examination Reports. Notably, the Veteran had full range of motion in the fourth finger at the December 2020 VA examination. The Board notes that at the November 2021 VA examination the Veteran had full range of motion in the MCP joint, flexion to 80 degrees in the PIP joint, and flexion to 30 degrees in the DIP joint. He has had full extension throughout the finger throughout the appeal period. The Veteran has not alleged that his fourth finger is fixed in any position. Thus, although there is evidence of reduced range of motion in the fourth finger, the evidence does not illustrate that the Veteran's fourth finger is ankylosed or the equivalent of ankylosed. As such, a separate rating under Diagnostic Code 5227 is not warranted at any point throughout the appeal period. See Chavis, 34 Vet. App. 1. Regarding the Veteran's fifth finger, the Board notes that the Veteran's right fifth finger disability is rated under Diagnostic Code 5230. However, prior to December 30, 2015, the Veteran's right fifth finger disability was assigned a noncompensable rating under Diagnostic Code 5227. For the reasons that follow, the Board has concluded that the Veteran's right fifth finger disability is most appropriately evaluated under Diagnostic Code 5227 for ankylosis of the fifth finger throughout the appeal period. VA can change the diagnostic code that a particular disability is rated under so long as the rating under that diagnostic code has not been in effect for 20 years. See 38 C.F.R. § 3.951(b); see Murray v. Shinseki, 24 Vet. App. 420, 425 (2011). VA must explain the change in the diagnostic code. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The December 2020 and November 2021 VA examinations and the Veteran's report of symptoms illustrate the Veteran's fifth finger is the equivalent of ankylosed, even though the December 2020 and November 2021 VA examination reports do not reflect that his fifth finger is ankylosed. See Chavis, 34 Vet. App. 1. Of note, the December 2020 VA examination report reflects that the Veteran's fifth finger remains contracted and does not assist with hand gripping. Therefore, the Board concludes that Diagnostic Code 5227 best reflects the Veteran's right finger disability. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). Changing the diagnostic code from 5230 to 5227 does not reduce the Veteran's rating at any time during the appeal period. In addition, using Diagnostic Code 5227 for the right fifth finger disability is more beneficial to the Veteran than using Diagnostic Code 5230 for the fifth finger under 38 C.F.R. § 4.71a, as it provides for the possibility of a higher rating based on the interference with the overall function of the hand. Accordingly, the Board has changed the diagnostic code to 5227 for the right fifth finger disability. As indicated above, Diagnostic Code 5227 provides that ankylosis of the fifth finger is noncompensable. 38 C.F.R. § 4.71a. Thus, a compensable rating under Diagnostic Code 5227 is not warranted at any point throughout the appeal period for the Veteran's right fifth finger. However, the Note to Diagnostic Code 5227 states that an additional evaluation is warranted for any resulting limitation of motion of other digits or interference with the overall function of the hand due to the service-connected residuals of fifth finger ankylosis. After reviewing the evidence of record, the Board finds that a separate 10 percent disability rating is warranted for the Veteran's right fifth finger disability based on the impact of the disability on the overall function of the hand. The diagnostic code which best approximates this disability picture is found in 38 C.F.R. § 4.73a, Diagnostic Code 5309. Thus, an additional evaluation under Diagnostic Code 5309 is warranted, based on the anatomical location and functions affected. 38 C.F.R. § 4.20. Injury to the intrinsic muscles of the hand may be rated under Diagnostic Code 5309 for muscle group IX, which controls grasping and delicate manipulative movements. Muscle Group IX consists of the intrinsic muscles of hand; thenar eminence; short flexor, opponens, abductor, and adductor of the thumb; hypothenar eminence; short flexor, opponens, and abductor of the little finger; four lumbricales; and four dorsal and three palmar interossei. The forearm muscles act in strong grasping movements and are supplemented by the intrinsic muscles in delicate manipulative movements. The hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc. Thus, injury to muscle group IX should be rated on limitation of motion, with a minimum 10 percent assigned. 38 C.F.R. § 4.73, Diagnostic Code 5309, Note. The evidence demonstrates that the Veteran has had problems with gripping with the right hand and decreased hand strength since July 1, 2018. On July 20, 2018, the Veteran reported a three week history of a sore stiff right fifth finger, and in June 2019, the Veteran reported continued stiffness in the right fifth finger. Furthermore, he reported constant discomfort and difficulty with flexion and extension at times. December 2020 and November 2021 VA examination reports reflect that the Veteran's right fifth finger disability causes functional impact in the form of reduced gripping. Furthermore, the December 2020 VA examiner noted that the Veteran is unable to use his right fifth finger for functioning as it remains contracted. In addition, the December 2020 examiner noted that the Veteran limits his activity with the right hand and relies on the left hand to do work. However, the November 2021 VA examiner noted that the Veteran had "some impairment of grip." Notably, the November 2021 VA examination report does not reflect that the Veteran has lost all use of his right hand. Although the record reflects that gripping type functions are still possible, and hence no loss of use is shown, they are more difficult to perform with the right fifth finger disability. As such, the Board concludes that ankylosis in the right fifth digit beginning July 1, 2018 has impacted the overall function of the right hand. Therefore, a separate 10 percent rating under Diagnostic Code 5309 is appropriate from July 1, 2018 considering the impairment of hand function from the Veteran's right fifth finger disability. A compensable rating prior to July 1, 2018 is not warranted under Diagnostic Code 5309 as the evidence of record prior to that date does not show that the Veteran's right fifth finger disability impacted the overall function of the right hand. The March 2016 VA examination report reflects that the Veteran had normal grip strength in the right hand, and that the Veteran's right fifth finger disability caused no functional impact. The Board acknowledges that the record reflects that the Veteran had pain in his right fifth digit and that it was bent out of place prior to July 1, 2018. See March 2016 VA Examination Report; January 2017 VA Form 21-0958, Notice of Disagreement; January 2018 VA Form 9, Appeal to Board of Veterans' Appeals. However, such evidence does not illustrate that the Veteran's right fifth finger disability impacted the overall function of the right hand. Therefore, as the evidence persuasively weighs against such a finding, a separate compensable rating prior to July 1, 2018 is not warranted. In addition, the Board notes that the VA X-ray reports prior to July 1, 2018 do not demonstrate that there is arthritis established by X-ray evidence of involvement of two or more major joint groups or two or more minor joint groups to warrant a higher 10 percent rating under Diagnostic Code 5003 prior to July 1, 2018. The first X-ray showing evidence of arthritis in the right fifth finger and right hand was a December 2020 VA X-ray. As the Veteran is being compensated based on range of motion and functional limitation from July 1, 2018, further discussion of Diagnostic Code 5003 is unnecessary. A review of the schedular criteria also does not indicate another diagnostic code more analogous to the service-connected disabilities that would provide for a higher rating. Additionally, there is no other impairment, including impairment of the thumb under Diagnostic Code 5228 that would entitle him to any further separate ratings. In summary, a separate 10 percent, but no higher, rating from July 1, 2018 is warranted for the Veteran's right fifth finger disability under Diagnostic Code 5309, based on the Note to Diagnostic Code 5227 that provides for an additional evaluation where there is interference with overall function of the hand. For the Veteran's right third finger disability, a rating in excess of 10 percent from November 12, 2021 is denied. Prior to November 12, 2021, a compensable rating is not warranted as the evidence persuasively weighs against the claim. For the Veteran's right fourth finger disability, a compensable rating is not warranted at any point during the appeal period as the evidence persuasively weighs against the claim. DEA Benefits The AOJ has assigned an effective date of November 12, 2021 for the award of Chapter 35 DEA benefits. The date assigned by the AOJ was the same date the Veteran was initially in receipt of a combined 100 percent rating. As discussed above, with the award of a 10 percent rating in this decision from July 1, 2018, the Veteran is now in receipt of a combined total disability rating for his service-connected disabilities effective October15 , 2021. Chapter 35 benefits may be awarded effective the date of an award of a permanent and total disability rating but not prior to the award of a permanent and total disability rating. Therefore, the Board concludes the Veteran is entitled to an effective date of October 15, 2021, but no earlier, for the award of entitlement to Chapter 35 benefits. 38 U.S.C. §§ 3501, 3510. M. SORISIO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Breitbach, 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.