Citation Nr: 1301896 Decision Date: 01/17/13 Archive Date: 01/23/13 DOCKET NO. 09-20 742 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a disability rating in excess of 20 percent for residuals of a right acromioclavicular separation. 3. Entitlement to a disability rating in excess of 10 percent for service-connected residuals of a scalp laceration secondary to shell fragment wound (SFW)/traumatic brain injury (TBI) with headaches prior to September 23, 2008. 4. Entitlement to a disability rating in excess of 10 percent for service-connected residuals of SFW/TBI with headaches as of September 23, 2008. 5. Entitlement to a compensable disability for service-connected residuals of a scalp laceration secondary to SFW/TBI as of September 23, 2008. 6. Entitlement to a compensable disability rating for service-connected scar of the right knee. REPRESENTATION Appellant represented by: Brooks S. McDaniel, Agent ATTORNEY FOR THE BOARD B. Berry, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1968 to December 1976. These matters come to the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in November 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Veteran requested a Travel Board hearing in the June 2009 substantive appeal. He was scheduled for a hearing in July 2012; however, he failed to appear at the hearing. The Veteran did not request to reschedule the hearing or provide the Board with good cause for missing the hearing. Therefore, the request is deemed withdrawn. See 38 C.F.R. § 20.704(d). With respect to the Veteran's claim for a total disability rating based on individual unemployability, the RO granted this claim in a May 2012 rating decision. As the RO granted in full the benefits on appeal, the claim for TDIU is no longer in appellate status and no further consideration is required. With respect to the increased rating claim for residuals of a scalp laceration secondary to shell fragment wound (SFW)/traumatic brain injury (TBI) with headaches, during the appeal, the RO separated the Veteran's residuals of a scalp laceration secondary to SFW and residuals of SFW/TBI with headaches and evaluated them under different rating codes as of September 23, 2008. The RO provided a 10 percent disability rating for residuals of SFW/TBI with headaches and a noncompensable disability rating for residuals of a scalp laceration secondary to SFW. The overall combined rating did not change. Thus, the separation of the Veteran's residuals of SFW/TBI with headaches and residuals of scalp laceration secondary to SFW as of September 23, 2008 is reflected in the Issue section above. FINDINGS OF FACT 1. The Veteran's PTSD is manifested by sleep impairment with nightmares of Vietnam, flashbacks, daily intrusive thoughts, hypervigilence, avoidance, anxiety, emotional detachment, moderate social impairment and some occupational impairment; the Veteran's GAF score ranged from 54 to 55. 2. The Veteran's residuals of a right acromioclavicular separation are characterized by range of motion of the arm greater than shoulder level with evidence of pain. 3. Residuals of a scalp laceration secondary to SFW/TBI with headaches were manifested by subjective headaches with no evidence of purely neurological disabilities and no characteristics of disfigurement prior to September 23, 2008. 4. Residuals of SFW/TBI with headaches is characterized by headaches that occur on average less than one in two months, no evidence of purely neurological disabilities, a level of impairment less than 2 for all facets of cognitive impairment and other residuals of TBI as of September 23, 2008. 5. Residuals of a scalp laceration secondary to SFW are manifested by no characteristics of disfigurement as of September 23, 2008. 6. Residuals of right knee scar is superficial, encompasses an area less than 144 square inches (929 square centimeters), is not unstable or painful on examination and does not result in limitation of function of the right knee or lower extremity. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for service-connected PTSD have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a disability rating in excess of 20 percent for service-connected residuals of a right acromioclavicular separation have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 38 C.F.R. § 4.71a, Diagnostic Codes 5200-5203 (2012). 3. The criteria for a disability rating in excess of 10 percent for service-connected residuals of a scalp laceration secondary to SFW/TBI with headaches prior to September 23, 2008 have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.118, Diagnostic Code 7800 (2008), 4.124a, Diagnostic Codes 8045 (2008), 8045, 8100 (2012). 4. The criteria for a disability rating in excess of 10 percent for service-connected residuals of SFW/TBI with headaches as of September 23, 2008 have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Codes 8045 (2008), 8045, 8100 (2012). 5. The criteria for a compensable disability rating for service-connected residuals of a scalp laceration secondary to SFW/TBI as of September 23, 2008 have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). 6. The criteria for a compensable disability rating for service-connected scar of the right knee have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA) imposes a duty on the United States Department of Veterans Affairs (VA) to notify and assist a claimant in developing a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). For increased-compensation claims, section 5103(a) requires, at a minimum, that the Secretary (1) notify the claimant that to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment; (2) provide examples of the types of medical and lay evidence that may be obtained or requested; (3) and further notify the claimant that "should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic Codes," and that the range of disability applied may be between 0 percent and 100 percent "based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment." Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (holding that VCAA notice need not be veteran specific, or refer to the effect of the disability on "daily life"). After careful review of the claims folder, the Board finds that an April 2008 letter satisfied the duty to notify provisions prior to the initial AOJ decision on appeal. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The letter informed the Veteran that he should submit evidence showing his service-connected right knee scar, PTSD, residuals of right acromioclavicular separation and laceration to scalp have increased in severity. The RO notified the Veteran of the types of medical or lay evidence that he may submit. Specifically, the Veteran was informed that evidence which may show an increase in severity may include a statement from his physician containing clinical findings or statements from individuals that are able to describe from their knowledge and personal observations in what manner his disabilities have become worse. The letter notified the Veteran of the evidence that VA will seek to provide and the information the Veteran is expected to provide in substantiating his claim. The Veteran was also informed of how VA determines the effective date if an increased rating is granted. Regarding VA's duty to assist, the Board finds that VA has fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's service treatment records, VA treatment records and VA examination reports dated in July 2008 and December 2010. The July 2008 and December 2010 VA examination reports reflect that the examiners conducted a review of the Veteran's claims file in addition to obtaining an oral history and evaluation of the Veteran with respect to his service-connected disabilities. The examiners documented the claimed symptoms and the objective symptoms found on evaluation of the Veteran. Accordingly, the Board concludes that the examinations are adequate for rating purposes. Furthermore, the claims file contains the Veteran's statements in support of his claim. The Veteran has not identified, and the record does not otherwise indicate, any existing, pertinent evidence that has not been obtained. The record also presents no basis for further development to create any additional evidence to be considered in connection with the matter currently under consideration. Under these circumstances, the Board finds that the Veteran is not prejudiced by appellate consideration of the claim on appeal at this juncture, without directing or accomplishing any additional notification and/or development action. II. Merits of the Claims for an Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2010). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2010). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2010). When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. See 38 U.S.C.A. § 5107(b). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). PTSD When evaluating a mental disorder, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (2012). The Veteran's service-connected PTSD is presently assigned a 50 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9411. PTSD is rated pursuant to the General Rating Formula for Mental Disorders. Id. Under the General Rating Formula for Mental Disorders, a 50 percent rating is prescribed for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is prescribed for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is prescribed for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. The use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the Veteran's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In determining whether the Veteran meets the criteria for a 70 percent rating, the Board must consider whether the Veteran has deficiencies in most of the following areas: work, school, family relations, judgment, thinking, or mood. Bowling v. Principi, 15 Vet. App. 1, 11 (2001). The Global Assessment of Functioning (GAF) Scale is used to report the clinician's judgment of the individual's overall level of functioning. The GAF Scale is to be rated with respect only to psychological, social and occupational functioning. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1994 (DSM-IV), at 44. GAF scores range from 1-100 with the higher numbers representing higher levels of functioning. A GAF score between 51 and 60 reflects moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupation, or school functioning (e.g., few friends, conflicts with peers or co-workers). The medical evidence of record consists of lay statements from the Veteran, VA treatment records and two VA examinations dated in July 2008 and December 2010. The Board finds that this evidence, the most pertinent of which is summarized below, shows that the Veteran's condition as a whole more closely approximates the criteria for a rating of 50 percent. In this regard, the evidence of record is negative for characteristics such as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation or neglect of personal appearance and hygiene or difficulty in adapting to stressful circumstances (including work or a work like setting). See 38 C.F.R. § 4.130, Diagnostic Code 9411. Specifically, the VA examinations evaluating the Veteran's PTSD noted that the Veteran's eye contact and behavior were appropriate and he was oriented. The evidence of record shows that the Veteran does not have any delusions or hallucinations. His overall affect was broad and his mood appeared euthymic during the examinations. The July 2008 examination indicated that the Veteran became more dysphoric and close to tears when discussing his experience in Vietnam. The July 2008 VA examination also revealed that the Veteran demonstrated mild impairment of thought processing or communication as he would sometimes miss the point of some questions, his thinking and speech were circumstantial and tangential and he would sometimes jump from topic to topic. However, the December 2010 VA examination revealed that there was no impairment of thought processing or communication. VA treatment records and the VA examinations indicate that the Veteran does not have any suicidal or homicidal ideation. The Veteran does not have problematic impulse control or significant outbursts. He is adequate with personal hygiene and activities of daily living. There was no evidence of significant memory impairment or obsessive-compulsive behavior. The Veteran denied experiencing panic attacks. The medical evidence shows that the Veteran experiences anxiety. He explained that he is nervous and anxious all of the time and that it is worse in crowds or social/public situations. The Veteran has reported that he experiences hypervigilence, which creates anxiety. He is watchful, mistrustful and does not like people behind him. He also experiences war-related nightmares one to three times a week. At times he sleepwalks with these nightmares and one time he broke the bathroom door. The December 2010 VA examiner described the Veteran's sleep impairment as mild. The Veteran also experiences daily, intrusive memories of Vietnam that induce feelings of sadness and guilt. Helicopters, Asians, anniversary times of trauma, gunshot/explosions type sounds, rain, fog, thunderstorms and his scars/wounds trigger negative upsetting memories for him. The Veteran avoids crowds, fireworks and watching war-related movies. Although it appears that the Veteran has near-continuous anxiety, the Board finds that he is able to function independently, appropriately and effectively. He is able to get out of the house to run various errands and eat at restaurants during low-crowd times. The medical evidence reveals that the Veteran's symptoms result in some occupational impairment. The Veteran is currently unemployed. He previously worked for the United States Post Office until the 1990's. During the December 2010 VA examination, the Veteran indicated that he had trouble getting along with his coworkers at the Post Office. He also worked for about four months in 2002 with an electrical company putting down power lines. He enjoyed that job, because he was able to operate in a solitary manner and he denied any significant troubles with that job. He ended up leaving that job due to a myocardial infarction. The July 2008 VA examiner determined that a combination of his mental health (flashbacks triggered by the blasting sounds) and physical problems combined to make the 2002 job difficult. With respect to social impairment, the Board finds that the evidence indicates his PTSD results in moderate social impairment. The Veteran divorced his first wife after 23 years of marriage. He obtained custody of their three children and raised them. The Veteran remarried in 2006. Although, during the July 2008 VA examination, the Veteran reported that the relationship was rocky and they were discussing divorce, the Veteran and his wife were still married at the December 2010 VA examination. The Veteran stated to the December 2010 VA examiner that he and his wife get along great during his waking hours, but his wife fears his nightmares and he has inadvertently struck or kicked her in his thrashings at night. His wife complains that he is isolative and distant. Generally, he and his wife get along adequately. The Veteran gets along with two of his sons. He does not get along with the third son, because he is an alcoholic and he has stolen from him. The Veteran is distant with his 14 siblings. Outside of his sons and their families, he reported very limited social interactions or non-family contacts. A VA treatment record dated in January 2008 reveals that the Veteran is fairly guarded and chooses to stay away from others. He has some acquaintances, but no close friendships. The Veteran enjoys deep sea fishing, but he does not like to be on a boat with more than four people on it. A March 2008 VA treatment record reveals that he went with some family and friends to the coast to fish in 2007. At the December 2010 VA examination the Veteran reported that he reconnected with an old Army buddy and he visited him in Georgia. He and the other Veteran have also gone to Virginia Beach for saltwater fishing. Most of the Veteran's activities are solitary in nature and he spends a lot of time in the woods. Based on the foregoing, the Veteran's symptoms do not result in the Veteran's inability to establish and maintain effective relationships or difficulty with family relations. Although the evidence indicates the Veteran's PTSD has contributed to his current unemployment and caused moderate impairment in social functioning, in reviewing the entire evidence of record, his symptoms do not more closely approximate deficiencies in most areas, such as work, family relations, judgment, thinking or mood due to PTSD. Based on the evidence and analysis discussed above, the criteria for a 70 percent rating have not been met or approximated. The Veteran's GAF score ranged between 54 and 55 throughout the entire claims period. This range in GAF score reveals moderate symptoms with moderate difficulty in social and occupational activities. The Board recognizes that while a GAF score may be indicative of a certain level of occupational impairment, it is only one factor in determining the Veteran's degree of disability. See Bowling v. Principi, 15 Vet. App. 1, 14 (2001). In this case, the Veteran's GAF score is consistent with the Veteran's overall disability picture including symptoms reported at the VA examinations and discussed in the lay evidence indicating that the Veteran's disability picture more closely approximates the current 50 percent disability rating as the evidence shows that the Veteran has difficulty in establishing and maintaining effective work and social relationships. The Board has considered whether staged ratings are appropriate. The evidence of record shows that the Veteran's PTSD symptoms have not fluctuated materially during the course of this appeal. As such, a staged rating is not warranted. According to VA regulation, in exceptional cases where schedular ratings are found to be inadequate, the RO may refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extraschedular 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). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and it is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, the evidence does not show such an exceptional disability picture that the available schedular evaluation for service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria found in the rating schedule for a mental disorder shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. The Board notes that the record indicates the Veteran is unemployed in part due to his PTSD symptoms; however, this is contemplated in the assignment of the 50 percent disability rating. In this case the Board finds that the evidence of record shows that the Veteran's PTSD symptoms have not caused marked interference with employment that has not already been considered in the Veteran's current disability rating. Furthermore, the medical record does not show that the Veteran's PTSD has necessitated frequent periods of hospitalization or otherwise rendered impracticable the regular schedular standards for rating such disability. Under these circumstances, and in the absence of factors suggestive of an unusual disability picture, further development in keeping with the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) is not warranted. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Residuals of Right Acromioclavicular Separation The Veteran's service-connected residuals of right acromioclavicular separation is currently evaluated as 20 percent disabling under Diagnostic Code 5322-5203. 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 (2012). In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. The hyphenated diagnostic code in this case indicates that muscle injury of Group XXII of the neck and torso under Diagnostic Code 5322 is the service-connected disorder and that impairment of the clavicle or scapula rated under Diagnostic Code 5203 is the residual disability. Disabilities of the shoulder and arm are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5200 through 5203. A distinction is made between major (dominant) and minor musculoskeletal groups for rating purposes. 38 C.F.R. § 4.69 (2012). The July 2008 VA examination reveals that the Veteran's right arm is dominant. Diagnostic Code 5203 provides a 20 percent rating for nonunion of the clavicle or scapula with loose movement. 38 C.F.R. § 4.71a, Diagnostic Code 5203. Dislocation of the clavicle or scapula also warrants a 20 percent rating for either the major extremity. Id. The Board notes that the 20 percent disability rating currently assigned for the Veteran's residuals of right acromioclavicular separation is the highest available under Diagnostic Code 5203. Accordingly, the claim for a disability rating in excess of 20 percent under this diagnostic code must be denied. However, impairment of the clavicle or scapula may also be evaluated based upon impairment of function of the contiguous joint. Id. Diagnostic Code 5201 provides the rating criteria for limitation of motion of the arm. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Under that code, a 30 percent disability rating is warranted for limitation of motion of the dominant arm midway between the side and shoulder level. Id. Limitation of motion of the dominant arm to 25 degrees from the side warrants a 40 percent disability rating. Id. The regulations define normal range of motion for the shoulder as forward flexion from zero to 180 degrees, abduction from zero to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. 38 C.F.R. § 4.71a, Plate I. With forward elevation (flexion) and abduction, range of motion for the arm is from the side of the body (zero degrees) to above the head (180 degrees) with the mid-point of 90 degrees where the arm is held straight out from the shoulder. Id. A July 2008 VA examination reveals that flexion and abduction of the Veteran's right shoulder was from zero to 170 degrees. Right internal and external rotation was from zero to 90 degrees. There was objective evidence of pain following repetitive motion, but there was no additional limitation after three repetitions of range of motion. Muscle strength of the right shoulder was five out of five. There were no acute findings in the X-rays of the right shoulder. The VA examination in December 2010 reveals that right flexion was from zero to 145 degrees and right abduction was from zero to 150 degrees. Right internal and external rotation was from zero to 90 degrees. There was objective evidence of pain following repetitive motion, but there was no evidence of additional limitations after three repetitions of range of motion. Therefore, the evidence of record shows that the Veteran's limitation of motion of the arm was greater than shoulder level. Accordingly, the Veteran is not entitled to a disability rating in excess of 20 percent under Diagnostic Code 5201 at any time during the appeal period. The Board has also considered whether the Veteran's residuals of right acromioclavicular separation are entitled to a higher disability evaluation under other diagnostic codes for the shoulder. Diagnostic Code 5200, which evaluates ankylosis of scapulohumeral articulations and Diagnostic Code 5202, which evaluated other impairment of the humerus, are the only remaining provisions that evaluate shoulder disabilities. 38 C.F.R. § 4.71a. The evidence of record shows that the Veteran's right shoulder disability does not result in ankylosis or impairment of the humerus. Accordingly, there are no other diagnostic codes relevant to the shoulder that are applicable in this case. The competent medical evidence of record shows that the residuals of right acromioclavicular separation have not fluctuated materially during the course of this appeal. As such, a staged rating is not warranted. Based on the foregoing, the Board finds that a preponderance of the evidence is against a disability rating in excess of 20 percent for service-connected residuals of right acromioclavicular separation for the entire appeals period. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Regarding whether the Veteran's residuals of right acromioclavicular separation warrants a referral for extraschedular consideration, the evidence does not show such an exceptional disability picture that the available schedular evaluation for the service-connected residuals of right acromioclavicular separation is inadequate. A comparison between the level of severity and symptomatology of the Veteran's residuals of right acromioclavicular separation with the established criteria found in the rating schedule for disabilities of the shoulder and arm shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. In this case, the evidence does not indicate that the residuals of right acromioclavicular separation have caused marked interference with employment that is not already contemplated in the schedular rating. In this regard, the Board notes that the VA examiner in December 2010 determined that the Veteran's residuals of right acromioclavicular separation have a significant effect on occupation activities such as problems lifting and carrying, difficulty reaching and pain. All of these symptoms that affect the Veteran's ability to work in a physical demanding job or long distance driving are contemplated in the rating criteria. Furthermore, the medical record does not show that the Veteran's service-connected residuals of right acromioclavicular separation has necessitated frequent periods of hospitalization during the appeal period or otherwise rendered impracticable the regular schedular standards for rating such disability. Under these circumstances, and in the absence of factors suggestive of an unusual disability picture, further development in keeping with the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) is not warranted. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Residuals of a Scalp Laceration Secondary to SFW/TBI with Headaches The Veteran's residuals of a scalp laceration secondary to shell fragment wound (SFW)/traumatic brain injury (TBI) with headaches was evaluated as 10 percent disabling under Diagnostic Code 7800-8045 prior to September 23, 2008. 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. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. The hyphenated diagnostic code in this case indicates that residuals of a scalp laceration under Diagnostic Code 7800 for scars of the head, face or neck is the service-connected disorder and that traumatic brain injury under Diagnostic Code 8045 is the residual disability of which the rating is determined. The criteria for evaluating traumatic brain injury were revised during the pendency of this appeal. 73 Fed. Reg. 54,693 (Sept. 23, 2008). The effective date for these revisions is October 23, 2008. 38 C.F.R. § 4.124, Note (5). For claims received by VA prior to that effective date, a veteran is to be rated under the old criteria for any periods prior to October 23, 2008; however, for any period beginning on October 23, 2008, a veteran will be rated under the new criteria or the old criteria, whichever is more favorable. The claim is to be rated under the old criteria unless applying the new criteria results in a higher disability rating as of October 23, 2008. See VBA Fast Letter 8-36 (October 24, 2008). Given that the Veteran's claim was received prior to the effective date of the new criteria and such claim was not final as of October 23, 2008, the Board will rate the claim as directed by the October 2008 VA Fast Letter. Furthermore, as noted in the Introduction, it appears that the RO also evaluated the Veteran under the old and new criteria and evaluated the laceration and headache residuals of the SFW/TBI under separate diagnostic codes (Diagnostic Code 8000 for laceration of the scalp and under Diagnostic Code 8045 for headaches) as of September 23, 2008. However, the overall disability rating did not change. In evaluating brain disease due to trauma under the criteria for Diagnostic Code 8045 prior to October 23, 2008, purely neurological disabilities, such as hemiplegia, epileptiform seizures, facial nerve paralysis, etc., following trauma to the brain, were rated under the diagnostic codes specifically dealing with such disabilities, with citation of a hyphenated Diagnostic Code (e.g., 8045-8207). Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, were rated at a maximum of 10 percent under Diagnostic Code 9304, "Dementia due to head trauma." This 10 percent rating was not to be combined with any other rating for a disability due to brain trauma. Ratings in excess of 10 percent for brain disease due to trauma under Diagnostic Code 9304 were not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2008). From October 23, 2008, the new version of Diagnostic Code 8045 continues to provide for the evaluation of TBI. 38 C.F.R. § 4.124a (effective October 23, 2008). However, the revised regulation describes three main areas of dysfunction listed that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2012). Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Cognitive impairment is to be evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. Emotional/behavioral dysfunction are evaluated under § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, any emotional/behavioral symptoms due to TBI should be assessed under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." Physical (including neurological) dysfunction should be evaluated based on the following list, under an appropriate diagnostic code: motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. The preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI. Residuals that are not listed here that are reported on an examination should be evaluated under the most appropriate diagnostic code. Each condition should be assessed separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. The regulation directs VA to consider the need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc. Evaluation of Cognitive Impairment and Subjective Symptoms: the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" contains 10 important facets of a TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, and labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. Assign a 100-percent evaluation if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled ""Evaluation of Cognitive Impairment And Other Residuals of TBI Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. Prior to September 23, 2008 A July 2008 VA examination of the brain reveals that the Veteran reported that he was hit with shrapnel in his head from the enemy and he received sutures to the wound. Course since onset was intermittent with remissions. He was not receiving any current treatment for residuals of brain trauma. The Veteran denied a history of neoplasm, fever, dizziness, weakness, paralysis, dysesthesias, numbness, paresthesias, seizures, tremors, gait difficulty, rigidity, difficulty swallowing, impairment of bowel function impaired bladder function, fatigability, impaired smell, impaired taste, difficulty breathing, vision problems, insomnia, tinnitus, speech problems, memory loss, cognitive problems or cerebrovascular accident. The Veteran reported that headaches were an issue in the past, but they were not at the time of the examination. The examiner also observed that the Veteran was a good conversationalist. Physical examination revealed normal muscle tone with no atrophy present. Deep tendon reflexes were normal. There were no findings of dysesthesias, tremors or fasciculations. The Veteran's gait and balance were normal. The Veteran did not have ataxia, incoordination or spasticity. There was no evidence of speech impairment. The examiner found no evidence of autonomic nervous system problems that have not been addressed. Sensory function of a nerve or group of nerves was not affected. There was no evidence of bowel or bladder impairment. There was no evidence of cranial, cognitive or psychiatric impairment. The Veteran did not have loss of sense of taste or smell. There was no evidence of limitation of motion of one or more joints due to a brain injury. X-rays revealed retained shrapnel to the posterior scalp. Based on the evidence of record prior to September 23, 2008, the Board finds that there is no evidence of purely neurological disabilities. The Veteran was originally assigned a 10 percent rating under Diagnostic Code 8045 for purely subjective headaches. Furthermore, there was no evidence of any current subjective complaints to include headaches. Diagnostic Code 8045 (in effect prior to October 23, 2008) only provides a 10 percent disability rating for such symptoms. Accordingly, the Board finds the Veteran is not entitled to a disability rating in excess of 10 percent prior to September 23, 2008 under Diagnostic Code 8045 for brain disease due to trauma. The Board has also considered whether the Veteran is entitled to a higher disability rating for his headache symptoms under Diagnostic Code 8100 for migraine headaches. Diagnostic Code 8100 provides that migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months warrants a 30 percent disability rating. VA regulations do not define "prostrating;" nor has the Court. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack.). By way of reference, the Board notes that according to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "prostration" is defined as "complete physical or mental exhaustion." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st Ed. 2007), in which "prostration" is defined as "extreme exhaustion or powerlessness." In this case, the evidence of record reveals that the Veteran does not have any current problems with headaches prior to September 23, 2008. As there is no evidence suggesting that the Veteran has had prostrating headaches attacks occurring on an average of once a month over the last several months, the Veteran is not entitled to a higher disability rating under Diagnostic Code 8100. The Board has also considered whether the Veteran is entitled to a separate compensable disability rating for the Veteran's scar of the scalp. During the appeal the applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were amended in October 2008. The October 2008 revisions are applicable to claims for benefits received by the VA on or after October 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). In this case, the Veteran filed his claim in February 2008. Therefore, the Board will only consider the schedular criteria for scars in effect between August 2002 and October 2008. Prior to October 23, 2008, under Diagnostic Code 7800, disfigurement of the head, face, or neck with one characteristic of disfigurement warrants a 10 percent evaluation. Disfigurement of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement warrants a 30 percent evaluation. Disfigurement of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement warrants a 50 percent evaluation. Disfigurement of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement warrants an 80 percent evaluation. 38 C.F.R. § 4.118, DC 7800 (2008). The eight characteristics of disfigurement are: scar five or more inches (13 or more cm.) in length; scar at least one-quarter inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding six square inches (39 square cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square cm.); underlying soft tissue missing in an area exceeding six square inches (39 square cm.); and skin indurated and inflexible in an area exceeding six square inches (39 square cm.). Id. at Note (1). The Board finds that a separate compensable rating is not warranted under Diagnostic Code 7800 prior to September 23, 2008. The evidence of record does not show that the Veteran's scar on the forehead has caused disfigurement of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. The July 2008 VA examination reveals that the Veteran had a superficial scar to the upper frontal scalp near the hairline. The scar was approximately 9 cm long and 2 mm wide. The examiner observed that the scar was very faint, almost indistinguishable, flesh colored and it had a smooth surface. There was no tenderness on palpation, adherence to underlying and it did not result in limitation of motion or loss of function. There was no underlying soft tissue damage, skin ulceration or breakdown over the scar, underlying tissue loss. The scar was not elevated or depressed. There was no disfigurement to the head, face or neck. The scar had no induration or inflexibility. Thus, the evidence shows that the Veteran's scar was not 5 or more inches in length, it was not at least one-quarter inch wide at the widest point, the surface of the scar was not elevated or depressed on palpation, it was not adherent to underlying tissue, there was no hypo-pigmented area of the skin, underlying soft tissue was not missing, and the skin was not indurated and inflexible in an area exceeding six square inches. As of September 23, 2008 The Board observes that the RO rated separately the Veteran residuals of SFW/TBI with headaches as 10 percent disabling under Diagnostic Code 8045 and residuals of scalp lacerations as noncompensable under Diagnostic Code 7800 as of September 23, 2008. The combined rating did not change. Accordingly, the Board will evaluate the Veteran's headaches and residuals of scalp lacerations separately as of September 23, 2008. With respect to the Veteran's residuals of SFW/TBI with headaches, the Veteran was provided with another VA examination in December 2010 for traumatic brain injury. The examiner noted that the Veteran sustained a shrapnel injury to the head while in Vietnam in 1968, which was the etiology of his TBI. He had loss of consciousness for approximately one to two days and he was hospitalized in a MASH unit. He returned to light duty after approximately two weeks. The examiner documented that the original injury was severe and the condition has stabilized. The Veteran denied a history of dizziness or vertigo, seizures, balance and coordination problems, pain, autonomic dysfunction, numbness, paresthesias or other sensory changes, weakness or paralysis, mobility problems, fatigue, malaise, other cognitive symptoms, neurobehavioral change, bowel or bladder problems, erectile dysfunction, hearing loss, tinnitus, hypersensitivity to light or sound, vision problems, speech or swallowing difficulty, decreased sense of taste or smell, endocrine dysfunction or cranial nerve dysfunction. The Veteran reported having moderately-severe headaches four to five times a year lasting one to two days. The examiner noted these headaches prevent normal activities. The Veteran has mild memory impairment that is recent and not related to TBI. Reflex and sensory examinations were normal. Motor examination was normal, except the right upper extremity was slightly weak partially secondary to pain in the right shoulder. Muscle tone was normal. There were no physical findings of autonomic nervous system impairment, gait abnormalities, imbalance or tremors, muscle atrophy or loss of muscle tone, spasticity or rigidity, fasciculations, cranial nerve dysfunction, hearing problems, skin breakdown, vision problems, psychiatric manifestations or other abnormalities. Neuropsychological testing was normal for the Veteran's age and education. The Board finds that as of September 23, 2008 there is no evidence of any purely neurological disabilities as a result of the shrapnel wound injury to the head in service. Although there is evidence of subjective headaches, Diagnostic Code 8045 (in effect prior to October 23, 2008) only provides a 10 percent disability rating for such symptoms. Accordingly, the Board finds the Veteran is not entitled to a disability rating in excess of 10 percent as of September 23, 2008 under Diagnostic Code 8045 for brain disease due to trauma (in effect prior to October 23, 2008). In evaluating the Veteran's residuals of SFW/TBI with headaches under Diagnostic Code 8045 (2012) under the new criteria, the Board finds that an assignment of 0 under the sections of memory, attention, concentration, executive functions; judgment; social interaction; orientation; motor activity; visual spatial orientation; subjective symptoms; neurobiological effects and communication. The Board observes that the Veteran has reported mild memory loss; however this was not attributed to the Veteran's TBI. Thus, a level of impairment of 0 is warranted as there is no evidence of complaints of impairment of memory, attention, concentration or executive functions as a residual of the scalp laceration. The evidence of record shows that the Veteran's judgment is normal, therefore, the level of impairment of 0 is assigned for judgment. Social interaction appears to be routinely appropriate, thus the Veteran is assigned a level of impairment of 0 for social interaction. The evidence of record indicates that the Veteran is always oriented to person, time, place and situation and therefore, the Board has assigned a level of impairment of 0 for orientation. Motor activity warrants a level of impairment of 0 as the Veteran demonstrated normal motor activity. Visual spatial orientation is normal; therefore, a level of impairment of 0 is appropriate. The Board finds that a level of impairment of 0 for subjective symptoms is appropriate as there is no evidence that the Veteran has three or more subjective symptoms that mildly interfere with work, instrumental activities of daily living, work, family or other close relationships. The Veteran has reported moderate to severe headaches four to five times a year; however, there is no evidence of any other subjective symptoms and it appears that these headaches do not interfere with daily living or family relationships. An impairment level of 0 is appropriate for neurobehavior effects and communications as the evidence shows that the Veteran does not have any neurobehavioral problems and he is able to communicate by spoken and written language and comprehend spoken and written language. There is no evidence that the Veteran has a persistently altered state of consciousness. As the highest level assigned was not two or above in any of the facets, the Veteran is not entitled to a disability rating in excess of 10 percent under the amended criteria for Diagnostic Code 8045 as of October 23, 2008. The Board has also considered whether the Veteran is entitled to a separate disability rating under Diagnostic Code 8100 for migraine headaches. Under the amended Diagnostic Code 8045, residuals of traumatic brain injury may be separately rated when there is a distinct diagnosis, such as post-traumatic headaches. Diagnostic Code 8100 provides that migraine headaches with characteristic prostrating attacks averaging one in two months over the last several months are rated as 10 percent disabling. A 30 percent disability rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012). VA regulations do not define "prostrating;" nor has the Court. Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack.). By way of reference, the Board notes that according to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "prostration" is defined as "complete physical or mental exhaustion." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st Ed. 2007), in which "prostration" is defined as "extreme exhaustion or powerlessness." In this case, the evidence of record shows that the Veteran has moderate to severe headaches approximately four to five times a year. These headaches appear to be prostrating as they prevent normal activities. Nonetheless, the Board finds that the Veteran's headaches average less than one in two months over the last several months. Therefore, the Veteran is not entitled to a compensable rating under Diagnostic Code 8100. With respect to whether the Veteran is entitled to a compensable rating for residuals of scalp laceration secondary to shell fragment wound, as noted above, during the appeal the applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were amended in October 2008 and the new revisions are applicable to claims for benefits received by VA on or after October 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). As the Veteran filed his claim in February 2008, the Board will only consider the scheduler criteria for scars in effect between August 2002 and October 2008. After a review of the claims file, the Board has determined that a compensable rating is not warranted under Diagnostic Code 7800 as of September 23, 2008. The evidence of record does not show that the Veteran's scar on the forehead has caused disfigurement of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A December 2010 VA examination of the Veteran's scar shows that there is a scar on the Veteran's forehead that is faded, barely visible and curved. There is no skin breakdown and the Veteran reported no pain. Maximum width was .25 cm and maximum length was 6 cm. The examiner observed that the scar was superficial, with no inflammation, edema, or keloid formation. The scar did not have an abnormal texture, hypo- or hyper-pigmentation or underlying soft tissue loss. The scar was not indurated or inflexible. Contour was not elevated or depressed. It was not adherent to underlying tissue and there were no other disabling effects. The December 2010 VA examiner determined that the scar on the forehead was a well-healed shrapnel scar. Thus, the evidence reveals that the Veteran's scar was not 5 or more inches in length, it was not at least one-quarter inch wide at the widest point, the surface of the scar was not elevated or depressed on palpation, it was not adherent to underlying tissue, there was no hypopigmented area of the skin, underlying soft tissue was not missing, and the skin was not indurated and inflexible in an area exceeding six square inches. In light of the analysis discussed above, the Board concludes finds that a preponderance of the evidence is against a disability rating in excess of 10 percent for service-connected residuals of a scalp laceration secondary to SFW/TBI with headaches prior to September 23, 2008, in excess of 10 percent for residuals of SFW/TBI with headaches as of September 23, 2008 and in excess of a 0 percent rating for residuals of scalp laceration secondary to SFW as of September 23, 2008. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). With respect to whether the Veteran's residuals of a scalp laceration secondary to SFW/TBI with headaches warrants a referral for extraschedular consideration, the evidence does not show such an exceptional disability picture that the available schedular evaluation for the service-connected residuals of a scalp laceration is inadequate. A comparison between the level of severity and symptomatology of the Veteran's residuals of a scalp laceration and residuals of SFW/TBI with headaches with the established criteria found in the rating schedule for a skin disability shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. In this case, the evidence does not indicate that the residuals of a scalp laceration and residuals of SFW/TBI with headaches have caused marked interference with employment. Furthermore, the medical record does not show that the Veteran's service-connected residuals of a scalp laceration and residuals of SFW/TBI with headaches has necessitated frequent periods of hospitalization during the appeal period or otherwise rendered impracticable the regular schedular standards for rating such disability. Under these circumstances, and in the absence of factors suggestive of an unusual disability picture, further development in keeping with the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) is not warranted. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Right Knee Scar The Veteran's scar of the right knee is rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7805, which evaluates skin disorders manifested by scars. The Board notes that the applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were amended in October 2008. The October 2008 revisions are applicable to claims for benefits received by VA on or after October 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). In this case, the Veteran filed his claim in February 2008. Therefore, the Board will only consider the scheduler criteria for scars in effect between August 2002 and October 2008. Diagnostic Code 7805 provides that all other scars are to be rated based on limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008). A VA examination conducted in July 2008 reveals that the Veteran denied pain or skin breakdown. The examiner observed that the general location of the scar was on the right lower extremity. It was very faint and it required the Veteran to identify the location. There was approximately 2 cm by 1 mm skin alteration. The surface was smooth and flesh colored. The scar appeared to be in the crease of skin over the right patella. There was no tenderness on palpation, adherence to underlying tissue, underlying soft tissue damage or skin ulceration or breakdown over the scar. The scar did not result in limitation of motion or loss of function. The examiner provided a diagnosis of faint residual scar over the right patella. A December 2010 VA examination shows that the Veteran has scar located in the small depressed semi-circular area just below the right knee cap. The Veteran did not report any pain and there was no skin breakdown. Physical examination of the scar revealed that the area of scar was less than six square inches (39 square centimeters). The scar was not painful and there were no signs of skin breakdown. The scar was superficial and there was no evidence of inflammation edema or keloid formation. The examiner determined that there were no other disabling effects. She provided a diagnosis of well-healed shrapnel scar. Based on the evidence of record, the most pertinent of which was discussed above, the Board finds that the Veteran's scar does not result in limitation of motion or function of the right knee or right lower extremity. Accordingly, the Veteran's right knee scar does not warrant a compensable disability rating under Diagnostic Code 7805 for limitation of function of the right knee and/or right lower extremity. The Board has considered whether the Veteran is entitlement to a compensable rating under other Diagnostic Codes for scars. Diagnostic Code 7800 evaluates disfigurement of the head, face or neck. As the scar is not located on the head, face or neck, Diagnostic Code 7800 is not applicable. A 10 percent rating is warranted for scars, other than head, face, or neck, that are deep or that cause limited motion, when the area exceeds 6 square inches (39 square centimeters) under Diagnostic Code 7801. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2008). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Note (2) (2008). Diagnostic Code 7802 provides that scars, other than the head, face or neck, that are superficial and that do not cause limited motion are assigned a 10 percent rating when the area is 144 square inches (929 square centimeters) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2008). Under Diagnostic Code 7803, scars that are superficial and unstable warrant a 10 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2008). An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. Under Diagnostic Code 7804, scars that are superficial and painful on examination warrant a 10 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). The evidence of record shows that the Veteran's right knee scar is not manifested by deep or limited motion of an area in excess of 6 square inches (39 square centimeters). Although the Veteran's right knee scar is superficial and does not cause limited motion, it encompasses an area less than 144 square inches (929 square centimeters). Furthermore, the evidence of record shows that the Veteran's right knee scar is not unstable and it was not painful on examination. The competent medical evidence of record shows that the right knee scar has not fluctuated materially during the course of this appeal. As such, a staged rating is not warranted. Based on the foregoing, the Board finds that a preponderance of the evidence is against a compensable disability rating for service-connected right knee scar for the entire appeals period. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Regarding whether the Veteran's right knee scar warrants a referral for extraschedular consideration, the evidence does not show such an exceptional disability picture that the available schedular evaluation for the service-connected scar of the right knee is inadequate. A comparison between the level of severity and symptomatology of the Veteran's right knee scar with the established criteria found in the rating schedule for a skin disability shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. In this case, the evidence does not indicate that the right knee scar has caused any interference with employment. Furthermore, the medical record does not show that the Veteran's service-connected right knee scar has necessitated frequent periods of hospitalization during the appeal period or otherwise rendered impracticable the regular schedular standards for rating such disability. Under these circumstances, and in the absence of factors suggestive of an unusual disability picture, further development in keeping with the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) is not warranted. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). (CONTINUED ON NEXT PAGE) ORDER Entitlement to a disability rating in excess of 50 percent for service-connected PTSD is denied. Entitlement to a disability rating in excess of 20 percent for residuals of a right acromioclavicular separation is denied. Entitlement to a disability rating in excess of 10 percent for service-connected residuals of a scalp laceration secondary to SFW/TBI with headaches prior to September 23, 2008 is denied. Entitlement to a disability rating in excess of 10 percent for service-connected residuals of SFW/TBI with headaches as of September 23, 2008 is denied. Entitlement to a compensable disability for service-connected residuals of a scalp laceration secondary to SFW/TBI as of September 23, 2008 is denied. Entitlement to a compensable disability rating for service-connected scar of the right knee is denied. ______________________________________________ Mark W. Greenstreet Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs