Citation Nr: 1302601 Decision Date: 01/23/13 Archive Date: 01/31/13 DOCKET NO. 06-39 005 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial compensation rating for residuals of a right forearm wound. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. L. Douglas, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from July 1992 to September 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision by the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA). The case was remanded for additional development in October 2010 and March 2012. The requested development has been substantially completed. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of this appeal has been obtained. 2. The evidence demonstrates the Veteran's service-connected residuals of a right forearm wound is manifested by a deep, stable, non-linear scar to the right forearm that is less than 39 square centimeters in affected area but manifested by pain on examination prior to October 23, 2008, and credible reports of pain thereafter. CONCLUSION OF LAW The criteria for a 10 percent, but not greater, rating for residuals of a right forearm wound have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.118, Diagnostic Code 7801 (before and after October 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (hereinafter "the Court") have been fulfilled by information provided to the Veteran in March 2005. That letter notified the Veteran of VA's responsibilities in obtaining information to assist in completing her claim and identified the Veteran's duties in obtaining information and evidence to substantiate her claim. (See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a)), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006), Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006). The notice requirements pertinent to the issue on appeal have been met and all identified and authorized records relevant to the matter have been requested or obtained. The available record includes the Veteran's service treatment records, VA treatment and examination reports, private treatment records, and the Veteran's statements in support of her claim. The Board finds that further attempts to obtain additional evidence would be futile. The Court has held that 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). The Board finds that VA medical opinions obtained in this case are adequate as they are predicated on a substantial review of the record and medical findings and consider the Veteran's complaints and symptoms. 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 available medical evidence is sufficient for an adequate determination. There has been substantial compliance with all pertinent VA law and regulations and to move forward with the claim would not cause any prejudice to the appellant. Increased Rating Claim Factual Background Private medical records show the Veteran was treated for non-Hodgkin's lymphoma in March 2004, approximately six months after her discharge from active service. Records also note chemotherapy treatment. Service connection was established for non-Hodgkin's lymphoma in a June 2004 rating decision. In statements in support of her service connection claim for an open right forearm wound the Veteran reported she incurred an injury during private medical treatment in March 2004. She stated she developed blistering in the right arm at the site of her first chemotherapy treatment. VA examination in November 2005 noted that a right forearm wound had developed in March 2004 when chemotherapy was placed into a peripheral catheter with apparent irritation and phlebitis to the surrounding tissue which caused a local wound. The examiner noted there was local wound care only and that the area was completely healed at that time. No exercise or exertion was precluded by the disorder and it was found to be resolved with no occupational difficulties or difficulty with activities of daily living. A November 2005 rating decision established service connection for residuals, open wound, right forearm. A 0 percent rating was assigned under the provisions of 38 C.F.R. § 4.118, Diagnostic Code 7802. In her July 2006 notice of disagreement the Veteran stated that during her first chemotherapy treatment the needle had not been properly placed and medicine leaked under the skin resulting in scarred tissue that was still hard to the touch. She stated that if the right arm was held in any position for five to ten minutes its strength gave out and the arm would tingle and shake. She complained of constant muscle pain that extended from the forearm to the shoulder. In a VA Form 9 dated in December 2006 she reported that the wound had healed, but that the tissue and nerves had not totally healed. She further maintained that "[i]f any area around the scar is irritated or overworked this causes the forearm to limit daily activities." She reported her pain was only relieved by medication. VA scars examination in April 2008 noted a 5 centimeter (cm) by 8 cm scar to the anterior surface of the right forearm 4 cm distal to the elbow due to extravasation of chemotherapy in March 2004. The examiner noted there was tenderness on palpation, adherence to underlying tissue, underlying soft tissue damage, and underlying tissue loss, but there was no limitation of motion or loss of function and "no skin ulceration or breakdown" over the scar. The diagnosis was scar residual of service connected non-Hodgkin's lymphoma (extravasation of chemotherapy). A November 2010 VA examination report notes that the Veteran stated that her right forearm disorder had progressively worsened since onset and that she used pain-relief medication twice per day. A summary of right elbow/forearm joint symptoms included pain, stiffness, and weakness. There was no affect on joint motion. The VA examiner noted normal joint findings with 5/5 muscle strength, normal muscle tone, and no visible atrophy. Sensory examination was normal to fine touch, pinprick, position sense, and vibration sense including to the scar area. The range of motion studies revealed extension to 0 degrees, flexion to 145 degrees, pronation to 80 degrees, and supination to 85 degrees. There was no objective evidence of pain following repetitive motion and no additional limitations after three repetitions. The examiner's diagnosis was no objective evidence of right radio-ulnar joint pathology. It was noted that since the right upper extremity muscle and sensory examinations had been normal additional peripheral nerves and muscle injury worksheets were not indicated. The examiner, however, found the disorder had significant occupation effects due to pain and disfigurement resulting in the assignment of different duties. The effects on usual daily activities were severe with respect to exercise, sports, recreation, grooming, and driving, were moderate with respect to chores, shopping, traveling, bathing, and dressing, and were mild with respect to feeding and toileting. A November 2010 VA scars examination revealed a 4 cm by 7 cm nonlinear, irregular oval-shaped scar to the right anterior forearm. The area was described as less than 6 square (sq.) inches or 39 sq. cm. The scar was not unstable and there was no limitation of motion or loss of function. There was adherence to underlying tissue, underlying soft tissue damage, and the texture of the skin was irregular and rough with a small raised area. The area of underlying soft tissue loss and induration or inflexibility was described as less than 6 sq. inches or 39 sq. cm. The scar was depressed with a small one cm diameter raised area. There was hyperpigmentation with areas of normal pigmentation. The diagnosis was scar residual of service connected non-Hodgkin's lymphoma (extravasation of chemotherapy), with disfigurement, but no functional impairment or limitation. It was noted there were no significant effects on employment and no effects on usual daily activities. VA treatment records dated in December 2010 noted a diagnosis of right forearm pain secondary to right arm extravasation with some necrosis. The Veteran complained of current pain estimated as 5/10 and at its highest as 9/10. She described her pain as an ache which changed to throbbing pain with activity and which was relieved with better positioning and rest. A TENS unit was issued. In correspondence dated in December 2011 the Veteran reported that she was right-handed and that simple tasks such as cooking, cleaning, shopping, and holding the phone caused pain in her right arm. She described her pain as starting in the forearm, but spreading to the shoulder and into the hand and wrist. She stated the arm felt heavy and that her pain was intense. She reported that a TENS unit she had been provided was ineffective and that while Tramadol was effective its use made it impossible for her to perform necessary daily tasks for her children. She noted she was presently using over-the-counter medication for pain. VA elbow and forearm examination in June 2012 included no diagnosis for an elbow or forearm condition. Range of motion studies of the right elbow were from 0 to 145 degrees, with no objective evidence of painful motion. There were no additional limitations after repetitive-use testing and there was no functional loss or functional impairment of the elbow and forearm. Muscle strength was 5/5 on flexion and extension. It was noted the Veteran reported the disorder had an impact on her ability to work, but the examiner provided no additional comments. A June 2012 VA scars examination included a diagnosis of residual scar with hyperesthesia status post healed open wound to the right forearm associated with service-connected non-Hodgkin's lymphoma. The examiner noted the Veteran reported her symptoms were unchanged since her last VA examination with intermittent pain. She complained of excruciating pain at times at the site of the scar and stated she used a TENS unit when necessary. She reported she was off all mediation to avoid addiction and was learning to deal with the pain. The examiner noted the scar was not painful and unstable. The scar was described as a 7 cm by 4 cm scar that was deep and non-linear. The approximate total area affected was 28 sq. cm. It was adherent to the underlying tissue with loss of connective tissue causing irregular texture due to some areas of elevation and depression. It was further noted these findings were unchanged since the last examination. There was no evidence of ulceration or keloid formation. There is some disfigurement, predominantly due to the areas of hyperpigmentation, that was easily covered by clothing with no unexposed area. Range of motion at the right elbow and forearm was normal. Right upper extremity muscle strength was 5/5, muscle tone was normal, and there was no visible atrophy. Sensory examination was normal to fine touch, pinprick, position sense, and vibration sense. The examiner noted the scar itself was not painful, was not tender, and had no obvious sensory changes, but that the Veteran had a 2 cm area around the scar of patchy hyperesthesia that was not "localizable to a specific peripheral nerve." The examiner found that based upon the examination the completion of peripheral nerve and muscle examination worksheets were not indicated. It was further noted that the scar had an impact on the Veteran's ability to work and that she reported repeated movement caused pain at the site of the scar without preventing her from working. The Veteran also stated she tried to rest her arm and avoid too much movement. Pertinent Laws and Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. This Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, 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. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran's disability claim may require reratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is thus essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history. See 38 U.S.C.A. § 1155(West 2002); 38 C.F.R. § 4.1 (2012). The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2012). The Court has held that disabilities may be rated separately without violating the prohibition against pyramiding unless the disorder constitutes the same disability or symptom manifestations. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). A separate rating, however, must be based upon additional disability. If the veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. See Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997) (assignment of zero-percent ratings is consistent with requirement that service connection may be granted only in cases of currently existing disability). When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7 (2012). In Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that whether lay evidence is competent and sufficient in a particular case is an issue of fact and that lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. The Federal Circuit has also recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3 (2012). The Board notes that the regulations for the evaluation of skin disabilities were revised effective October 23, 2008. See 73 Fed. Reg. 54708-54712 (Sept. 23, 2008). The revised provisions are applicable only to claims received on or after October 23, 2008; however, a Veteran who VA rated under diagnostic codes 7800, 7801, 7802, 7803, 7804, or 7805 before October 23, 2008, can request review irrespective of whether the disability has increased since the last review. In no case will any such award be effective before October 23, 2008. The RO considered the new criteria and provided them to the Veteran, and thus, the Board finds that they may be applied to the Veteran's claim on appeal. VA's General Counsel, in a precedent opinion, has also held that when a new regulation is issued while a claim is pending before VA, unless clearly specified otherwise, VA must apply the new provision to the claim from the effective date of the change as long as the application would not produce retroactive effects. VAOPGCPREC 7-2003 (Nov. 19, 2003); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). 7801 Scars, other than head, face, or neck, that are deep and that cause limited motion: Area or areas of 144 square inches (929 sq. cm) or greater 40 Area or areas of 72 square inches (465 sq. cm) or greater 30 Area or areas of 12 square inches (77 sq. cm) or greater 20 Area or areas of 6 square inches (39 sq. cm) or greater 10 Note (1): Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25. Note (2): A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 (effective prior to October 23, 2008). 7802 Scars, other than head, face, or neck, that are superficial and that do not cause limited motion: Area or areas 0f 144 square inches (929 sq. cm) or greater 10 Note (1): Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25. Note (2): A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802 (effective prior to October 23, 2008). The revised regulations effective October 23, 2008, include: 7801 Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear: Area or areas of 144 square inches (929 sq. cm) or greater 40 Area or areas of 72 square inches (465 sq. cm) or greater 30 Area or areas of 12 square inches (77 sq. cm) or greater 20 Area or areas of 6 square inches (39 sq. cm) or greater 10 Note (1): A deep scar is one associated with underlying soft tissue damage. Note (2): If multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Combine the separate evaluations under § 4.25. Qualifying scars are scars that are nonlinear, deep, and are not located on the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7801 (effective October 23, 2008). §4.56 Evaluation of muscle disabilities. (a) An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. (b) A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. (c) For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. (d) Under diagnostic codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows: (1) Slight disability of muscles. (i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles. (i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. 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. (3) Moderately severe disability of muscles. (i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles. (i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56 (2012). 5307 Group VII. Dominant Non-dominant Function: Flexion of wrist and fingers. Muscles arising from internal condyle of humerus: Flexors of the carpus and long flexors of fingers and thumb; pronator. Severe 40 30 Moderately Severe 30 20 Moderate 10 10 Slight 0 0 38 C.F.R. § 4.73, Diagnostic Code 5317 (2012). 8517 Paralysis of: Major Minor Complete; weakness but not loss of flexion of elbow and supination of forearm 30 20 Incomplete: 20 20 Severe 10 10 Moderate 0 0 Mild 8617 Neuritis 8717 Neuralgia 38 C.F.R. § 4.124a, Diagnostic Codes 8517, 8617, 8717 (2012). 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. When the involvement is wholly sensory, the rating should be for mild, or at most, moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral the rating should include the application of the bilateral factor. 38 C.F.R. § 4.124a (2012). Based upon the evidence of record, the Board finds the Veteran's service-connected residuals of a right forearm wound are manifested by a deep, stable, non-linear scar to the right forearm that is less than 39 sq. cm in affected area but manifested by pain on examination prior to October 23, 2008, and credible reports of pain thereafter. The overall evidence demonstrates that the Veteran sustained an injury during chemotherapy for her service-connected non-Hodgkin's lymphoma that resulted in scarring and underlying soft tissue damage in March 2004. The service-connected disability is more appropriately evaluated under the revised criteria of Diagnostic Code 7801. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). The criteria, however, demonstrate entitlement to a 10 percent, but not higher, rating under any applicable diagnostic code throughout the period on appeal. The pertinent evidence of record shows that the Veteran's right forearm wound developed in March 2004 when chemotherapy was placed into a peripheral catheter with apparent irritation and phlebitis to the surrounding tissue. The Veteran has complained of pain that was at times severe and limited her daily activities. In April 2008, the diagnosis included scar residual of service-connected non-Hodgkin's lymphoma, and the scar was found to be tender on palpation. A December 2010 VA treatment report also reflects a diagnosis of right forearm pain secondary to right arm extravasation with some necrosis. Thus, giving the Veteran the benefit of the doubt, the Board finds there is sufficient evidence of a painful scar on examination to warrant the assignment of a 10 percent rating under former Diagnostic Code 7804. In addition, although the evidence does not support the existence of a scar that is painful on examination after the date of the new regulations, the new regulations do not specify that the pain symptoms be found on examination and the Board finds the Veteran's continued complaints to be credible and consistent with her previous complaints that were found on examination. Thus, the Board finds that the 10 percent rating may be assigned throughout the relevant period on appeal. On the other hand, the Board notes that VA examinations in April 2008, November 2010, and June 2012 have consistently shown underlying soft tissue damage with no limitation of motion or loss of function. The affected area is less than 39 sq. cm. The June 2012 VA scars examiner found the most appropriate diagnosis in this case was residual scar with hyperesthesia status post healed open wound to the right forearm associated with service connected non-Hodgkin's lymphoma. The scar was not painful and unstable, but was deep and non-linear. The approximate total area affected was estimated at 28 sq. cm. The scar was adherent to the underlying tissue with loss of connective tissue causing irregular texture due to some areas of elevation and depression. The range of motion at the right elbow and forearm was normal and right upper extremity muscle strength was 5/5, muscle tone was normal, and there was no visible atrophy. Sensory examination was normal to fine touch, pinprick, position sense, and vibration sense. The examiner noted a 2 cm area around the scar of patchy hyperesthesia, but the symptoms were not associated with a specific peripheral nerve. The Board acknowledges that the Veteran may believe that her service-connected disability is more severe than even the newly assigned 10 percent rating reflects. The Veteran, as a lay person, is considered competent to provide such evidence of how her disabilities affect her everyday life. See Layno v. Brown, 6 Vet. App. 465, 469-470 (1994) (finding lay testimony competent when it concerns features or symptoms of injury or illness). She is competent to report that which she can experience or observe. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Court has held, however, that statements as to subjective symptomatology alone (such as pain), without another diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which higher ratings may be assigned. The Board finds that the Veteran's reports of pain and limitation of function are not shown to be the result of a specific compensable muscle or peripheral nerve injury. The medical evidence of record does not demonstrate cardinal signs and symptoms of a muscle disability such as loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, or uncertainty of movement. The June 2012 VA scar examiner also specifically found that the Veteran's reports of hypesthesia area her scar were not associated with any specific peripheral nerve. The Board finds there is no basis for a higher or separate, compensable rating under any alternative diagnostic code criteria. Therefore, entitlement to a rating in excess of 10 percent is not warranted. Finally, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria adequately contemplate the service-connected scar disability at issue. Although the Veteran has complained of severe pain and limitation for function, the objective medical findings have revealed no symptoms other than pain on examination followed by continuing subjective reports of pain without scar instability, loss of motion, loss of function, cardinal signs of muscle injury, or specific symptoms associated with an identifiable peripheral nerve. The demonstrated symptomatology and manifestations associated with the Veteran's service-connected (less than 39 sq. cm, deep, non-linear) scar disability is contemplated in the rating criteria. Her complaints of more severe pain without an identifiable underlying cause are also found to be of little credible weight. The November 2010 and June 2012 VA scar examination opinions as to occupational and functional impairment in this case are persuasive. There is no evidence of a marked interference with employment and the Veteran has herself reported the disorder did not prevent her from working. As the rating criteria are adequate to evaluate the scar disability, referral for consideration of extraschedular rating is not warranted. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). While the Board will give the Veteran the benefit of the doubt, and assign a 10 percent rating for her painful scar under former and current Diagnostic Code 7804, the Board finds that a preponderance of the evidence in this case is against entitlement to an even higher or separate rating. ORDER Entitlement to a 10 percent, but not greater, evaluation for residuals of a right forearm wound is granted, subject to the statutes and regulations governing the payment of monetary benefits. ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs