Citation Nr: 1017664 Decision Date: 05/12/10 Archive Date: 05/26/10 DOCKET NO. 99-13 865A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an initial compensable evaluation for a right shoulder disorder. 2. Entitlement to an initial compensable evaluation for a left elbow disorder. 3. Entitlement to an initial evaluation in excess of 10 percent for a left inguinal hernia scar. 4. Entitlement to an initial compensable evaluation for the residuals of left hand third and fourth metacarpal fractures. 5. Entitlement to an initial evaluation in excess of 20 percent for residuals of a left orchiectomy with erectile dysfunction, for the period of November 1, 1997 to July 31, 2003. REPRESENTATION Appellant represented by: Michael R. Viterna, Esq. ATTORNEY FOR THE BOARD M. Katz, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1974 to December 1979 and from June 1982 to October 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 1999, May 2003, and January 2004 rating decisions by the Department of Veterans Affairs (VA) Regional Office in Detroit, Michigan (RO). The Board denied the Veteran's claims of entitlement to an initial compensable evaluation for a right shoulder disorder, entitlement to an initial compensable evaluation for a left elbow disorder, entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar, entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures, and entitlement to an initial evaluation greater than 20 percent for residuals of a left orchiectomy with erectile dysfunction for the period of November 1, 1997 to January 31, 2003 by a February 2009 decision. The Veteran appealed the denial of his claims to the United States Court of Appeals for Veterans Claims (Court). Based on a November 2009 Joint Motion for Remand (Joint Motion), the Court remanded the issues for additional reasons and bases and additional development as indicated in compliance with the Joint Motion. The issues of entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar and entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures are addressed in the remand portion of the decision below, and are remanded to the RO. FINDINGS OF FACT 1. That part of the Board's February 2009 decision which denied the Veteran's claims for entitlement to an initial compensable evaluation for a right shoulder disorder, entitlement to an initial compensable evaluation for a left elbow disorder, entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar, entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures, and entitlement to an initial evaluation greater than 20 percent for residuals of a left orchiectomy with erectile dysfunction for the period of November 1, 1997 to July 31, 2003 precluded effective judicial review. 2. Since the initial grant of service connection, the Veteran's right shoulder disorder has been manifested by abduction to 170 degrees, forward flexion to 170 degrees and 110 degrees, internal rotation to 75 degrees and 60 degrees, and external rotation to 75 degrees and 90 degrees. 3. Since the initial grant of service connection, the Veteran's left elbow disorder has been manifested by normal alignment, no deformity, and no evidence of malunion or nonunion of the ulna, and full or almost full range of motion. 4. A left elbow scar is sensitive to touch and tender on examination. 5. From November 1, 1997 to July 31, 2003, the Veteran's residuals of a left orchiectomy were manifested by some urine hesitancy, dysuria, urge incontinence, and erectile dysfunction. There was no recurrence of a tumor or metastasis, no indication of renal dysfunction, and no evidence of a daytime voiding interval of less than one hour or awakening to void 5 or more times per night. 6. The evidence of record shows sensitivity over the post orchiectomy surgical scar. CONCLUSIONS OF LAW 1. That part of the February 2009 Board decision which denied the Veteran's claims for entitlement to an initial compensable evaluation for a right shoulder disorder, entitlement to an initial compensable evaluation for a left elbow disorder, entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar, entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures, and entitlement to an initial evaluation greater than 20 percent for residuals of a left orchiectomy with erectile dysfunction for the period of November 1, 1997 to July 31, 2003, is vacated. 38 U.S.C.A. § 7104(a) (West 2002); 38 C.F.R. § 20.904(a) (2009). 2. The criteria for an initial compensable evaluation for a right shoulder disorder have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5024, 5201 (2009). 3. The criteria for a compensable evaluation for a left elbow disorder have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5019, 5211 (2009). 4. The criteria for a separate 10 percent evaluation for a left elbow scar have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2009). 5. From November 1, 1997 to July 31, 2003, the criteria for an initial evaluation in excess of 20 percent for residuals of a left orchiectomy have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.115b, Diagnostic Codes 7528, 7522 (2009). 6. The criteria for a separate 10 percent evaluation for a post orchiectomy surgical scar have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Vacatur The Board denied the claims of entitlement to an initial compensable evaluation for a right shoulder disorder, entitlement to an initial compensable evaluation for a left elbow disorder, entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar, entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures, and entitlement to an initial evaluation greater than 20 percent for residuals of a left orchiectomy with erectile dysfunction for the period of November 1, 1997 to July 31, 2003 by a February 6, 2009 decision. In that decision, the Board also denied entitlement to an initial compensable evaluation for a right inguinal hernia scar, restored the Veteran's evaluation of 20 percent for service-connected residuals of a left orchiectomy, effective August 1, 2003, and remanded the issues of entitlement to an initial disability evaluation in excess of 10 percent for irritable colon syndrome, entitlement to a total disability rating based on individual unemployability (TDIU), and entitlement to an increased evaluation for allergic rhinitis. The Veteran appealed the denial of the issues of entitlement to an initial compensable evaluation for a right shoulder disorder, entitlement to an initial compensable evaluation for a left elbow disorder, entitlement to an initial compensable evaluation for a right inguinal hernia scar, entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar, entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures, and entitlement to an initial evaluation greater than 20 percent for residuals of a left orchiectomy with erectile dysfunction for the period of November 1, 1997 to July 31, 2003 to the Court. Based on a November 2009 Joint Motion, the Court remanded the issues of entitlement to an initial compensable evaluation for a right shoulder disorder, entitlement to an initial compensable evaluation for a left elbow disorder, entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar, entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures, and entitlement to an initial evaluation greater than 20 percent for residuals of a left orchiectomy with erectile dysfunction for the period of November 1, 1997 to July 31, 2003 for additional reasons and bases and development as indicated in compliance with the Joint Motion, and dismissed the Veteran's appeal of the issue of entitlement to an initial compensable evaluation for a right inguinal hernia scar. A November 2009 letter was sent to the Veteran in which he was given 90 days from the date of the letter to submit additional argument or evidence in support of his appeal prior to the Board's readjudication. In February 2010, the Veteran's representative submitted a response to the November 2009 letter, which indicated that the Veteran had nothing else to submit. The Board may vacate an appellate decision at any time upon request of the Veteran or his or her representative, or on the Board's own motion, when a Veteran has been denied due process of law or when benefits were allowed based on false or fraudulent evidence. 38 U.S.C.A. § 7104(a); 38 C.F.R. § 20.904(a). Here, the Court remanded that part of the Board's February 2009 decision that denied entitlement to an initial compensable evaluation for a right shoulder disorder, entitlement to an initial compensable evaluation for a left elbow disorder, entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar, entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures, and entitlement to an initial evaluation greater than 20 percent for residuals of a left orchiectomy with erectile dysfunction for the period of November 1, 1997 to July 31, 2003, based on the Joint Motion. Accordingly, in order to prevent prejudice to the Veteran, that portion of the February 2009 Board decision denying entitlement to an initial compensable evaluation for a right shoulder disorder, entitlement to an initial compensable evaluation for a left elbow disorder, entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar, entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures, and entitlement to an initial evaluation greater than 20 percent for residuals of a left orchiectomy with erectile dysfunction for the period of November 1, 1997 to July 31, 2003 must be vacated, and a new decision regarding these issues will be entered as if the portion of the Board decision addressing those issues had never been issued. II. Increased Rating Claims VA has certain notice and assistance requirements. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2009). Upon receipt of a substantially complete application for benefits, VA must notify the Veteran of what information or evidence is needed in order to substantiate his claims, and it must assist the Veteran by making reasonable efforts to obtain the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). With respect to the Veteran's claims for entitlement to an initial compensable evaluation for a right shoulder disorder, entitlement to an initial compensable evaluation for a left elbow disorder, and entitlement to an initial evaluation greater than 20 percent for residuals of a left orchiectomy with erectile dysfunction for the period of November 1, 1997 to July 31, 2003, VA has met all statutory and regulatory notice and duty to assist provisions. Prior to a September 2008 readjudication of the Veteran's claims, letters dated in November 2004, March 2006, May 2007, and October 2007 letters satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 491 (2006); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded, Vazquez- Flores v. Shinseki, No. 2008-7150 (Fed. Cir. Sept. 4, 2009); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA defect may be cured by the issuance of a fully compliant notification letter followed by a re- adjudication of the claim). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d. 881, 887 (Fed. Circ. 2007), rev'd on other grounds, Sanders v. Shinseki, 556 U.S. - (2009). The duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records, VA medical treatment records, identified private medical treatment records, and Social Security Administration (SSA) records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In addition, the Veteran has been provided with VA examinations with regard to his right shoulder disorder, left elbow disorder, and residuals of a left orchiectomy with erectile dysfunction, and he has not indicated that he found any of these examinations to be inadequate with regard to those issues. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Further, the Board finds that the VA examinations obtained with regard to those issues are more than adequate, as they provided sufficient detail to rate the Veteran's service-connected right shoulder, left elbow, and residuals of a left orchiectomy. Pursuant to June 2004 and April 2007 Board remands, the RO contacted the Veteran three times and requested that he submit or identify the source of treatment records pertaining to a left elbow surgery in September 2001, but the Veteran did not respond to any of the RO's attempts. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (holding that the duty to assist is not always a one-way street, and that the veteran cannot passively wait for help where he may or should have information that is essential in obtaining evidence). Finally, there is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2009). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2009). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2009). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). As the current appeal is based on the assignment of initial ratings for disabilities following initial awards of service connection for these disabilities, evidence contemporaneous with the claims and the initial rating decisions are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Id. A. Right Shoulder Disorder By a February 1999 rating decision, the RO granted service connection for a right shoulder disorder and assigned a noncompensable evaluation, effective November 1, 1997. The Veteran timely filed an appeal of this decision, contending that he is entitled to a compensable initial evaluation. The Veteran's right shoulder disorder is rated under hyphenated Diagnostic Code 5201-5024. See 38 C.F.R. § 4.71a. The hyphenated code used for rating the Veteran's disability indicates that the Veteran's right shoulder disorder includes tenosynovitis, Diagnostic Code 5024, and limitation of motion, Diagnostic Code 5201. See 38 C.F.R. § 4.27 (2009). Diagnostic Code 5024 directs that disability due to tenosynovitis be rated on limitation of motion of the affected body part, or in this case, Diagnostic Code 5201 for limitation of motion of the arm. Under Diagnostic Code 5201, a 20 percent evaluation is for assignment when limitation of arm motion of the major extremity is to shoulder level. A 30 percent evaluation is contemplated when arm motion of the major extremity is limited to midway between the side and shoulder level (between 45 and 90 degrees), and a 40 percent evaluation is warranted for arm motion limited to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. In every instance where the schedule does not provide a 0 percent rating for a diagnostic code, a 0 percent rating shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31 (2009). Since the medical evidence reveals that the Veteran is right-handed, the right shoulder is considered to be the major extremity and the left shoulder is the minor extremity. See 38 C.F.R. § 4.69 (2009). The Veteran's service treatment records reveal complaints of right shoulder pain. A November 1992 treatment record reflects that the Veteran reported right shoulder pain after a motor vehicle accident. He reported that he did not hit anything inside of the car during the accident. He also complained of stiffness in the neck and chest. In a June 1996 report of medical history, the Veteran noted a painful or trick shoulder or elbow. In July 1997, the Veteran underwent a retirement examination. His upper extremities and musculoskeletal system were found to be normal. In a report of medical history, completed at that time, the Veteran complained of a painful or trick elbow or shoulder and indicated arthritis, rheumatism, or bursitis. In November 1998, the Veteran underwent a VA examination for joints. He reported difficulty lifting anything heavy and right shoulder pain. Physical examination of the right shoulder revealed normal contour and no deformity or swelling. The Veteran noted that his right shoulder pain was located anteriorly in the front of the right shoulder. Range of motion of the right shoulder showed abduction to 170 degrees, forward flexion to 170 degrees, and external and internal rotation to 75 degrees. The Veteran's power was satisfactory against resistance and his grip strength was good. X-rays of the right shoulder were within normal limits without any residual of trauma. The diagnosis was likely chronic tendonitis of the right shoulder. A November 1998 x-ray of the right shoulder revealed minimal hypertrophic change over the superior aspect of the glenoid labrum suggesting degenerative disease. The impression was consistent with clinically questioned arthritis. In July 2003, the Veteran underwent another VA examination for joints. The report notes his complaints of right shoulder pain and weakness. He reported that he was unable to lift objects and that his activities of daily living were somewhat limited. He indicated that he could not raise his arm due to a feeling of weakness. Physical examination of the right shoulder showed normal contour without atrophy or other deformity. Muscle tone was good. Range of motion of the right shoulder showed abduction to 170 degrees, forward flexion to 170 degrees, and internal and external rotation to 75 degrees. Power against resistance was good. There were no abnormal neurological findings in the upper limbs. X-rays of the right shoulder were within normal limits. The diagnosis was subjective complaints of weakness and pain in the right shoulder with adequate range of motion and power. The VA examiner concluded that, "[b]ased purely on service- connected left elbow and right shoulder conditions, the veteran is employable." In June 2008, the Veteran underwent another VA examination for joints. He complained of dull aching right shoulder pain with associated weakness and stiffness. The Veteran denied swelling and redness, but noted instability and giving way. There was no locking. The Veteran was right-hand dominant. He reported flare-ups about four times per month and rated his pain as a 4 to 5 out of 10. He indicated that rest and heat provided relief. He denied any episodes of dislocation or recurrent subluxation and did not use a brace. He reported that his right shoulder did not cause difficulty walking, shopping, or driving, but that he had some difficulty grooming, toileting, and eating. He had no incapacitating episodes over the prior 12 months and denied any numbness or tingling. The VA examiner reported that "at the onset of the examination the observation of the veteran's right shoulder motion seemed without restriction and without discomfort. However, upon him realizing his evaluation was for his right shoulder his symptoms increased." Physical examination revealed range of motion of the right shoulder with forward flexion to 110 degrees and extension and internal rotation to the lower lumbar region, which corresponded to the contralateral side. There was internal rotation to 60 degrees without pain and external rotation to 90 degrees without pain. A Crossover test was equivocal and a Neer test was negative. Lhermitte and Spurling signs were negative and pulses were intact. The anterior interousseus, posterior interousseus, median, radial, ulnar, and axillary nerve distributions were grossly intact. Rotator cuff strength was 5/-5 and limited by the Veteran's cooperation and resultant effort. A Jobe test was equivocal and distal neurovascular status was grossly intact. X-rays of the right shoulder revealed no acute osseus abnormality. There was, however, slight joint space narrowing in the acromioclavicular articulation. The VA examiner diagnosed right shoulder mild acromioclavicular arthritis, and concluded that there was no additional limitation of motion due to pain, fatigue, weakness, or lack of endurance on repetitive use. The VA examiner also found that there was no functional impairment of daily occupational activities due to the Veteran's right shoulder disorder. The Board finds that an initial compensable evaluation for a right shoulder disorder is not warranted. The medical evidence of record shows right shoulder abduction to 170 degrees, forward flexion to 170 degrees and 110 degrees, internal rotation to 75 degrees and 60 degrees, and external rotation to 75 degrees and 90 degrees. A 20 percent evaluation is not warranted as limited motion to the shoulder level has not been shown. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Accordingly, an initial compensable evaluation for a right shoulder disorder is not warranted. An increased evaluation under other potentially applicable diagnostic codes has also been considered. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). For ankylosis of the scapulohumeral articulation, a 30 percent evaluation is assigned for major arm favorable abduction to 60 degrees with the ability to reach the mouth and head. 38 C.F.R. § 4.71a, Diagnostic Code 5200 (2009). However, there is no medical evidence of right shoulder ankylosis. Id. The medical evidence of record also does not demonstrate impairment of the humerus, to include malunion, recurrent dislocation, fibrous union, false flail joint, or flail shoulder. 38 C.F.R. § 4.71a, Diagnostic Code 5202 (2009). Additionally, a compensable evaluation is not warranted under Diagnostic Code 5203, as there is no impairment of the major arm clavicle or scapula. 38 C.F.R. § 4.71a, Diagnostic Code 5203 (2009). Moreover, there is no evidence of any right elbow or forearm impairment. 38 C.F.R. § 4.71a, Diagnostic Codes 5205-5213 (2009). Accordingly, a compensable evaluation for a right shoulder disorder is not warranted under these diagnostic codes. As there is no evidence of a right shoulder muscle disorder, a compensable evaluation for a right shoulder disorder under the diagnostic codes for muscle injuries is not warranted. 38 C.F.R. § 4.73 (2009). Moreover, as there is no evidence of a right shoulder neurological disorder, a compensable evaluation for a right shoulder disorder under the diagnostic codes for neurological disorders is not warranted. 38 C.F.R. § 4.124a (2009). Evaluating the right shoulder disorder under the diagnostic codes for degenerative joint disease has also been considered. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (2009). Degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Although a November 1998 x-ray showed findings consistent with arthritis, a June 2008 x-ray showed slight joint space narrowing in the acromioclavicular articulation, and the medical evidence of record showed that there was range of motion with abduction to 170 degrees, forward flexion to 170 degrees and 110 degrees, internal rotation to 75 degrees and 60 degrees, and external rotation to 75 degrees and 90 degrees, as discussed above, the Veteran's right shoulder limitation of motion is noncompensable under the pertinent diagnostic code for evaluating limitation of motion of the arm. While an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion when the limitation of motion for the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In this case, although the medical evidence notes the Veteran's subjective complaints of right shoulder pain, there is no objective evidence confirming limitation of motion, such as swelling, muscle spasm, or satisfactory evidence of painful motion. The Veteran's subjective reports included complaints of right shoulder pain; difficulty lifting anything heavy; right shoulder weakness with difficulty raising the arm; right shoulder stiffness, instability, and giving way. However, the objective evidence of record showed that there was normal right shoulder contour without atrophy or deformity; good muscle tone; good power against resistence with range of motion; no swelling; good grip strength; range of motion without pain; and 5/-5 rotator cuff strength which was limited only by the Veteran's cooperation and resultant effort. In addition, the July 2003 VA examiner diagnosed "[s]ubjective complaint of weakness and pain in both shoulders" and noted that "there is adequate range of motion on both sides and power is also satisfactory." Also, the June 2008 VA examiner found that "at the onset of the examination the observation of the Veteran's right shoulder motion seemed without restriction and without discomfort. However, upon him realizing his evaluation was for his right shoulder his symptoms increased." Thus, although there are numerous subjective complaints of right shoulder pain, the objective evidence does not show that limitation of motion was confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2009). Accordingly, a compensable evaluation based on degenerative arthritis is not warranted. The Board has also considered whether there is any additional functional loss of the Veteran's right shoulder. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2009); see also DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Factors involved in evaluating and rating disabilities of the joints include: weakness; fatigability; lack of coordination; restricted or excess movement of the joint; or, pain on movement. 38 C.F.R. § 4.45. The Veteran reported right shoulder pain. He denied medication or treatment for his right shoulder pain. He reported flare-ups four times per month and noted that his right shoulder pain affected his day-to-day activities or occupation. The subjective evidence of record indicates right shoulder pain, but there is no evidence of muscle spasm, guarding, weakness, lack of endurance, or fatigue. Also, the June 2008 VA examiner found that there was no additional limitation of motion due to pain, fatigue, weakness, or lack of endurance on repetitive use and that there was no functional impairment of daily occupational activities due to the right shoulder disorder. In summary, the subjective evidence of record demonstrates right shoulder pain, flare-ups, and reported interference in his day-to-day life. The objective evidence of record demonstrates no lack of endurance, fatigue, or weakness. In addition, the VA examiner found that the Veteran's right shoulder symptoms appeared to increase in severity when he realized that the examination was for his right shoulder and not another service-connected disability. A compensable evaluation is thus not warranted because the evidence shows no additional functional impairment, fatigability, incoordination, weakness, or pain sufficient to warrant a compensable evaluation. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca, 8 Vet. App. at 206. B. Left Elbow Disorder By a February 1999 rating decision, the RO granted service connection for a left elbow disorder and assigned a noncompensable evaluation, effective November 1, 1997. The Veteran timely filed an appeal of this decision, contending that he is entitled to a compensable initial evaluation. The Veteran's left elbow disorder is rated under hyphenated Diagnostic Code 5211-5019. See 38 C.F.R. § 4.71a. The hyphenated code used for rating the Veteran's disability indicates that the Veteran's left elbow disorder includes bursitis, Diagnostic Code 5019, and impairment of the ulna, Diagnostic Code 5211. See 38 C.F.R. § 4.27. Under Diagnostic Code 5019, bursitis is rated based on limitation of motion of the affected part, as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5019. Degenerative arthritis requires rating under limitation of motion of the affected joints, if such would result in a compensable disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion of the forearm is rated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207, and 5208. The Veteran is right-handed; accordingly, his left elbow is his minor elbow. 38 C.F.R. § 4.69. The Veteran's service medical records reveal complaints of and treatment for left elbow pain. January 1992 treatment records reveal the Veteran's complaints of left forearm and elbow pain with weakness and loss of strength. The Veteran reported that he was unable to pick up a phone without pain. He also noted some fatigue in fine motor skills and some tingling in the forearm. Reflexes were normal, bilaterally, and muscle strength of the left forearm was 4/5 with associated discomfort. A sensory examination was normal, and there was no atrophy or spasm of the left forearm. The diagnosis was left bracheoradialis muscle and C-6 muscle weakness. A February 1992 treatment record reveals the Veteran's complaints of left elbow aching and pain, with tingling in the hand. Physical examination showed the Veteran's reflexes and motor strength to be intact, but there was pain with pronation. The Veteran's symptoms increased with a Phalen's test. The diagnoses were possible left brachioradialis muscle and C-6 weakness and possible carpal tunnel syndrome. In a June 1996 report of medical history, the Veteran reported a painful or trick shoulder or elbow, which was explained as infrequent left elbow pain. In July 1997, the Veteran underwent a retirement examination. The report notes that his upper extremities and musculoskeletal system were normal. In a report of medical history, completed at that time, the Veteran complained of a painful or trick shoulder or elbow. The physician's notes indicate that the Veteran reported that his elbows gave the sensation of "broken glass" at times when popping. In November 1998, the Veteran underwent a VA joints examination. He noted difficulty resting his left elbow on a hard surface and complained of left arm numbness. Physical examination revealed the Veteran's left elbow was normal looking, without swelling or deformity. There was minimal soft tissue swelling over the olecranon body but no tenderness. There was full range of motion and power. An x- ray of the left elbow was within normal limits and revealed no significant impairment of the left elbow. The diagnosis was likely chronic olecranon bursitis of the left elbow. A March 2001 private treatment record reveals the Veteran's complaints of left arm numbness and weakness in the distribution of the left ulnar nerve with numbness along the right and little finger. Physical examination of the upper extremities was symmetric. There was no atrophy or fasciculations of the upper limbs. Strength, tone, and coordination were well preserved. There were no dystrophic signs noted. Reflexes were plus 2 at the biceps, triceps, and radiobrachialis regions and plus 1 at the finger levels. A sensory examination was unremarkable. The Veteran was able to manipulate objects with the left and right hand and was able to dress and undress without much difficulty. The Veteran underwent an electromyographic study of the left upper limb, which showed the insertional potentials were brisk with electrical silence at rest. There were no fibrillations, fasciculations, or sharp waves noted distally or proximally. The Veteran also underwent nerve conduction studies, which revealed ulnar nerve motor latency at the elbow of 5.2 magnetic stimulation (ms.). Ulnar nerve sensory latency at the elbow was 6.1 ms. Ulnar nerve latency at the wrist was 2.3 ms. motor phase and 2.4 ms. as to the sensory phase. The physician concluded that the neurological examination and the electrophysiological examination were unremarkable and did not reflect any nerve damage either along the ulnar nerve or along the C7 nerve root level. The physician found that it was possible that the Veteran may have sustained either ulnar neuropathy or a C7 radiculopathy, but not enough to cause any electrophysiological changes. A March 2001 computed tomography (CT) scan of the left upper extremity showed mild anterior spur formation at C6-7, mild asymmetric hypertrophy of the left unciate process with moderate associated encroachment on the left neuroforamina at C6-7, and minimal anterior spur formation elsewhere. No other apparent area of stenosis was identified. In July 2003, the Veteran underwent a VA joints examination. The report noted his complaints of left elbow pain. The Veteran reported that he had left elbow surgery in September 2001. He stated that his current pain was a 3 out of 10. He explained that, in November 2000, he experienced a sudden onset of pain in his left elbow, and his whole arm and hand became numb. He had an examination and an electromyography, and eventually, he had elbow surgery. Physical examination of the left elbow revealed normal alignment, without deformity or swelling. There was a surgical scar running on the medial side which appeared to be well healed. There was no abnormal discoloration and there were no adhesions. The scar was sensitive to touch. The ulnar nerve was located in the trochlear groove and there was no thickening. There were no adhesions, but the Veteran complained of pain on palpation. An x-ray of the left elbow was within normal limits. The diagnosis was history of chronic discomfort and pain in the left elbow followed by surgery for the ulnar nerve, with a residual scar on the ulnar side of the left elbow. There was no clinical evidence of a neurological deficit. The VA examiner concluded that, "[b]ased purely on service-connected left elbow and right shoulder conditions, the Veteran is employable." In November 2007, the Veteran underwent a VA joints examination. He complained of left elbow weakness and numbness. He reported ulnar neuropathy was diagnosed in 2000 and that he underwent ulnar nerve surgery in September 2001. The Veteran noted current symptoms including occasional pain and numbness, which affected his activities of daily living. He also indicated that repetitive motion increased his left elbow pain. He denied flare-ups and instability and reported that he did not use an elbow brace. Physical examination revealed the left elbow had a normal appearance. The olecranon was normal and there was no swelling. The skin was healthy and there was no tenderness. There was a 3 inch by 1/16 inch surgical scar on the medial side of the elbow. There were no adhesions and there was no tenderness. The skin was dry and smooth. Range of motion of the elbow revealed extension to 0 degrees and flexion to 145 degrees. There was rotation to 80 degrees. Power was 5/5 and there was no pain on movement. There was no evidence of nonunion affecting the upper or lower ulna. There were no abnormal neurological findings. An x-ray of the left elbow was normal. The diagnosis was status post surgery to the left elbow in 2001, with no evidence of left ulnar neuropathy. The VA examiner also indicated that there was no functional impairment of the left elbow such as weakness, fatigability, incoordination, or pain due to repetitive use or flare-ups. The VA examiner stated that there was no evidence of impairment of the left ulna and that the question of any evidence of nonunion did not arise because the ulna was not involved; nor was there any question of nonunion affecting the upper or lower half of the ulna. There was no deformity, no evidence of malunion of the ulna, no evidence of bad alignment of the bone, and no evidence of a flail joint of the elbow. There was no additional limitation of motion due to pain, fatigue, weakness, or lack of endurance on repetitive use of the joints, and there was minimal impairment of daily occupational activities. An initial compensable evaluation for a left elbow disorder is not warranted under Diagnostic Code 5211. Under Diagnostic Code 5211, impairment of the ulna in the minor extremity with nonunion in the upper half with false movement warrants a 10 percent evaluation when there is malunion with bad alignment; a 20 percent evaluation when there is nonunion in the lower half or without loss of bone substance or deformity; and a 30 percent evaluation when there is loss of bone substance (1 inch (2.5centimeters) or more) and marked deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5211. In the instant case, there is no medical evidence indicating malunion of the ulna, bad alignment of the ulna, nonunion of the ulna, loss of bone substance, or deformity. A July 2003 VA examiner found normal alignment with no deformity or swelling. The November 2007 VA examiner concluded that there was no evidence of impairment of the left ulna, no malunion or nonunion, no deformity, and no bad alignment. Accordingly, an initial compensable evaluation is not warranted under Diagnostic Code 5211. See 38 C.F.R. § 4.71a, Diagnostic Code 5211. The Board also finds that an initial compensable disability evaluation is not warranted for the Veteran's left elbow disorder under Diagnostic Code 5019, which rates based on limitation of motion of the affected part. Under Diagnostic Code 5206, limitation of flexion of the forearm of the minor extremity to 100 degrees warrants a 10 percent evaluation; a 20 percent evaluation is for application when flexion is limited to 70 degrees or 90 degrees; a 30 percent evaluation is warranted when flexion is limited to 55 degrees; and a 40 percent evaluation is warranted when flexion is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5206. Under Diagnostic Code 5207, limitation of extension of the forearm minor extremity to 45 degrees or 60 degrees warrants a 10 percent evaluation; a 20 percent evaluation is for application when extension is limited to 75 degrees or 90 degrees; a 30 percent evaluation is warranted when extension is limited to 100 degrees; and a 40 percent evaluation is warranted when extension is limited to 110 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5207. Under Diagnostic Code 5208, a 20 percent evaluation is warranted when forearm flexion is limited to 100 degrees and extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5208. However, in this case, a November 1998 VA examination found that the Veteran had full range of motion of the left elbow. A November 2007 VA examination noted left elbow flexion to 145 degrees and extension to 0 degrees. Accordingly, an initial compensable evaluation is not warranted under Diagnostic Codes 5206, 5207, 5208. See 38 C.F.R. § 4.71a, Diagnostic Code 5019. The Board has considered whether there is any additional functional loss of the Veteran's left elbow disorder. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. at 206. Factors involved in evaluating and rating disabilities of the joints include: weakness; fatigability; lack of coordination; restricted or excess movement of the joint; or, pain on movement. 38 C.F.R. § 4.45. The Veteran consistently reported left elbow pain and some difficulty with the activities of daily living. The Veteran did not use a brace and denied flare-ups and instability. The objective medical evidence of record consistently showed no pain on movement, good strength, good range of motion, and no limitation due to weakness, fatigability, incoordination, or flare-ups. There was also no muscle atrophy, and there was intact sensation. Accordingly, the Board finds that there is no additional functional loss of the Veteran's service- connected left elbow disorder, and an initial compensable evaluation on this basis is not warranted. The Board has also considered an initial compensable evaluation for the Veteran's left elbow disorder under other pertinent diagnostic codes. See Schafrath, 1 Vet. App. at 595. However, there is no medical evidence of ankylosis of the left elbow, impairment of the flail joint, nonunion of the radius and ulna with flail false joint, impairment of the radius, or impairment of supination or pronation. Accordingly, initial compensable evaluations are not warranted under Diagnostic Codes 5205, 5209, 5210, 5212, or 5213. See 38 C.F.R. § 4.71a, Diagnostic Codes 5205, 5209, 5210, 5212, 5213 (2009). The Board has also considered whether a separate evaluation is warranted for the Veteran's left elbow surgical scar. Such a separate evaluation may only be assigned if there are separate and distinct manifestations from the same injury. See 38 C.F.R. § 38 C.F.R. § 4.14 (2009) (noting that the evaluation of the same disability or the same manifestations of a disability under various diagnoses constitutes prohibited pyramiding); but see Esteban v. Brown, 6 Vet. App. 259 (1994) (finding that when a veteran has separate and distinct manifestations from the same injury he should be compensated under different diagnostic codes). During the pendency of this appeal, VA revised the criteria for diagnosing and evaluating the skin, effective August 30, 2002 and October 23, 2008. See 67 Fed. Reg. 49596 (July 31, 2002); 73 Fed. Reg. 54708-12 (Sept. 23, 2008). With regard to the revisions made to the skin regulations effective October 23, 2008, the revised criteria apply to all applications for benefits received by VA on or after that date. As the Veteran's claim was received prior to October 23, 2008, the revised criteria are not for application in his case. The amendment allows for a Veteran to request a review of a scar disability under the revised criteria irrespective of whether the Veteran's disability has increased since the last review. Id. However, no such request has been made. Accordingly, the Veteran's left elbow scar will not be considered under the revised criteria effective October 23, 2008. Under the skin regulations in effect prior to August 30, 2002, a maximum 10 percent evaluation was assigned for a superficial scar that was tender and painful on objective examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2002). Although the Veteran did not respond to the RO's requests to identify the source of any medical records pertaining to his September 2001 left elbow surgery, the medical evidence of record does identify a surgical scar on the left elbow. Specifically, the July 2003 VA examiner noted a surgical scar running on the medial side of the elbow which appeared to be well-healed. There was no abnormal discoloration or any adhesions, but it was sensitive to touch and the Veteran complained of pain on palpation. The November 2007 VA examiner reported a 3 inch by 1/16 inch long surgical scar on the medial side of the elbow. There were no adhesions or tenderness. The skin was dry and smooth. Thus, as the Veteran indicated during his July 2003 VA examination that he underwent left elbow surgery in September 2001 and that his left elbow scar was sensitive to touch with pain on palpation, there is objective evidence that the Veteran's scar was painful on examination. Accordingly, a separate evaluation of 10 percent for a left elbow scar is warranted, which is the maximum rating allowed for scars which are painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804. However, a rating in excess thereof is not warranted. No other scar diagnostic codes, under the skin regulations in effect prior to August 30, 2002 are for application as the evidence of record does not demonstrate that the scar causes disfigurement of the head, face, or neck; limited motion; is deep; 144 square inches or more; unstable; is a burn; or has been poorly nourished with repeated ulceration. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7803, 7805 (2002). C. Residuals of Left Orchiectomy with Erectile Dysfunction Service connection was granted for residuals of a left orchiectomy, and a 20 percent evaluation was assigned, effective November 1, 1997. For the period of November 1, 1997 to July 31, 2003, the Veteran's residuals of a left orchiectomy were rated as 20 percent disabling under 38 C.F.R. § 4.115b, Diagnostic Codes 7528-7522 (2009). See 38 C.F.R. § 4.27 (noting that the diagnostic code for diseases may contain the diagnostic code for the disease followed by a hyphen and the diagnostic code for the residual condition on which the rating is based). Under Diagnostic Code 7528, malignant neoplasms of the genitourinary system, if there has been no local reoccurrence or metastasis, are rated on their residuals as voiding dysfunction or renal dysfunction, whichever is predominant. Under 38 C.F.R. § 4.115a, a renal dysfunction is rated as 30 percent disabling when there is albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling. A voiding dysfunction requiring the wearing of absorbent materials which must be changed 2 to 4 times per day warrants a 40 percent evaluation. A urinary frequency dysfunction is rated as 40 percent disabling when there is a daytime voiding interval of less than one hour, or; awakening to void five or more times per night. An obstructed voiding dysfunction is assigned a 30 percent evaluation when there is urinary retention requiring intermittent or continuous cathertization. A urinary tract infection is rated as 30 percent disabling when there is recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. See 38 C.F.R. § 4.115a (2009). Under Diagnostic Code 7522, a deformity of the penis with loss of erectile power warrants a maximum 20 percent evaluation. See 38 C.F.R. § 4.115b, Diagnostic Code 7522 (2009). The Veteran's service treatment records reveal that he was diagnosed with pure seminoma of the left testicle and underwent a left orchiectomy in June 1996. He had radiation therapy from July 17, 1996 to August 13, 1996. In October 1996, the Medical Board recommended that the Veteran return to duty. In a December 1996 memorandum regarding the Medical Evaluation Board, it was noted that the Veteran was diagnosed with pure seminoma of the left testicle, Stage I, TNM stage T1N0M0 of the left testicle, status post radical orchiectomy and radiation therapy to the left hemi-pelvis and peri-aortic areas. The Veteran was found fit for continued service. A February 1997 Physical Evaluation Board report notes a diagnosis of pure seminoma, left testicle, stage I, TNM Stage T1N0M0, status post left inguinal orchiectomy and radiation therapy. It was recommended that the Veteran return to duty. The report also noted that the Veteran had a "successful radical resection of his pure seminoma with radiation therapy. His current physical examination was normal and there is no evidence of metastatic disease." A July 1997 retirement physical reveals that the Veteran had a history of a left orchiectomy. In a March 1998 VA treatment record, the Veteran reported that the quality of his life had deteriorated and that he was not able to work or to perform daily activities. A May 1998 CT scan of the abdomen and pelvis revealed no discrete abdominal masses or pelvic masses. There was scarring and secondary changes in the scar along with possible post- surgical changes in the left inguinal area. In November 1998, the Veteran underwent a VA examination. He complained of pain, discomfort, and erectile dysfunction since his orchiectomy. He reported that he had not been sexually active since early 1998. He denied frequent urinary tract infections. Physical examination revealed the left scrotal sac to be empty. The testis was present on the right side. There were no palpable masses. The external genitalia was normal. The diagnoses were left orchiectomy for testicular cancer, status-post radiation, no recurrence, and impotence post orchiectomy by history. July 1999 CT scans of the abdomen and pelvis were negative. In May 2002, the Veteran underwent another VA examination. He complained of pain and discomfort at the surgical site of the left orchiectomy and pain in his scrotum. He denied fever, chills, and urinary tract infections. He noted that his appetite was fair and his weight was stable. His daytime urination frequency was 8 to 16 times and nighttime frequency was 2 times. He complained of some urinary hesitancy, urge incontinence, and dysuria on and off. His urine stream was fairly good. He denied use of diapers or pads and there was no hematuria. There was no nephrolithiasis or acute nephritis and no recent hospitalization for a urogenital disorder. He denied use of intermittent or continuous cathertization. Physical examination revealed a normal phallus. He complained of erectile dysfunction with partial erections since his left orchiectomy and diminished libido. The left testis was absent. There was diffuse hyperthesia and sensitivity over the scrotum and also over the left inguinoscrotal surgical scar. The diagnoses were status-post left orchiectomy for left testicular carcinoma in 1996, subjective paresthesias over the surgical site and also over the scrotum, no recurrence of tumor or metastasis as per history, erectile dysfunction and diminished libido by history, and no penile deformity. The Board finds that an initial evaluation in excess of 20 percent for the Veteran's service-connected residuals of a left orchiectomy for the period of November 1, 1997 to July 31, 2003 is not warranted. There is no medical evidence of local recurrence of testicular cancer or metastasis; nor has the Veteran so alleged. 38 C.F.R. § 4.115b, Diagnostic Code 7528. There is also no medical evidence of renal dysfunction. 38 C.F.R. § 4.115a. In addition, although the Veteran reported some urine hesitancy, dysuria, and urge incontinence, he denied the use of diapers or pads, frequent urinary tract infections, hospitalization for a urogenital disorder, and intermittent or continuous cathertization. Id. Further, although the Veteran reported daytime voiding of 8 to 16 times per day and nighttime voiding of 2 times per night, the Veteran has not alleged or provided evidence that there was a voiding interval of less than one hour or awakening to void 5 or more times per night. Id. While the Veteran reported a daytime voiding frequency of 8 to 16 times per day "which may or may not be an interval of less than an hour, depending on how many hours the appellant sleeps," (see Joint Motion for Remand at 9), there is simply no conclusive medical or lay evidence of a voiding interval of less than one hour or awakening to void 5 or more times per night. The Board acknowledges that, if the evidence showed that the Veteran slept for 8 hours per night and regularly voided 16 or more times per day, that he would be entitled to a 40 percent evaluation. However, if the Veteran regularly slept for 6 hours per night and regularly voided 16 times per night, he would not be entitled to a 40 percent evaluation. Unfortunately, the evidence of record does not speak to the Veteran's sleeping patterns. It also does not show that the Veteran regularly voided 16 times per day and not 8, as he reported that he voided between 8 and 16 times per day. The Veteran is not entitled to an increased evaluation based on a possibility that his voiding of between 8 and 16 times per day equates to a voiding interval of less than one hour on a regular basis. Again, the evidence of record does not speak to the Veteran's sleeping patterns or otherwise indicate that, based on regular voiding of between 8 and 16 times per day, it would equate to a voiding interval of less than one hour during the day. Thus, in the absence of any medical or lay evidence sufficient to conclude that there was a daytime voiding frequency of less than one hour or awakening to void 5 or more times per night, an initial evaluation greater than 20 percent is not warranted for residuals of a left orchiectomy with erectile dysfunction from November 1, 1997 to July 31, 2003. An initial evaluation in excess of 20 percent for residuals of a left orchiectomy for the period of November 1, 1997 to July 31, 2003 is also not warranted under Diagnostic Code 7522 for deformity of the penis with loss of erectile power, as the Veteran receiving the maximum schedular evaluation under Diagnostic Code 7522. 38 C.F.R. § 4.115b, Diagnostic Code 7522. The Board has also considered other potentially applicable diagnostic codes. Schafrath, 1 Vet. App. at 595. But there is no evidence of testicular atrophy or prostate gland injuries. 38 C.F.R. § 4.115b, Diagnostic Codes 7523, 7527 (2009). Although there is evidence of removal of one testis, a 30 percent evaluation is only appropriate when there is evidence of removal of both testes. Accordingly, an initial evaluation in excess of 20 percent is not warranted under Diagnostic Code 7524. See 38 C.F.R. § 4.115b, Diagnostic Code 7524 (2009). Therefore, an initial evaluation in excess of 20 percent for residuals of a left orchiectomy for the time period of November 1, 1997 to July 31, 2003 is not warranted under other diagnostic codes. The Board has considered whether a separate evaluation is warranted for any neurologic component of the Veteran's left orchiectomy for the period of November 1, 1997 to July 31, 2003. While the May 2002 examination found increased sensitivity over the scrotum, a diagnosis of a neurological disorder was not made based on this finding. Accordingly, from November 1, 1997 to July 31, 2003, a separate evaluation for a neurological component of the Veteran's service-connected left orchiectomy is not warranted. The Board has also considered whether a separate evaluation is warranted for the left orchiectomy post surgical scar for the period of November 1, 1997 to July 31, 2003. Under the skin regulations in effect prior to August 30, 2002, a maximum 10 percent evaluation was assigned for a superficial scar that was tender and painful on objective examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2002). A May 2002 VA examination reflects that there was diffuse hyperesthesia over the left inguinoscrotal surgical scar. Accordingly, a separate evaluation of 10 percent for a left orchiectomy post surgical scar is warranted, which is the maximum rating allowed for scars which are painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804. However, a rating in excess thereof is not warranted. No other scar diagnostic codes, under the skin regulations in effect prior to August 30, 2002 are for application as the evidence of record does not demonstrate that the scar causes disfigurement of the head, face, or neck; limited motion; is deep; 144 square inches or more; unstable; is a burn; or has been poorly nourished with repeated ulceration. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7803, 7805 (2002). D. Other Considerations Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2009). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2009). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria under the Rating Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate, and no referral is required. The Board finds that the Veteran's disability picture, throughout all of the time periods on appeal, was not so unusual or exceptional in nature as to render the current ratings inadequate. The Veteran's right shoulder disorder is evaluated pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5024 and 5201, the criteria for which are found to specifically contemplate the level of disability and symptomatology. Since the initial grant of service connection, the Veteran's right shoulder disorder was manifested by abduction to 170 degrees, forward flexion to 170 degrees and 110 degrees, internal rotation to 75 degrees and 60 degrees, external rotation to 75 degrees and 90 degrees, and degenerative arthritis with no objective evidence of swelling, muscle spasm, or satisfactory evidence of painful motion. The Veteran's left elbow disorder is evaluated pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5019 and 5211, and 38 C.F.R. § 4.118, Diagnostic Code 7804, the criteria of which are found to specifically contemplate the Veteran's left elbow disorder. The Veteran's left elbow disorder was manifested by normal alignment, no deformity, no evidence of malunion or nonunion of the ulna, full or almost full range of motion, and a scar which was painful on examination. From November 1, 1997 to July 31, 2003, the Veteran's residuals of a left orchiectomy were evaluated pursuant to 38 C.F.R. § 4.115b, Diagnostic Codes 7528 and 7522, and 38 C.F.R. § 4.118, Diagnostic Code 7804, the criteria of which are also found to specifically contemplate the level of disability and symptomatology. From November 1, 1997 to July 31, 2003, the Veteran's residuals of a left orchiectomy were manifested by some urine hesitancy, dysuria, urge incontinence, and erectile dysfunction. There was no recurrence of a tumor or metastasis, no indication of renal dysfunction, and no evidence of a daytime voiding interval of less than one hour or awakening to void 5 or more times per night, and a sensitive scar. When comparing these disability pictures with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the current disability ratings for his service-connected right shoulder disorder, left elbow disorder, and residuals of a left orchiectomy from November 1, 1997 to July 31, 2003. Ratings in excess thereof are provided for certain manifestations of the service-connected disorders, but the medical evidence of record did not demonstrate that such manifestations were present in this case. The criteria for the current disability ratings more than reasonably describe the Veteran's disability levels and symptomatology and, therefore, the currently assigned schedular evaluations are adequate and no referral is required. As these issues involve initial ratings following the grant of service connection, the Board has considered whether "staged ratings" are warranted. Fenderson, 12 Vet. App. at 126. While there may have been day-to-day fluctuations in these disorders, the evidence shows no distinct periods of time, since service connection became effective for these disorders, during which manifestations varied to such an extent that ratings greater or less than those assigned would be warranted. Cf. 38 C.F.R. § 3.344 (2009) (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). Finally, in reaching these decisions the Board considered the doctrine of reasonable doubt. However, as discussed above, the preponderance of the evidence is against these claims and therefore, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER That part of the February 2009 Board decision which denied the Veteran's claims for entitlement to an initial compensable evaluation for a right shoulder disorder, entitlement to an initial compensable evaluation for a left elbow disorder, entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar, entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures, and entitlement to an initial evaluation greater than 20 percent for residuals of a left orchiectomy with erectile dysfunction for the period of November 1, 1997 to July 31, 2003, is vacated. An initial compensable evaluation for a right shoulder disorder is denied. An initial compensable evaluation for a left elbow disorder is denied. A separate 10 percent rating for a painful scar on the left elbow is granted, subject to the laws and regulations governing the payment of monetary benefits. An initial evaluation in excess of 20 percent from November 1, 1997 to July 31, 2003 for residuals of a left orchiectomy with erectile dysfunction is denied. A separate 10 percent rating for a post orchiectomy surgical scar is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND The issues of entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar and entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures must be remanded for compliance with the November 2009 Joint Motion for Remand. With regard to the issue of entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar, the Joint Motion for Remand noted that the evidence of record showed a diagnosis of postoperative neuralgia in a November 1998 VA examination. The Joint Motion instructed the Board to consider whether an increased evaluation or a separate evaluation was warranted for neurological manifestations associated with the Veteran's left inguinal hernia surgery. The Joint Motion also directed the Board to determine whether a VA examination was warranted if the Board was unable to determine whether the Veteran's neurological manifestations are associated with his left hernia repair. While there is evidence of postoperative neuralgia in November 1998, the evidence is silent as to whether the postoperative neuralgia continued thereafter, and for how long, and whether it still exists now. Thus, the Board concludes that a VA examination and opinion is necessary to determine whether the Veteran's postoperative neuralgia associated with his bilateral inguinal hernia repair was a permanent or chronic residual of his surgery and whether the Veteran currently has neurological manifestations of his left inguinal hernia surgery. With regard to the issue of entitlement to an initial compensable evaluation for residuals of left hand third and fourth metacarpal fractures, the Joint Motion noted that the RO improperly granted service connection for the third and fourth metacarpal fractures, when the Veteran's service treatment records showed that he fractured his fourth and fifth metacarpals during service. Although the Board acknowledged this mistake and considered whether an initial compensable evaluation was warranted for residuals of left fourth and fifth metacarpal fractures, the Joint Motion directed the Board to remand the issue to the RO for the RO to correct the error to reflect service connection for the fourth and fifth metacarpals, and not the third and fourth metacarpals. Accordingly, this issue is remanded for compliance with the Joint Motion. Accordingly, the case is remanded for the following action: 1. The RO must correct its error in granting service connection for left hand third and fourth metacarpal fractures to reflect a grant of service connection for fourth and fifth metacarpal fractures. 2. The RO must afford the Veteran a VA examination to determine the current severity of his service-connected residuals of a left inguinal hernia repair. The claims file and a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail. Any indicated special diagnostic tests that are deemed necessary for an accurate assessment must be conducted. Any further studies deemed relevant by the examiner must also be conducted. The examiner must record all pertinent medical complaints, symptoms, and clinical findings, in detail. The examiner must also report any associated neurological complaints or findings attributable to the Veteran's service- connected residuals of a left inguinal hernia repair. In addition, the examiner must opine as to whether the November 1998 finding of postoperative neuralgia associated with the Veteran's bilateral inguinal hernia repair is a neurological component of his left inguinal hernia repair and whether it is a chronic or permanent residual thereof. All opinions provided must include an explanation of the bases for the opinion. If the requested opinion(s) cannot be made without resort to speculation, the examiner must state this and specifically explain why an opinion(s) cannot be provided without resort to speculation. The report must be typed. 3. The RO must notify the Veteran that it is his responsibility to report for any scheduled VA examination, and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2009). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. Copies of all documentation notifying the Veteran of any scheduled VA examination must be placed in the Veteran's claims file. 4. The examination report must be reviewed by the RO to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO must implement corrective procedures at once. 5. The RO must then readjudicate the issues of entitlement to an initial evaluation greater than 10 percent for a left inguinal hernia scar and entitlement to an initial compensable evaluation for residuals of left hand fourth and fifth metacarpal fractures. If any claim on appeal remains denied, the Veteran and his representative must be provided a supplemental statement of the case. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs