Citation Nr: 1307440 Decision Date: 03/05/13 Archive Date: 03/11/13 DOCKET NO. 09-08 297 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to a compensable initial evaluation for residuals of a crush injury, left (non-dominant) forearm, to include whether the Veteran is entitled to separate evaluations for muscle injury, nerve damage, or scarring, to include entitlement to a compensable initial evaluation for a laceration scar along the left elbow, common extensor. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Tresa M. Schlecht, Counsel INTRODUCTION The Veteran served on active duty from October 1992 to July 1997. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board Remanded the appeal in February 2011. In compliance with Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the issue on appeal is recharacterized to more accurately reflect that the Veteran seeks an increased (compensable) initial evaluation for left forearm injury. In October 2010, the Veteran testified before the undersigned at a Travel Board hearing. A transcript of the hearing is of record. FINDINGS OF FACT 1. The residuals of a crush injury to the left forearm include injury to Muscle Group (MG) V and MG VII, and injury to three nerves, resulting in pain at the extremes of range of motion of the left wrist, intramuscular scarring and loss of intramuscular substance of the left brachioradialis muscle and of the left flexor carpi radialis muscle, pain in the left forearm, some decrease in strength of grip and ability to lift heavy objects, mild incomplete paralysis, and neuropathy manifested by pain, parasthesias, and involuntary movement. 2. A laceration scar on the left forearm is asymptomatic. CONCLUSIONS OF LAW 1. The criteria for a separate, compensable, 10 percent initial evaluation for left arm crush injury residuals, MG V, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.55, 4.56, 4.69, 4.73, Diagnostic Code 5305 (2012). 2. The criteria for a separate, compensable, 10 percent initial evaluation for left arm crush injury residuals, MG VII, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.55, 4.56, 4.69, 4.73, Diagnostic Code 5307 (2012). 3. The criteria for a separate, compensable, 30 percent initial evaluation for injury to the median, ulnar, and antebrachial nerves (lower radicular group), left forearm, are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.123, 4.124, 4.124a, Diagnostic Codes 8512, 8612, 8515, 8516, 8517 (2012). 4. No criterion for a compensable initial rating for a laceration scar on the left forearm is met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.14, 4.118, Diagnostic Codes 7804, 7805 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before addressing the Veteran's claim for an increased initial rating on the merits, the Board will review whether VA has met its duties or notify and assist the Veteran. Duties to Assist and Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper notice from VA must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The claims addressed in this appeal are in the context of a claim for an increase in the initial rating following a grant of service connection for residuals of a crush injury, left forearm. Because the claim for service connection for a left forearm injury has been granted, the letters issued to notify the Veteran under the VCAA have satisfied VA's duty to notify the Veteran of the evidence required to substantiate the claim. Next, VA has a duty to assist a Veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent VA treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO associated the Veteran's service treatment records and VA outpatient treatment records with the claims files. No outstanding evidence has been identified that has not otherwise been obtained and associated with the record. The Board Remanded the appeal in 2011 to obtain a more complete VA examination, and the Veteran was afforded additional VA examination. The February 2011 VA examination report is thorough, and adequate upon which to base a decision with regard to the Veteran's increased rating claim. The Board is satisfied that there has been substantial compliance with the requirements of the remand. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). Some discussion of the Veteran's hearing is necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here. The issue on appeal was identified at the October 2010 Travel Board hearing. The symptoms of his disability were described in detail. The Veteran's testimony establishes that he understood the criteria for a higher rating for his left arm injury, and comparison of the hearing transcript with the report of the 2011 VA examination demonstrates that the Veteran's lay statements were considered during the 2011 VA examination. In view of the above, the Board finds no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Claim for increased (compensable) initial evaluation, left forearm injury In December 1993, during his military service, the Veteran sustained injury to his left forearm when a tire flew off a rim and crushed his left forearm in a tire cage. After the initial injury, the Veteran was noted to have decreased grip strength, decreased motion of the left wrist, and pain on use and motion of the left forearm. The service treatment records show that the Veteran's left forearm was treated for several months following the injury. No separation examination is of record. The Veteran sought service connection for residuals of the left forearm injury, among other disorders, in January 2007. The examiner who conducted February 2008 physical examination stated that the Veteran did not have pain with use of the left forearm, which was identified as being his non-dominant extremity, but did have weakness of the left extensors, as compared to the right side. There was giving way if the Veteran attempted to lift a heavy weight. January 2008 radiologic examination of the left elbow disclosed no abnormality. The examiner concluded that the Veteran had an old injury to the left elbow common extensor muscles with a muscle scar but essentially normal muscle function. The examiner noted that the left arm and elbow functioned normally despite the common extensor muscle contracture scar. The Veteran disagreed with the assignment of a noncompensable evaluation. In a May 2008 notice of disagreement, the Veteran reported that use of the left arm for driving, sweeping, or mopping the floor would cause tingling in the forearm down to the fingers and numbness. With physical activities, there was pain and sometimes loss of grip in the left arm. In a September 2008 statement, and in his February 2009 substantive appeal, the Veteran reiterated that there was muscle damage, not bone damage, with loss of strength. At his October 2010 hearing before the Board, the Veteran vigorously contended that he had muscle and nerve injuries as well as scar injuries, and he contended that he was entitled to a compensable evaluation for the residuals of the left forearm crush injury. The Veteran testified that he had pain with touch to the scars on his muscles and had pain in the left forearm without touch at times. The examiner who conducted an April 2011 VA examination identified two depressions due to intramuscular scarring, one on the left brachioradialis muscle and one on the left flexor carpi radialis muscle. The examiner described a laceration scar on the left elbow extensor area. The examiner stated that the laceration scar was not tender, not adherent, not painful on palpation, and was asymptomatic. The examiner identified muscle injury to the left brachioradialis and to the left flexor carpi radialis, and injury to three nerves, the median nerve, the ulnar nerve, and the antebrachial branch of the musculocutaneous nerve. The examiner explained that the residuals of the nerve injuries were manifested by tremors, paresthesia, numbness, and pain in the fingers of the left hand, decreased sensation to light touch in the distribution of the median nerve, ulnar nerve, and medial and lateral antebrachial nerve, including the left forearm and palmer surface of the left hand. The examiner stated that the Veteran had neuritis and neuralgia in the left forearm and hand. The examiner noted that the Veteran had slight decreases in left hand grip strength, long finger flexion, and left wrist dorsiflexion as a result of the nerve injuries. There was pain on range of motion of the left wrist; the examiner stated that there was no pain on motion of the left elbow. No actual loss of range of motion was identified, however. The examiner stated that decrease in strength in the left forearm was primarily a problem with lifting heavy objects. VA outpatient treatment records dated from 2008 through 2011 reflect that the Veteran reported complaints of left forearm and hand pain in November 2010. Sensory examination in November 2010 disclosed decreased sensation to pinprick on the posterior aspect of the left forearm and the entire left hand. The neurologic examiner noted tremoring and paroxysmal twitching of the fingers and low-level burning pain. Gabapentin (Neurontin) was prescribed. For purposes of information only, the Board notes that gabapentin (Neurontin) is used to relieve neuropathic pain. The Veteran noted some relief of left forearm and hand pain and tingling. Electrodiagnostic studies showed normal conduction. The most recent VA records reflect that the Veteran continues to take gabapentin. The discussion below addresses the appropriate evaluations for the residuals of the left forearm crush injury, given the medical evidence of muscle injury, nerve injury, and a scar. The Veteran's service-connected residuals, left forearm crush injury, are currently rated noncompensable for the visible scars on the left forearm. Under VA regulations, separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Thus, to the extent the left forearm crush injury results in muscle injury, injury to nerves, and a scar, each type of injury will be discussed in a separate analysis below. For impairment of an upper extremity, the disability rating assigned depends on whether the extremity is the major extremity or the minor extremity. The major extremity is the one predominantly used. 38 C.F.R. § 4.69 . The evidence reveals that the Veteran is right handed. Thus, his left upper extremity is the minor extremity. The combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. 38 C.F.R. § 4.68. Amputation of the minor forearm below insertion of the pronator teres warrants a 60 percent rating; amputation above the insertion of the pronator teres warrants a 70 percent rating. 38 C.F.R. § 4.71a, DC 5124. The Board notes that the description of the injuries in this case warrants a finding that elective amputation above the site of injury would be above the insertion of the pronator teres. The Board further notes that the evaluations assigned in this decision are not limited by 38 C.F.R. § 4.68. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 When, as here, the Veteran is requesting a higher rating following an initial grant of service connection, "staged" ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). (CONTINUED NEXT PAGE) I. Evaluation of muscle injury Law governing evaluation of muscle injury Muscle injuries are evaluated pursuant to criteria at 38 C.F.R. §§ 4.55, 4.56, and 4.73. For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions, which include six muscle groups for the shoulder girdle and arm (Diagnostic Codes 5301 through 5306) and three muscle groups for the forearm and hand (Diagnostic Codes 5307 through 5309). 38 C.F.R. § 4.55(b). The specific bodily functions of each group are listed at 38 C.F.R. § 4.73. Under 38 C.F.R. § 4.56(d), disabilities resulting from muscle injuries are classified as slight, moderate, moderately severe, or severe. 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. 38 C.F.R. § 4.56(c). For muscle group injuries in different anatomical regions which do not act upon ankylosed joints, each muscle group injury shall be separately rated and the ratings combined only under the provisions of 38 C.F.R. § 4.25. 38 C.F.R. § 4.55(f). Slight disability is characterized by a simple wound of muscle without debridement, infection, or effects of laceration. History and complaints are of a wound of slight severity or relatively brief treatment and return to duty, healing with good functional results, and no consistent complaint of cardinal symptoms of muscle injury as defined in 38 C.F.R. § 4.56(c), or painful residuals. Objective findings include minimal scar, with no evidence of fascial defect or atrophy of impaired tonus, and no significant impairment of function and no retained metallic fragments. 38 C.F.R. § 4.56(d)(1). A moderate disability of the muscles is shown by through and through or deep penetrating wounds of short track by a single bullet, small shell, or shrapnel fragment, without the explosive effect of a high velocity missile, and with residuals of debridement or prolonged infection. The history of a moderate muscle disability includes treatment for the wound and a record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability, particularly a lowered threshold of fatigue after use which affects the particular functions controlled by the injured muscles. Objective findings include small or linear entrance and (if present) exit scars which indicate a short track of the missile through muscle tissue, some loss of deep fascia or muscle substance, impairment of muscle tonus and loss of power, or a lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). Moderately severe disability of muscles is characterized by a through and through or deep penetrating wound by a small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intramuscular scarring. History and complaints characteristic of moderately severe muscle injury include service department records or other evidence showing hospitalization for a prolonged period. Moderately severe muscle disability should include a record of consistent complaints of cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), and, if present, evidence of inability to keep up with work requirements. Objective findings characteristic of moderately severe muscle disability include entrance and (if present) exit scars indicating the track of the 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 the sound side are also indicative of moderately severe muscle disability. Tests of strength and endurance compared with the sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). Severe disability of muscles is characterized by a through and through or deep penetrating wound due to high-velocity missile, or large multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intramuscular binding and scarring. History and complaints characteristic of severe disability of muscle include service department records or other evidence showing hospitalization for a prolonged period for treatment of wound; a record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), worse than those shown for moderately severe muscle injuries; and, if present, evidence of inability to keep up with work requirements. Tests of strength, endurance, or coordinated movements compared with corresponding muscles of the uninjured side indicate severe impairment of function. Signs of severe muscle disability include X-ray evidence of minute multiple scattered foreign bodies, adhesion of scar to one of the long bones, diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; visible or measurable atrophy, and adaptive contraction of an opposing group of muscles, among other signs. 38 C.F.R. § 4.56(d)(4). When determining the severity of musculoskeletal disabilities such as the one at issue, which is at least partly rated on the basis of range of motion, VA must also consider the extent the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated due to the extent of pain/painful motion, limited or excess movement, weakness, incoordination, and premature/excess fatigability, etc., particularly during times when his symptoms "flare up," such as during prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. 38 C.F.R. §§ 4.40, 4.45. Analysis The examiner who conducted the 2011 VA examination identified muscle injury to two muscles, the left brachioradialis and the left flexor carpi radialis. The left brachioradialis is defined as being in MG V, and the flexor carpi radialis is defined as being located in MG VII. 38 C.F.R. § 4.73, Diagnostic Codes 5305, 5307. 1. Evaluation of MG V injury Diagnostic Code (DC) 5305 rates impairment to MG V. MG V includes the long head of the biceps, brachialis, and brachioradialis muscles. A 10 percent rating is assigned for a moderate disability of the dominant or non-dominant hand; a moderately severe disability warrants a 20 percent rating for the non-dominant hand, and a 30 percent rating is warranted for severe disability of the non-dominant hand. DC 5305. In this case, the examiner has stated that there is intramuscular scarring of the brachioradialis, shown by a 2-cm depression in the muscle. The examiner has stated that the Veteran's muscle injuries result in decreased ability to lift and carry objects, with occasional giving way, primarily with heavy objects. The VA examination report establishes that the Veteran manifests each of the cardinal symptoms of muscle injury, as defined for VA rating purposes at 38 C.F.R. § 4.56, except impairment of coordination and uncertainty of movement. Thus, the Board finds moderate severity MG V injury, which warrants a 10 percent evaluation. The Board must next consider whether an evaluation in excess of 10 percent is warranted. The next higher rating is granted for moderately severe disability. On review of the description of moderately severe muscle injury, the evidence establishes that the initial injury did not require hospitalization, although the Veteran was apparently told at one point that surgery might be required. There was no debridement, prolonged infection, or sloughing of tissue. Moderately severe muscle injury is manifested by loss of deep fascia, muscle substance, or loss of normal firm resistance. Loss of deep fascia or loss of normal firm resistance are not demonstrated. The demonstrated 2-cm depression is consistent with "some" intramuscular scarring and "some" loss of muscle substance, warranting a finding of moderate disability, but does not demonstrate injury equivalent to a deep penetrating wound by a small high-velocity missile or large low-velocity missile. In particular, the Veteran's muscle resistance with the left forearm is evaluated as 5/5, similar to the uninjured (right) side, but with recognition that there is pain or pain/fatigue with repeated use at times, and diminished grip strength for heavy objects. This objective finding is consistent with moderate, but not moderately severe muscle injury to MG V. For moderately severe injury, cardinal symptoms of muscle injury are present, plus inability to keep up with work requirements. In this case, the Veteran is employed as a truck driver. He was employed full-time as a truck driver at the time of the 2008 VA examination; he remained employed full-time as a truck driver at the time of the 2011 VA examination. At his Travel Board hearing, the Veteran testified that pain in the left arm caused him to leave better-paying employment driving a garbage truck, which required him to be able to load trash onto the truck as well as to drive the truck, for a lower-paying job as a truck driver which requires less lifting. Tr. 13. The Veteran testified that his primary limitation was pain and loss of grip with lifting heavy objects. Tr. 11, 12. The Veteran's ability to drive a truck, but inability to lift, carry, and load trash onto a garbage truck is more consistent with moderate disability than with moderately severe disability, as the Veteran demonstrates ability to perform the work requirements of driving a truck, which requires significant use of both hands. He has testified that he is unable to keep up with work requirements which require ability to perform heavy manual labor with both arms. The Veteran's ability to perform manual labor requiring occasional use of both hands to lift and carry heavy objects, but not heavy manual labor requiring use of both hands to lift and carry heavy objects routinely, is consistent with moderate, but not moderately severe disability. The Board notes that the Veteran described the depressions on his muscles as "scars" and testified that the scars were painful. The examiner described the depressions as symptoms of intramuscular scarring, and noted that the Veteran had pain with use of the damaged muscles. The Veteran's testimony that these "scars" were painful is credible, and is consistent with the objective findings. However, the pain of these "scars" is most accurately evaluated as pain which is a cardinal symptom of muscle injury rather than as a tender or painful "scar" under DCs 7804 or 7805. The signs and findings which distinguish moderate, moderately severe, and severe injuries are a matter of degree. The Veteran has some symptoms of moderately severe or severe muscle injury, but the symptoms and findings shown in the 2008 and 2011 VA examinations are more consistent with moderate injury than with moderately severe or severe injury. The Veteran's testimony, which reflects that he has use of the left forearm which is sufficient to allow him to drive a truck, but causes pain when he works loading trash into a trash truck, is consistent with moderate, but not moderately severe injury. For these reasons, the Board finds that the Veteran has moderate muscle injury, but not moderately severe injury, of MG V. Moderate disability of MG V in the non-dominant extremity warrants a 10 percent initial evaluation, separate from the evaluation for other muscle, nerve, or scar injury, but no higher evaluation. 2. Evaluation of MG VII injury DC 5307 rates impairment to MG VII. MG VII includes the flexors of the carpus and long flexors of the fingers and thumb, including the flexor carpi radialis. A 10 percent rating is assigned for a moderate disability of the dominant or non-dominant wrist and finger flexors; a moderately severe disability of flexion of the non-dominant hand and wrist warrants a 20 percent rating, and a 30 percent rating is warranted for severe disability. DC 5307. In this case, the examiner has stated that there is intramuscular scarring of the flexor carpi radialis, shown by a 2-cm depression in the muscle. The examiner has stated that the Veteran's muscle injuries result in decreased ability to lift and carry objects, with occasional giving way, primarily with heavy objects. The VA examination report, as noted in the discussion above, establishes that the Veteran manifests some of the cardinal symptoms of muscle injury, as defined for VA rating purposes at 38 C.F.R. § 4.56, but impairment of coordination of the left wrist or hand or uncertainty of movement are not present. Thus, the Board finds that the severity of the Veteran's injury to MG VII is moderate. The Board also finds that the 2011 VA examination report establishes that the injury to MG VII is less severe than disability defined as "moderately severe." There was again no hospitalization, debridement, prolonged infection or sloughing of tissue. Further, as noted in the discussion of injury to MG V, the Veteran drives a truck. The Veteran's ability to drive a truck, but inability to lift, carry, and load trash onto a garbage truck is more consistent with moderate disability than with moderately severe disability, as driving a truck requires significant use of both hands. The Veteran has testified that he is unable to keep up with work requirements which require ability to perform heavy manual labor with both arms. The Veteran's ability to perform manual labor requiring occasional use of both hands to lift and carry heavy objects, but not heavy manual labor requiring use of both hands to lift and carry heavy objects routinely, is consistent with moderate, but not moderately severe disability. The Veteran does have loss of muscle substance of MG VII, but that muscle substance loss is manifested by a 2-cm depression. This evidence is consistent with "some" intramuscular scarring and "some" loss of muscle substance, but does not demonstrate injury equivalent to a deep penetrating wound by a small high-velocity missile or large low-velocity missile. Muscle resistance with the left forearm is evaluated as 5/5, similar to the uninjured (right) side, but with recognition that there is pain or pain/fatigue with left wrist flexion, and diminished grip strength for heavy objects. This objective finding is consistent with moderate, but not moderately severe muscle injury to MG VII. Because the signs and findings which distinguish moderate, moderately severe, and severe injuries are a matter of degrees, the Veteran has some symptoms of moderately severe or severe MG VII injury, but the symptoms and findings shown in the 2008 and 2011 VA examinations are more consistent with moderate injury rather than moderately severe or severe injury. For these reasons, the Board finds that the Veteran has moderate muscle injury, but not moderately severe injury, of MG VII. Moderate disability of MG VII in the non-dominant extremity warrants a 10 percent initial evaluation, separate from the evaluation for other muscle, nerve, or scar injury, but no higher evaluation. (CONTINUED NEXT PAGE) II. Nerve injury evaluation The examiner who conducted the 2011 VA examination identified injury to three nerves, the median nerve, the ulnar nerve, and the median and lateral antebrachial branch of the musculocutaneous nerve. Disability of these nerves is evaluated under DCs 8515, 8516, and 8517. 38 C.F.R. § 4.124a. Neuritis and neuralgia of these nerves is evaluated under DCs 8616, 8715, 8616, 8717, 8617, and 8717. 38 C.F.R. § 4.123, 4.124. Law governing evaluation of nerve injury The Board notes that radicular groups may be evaluated under DCs 8510 to 8513, Neurological disabilities of the upper extremities are rated under the schedular criteria of 38 C.F.R. § 4.124a, DCs 8510 to 8519. DC 8510, concerns impairment of the upper radicular group (the fifth and sixth cervicals); DC 8511 concerns impairment of the middle radicular group; DC 8512 concerns impairment of the lower radicular group; DC 8513 concerns impairment of all radicular groups. DC 8515 concerns the median nerve; DC 8516 concerns the ulnar nerve; DC 8517 addressed impairment of the musculocutaneous nerve. DC 8512, a 20 percent disability rating is warranted when there is mild incomplete paralysis of the lower radicular group in the minor or major hand. A 30 percent is appropriate when there is moderate incomplete paralysis of the minor hand. A 40 percent is appropriate when there is severe incomplete paralysis of the lower radicular group of the minor extremity. When there is complete paralysis of the lower radicular group, involving all intrinsic muscles of the hand, and some or all flexors of the wrist and fingers, wherein the paralysis results in the substantial loss of use of the minor hand, the maximum 60 percent disability rating is awarded. 38 C.F.R. § 4.124, DC 8512. Under DC 8515, a 10 percent rating is warranted for mild incomplete paralysis of the median nerve of the non-dominant upper extremity. A 20 percent rating is warranted for moderate incomplete paralysis of the minor extremity. A 40 percent rating requires severe incomplete paralysis of the median nerve in the minor extremity. Complete paralysis warrants a 60 percent rating. Under DC 8516, complete paralysis of the ulnar nerve includes the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened. DC 8516. For incomplete paralysis, which is the case here, a 10 percent rating is assigned for a mild disability on the non-dominant arm, a 20 percent rating is assigned for a "moderate" disability afflicting the non-dominant hand, and a 30 percent rating is assigned for "severe" disability afflicting the non-dominant hand. Under DC 8517, moderate incomplete paralysis of the musculocutaneous nerve warrants a 10 percent evaluation for both the major and minor extremities. Severe incomplete paralysis of the musculocutaneous nerve warrants a 20 percent evaluation for both the major and minor extremities. DCs 8613, 8713, 8616, 8715, 8616, 8717, 8617, and 8717 address the criteria for evaluating neuritis and neuralgia of the median, ulnar, and musculocutaneous nerves or the lower radicular group. Peripheral neuralgia characterized usually by a dull and intermittent pain in the typical nerve distribution is given a maximum rating of moderate incomplete paralysis. 38 C.F.R. § 4.124. Neuralgia is defined as pain extending along the course of a nerve. Dorland's Illustrated Medical Dictionary 1281 (31st ed. 2007). Peripheral neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is given a maximum rating of severe incomplete paralysis. 38 C.F.R. § 4.123. Neuritis is defined as inflammation of a nerve, causing pain and tenderness. Dorland's Illustrated Medical Dictionary 1282 (31st ed. 2007). Analysis In this case, the examiner has stated that the Veteran has peripheral neuropathy of the left upper extremity due to injury to three nerves. The examiner has stated that the nerve injuries result in weakness of motion of the wrist and of certain fingers. However, the examiner has not distinguished the symptoms of injury of each specific nerve from the injuries to the other nerves. The examiner has stated that there is peripheral neuropathy, but has not applied that finding to a specific nerve. For this reason, an evaluation based on consideration of the nerves as the lower radicular group rather than consideration of each nerve separately is most appropriate in this case. The examiner has described mild incomplete paralysis. The Veteran's testimony that, on occasion, he must use his other hand to manually release the left hand from a position of flexion is encompassed within the criteria for mild paralysis. The Veteran testified that he sometime has numbness in the tips of his fingers (Tr.8) and sometimes has radiating pain (Tr.9). The VA neurologist who evaluated the Veteran in November 2010 stated that the Veteran had a tremor, paroxysmal twitching, and a constant low-level burning pain. The Veteran has been treated with gabapentin since the 2010 neurology consultation, and the examiner who conducted 2011 VA examination did not describe each of the symptoms noted in November 2010, but did assign a diagnosis of peripheral neuropathy. Because the peripheral neuropathy is not attributable to a single or specific affected nerve, it is appropriate to evaluate the nerve injury as injury to the lower radicular group. Given that the Veteran has some symptoms of mild incomplete paralysis of the lower radicular group and has peripheral neuropathy resulting from the injury to the lower radicular group of nerves, the evidence warrants a 30 percent evaluation for moderate incomplete paralysis and neuropathy. The Board finds that the evidence does not support a finding of severe incomplete paralysis and neuropathy. In particular, the Veteran did not testify that he had constant severe pain in his left forearm at all times. Rather, he testified that he had pain with touch, and episodes of increased pain. This evidence does not demonstrate severe neuritis or neuralgia so as to warrant the next higher evaluation. The Veteran did not report severe, constant pain to the treating VA neurologists who have been treating him since November 2010. Rather, the outpatient treatment notes specify that the Veteran had a low-level burning pain. This description of the pain is consistent with moderate disability of the lower radicular group, but not severe disability. Moreover, this description is consistent with the findings reported by the VA examiner. Finally, the Board is persuaded that the Veteran's described occupation, his full-time employment, his family activities and activities of daily living, are not consistent with severe disability of the left forearm. An initial, separate evaluation of 30 percent, for moderate left forearm nerve disability, but not a higher evaluation for severe nerve disability of the left forearm, is warranted. III. Scar evaluation Currently, an initial non-compensable evaluation is in effect for a laceration scar along the left elbow, common extensor. The Veteran contends he is entitled to a compensable evaluation for his scars because the scars on his muscles are tender to touch. As discussed above, the medical evidence establishes that the depressed areas the Veteran referred to as "scars" are attributed to muscle injury. Therefore, only the laceration scar below the Veteran's left elbow is addressed in this portion of the decision. Law governing evaluation of scars As an initial matter, the Board notes that the rating criteria for evaluating scars under 38 C.F.R. § 4.118, DCs 7800-7805 were amended during the pendency of this appeal (effective October 23, 2008). While the revised criteria apply only to applications for benefits received by VA on or after the effective date of October 23, 2008, a Veteran who was rated under DCs 7800-7805 before October 23, 2008 can request review under the new regulations. See 73 Fed. Reg. 54,710 (Sept. 23, 2008). The Board considers the Veteran's testimony and statements as raising such a request. The rating criteria in effect when the Veteran submitted his claim provided a 10 percent evaluation for superficial, unstable scars. 38 C.F.R. § 4.118, DC 7803. This diagnostic code defines an unstable scar as one where, for any reason, there is frequent loss of covering of the skin over the scar. A 10 percent evaluation was authorized for superficial scars that were painful on examination. DC 7804. Scars were also rated based on the limitation of function of the affected part. DC 7805. Effective October 23, 2008, DC 7803 was eliminated, and DC 7804 was changed to encompass both unstable and/or painful scars. Under the revised DC 7804 different ratings are available based on whether there are two or less scars as opposed to more than two scars. 38 C.F.R. § 4.118. A 10 percent rating is available for one or two scars that are unstable or painful, a 20 percent rating is assigned for three or four scars that are unstable or painful, and a 30 percent rating is assigned for five or more scars that are unstable or painful. Id. Scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7804 when applicable. Id. Analysis The medical evidence establishes that a laceration scar on the Veteran's left elbow area is not tender, adherent, painful on use or palpation, and does not result in painful motion or limitation of motion of the elbow. The examiner who conducted the 2011 VA examination noted that the Veteran had painful motion of the left wrist, but that pain was attributed to the nerve injuries which have been evaluated under DC 8513. In short, the medical evidence establishes that the laceration scar in the left elbow area is asymptomatic. Therefore, regardless of the criteria used to evaluate the laceration scar, a noncompensable evaluation must be assigned. As noted, the Veteran has repeatedly stated that he has scars that are tender. The Veteran has clearly testified that the tender "scars" are depressions on the left brachioradialis and the left flexor carpi radialis muscles which have been medically attributed to intramuscular scarring. As discussed above, intramuscular scarring is evaluated as part of the compensable evaluations assigned for MG V and MG VII muscle injury. Thus, the pain on palpation of the depressions on the left brachioradialis and the left flexor carpi radialis muscles may not serve as a factual basis for an increased (compensable) rating for a scar. For the reasons stated above, the Board has concluded that the preponderance of the evidence is against assignment of an initial compensable rating for a laceration scar, left elbow. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b). Consequently, the appeal for an initial compensable evaluation for a laceration scar, left elbow extensor, must be denied. Lay assertions The Board has also considered the Veteran's statements that his left arm/shoulder is worse than currently evaluated. He is clearly competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Veteran is not competent to identify a specific level of disability pursuant to the appropriate diagnostic codes. He equally lacks the competence to discern dysfunction related to a "scar" versus that of a muscle injury. Such competent evidence concerning the nature and extent of the Veteran's muscle and neurological disorders has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings address the criteria under which the disability is evaluated. The Board finds these records to be more probative than the Veteran's subjective evidence of complaints of increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect the credibility of testimony). Extraschedular Consideration The Board has considered whether the Veteran is entitled to consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F. 3d 1366 (Fed. Cir. 2009). The first question in such consideration is whether the assigned schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptoms, then the claimant's disability picture is contemplated by the rating schedule. If the schedular evaluation is adequate, no referral is required. In this case, initial 10 percent evaluations are assigned for MG V and MG VII injuries, and an initial 30 percent evaluation is assigned for injury to three nerves. Within these schedular evaluations, the Board has considered objective findings and testimony regarding both constant pain and episodic increases in pain, intramuscular scarring, loss of intramuscular substance of the left brachioradialis muscle and the left flexor carpi radialis muscle, decreased strength for certain activities (primarily with lifting heavy objects and grip strength), mild incomplete paralysis, and neuropathy manifested by pain, parasthesias, and involuntary movement. Each complaint, symptom, or finding of muscle, nerve, or scar injury of the left forearm has been considered and is encompassed within an assigned schedular rating. If a schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. In this case, the Board finds that the schedular criteria are adequate, and that the symptoms of the Veteran's left forearm injury, including muscle, nerve, and scar residuals, are fully contemplated by the applicable rating criteria. Additionally, the Board notes that the Veteran's disability picture is consistent with the evaluations assigned, and left forearm injury has not precluded full-time employment. Additionally, the Veteran does not contend that he would be better served by amputation of the left forearm. Based on the foregoing, referral for consideration of extraschedular evaluation for a muscle, nerve, or scar disability of the left forearm is not warranted. 38 C.F.R. § 3.321(b). ORDER A separate, compensable, 10 percent initial evaluation for left forearm crush injury residuals to MG V is granted, subject to law and regulations governing the effective date of an award of monetary compensation; the appeal is granted to this extent only. A separate, compensable, 10 percent initial evaluation for left forearm crush injury residuals to MG VII is granted, subject to law and regulations governing the effective date of an award of monetary compensation; the appeal is granted to this extent only. A separate, compensable, 30 percent initial evaluation for left forearm nerve injury to the median nerve, ulnar nerve, and antebrachial nerve (lower radicular group), left forearm, is granted, subject to law and regulations governing the effective date of an award of monetary compensation; the appeal is granted to this extent only. The appeal for an increased (compensable) initial rating for a laceration scar, left forearm, is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs