Citation Nr: 0718581 Decision Date: 06/21/07 Archive Date: 07/03/07 DOCKET NO. 05-16 717 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Honolulu, Hawaii THE ISSUES 1. Entitlement to an increased rating for residuals of a shell fragment wound of the right lower leg (Muscle Group XI), currently rated as 30 percent disabling. 2. Entitlement to an increased rating for vitiligo of the right lower leg, currently rated as 10 percent disabling. 3. Entitlement to an increased rating for varicosities of the right lower leg with post-traumatic thrombotic change of the saphenous vein, currently rated as 10 percent disabling. 4. Entitlement to an initial rating in excess of 10 percent for a scar of the right lower leg, status post varicose vein removal. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Nancy S. Kettelle, Counsel INTRODUCTION The veteran served on active duty from June 1969 to June 1971. His awards include the Combat Infantryman's Badge and the Purple Heart Medal. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii. In that rating decision, the RO denied increased ratings for the veteran's service-connected residuals of a shell fragment wound of the right lower leg, vitiligo of the right lower leg, and for varicosities of the right lower leg. At the same time, the RO granted service connection for a scar of the right lower leg, status post varicose vein removal, and assigned a 10 percent rating effective May1, 2003, the date of surgery. The veteran's disagreement with the denial of the increased ratings and his disagreement with the 10 percent rating for the surgical scar led to this appeal. At the time the veteran filed his substantive appeal in May 2005, he requested a hearing before the Board to be held at the RO. The veteran later stated he would accept a videoconference hearing, but in January 2007 withdrew his hearing request. FINDINGS OF FACT 1. Residuals of the veteran's shell fragment wound, in terms of muscle disability of the right lower leg, which includes numerous metallic fragments in the soft tissue and complaints of severe muscle pain, are currently evaluated at the schedular maximum of 30 percent for severe impairment, and they have not been shown to markedly interfere with employment beyond that contemplated by the assigned evaluation or to have resulted in any post-service hospitalization. 2. The veteran's vitiligo of the right lower leg is manifested primarily by complaints of nearly constant itching; it involves less than 20 percent of the entire body and less than 20 percent of an exposed area; treatment has included topical, but not systemic, therapy. 3. The veteran's varicosities of the right lower leg are manifested primarily by intermittent edema of the leg; the evidence does not show persistent edema of the right leg that is incompletely relieved by elevation of the leg. 4. The painful surgical scar of the right lower leg has not been shown to result in limitation of function of an affected part, such as the right calf, knee, or ankle. CONCLUSIONS OF LAW 1. The criteria for the assignment of an evaluation in excess of 30 percent for residuals of the shell fragment wound in terms of muscle disability of the right lower leg (Muscle Group XI) have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.56, 4.73, Diagnostic Code 5311 (2006). 2. The criteria for an increased rating for vitiligo of the right lower leg have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.20, 4.118, Diagnostic Code 7806 (2006). 3. The criteria for an increased rating for varicosities of the right lower leg have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7120 (2006). 4. The criteria for an initial rating in excess of 10 percent for a scar of the right lower leg, status post varicose vein removal, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.118, Diagnostic Codes 7803, 7804, 7805 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA duties to notify and assist Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2006). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his or her possession that pertains to the claim. See 38 C.F.R. § 3.159. These notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability; a connection between the veteran's service and the disability; degree of disability; and the effective date of any award of benefits. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits is issued by the agency of original jurisdiction. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In a letter to the veteran dated in June 2003, the RO explained that to establish entitlement to an increased evaluation for a service-connected disability, the evidence must show that the service-connected condition had gotten worse. The RO told the veteran that it had received his claim and an April 2003 statement from his private physician. The RO notified the veteran that he should complete and return release authorization forms so that it could get his records if there were private medical records he wanted VA to obtain on his behalf. The RO also notified the veteran that he should furnish the name and location of any VA or military facility where he received medical care, and the approximate dates of the care. The RO requested that the veteran inform the RO if he had no additional medical evidence to submit. The RO explained that VA was responsible for getting relevant records from any Federal agency and that on his behalf VA would make reasonable efforts to get other relevant records he identified and for which he supplied appropriate release authorizations. The RO emphasized to the veteran that it was his responsibility to make sure it received all requested records that were not in the possession of a Federal department or agency. In addition, in a letter dated in March 2006, the RO provided the veteran information about evidence needed to evaluate disabilities and to determine the beginning date of any payment to which he might be entitled. The RO explained that in determining a disability rating it considered evidence of the nature and symptoms of the condition, the severity and duration of the symptoms, and the impact of the condition and symptoms on employment. The RO explained that VA uses a schedule for evaluation disability, but that in rare cases it could assign a disability level other than the levels found in the schedule for a specific condition if his impairment was not adequately covered by the schedule. The RO also identified the factors used to determine the beginning date of entitlement to increased benefits, provided of examples of evidence he should submit or identify related to disability ratings and effective dates, and also notified him of what evidence VA would obtain. In a letter dated in June 2006, the RO repeated what it had told the veteran in the March 2006 letter and notified the veteran that in order to support his claim for an increased evaluation for a service connected disability, the evidence must show that his service-connected condition had gotten worse. The RO notified the veteran what evidence it would obtain. The RO told the veteran that he could submit evidence showing that his service-connected conditions for which he was seeking higher ratings had increased in severity. The RO explained that this evidence could be a statement from his doctor and that he could also submit his own statement or statements from other people describing in what manner his disability had become worse. The RO requested that the veteran submit any evidence in his possession pertaining to his claims. In view of the foregoing, the Board finds that the veteran was effectively informed to submit all relevant evidence in his possession and that he received notice of the evidence needed to substantiate his claims, the avenues by which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005); see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005) rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). As to timing of notice, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that timing-of-notice errors can be "cured" by notification followed by readjudication. Mayfield v. Nicholson, 444 F.3d 1328, 133-34 (Fed. Cir. 2006) (Mayfield II); see Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) ("The Federal Circuit specifically mentioned two remedial measures: (1) The issuance of a fully compliant [section 5103(a)] notification, followed by (2) readjudication of the claim."); Pelegrini v. Principi, 18 Vet. App. 112, 122-24 (2004) ("proper subsequent VA process" can cure error in timing of notice). The most recent notice was given to the veteran in June 2006, and the RO thereafter readjudicated the veteran's claims and issued a supplemental statement of the case (SSOC) in July 2006. The United States Court of Appeals for Veterans Claims (Court) has held that a SSOC that complies with applicable due process and notification requirements constitutes a readjudication decision. Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III); see also Prickett v. Nicholson, 20 Vet. App. 370 (2006) (holding a Statement of the Case that complies with all applicable due process and notification requirements constitutes a readjudication decision). As the SSOC complied with the applicable due process and notification requirements for a decision, it constitutes a readjudication of the claim. As a matter of law, the provision of adequate notice followed by a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. Mayfield III, citing Mayfield II, 444 F.3d at 1333-34. Finally, service medical records are in the file, and VA medical records and available private medical records have been obtained. The veteran submitted private medical records, and he has been provided VA examinations with medical opinions. As noted in the Introduction, the veteran withdrew his request for a hearing before the Board. The Board finds the record adequate for rating purposes, and under these circumstances, there is no duty to provide another examination or medical opinion. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the veteran, and thus, no additional assistance or notification is required. The veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384, 392-94(1993). Disability ratings-in general Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2006). Separate diagnostic codes identify the various disabilities. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2006). Ratings for service- connected disabilities are determined by comparing the symptoms the veteran is presently experiencing with the various criteria set forth in the Rating Schedule. When an unlisted condition is encountered, it is permissible to rate it under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2006). Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis or for those not fully supported by clinical and laboratory findings. Id. In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2006) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities at issue. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Court held in Francisco v. Brown, 7 Vet. App. 55, 58 (1994), that compensation for service-connected injury is limited to those claims which show present disability and held: "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 importance." In contrast, in Fenderson v. West, 12 Vet. App. 119 (1999), the Court held that the rule from Francisco does not apply where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability. Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Background The veteran's service medical records show that in Vietnam in March 1970, while walking point on a patrol, the veteran was hit by fragments from a hostile exploding booby trap. On the day of the injury he was treated at the 3rd Field Hospital, and the diagnoses were multiple open wounds of both legs, with severe soft tissue damage medially above the right ankle, with no major artery or nerve involvement. His wounds included an open wound of the thenar eminence of the left hand, with no artery or nerve involvement. The wounds were debrided, and two days later the veteran was sent on to the U.S. Army Hospital, Camp Zama, Japan. There, he underwent delayed primary closure of the wounds under general anesthesia, with closing of all the wounds with the exception of the wound near the right ankle. After approximately two weeks, the veteran was transferred to Tripler General Hospital in Hawaii. There, in April 1970, the veteran underwent a split thickness skin graft from the right thigh to the medial aspect of the right ankle. X-rays taken in April 1970 showed multiple metallic foreign bodies in the both calves. The radiologist stated that he saw no definite fracture lines. The veteran remained hospitalized until late May 1970, when he was sent on a month's convalescent leave followed by a return to duty with a temporary profile for 30 days. The final diagnoses were: multiple fragment wounds, both lower extremities, and full thickness skin loss, medial aspect, right ankle, without bone, nerve, or artery involvement; and open wound, thenar eminence, left hand, no artery or nerve involvement. The examiner who conducted the veteran's service separation examination in June 1971 noted multiple scars on both legs. The earliest post-service evidence is the report of a VA examination in early October 1984. The veteran gave a history of having stepped on a booby trap in Vietnam in 1970 injuring his right ankle and requiring a skin graft. The veteran reported that before service and since service he worked as a cowboy. The examiner noted multiple trauma scars on both lower extremities, and on the medial side of the right ankle a post-operative skin graft measuring 4 by 7 centimeters (cm) with pigmentation changes. Range of motion of the knees and ankles was normal. X-rays of the right ankle including the distal leg showed no recent or old fractures. There were no bone or joint pathologies, but there were multiple small opacities of metallic density in the soft tissues of the mid to lower calf and in the soft tissues on the plantar aspect of the foot posteriorly just below the calcaneus. Office notes from a private physician show that in mid- October 1984 the veteran complained of itching on the medial aspect of the right lower leg, and he reported that he used steroid cream. The physician noted excoriations, pinkness, and irritation in the area of the graft and scar on the right lower leg and told the veteran to continue the steroid cream for his skin. A few days later, the veteran returned complaining of swelling of his right ankle after having jumped off his horse. X-rays showed a fracture in the distal third of the fibula. The veteran was referred to Queens Medical Center. At a VA examination in August 1996, it was noted that the veteran reported progressive pain over the scarred area over the past few years and constant aching especially with weather changes or when his boots rubbed against the old wound. The examiner noted the veteran's work as a cowboy requiring him to wear boots and ride a horse all day. Examination showed deformity of the medial right leg with hyperpigmented changes over most of the leg, central of which was a keloid linear scarred area with about four, 2-cm round, hypertrophy nodules, which were raw and tender to palpation. Adjacent was a depigmented area, and the examiner noted some varicosities. The veteran's gait was normal, and range of motion of the ankle was normal. The examiner said he noted no hyperpigmented or varicosity changes in the left leg. The diagnoses at the August 1996 examination was residuals of shrapnel wounds/booby trap: keloid scar deformity with hypertrophy nodular forms along the scar; vitiligo now present secondary to original trauma; varicosities now developing secondary to original trauma; and hyperpigmentation of involved areas representing either a vascular or post-inflammatory effect secondary to injury. Subsequent VA outpatient records dated from September 1996 to February 1997 show the veteran complained a rash on his right lower extremity. Examination showed hypopigmented and hyperpigmented trophic changes near the right ankle with tiny open areas from scratching. Mycostatin cream, Lidex cream, and Ketoconazol cream were prescribed at various times. At a VA orthopedic examination in April 1998, the veteran complained of itchiness over the wound on the distal medial aspect of the right lower leg. He said that when cold, the wound started to ache. The veteran said he did not notice swelling. He explained that he worked as a cowboy and sometimes had soreness when he walked long distances. He complained of difficulty sleeping due to pain and said he had to take a break when working. He said he took plain Tylenol for pain when he had soreness, which was every other day. He had no complaints of knee pain; he said he had light pain in the right ankle and no pain in the right foot. Examination in April 1998 showed a 12-cm scar of the distal medial aspect of the right lower leg, and at the distal end a 4 by 5-cm, tender, hypopigmented area. There were nontender scars on the medial aspect of the right thigh and the medial aspect of the left thigh. In addition, there was a longitudinal, nontender, surgical scar of the lateral aspect of the right lower leg. The veteran's gait was normal, and there was no swelling or tenderness in the right ankle. Sensation and motor strength were normal in the right ankle and foot. X-rays of the right tibia and fibula showed shrapnel fragments around the tibia. They also showed a healed right ankle fracture with metal plate and screws in the distal fibula with early degenerative joint disease of the right ankle. At a VA fee-basis dermatology examination in April 1998, the veteran complained of profound itching of his right lower leg, especially at night or when wearing high boots, to the point where scratching became irresistible. He reported shocking pains down the leg, especially at night, at rest, more so in cold weather, with the pain sensation radiating into his toes. He said the pain localized in the scars and ankle, especially when climbing or walking. The physician noted that the veteran's gait was normal, and the veteran was able to negotiate climbing and descending from the examination table and removing his shoes and clothes, as well as getting dressed again. The physician said there was keloidal scarring with hyper- and hypopigmentation localized and restricted to traumatized skin area (scarring, not vitiliginous). He said there was irregular pigment loss in a 4 by 21/2 cm area with its center 7 cm above the right internal malleolus with a linear extension obliquely toward and up the right calf, 8 cm long. In addition, he said there was shocking pain sensation from the scarred area into the foot and toes, especially at night in cold weather. The diagnoses were: post-traumatic scarring above and posterior of the right internal malleolus; post-traumatic neuralgic pain; dry skin with superficial scaling, no fungal infection. Color photos accompany the examination report. VA medical records show that from 1998 to 2000, the veteran was seen with continuing complaints of itching and rashes of the right lower leg with treatment with topical creams. In February 2001, the veteran was seen at the Straub Clinic on referral from VA for consultation regarding varicose veins of the right leg. The veteran gave a history of having developed swelling of the right lower leg with sometimes pain, ache, and itch, making him scratch his leg; he also reported noticing some varicose veins coming up on the medial aspect of the calf. On examination of the right leg, there was some swelling at the ankle level. There was scarring on the inside above the medial malleolus. Above this were some large varicose veins. Doppler examination revealed patent and competent deep venous system. Duplex scanning of the veins of the right leg in March 2001 showed no signs of post- thrombitic changes of the deep venous system. Scanning did show post thrombotic changes of the proximal long saphenous vein and shrapnel in the medial aspect of the lower leg. At a March 2001 follow-up visit, the physician discussed treatment alternatives and noted that the veteran basically had some tingling in the lower leg and said he could sleep well and would be interested in treatment should he develop more symptoms. In a rating decision dated in February 2002, the RO granted an increased rating for the veteran's service-connected post- traumatic stress disorder (PTSD) from 30 percent to 100 percent effective in June 1998. At the same time, based on receipt of service medical records not previously in the claims file (which were discussed above), the RO granted service connection for a shell fragment wound of the left hand with a 10 percent rating effective from August 1984 and service connection for a shell fragment wound of the left lower leg with a 10 percent rating effective from August 1984. In addition, the RO granted service connection for a shell fragment wound of the right lower leg with a 30 percent rating from August 1984. The RO also assigned a 10 percent rating for right lower leg vitiligo and a 10 percent rating for varicosities with post-traumatic thrombotic change of the saphenous vein from June 1996. In the February 2002 rating decision, the RO also granted entitlement to special monthly compensation at the housebound rate from June 1998 based on the veteran having one service- connected disability rated at 100 percent with additional disabilities with a combined rating of 60 percent or more. The RO notified the veteran of these decisions in a March 2002 letter. Thereafter, in a signed written statement received at the RO in March 2002, the veteran withdrew his appeal regarding all pending increased rating claims. VA medical records show that in May 2002, the veteran was seen for follow-up of chronic skin rash, and he stated he had been having cramping in his right leg just over the wound site, with cramping more significant over the last month. He reported that he continued to use the steroid cream on an as needed basis. He reported he drank a lot of sodas, but no water, and had not changed any exercise. On examination, the extremities were without edema. There were persistent hyperpigmented changes and fine hyperpigmented papules on the medial aspect of the right leg. At a VA clinic visit in July 2002, the veteran complained of a shock-like pain in his right ankle, which he said was especially worse at night and was exacerbated by walking. The veteran stated that he had had this for many years since he stepped on a booby trap in Vietnam but he felt it was now getting worse. He denied any swelling, redness, or warmth but endorsed subjective weakness of the right foot. The veteran also complained of a pruritic rash at the site of his right leg injury. On examination, the physician noted a large scar on the medial portion of the right leg. Neurological examination, limited to the right foot, revealed diminished pinprick and position sense. There was also weakness of the dorsi- and plantar flexors of the right foot. Range of motion was intact. Skin examination was remarkable for a patchy dermatitis involving the distal right leg. The physician renewed a prescription for Lidex cream. At a follow-up VA clinic visit in October 2002, the veteran continued to complain of persistent pain in the right ankle, particularly at night, and he also complained of the persistent pruritic rash involving his right leg. Extremity examination revealed trace pitting edema of the right leg. There was full range of motion at the right ankle. The physician stated there were several small varicosities on the medial aspect of the right calf as well as extensive scarring and chronic dermatitis changes. The physician renewed the prescription for Lidex cream and said the veteran should limit the use to two weeks at a time. At a vascular consultation at Tripler Army Medical Center in November 2002, the veteran stated that for many years he had noticed discomfort and itching in the distal right lower leg, and he also complained of aching and tingling in the area of his wound, particularly during cold weather. He did not complain of any claudication type symptoms, nor did he note any swelling of the leg. Examination of the right lower extremity revealed a well-healed scar along its medial aspect. There was no edema on his right lower leg, and there were no chronic venous stasis changes. There were small, superficial varicosities on the posterior calf. The physician said that the superficial varicosities did not appear to be related to the veteran's complaint of aching and tingling in the region of his scar. The physician said the 2001 ultrasound finding of retained shrapnel could potentially be related to the veteran's present complaints. At a VA clinic visit in April 2003, extremity examination revealed scarring and atrophy of the right ankle, and there was trace pitting edema below the right knee. Skin examination revealed chronic dermatitis below the right mid calf. The physician noted that the veteran reported he had recently been seen at Straub Clinic and was scheduled for surgery in May 2003 to remove shrapnel and to "flush out" his leg veins. Records from Straub Clinic show that in March 2003, the veteran returned after two years reporting that he continued to have problems from his right lower leg, mainly with itching and eczema and small ulcerations. The physician noted that duplex scanning in March 2001 had shown there was shrapnel buried under the scarred skin and that the veteran also had developed incompetent perforators with varicosities around the scarred area. In an April 2003 memorandum , the veteran's private physician, N.E.A., M.D., said he had seen the veteran in April 2003 with ongoing complaints of tenderness and pain in his right ankle, difficulty ambulating and bearing weight on his right foot, and recurrent dermatitis in the area. The physician noted that in 2002, the veteran had been seen by a vascular specialist at Tripler Army Medical Center and that he had been seen by a vascular specialist at Straub Clinic in March 2003 with a follow-up and surgery planned for May 2003. Records from Straub Clinic include the report of duplex scanning of the veins of the right leg done in April 2003; the impression was incompetent perforators of the right lower leg with effects of shrapnel. In early May 2003, the veteran underwent perforator ligation phlebectomies and shrapnel extraction from the right leg. VA outpatient records show that in May 2003, a week following surgery, the veteran was seen for removal of the surgical dressing and Ace wrap of the right leg scar area. The surgical area was clean, dry, and healing well with minimal bruising to the area. In May 2003, the veteran filed his claim for increased ratings for his shell fragment wound of the right lower leg, right lower leg varicosities, and right lower leg vitiligo stating that he felt those disabilities had become worse. At a VA examination in September 2003, the physician noted the veteran's history of shrapnel injury to the right calf, which over the years had hurt when it was cold and rainy. It was noted that the veteran developed a superficial varicose vein, which was removed along with some shrapnel in May 2003. The veteran reported that the area was still quite uncomfortable. On physical examination, there was a 2 cm by 1 cm area of vitiligo, which the physician said was irregular in shape and minimally deforming. It was not depressed, elevated, indurated, or infected. There was a scar the shape of "a seven" which was approximately 6 to 8 cm in length, total. There were areas of induration and elevation, and the physician said that in spite of the scar being almost four months old, the whole area of the scar was still exquisitely tender and there might be shell fragments in the subcutaneous tissue. The physician said the veteran's gait was entirely normal. The diagnoses were: shell fragment wound, right lower leg with retained fragments, hurting when weather is cold; varicose vein, status post surgical removal with no residual problem; vitiligo of the right lower extremity secondary to the shell fragment wound, minimally deforming vitiligo; and scar in early healing stages, very tender, minimally deforming at this time. Color photos accompany the examination report. September 2003 VA X-rays of the right tibia and fibula showed a plate and six bone screws in the lateral surface of the distal right fibula. The impression was old fracture with internal fixation of the distal right fibula. The radiologist also stated there were numerous metallic shrapnel fragments present in soft tissues. At a VA clinic visit in December 2003, the veteran reported decreased pain since the May 2003 surgery but said the area remained itchy and was painful at times. He said he took Tylenol as needed for it. On examination, the physician said there was an angulation deformity of the right leg with chronic scarring. He said varicose vein changes were present. Skin examination revealed a papular rash over the right ankle and foot. The physician renewed a prescription for Vicodin. In March 2004, the veteran's main complaint was a stinging pain and coolness in the right foot especially in cool weather. He rated the pain at a 5/10 intensity during the day increasing to 8-9/10 at night. He reported some blanching of the foot, but no other color changes. He denied claudication. Extremity examination revealed scarred areas with trace pitting edema of the right leg. The toes were cool. Pedal pulses were 2+, and capillary refill was intact. Skin examination revealed a raised rash over the right ankle and foot with excoriation. The physician noted that veteran was poorly compliant with oral medication, and he was encouraged to use the Vicodin as needed for pain. He was given a trial of Zostrix high potency cream. The veteran was also noted to have been noncompliant with topical corticosteroids and was encouraged to resume the Lidex cream as needed. At a follow-up VA clinic visit in July 2004, the veteran had no specific complaints. He reported a decrease in his right foot pain with warmer weather. He said he had not obtained any pain relief with the Zostrix high potency cream and had stopped using it. He denied any swelling or significant cramping in the right leg. Extremity examination revealed no clubbing, cyanosis, or edema. At his next VA clinic visit in January 2005, the veteran voiced no specific complaints. He stated he was doing well and denied any swelling or significant cramping in his right leg. Extremity examination revealed no clubbing, cyanosis, or edema. The veteran requested refills of his Lidex cream and Vicodin. At a VA clinic visit in April 2005, the veteran presented for evaluation of a painful rash on his right leg. He reported worsening pain in his right leg with cool weather and described a shock-like pain that interfered with his sleep. He also reported an itchy rash that he felt compelled to scratch. He said that he had been applying the Lidex cream and taking Vicodin, but the physician said that the veteran appeared to use these medications on an inconsistent basis. Examination of the right leg revealed scarring over the medial aspect. There was chronic dermatitis with excoriations, and there was trace pitting edema. The physician gave the veteran a trial of lidocaine ointment for his right leg pain and noted there might be some skin atrophy from chronic use of high-potency steroids. He planned to switch the veteran to a lower potency steroid cream such as triamcinolone, 0.1 percent. At a VA clinic vast in October 2005, the veteran reported continuance of intermittent episodes of a rash on the scar area on his right lower leg. He stated that he continued to wear cowboy boots daily. Extremity examination revealed no clubbing, cyanosis, or edema. There was discoloration and loss of pigmentation on the right lower leg. When the veteran was seen in February 2006, he reported that he had received prescriptions for acyclovir, prednisone, and Lortab for an outbreak of shingles in the last month. His main complaint at the clinic visit was his chronic pain in the right leg, particularly at night. It was noted the trial of lidocaine ointment had not given him any relief, and he did not recall what his response was to a more recent trial of gabapentin. Extremity examination revealed no clubbing, cyanosis, or edema. Skin examination revealed no active dermatitis. The physician said there appeared to be very little that could be done for the veteran's chronic leg pain secondary to his shrapnel wounds. The physician said resumption of narcotic analgesics for as needed use would be considered. At a VA examination in June 2006, the physician noted the veteran was injured with an explosion/booby trap while Vietnam having sustained shrapnel injury to the right calf, which over the years had hurt, particularly in cold and rainy weather. The veteran said the pain was even worse at night, at which time he estimated it to be 8-9 on a scale of 10. He reported that he had finished the narcotics he had been given for this and now used extra strength Tylenol or Motrin at least three to four times a day for the discomfort. The physician noted that the veteran developed a superficial varicose vein, which was removed along with some shrapnel in May 2003 at Straub Medical Center. The veteran said the area was still quite uncomfortable even with doing something like lifting a garbage can. The veteran said he could walk and stand no more than five minutes before he had pain in the right leg. He said sitting was okay. The veteran stated that he wears boots because it makes his legs feel better. The veteran said he uses a steroid cream on the depigmented skin. He said he usually used it every morning and every evening and that it decreased the itch tremendously. On examination in June 2006, the area of vitiligo was approximately 2 by 1 cm, irregular in shape, shiny, and minimally deforming. It was not depressed, elevated, indurated, or infected. There was a scar in the shape of a number seven, which was approximately 6 to 8 cm in length, total. The scar was mildly tender to palpation. The physician noted that June 2006 X-rays of the right tibia/fibula were compared with the September 2003 X-rays and again showed status post open reduction with internal fixation of the fibula with retained foreign bodies in soft tissue. The assessment after the clinical examination and review of X-rays was: shell fragment wound to the right lower leg with retained shrapnel fragments hurting with cold, wet weather changes; varicose veins, status post surgical removal with no residual problems; vitiligo of the right lower extremity secondary to the shell fragment wound, minimally deforming, still uses steroid cream to diminish the itch; and scar minimally tender to the touch and minimally to moderately deforming. Color photos of the right lower leg accompany the examination report. Muscle disability 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. For Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56 (2006). Disability is considered to be slight if the disability results from a simple wound without debridement, infection, shown by service medical records to be a superficial wound requiring brief treatment and return to duty and healing with good functional results, without any of the cardinal signs of muscle disability as shown above. The objective evidence of slight disability consists of a minimal scar, no evidence of fascial defect, atrophy, or impaired tonus. There is no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(1). Muscle disability is considered to be moderate if it was caused by a through and through or deep penetrating wound of short track from a single bullet or a small shell or shrapnel fragment, without the explosive effect of a high velocity missile, with the residuals of debridement or prolonged infection. Evidence of moderate disability consists of consistent complaints of one or more of the cardinal signs and symptoms of muscle disability as shown above, particularly lowered threshold of fatigue after average use, which affects the particular functions controlled by the injured muscles. The objective signs of moderate disability include small or linear entrance and (if present) exit scars, indicating a short track of the missile through muscle tissue. There is some loss of deep fascia or muscle substance, impairment of muscle tonus and loss of power, or a lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). Muscle disability is considered to be moderately severe if it results from a through and through or deep penetrating wound by a small high velocity missile or large low-velocity missile, with evidence of debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. Evidence of a moderately severe muscle injury includes service department records or other evidence showing hospitalization for a prolonged period for treatment of the wound, consistent complaints of the cardinal signs and symptoms of muscle disability as shown above and, if present, evidence of inability to keep up with work requirements. The objective evidence of a moderately severe muscle disability includes entrance and (if present) exit scars that indicate a track of the missile through one or more muscle groups. There is indication of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side. Tests indicate impairment of strength and endurance in comparison to the sound side. 38 C.F.R. § 4.56(d)(3). A severe muscle disability results from 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, intermuscular binding and scarring. The objective findings would include ragged, depressed and adherent scars indicating wide damage to muscle groups in the missile track; palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in the wound area; muscles that swell and harden abnormally in contraction; tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; (B) adhesion of the 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; (C) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) visible or measurable atrophy; (E) adaptive contraction of an opposing group of muscles; (F) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (G) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4). Increased rating for shell fragment wound of the right lower leg The RO has evaluated the veteran's shell fragment wound of the right lower leg under 38 C.F.R. § 4.73, Diagnostic Code 5311 (Injuries to Muscle Group XI) (2006). Diagnostic Code 5311 specifies that Muscle Group XI includes the posterior and lateral crural muscles and muscles of the calf. Functions include propulsion, plantar flexion of the foot, stabilization of the arch, flexion of the toes, and flexion of the knee. The medical evidence at the time of the veteran's injury did not specifically identify the muscle group involved. The veteran's primary complaints center on intense pain in the right calf and ankle area, and there is some evidence of weakness in the right foot and ankle. The fact that the veteran has retained shrapnel fragments in this area is undisputed. The Board therefore finds that it is appropriate to rate the veteran's disability under Diagnostic Code 5311 because it pertains to muscle injuries of the area identified in the veteran's case. There is no evidence that any other muscle group is involved. Neither the veteran nor his representative has suggested that another diagnostic code be used. In the present case, the RO has evaluated the veteran's shell fragment wound of the right lower leg at the 30 percent rate under Diagnostic Code 5311. Under this diagnostic code, a maximum 30 percent evaluation is assigned in cases of severe disability. Prior to and throughout the appeal period, the veteran's shell fragment wound of the right lower leg has been evaluated at this 30 percent maximum rate under Diagnostic Code 5311, and there exists no schedular basis for a higher disability evaluation. While examiners have, on some occasions, said that the veteran's chronic right leg pain appears to be neuropathic in nature, it is the judgment of the Board that a separate evaluation of the right leg under a diagnostic code for neurological symptoms would constitute pyramiding, as 38 C.F.R. § 4.56 as Diagnostic Code 5311 already contemplates pain, weakness, and any impairment of leg and ankle function. See 38 C.F.R. § 4.14. The Board has considered whether to remand this matter to the RO for procedural actions outlined in 38 C.F.R. § 3.321(b)(1), which concern the assignment of extra- schedular evaluations in exceptional cases. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 94-95 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board finds no basis for such action in this case. The record includes no evidence showing that the veteran's shell fragment wound of the right lower leg, in and of itself, has markedly interfered with his employment status beyond that interference contemplated by the assigned schedular 30 percent evaluation. In this regard, medical records show that the veteran has reported that he stopped working as a cowboy because of work injuries including a "straddle" injury involving his urinary system and a shoulder injury requiring multiple surgeries. Since then he has reportedly worked doing leather work and saddle construction. Further, the veteran has not been hospitalized for the muscle injury itself during the pendency of this appeal. In short, the history of muscle disability from the shell fragment wound of the right lower leg is not consistent with the type of disability picture for which further consideration under 38 C.F.R. § 3.321(b)(1) is warranted. For these reasons, the preponderance of the evidence is against an increased rating for the shell fragment wound of the right lower leg, and the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The claim must be denied. Vitiligo Because of the itching associated with the vitiligo of the right lower leg, the RO has rated the veteran's vitiligo under Diagnostic Code 7806, which is the diagnostic code for dermatitis or eczema. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2006). Vitiligo is not listed in the VA Rating Schedule, and in view of the associated symptoms, the Board agrees that it is appropriately rated by analogy under the diagnostic Code 7806. See 38 C.F.R. § 4.20. Under the provisions of Diagnostic Code 7806, a noncompensable rating will be assigned if less than 5 percent of the entire body is affected or less than 5 percent of exposed areas are affected, and; no more than topical therapy was required during the past 12-month period. A 10 percent rating is warranted when at least 5 percent, but less than 20 percent of the entire body or at least 5 percent, but less than 20 percent of exposed areas are affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating requires that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; a 30 percent rating is warranted where systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating requires that more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; a 40 percent rating is warranted when constant or near-constant systemic therapy such a corticosteroids or other immunosuppressive drugs were required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. In this case, the evidence shows that the veteran's vitiligo is manifested primarily by discoloration and loss of pigmentation on the right lower leg, particularly in the area of the in-service skin graft, along with a papular rash on the leg and ankle with severe itching evidenced by excoriation at times. There has been treatment with a variety of topical creams; systemic therapy has not been used. As the affected area involves the right lower leg and ankle, it is not on an exposed area. This means that percentage of exposed area affected is not applicable as a criterion for a higher rating. Further, there is no showing that the affected area involves at least 20 percent of the entire body, and the requirements for the next higher 30 percent rating cannot be met on that basis. While the veteran was treated with various medications including prednisone for shingles in 2005, there is no evidence, nor does the veteran contend, he has received systemic therapy for his service-connected disability. Rather, the evidence shows he has been treated with topical therapy with trials of multiple topical creams for his symptoms throughout the appeal period. Given these findings, it is clear that the manifestations of the veteran's vitiligo do not meet or more nearly approximate the criteria for a 30 percent rating. In view of the forgoing, the Board finds that the preponderance of the evidence is against the claim for an increased rating for the veteran's vitiligo of the right lower leg, and the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The claim must be denied. Varicosities of the right lower leg The veteran is also seeking an increased rating for varicosities of the right lower leg with post-traumatic thrombotic change of the saphenous vein, currently rated as 10 percent disabling. The veteran's varicose veins have been evaluated using criteria of 38 C.F.R. § 4.104, Diagnostic Code 7120. In pertinent part, this diagnostic code allows for the assignment of a 20 percent evaluation when there is evidence of persistent edema incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema; a 40 percent evaluation when there is evidence of persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration; and, a 60 percent evaluation when there is evidence of persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. 38 C.F.R. § 4.104, Diagnostic Code 7120. The medical evidence outlined above shows that at various times, specifically in October 2002, April 2003, March 2004, and April 2005, examiners noted trace pitting edema of the right lower leg, but otherwise during the rating period, which included many clinic visits pertaining to complaints involving the right lower leg, edema was not mentioned or there was an explicit finding of no edema on examination. Further, at the VA examinations in September 2003 and June 2006, both of which were after the varicose vein surgery in May 2003, the pertinent diagnoses were varicose vein, status post removal with no residual problems. Based on this evidence, the Board cannot find the presence of persistent edema of the right lower leg, which would be required for the next higher 20 percent rating for varicose veins under Diagnostic Code 7120. The Board acknowledges that the Rating Schedule includes pigmentation changes and eczema as factors in rating varicose veins, particularly the higher rating levels, but in this case pigmentation changes and the veteran's skin symptoms have been rated as part of his service-connected vitiligo under Diagnostic Code 7806. Consideration of these symptoms in deciding whether an increased rating is warranted for varicose veins of the right lower leg would violate the rule on avoidance of pyramiding at 38 C.F.R. § 4.14, which states the evaluation of the same disability under various diagnoses is to be avoided. See Fanning v. Brown, 4 Vet. App. 225 (1993). The Board thus finds that the evidence does not demonstrate the presence of persistent edema associated with the veteran's service-connected varicosities of the right lower leg with post-traumatic change of the saphenous vein, which is an essential element factor for a rating higher than 10 percent for varicose veins. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The claim must be denied. Scar of the right lower leg, status post varicose vein removal Effective May 1, 2003, the date of the varicose vein surgery of the right lower leg, the RO granted service connection for the surgical scar and assigned a 10 percent rating under 38 C.F.R. § 4.118, Diagnostic Code 7804. Diagnostic Code 7804 provides a maximum 10 percent rating for superficial scars (i.e., scars that are not associated with underlying tissue damage) that are painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2006). The Board agrees that Diagnostic Code 7804 is the most appropriate diagnostic code for evaluation of the veteran's post-surgical scar of the right lower leg. While a number of other diagnostic codes deal specifically with scarring, there is no appropriate diagnostic code that provides a higher rating than that assigned under Diagnostic Code 7804. In this regard, Diagnostic Code 7800 is inapplicable as that diagnostic code covers scars on the head, face, and neck only. Diagnostic Codes 7802 and 7803, which respectively apply to superficial scars covering a large areas and superficial scars that are unstable, each provide a maximum 10 percent rating - the same as that which is currently assigned. Diagnostic Code 7805, which provides for rating scars based on limitation of the affected part, is also inapplicable as the medical evidence does not show, nor does the veteran contend, that the post surgical right lower leg scar produces any limitation of function. (As has been discussed above, any limitation of function of the right lower leg itself or the right ankle and foot is included in the 30 percent rating under Diagnostic Code 5311.) The only other diagnostic code potentially applicable in rating the post-surgical scar is Diagnostic Code 7801. Diagnostic Code 7801 provides that a 10 percent disability rating is warranted for scars other than the head, face, or neck that are deep or cause limited motion and that have an area or areas exceeding 6 square inches (39 sq. cm.). A 20 percent disability rating requires an area or areas exceeding 12 square inches (77 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7801. In this case, there is no medical evidence that the scar is deep or that it causes limitation of motion. Further, while the scar is from 6 to 8 cm in length, there is no statement as to width, but photos show the scar's width to be much less than one sixth of its length. Total area thus does not remotely approximate an area in excess of 77 sq. cm. required for a 20 percent rating under Diagnostic Code 7801. Review of the record shows that as of the time of the VA examination in September 2003, the surgical scar of the right leg was very tender and minimally deforming and that by the time of the June 2006 VA examination, it was minimally tender, and the examiner described it as minimally to moderately deforming. Disfigurement related to scars is a factor only when rating scars of the head face or neck. See 38 C.F.R. § 4.118, Diagnostic Code 7800. While the evidence shows variability in the level of pain associated with the scar, the highest possible rating of 10 percent under Diagnostic Code 7804 for the entire rating period. For the reasons expressed above, the Board finds that the scar of the right lower leg, status post varicose vein removal, is appropriately rated as 10 percent disabling throughout the rating period. As preponderance of the evidence is against the claim to a higher initial rating, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The claim must be denied. (Order follows on next page.) ORDER Entitlement to an increased rating for residuals of a shell fragment wound of the right lower leg (Muscle Group XI) is denied. Entitlement to an increased rating for vitiligo of the right lower leg is denied. Entitlement to an increased rating for varicosities of the right lower leg with post-traumatic thrombotic change of the saphenous vein is denied. Entitlement to an initial rating in excess of 10 percent for a scar of the right lower leg, status post varicose vein removal is denied. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs