Citation Nr: 1304792 Decision Date: 02/08/13 Archive Date: 02/19/13 DOCKET NO. 09-24 468 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to an initial disability rating greater than 10 percent for shrapnel fragment wound (SFW) residuals of the left hip. 2. Entitlement to an initial compensable disability rating for left knee patellofemoral syndrome (PFS). 3. Entitlement to an initial compensable disability rating for left ankle tendonitis. 4. Entitlement to an initial compensable disability rating for left (minor) elbow bursitis. 5. Entitlement to an initial compensable disability rating for scar residuals of SFW of the left ischial area. 6. Entitlement to an initial compensable disability rating for scar residuals of SFW of the left elbow. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD W.T. Snyder, Counsel INTRODUCTION The Veteran had active service from July 2003 to December 2003 and from August 2004 to August 2005. His decorations include the Purple Heart Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2007 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Togus, Maine, which granted service connection for the disabilities captioned above. Local jurisdiction of this matter is currently with the RO located in Newark, New Jersey. In September 2011, the Veteran testified at a personal hearing over which the undersigned Veterans Law Judge presided while at the RO. A transcript of that hearing has been associated with his claims file and has been reviewed. During his September 2011 hearing, the Veteran appeared to raise a claim of entitlement to an increased disability rating for posttraumatric stress disorder. To date, this has not been adjudicated and the issue is therefore referred to the RO for appropriate action. In May 2012, the Board remanded the case to the AMC in Washington, DC, for additional development. The AMC completed the development as directed, continued to deny the claims, and returned the case to the Board for additional appellate review. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they were considered by the Agency of Original Jurisdiction (AOJ), as noted in the most recent Supplemental Statement of the Case (SSOC). The issue of entitlement to an initial disability rating greater than 10 percent for arthritis of the left hip is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The AMC completed the additional development directed in the May 2012 Board remand by obtaining the evidence identified and by arranging the examinations directed by the Board. 2. The Veteran's left knee PFS manifests with subjective complaints of pain and sensations of instability. Objective findings on clinical examination reflect normal, pain-free range of motion (ROM). Neither limitation of motion (LOM) nor instability has manifested during the initial rating period. 3. The Veteran's left ankle disability manifests with subjective pain and sensations of instability. Objective findings on clinical examination reflect normal, pain-free ROM. Neither LOM nor instability has manifested during the initial rating period. 4. The Veteran's left elbow disability manifests with subjective pain. Objective findings on clinical examination reflect normal, pain-free ROM. LOM has not manifested during the initial rating period. 5. The SFW scar residuals of the left elbow and left hip manifest as asymptomatic superficial scars. Neither scar has manifested as painful on examination or caused limitation of function. CONCLUSIONS OF LAW 1. The requirements for an initial compensable evaluation for left knee PFS have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321(b)(1), 4.1, 4.10, 4.31, 4.40, 4.45, 4.59,4.71a, Diagnostic Code (DC) 5260 (2012). 2. The requirements for an initial compensable evaluation for the left ankle disorder have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321(b)(1), 4.1, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71a, DC 5271. 3. The requirements for an initial compensable evaluation for the left elbow disorder have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321(b)(1), 4.1, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71a, DC 5206. 4. The requirements for an initial compensable evaluation for the left elbow SFW scar residual have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321(b)(1), 4.1, 4.10, 4.31, 4.118, DC 7804 (2007). 5. The requirements for an initial compensable evaluation for the left hip SFW scar residual have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321(b)(1), 4.1, 4.10, 4.31, 4.118, DC 7804 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The Veteran's claims arise from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. See 38 C.F.R. § 3.159(c). The Board also remanded the case for additional development and current examinations, both of which were accomplished by the AMC. The Veteran has not asserted that there is additional evidence to be obtained, or that VA fail to seek evidence identified as relevant to his claims. In sum, there is no evidence of any VA error in notifying or assisting him that reasonably affects the fairness of this adjudication. See id. Hence, the Board may address the merits of the appeal without prejudice to the Veteran. The Board has reviewed all the evidence in the claims file. Although there is an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by an appellant or obtained on his behalf be discussed in detail. Rather, the analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Applicable Law and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. Id. VA must also interpret reports of examination in 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. 38 C.F.R. § 4.2. VA must resolve any reasonable doubt regarding the degree of disability in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. VA must also evaluate functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when either disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999). Analysis When rating musculoskeletal disabilities based on LOM, a higher rating must be considered where the evidence demonstrates functional loss due to pain, weakness, excess fatigability, or incoordination, if those factors are not contemplated in the relevant rating criteria. 38 C.F.R. §§ 4.40, 4.45, and 4.59). Additionally, the rule against pyramiding does not forbid consideration of a higher rating based on greater LOM due to pain on use, including during flare-ups. 38 C.F.R. § 4.14; DeLuca v. Brown, 8 Vet. App. 202 (1995). Left Knee The January 2007 rating decision reflects the RO evaluated the Veteran's left knee under DC 5260. See 38 C.F.R. § 4.71a. Those criteria provide for a compensable rating of 10 percent where ROM on flexion is 0 to 45 degrees. Flexion limited to 30 degrees warrants a 20 percent rating. Id. LOM on extension of -10 degrees warrants a 10 percent rating, and extension limited to -15 degrees warrants a 20 percent rating. Id. The Secretary, VA, has interpreted the rating criteria to allow separate ratings for compensable LOM on flexion and extension, where shown by the evidence of record. VA's General Counsel has interpreted the rating criteria as allowing separate ratings, where shown by the clinical findings, for compensable LOM on extension and flexion. See VAOPGCPREC No. 9-2004 (September 17, 2004), 69 Fed. Reg. 59,990 (2004). Limitation of knee extension is rated as follows: a noncompensable rating is warranted when it is limited to 5 degrees; a 10 percent rating is warranted when it is limited to 10 degrees; a 20 percent rating is warranted when it is limited to 15 degrees; a 30 percent rating is warranted when it is limited to 20 degrees; a 40 percent rating is warranted when it is limited to 30 degrees; and a 50 percent rating is warranted when it is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Upon VA examination in November 2005, the Veteran denied the use of any assistive devices for ambulation, and he was a full-time student at the time of the examination. He reported that his left knee pain started in 2005 when he was sitting a lot. He experienced considerable pain when he transitioned from seated to standing position. The Veteran described his pain as occurring daily, and it lasted for approximately a minute. Walking provided relief. He denied any instability, locking, or buckling, and had not undergone any regimen of physical therapy. His left knee symptoms did not interfere with his daily activities. Physical examination of the left knee revealed no evidence of cellulitis, swelling, or effusion. Anterior, posterior, medial, and lateral, stress tests revealed no instability. McMurray's sign was negative. ROM was 0 to 140 degrees without any pain. Motor strength was 5/5 distal and proximal on flexion and extension. Patellar grind test was positive. The examiner diagnosed PFS. The objective findings on clinical examination showed the left knee to be essentially normal. Indeed, normal motion for the knee is 0 to 140 degrees. See 38 C.F.R. § 4.71a, Plate II. The Board acknowledges the Veteran's lay report of his left knee pain and acknowledges that he is fully competent to report his left knee symptoms, 38 C.F.R. § 3.159(a)(2). Moreover, the Board deems the Veteran credible in this regard. Nonetheless, the Court Of Appeals For Veterans Claims (Court), interpreting 38 C.F.R. § 4.59, has held that is not the mere presence of pain that garners a disability rating but rather the functional loss due to the pain. See Mitchell v. Shinseki, 25 Vet. App. 32, 37-38 (2011). Thus, the Board finds the left knee did not meet or approximate the criteria for a compensable rating as of the November 2005 examination. 38 C.F.R. § 4.1, 4.31, 4.40, 4.45, 4.59, 4.71a, DC 5260. In so finding, the Board acknowledges the positive patellar grind test but, again, the examination revealed no functional loss, as determined by the examination of ROM and instability. Moreover, the examiner expressly found that there was no additional loss of ROM with repetitive motion due to pain, weakness, fatigability and related factors, and that the Veteran's motion was pain free. See 38 C.F.R. §§ 4.40 and 4.45; see also Mitchell, 25 Vet. App. at 44. The Veteran was again examined in December 2008. That report reflects reported symptoms essentially identical to those noted at the 2005 examination. He denied any episodes of locking or buckling, but he did report daily pain. Rising from a sitting position and using stairs caused a sudden sharp pain. He denied any incapacitating episodes, flare-ups, problems with repetitive use, or interference with his job or daily activities. Physical examination revealed no signs of cellulitis, swelling, deformity, or medial or lateral joint line tenderness. Patellar grind test was positive, but the left knee ROM was full and normal at 0 to 140 degrees. There was no instability to varus, valgus, posterior, and anterior stress. McMurray's sign was negative. Neurological examination was normal. Despite the Veteran's reports of daily pain, the objective findings on clinical examination continued to show the absence of functional loss in the left knee. The earlier discussion on pain and functional loss is hereby incorporated here by reference. The Board again notes the positive patellar grind test, but a March 2008 physical medicine and rehabilitation entry notes patellar grind test was negative- in any event, the patellar grind function is not indicative of functional loss in light of the normal findings with respect to ROM and stability. Moreover, a February 2007 outpatient entry notes the Veteran exhibited pain on motion, but there is no indication that the left knee manifested LOM. Hence, the Board is constrained to find that the evidence, as of the December 2008 examination, continued to show the left knee more nearly approximated a noncompensable rating. 38 C.F.R. §§ 4.10, 4.31, 4.71a, DC 5260. An April 2010 VA examination again showed normal ROM and stability findings. There was no additional limitation of function with repetitive motion. At that time, the Veteran reported pain with stair climbing and squatting. He denied locking, buckling, or instability. At the Board hearing, the Veteran described how he experienced sudden left knee pain when he used stairs and had the sensation of the knee giving away. When that happened, he would rest and then gingerly proceed up the stairs. He related that he had a knee brace which helped sometimes, but he still experienced pain while wearing it. The Veteran also experienced instability about once a week. He testified further that he used heat, rest, the exercises taught to him in physical therapy, as well as muscle relaxants and pain medicine, to control his left knee symptoms. Following the hearing, the Board remanded for a more current examination. The July 2012 examination report reflects the examiner reviewed the claims file. The Veteran reported his left knee history as before, and he noted daily flare-ups that lasted five minutes. He was incapacitated during that brief period. The Veteran reported difficulty on prolonged standing of 15 minutes, walking more than 30 minutes, using stairs, and squatting, all actions that related to his work as a librarian and his activities of daily living. Physical examination revealed no evidence of tenderness to palpation, swelling, deformity, or atrophy of disuse. ROM was 0 to 140 degrees without evidence of pain. The examiner specifically noted the absence of wincing of facial expression. All joint instability tests were negative. The examiner noted that repetitive use testing revealed no additional loss of ROM due to pain, fatigue, or weakness, etc. Muscle strength testing was normal at 5/5 on flexion and extension. The examiner noted the Veteran's report of his symptoms during his regular daily activities, to include the reported pain, weakness, and fatigue of the left knee. The examiner observed that left knee excursion, strength, speed, coordination, and endurance, were all normal. There was no evidence of patellar subluxation or dislocation. There was neither more nor less movement than normal. There was also no evidence of additional conditions such as shin splints, stress fractures, compartment syndrome, tibiofibular impairment, or leg length disparity. The Veteran had a normal gait and propulsion, and he denied the use of a cane. The examiner found no left knee impairment with respect to the Veteran's work as a librarian or his activities of daily living. The totality of the evidence of record, as set forth above, is that while the Veteran experiences daily pain, etc., the medical evidence shows no functional loss due to his pain. See Mitchell, 25 Vet. App. at 37-41. Indeed, the Board notes a March 2012 outpatient entry that reflects the Veteran's report that he had overexerted himself on a treadmill, indicating that his left knee could withstand that type of use. Regarding the Veteran's repeated assertions that he experienced episodes of left knee instability, the Board is constrained to reject it. While he is competent to report instability of the knee, this report is outweighed by the numerous examinations consistently indicating a stable left knee. Accordingly, an increased or separate rating is not warranted on this basis here. In light of the above, the Board finds the left knee has more nearly approximated the assigned noncompensable rating throughout the entire rating period. 38 C.F.R. §§ 4.1, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71a, DC 5260. Left Ankle The Veteran's left ankle disability has been evaluated under DC 5271. See 38 C.F.R. § 4.71a. Those criteria provide for a 10 percent rating for moderate LOM, and a 20 percent rating for marked LOM. Id. The November 2005 examination report reflects the Veteran's history and symptoms for the left ankle similar to the left knee. He denied any specific trauma to the left ankle and reported left ankle pain with walking and when he transitioned from sitting to standing. The pain was over the anterior aspect of the ankle. He denied any problems with repetitive use and he denied having experienced any flare-ups. Physical examination of the left ankle revealed no evidence of cellulitis, swelling, effusion, or instability. Anterior drawer and talar tilt tests were negative. Motor strength was 5/5 with dorsiflexion, plantar flexion, inversion, and eversion. ROM on dorsiflexion was 0 to 20 degrees, and 0 to 45 degrees on plantar flexion. X-rays were read as having shown no abnormality. The examiner diagnosed left ankle tendinitis. The Board notes that another VA examination conducted on the same day, relating to a foot disability (as opposed to an examination specifically addressing the joints) showed that as to left ankle dorsiflexion, "5 degrees of motion was available." This appears to contradict the findings above, taken on the same day. As the previously described examination was more thorough, and is more consistent with the record as a whole, the Board finds the results of that examination to be more probative. Normal ROM of the ankle on dorsiflexion is 0 to 20 degrees, and 0 to 45 degrees on plantar flexion. See 38 C.F.R. § 4.71, Plate II. The earlier discussion of lay evidence and credibility is incorporated here by reference. As was the case with the left knee, the objective findings on clinical examination showed the Veteran's reported left ankle pain was not productive of functional loss. ROM at the joints examination was normal, and examiner did not note any objective indicia of pain. Further, the examiner noted there was no additional loss of ROM or functional use revealed by repetitive use testing. See 38 C.F.R. §§ 4.40, 4.45, and 4.59. Thus, the Board is constrained to find the left ankle more nearly approximated a noncompensable rating. 38 C.F.R. §§ 4.10, 4.31, 4.71a, DC 5271. The examination findings showed no factual basis for a compensable rating under DC 5272, 73, or 5274. The December 2008 examination report reflects the Veteran's reported his left ankle symptoms had not changed. He denied any episodes of buckling, incapacitating episodes, or problems with repetitive use, but he did report daily pain with the use of stairs. He also denied having undergone physical therapy but, as indicated earlier, there are outpatient entries related to physical medicine and rehabilitation. Physical examination of the left ankle revealed no evidence of cellulitis, swelling, effusion, or instability. Anterior drawer and talar tilt tests were negative. Motor strength was 5/5 with dorsiflexion, plantar flexion, inversion, and eversion. ROM on dorsiflexion was 0 to 20 degrees, and 0 to 45 degrees on plantar flexion, both without pain. The examiner diagnosed left ankle tendinitis. The examiner noted there was no additional loss of ROM or functional use revealed by repetitive use testing. See 38 C.F.R. §§ 4.40, 4.45, and 4.59. The earlier discussion of the rating criteria and functional loss is hereby incorporated here by reference. The Board also notes the March 2008 physical medicine entry, which noted the Veteran's sensation of left ankle instability was possibly related to an earlier ankle sprain with impaired left leg stance dynamic balance. As noted, the examiner at the December 2008 examination noted that there was no left ankle instability. Hence, the Board finds the left ankle continued to more nearly approximate the assigned noncompensable rating. 38 C.F.R. §§ 4.10, 4.31, 4.71a, DC 5260. At an April 2010 VA examination, the Veteran denied left ankle instability, flare-ups, or incapacitating episodes. He did not use assistive devices and had not recently undergone any physical therapy. Objectively, there was no swelling and no instability. Dorsiflexion was to 20 degrees and plantar flexion was to 45 degrees with no additional LOM on repetition. Neurologic findings were normal. At his hearing, the Veteran testified his left ankle pain occurred primarily when using stairs. He also experienced instability when he used stairs. These symptoms occurred a few times a week. The Veteran testified that he could walk about two blocks; while he did not use an ankle brace, he wore high top sneakers or boots. Stretching exercises and ankle rotations provided relief. When needed, he used pain medication. The Veteran also related that his left ankle had restricted his ability to enjoy outings such as walks with his family. Upon VA examination in July 2012, the Veteran reported daily flare-ups that lasted five minutes. He reported difficulty standing for more than two hours, walking more than 15 minutes, and with using stairs. Physical examination revealed no evidence or pain or tenderness to palpation. Active and passive ROM was 0 to 20 degrees on dorsiflexion, and 0 to 45 degrees on plantar flexion. Inversion was to 30 degrees, and eversion to 40 degrees. The examiner noted the movements were done without objective evidence of pain, as there was no wincing of facial expression. Repetitive use testing did not elicit additional pain, fatigue, weakness, or lack of endurance. Post-rest ROM was unchanged. The examiner's findings on the Veteran's left ankle functional loss, to include DeLuca, are identical to those set forth earlier for the left knee. Hence, they are incorporated here by reference. The examiner found no functional impairment of the left ankle as concerned the Veteran's occupation or his activities of daily living. The Board also incorporates the discussion on instability here by reference. In light of the totality of the evidence of record, the Board finds the Veteran's left ankle has more nearly approximated the assigned noncompensable rating for the entire rating period. 38 C.F.R. §§ 4.1, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71a, DC 5206. Left Elbow When rating the upper extremities, a distinction is made between major (dominant) and minor upper extremities for rating purposes. In the instant case, the December 2008 examination reports reflects that the Veteran is right handed, which means that his left elbow is the minor or non-dominant extremity. A handwritten annotation on the January 2007 rating decision reflects the RO assigned DC 5201 for evaluation of the left elbow. The Board notes, however, that DC 5201 rates the shoulder. The Board notes DCs 5205 through 5209 rate the elbow and forearm. Thus, the Board will review the Veteran's appeal under those rating criteria. DC 5205 concerns ankylosis of the elbow. As this has not been shown, this DC is not for consideration here. The applicable rating criteria provide for a 10 percent rating where forearm flexion is limited to 100 degrees, and flexion limited to 90 degrees warrants a 20 percent rating for both the minor and major arm. 38 C.F.R. § 4.71a, DC 5206. Forearm extension limited to 45 degrees warrants a 10 percent rating, and extension limited to 75 degrees warrants a 20 percent rating. Id., DC 5207. Normal ROM of the elbow on extension and flexion is 0 to 145 degrees. See 4.71a, Plate I. Normal ROM of the forearm is 0 to 80 degrees on pronation, and 0 to 85 degrees on supination. Id. The December 2008 examination report reflects the Veteran's reports of left elbow pain when he used it a lot. He denied any incapacitating episodes, flare-ups, problems with repetitive use, or impact on his job or daily activities. Physical examination revealed the scar, which is discussed separately later in this decision. ROM was 0 to 145 degrees on flexion and extension, and 0 to 85 degrees on both pronation and supination, all movements without pain. Motor strength was 5/5 on flexion and extension. Resistance wrist dorsiflexion revealed some discomfort over the lateral aspect. The examiner noted that repetitive use testing revealed no additional loss of ROM due to pain, weakness, and related factors. The examiner diagnosed left tennis elbow. A March 2008 physical medicine entry notes that the Veteran reported left elbow pain of 7/10 at the olecronon area, with increased pain when doing push-ups, lifting, and extension. He reported that the pain was present on rest, and ice and heat provided no relief. Rest did provide mild relief. The entry did not provide any ROM findings. The examiner did note, however, examination revealed no significant tenderness to palpation or loss of strength. Thus, the Board discerns no factual basis for determining whether there is any loss of left elbow ROM on repetitive or rigorous use due to pain, fatigue, etc. In light of the objective findings on clinical examination at the December 2008 examination, the Board finds the left elbow more nearly approximated the assigned noncompensable rating. 38 C.F.R. §§ 4.1, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71a, DC 5206. Upon VA in April 2010, the Veteran denied weakness, flare-ups or incapacitating episodes with respect to his left elbow. There was no interference with his job or with the activities of daily living. He could extend the elbow to 80 degrees. Flexion was to 145 degrees without pain. Supination was to 80 degrees and pronation was to 85 degrees with no pain. There was no additional LIMITATION OF MOTION with repetitive testing. The Veteran testified at the hearing that exertion of force caused left elbow pain, and he tried to use his right hand as much as possible. He testified his symptoms were present throughout the day, and he used the same modalities for relief as he used for his other joint pain. Upon examination in July 2012, the Veteran reported his symptoms consistently as at earlier examinations. He reported difficulty lifting or pulling more than 20 pounds. Physical examination revealed no evidence of tenderness, swelling, or deformity. ROM was 0 to 145 degrees on flexion and extension, 0 to 85 degrees on supination, and 0 to 80 degrees on pronation, and all movements done without evidence of pain. The examiner noted there was no wincing of facial expression. The examiner noted further that repetitive use testing did not elicit additional pain, fatigue, weakness, or loss of endurance. Post-rest ROM was unchanged. As shown by the objective findings, the examiner noted elbow ROM was normal. See 38 C.F.R. § 4.71a, Plate I. The examiner's findings on the Veteran's left elbow functional loss, to include DeLuca, are identical to those set forth earlier for the left knee and left ankle. Hence, they are incorporated here by reference. The examiner noted he found no functional impairment of the left elbow as concerned the Veteran's occupation or his activities of daily living. In light of the totality of the evidence of record, as set forth and discussed above, the Board finds the Veteran's left elbow has more nearly approximated the assigned noncompensable rating for the entire rating period. 38 C.F.R. §§ 4.1, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71a, DC 5206. Moreover, in so finding the Board has considered the Veteran's credible reports of pain. However, as previously discussed, pain alone, without additional functional loss resulting therefrom, cannot serve as a basis for an increased rating. Scar Residuals Applicable Regulations The rating criteria for skin disorders were changed, effective in October 2008 and are applicable for claims received by VA on and after October 23, 2008. See 38 C.F.R. § 4.118. VA received the Veteran's claim in November 2005. Thus, the prior rating criteria are applicable to his claim. Those criteria provide for a 10 percent rating for a superficial scar that is painful on examination. Id., DC 7804 (2007). A superficial scar is one not associated with underlying soft tissue damage. Id., Note (1). A scar that causes LOM is rated under the appropriate diagnostic code for the affected joint. See DC 7805. Analysis Left Elbow Scar Historically, the Veteran sustained his SFW as a result of the detonation of an Implemented Explosive Device (IED) while on patrol in Iraq. Service treatment records note that foreign bodies were removed from the left arm and the site was sutured. In the September 2006 scar examination report the Veteran denied any pain or restricted movement due to the scar residual, but he did describe itching around the scar site with humidity. Otherwise, he denied ulceration or bleeding. Physical examination revealed the scar as a 2 cm x 1.5 cm elliptical-shaped scar at the left elbow. It is well healed, flat, and without convexity or concavity. The border appeared irregular with several small circular extensions that are connected to the scar site, which was the result of the suture material. The scar was covered and hypopigmented. There was no deep tissue involvement, and the surrounding skin was otherwise normal in texture and without atrophy or induration. There was no tenderness to palpation, and there was no adherence to underlying soft tissue. There was no restriction of movement of the left elbow. The objective findings on clinical examination show the left elbow scar to be a superficial scar. 38 C.F.R. § 4.118, DC 7804, Note (1). The examination also showed the scar to have been asymptomatic at the September 2006 examination. Thus, it did not meet or approximate the criteria for a compensable rating. Id. Further, in light of the size, location, and texture, of the scar, neither is a compensable rating approximated under the other scar diagnostic codes. See 38 C.F.R. § 4.118, DCs 7800 - 7803. A March 2008 outpatient physical medicine entry noted the left elbow scarring, and that there was no significant tenderness to palpation or loss of strength. The December 2008 joints examination report reflects the examiner described the scar as circular, deep, fixed, slightly whitish as compared to the surrounding skin, and 3 cm x 3 cm over the distal lateral aspect of the elbow. The examiner noted that it was stable and nontender. The Board notes the examiner's description of the scar as deep. However, the examiner did not describe a deep scar as defined by the skin rating criteria. Further, the September 2006 skin examination report reflects the scar does not meet the definition of a deep scar, which is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801 Note (2). In any event, in light of the objective findings, the Board finds the left elbow scar continued to more nearly approximate the assigned noncompensable rating. 38 C.F.R. § 4.118, DC 7804. The July 2012 scar examination report reflects the examiner conducted a review of the claims file as part of the examination. The examiner noted the service treatment records noted the incision, drainage, and removal of a foreign body from the left proximal upper extremity and left lateral proximal lower extremity; and, there was no joint, muscle, or tendon, involvement. Neither was there any bone fracture. The Veteran denied having received any treatment for the wound site. Physical examination revealed a 1 cm x 0.8 cm scar in the medial aspect of the left elbow. The examiner noted the scar was asymptomatic, nontender, nonpainful, smooth, and vertical. The scar is not elevated or depressed, and it is not adherent to underlying tissue. There was no ulceration or breakdown at the scar site, and there was no loss of underlying tissue. The examiner noted the absence of inflammation, edema, or keloid formation. The scar is slightly hypopigmented as compared to the surrounding skin. The examiner noted there was no loss of function from the scar. The examiner opined the scar had no impact on the Veteran's work as a librarian or his activities of daily living. The Board notes the Veteran's hearing testimony that the elbow scar was tender to touch and became inflamed. While he is competent to comment as to the tenderness of a scar, an observable symptom, the Board accords greater weight to the training and experience of the scar examiners who, on multiple occasions indicated that the scar was nontender. In light of the evidence set forth above, the Board finds the left elbow scar has more nearly approximated the assigned noncompensable rating throughout the initial rating period. 38 C.F.R. §§ 4.1, 4.10, 4.31, 4.118, DC 7804 (2007). The Board has considered the other skin rating criteria for scars but finds they are not benefit to the Veteran. His left elbow scar is not deep or unstable, it does not cause limited motion, and it is less than 929 sq cm in area. See 38 C.F.R. § 4.118, DCs 7801 - 7803. Left Hip Scar The September 2006 examination report reflects the hip scar two is a 3 cm x 2 cm ovoid-shape scar located on the left ischial area. It has irregular borders similar to those on the elbow scar, which also are the result of the sutures used. It is well healed, hypopigmented, and flat. It is motile without soft tissue involvement or adherence to underlying soft tissue. There is no convexity or concavity, and the surrounding skin is otherwise normal in texture and without atrophy or induration. There is no keloid formation, and there was no tenderness to palpation. The objective findings on clinical examination show the left hip scar to be superficial scar. 38 C.F.R. § 4.118, DC 7804, Note (1). The examination also showed the scar to have been asymptomatic at the September 2006 examination. Thus, it did not meet or approximate the criteria for a compensable rating. Id. Further, in light if the size, location, and texture, of the scar, neither is a compensable rating approximated under the other scar diagnostic codes. See 38 C.F.R. § 4.118, DCs 7800. The Board remanded for another examination, as the 2008 skin examination did not address the left hip scar. The July 2012 scar examination report reflects the scar is in the left lateral proximal lower extremity. The examiner described it as an asymptomatic, nontender, and nonpainful, oval-shaped scar that measured 3 cm by 2 cm in the proximal lateral aspect of the left extremity approximately 7 cm distal of the pelvic rim. The examiner noted it had minimal irregular texture, and that it was superficial. The scar is not depressed or elevated, and it is not adherent to the underlying tissue. There was no ulceration or skin breakdown or loss of underlying tissue at the scar site. There was no inflammation, edema, or keloid formation, and it caused mild disfigurement in the left hip region. The scar is the same color as the surrounding skin with a hyperpigmented border. The examiner noted there was no loss of function due to the scar. As was the case with the left elbow scar, the Veteran testified at the hearing that the left hip scar was tender to touch and became inflamed. The Board hereby incorporates here by reference, the discussion and findings set forth for the left elbow scar. Hence, in light of the evidence set forth above, the Board finds the left hip scar has more nearly approximated the assigned noncompensable rating throughout the initial rating period. 38 C.F.R. §§ 4.1, 4.10, 4.31, 4.118, DC 7804 (2007). The Board has considered the other skin rating criteria for scars but finds they are not of benefit to the Veteran. His left hip scar is not deep or unstable, it does not cause limited motion, and it is less than 929 sq cm in area. See 38 C.F.R. § 4.118, DCs 7801 - 7803. As noted in the discussion of each disability, the Board found no basis for a staged rating for any portion of the rating period for either disability. The Board notes that the impact on a claimant's work and employability is a part of an increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Nonetheless, the Veteran has not asserted in either his written submissions or hearing testimony that his disabilities render him unable to obtain and maintain substantially gainful employment. See 38 C.F.R. §§ 3.340 and 4.16. Indeed, the evidence in fact shows the Veteran was a full-time student and is now employed full time as a librarian. Thus, the Board finds the issue of a total disability evaluation on the basis of individual unemployability has not been raised by the evidence. Extraschedular Consideration Although the Veteran has not asserted unemployability due to his disabilities, he did testify to the impact of his disabilities on his ability to perform his work as a librarian. This raises the issue of the propriety of referral for consideration of a higher rating on an extraschedular basis under 38 C.F.R. § 3.321(b)(1). See Barringer v. Peake, 22 Vet. App. 242 (2008) (Board must discuss whether referral for extraschedular consideration is indicated where raised by the evidence of record). Applicable Legal Requirements In exceptional cases, where the rating schedule is deemed inadequate, the Under Secretary for Benefits (Under Secretary) or the Director, Compensation and Pension Service (Director), upon field station submission, is authorized to approve on the basis of the applicable criteria, 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). The Board is precluded from granting an increased rating on an extraschedular basis in the first instance. 38 C.F.R. § 3.321(b)(1); Floyd v. Brown, 9 Vet. App. 88, 95 (1996). The Board may, however, determine whether a particular claim merits submission for an extraschedular evaluation. Brannon v. West, 12 Vet. App. 32, 35 (1998); Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Further, where the RO has considered the issue of an extraschedular rating and determined it inapplicable, the Board is not specifically precluded from affirming a RO conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1) for an extraschedular rating. Bagwell, 9 Vet. App. at 339. Before the Board may refer a case for extraschedular consideration, however, there first must be a finding that the Veteran's disability picture is exceptional. To do so, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. See Thun v. Peake, 22 Vet. App. 111 (2008). Analysis The Board first notes the Veteran's testimony that his disability precluded him from pursuing occupations other than the one in which he currently works. The Board notes further that such situations do not provide a basis for referral for extraschedular consideration. See, e.g., id., at 116. The Board finds a comparison of the schedular rating criteria for the Veteran's disabilities and their symptomatology shows the rating criteria describe the disabilities and the levels of their severity, as discussed earlier in detail for each disability. Thus, the rating schedule contemplates the Veteran's disability picture, which means they are not exceptional. Thus, the applicable analysis ceases at this point. Id. In the absence of an exceptional disability picture, there is no factual basis for referral for extraschedular consideration. 38 C.F.R. § 3.321(b)(1). In reaching this decision the Board considered the doctrine of reasonable doubt where applicable. As the preponderance of the evidence is against the Veteran's claims, however, the doctrine is not for application. Schoolman v. West, 12 Vet. App. 307, 311 (1999). ORDER Entitlement to an initial compensable disability rating for left knee PFS is denied. Entitlement to an initial compensable disability rating for left ankle tendonitis is denied. Entitlement to an initial compensable disability rating for left elbow bursitis is denied. Entitlement to an initial compensable disability rating for scar residuals of SFW of the left ischial area is denied. Entitlement to an initial compensable disability rating for scar residuals of SFW of the left elbow is denied. REMAND The RO evaluated the left hip as arthritis under 38 C.F.R. § 4.71a, DC 5003. The Board notes the several examination reports related to the Veteran's left hip, as well as his detailed description of the chronic symptomatology of his left hip, including constant pain, weakness, temporary inability to move, etc. These symptoms are similar to the cardinal signs and symptoms of muscle disability. See 38 C.F.R. § 4.56(c). The RO evaluated the left hip disability on the basis of LOM, as required by DC 5003. However, consideration should be given to evaluation on the basis of Muscle Group (MG) involvement. Indeed, an October 2008 physical medicine entry notes the Veteran's left hip pain on flexion and external rotation and weak pelvic stabilizers was suggestive of muscular involvement due to shrapnel near the lesser trochanter. Service treatment records of October 2004 describe the wound as a puncture wound to the left thigh. As discussed above, the service treatment records note the fact the shrapnel was not removed from the left hip. A November 2004 follow-up notes the wound was irrigated, debrided, and closed. Although the Veteran's lower extremity manifested ROM, sensory perception, and pedal pulses, immediately after the wound was sustained, the surgical notes do not indicate whether there was muscle or nerve involvement of the left hip. Nonetheless, the nature of the wound, the fact the foreign body is still in the left hip, and the Veteran's treatment and recovery, appear to reflect the criteria for a moderate muscle group injury. See 38 C.F.R. § 4.56(d)(2). Accordingly, the case is REMANDED for the following action: 1. The AMC/RO will arrange a muscle examination of the Veteran by an appropriate examiner to determine if the residuals of the left hip SFW manifest with a MG Injury. All indicated diagnostic tests should be performed. If a MG injury is diagnosed, the examiner is asked to identify the specific MG(s) involved and the severity of any muscle injuries (i.e., slight, moderate, moderately severe, or severe). The examiner should be provided a copy of 38 C.F.R. § 4.56 and should consider the presence or absence of objective findings referenced therein. 2. After completion of all of the above, the AMC/RO should re-adjudicate the claim on appeal. If the decision remains in any way adverse to the Veteran, he and his representative, if any, should be provided with a SSOC. The SSOC must contain notice of all relevant actions taken on the claims for benefits, to include the applicable law and regulations considered pertinent to the issue on appeal as well as a summary of the evidence of record. An appropriate period of time should be allowed for response. The case should thereafter be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise notified. VA will notify him if further action is required on his part. He has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs