Citation Nr: 1222331 Decision Date: 06/26/12 Archive Date: 07/02/12 DOCKET NO. 07-00 905 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent for right (major) hand shrapnel wounds, with right 2nd, 4th and 5th metacarpal fractures and degenerative arthritis in the ulnar carpal/metacarpal joints at the base of the 5th metacarpal. 2. Entitlement to an initial evaluation in excess of 10 percent for right (major) wrist fracture with degenerative arthritis and right wrist and right forearm shrapnel wounds. 3. Entitlement to an initial evaluation in excess of 20 percent for a left (minor) lower leg shrapnel wound with retained foreign body. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Christine C. Kung, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from August 1997 to November 2004. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a August 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which in pertinent part, granted service connection for (1) right (major) hand shrapnel wounds, with right 2nd, 4th and 5th metacarpal fractures and degenerative arthritis in the ulnar carpal/metacarpal joints at the base of the 5th metacarpal; (2) a right (major) wrist fracture with degenerative arthritis and right wrist and right forearm shrapnel wounds; and (3) a left (minor) lower leg shrapnel wound with retained foreign body. The Veteran appealed his assigned ratings. The claims file was subsequently transferred to the RO in Waco, Texas. The Board remanded the case to the RO for further development in October 2010. Development has been completed and the case is once again before the Board for review. FINDINGS OF FACT 1. Right (major) hand shrapnel wounds, with right 2nd, 4th and 5th metacarpal fractures and degenerative arthritis in the ulnar carpal/metacarpal joints at the base of the 5th metacarpal do not approximate severe, incomplete paralysis of the right median nerve. 2. The Veteran has evidence of a gap of 2.5 centimeters or more between the right thumb and the base of the little finger with the thumb attempting to oppose the fingers; a gap of 2.5 centimeters or more between the fingertip of the right index finger and the proximal transverse crease of the palm; and a gap of 2.5 centimeters or more between the fingertip of the right long finger and the proximal transverse crease of the palm. 3. A combined rating based on limitation of motion of the individual digits of the hand would not exceed the Veteran's currently assigned rating under Diagnostic Code 8615, and a separate rating would constitute pyramiding under 38 C.F.R. § 4.14. 4. The Veteran does not have favorable or unfavorable ankylosis of the right wrist. 5. The Veteran does not have a moderate muscle injury to Muscle Group VII or Muscle Group VIII from a through-and-through or deep penetrating wound without explosive effect of a high velocity missile, residuals of debridement or prolonged infection; he does exhibit one or more cardinal signs and symptoms of a muscle disability; and scars are minimal, small or linear, with no loss of deep fascia, muscle substance, or impairment of muscle tonus. 6. The Veteran has 90 degrees flexion in the left leg after repetitive use, with pain beginning at 40 degrees. 7. The Veteran does not have a moderate left ankle disability; and disability of the left knee is no more than slight. 8. The Veteran has a moderate muscle injury to Muscle Group XII from a deep penetrating wound due to multiple low velocity missiles, evidence of in-service treatment for the wound; a record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability; and scars are minimal, small or linear, with no loss of deep fascia, muscle substance, or impairment of muscle tonus. 9. A separate rating for a left (minor) lower leg shrapnel wound based on injury to Muscle Group XII would constitute pyramiding under 38 C.F.R. § 4.14. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 30 percent right (major) hand shrapnel wounds, with right 2nd, 4th and 5th metacarpal fractures and degenerative arthritis in the ulnar carpal/metacarpal joints at the base of the 5th metacarpal have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.40, 4.56, 4.71a, Diagnostic Codes 5228-5229, 4.73 Diagnostic Codes 5307 and 5308, 4.124a Diagnostic Code 8615 (2011). 2. The criteria for an evaluation in excess of 10 percent for a right (major) wrist fracture with degenerative arthritis and right wrist and right forearm shrapnel wounds have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.40, 4.56, 4.71a Diagnostic Codes 5214 and 5215, 4.73 Diagnostic Codes 5307 and 5308 (2011). 3. The criteria for an evaluation in excess of 20 percent for a left (minor) lower leg shrapnel wound with retained foreign body have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 4.40, 4.56, 4.71a Diagnostic Code 5260 - 5262, 4.73 Diagnostic Code 5312 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004). VA has met its duty to notify and assist the Veteran in this case. In a January 2005 and April 2005 letters, VA informed the Veteran of the evidence necessary to substantiate his initial claims for service connection, evidence VA would reasonably seek to obtain, and information and evidence for which the Veteran was responsible. VA did not provide the Veteran with notice of the type of specific evidence necessary to establish a disability rating or effective date prior to the initial rating decision. However, despite inadequate notice on these two elements, the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Id; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In that regard, January 2005 and April 2005 letters addressed the Veteran's original application for service connection. In August 2005, the RO awarded service connection for right (major) hand shrapnel wounds, with right 2nd, 4th and 5th metacarpal fractures and degenerative arthritis in the ulnar carpal/metacarpal joints at the base of the 5th metacarpal; a right (major) wrist fracture with degenerative arthritis and right wrist and right forearm shrapnel wounds; and a left (minor) lower leg shrapnel wound with retained foreign body. Therefore, the January 2005 and April 2005 letters served their purpose in providing VCAA notice and their application is no longer required because the original claim has been "substantiated." See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's current appeal is for higher initial ratings his service-connected disabilities. The RO issued a statement of the case in December 2006, providing the Veteran with the pertinent criteria for establishing higher initial ratings. Thus, the Board finds that VA complied with the procedural requirements of 38 U.S.C.A. §§ 5104, 7105(d), and 38 C.F.R. § 3.103(b). Given the nature of the Veteran's claim, the fact that he was examined by VA during the appeal, and was provided the criteria required for a higher evaluation, the Board finds that a reasonable person would have generally known about the requirements necessary to establish a higher rating. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Veteran's service treatment records, VA treatment records, and VA examinations have been associated with the claims file. The Board notes specifically that the Veteran was afforded a VA examination in March 2005, February 2010, and March 2012 with an April 2012 electromyography (EMG) study. 38 C.F.R. § 3.159(c)(4) (2011). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As set forth in greater detail below, the Board finds that, cumulatively, the VA examinations obtained in this case are adequate as they are predicated on a review of pertinent evidence of record; contain a description of the history of the disability at issue; document and consider the Veteran's complaints and symptoms; fully address the relevant rating criteria; and contain a discussion of the effects of the Veteran's service-connected disabilities on his occupational and daily activities. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board finds that the updated VA examinations and addendums are adequate for rating purposes and finds that the RO has fully complied with the October 2010 Board Remand directives. See Stegall v. West, 11 Vet. App. 268, 270 (1998), (holding that a remand by the Board imposes upon the Secretary of the VA a concomitant duty to ensure compliance with the terms of the remand). VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claim, and to respond to VA notices. The Veteran and his representative have not made the Board aware of any additional evidence that needs to be obtained prior to appellate review. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2011). B. Disability Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2011). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2011). Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2011). VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The United States Court of Appeals for Veterans Claims (Court or CAVC) has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered whether staged ratings are for consideration; however, the Board finds that the evidence of record does not establish distinct time periods where the Veteran's service-connected disabilities result in symptoms that would warrant different ratings. Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2011). Pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45 (2011). Painful, unstable, or malaligned joints, due to a healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59 (2011). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14 (2011). However, it is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Paralysis, Neuritis, and Neuralgia of the Median Nerve Diagnostic Codes 8515, 8615, and 8715 provide ratings for paralysis, neuritis, and neuralgia of the median nerve. 38 C.F.R. § 4.124a. Neuritis and neuralgia are rated as incomplete paralysis. Disability ratings of 10, 30, and 50 are warranted, respectively, for mild, moderate, and severe incomplete paralysis of the major median nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8615 (2011). A disability rating of 70 is warranted for complete paralysis of the median nerve; the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended and cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. Id. The Board notes that in rating diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a (2011). When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. Degenerative Arthritis Arthritis due to trauma is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2011). Degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2011). However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent evaluation is assigned with x-ray evidence of involvement of two or more major joints; a 20 percent rating is assigned with x- ray evidence of involvement of two or more major joints with occasional incapacitating exacerbations. Id. Limitation of motion of individual digits of the hand is evaluated under Diagnostic Codes 5228-5230. 38 C.F.R. § 4.71a (2011). Diagnostic Code 5228 for limitation of motion of the thumb assigns a noncompensable rating with evidence of a gap of less than one inch (2.5 cm. between the thumb pad and the finger, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5228. A 10 percent evaluation is assigned with evidence of a gap of one inch to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Id. Diagnostic Code 5229 for limitation of motion of the index or long finger of either hand assigns noncompensable rating with evidence of a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5229. A 10 percent evaluation is assigned with evidence of a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. Id. Under Diagnostic Code 5230, a noncompensable rating is assigned with any limitation of motion of the ring or little finger. 38 C.F.R. § 4.71a, Diagnostic Code 5230. Limitation of motion of the wrist is rated under Diagnostic Codes 5214 and 5215. 38 C.F.R. § 4.71a (2011). Under Diagnostic Code 5214, a 30 percent disability evaluation is warranted when there is favorable ankylosis in 20 to 30 degrees dorsiflexion in the major wrist. 38 U.S.C.A. § 4 .71a, Diagnostic Code 5214 (2011). A higher 40 percent disability evaluation is contemplated for ankylosis of the major wrist in any other position, except favorable. Id. A 50 percent rating is assigned for ankylosis of the major wrist when ankylosis is unfavorable, in any degree of palmar flexion, or with ulnar or radial deviation. Id. Under Diagnostic Code 5215, a maximum 10 percent rating is assigned when there is limitation of motion of the wrist with dorsiflexion less than 15 degrees or with palmar flexion limited in line with the forearm. 38 U.S.C.A. § 4.71a, Diagnostic Code 5215 (2011). Normal range of motion for the wrist is 70 degrees of dorsiflexion (extension); 80 degrees of palmar flexion; 45 degrees of ulnar deviation; and 20 degrees of radial deviation. See 38 C.F.R. § 4.71a, Plate I. Limitation of motion of the leg is rated under Diagnostic Codes 5260 - 5262. 38 C.F.R. § 4.71a (2011). Under Diagnostic Code 5260, limitation of flexion of the leg is noncompensable where flexion is limited to 60 degrees. A 10 percent evaluation is warranted where flexion is limited to 45 degrees; a 20 percent evaluation is warranted where flexion is limited to 30 degrees; and a 30 percent evaluation is warranted where flexion is limited to 15 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2011). Limitation of extension of the leg is noncompensable where extension is limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees; a 20 percent rating is warranted where extension is limited to 15 degrees; a 30 percent rating is warranted where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2011). Diagnostic Code 5262 applies to impairment of the tibia. 38 C.F.R. § 4.71a, Diagnostic Code 5062 (2011). A 10 percent rating is assigned with a slight knee or ankle disability. Id. A 20 percent rating is assigned for malunion of the tibia and fibula with moderate knee or ankle disability. Id. A 30 percent rating is assigned for malunion of the tibia and fibula with a marked knee or ankle disability. Id. A 40 percent evaluation is assigned for nonunion of the tibia and fibula with loose motion requiring a knee brace. Id. VA General Counsel has held that separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261 for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). Specifically, where a veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Limitation of motion of the ankle is rated under Diagnostic Code 5271. A 10 percent evaluation is assigned with moderate limited motion of the ankle, and a maximum 20 percent evaluation is assigned with marked limited motion of the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2011). The Board notes that normal ankle dorsiflexion is from 0 to 20 degrees, and normal ankle plantar flexion is from 0 degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II. Muscle Injuries Muscle Group VII is rated under Diagnostic Code 5307. This Muscle Group addresses flexion of wrist and fingers, those muscles arising from internal condyle of the humerus, flexors of the carpus and long flexors of fingers and the thumb, and the pronator. Under Diagnostic Code 5307, a noncompensable evaluation is warranted if impairment of this muscle group is slight; a 10 percent rating is warranted if impairment of this muscle group is moderate; a 30 percent rating is warranted if impairment of this muscle group is moderately severe; and a 40 percent rating is warranted if it is severe (in the non-dominant hand). 38 C.F.R. § 4.73(2011). Muscle Group VIII is rated under Diagnostic Code 5308. This Muscle Group comprises the muscles arising mainly from the external condoyle of the humerus. The functions of these muscles include extension of the wrist, fingers, and thumb, and abduction of the thumb. Under this Diagnostic Code, a noncompensable evaluation is warranted if impairment of this muscle group is slight; a 10 percent rating is warranted if impairment of this muscle group is moderate; a 20 percent rating is warranted if impairment of this muscle group is moderately severe; and a 30 percent rating is warranted if it is severe. 38 C.F.R. § 4.73 (2011). Diagnostic Code 5312 addresses injuries to Muscle Group XII. Muscle group XII involves the anterior muscles of the leg. The function of this muscle group includes dorsiflexion; extension of toes; and stabilization of arch. Under Diagnostic Code 5312, a slight disability warrants a noncompensable rating, a moderate disability warrants a 10 percent rating, a moderately severe disability warrants a 20 percent rating, and a severe disability warrants a 30 percent rating, the highest rating available under the diagnostic code. Id. Disabilities resulting from muscle injuries are classified as slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56(d) (2011). Slight muscle disability contemplates a simple wound of the muscle without debridement or infection; a service department record of a superficial wound with brief treatment and return to duty; healing with good functional results; and no cardinal signs or symptoms of muscle disability. Objectively, there is a minimal scar; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(1) (2011). Moderate muscle disability contemplates a through-and-through or deep penetrating wound of short track from a single bullet, small shell, or shrapnel fragment, without the explosive effect of a high velocity missile, residuals of debridement, or prolonged infection; a service department record or other evidence of in-service treatment for the wound; and a record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objectively, there are entrance and (if present) exit scars that are small or linear, indicating a short track of missile through muscle tissue; and some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2) (2011). Moderately severe muscle disability contemplates a through-and-through or deep penetrating wound by a small high-velocity missile, or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intramuscular scarring; a service department record or other evidence showing hospitalization for a prolonged period for the wound; a record of consistent complaint of cardinal signs and symptoms of muscle disability; and, if present, evidence of inability to keep up with work requirements. Objectively, there are entrance and (if present) exit scars indicating track of missile through one or more Muscle Groups; indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscle compared with the sound side; and tests of strength and endurance compared with the sound side demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3) (2011). Severe muscle disability contemplates a through-and-through or deep penetrating wound due to a 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, intramuscular binding, and scarring; a service department record or other evidence showing hospitalization for a prolonged period for treatment of the wound; a record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries; and, if present, evidence of inability to keep up with work requirements. Objectively, there are 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 swell and harden abnormally in contraction; and tests of strength, endurance, or coordinated movements indicate severe impairment of function when compared with the uninjured side. 38 C.F.R. § 4.56(d)(4) (2011). If present, the following are also signs of severe muscle disability: (a) x-ray evidence of minute, multiple scattered foreign bodies indicating intramuscular trauma and explosive effect of the missile; (b) adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum, or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (c) diminished muscle excitability to pulsed electrical current in electro diagnostic 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. Id. For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lower threshold of fatigue, fatigue-pain, impairment of coordination; and uncertainty of movement. 38 C.F.R. § 4.56(c) (2011). (CONTINUED ON NEXT PAGE) C. Rating Analysis At the outset, it is noted that the Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate. The Board notes that evaluating residuals of a muscle injury entails reviewing the initial injury. In this case, service treatment records show that prior to service, the Veteran was treated for a fracture of the right ring finger with pinning of the right proximal phalnex. He was seen for an injury to the right wrist and hand in September 1998, with a fracture at the proximal metatarsalphalangeal joint. The Veteran sustained shrapnel wounds to the right hand and left lower leg in Iraq in June 2004. September 2004 x-rays of the right hand reflect multiple shrapnel projected at the base of the second metacarpal, with the largest fragments measuring about 4 millimeters each. There was broadening of the base of the fifth metacarpal with degenerative changes likely due to old injury. The Veteran had retained shrapnel near the fibular head by the peroneal nerve, measuring 5 millimeters. Surgery was recommended due to the proximity to the peroneal nerve. The Veteran injured his right hand again in November 2004 with a commuted fracture of the second phalnex. The Right (Major) Hand The RO rated shrapnel wounds to the right (major) hand with right 2nd, 4th and 5th metacarpal fractures and degenerative arthritis under Diagnostic Codes 5010-8615, based on traumatic arthritis with neuritis of the median nerve. See 38 C.F.R. §§ 4.71a, 4.124a (2011); see also 38 C.F.R. § 4.27 (2011). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2011). The Veteran is currently in receipt of a 30 percent rating based on neurological impairment in the right (major) hand. See 38 C.F.R. § 4.124a, Diagnostic Code 8516 (2011). The Board notes that the RO indicated in the August 2005 rating decision, that the Veteran's disability was rated under the criteria for peripheral nerves rather than the musculoskeletal system because it resulted in a higher rating criteria. The Board has considered whether a higher rating is warranted under all potentially applicable Diagnostic Codes. The Board finds that the Veteran does not have severe incomplete paralysis of the right (major) median nerve to warrant a higher 50 percent rating under Diagnostic Code 8615. 38 C.F.R. § 4.124a, Diagnostic Code 8615 (2011). The March 2005 VA examination shows that the Veteran reported symptoms of constant pain and limited use of the right hand. The Veteran had difficulty tying shoelaces, fastening buttons, and picking up or tearing paper. He had decreased range of motion in the fingers of the right hand. The VA examiner noted that right hand strength was severely reduced. VA treatment records show that the Veteran reported pain, swelling, weak grip, and decreased dexterity in the right hand. A February 2010 VA examination reflects pain in the right hand; decreased dexterity; decreased muscle strength with active movement against gravity; reported flare-ups of pain with gripping, writing, straining of the hand, and repetitive use. However, an examination of the median and ulnar nerves was normal at the time of a more recent March 2012 VA examination, with no indication of incomplete paralysis. April 2012 EMG testing revealed mild median nerve neuropathy or carpal tunnel syndrome. The Veteran had right hand numbness and decreased pinprick sensation on examination. While the Veteran has reported significant neurological symptoms in the hand and wrist; objective EMG testing shows that median nerve neuropathy was mild in degree. The Board finds that more recent April 2012 EMG testing is probative in assessing the severity of the Veteran's neurological impairment. Probative medical and lay evidence of record shows that the Veteran has symptoms of pain, numbness, decreased sensation, and decreased strength in the right hand. The Board notes that when neurological involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a (2011). The Board finds that with the exception of decreased strength in the hand and wrist, the Veteran's symptoms are largely sensory in nature. The Board finds, overall, that neurological findings in the right hand and wrist are moderate in degree and do not approximate a rating for severe incomplete paralysis. The Board finds, therefore, that an evaluation in excess of 30 percent is not warranted under Diagnostic Code 8615. The Board has considered whether an evaluation in excess of 30 percent is warranted under Diagnostic Codes 5228-5230 based on limitation of motion of the digits of the major hand. While the Board finds that service-connected right (major) hand shrapnel wounds, with right 2nd, 4th and 5th metacarpal fractures and degenerative arthritis in the ulnar carpal/metacarpal joints at the base of the 5th metacarpal could alternately be rated based on limitation of motion of the thumb, index finger, and long finger, as discussed in further detail below; the Board finds that this would not result in a higher rating. In that regard, a 10 percent evaluation is assignable based on limitation of motion of the thumb under Diagnostic Code 5228. 38 C.F.R. § 4.71a, Diagnostic Code 5228. A March 2005 VA examination shows that the Veteran had a 4 centimeter gap between the thumb and the base of the little finger with the thumb attempting to oppose the fingers. A February 2010 VA examination shows that the Veteran did not have any gap between the thumb pad and the fingers at the time of examination. A March 2012 VA examination did not include range of motion testing of the digits of the right hand. The Board finds that a 10 percent evaluation may be assigned under Diagnostic Code 5228, in this case, where there is evidence a gap of one inch to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 4.3, 4.7, § 4.71a, Diagnostic Code 5228 (2011). A 10 percent rating is the maximum rating available under Diagnostic Code 5228; therefore, a higher evaluation is not available under this Diagnostic Code. A 10 percent evaluation is assignable based on limitation of motion in the right index finger under Diagnostic Code 5229 where the Veteran has evidence of a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm. See 38 C.F.R. § 4.71a, Diagnostic Code 5229. A March 2005 VA examination reflects a 4 centimeter gap between the fingertip and the proximal transverse crease of the palm. A February 2010 VA examination reflects a one inch or 2.5 centimeter gap between the fingertip and the proximal transverse crease of the palm. The Board finds, therefore, that a separate 10 percent rating may be assigned under Diagnostic Code 5229. A 10 rating is the maximum rating available under Diagnostic Code 5229; therefore, a higher evaluation is not available based on limitation of motion of the index finger under this Diagnostic Code. The Veteran is also shown to have limited motion of the long finger, which is also rated under Diagnostic Code 5229. A 10 percent evaluation is assignable based on limitation of long finger under Diagnostic Code 5229 where the Veteran has evidence of a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm. See 38 C.F.R. § 4.71a, Diagnostic Code 5229. A March 2005 VA examination reflects a 4 centimeter gap between the long fingertip and the proximal transverse crease of the palm. A February 2010 VA examination reflects a one inch or 2.5 centimeter gap between the fingertip and the proximal transverse crease of the palm. The Board finds, therefore, that a 10 percent rating may be assigned under Diagnostic Code 5229 for limited motion in the long finger. Again, an evaluation in excess of 10 percent is not available under Diagnostic Code 5229. The Board notes that 10 percent ratings are the maximum ratings available under Diagnostic Codes 5228 and 5229; therefore, the Board need not consider whether the Veteran has additional functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness in determining whether higher ratings are warranted under these Diagnostic Codes. 38 C.F.R. §§ 4.40, 4.45 (2011); DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). While the Veteran is also shown to have limited motion in the ring and little fingers of the right hand, Diagnostic Code 5230 assigns a noncompensable rating with any limitation of motion of the ring or little finger. Therefore, a compensable rating is not available Diagnostic Code 5230. See 38 C.F.R. § 4.71a, Diagnostic Code 5230. While the Board finds that the Veteran may alternately be assigned separate 10 percent ratings based on limitation of motion in the thumb, index finger, and long finger of the major hand under Diagnostic Code 5228 and 5229; his combined rating would not exceed his currently assigned 30 percent rating under Diagnostic Code 8615. See 38 C.F.R. § 4.25 (2011). The three 10 percent ratings, combined under Table I in accordance with 38 C.F.R. § 4.25 would result in a disability rating of 27 percent in this case. The Board finds that the Veteran's right hand disability may not be rated under both Diagnostic Code 8615 and Diagnostic Codes 5228 and 5229, where the impairment in the Veteran's right hand is shown to involve the same manifestations, in the same localized area. See 38 C.F.R. 4.14. The Veteran's right hand disability was rated as moderate neuritis based on his symptoms of pain, decreased range of motion, decreased dexterity, decreased strength or weakness, and decreased sensation in the right hand. The Board emphasizes that the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. Id. The Board finds that the Veteran's overall functional limitation, caused by service-connected right hand shrapnel wounds, with right 2nd, 4th and 5th metacarpal fractures and degenerative arthritis in the ulnar carpal/metacarpal joints at the base of the 5th metacarpal, has been addressed by his assigned 30 percent rating under Diagnostic Codes 8615. Therefore, separate ratings are not warranted. The Right Wrist and Forearm A right (major) wrist fracture with degenerative arthritis and right wrist and right forearm shrapnel wounds is rated under Diagnostic Code 5299-5215 based on limitation of motion of the wrist. See 38 C.F.R. § 4.71a (2011). When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" as follows: the first two digits will be selected from that part of the schedule most closely identifying the part, or system of the body involved, in this case, dental and oral conditions, and the last two digits will be "99" for all unlisted conditions. Then, the disability is rated by analogy under a diagnostic code for a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. 38 C.F.R. §§ 4.20, 4.27 (2011). The Veteran is currently in receipt of a 10 percent evaluation under Diagnostic Code 5215. A 10 percent evaluation is the maximum rating available under Diagnostic Code 5215; therefore, a higher evaluation is not available to the Veteran under this Diagnostic Code. The Veteran's disability is not shown to approximate favorable or unfavorable ankylosis of the right wrist at any time during the course of this appeal to warrant a higher rating under Diagnostic Code 5214. See 38 U.S.C.A. § 4.71a, Diagnostic Code 5214 (2011). During a March 2005 VA examination, the Veteran had 30 degrees of dorsiflexion in the right wrist with pain starting at 15 degrees; 55 degrees of palmar flexion with pain at 40 degrees; 25 degrees of ulnar deviation with pain at 15 degrees; and 14 degrees of radial deviation with pain at 5 degrees. During a February 2010 VA examination, the Veteran had 15 degrees of dorsiflexion; 45 degrees of palmar flexion; 30 degrees of ulnar deviation; and 15 degrees of radial deviation. Range of motion was additionally limited by pain with repetitive motion. The Veteran had 15 degrees of dorsiflexion; 35 degrees of palmar flexion; 15 degrees of ulnar deviation; and 5 degrees of radial deviation in the right wrist after repetitive motion. VA treatment records and VA examinations reflect pain, swelling, and decreased strength in the wrist. Despite objective findings of painful, limited motion in the right wrist; the Board finds that the Veteran's right wrist disability does not approximate ankylosis of the major wrist under Diagnostic Code 5214. The Veteran's functional loss due to pain has already been considered in assigning his 10 percent evaluation under Diagnostic Code 5215. See 38 C.F.R. §§ 4.40, 4.45 (2011); DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). The Veteran has not been diagnosed with ankylosis, and has had measurable ranges of motion in the right wrist on examination during the pendency of this appeal. Therefore, absent a finding of ankylosis of the right wrist, a higher evaluation is not warranted under Diagnostic Code 5214. The Board notes that VA treatment records dated in March 2007 indicate that the Veteran had apparently developed reflex sympathetic dystrophy in his right upper extremity to the point where he was hesitant "to even shake hands with his right hand." However, no mention whatsoever was made of reflex sympathetic dystrophy at the time of the Veteran's March 2005 and February 2010 VA examinations. EMG testing was completed in April 2012 and reflex sympathetic dystrophy was not noted at that time. Finally, a May 2012 addendum opinion shows that the Veteran did not have chronic reflex sympathetic dystrophy, based on a review of EMG findings. The VA examiner further reasoned that the Veteran's median nerve was compressed at the wrist and not the cervical spine. The Board finds, therefore, that the Veteran does not have reflex sympathetic dystrophy related to his service-connected right wrist fracture with degenerative arthritis and right wrist and right forearm shrapnel wounds. April 2012 EMG testing did reveal a diagnosis of right carpal tunnel syndrome or right median neuropathy. The Veteran's neurological symptoms in the right wrist and hand, to include pain, decreased dexterity, decreased wrist strength or weakness, decreased grip strength, and loss of sensation in the distribution of the right median nerve, are already contemplated by his 30 percent rating under Diagnostic Code 8615 discussed above. Therefore, an additional rating for neurological findings in the right wrist would constitute impermissible pyramiding. See 38 C.F.R. § 4.14 (2011); Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Shrapnel Wounds to the Right Hand, Wrist and Forearm The Board has also considered the applicability of ratings under Diagnostic Codes 5307 and 5308, which address muscle injuries to the wrist, fingers, and forearm. See 38 C.F.R. § 4.73 (2011). The Board notes that while a March 2012 VA examination included an evaluation of the right shoulder and biceps in this case; the Veteran is not service-connected for a muscle injury to the biceps or shoulder, nor is such a disability currently on appeal. The Board finds that an increased evaluation is not warranted for shrapnel wounds to the right (major) hand, wrist, or forearm under Diagnostic Code 5307 (Muscle Group VII) or Diagnostic Code 5308 (Muscle Group VIII). The evidence shows that the Veteran's overall disability picture is best described by a slight muscle injury to Muscle Group VII and Muscle Group VIII. The Board finds that the Veteran has not established that he has a moderate muscle injury to Muscle Group VII or Muscle Group VIII based on clinical findings. Specifically, there is no evidence of a through-and-through or deep penetrating wound from a shrapnel fragment in service. See 38 C.F.R. § 4.56(d)(2). Instead, the Board finds that service treatment records and a March 2005 VA examination, completed a few months after the Veteran's separation from service, reflect a simple wound of the muscle in service without debridement or infection as described for slight muscle disability under 38 C.F.R. § 4.56(d)(2). A March 2005 VA examiner indicated that treatment for the Veteran's actual shrapnel wounds in service was brief. A March 2012 VA examination notes that the Veteran's wounds were dressed at the time of his in-service injuries with some shell fragments removed, and he was returned to duty the following day. A March 2012 VA examination describes entrance scars as being both minimal, as noted for a slight muscle disability; and small or linear indicating a short track of missile through muscle tissue. However, the Board finds that there was no loss of deep fascia or muscle substance; or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side as described for a moderate disability. See 38 C.F.R. § 4.56(d)(3). The March 2005 VA examination shows that the Veteran had a 1 centimeter by 1 centimeter scar in the right hand with no tenderness, ulceration, adherence, instability, tissue loss, or limitation of motion. A February 2010 VA examination reflects a 1 centimeter by 2 centimeter well-healed scar without pain. February 2010 x-rays of the right wrist show that there were still shrapnel in the 4th and 5th metatarsal area. As compared to the last x-ray, the shrapnel was in a tighter grouping. Pain was noted on flexion and extension of the wrist, and the Veteran reported that a few weeks prior, a piece of shrapnel or something came out of his upper forearm. The area was red where the shrapnel came out, but was healed and nontender. A March 2012 VA examination shows that the Veteran did not have loss of deep facia or loss of muscle substance. While the Veteran is shown to have loss of threshold fatigue, he did not have associated impairment of muscle tonus described for a moderate disability. The evidence of record does reflect complaints of related to loss of power or weakness, fatigue, and impairment of coordination in the right hand and wrist, and reduced strength and endurance as compared with the sound side as indicated for a moderate muscle disability. A February 2010 VA examination reflects decrease in hand strength and dexterity on examination. Loss of threshold fatigue in the right hand and wrist was noted at the time of the March 2012 VA examination. However, the Veteran's decreased strength, weakness, numbness, pain, decreased dexterity, and loss of sensation in the right hand and wrist have been considered by the RO in the Veteran's 30 percent rating for right median nerve neuropathy, secondary to arthritis and shell fragment wounds. The Board notes, in that regard, that pyramiding, the evaluation of the same disability or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2011). The Board finds, therefore, that the Veteran's symptoms related to decreased strength, fatigue, and impairment of coordination or dexterity cannot be considered again in the evaluation of the severity of his muscle disability of the right hand, wrist, and forearm. For the reasons discussed above, the Board finds that medical evidence does not reflect a moderate injury as described under the 38 C.F.R. § 4.56 guidelines for the evaluation of muscle disabilities. Aside from symptoms related to loss of strength, fatigue, and impairment of coordination (considered by the Veteran's rating under Diagnostic Code 8516), the Board finds that Veteran does not exhibit other signs and symptoms indicative of a moderate muscle injury under Diagnostic Code 5307 or 5308. The Board finds that shell fragment wounds to the right hand, wrist, and forearm more closely resemble a slight muscle disability. Therefore, a compensable evaluation is not warranted for shell fragment wounds to the right hand, wrist, or forearm under Diagnostic Codes 5307 or 5308. The Left Lower Leg A shrapnel wound to the left (minor) lower leg is rated under Diagnostic Code 5299-5262 based on impairment to the tibia and fibula. See 38 C.F.R. § 4.71a (2011). The record shows that the Veteran sustained shrapnel wounds to the left tibia and fibula in service. At the time of a March 2005 VA examination, the Veteran reported symptoms of tightness, soreness, and pain in the left leg. Examination of the tibia and fibula revealed normal findings. The Veteran had 0 degrees extension in the left knee. He had 110 degrees flexion with pain at 100 degrees flexion. Range of motion was additionally limited following repetitive of use due to pain. The Veteran had 0 degrees dorsiflexion in the left ankle and 30 degrees plantar flexion. Range of motion was additionally limited following repetitive use due to pain, weakness, and lack of endurance. The Veteran was diagnosed with a left lower leg shrapnel wound with retained foreign body and persistent neuralgia, with a shrapnel fragment noted on x-ray, small scars, and weakness in dorsiflexion of the ankle. A February 2010 VA examination shows that the Veteran reported symptoms of pain, numbness, and muscle spasm in the left leg. Range of motion in the left knee and ankle was reported in a March 2010 addendum. The Veteran had 100 degrees flexion in the left knee. Range of motion was additionally limited following repetitive use due to pain, weakness, and lack of endurance. The Veteran had additional loss of motion after three repetitive cycles; he had 40 degrees flexion without pain, and then continued with pain to 90 degrees. Range of motion in the left ankle was noted to be within normal limits. The Board notes that a March 2012 VA examination did not include range of motion testing for the knee or ankle. The Veteran's left lower leg shrapnel wound is currently rated as analogous to a malunion of the tibia and fibula with moderate knee or ankle disability under Diagnostic Code 5262. See 38 C.F.R. § 4.71a, Diagnostic Code 5062 (2011). The Board finds that the evidence of record does not reflect malunion of the tibia and fibula with marked knee or marked ankle disability to warrant a higher 30 percent rating under Diagnostic Code 5262. In that regard, a March 2005 VA examination shows that the Veteran had 110 degrees flexion in the left knee with pain at beginning at 100 degrees. He had full extension in the left knee. A March 2010 addendum examination shows that the Veteran had 90 degrees flexion after repetitive use with pain beginning at 40 degrees. Both VA examinations show that the major functional impairment in the left knee is due to pain, or painful motion. The Veteran had 0 dorsiflexion in the left ankle and full plantar flexion. However, a more recent February 2010 findings show that the Veteran had full range of motion in the left ankle. Based on findings from the Veteran's VA examinations, the Board finds that painful motion in the left ankle is not marked in degree, and painful motion in the left knee is not marked in degree. The Board finds, therefore, that a higher 30 percent evaluation is not warranted under Diagnostic Code 5262. The Board notes that the Veteran's assigned 20 percent evaluation under Diagnostic Code 5262 may be based on malunion of the tibia or fibula with a moderate knee disability; or alternately may be based on malunion of the tibial or fibula with a moderate ankle disability. X-rays completed at the time of the Veteran's VA examinations do not reflect malunion of the tibia and fibula. Additionally, the Board finds that the evidence of record reflects only a slight disability of the left knee and a slight disability of the left ankle in this case. However, the Board will not disturb the Veteran's currently assigned 20 percent evaluation under Diagnostic Code 5262. Because the Veteran's assigned evaluation under Diagnostic Code 5262 may represent either a moderate knee disability "or" a moderate ankle disability; the Board has considered whether separate evaluations are available to the Veteran under other provisions of the Diagnostic Code as they pertain to the knee or ankle. A 10 percent evaluation is assignable under Diagnostic Code 5260 where flexion in the leg is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2011). A February 2010 VA examination shows that the Veteran had 90 degrees flexion in the left leg after repetitive use, with pain beginning at 40 degrees. The Board finds that the Veteran does not have flexion limited to 90 degrees to warrant a compensable rating under Diagnostic Code 5262. The Board notes that while functional loss due to flare-ups of pain, fatigability, pain on movement, and weakness must be considered in evaluating disabilities of the musculoskeletal system; in the present case, the Veteran is currently in receipt of a separate 10 percent rating under Diagnostic Codes 8699-8620 for neuralgia in the left lower leg associated with his left lower leg shrapnel wound with retained foreign body. See 38 C.F.R. §§ 4.40, 4.45 (2011); DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). The Veteran's rating based on neuralgia in the left leg, contemplates his symptoms of pain and numbness in the left lower extremity, weakness, and lack of endurance. Because the Veteran's left leg pain has already been considered in his assigned 10 percent rating under Diagnostic Code 8699-8620, the Board may not consider his pain in the assignment of a higher rating under Diagnostic Code 5262, where limitation of motion in the left leg is otherwise noncompensable. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). The Board finds, therefore, that a separate 10 percent evaluation is warranted under Diagnostic Code 5260 based on limitation of flexion of the leg. VA examinations show that the Veteran had full extension in the left leg to 0 degrees without additional functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45 (2011); DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). Therefore, the Board finds that a compensable evaluation is not warranted under Diagnostic Code 5261. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2011). The Board has alternately considered whether a separate evaluation would be assignable under Diagnostic Code 5262 based on disability of the knee, assuming that the Veteran's currently assigned evaluation under Diagnostic Code 5262 is based on findings related to a moderate ankle disability. However, the Board finds that disability to the Veteran's left knee is no more than slight in degree, and is largely characterized by leg pain, or painful motion. Again, because the Veteran's symptoms of pain in the left leg are already contemplated by his 10 percent rating under Diagnostic Codes 8699-8620; the Board finds that a separate evaluation is not warranted under Diagnostic Code 5262 based on slight disability of the left knee as it would constitute impermissible pyramiding. See 38 C.F.R. § 4.14 (2011). The Veteran is not shown to have ankylosis of the left ankle to warrant a compensable rating under Diagnostic Code 5270. See 38 C.F.R. § 4.71a, Diagnostic Code 5270 (2011). The Veteran's left ankle was not noted to be in fixation at any time during the course of this appeal. Therefore, a higher rating is not warranted under Diagnostic Code 5270. The record shows that the Veteran had 0 dorsiflexion in the left ankle in March 2005. Range of motion was additionally limited after repetitive use due to pain, weakness and lack of endurance. The Veteran had full plantar flexion without pain. During a more recent February 2010 evaluation, the Veteran range of motion in the left ankle was within normal limits. The Board finds, therefore, that the Veteran does not have moderate limitation of motion in the left ankle to warrant a compensable rating under Diagnostic Code 5271. See 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2011). The Veteran is in receipt of a separate 10 percent rating for left lower leg neuralgia under Diagnostic Codes 8699-8620. The issue of entitlement to an increased rating for left lower leg neuralgia is not currently on appeal and has not been considered by the Board. Shrapnel Wound to the Left Lower Leg The Board has also considered whether a higher rating is warranted for residuals of a gunshot wound to the left leg with retained foreign body, based on the diagnostic criteria for a muscle injury to Muscle Group XII. 38 C.F.R. § 4.73, Diagnostic Codes 5312. The evidence shows that the Veteran's overall disability picture is best described by a moderate muscle injury to Muscle Group XII. March 2005 and March 2012 VA examinations reflect involvement of Muscle Group XII in this case. A March 2005 VA examination shows that the Veteran had a deep penetrating wound in the left lower leg from shrapnel fragments and service department record of in-service treatment for the wound. See 38 C.F.R. § 4.56(d)(2). Service treatment records show that the Veteran had a 5 millimeter retained fragment at the medial aspect of the proximal fibula. This was not constant in position and was not in the soft tissue. It was noted that it may be in a muscle bundle. While a February 2010 VA examination shows that the Veteran did not have a through-and through wound injury in service, a March 2005 VA examination shows that the Veteran did have a "deep and penetrating wound" inflicted by multiple low velocity missiles. 38 C.F.R. § 4.56(d)(2). The March 2005 VA examiner noted that the Veteran received treatment, including hospitalization in service, lasting three weeks. A March 2005 VA examiner indicated that the destruction involved bone, fascia, and nerve. It was noted that the bone had never been infected. The Veteran is shown to have consistent complaint of one or more of the cardinal signs and symptoms of muscle disability. See 38 C.F.R. § 4.56(d)(2). A March 2005 VA examination reflects loss of strength, weakness, fatigability, pain, impairment of coordination, and inability to control movement well in the left lower leg. A February 2010 VA examination reflects pain, decreased coordination, increased fatigability, and weakness in the left lower leg, as well as muscle spasm and cramping. The medical evidence does not reflect small or linear scars with some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side as described for a moderate muscle disability. 38 C.F.R. § 4.56(d)(2). Service treatment records and a March 2005 VA examination reflect small scars present. However, a February 2010 VA examination shows that no muscle had been injured, destroyed, or traversed and there was no loss of deep fascia or muscle substance. A March 2012 VA examination describes entrance scars as being both minimal, as noted for a slight muscle disability, and small or linear indicating a short track of missile through muscle tissue as described for a moderate muscle disability. However, a March 2012 VA examination did not reflect loss of deep fascia or muscle substance, impairment of muscle tonus, or lowered threshold fatigue indicated in the left lower extremity as described for a moderate muscle disability. Additionally, loss of threshold fatigue was not indicated in the left lower leg. In the present case, the Veteran's type of injury, history and complaint are consistent with a moderate muscle disability, while the Veteran's scars and objective findings pertaining to muscle substance and tone are indicative of a slight muscle disability. See 38 C.F.R. § 4.56 (d) (2011). The Board finds, therefore, that left (minor) lower leg shrapnel wound with retained foreign body is most consistent with a 10 percent evaluation under Diagnostic Code 5312. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 4.3, 4.7 (2011). The Veteran does not have evidence of a through-and-through or deep penetrating wound by a small high-velocity missile, or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intramuscular scarring as described for a moderately severe disability. See 38 C.F.R. § 4.56(d)(3). Service treatment records do not reflect evidence of debridement, prolonged infection or sloughing of soft parts related to treatment of the Veteran's left lower leg shrapnel wound. The March 2005 VA examination noted that the Veteran was treated for a period of three weeks, to include a period of hospitalization. The Board finds that the Veteran's hospitalization was not prolonged. Cardinal signs and symptoms of muscle disability have been noted; however, the Veteran is not shown to have an inability to keep up with work requirements due to his left leg muscle injury. See 38 C.F.R. § 4.56(d)(3). While a March 2005 VA examination shows that the Veteran was unable to maintain his prior work in security because he was unable to stand for prolonged periods of time; he was able to work at a different job in force protection at that time. At the time of a February 2010 VA examination, the Veteran was working at a post office. Job duties included standing in a mail case sorting mail, loading trucks and carrying heavy mail bags and parcels within his building. A March 2012 VA examination shows that the Veteran had been employed at the post office since 2006 and continued to be employed there. Objectively, VA examinations and service treatment records do not reflect a track of missile through one or more Muscle Groups. The Veteran had retained foreign bodies shown by x-ray within the muscle groups where he was initially injured. Additionally, there was no indication of loss of deep fascia, muscle substance, or normal firm resistance of muscle compared with the sound side. The Board finds that overall, the Veteran is not shown to have a moderately severe muscle disability under Diagnostic Code 5312. The Board finds that, while the Veteran may alternately be assigned a 10 percent rating under Diagnostic Code 5312 for a moderate muscle injury to Muscle Group XII, this rating would not exceed his 20 percent rating under Diagnostic Codes 5262. Therefore, the Board finds that a higher rating is not warranted under Diagnostic Code 5312. The Board finds that the Veteran's left leg disability may not be rated under both Diagnostic Codes 5262 and Diagnostic Code 5312, where impairment in the Veteran's left leg is shown to involve the same manifestations, in the same localized area. See 38 C.F.R. 4.14. The Veteran's current ratings under Diagnostic Code 5262 and Diagnostic Codes 8699- 8620 are based on his symptoms of pain and numbness in the left leg and ankle, weakness, and lack of endurance. The Board finds that the Veteran's overall functional limitation, caused by service-connected left (minor) lower leg shrapnel wound with retained foreign body, have been addressed by his current assigned ratings. Therefore, a separate evaluation under Diagnostic Code 5312 would constitute impermissible pyramiding. See 38 C.F.R. § 4.14 (2011). Consideration of Lay Evidence In reaching the above conclusions, with respect to the Veteran's increased rating claims, the Board has not overlooked the Veteran's statements with regard to the severity of his claimed right hand, right wrist and forearm, and left lower leg disabilities. In this regard, the Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing pain and weakness; and the Board finds that the Veteran's reports have been credible. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). During the course of his VA examinations, the Veteran has provided lay evidence with respect to the presence of pain and the severity of such, weakness, loss of strength and dexterity, and with respect to limitations in his functional capacity due to his disability. The Veteran also gave additional history on his claimed in-service injuries. He is competent to provide such testimony, and the Board finds that the Veteran's statements are credible. The Board has considered the Veteran's reports with respect to pain, and associated limitation of function due to pain and with respect to his neurological symptomatology in evaluating his assigned ratings. The Board notes, however, that with respect to the Rating Schedule, where the criteria set forth therein require medical expertise which the Veteran has not been shown to have, or where these types of findings are not readily observable by a lay person the objective medical findings and opinions provided by the Veteran's treatment reports and his VA examination reports have been accorded greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Extraschedular Consideration Consideration has also been given regarding whether any of the schedular evaluations discussed above are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2011); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate and referral is not required. Id. The Board finds that the evidence in this case does not reflect an exceptional disability picture such that the available schedular evaluations for the Veteran's service-connected disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities as discussed above, with the established criteria found in the rating schedule shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. While the Veteran's service-connected disabilities, in this case, are shown affect the musculoskeletal system, the muscles, and the peripheral nerves; the applicable ratings for each of these have been considered and discussed by the Board. 38 C.F.R. § 4.1 specifically sets out that "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." Factors such as requiring periodic medical attention are clearly contemplated in the Schedule and provided for in the evaluations assigned herein. What the Veteran has not shown in this case is that the manifestations of his service-connected disabilities have resulted in unusual disability or impairment that has rendered the criteria and/or degrees of disability contemplated in the Schedule impractical or inadequate. Accordingly, consideration of 38 C.F.R. § 3.321(b)(1) is not warranted in this case. C. Conclusion The preponderance of the evidence is against finding that the Veteran's right (major) hand shrapnel wounds, with right 2nd, 4th and 5th metacarpal fractures and degenerative arthritis in the ulnar carpal/metacarpal joints at the base of the 5th metacarpal warrant a higher rating evaluation. The preponderance of the evidence is against finding that the Veteran's right (major) wrist fracture with degenerative arthritis and right wrist and right forearm shrapnel wounds warrants a higher rating evaluation. The preponderance of the evidence is against finding that the Veteran's left (minor) lower leg shrapnel wound with retained foreign body warrants a higher rating evaluation. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b) regarding benefit of the doubt, but there is not such a state of equipoise of positive and negative evidence to otherwise grant the Veteran's claim. ORDER An initial evaluation for right (major) hand shrapnel wounds, with right 2nd, 4th and 5th metacarpal fractures and degenerative arthritis in the ulnar carpal/metacarpal joints at the base of the 5th metacarpal, in excess of 30 percent is denied. An initial evaluation for a right (major) wrist fracture with degenerative arthritis and right wrist and right forearm shrapnel wounds percent, in excess of 10 percent, is denied. An initial evaluation for a left (minor) lower leg shrapnel wound with retained foreign body, in excess of 10 percent, is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs