Citation Nr: 0006047 Decision Date: 03/07/00 Archive Date: 03/14/00 DOCKET NO. 96-48 948 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to a disability evaluation in excess of 30 percent for severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. L. Krasinski, Counsel INTRODUCTION The veteran served on active duty from October 1966 to October 1969, and from June 1971 to December 1986. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from rating decisions of the Department of Veterans Affairs (VA), San Diego, California, Regional Office (RO). FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's claim for an increased evaluation has been obtained insofar as possible by the RO. 2. The veteran's service-connected severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major) is principally manifested by complaints of pain and objective findings of a solid fusion of the metacarpophalangeal joint of the right thumb in full extension and with no motion; normal motion of the interphalangeal joint of the right thumb without pain; full range of motion of the second, third, fourth and fifth fingers of the right hand; a four centimeter scar on the dorsum of the metacarpophalangeal joint of the right thumb which was well-healed, nontender and nonpainful upon objective demonstration; degenerative changes of the first carpometacarpal joint and interphalangeal joint of the right thumb; and full range of motion of the right wrist, which is productive of moderately severe disability. CONCLUSION OF LAW The criteria for a disability evaluation in excess of 30 percent for a severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major) have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, 4.73, Diagnostic Codes 5224, 5307 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION In general, an allegation of increased disability is sufficient to establish a well-grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is satisfied that all relevant facts have been properly developed. The veteran was afforded VA examinations in October 1995, June 1996, and April 1997. Pertinent treatment records were obtained. The Board finds that no further assistance is required to comply with the duty to assist the veteran mandated by 38 U.S.C.A. § 5107(a). Pertinent Law and Regulations In evaluating the severity of a particular disability, it is essential to consider its history. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1 and 4.2 (1999). However, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. Cf. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991). Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (1999). Where 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 (1999). When an unlisted condition is encountered it will be permissible to rate under a closely related disease to injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (1999). The provisions of 38 C.F.R. § 4.40 state that the disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. According to this regulation, it is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 (1999). The provisions of 38 C.F.R. § 4.45 state that when evaluating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45 (1999). With any form of arthritis, painful motion is an important factor of disability. The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or maligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (1999). Except as otherwise provided in the Rating Schedule, all disabilities, including those arising from a single entity, are to be rated separately, and then all ratings are to be combined pursuant to 38 C.F.R. § 4.25 (1999). One exception to this general rule, however, is the anti-pyramiding provision of 38 C.F.R. § 4.14 (1999), which states that evaluation of the same disability under various diagnoses is to be avoided. The Board notes that the Court of Appeals for Veterans Claims (formerly the Court of Veterans Appeals) (Court), in Esteban v. Brown, 6 Vet. App. 259 (1994), held that conditions are to be rated separately unless they constitute the "same disability" or the "same manifestation" under 38 C.F.R. § 4.14. Esteban, at 261. Thus, where manifestations such as symptomatic scarring, bone or joint deformity or limitation of motion, and/or nerve involvement are present, VA must assess whether such are, in fact, separately compensable. After reviewing all the evidence and material of record, where there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given the claimant. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.102 (1999). Thus, when a veteran seeks benefits and the evidence is in relative "equipoise," the law mandates that the veteran prevails. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis Service connection for fusion of the metacarpophalangeal joint of the right thumb was established in November 1987. A 10 percent disability evaluation was assigned effective December 20, 1986, under Diagnostic Code 5224. The award was based upon service medical records and the findings of the March 1987 VA examination. The service medical records show that the veteran had a laceration of the flexor pollicis longus tendon of the right hand in 1974. Following surgical repairs, the veteran continued to have problems with adhesions. In August 1976, the veteran had arthrodesis of the metacarpophalangeal joint. In May 1995, the veteran filed a claim for an increased evaluation. A November 1995 rating decision increased the evaluation of the service-connected fusion of the metacarpophalangeal joint of the right thumb to 20 percent effective May 2, 1995, under Diagnostic Code 5307. In a July 1996 rating decision, the RO characterized the service-connected right thumb disability as residuals of severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring. A 30 percent evaluation was assigned effective April 1, 1996 for the residuals of a severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring. Under Diagnostic Code 5307, Injuries to Muscle Group VII, muscles arising from the internal condyle of the humerus (flexors of the carpus and long flexors of the fingers and thumb and pronator) whose function is the flexion of the wrist and fingers, a noncompensable evaluation is warranted for slight muscle injury to the dominant arm; a 10 percent evaluation is warranted for moderate injury of the dominant arm; a 30 percent evaluation is warranted for moderately severe injury of the dominant arm; and a 40 percent evaluation is warranted for severe injury to the dominant arm. 38 C.F.R. § 4.73, Diagnostic Code 5307. Muscle injuries are evaluated in accordance with the principles and criteria set forth in 38 C.F.R. §§ 4.55, 4.56, and 4.73, Diagnostic Codes 5301 to 5329. Amendments to these regulations became effective on July 3, 1997, during the pendency of the veteran's appeal. 62 Fed. Reg. 106, 30235- 30240 (Jun. 3, 1997) (codified at 38 C.F.R. §§ 4.55-4.73 Diagnostic Codes 5301-5329; 38 C.F.R. §§ 4.47-4.54, 4.72 were removed and reserved). The defined purpose of the changes was to incorporate updates in medical terminology, advances in medical science, and to clarify ambiguous criteria. The comments clarify that the changes were not intended to be substantive. See 62 Fed. Reg. No. 106, 30235-30237. The Board notes that the ratings assigned to the different disability levels; i.e. severe, moderately severe, moderate, and slight, did not change. The definitions of those terms changed as did the principals of combining evaluations for such injuries under 38 C.F.R. §§ 4.55 and 4.56. The Board finds that no substantive changes were made to the provisions of 38 C.F.R. § 4.56 or to Diagnostic Code 5307. The revised provisions of 38 C.F.R. § 4.55 (1999) provide that a muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions: 6 muscle groups for the shoulder girdle and arm (diagnostic codes 5301 through 5306); 3 muscle groups for the forearm and hand (diagnostic codes 5307 through 5309); 3 muscle groups for the foot and leg (diagnostic codes 5310 through 5312); 6 muscle groups for the pelvic girdle and thigh (diagnostic codes 5313 through 5318); and 5 muscle groups for the torso and neck (diagnostic codes 5319 through 5323). 38 C.F.R. § 4.55 (1999). The revised provisions of §4.56 provide that for VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. Id. A slight muscle disability is a type of injury from a simple wound of muscle without debridement or infection. 38 C.F.R. § 4.56(d)(1). History includes brief treatment of a superficial wound in service and return to duty; healing with good functional results; and no cardinal signs or symptoms of muscle disability as defined in paragraph (c) of 38 C.F.R. § 4.56. Id. Objective findings include minimal scarring; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. Id. A moderate muscle disability is a type of injury from a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. 38 C.F.R. § 4.56(d)(2). History includes service department records or other evidence of in-service treatment for the wound and a record of a consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56, particularly lowered threshold of fatigue after average use affecting the particular functions controlled by the injured muscles. Id. Objective findings include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue and some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. Id. A moderately severe muscle disability is a type of injury resulting from a through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. 38 C.F.R. § 4.56(d)(3). History includes service department records or other evidence showing hospitalization for a prolonged period for treatment of wound and a record of consistent complaints of cardinal signs and symptoms of muscle disability; and, if present, evidence of inability to keep up with work requirements. Id. Objective findings include an entrance and (if present) exit scars indicating track of missile through one or more muscle groups; indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side; and tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. Id. A severe muscle disability is a type of injury caused by a through and through or deep penetrating wound due to high- velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, and intermuscular binding and scarring. 38 C.F.R. § 4.56(d)(4). History includes service department records or other evidence showing hospitalization for a prolonged period for treatment of wound, a record of consistent complaints of cardinal signs and symptoms of muscle disability, as defined by 38 C.F.R. § 4.56(c), which are worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Id. Objective findings include ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track; palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area; and muscles swell and harden abnormally in contraction. Id. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. 38 C.F.R. § 4.56. If present, the following are also signs of severe muscle disability: X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; visible or measurable atrophy; adaptive contraction of an opposing group of muscles; atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; or induration or atrophy of an entire muscle following simple piercing by a projectile. Id. In applying the law to the existing facts, the record does not demonstrates the requisite objective manifestations for a 40 percent evaluation to the severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major) under the provisions of Diagnostic Code 5307. Under Diagnostic Code 5307, in order for a 40 percent disability evaluation to be assigned, the medical evidence of record must demonstrate severe muscle injury. See 38 C.F.R. § 4.73, Diagnostic Code 5307. The service medical records show that the veteran had a laceration of the flexor pollicis longus tendon of the right hand in 1974. Following surgical repairs, the veteran continued to have problems with adhesions. In August 1976, the veteran had arthrodesis of the metacarpophalangeal joint. The March 1987 VA orthopedic examination report indicates that the veteran was right-handed. He was able to use his right hand for ordinary purposes, including dressing, eating, and the like, but he reported that objects tended to fall out of his hand. He no longer typed with his right hand. Examination revealed that the veteran had full range of motion of all of his joints of his upper extremity without crepitus deformity or muscular atrophy, with the exception of the right hand. He had fusion of the metacarpophalangeal joint of the right thumb; he lacked 30 degrees of abduction. There was no motion of the fused metacarpophalangeal joint. Flexion of the interphalangeal joint of the right thumb was 15 degrees, compared with 90 degrees on the left; there was a loss of 75 degrees of flexion to the interphalangeal joint. The veteran was able to oppose the thumb to the middle and index fingers, but not to the 4th and 5th fingers. There was a 4 centimeter scar of the dorsum of the right thumb overlaying the metacarpophalangeal joint. There was an 11 inch scar skirting from the interphalangeal joint across the thenar eminence to the wrist. There was a mild loss of sensation in the palmar aspect of the thenar eminence. The veteran was able to abduct and adduct the fingers from the central ray on both hands but he could not make a cone with the fingers of the right hand. The diagnosis, in pertinent part, was fusion of the metacarpophalangeal joint of the right thumb, and status post laceration of the flexor tendon laceration of the right thumb with tendon repairs. X-ray examination revealed a deformity and fusion of the right first metacarpophalangeal joint which was most likely due to trauma. Review of the record reveals that the veteran underwent VA examinations in October 1995, June 1996, and April 1997. The October 1995 VA examination report indicates that upon examination, in attempting to make a fist, all of the fingertips reached the medial palmar crease. The veteran was able to adduct and abduct the fingers from a central ray. He lacked 45 degrees of adduction of the right thumb. He was able to oppose the thumb to the index and middle finger but not the ring finger or the fifth finger of the right hand. These motions were normal on the left. Flexion of the interphalangeal joint of the right thumb was 30 degrees, compared with 90 degrees on the left. Grasp with the right or major hand was 180 units; it was 300 units on the left. The diagnosis was status post laceration of the flexor pollicis longus tendon of the right thumb with failed repairs, fusion of the metacarpophalangeal joint of the right thumb, limitation of motion of the interphalangeal joint and limitation of adduction of the right thumb, and relative weakness of the grasp of the right hand or major hand as described above. A June 1996 VA examination report indicates upon examination, the tendon of the flexor pollicis longus stood out. The veteran was told to approximate the tip of each finger respectively to the median transverse fold at palmar aspect of both hands. The right thumb was one inch away from that fold. The right index and middle fingers are one inch away from the fold. The right ring and little fingers are two inches away. The veteran's ability to pick up a piece of paper between the thumb and middle finger was weak. The veteran could not get contact of the thumb with other fingers when fully flexed. Grasping objects was weak for the right hand. The diagnosis, in pertinent part, was residual injury to the right thumb status post surgeries, with weakness, decreased sensation to light touch pain, and temperature; decreased range of motion of all right fingers; tender scar; and residual of carpal tunnel syndrome status post surgery with diminishment of the motion of the right wrist and a tender scar. An April 1997 VA examination report indicates that examination revealed that there was a 9 centimeter scar on the volar aspect of the thumb, which extended along to the flexor pollicis longus tendon area and through the thenar eminence. It came down the volar carpal ligament. There was a 4 centimeter scar on the dorsum of the metacarpophalangeal joint of the right thumb as well. Both of the scars were well-healed. Examination revealed that the veteran had a solid fusion of the metacarpophalangeal joint. He had active motion of the interphalangeal joint from zero degrees to 70 degrees. This was equal to the left thumb interphalangeal joint motion. The veteran complained that he could not touch the thumb to the other fingers, which was a position of opposition, but the examiner finally got him to touch the thumb-tip to the index and long fingers and almost to the ring finger of the right hand. There was no pain or tenderness at the carpometacarpal joint, which was the joint that would permit the veteran to do opposition of the thumb with the fingertips. The veteran complained that he could not move his long finger down into the palm. However, when the veteran moved his fingers, he brought his finger tips to the distal palmar crease. There was full range of motion of the interphalangeal joints and the metacarpophalangeal joints of the fingers 2, 3, 4,and 5 and he could bring the fingertips to the distal palmar crease. The examiner noted that the veteran's sublimis tendon had been removed; the profundus tendon was not removed. Sensation was completely normal in the entire hand. This first dorsal interosseous muscle was perfectly strong in the right hand and equal to the strength of the first dorsal interosseous of the left hand. The veteran did not have any median sensory loss or motor loss in the hand or opponens function. He did not have any ulnar motor loss; ulnar sensory loss was inconsistent. The diagnosis was flexor pollicis longus laceration right thumb, with multiple operations, ending up with metacarpophalangeal fusion. The examiner noted that the veteran had flexor pollicis longus function and flexion of the interphalangeal joints of the right thumb. He flexed the interphalangeal joint of the right thumb as much as he flexed the interphalangeal joint of the left thumb. Strength was equal in these two motor functions of each thumb. He did have limited opposition of the thumb to the other fingers on the right hand. He was able to touch the tip of the right thumb to the index and long fingers, and almost to the ring finger of this right hand. The examiner indicated that from a functional standpoint at that time, the veteran did have complete and solid fusion of the metacarpophalangeal joint of this right thumb. It was in a good position, in full extension, and was solid. The examiner did not find tenderness in the scar on the dorsum through which the arthrodesis of the metacarpophalangeal joint was done. The veteran complained that there was a little pain there, but the examiner was quite convinced that it was not so. The examiner concluded that from an impairment standpoint, the veteran did have an arthrodesis of the joint and no motion in that joint. He has normal motion in the interphalangeal joint of this right thumb. It was not painful motion. The examiner did not find weakness or fatigability or incoordination of these motions. The veteran did have a decrease in opposition of the thumb to the other fingers, but this was not due to the flexor pollicis longus injury or the arthrodesis of the metacarpophalangeal joint. X-ray examination revealed that there was a fusion of the 1st metacarpophalangeal joint. Degenerative changes were seen in the 1st carpometacarpal joint space, and minimally at the 1st interphalangeal joint. The remainder of the hand demonstrated mild degenerative changes involving several interphalangeal joints and at the radiocarpal joint space. The VA examination reports indicate that the veteran reported that he took pain medication daily for the constant pain in his right hand and thumb. He stated that he had difficulty handling small objects with his right hand and he could not type. The veteran indicated that when eating, he frequently dropped food because he could not firmly handle the spoon. At a hearing before the RO in January 1997, the veteran stated that he had swelling of the right hand and the hand was hard to use. Hearing Transcript, hereinafter Tr., 4. He indicated that he was unable to grasp things and he had constant pain. Tr. 4. The veteran took Ibuprofen, 800 milligrams, for the pain, about five days a week, two or three times a day. Tr. 5 and 6. The veteran had problems grasping utensils or writing. Tr. 7. He used both of his hands to eat, but he mainly used his left hand. Tr. 7. He was only able to hold a pen and write for about ten or fifteen minutes. Tr. 7. He used his left hand to grasp objects. Tr. 7. His right hand hurt when he drove a car. Tr. 8. The veteran indicated that during the course of a day, he used his right hand to wash his face, to cut food, use the ATM machine, and to drive. Tr. 11 to 14. The veteran tried to use his right hand for cooking, eating and holding things. Tr. 11 to 15. Overall, the Board finds the symptomatology of the severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major) does not exceed the criteria for moderately severe muscle disability under Diagnostic Code 5307, when consideration is given to the extent of the orthopedic symptoms. As discussed in detail above, the medical evidence of record establishes that the veteran has a fusion of the metacarpophalangeal joint of the right thumb with no motion. He has normal motion of the interphalangeal joint of the right thumb without pain and full flexion of the other fingers of the right hand. The veteran has full flexion of the right wrist. The medical evidence does not demonstrate severe muscle disability. There is no evidence of wide damage to the muscle group, loss of deep fascia or muscle substance, soft, flabby muscles in the wound area, or muscles that swell or harden abnormally in contraction. There is no evidence of severe impairment of the right hand or right thumb. There is no evidence of visible or measurable atrophy as compared to the left hand and thumb. Thus, the Board finds that a disability rating in excess of 30 percent is not warranted. Diagnostic Code 5307. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.73, Diagnostic Code 5307. The Board has examined the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 in order to evaluate the existence of any functional loss due to pain, or any weakened movement, excess fatigability, incoordination, or pain on movement of the veteran's right thumb and hand. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In this case, the veteran reported having constant pain in his right hand and thumb and he took pain medication. However, there are no objective findings of painful motion of the fingers of the right hand. The medical evidence of record establishes that the veteran has a weak grasp of the right hand. However, there is no evidence of atrophy. Motor function of the interphalangeal joint of the right thumb was equal to that of the corresponding joint of the left thumb. There is no evidence of weakened movement, incoordination or excess fatigability of the interphalangeal joint of the right thumb or the remaining fingers of the right hand. The evidence shows that the veteran is able to use his right hand for washing, driving, cutting food, and using an ATM machine. The Board finds that the degree of dysfunction caused by pain and weakness is not shown to be greater than that which the current 30 evaluation reflects. Thus, an evaluation in excess of 30 percent for moderately severe disability is not warranted based on 38 C.F.R. §§ 4.40, 4.45, 4.59. The veteran's service-connected severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major) may also be rated under Diagnostic Code 5224, ankylosis of the thumb. Limitation of function of the fingers is rated under Diagnostic Codes 5216 to Diagnostic Code 5227 (1999). See 38 C.F.R. § 4.71a, Diagnostic Codes 5216 to 5227 (1999). Diagnostic Codes 5216 to 5219 set forth the criteria for rating unfavorable ankylosis of multiple fingers. See 38 C.F.R. § 4.71a, Diagnostic Codes 5216 to 5219. Diagnostic Codes 5220 to 5223 set forth the rating criteria for favorable ankylosis of multiple fingers. See 38 C.F.R. § 4.71a, Diagnostic Codes 5220 to 5223 (1999). Diagnostic Codes 5224 to 5227 set forth the rating criteria for ankylosis of individual fingers. See 38 C.F.R. § 4.71a, Diagnostic Codes 5224 to 5227 (1999). Under Diagnostic Code 5224, ankylosis of the thumb, a 10 percent evaluation is warranted for favorable ankylosis of the major thumb and a 20 percent evaluation is warranted for unfavorable ankylosis of the major thumb. See 38 C.F.R. § 4.71a, Diagnostic Code 5224. The Rating Schedule provides that extremely unfavorable ankylosis will be rated as amputation under diagnostic codes 5152 through 5156. In classifying the severity of ankylosis and limitation of motion of single digits and combinations of digits, the following rules will be observed: (1) Ankylosis of both the metacarpophalangeal and proximal interphalangeal joints, with either joint in extension or in extreme flexion, will be rated as amputation; (2) Ankylosis of both the metacarpophalangeal and proximal interphalangeal joints, even though each is individually in favorable position, will be rated as unfavorable ankylosis; (3) With only one joint of a digit ankylosed or limited in its motion, the determination will be made on the basis of whether motion is possible to within 2 inches (5.1 centimeters) of the median transverse fold of the palm; when so possible, the rating will be for favorable ankylosis, otherwise unfavorable; (4) With the thumb, the carpometacarpal joint is to be regarded as comparable to the metacarpophalangeal joint of other digits. 38 C.F.R. § 4.71a, Multiple Fingers: Favorable Ankylosis, Notes (1) through (4) (1999). Under Diagnostic Code 5152, a 40 percent evaluation is assigned for amputation of the major thumb with metacarpal resection. 38 C.F.R. § 4.71a, Diagnostic Code 5152. A 30 percent evaluations assigned for amputation of the major thumb at the metacarpophalangeal joint or through the proximal phalanx. Id. A 20 percent evaluation is assigned for amputation of the major thumb at the distal joint or through the distal phalanx. 38 C.F.R. § 4.71a, Diagnostic Code 5152 (1999). The Board points out that a disability evaluation in excess of 30 percent is not available under Diagnostic Code 5224; the highest possible evaluation under this diagnostic code is 20 percent. However, a disability evaluation in excess of 30 percent is possible under Diagnostic Code 5152, amputation of the thumb. As noted above, the Rating Schedule provides that ankylosis of both the metacarpophalangeal and proximal interphalangeal joints, with either joint in extension or in extreme flexion, will be rated as amputation. See 38 C.F.R. § 4.71a, Multiple Fingers: Favorable Ankylosis, Notes (1) through (4) (1999). In the present case, the evidence of record does not demonstrate ankylosis of both the metacarpophalangeal and proximal interphalangeal joints of the right thumb, with either joint in extension or in extreme flexion. The evidence of record shows that there is a fusion of the metacarpophalangeal joint of the right thumb in full extension without motion. However, the veteran had normal motion of the interphalangeal joint of the right thumb upon VA examination in 1997. Thus, the Board finds that a 40 percent evaluation is not warranted under Diagnostic Code 5152. The veteran's severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major) may also be rated under Diagnostic Code 5003, degenerative arthritis. See 38 C.F.R. 4.71 a, Diagnostic Code 5003. Under the provisions of Diagnostic Code 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the joint or joints affected. 38 C.F.R. 4.71a, Diagnostic Code 5003. However, as discussed above, the veteran is currently being compensated for limitation of motion of the right thumb under Diagnostic Code 5307. Thus, a separate disability rating for limitation of motion of the thumb is not appropriate under Diagnostic Code 5003, as this symptomatology is duplicative and overlapping as that considered under Diagnostic Code 5307. See Esteban v. Brown, 6 Vet. App. 259; 38 C.F.R. 4.14, 4.55. The Board also points out that, as discussed in detail above, a disability evaluation in excess of 30 percent, based upon limitation of motion of the right thumb is not warranted under the appropriate diagnostic codes. See 38 C.F.R. § 4.71a, Diagnostic Codes 5152, 5224. Review of the record reveals that the veteran underwent carpal tunnel surgery of the right upper extremity. The Board points out that there is medical evidence of record which establishes that the veteran's carpal tunnel syndrome is not related to the service-connected severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major). The April 1997 VA examination report indicates that the examiner concluded that the carpal tunnel syndrome and subsequent operations were not related to the injury of the thumb or to the operations. The examiner noted that it most certainly was a straight forward laceration of the flexor pollicis longus tendon and multiple procedures were done. The examiner suspected there were several attempts at repair of the tendon and the sublimis muscles from the long finger of the veteran's right hand was used for the motor. It was attached to the distal tendon of the flexor pollicis longus and that was functioning. The examiner indicated that it would be quite unusual and very unlikely that these operations would have produced a carpal tunnel syndrome in the veteran. It would also be quite unusual and very unlikely that any of these operations or the injury to the flexor pollicis longus would have produced any pressure on the ulnar nerve or ulnar nerve symptoms. Thus, the Board finds that an additional disability evaluation, for the service-connected severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major), is not warranted under the diagnostic codes pertinent to disease of the peripheral nerves of the hand and fingers. See 38 C.F.R. § 4.124a, Diagnostic Codes 8510 to 8716 (1999). The veteran's service-connected severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major) may also be rated under the provisions of Diagnostic Codes 7803, 7804, or 7805, since there is evidence that the veteran has a scar due to the surgery for the fusion of the right metacarpophalangeal joint of the right thumb. Under Diagnostic Code 7804, superficial scars, which are tender and painful on objective demonstration, warrant a 10 percent evaluation. 38 C.F.R. § 4.118, Diagnostic Code 7804 (1999). Superficial scars which are poorly nourished with repeated ulceration are rated as 10 percent disabling under 38 C.F.R. § 4.118, Diagnostic Code 7803 (1999). Other scars are ratable on the limitation of the part affected under 38 C.F.R. § 4.118, Diagnostic Code 7805 (1999). The evidence of record establishes that the veteran has a 4 centimeter scar on the dorsum of the right thumb due to the fusion of the right metacarpophalangeal joint of the right thumb. However, there are no objective findings that this scar is tender or painful upon objective demonstration, poorly nourished with repeated ulceration, or that the scar causes functional limitation of the right thumb. An October 1995 VA examination report indicates that there was a 2 inch dorsal scar over the metacarpophalangeal joint of the right thumb. It was noted that the scar was well- healed and not keloidal, and it did not limit function. A June 1996 VA examination report indicates upon examination, there was a surgical scar measuring 2 inches in length and 1/16 inch in width on the anterior dorsal aspect over the right metacarpophalangeal joint of the thumb. The scar was not keloidal or hypertrophic. It was noted that the scar was slightly tender and adherent to the underlying bone. However, the April 1997 VA examination report indicates that the examiner concluded that the veteran did not have pain or tenderness in the dorsal aspect of the thumb scar, which was the scar of the fusion. Examination revealed that there was a 4 centimeter scar on the dorsum of the metacarpophalangeal joint of the right thumb. The scar was well-healed. It was noted that the examiner asked the veteran about the pain in the dorsal scar and evaluated the scar very carefully. The examiner had the veteran lay his hand flat on the table and he pressed on the dorsal scar. The veteran complained that it hurt "a little bit." The examiner indicated that he picked up the veteran's hand, held it in his hand, and pressed on the volar aspect of the thenar muscles of the right thumb. The examiner noted that he pressed on both sides of the thumb and he pressed very hard. He asked the veteran if that hurt. The examiner noted that he was obviously pressing as much on the dorsum of the thumb as on the volar aspect. The veteran said it hurt a little bit on the volar aspect of the thumb. The examiner asked the veteran if it hurt any other place and the veteran said it did not hurt in any other place at all. The examiner noted that he repeatedly pressed on the dorsal scar of the metacarpophalangeal joint when he had the veteran's attention diverted to some other area and he had no pain there. Examination also revealed that sensation was completely normal in the entire hand. The examiner did not find tenderness in the scar on the dorsum through which the arthrodesis of the metacarpophalangeal joint was done. Consequently, an additional disability evaluation for the service-connected severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major) under Diagnostic Codes 7803, 7804, or 7805 is not warranted. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.118, Diagnostic Codes 7803, 7804, and 7805. As shown above, and as required by Schafrath, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran. In this case, the Board finds no provision upon which to assign a rating in excess of 30 percent to the severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major). The preponderance of the evidence is against the veteran's claim for an increased evaluation. In summary, after considering all possible rating criteria, the Board finds that a disability evaluation in excess of 30 percent is not warranted for the severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major), for the reasons discussed above. ORDER Entitlement to an increased evaluation for severed flexor pollicis longus status post multiple surgeries with fusion of the metacarpophalangeal joint of the right thumb with degenerative changes and tender scarring (major) is denied. THOMAS J. DANNAHER Member, Board of Veterans' Appeals