Citation Nr: 1312772	
Decision Date: 04/17/13    Archive Date: 05/02/13

DOCKET NO.  07-07 827	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania


THE ISSUES

1.  Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD).

2.  Entitlement to a compensable rating for residuals of a gunshot wound to the right index finger with osteoarthritis of the distal interphalangeal joint.

3.  Entitlement to a rating in excess of 30 percent for residuals of a gunshot wound to the left thigh.

4.  Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities.


REPRESENTATION

Appellant represented by:	The American Legion


ATTORNEY FOR THE BOARD

B. Elwood, Associate Counsel


INTRODUCTION

The Veteran served on active duty from June 1966 to June 1969.  He received the Purple Heart Medal, Bronze Star Medal with combat "V," and Combat Action Ribbon.

These matters initially came before the Board of Veterans' Appeals (Board) from a March 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania.  

In his March 2007 substantive appeal (VA Form 9), the Veteran requested a Board hearing before a Veterans Law Judge.  In December 2008, he withdrew his hearing request.

In December 2010, the Board remanded these matters for further development.

(The individual rating claims are addressed in the decision below.  The claim of entitlement to a TDIU is addressed in the remand that follows the decision.)


FINDINGS OF FACT

1.  Prior to March 1, 2008, the Veteran's PTSD was manifested by social isolation, employment difficulties, anger, irritability, a euthymic mood, depression, suicidal ideation, intrusive thoughts, feelings of helplessness, nightmares, hypervigilance, a hyperstartle response, impaired sleep, and possible panic attacks; a Global Assessment of Functioning (GAF) score of 55 was assigned and there were not deficiencies in most of the areas of work, school, family relations, judgment, thinking or mood.
2.  Since March 1, 2008, the Veteran's PTSD has been manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood; there has not been total social and occupational impairment.

3.  The Veteran's residuals of a gunshot wound to the right index finger have been manifested by a right index finger deformity with dysfunction, pain, stiffness, swelling, tenderness, right hand weakness, decreased dexterity of the index finger, limitation of extension of the metacarpophalangeal joint to at most 70 degrees, index finger ankylosis, a scar, degenerative joint disease of the distal interphalangeal joint, and mild incomplete paralysis of the median nerve.

4.  The Veteran's residuals of a gunshot wound to the left thigh involve Muscle Group XV and have been manifested by left buttock pain, a limp, tenderness, muscle atrophy, numbness, left knee and hip pain, left knee crepitus, limitation of flexion of the left hip to between 80 and 125 degrees, muscle loss, intermuscular scarring, deep and adherent left thigh scars, and fatigue, stiffness, and weakness of the left thigh, hip, and knee, resulting in no worse than severe muscle disability.


CONCLUSIONS OF LAW

1.  The criteria for a 50 percent rating (but not more) for the entire claim period until March 1, 2008, and a 70 percent rating (but not more) since March 1, 2008, for PTSD have been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.2, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411 (2012).

2.  The criteria for a 10 percent rating (but not more) for residuals of a gunshot wound to the right index finger with osteoarthritis of the distal interphalangeal joint have been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.2, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, DCs 5003, 5225, 5229 (2012), 4.118, DCs 7800-7805 (2008).

3.  The criteria for a separate initial 10 percent rating for peripheral neuropathy of the right median nerve have been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.123, 4.124, 4.124a, DC 8515 (2012).

4.  The criteria for a rating in excess of 30 percent for residuals of a gunshot wound to the left thigh have not been met.  38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.55, 4.56, 4.59, 4.71a, DCs 5250-5256, 5260-5262, 4.73, DC 5315 (2012), 4.118, DCs 7800-7805 (2008), 4.123, 4.124, 4.124a, DC 8529 (2012).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I. Duties to Notify and Assist

The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance.  38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012).  

Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim.  Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b).

The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim.  Those five elements include:  (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.  Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).

In a pre-adjudication letter dated in January 2006, the RO notified the Veteran of the evidence needed to substantiate his claim for increased ratings for PTSD, residuals of a gunshot wound to the right index finger with osteoarthritis of the distal interphalangeal joint, and residuals of a gunshot wound to the left thigh.  This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide.  Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002).

The claimant's veteran status has been substantiated.  He was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claims, in a March 2006 letter, which was also sent prior to the March 2006 rating decision.  

The Court held in Vazquez-Flores v. Peake that 38 U.S.C.A § 5103(a) requires, at a minimum, that the Secretary notify the Veteran that, to substantiate an increased rating claim, the Veteran must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment.  Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated sub nom, Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009).  

Additionally, the Veteran must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment.  Id.

Furthermore, the Court directed that as with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability.  Id.

The January 2006 letter told the Veteran that evidence of worsening could substantiate the increased rating claim.  He was notified in the letter that medical or lay evidence could be submitted to substantiate his increased rating claim and was provided with specific examples.  The letter also stated that the Veteran could submit letters from individuals who could describe the manner in which his disabilities had worsened.  

The March 2006 letter explained that disability ratings are determined by applying VA's rating schedule under which the RO would assign a rating from 0 to 100 percent, and that it would consider evidence of the nature of the symptoms of the condition, their severity and duration, and their impact upon employment.  Thus, VA's duty to notify has been met.

The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim.  38 U.S.C.A. § 5103A; 38 C.F.R. 
§ 3.159(c), (d).  This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim.  38 C.F.R. § 3.159(c)(4).  

VA obtained the Veteran's service treatment records and all of the identified relevant post-service VA treatment records.  The Veteran has not reported, and the evidence does not otherwise reflect, that he has received any relevant post-service private medical treatment for PTSD, residuals of a gunshot wound to the right index finger, or residuals of a gunshot wound to the left thigh.  In addition, he was afforded VA examinations to assess the severity of these service-connected disabilities.  The evidence in the examination reports is sufficient for evaluating the Veteran's service-connected disabilities in the context of the rating criteria.  See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination, it must provide an adequate one).

In the December 2010 remand, the Board instructed the agency of original jurisdiction (AOJ) to, among other things, obtain all relevant treatment records from the VA Medical Center (VAMC) in Buffalo, New York, dated since October 2007 and to schedule the Veteran for VA examinations to assess the severity of his service-connected PTSD, residuals of a gunshot wound to the right index finger, and residuals of a gunshot wound to the left thigh.

As explained above, all relevant post-service VA treatment records (including from the Buffalo VAMC) have been obtained and associated with the claims file.  Additionally, VA examinations were conducted in January 2011 to assess the severity of the Veteran's service-connected PTSD, residuals of a gunshot wound to the right index finger, and residuals of a gunshot wound to the left thigh.  These examinations were thorough, contained all pertinent findings, and were responsive to the questions posed by the Board.  Accordingly, with regard to the claims decided herein, the AOJ substantially complied with all of the Board's relevant October 2010 remand instructions and VA has no further duty to obtain any additional records or conduct additional examinations.  See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998).

II. Analysis

Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule).  38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012).

If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned.  38 C.F.R. § 4.7 (2012).

In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified.  Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances.  38 C.F.R. § 4.21 (2012).

In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition.  The Board has a duty to acknowledge and consider all regulations that are potentially applicable.  Schafrath v. Derwinski, 1 Vet. App. 589 (1991).  The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required.  38 C.F.R. §§ 4.1, 4.2, 4.10.

Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings.  Francisco v. Brown, 7 Vet. App. 55 (1994).  Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings.  

The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim.  Hart v. Mansfield, 21 Vet. App. 505 (2007).

Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45 (2012), pertaining to functional impairment.  The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare ups.  Such inquiry is not to be limited to muscles or nerves.  These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare ups, or pain.  The examiner should also determine the point, if any, at which such factors cause functional impairment.  Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59.

When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission.  The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination.  38 C.F.R. § 4.126(a) (2012).

When evaluating the level of disability from a mental disorder, VA will also consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment.  38 C.F.R. § 4.126(b).

The schedular criteria for rating psychiatric disabilities incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).  See 38 C.F.R. §§ 4.125, 4.130 (2012).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.  38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).


A. PTSD

The Veteran's PTSD is rated under 38 C.F.R. § 4.130, DC 9411 according to the General Rating Formula for Mental Disorders.  Under the General Rating Formula, a 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events).  38 C.F.R. § 4.130, DC 9411.

A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships.  Id.

A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances ( including work or a worklike setting); and inability to establish and maintain effective relationships.  Id.

A 100 percent disability rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name.  Id.

The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned.  Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004);
Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). 

The Board has considered the GAF scores assigned during the claim period.  The GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness."  Richard v. Brown, 9 Vet. App. 266, 267 (citing DSM-IV at 32).  GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).  Also, GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).  Id.

The GAF score assigned in a case, however, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue.  Rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned.  See 38 C.F.R. § 4.126(a).

In this case, the Veteran reported during a September 2003 VA psychiatric examination that he did not want to be "involved too much with people" because of discomfort.  As a result, he worked approximately 100 hours per week at his full time job with the Postal Service and on his farm.  He had a capacity for enjoyment, which he channeled into his family and work.  He had been employed with the Postal Service for 33 years and was working as a postmaster at the time of the September 2003 examination.  He was "expected to be retiring in the near future" and did not associate with his coworkers "since he [was] the boss."  However, he did have other friends.  Although he worked to a degree that most people would consider excessive, he and his wife reported that such work was his source of enjoyment and that he did not view it negatively.

A "Request for Employment Information in Connection with Claim for Disability Benefits" form (VA Form 21-4192) dated in November 2003 reveals that the Veteran was still employed full time as a postmaster with the Postal Service, but that he had been on sick leave since approximately August 2002 and was expected to retire.

VA treatment records dated from August 2004 to November 2005, an April 2005 statement from the Veteran's representative (VA Form 21-4138), and the Veteran's October 2005 claims ("Veteran's Application for Increased Compensation Based on Unemployability" form and VA Form 21-4138), indicate that he experienced both occupational and social impairments due to grossly impaired thought processes where he believed that nobody cared about anything anymore.  He was unable to maintain employment due to his service-connected PTSD, residuals of gunshot wounds to the right index finger and left thigh, hearing loss, and tinnitus.  For example, as a result of his PTSD he was unable to get along with people and interact without becoming angry and disillusioned about expectations of life and fairness.  His disabilities affected full time employment beginning in 2000 and he had last worked full time in November 2002.  

As part of his October 2005 claim, the Veteran submitted a "Request for or Notification of Absence" form (PS Form 3971) and an "Employee Training History Report" from the Postal Service which reflect that he attended a training course entitled "The Attitude Virus" in July 2002.  He reported that he had been directed to take this course on three occasions.  The PS Form 3971 reportedly showed that he was directed to take a leave of absence by the Postal Operations Manager (POOM) from October to December 2002 due to his inability to work with others.  He was then directed to take sick leave/a leave of absence for the last 12 months of his employment and reportedly lost his job/retired early from the Postal Service in November 2003, at which time he had been instructed that he had to retire early.  The Veteran reported that a physician had attributed his early retirement to nonservice-connected chronic obstructive pulmonary disease (COPD), but that the physician did not put stress on his medical excuses.  The physician reportedly claimed COPD as the cause of retirement because it could not be argued.  However, the Veteran claimed that his PTSD was the actual cause of the need for sick leave prior to his retirement and that he was required to attend "Attitude Adjustment Training" on two occasions.  He had refused such training on three other occasions.  

Following his retirement, the Veteran worked alone at home as a self employed cattle and maple syrup farmer and his breathing did not prevent such work.  He had isolated himself and had not traveled more than 110 miles from his home since service.  He was diagnosed as having severe and chronic PTSD with associated depression.

A February 2006 VA examination report reflects that the Veteran had not received any inpatient psychiatric treatment or alcohol/substance abuse treatment since his September 2003 VA psychiatric examination and that he had not taken any psychiatric medications.  He briefly participated in psychotherapy with VA in August and September 2004, but discontinued such treatment due, in part, to a belief that he did not wish to share his problems in public and rather wished to deal with such problems on his own.  He had worked for the Postal Service for 33 years and was employed as a postmaster for the last 11 years of such employment.  He retired in 2003, but remained active on his family farm and typically worked 7 days per week.  Although he worked excessively, he recognized such work as a source of enjoyment and used it as a "positive outlet."  He had been active on the advisory board for the Future Farmers of America at a local school for the previous 10 years, however he had experienced an interpersonal conflict at the most recent meeting, at which time he "blew up" due to a conflict with another board member.  He was considering resigning from his position due to the conflict.

With respect to his social functioning, the Veteran reported that he had been in a stable marriage for the previous 37 years, that he had good relationships with his wife, children, and grandchildren, and that he enjoyed his family life.  However, he was otherwise generally socially isolated and avoided "the need for friendship with his active involvement in work" because it was "easier that way" and allowed him to avoid potential conflicts with others.  As a result of his daily work on the family farm, he had little time for other pursuits and did not have any other hobbies or interests.  Although he had tried vacationing on one occasion, he reported that it "didn't work."

Examination revealed that the Veteran was casually dressed and adequately groomed.  He maintained good eye contact, had normal speech and motor functioning, was fully oriented, and had intact attention, concentration, and memory.  There was no reported or evident impairment of thought process and the Veteran denied having any hallucinations, delusions, obsessions, or compulsions.  He was able to perform activities of daily living and did not experience any panic attacks.  His affect was friendly, joking, smiling, and relaxed, he did not experience any significant irritability or anger (with the exception of the reported conflict at the Future Farmers of America meeting), and there was no homicidal ideation, intent, plan, or attempts.  However, the Veteran described his mood as generally euthymic with occasional depression.  He actively tried to avoid such feelings by not dwelling on them and they did not significantly interfere with his daily functioning.  Also, he occasionally experienced fleeting, vague suicidal ideation.  However, he firmly stated that he would "never do it" and he denied any specific ideation, intent, plan, or attempts.

Moreover, the Veteran continued to experience symptoms consistent with a diagnosis of PTSD, including recurrent and intrusive distressing thoughts of in-service trauma, a feeling of helplessness, nightmares, avoidance of social interaction beyond his family, hypervigilance, a hyperstartle response, impaired sleep, and social isolation.  Such symptoms were moderate and chronic in nature.  A diagnosis of chronic moderate PTSD was provided and a GAF score of 55 was assigned, indicative of moderate impairment.

The examiner who conducted the February 2006 VA examination concluded that the Veteran continued to report significant symptoms of PTSD, including re-experiencing of past trauma, avoidance of stimuli associated with such trauma, and symptoms of increased arousal.  These symptoms were chronic and moderate in severity.  Since his September 2003 VA examination, he had continued to enjoy occupational success until his retirement in 2003 and subsequently worked every day on his family farm.  Also, he continued to enjoy good relationships with his immediate family.  Overall, it was evident that his PTSD had a significant negative impact on his psychosocial functioning over the years, but that he had coped relatively well with his considerable psychological distress by restricting himself socially and channeling his anxiety into his work.  His functioning appeared largely unchanged since the September 2003 examination.  However, the GAF score of 65 assigned at the time of that examination appeared to be an overestimate of his functioning given the moderate degree of his symptoms, despite his relatively good family and occupational functioning.  Rather a GAF score of 55 more accurately reflected the fact that he continued to experience moderate symptoms of PTSD which had given rise to considerable social isolation and excessive work behavior as coping strategies.

In statements dated in June 2006 (VA Form 21-4138) and March 2007 (VA Form 9), the Veteran's representative reported that the Veteran experienced suicidal ideation, depression, unprovoked irritability, difficulty in adapting to stressful situations, and an inability to establish and maintain effective relationships.  He was unable to leave the immediate property where he lived, worked excessively on the family farm which was a hobby and did not provide gainful employment, had not been on vacation in 30 years, and had no friends.  When panic attacks were explained to him, he explained that he would frequently sit with a "host of things running through his mind" and his heart racing, and he was unable to attempt any activity for approximately 1 to 2 hours.  Since he was unable to leave his home due to PTSD, he was unable to be gainfully employed.  While he was employed with the Postal Service, he displayed a social dysfunction and was required to attend a "charm school" on three occasions due to an inability to work with others.  Thus, no matter what the reason was for his retirement, his PTSD did influence his retirement.

During a VA examination dated on March 1, 2008, the Veteran reported that he was not receiving any psychotherapy, was not taking any psychotropic medications, and had never been hospitalized for psychiatric treatment.  His psychiatric symptoms had stabilized since he quit an advisory board, but he continued to experience intrusive thoughts and avoidance of activities that may have aroused recollections of trauma.  There had been no remissions of such symptoms.  Since the February 2006 VA examination, he had not engaged in any violence, had not made any suicide attempts, and did not experience any substance abuse.

As for occupational and social functioning, the Veteran reported that following his forced retirement from the Postal Service in 2001, he was involved in farming with his wife as a hobby.  He had been married to his wife since 1968 and his marriage was going "very well".  He had a fair relationship with his children.  However, he did not interact socially outside of his immediate family and spent his time working on the farm and working on farm equipment.  Overall, he was reportedly maintaining essentially the same level of functioning as that which he maintained at the time of the February 2006 examination.

Examination revealed that the Veteran was cooperative and had an adequate manner of relating.  He was casually dressed with a beard and appeared fairly well groomed.  His speech was fluent, the quality of his voice was clear, expressive and receptive language were both adequate, and his thought processes were coherent and goal directed with no evidence of obvious hallucinations, delusions, obsessions, or compulsions.  His sensorium appeared clear, he was fully oriented, and his attention, concentration, and memory were intact.  He did not relate any symptoms that would be significant for obsessive compulsive disorder, panic disorder, thought disorder, cognitive dysfunction, or mood disorder.  Also, he did not experience any suicidal/homicidal ideations or manic episodes.  However, his eye contact was fair, his affect was dysphoric but appropriate to the content of the discussion, his mood was dysthymic, his insight was fair to good, and his judgment was fair.  Also, he experienced intrusive ideation on a weekly basis, nightmares more than once a week, flashbacks, avoidance of situations which reminded him of past trauma, a significantly diminished interest in significant social activities, a sense of estrangement from others, a restricted range of affect, hypervigilance, and a hyperstartle response.

The Veteran was diagnosed as having chronic PTSD and a GAF score of 51 was assigned, indicative of moderate impairment.  The examiner who conducted the March 2008 VA examination concluded that the Veteran's PTSD symptoms appeared to have only slightly worsened since the February 2006 VA examination.  He had reportedly been doing fairly well until he went to the advisory board meeting, which seemed to have exacerbated his symptoms.  He was returning to his pre-advisory board meeting status emotionally at the time of the March 2008 examination.  His prognosis was guarded since he was not involved in any psychotherapy and did not take any psychiatric medications.  In sum, there was reduced reliability and productivity due to his PTSD signs and symptoms.

A VA Form 21-4192 dated in April 2008 from the Postal Service reflects that the Veteran had been employed full time as a postmaster from August 1973 to November 2003.  It was unknown as to whether there had been any concessions made by reason of disability, but it was reported that the Veteran had retired and had not left his job due to disability.

A report of a VA examination dated in January 2011 indicates that the Veteran had not received any outpatient treatment or been hospitalized for a psychiatric disability.  He remained married to his wife of 43 years and their relationship was generally good.  However, he acknowledged that their relationship was strained due to his PTSD symptoms, including emotional distancing.  He had good relationships with his children and brother and had occasional contact with his sister.  Although he had friends, he never saw them, was a loner, and had no activities or leisure pursuits.  He retired as a postmaster in 2002 due to psychiatric problems (e.g. interpersonal difficulties) and other physical medical problems (e.g. left knee and hip pain).  There was no history of suicide attempts or violence/assaultiveness and the Veteran did not experience substance abuse.  However, he did report a severe level of psychosocial impairment.  Overall, his psychiatric symptoms had been present during the previous year.

Examination revealed that the Veteran was clean, neatly groomed, and appropriately and casually dressed.  Psychomotor activity, speech, and thought process and content were all unremarkable, the Veteran's attitude towards the examiner was cooperative (but guarded), his attention, memory, judgment, and insight were all intact, he was fully oriented, and he did not experience any delusions, hallucinations, panic attacks, homicidal/suicidal thoughts, or episodes of violence.  Also, he did not exhibit any inappropriate, obsessive, or ritualistic behavior, his impulse control was good, and he was able to maintain minimum personal hygiene.  However, the Veteran's mood was dysphoric, his affect was constricted, and he experienced impaired sleep, recurrent and intrusive distressing recollections of traumatic events, flashbacks, recurrent nightmares, avoidance of situations that reminded him of past trauma, a markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, hypervigilance, a hyperstartle response, and social avoidance.  Such symptoms were chronic and moderate and there had not been any periods of remission.  There were some slight to severe problems with some activities of daily living (e.g. shopping, engaging in sports/exercise, and other recreational activities).

The Veteran was diagnosed as having chronic and moderate PTSD and a GAF score of 43 was assigned, indicative of serious impairment.  The psychologist who conducted the January 2011 VA examination explained that this GAF score was based upon the Veteran's severe PTSD symptoms and resultant severe occupational and social impairment with extreme social isolation.  His PTSD symptoms resulted in changes in his behavioral and social functioning.  Although he was retired, it was expected that he would have had a severe level of difficulty in occupational functioning  due to his severe PTSD symptoms if he were to attempt to return to work.  However, there was not total occupational and social impairment due to PTSD, but rather reduced reliability and productivity (i.e. the criteria for a 50 percent rating under DC 9411).  The examiner reasoned that the Veteran had retired in 2002, that he was guarded during the examination (answered questions, but appeared to minimize his difficulties), he denied any problems with mood and thinking, and he acknowledged a strained marriage.  Also, he reported extreme social isolation.  As a result, it was expected that if he were to attempt to return to work, he would exhibit at least a level of impairment of reduced reliability and productivity due to anticipated social interaction in the work environment.

Moreover, the Veteran reported occasional sadness, but did not specify the amount of time that such symptoms persisted and stated that there was "nothing out of normal."  Although he experienced a loss of interest in his usual activities and sleep disturbance, he had signed a Do Not Resuscitate Order immediately prior to the examination and denied feelings of depression.  Rather, he felt sadness for his family.  Thus, it did not appear as if he was experiencing symptoms of depression at the time of the examination.  Also, he denied manic episodes, excessive anxiety, obsessions, compulsions, and panic attacks.  His prognosis was poor given the severity and chronicity of his psychiatric symptoms with no treatment and extreme social isolation.

Initially, the Board notes that the Veteran has been diagnosed as having nonservice-connected depression during the claim period.  However, where an examiner is unable to distinguish the symptoms of a service-connected disability from non-service connected manifestations, all the manifestations will be considered part of the service-connected disability.  Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996)).

In this case, there is no evidence to clearly distinguish the symptoms of the Veteran's service-connected PTSD from his diagnosed nonservice-connected depression.  Moreover, the depression was noted to be associated with the Veteran's PTSD.  Thus, the Board will attribute all of the Veteran's psychiatric symptoms to PTSD for the purposes of assessing the severity of that disability.  Id.

The above evidence reflects that during the claim period prior to March 1, 2008, the symptoms of the Veteran's PTSD most closely approximated the criteria for a 50 percent rating under DC 9411.  For example, he reported that while had had been employed he experienced problems due to his mood and an impaired ability to interact with others.  Also, he did not have any social interactions beyond his immediate family.  Moreover, he experienced symptoms such as a euthymic mood, occasional depression and suicidal ideation, recurrent distressing thoughts of in-service trauma, a feeling of helplessness, nightmares, hypervigilance, a hyperstartle response, impaired sleep, and possible panic attacks.  The examiner who conducted the February 2006 VA examination diagnosed the Veteran as have moderate PTSD and assigned a GAF score of 55, indicative of moderate impairment. 

The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood.  Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001).

The Veteran consistently reported that he experienced problems due to PTSD while he was employed with the Postal Service.  Also, he reported distressing thoughts of in-service trauma, nightmares, and a depressed/euthymic mood.  Thus, the record demonstrates deficiencies in the areas of work, thinking, and mood due to psychiatric symptoms during the period prior to March 1, 2008.  However, the Veteran was in a long-term marriage, had a good relationship with his family, and reported that he enjoyed his family life.  Also, there is no evidence of impaired schooling or judgment during this period.

Additionally, the evidence fails to show most of the symptoms listed as examples in the criteria for a 70 percent rating during the period prior to March 1, 2008.  The Veteran did not demonstrate obsessed rituals, impaired speech, or spatial disorientation, and the February 2006 VA examination reflects that he was adequately dressed and groomed.  Although the Veteran reported depression and his representative reported symptoms possibly indicative of panic attacks in its March 2007 statement, he did not otherwise report panic attacks (they were specifically denied during the February 2006 VA examination) and there is no evidence of near-continuous panic.  He was able to perform all activities of daily living and his depression was not otherwise shown to affect his ability to function independently, appropriately, and effectively.  Furthermore, despite the fact that the Veteran reportedly experienced a conflict during a Future Farmers of America meeting and his representative reported unprovoked irritability, the Veteran acknowledged during the February 2006 VA examination that he did not experience any significant irritability or anger (with the exception of the reported conflict at the Future Farmers of America meeting).

With respect to the remainder of the claim period, the evidence reflects that the Veteran has exhibited deficiencies in most of the areas needed for a 70 percent rating under DC 9411.  Although the examiner who conducted the March 2008 VA examination noted that the Veteran maintained approximately the same level of functioning as that which was present during the February 2006 VA examination, he acknowledged that there was a slight worsening of symptoms, he reported that the Veteran had stopped his involvement with the Future Farmers of America, and he assigned a GAF score of 51 (i.e. the minimum score reflecting moderate impairment.  The examiner who conducted the January 2011 VA examination also initially reported that the Veteran's PTSD symptoms were moderate.  However, she subsequently explained that such symptoms were severe and caused severe occupational and social impairment.  Also, she assigned a GAF score of 43, indicative of severe impairment.

As for the specific criteria for a 70 percent rating, the Veteran has consistently reported that he experienced problems while employed with the Postal Service due to his PTSD and the January 2011 examiner acknowledged that there was severe occupational impairment due to PTSD.  Specifically, she explained that if the Veteran were to attempt to return to work, he would be impaired due to anticipated social interaction in the work environment.  The Veteran remains married to his long-term wife and maintains relationships with his children.  However, he has reported marital strain due to his psychiatric symptoms and is socially isolated outside of his family.  Also, his judgment was found to be only fair during the March 2008 VA examination, he has experienced nightmares, intrusive thoughts, and flashbacks, and he has exhibited a dysthymic mood.  These findings are indicative of deficiencies in the areas of work, family relations, judgment, thinking, and mood.  The March 1, 2008, VA examination report represents the best evidence, as well as the best date, for ascertaining when the increase from 50 percent to 70 percent level of disability occurred.  See Hart, 21 Vet. App. at 505.

The Board finds that the Veteran's PTSD has not met the criteria for a 100 percent rating at any time during the claim period because total occupational and social impairment has not been shown.  The Board recognizes that the Veteran has reported that he experienced occupational difficulties due to his PTSD and that he was forced to retire from the Postal Service due to symptoms associated with this disability.  He is competent to report his psychiatric symptoms, their impact upon his employment, and his employment history.  These reports, however, must be weighed against the objective evidence and their credibility must be assessed.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006).  

The February 2006 and March 2008 VA examinations indicate that the Veteran was diagnosed as having moderate PTSD and that the GAF scores assigned during the examinations were indicative of moderate impairment.  The April 2008 VA Form 21-4192 submitted by the Postal Service reveals that the Veteran had been employed full time from August 1973 to November 2003 and that he had retired and not left his job due to disability.  

The January 2011 VA examination report reflects severe occupational impairment due to PTSD, includes a GAF score which is indicative of an inability to work, and includes a conclusion from the examiner that it was expected that the Veteran would have had a severe level of difficulty in occupational functioning due to his severe PTSD symptoms if he were to attempt to return to work.  However, the examiner ultimately opined that there was not total occupational impairment due to PTSD, but rather reduced reliability and productivity (i.e. the criteria for a 50 percent rating under DC 9411).  She explained that the Veteran had retired in 2002, that he was guarded during the examination (answered questions, but appeared to minimize his difficulties), that he denied any problems with mood and thinking, and that he acknowledged a strained marriage.  Also, he reported extreme social isolation.  As a result, it was expected that if he were to attempt to return to work, he would exhibit at least a level of impairment of reduced reliability and productivity due to anticipated social interaction in the work environment.

Moreover, the Veteran has provided varying statements as to the history of his employment and the impact of his PTSD on such employment.  He has contended on numerous occasions that he experienced interpersonal difficulties while employed and that he was forced to retire due to such symptoms.  In support of this contention, he submitted the "Request for or Notification of Absence" form (PS Form 3971) and "Employee Training History Report" from the Postal Service which reflect that he attended a training course entitled "The Attitude Virus" in July 2002.  The PS Form 3971 also reportedly shows that he was directed to take a leave of absence by the Postal Operations Manager due to his inability to work with others.  The November 2003 VA Form 21-4192 confirms that he was still employed full time as a postmaster with the Postal Service at that time, but that he had been on sick leave since approximately August 2002 and was expected to retire.

However, the Veteran reported during the September 2003 VA psychiatric examination that he worked approximately 100 hours per week at his full time job with the Postal Service and on his farm and that his employment was a source of enjoyment.  He was "expected to be retiring in the near future," but he did not attribute such expected retirement to his psychiatric disability.  Also, he claimed that he did not associate with his coworkers "since he [was] the boss."  
He reported on his October 2005 claim for a TDIU ("Veteran's Application for Increased Compensation Based on Unemployability" form) that he was prevented from securing or following any substantially gainful occupation due to a combination of his PTSD, residuals of gunshot wounds to the right index finger and left thigh, hearing loss, and tinnitus, and he acknowledged that a physician had attributed his early retirement to nonservice-connected COPD.  Additionally, he reported during the January 2011 VA examination that he had retired as a postmaster in 2002 due to both psychiatric problems (e.g. interpersonal difficulties) and other physical medical problems (e.g. left knee and hip pain).  

The Board accepts the fact that the Veteran experienced employment difficulties due to his PTSD.  However, in light of the objective evidence set forth above (including the April 2008 VA Form 21-4192 submitted by the Postal Service and the opinion of the examiner who conducted the January 2011 VA examination) and the Veteran's inconsistent reports concerning his employment history and the impact of his PTSD on such employment, the Board finds that his reports attributing his retirement solely to PTSD are not credible.  Hence, the weight of the evidence supports a conclusion that there has not been total occupational impairment due solely to the Veteran's psychiatric disability at any time during the claim period.
Moreover, the Veteran maintains a long term relationship with his wife (albeit a strained relationship) and has maintained good relationships with his family.  Similarly, his symptoms have not been manifested by gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, an inability to perform activities of daily living (such as maintenance of minimal personal hygiene), disorientation to time or place, or  memory loss for names of close relatives, own occupation, or own name.  Although he has reported occasional and fleeting suicidal ideation without any intent or plan, there is no evidence of persistent danger of hurting self or others.  Thus, a 100 percent rating is not warranted at any time during the claim period.

In sum, the Veteran was found to have moderate impairment in occupational and social functioning during the entire claim period prior to March 1, 2008, as evidenced by the GAFs and assessments of his level of disability.  As for the period since March 1, 2008, he has experienced impairment in most of the areas needed for a 70 percent rating under DC 9411.  Accordingly, the Board finds that a 50 percent rating (but not more), prior to March 1, 2008, and a 70 percent rating (but not more), since March 1, 2008, for PTSD is warranted.  See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.7, 4.130, DC 9411.  As the preponderance of the evidence is against even higher ratings, the benefit-of-the-doubt doctrine is not for application.  See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53.

B. Residuals of a Gunshot Wound to the Right Index Finger

The Veteran's residuals of a gunshot wound to the right index finger with osteoarthritis of the distal interphalangeal joint are currently rated under 38 C.F.R. § 4.71a, DC 5229 (2012) as limitation of motion of the index finger.  The diagnostic codes pertaining to range of motion of the fingers are found in 38 C.F.R. § 4.71a, DCs 5216 to 5230.  As applicable to this case, the preamble to 38 C.F.R. § 4.71a, DCs 5216-5230 provides in particular, that:

(1)  For the index finger (digit II), zero degrees of flexion represents the finger fully extended, making a straight line with the rest of the hand.  The position of function of the hand is with the wrist dorsiflexed 20 to 30 degrees, the metacarpophalangeal and proximal interphalangeal joints flexed to 30 degrees, and the thumb (digit I) abducted and rotated so that the thumb pad faces the finger pads.  Only joints in these positions are considered to be in favorable position.  For digits II through V, the metacarpophalangeal joint has a range of zero to 90 degrees of flexion, the proximal interphalangeal joint has a range of zero to 100 degrees of flexion, and the distal (terminal) interphalangeal joint has a range of zero to 70 or 80 degrees of flexion.  38 C.F.R. § 4.71a, Table "Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand."

(2)  When two or more digits of the same hand are affected by any combination of amputation, ankylosis, or limitation of motion that is not otherwise specified in the rating schedule, the evaluation level assigned will be that which best represents the overall disability (i.e., amputation, unfavorable or favorable ankylosis, or limitation of motion), assigning the higher level of evaluation when the level of disability is equally balanced between one level and the next higher level.  Id.

(3)  Evaluation of ankylosis of the index finger: (i)  If both the metacarpophalangeal and proximal interphalangeal joints of a digit are ankylosed, and either is in extension or full flexion, or there is rotation or angulations of a bone, evaluate as amputation without metacarpal resection, at proximal interphalangeal joint or proximal thereto; (ii)  If both the metacarpophalangeal and proximal interphalangeal joints of a digit are ankylosed, evaluate as unfavorable ankylosis, even if each joint is individually fixed in a favorable position; (iii)  If only the metacarpophalangeal or proximal interphalangeal joint is ankylosed, and there is a gap of more than two inches (5.1 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, evaluate as unfavorable ankylosis; (iv)  If only the metacarpophalangeal or proximal interphalangeal joint is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, evaluate as favorable ankylosis.  Id.

(5)  If there is limitation of motion of two or more digits, evaluate each digit separately and combine the evaluation.  Id.

Under DC 5225, a 10 percent rating is warranted for unfavorable or favorable ankylosis of the index finger.  38 C.F.R. § 4.71a, DC 5225.
A note to DC 5225 provides that consideration should also be given to whether a rating as amputation is warranted and whether an additional rating is warranted for resulting limitation of motion of other digits or interference with overall function of the hand.  Id.

Under DC 5229, a noncompensable rating is warranted for limitation of motion of the index finger with a gap of less than 1 inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees.  A 10 percent rating is warranted for limitation of motion of the index finger with a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees.  38 C.F.R. § 4.71a, DC 5229.  This is so for both the dominant and non-dominant hand.

Additionally, under 38 C.F.R. § 4.71a, DC 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved.  If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003.  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.  In the absence of limitation of motion, a 20 percent rating is merited for x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations.  A 10 percent rating is merited for x-ray evidence of involvement of two or more major joints or two or more minor joint groups.

For the purpose of rating disability from arthritis, the shoulder, elbow, wrist, hip, knee, and ankle are considered major joints.  Multiple involvements of the interphalangeal, metacarpal, and carpal joints of the upper extremities, the interphalangeal, metatarsal, and tarsal joints of the lower extremities, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae, are considered groups of minor joints, ratable on a parity with the major joints.  The lumbosacral articulation and both sacroiliac joints are considered to be a group of minor joints, ratable on disturbance of lumbar spine functions.  38 C.F.R. § 4.45(f).

In this case, VA treatment records dated from November 2004 to September 2005 include reports of loss of sensation, numbness, and proximal joint problems in the right index finger.  The finger would catch on the Veteran's clothing when he put his hand in his pocket.  Examinations revealed that there was a deformity of the right index finger, including a prominence/slight increase to the distal interphalangeal joint of the finger compared to the left.  X-rays of the right hand revealed advanced degenerative joint disease involving the distal interphalangeal joint of the index finger (possibly posttraumatic in etiology) and minor degenerative changes at the interphalangeal joint of the thumb and the distal interphalangeal joints of the other fingers.  The Veteran was diagnosed as having residuals of a gunshot wound to the right index finger.

During a February 2006 VA examination, the Veteran reported that he was right handed and that he experienced worsening right index finger pain, stiffness, and dysfunction.  He was not receiving any active treatment for his finger and had not received any injections, physical therapy, or further surgeries.  However, he did take medication (meloxicam) which provided minimal relief.  There were no significant flare ups of the index finger symptoms and they generally always remained the same.  He was able to perform most activities of daily living, but experienced difficulty with any repetitive gripping or grabbing with the right hand due to the index finger.

Examination revealed that there was an obvious deformity of the right index finger.  The distal interphalangeal joint was somewhat swollen and had a deformity of radial deviation of 30 degrees.  There was a scar over the radial aspect of the index finger, the proximal interphalangeal joint was slightly swollen, and the distal interphalangeal joint was slightly held in flexion at 15 degrees.  The remainder of the hand showed no significant abnormality of color, deformity, swelling, or atrophy.  Palpation of the right hand elicited no abnormality of temperature or atrophy.  However, there was some swelling and tenderness of the right index finger predominantly over the proximal interphalangeal and distal interphalangeal joints.  The Veteran was able to touch the tip of his right thumb to the index, long, ringer, and baby fingers without difficulty.  While making a hand grip, the right index finger was 1 cm. separated from the distal transverse palmar crease as compared to the left index finger which was able to touch the left distal palmar transverse crease of the palm.  The Veteran was able to pick up a pen and write his name rhythmically.

Ranges of motion of the right index finger were recorded as follows: extension and flexion of the metacarpophalangeal joint were to 70 degrees and 90 degrees, respectively; extension and flexion of the proximal interphalangeal joint were to 10 and 90 degrees, respectively; and extension and flexion of the distal interphalangeal joint were to zero and 60 degrees, respectively.  X-rays of the right hand revealed degenerative osteoarthritic changes of the distal interphalangeal joint of the index finger, which were possibly post-traumatic in etiology.  The Veteran was diagnosed as having post-traumatic arthritis and osteoarthritis of the distal interphalangeal joint of the right index finger and a right index finger scar.

In its March 2007 statement (VA Form 9), the Veteran's representative reported that the Veteran's right index finger was constantly numb and would catch on his pocket.  Although he had been able to write during the February 2006 VA examination, he had bypassed his index finger and used his middle finger to support the pencil because he was unable to pick up small objects with the thumb and index finger.

A report of a VA examination dated in March 2008 indicates that the Veteran reported that he did not have any right index finger pain, but that the right hand was weak and slightly impaired him in his job.  There was no history of any neoplasm.  Examination revealed that there was some decreased strength and dexterity of the right index finger, which slightly impaired his occupational functioning and activities of daily living.  There was evidence of degenerative joint disease of the distal interphalangeal joint of the right index finger.  The distal interphalangeal joint was ankylosed at a 5 degree flexion angle and at a 5 degree lateral angulation.  Range of motion of the metacarpophalangeal joint was from zero to 80 degrees, ranges of motion of the lateral and proximal interphalangeal joints were from zero to 90 degrees without pain, and range of motion of the distal interphalangeal joint was from zero to 20 degrees.  The hand was not very strong as a unit and grip was extremely weak, but there was no gap between the tip of the thumb and the tip of the fingers, between the tip of the fingers and the proximal transverse crease of the palm, or between the thumb pad and the fingers with the thumb attempting to oppose the fingers.  Strength in pushing, pulling, and twisting was very weak in the right index finger and dexterity and twisting or writing were impaired.  The flexion deformity of the index finger did not interfere with the functioning of the other fingers.  A diagnosis of residuals of a gunshot wound to the right index finger with post-traumatic degenerative joint disease of the distal interphalangeal joint was provided.

During a VA examination dated on January 20, 2011, the Veteran reported that he was right hand dominant and there was a deformity of the right index finger which caused some difficulty in writing and holding objects.  However, there was no pain, history of any neoplasm of the hand, overall decrease in hand strength, decrease in hand dexterity, flare ups of joint symptoms, or any other hand symptoms.

Examination of the right hand revealed that there was no objective evidence of pain with ranges of motion.  Extension of the metacarpophalangeal joint was normal (i.e. zero degrees-the finger aligned with the hand), but extension of the distal and proximal interphalangeal joints was limited by 5 degrees in both joints.  There was no gap between the index finger and the proximal transverse crease of the hand on maximal flexion of the finger.  Also, there was no objective evidence of pain or additional/new limitations of motion following repetitive motion.  There was no amputation of a digit or part of a digit and no ankylosis of one or more digits.  However, there was lateral deviation and some flexion deformity of the distal and proximal interphalangeal joints of the "left" index finger.  The angulation deformity was at 5 degrees.  There was no decreased strength for pushing, pulling, or twisting and no decreased dexterity for twisting, probing, writing, touching, or expression.  The Veteran was diagnosed as having residuals of a gunshot wound to the right index finger.  This disability did not have any significant effects on his occupation or activities of daily living.

A report of a VA neurologic examination, also dated in January 2011, reveals that bicep, tricep, brachioradialis, and finger jerk reflexes were all normal (2+) on the right and motor strength associated with elbow, wrist, and finger flexion, finger abduction, and thumb opposition was normal (5/5) on the right.  There were no tremors and no evidence of fasciculations and no joint function was affected by a nerve disorder.

1. Orthopedic Impairment

The above evidence reflects that there is a right index finger disability with pain, limitation of motion, stiffness, deformity, and dysfunction.  Such symptoms result in difficulties with gripping and grabbing.  During the February 2006 VA examination, extension of the metacarpophalangeal joint of the index finger was limited to 70 degrees (with normal extension being to zero degrees).  Thus, extension of the index finger was limited by more than 30 degrees.  Also, the March 2008 VA examination report indicates that the distal interphalangeal joint of the right index finger was ankylosed at a 5 degree flexion angle and at a 5 degree lateral angulation.  

Hence, under both DCs 5225 and 5229, a 10 percent rating for residuals of a gunshot wound to the right index finger is warranted for the entire claim period on the basis of limitation of motion and ankylosis of the index finger.  38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.7, 4.71a, DCs 5225, 5229.  As the Veteran is being granted the maximum schedular rating based on limitation of motion of the right index finger during the entire claim period, the regulations pertaining to functional impairment (38 C.F.R. §§ 4.40, 4.45, 4.59) are not for application during this period.  See Johnston, 10 Vet. App. at 85.

The Board notes that the January 2011 VA examination report does not appear to reflect the same level of disability as is evident in the evidence from the prior examinations.  Nevertheless, the Board finds that the 10 percent rating is still warranted for the more recent time period particularly since the Veteran's right index finger was considered to have ankylosis.  The Board does not find that aspect of the January 2011 VA examination report to be credible given that there has been no intervening surgery or other treatment that would seem to rectify the problem of ankylosis.  Accordingly, when resolving reasonable doubt in favor of the Veteran, the Board concludes that a 10 percent rating is warranted for orthopedic impairment for the entirety of the rating period on appeal.  See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3.

2. Neurologic Impairment

The Board has also considered whether a separate rating is warranted for neurologic impairment resulting from residuals of a gunshot wound to the right index finger with osteoarthritis of the distal interphalangeal joint.  Under the anti-pyramiding provision of 38 C.F.R. § 4.14 (2012), the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided.  The Court held, in Esteban v. Brown, 6 Vet. App. 259 (1994), that for purposes of determining whether the appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with, the symptomatology of the other conditions.

There is evidence that the residuals of a gunshot wound to the right index finger include a neurologic impairment.  The rating schedule provides guidance for rating neurologic disabilities.  With regard to rating neurologic disabilities, cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis.  38 C.F.R. § 4.123 (2012).  The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis.  Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis.  38 C.F.R. § 4.124 (2012).

The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured 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 the mild, or at most, the moderate degree.  38 C.F.R. § 4.124a (2012).

Paralysis of the median nerve of the major extremity (the Veteran is right hand dominant) is rated as follows: a 10 percent rating is warranted for mild incomplete paralysis; a 30 percent rating is warranted for moderate incomplete paralysis; a 50 percent rating is warranted for severe incomplete paralysis; and a 70 percent rating is warranted for complete paralysis, with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of the thenar eminence, the thumb in the place of the hand (ape hand), pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, inability to make a fist, and the index and middle finger remain extended, inability to flex the distal phalanx of the thumb, defective opposition and abduction of the thumb at the right angle to the palm, weakened flexion of the wrist, and pain with trophic disturbances.  38 C.F.R. § 4.124a, DC 8515.

In this case, VA treatment records dated from November 2004 to September 2005, the March 2007 statement by the Veteran's representative, and the March 2008 VA examination report include reports of loss of sensation, numbness, and decreased strength of the right index finger.  Examination of the index finger during the March 2008 VA examination revealed decreased strength of the finger.

The Veteran is competent to report neurologic symptoms associated with his service-connected residuals of a gunshot wound to the right index finger, such as numbness and weakness of the index finger.  See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337.  Furthermore, there is nothing to explicitly contradict his reports, they are not inconsistent with the evidence of record, and right index finger weakness was objectively confirmed during the March 2008 VA examination.  Therefore, his reports of right index finger neurologic symptoms are credible.

Given the evidence of at most mild disability during the claim period, and resolving reasonable doubt in the Veteran's favor, a separate 10 percent rating for mild incomplete paralysis of the right median nerve under DC 8515 is warranted.  See 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.21, 4.124a, DC 8515.  This separate rating does not constitute pyramiding under 38 C.F.R. § 4.14 because the neurologic impairment does not overlap with symptoms of the orthopedic impairment.  See Esteban, 6 Vet. App. at 259.  Additionally, the amputation rule is not violated, as the combined orthopedic and neurologic ratings do not exceed the rating for amputation of the index finger.  See 38 C.F.R. §§ 4.68, 4.71a, DC 5153 (2012).

Similar to the orthopedic impairment, the evidence from the January 2011 VA examination report does not tend to reflect the same level of disability as the prior examinations.  However, when resolving reasonable doubt in the Veteran's favor, the Board finds that he likely still experiences some mild neurologic impairment and, thus, the separate 10 percent rating is warranted for the entire rating period on appeal.  See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3.

3. Scars

The February 2006 VA examination report reveals that there was a scar over the radial aspect of the right index finger.  Thus, the Board has also considered whether a separate rating is warranted for the scar.  See Esteban, 6 Vet. App. at 259.  The rating criteria for scars were revised during the course of this appeal, effective October 23, 2008.  See 73 Fed. Reg. 54708 (Sept. 23, 2008).  These amendments, however, are only effective for claims filed on or after October 23, 2008, although a claimant may request consideration under the amended criteria.  In this case, the Veteran has not requested such consideration.  As his claim for an increased rating was received in October 2005, the 2008 amendments are not applicable in this appeal.

To warrant a compensable rating under the applicable criteria, a scar would need to involve the head, face or neck and have at least one character of disfigurement (DC 7800); be deep or cause limited motion and affect an area or areas exceeding at least 6 square inches (39 square centimeters) (DC 7801); be superficial and affect an area or areas of 144 square inches (929 square centimeters) or greater (DC 7802); be superficial and unstable (DC 7803); be superficial and painful on demonstration (DC 7804); or cause some limitation of the function of the part affected (DC 7805). 38 C.F.R. § 4.118, DCs 7800-7805 (2008).  A deep scar is one associated with underlying soft tissue damage.  38 C.F.R. § 4.118, DC 7801, Note (2) (2008).

In this case, the right index finger scar does not involve the head, face, or neck and there is no evidence that it is deep, causes any limitation of motion or function, affects an area exceeding at least 6 square inches, or is unstable or painful.  Hence, a separate compensable rating for a right index finger scar is not warranted at any time during the claim period.  Id.

In sum, the Board finds that the claim for a compensable rating for residuals of a gunshot wound to the right index finger with osteoarthritis of the distal interphalangeal joint to the extent described above.  That is, a 10 percent rating is warranted for orthopedic impairment and a separate 10 percent rating is warranted for neurologic impairment.  As the preponderance of the evidence is against even higher or separate ratings, the benefit-of-the-doubt doctrine is not further applicable.  See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53.

C. Residuals of a Gunshot Wound to the Left Thigh

The Veteran's residuals of a gunshot wound to the left thigh are currently rated under 38 C.F.R. § 4.73, DC 5315 as injuries to the Muscle Group XV, the mesial thigh group muscles, which includes the adductor longus, adductor brevis, adductor magnus, and gracilis.  The function of these muscles is adduction and flexion of the hip and flexion of the knee.  38 C.F.R. § 4.73, DC 5315 (2012).

Under DC 5315, a 30 percent rating is warranted for severe injuries to Muscle Group XV.  This is the maximum schedular rating for injuries to Muscle Group XV under DC 5315.  A higher rating for the service-connected residuals of a gunshot wound to the left thigh requires an associated injury to a muscle group other than Muscle Group XV or other associated impairments which may be rated as greater than 30 percent disabling under the appropriate diagnostic criteria.

Muscle injuries are evaluated in accordance with 38 C.F.R. § 4.56 (2012).  The pertinent provisions of 38 C.F.R. § 4.56, are as follows:  (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.

(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:  (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.

Under DC 5252, the following ratings apply to limitation of flexion of the thigh:  a 30 percent rating is warranted when it is limited to 20 degrees; and a 40 percent rating is warranted when it is limited to 10 degrees.  38 C.F.R. § 4.71a, DC 5252.  

For rating purposes, normal range of motion in a knee joint is from zero to 140 degrees.  38 C.F.R. § 4.71, Plate II (2012).

Limitation of knee extension is rated as follows: 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.

In this case, service treatment records indicate that in September 1967 the Veteran sustained a 30 caliber gunshot wound to the left quadriceps femorus.  There was no neurovascular damage to the left thigh and physical examination of the thigh was otherwise within normal limits.  An operative repair was done of the traumatic herniation through the iliotibial band of the hamstring and the vastus lateralis muscle.  The post-operative course was unremarkable with the exception of some cellulitis around the lower drain site on the lateral or exit wound which responded rapidly to antibiotic and hot soak treatment.  The Veteran was diagnosed as having a gunshot wound to the left thigh with associated traumatic herniation of the iliotibial bands.  The Veteran was hospitalized for 18 days and was subsequently returned to duty in October 1967 with L3 profile change until the wound obtained maximal strength.

A November 2004 VA treatment record and a December 2004 statement by the Veteran's representative (VA Form 21-4138) include reports of left thigh scars that were constantly numb and adhered, and which contributed to the Veteran's awkward balancing.  Also, the Veteran reported left hip discomfort (especially following periods of prolonged sitting) and loss of feeling in the left thigh.

Examination revealed that there was no edema, that left hip ranges of motion (including flexion, extension, adduction, and abduction) were all normal, that muscle strength of the left lower extremity was normal (5/5), and that x-rays were negative.  However, there was left knee crepitus.  The Veteran was diagnosed as having a gunshot wound to the left thigh.  The medical professional who conducted the examinations opined that it was likely ("likely as not") that some of the Veteran's left hip pain may have been related to the service-connected residuals of a gunshot wound to the left thigh.

The February 2006 VA examination report reflects that the Veteran reported worsening left thigh, hip, and knee pain, stiffness, weakness, and dysfunction.  He used medication to treat such symptoms (i.e. meloxicam), but had not received any other treatment for left thigh, knee, or hip problems during the previous year.  The medication he used provided slight relief.  Flare ups of symptoms (which resulted in increased pain, limitations, and dysfunctions) occurred 4 to 6 times a week, lasted 2 to 3 hours at a time, required him to lie down and rest, and were aggravated by periods of prolonged sitting (e.g. while driving a car or tractor).  He had not undergone any further left thigh surgeries following service and did not use any braces, canes, splints, or corrective shoes.  Also, there was no history of any inflammatory arthritis.  He was able to fulfill his activities of daily living (including bathing, dressing, cleaning, cooking, eating, and driving), however prolonged sitting for more than 30 minutes caused significant problems.  The duration of such problems was variable depending upon the weather.

Examination revealed that the Veteran walked with a limp, that there was a 19 centimeter scar over the anterior medial aspect of the left thigh (which was at most 1 centimeter wide), and that there was some tenderness to Muscle Group XV with attention to the adductor muscles (specifically the adductor longus and gracilis).  There was also moderate atrophy of these muscles and some weakness of muscle strength associated with resisted adduction (4/5 as compared to 5/5 on the right).  However, there were no significant adhesions and no obvious muscle herniation.

The left knee showed no significant abnormality of color, deformity, swelling, or atrophy, and palpation elicited no abnormality of temperature.  However, there was some slight crepitus and tenderness.  Knee ranges of motion were recorded as flexion to 135 degrees and extension to zero degrees, with no pain during the range of motion.  Also, the lateral and medial collateral ligaments and the anterior and posterior cruciate ligaments were normal and stable.  With respect to the left hip, there was some tenderness.  However, there was no significant abnormality of color, temperature, deformity, swelling, crepitus, or atrophy.  Ranges of motion of the hip were recorded as flexion to 110 degrees with pain beginning at 100 degrees, extension to 30 degrees, internal rotation to 15 degrees with pain beginning at 10 degrees, external rotation to 40 degrees, abduction to 45 degrees, and adduction to 20 degrees.  Following repetitive motions, there was no change in the ranges of motion of the knee or hip due to pain, weakness, fatigability, or incoordination.  X-rays of the left hip and knee dated in September 2003 and September 2005 had been normal.  Diagnoses of a moderately severe to severe injury to Muscle Group XV and left knee and hip strains were provided.

The Veteran's July 2006 notice of disagreement, his representative's March 2007 statement, and a July 2007 VA orthopedic surgery consultation note include reports of left thigh muscle atrophy, left buttock pain, and left knee and hip problems.  The buttock pain was aggravated by standing and walking and was alleviated with rest.  The Veteran did not take any medication for such symptoms.  There was also reportedly pain, weakness, and fatigue following repeated motions, as well as constant prominent limping.

An examination revealed that the Veteran walked with a limp favoring his left side and that he identified left posterior buttock pain.  There was no gross abnormality of color, deformity, swelling, or atrophy associated with the left hip and palpation of the hip elicited no abnormality of temperature, crepitus, swelling, or tenderness.  Left hip ranges of motion were recorded as flexion to 120 degrees, extension and internal rotation both to 30 degrees, and external rotation to 45 degrees.  There was no pain associated with any ranges of motion.  There was significant tenderness in the posterior buttock area and pain was reproduced with some left side bend and left rotation and extension.  X-rays of the left hip were normal.  The Veteran was diagnosed as having left buttock pain.

With respect to the March 2008 VA examination report, the Board notes that various abnormal reports and findings are noted as pertaining to the right thigh.  However, in light of the fact that the examination was conducted for purposes of assessing the severity of the Veteran's service-connected left thigh disability and given various other findings made during the examination, the reported thigh abnormalities during this examination presumably pertain to the left thigh.  During that examination, the Veteran reported progressively worsening thigh pain which was provoked by cold.  Flare ups of pain (4/5-10 in intensity) occurred twice a week, lasted for several hours at a time, and were alleviated by rest and warmth.  Such flare ups reportedly caused an additional 20 percent of functional limitation.  The Veteran did not take any analgesics for the pain and was reportedly told that the pain was due to massive scar tissue which pressed on some of the "nerve twigs."  Such pain had caused him to change jobs on several occasions, but he believed that he had adapted well to the pain.  He did not use any assistive devices.  The left thigh muscles that had been injured in service were the lateral and medial thigh muscles (i.e. group XV muscles).

Ranges of motion of the left hip were recorded as flexion to 125 degrees with no pain, extension to 30 degrees with no pain, abduction to 25 degrees with no pain, adduction to 45 degrees with no pain, external rotation to 40 degrees with no pain, and internal rotation to 30 degrees with no pain.  Flexion of the hip was reduced to 100 degrees following repetitive motion due to lack of endurance.  There was no tumor of the left thigh muscles.  The entrance scar was on the lateral aspect of the thigh, located in the middle of the thigh, vertical in orientation, approximately 6 inches long and 1 inch wide, deep and adherent to the underlying tissues, and slightly hyperpigmented compared to the surrounding areas of normal skin.  There were multiple elevations and depressions of the surface contour of the scar, but there were no ulcerations over it.  Also, there was no inflammation, edema, keloid formation, or induration over the scar, and the scar did not cause any limitation of motion or function.  The exit scar was located in the medial aspect of the left thigh, vertical in orientation, approximately 6 inches in length and 1 inch deep, and well healed.  There were multiple elevations and depressions of the surface contour of the scar, but there were no ulcerations over the scar and the scar did not cause any limitation of motion or function.

Moreover, examination revealed that there had been a loss of approximately 5 percent of the muscles located on the medial and lateral aspect of the left thigh.  These muscles belonged to Muscle Group XV.  However, there were no adhesions and no tendon, bone, joint, or nerve damage.  Muscle strength was weak in the left thigh in terms of flexion and extension of the hip level, but there was no muscle herniation or complete loss of muscle function.  The Veteran was diagnosed as having residuals of a gunshot wound to the left thigh.

A June 2009 VA primary care treatment note includes a report of left hip and knee pain which was 5/10 in intensity and was treated with medication (i.e. Tylenol).  The Veteran's functional status was fair and he was diagnosed as having knee and hip pain.

During VA examinations dated in January 2011, the Veteran reported that he experienced left thigh weakness, pain, and fatigability.  Also, there was a 3 year history of progressively worsening tingling and numbness in the area of his left thigh scar following periods of prolonged activity as well as left knee and hip symptoms during periods of activity.  Left knee and hip symptoms included pain and weakness and there were mild flare ups of such symptoms which occurred on a weekly basis, lasted for hours at a time, and were precipitated by increased activity.  However, there was no left knee or hip deformity, giving way, instability, stiffness, incoordination, decreased speed of joint motion, episodes of dislocation or subluxation, locking, effusions, symptoms of inflammation, or effects on limitation of motion.  There were no constitutional symptoms of or incapacitating episodes of arthritis, the Veteran was able to stand up to an hour, and he did not use any assistive devices.  Nevertheless, he was unable to walk more than a few yards.

The Veteran also reported that he would limp when tired, but that he was not receiving any treatment for the left lower extremity other than medications (e.g. Advil).  Additionally, there was no decreased coordination, weakness, uncertainty of movement, flare ups of muscle symptoms, hospitalization or surgery due to nerve problems, balance, coordination, or mobility problems, or history of any neoplasm, hospitalization or surgery for knee or hip problems, trauma to the left knee or hip, or peripheral nerve trauma.  The muscles injured by his in-service gunshot wound included the left vastus medialis and quadriceps muscles.  

Examinations revealed that the muscles of Muscle Group XV had been injured on the left, including the adductor longus, adductor brevis, adductor mangus, and gracilis muscles.  Group XV muscle strength was 4/5 and there was left medial muscle group muscle loss.  There were no injuries to any other left thigh muscle groups (including groups XIII and XIV).  There was intermuscular scarring on the medial side of the left thigh, but muscle function was normal in terms of comfort, endurance, and strength sufficient to perform activities of daily living.  There was also a scar on the medial side of the thigh which measured 15 inches in length and was adherent, but was not tender to touch.  Moreover, there were no residuals of nerve, tendon, or bone damage, no findings of muscle herniation, and there was no limitation of motion of a joint due to muscle damage or injury.  There were no left knee bumps consistent with Osgood-schlatter's disease, crepitation, masses, clicks or snaps, grinding, instability, or patellar or meniscus abnormalities.  Also, there were no left hip abnormalities.  Ranges of motion of the left hip were recorded as flexion to 125 degrees, extension to 30 degrees, and abduction to 45 degrees.  The Veteran was able to cross his left leg over the right and toe out greater than 15 degrees.  The ranges of left knee motion were reported as flexion to 140 degrees and extension to zero degrees.  There was no objective evidence of pain with active motion of the hip or knee or following repetitive motions and no additional limitations after three repetitions of ranges of motion.  Moreover, there was no evidence of any joint ankylosis.

A neurologic examination revealed that sensation to vibration, pain/pinprick, position sense, and light touch in the left medial thigh were all abnormal, muscle strength associated with left hip extension was somewhat impaired (4/5), and that the Veteran walked with a mild limp.  However, there was no dyesthesias, reflexes associated with knee and ankle jerks were normal (2+), plantar (Babinski) reflex was normal, and muscle strength associated with hip flexion, knee flexion and extension, ankle dorsiflexion and plantar flexion, and great toe extension were all normal (5/5).  Also, muscle tone was normal, there was no muscle atrophy, imbalance or tremor, or evidence of fasciculations, and there was no joint function affected by a nerve disorder.  Diagnoses of residuals of a gunshot wound to the left thigh, cutaneous neuropathy secondary to left thigh scar tissue, and left knee and hip strains were provided.

1. Muscle Injury

The above evidence reflects that the gunshot wound to the left thigh involved injuries to Muscle Group XV and there is no evidence that any other muscle group is involved.  The Veteran is already in receipt of the maximum schedular rating for injuries to Muscle Group XV under DC 5315 (i.e. a 30 percent rating), which is representative of a severe muscle injury.  See 38 C.F.R. § 4.73, DC 5315.  Thus, this is the maximum rating allowable and a higher rating is not warranted under any other diagnostic code pertaining to muscle injuries at any time during the claim period.

2. Orthopedic Impairment

The Veteran has been diagnosed as having left hip and knee strains and the evidence reflects that these disabilities may be residuals of the gunshot wound to the left thigh.  Separate ratings may not be awarded for limitation of left hip or knee motion and injuries to Muscle Group XV because the 30 percent rating for muscle injuries includes consideration of joint symptoms, such as limitation of motion.  Accordingly, the assignment of separate ratings for limitation of motion of the hip and knee and muscle injuries affecting the left hip and knee would amount to impermissible pyramiding.  38 C.F.R. §§ 4.14, 4.71a, DCs, 5251-5253, 5260-5261, 4.73, DC 5315.

However, although separate ratings are not possible for limitation of motion of the left hip and knee, a rating in excess of 30 percent for residuals of a gunshot wound to the left thigh is potentially warranted if the criteria for ratings in excess of 30 percent for left hip and/or knee impairment are met.

A rating higher than 30 percent for impairment of the left hip would require ankylosis of the hip, limitation of thigh flexion to 10 degrees, flail joint of the hip, or impairment of the femur.  See 38 C.F.R. § 4.71a, DCs 5250, 5252, 5254-5255.  Also, a rating higher than 30 percent for impairment of the left knee would require ankylosis of the knee, limitation of knee extension to at least 30 degrees, or impairment of the tibia and fibula.  See 38 C.F.R. § 4.71a, DCs 5256, 5261-5262.

The above evidence indicates that the Veteran has been able to perform left hip flexion to between 100 and 125 degrees and that there is objective evidence of occasional pain and lack of endurance.  There are also subjective reports of weakness, fatigue, and flare ups.  There was pain at 100 degrees of hip flexion during the February 2006 VA examination and there were no changes in the ranges of motion of the hip due to pain, weakness, fatigue, or incoordiation following repetitive use.  During the March 2008 VA examination, hip flexion was initially to 125 degrees, but was reduced to 100 degrees following repetitive use due to lack of endurance.  Also, it was noted that there was an additional 20 percent of functional impairment during flare ups.  Hence, left hip flexion was to between 80 and 100 degrees during flare ups.  Moreover, hip flexion was to 125 degrees with no pain during the January 2011 VA examination and there were no additional functional limitations following repetitive motion.

With respect to the left knee, the Veteran has been able to perform extension to zero degrees and there has been no objective evidence of pain associated with knee motion.  However, the Veteran has reported pain, weakness, and flare ups.  Nevertheless, there were no changes in the ranges of knee motion due to pain, weakness, fatigue, or incoordination following repetitive motion during the February 2006 VA examination and there were no additional functional limitations during the January 2011 VA examination.

Thus, even considering pain, lack of endurance, flare ups, and other functional factors, the evidence does not support assignment of a rating in excess of 30 percent for residuals of a gunshot wound to the left thigh on the basis of either limitation of left hip flexion or limitation of left knee extension because the Veteran's symptoms are not shown to be so disabling to actually or effectively result in limitation of hip flexion to 10 degrees or limitation of knee extension to 30 degrees-the requirements for ratings in excess of 30 percent under DCs 5252 and 5261.  

Furthermore, there is no evidence of any left hip or knee ankylosis (the absence of ankylosis was specifically noted during the January 2011 VA examination), flail joint of the hip, or impairment of the femur, tibia, or fibula.  Thus, a rating in excess of 30 percent is not warranted for residuals of a gunshot wound to the left thigh on the basis of hip or knee impairment at any time during the claim period.  See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.7, 4.71a, DCs 5250-5256, 5260-5262.

3. Neurologic Impairment

There is evidence that the residuals of a gunshot wound to the left thigh include a neurologic impairment.  The Veteran has reported numbness of his left thigh scars as well as generalized pain, numbness, tingling, and weakness, of the thigh.  Examinations have revealed decreased sensation and weakened muscle strength of the thigh (e.g. somewhat impaired (4/5) muscle strength associated with left hip flexion).  A diagnosis of cutaneous neuropathy secondary to left thigh scar tissue was provided.

Paralysis of the external cutaneous nerve of the thigh is rated as follows: a noncompensable rating is warranted for both mild or moderate paralysis and a 10 percent rating is warranted for severe to complete paralysis.  38 C.F.R. § 4.124a, DC 8529.

However, a muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions.  38 C.F.R. § 4.55 (2012).  It is unclear as to whether the functions performed by Muscle Group XV are entirely different than those performed by the external cutaneous nerve of the thigh.  Nevertheless, even if it is assumed that the muscle group and nerve perform entirely different functions, the symptoms of the Veteran's neurologic impairment most closely approximate the criteria for at most moderate paralysis under DC 8529 in light of his reports of numbness, tingling, and weakness, the findings of decreased sensation and only somewhat impaired (4/5) muscle strength associated with left hip flexion during the January 2011 VA examination, and the otherwise normal neurologic findings during that examination.  
Thus, since moderate paralysis under DC 8529 only warrants a noncompensable rating, a separate compensable rating for the neuropathy of the left lower extremity is not warranted at any time during the claim period.  See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.7, 4.123, 4.124, 4.124a, DC 8529.

4. Scars

There is also evidence of scars associated with the gunshot wound to the left thigh.  The February 2006 VA examination report reflects that there was a scar on the medial aspect of the thigh which was at most 19 centimeters long and 1 centimeter wide.  The report of a VA examination conducted in March 2008 includes a report of both an entrance and exit scar on the lateral and medial aspects of the thigh.  The entrance scar was deep, adherent, and at most 6 inches long and 1 inch wide.  The exit scar was well healed and was at most 6 inches long and 1 inch deep.  Additionally, the January 2011 VA examination report reveals that there was a single scar on the medial aspect of the thigh which was 15 inches in length and adherent, but not tender.

The Veteran's left thigh scars do not involve the head, face, or neck, they do not cause any limitation of motion or function, they do not involve an area or areas exceed 144 square inches, and they are not unstable or painful on examination .  Deep/adherent scars were noted during the March 2008 and January 2011 VA examinations and the two separate scars that are described in the March 2008 VA examination report involve an area exceeding 6 square inches.  These symptoms meet the criteria for a 10 percent rating under DC 7801.  However, the 30 percent rating for a severe muscle injury under DC 5315 contemplates adherent (deep) scars.  Thus, it would constitute prohibited pyramiding to provide ratings for scars and muscle injury and a separate 10 percent rating for left thigh scars is not warranted at any time during the claim period.  38 C.F.R. § 4.14; see Esteban, 6 Vet. App. at 261-62 (separate ratings are permitted where none of the symptomatology for any of the subject conditions is overlapping).

Moreover, a rating in excess of 30 percent for residuals of a gunshot wound to the left thigh is not warranted on the basis of the left thigh scars as they do approximate the criteria for ratings in excess of 30 percent under DCs 7800 or 7801 (i.e. they do not involve the head, face, or neck and do not involve an area or areas exceeding 144 square inches).

In sum, a rating in excess of 30 percent is not warranted at any point during the rating period on appeal for residuals of a gunshot wound to the left thigh.  As the preponderance of the evidence is against a higher rating, the benefit-of-the-doubt doctrine is not applicable.  See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53.

D. Extraschedular Rating

Pursuant to 38 C.F.R. § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards."  38 C.F.R. § 3.321(b)(1) (2012).  The question of an extraschedular rating is a component of a claim for an increased rating.  See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996).  The Board must specifically address whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record.  Barringer v. Peake, 22 Vet. App. 242, 244 (2008).

If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability with the established criteria found in the rating schedule for that disability.  Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009).

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.  In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms."  38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization").

There is no allegation or evidence of exceptional factors in this appeal with regard to the Veteran's service-connected PTSD, residuals of a gunshot wound to the right index finger, or residuals of a gunshot wound to the left thigh.  The symptoms of his PTSD include social isolation, a strained marriage, impaired thought processes, anger, a euthymic/dysthymic mood, depression, suicidal ideation, feelings of helplessness, nightmares, hypervigilance, a hyperstartle response, impaired sleep, irritability, an impaired affect, flashbacks, intrusive thoughts, impaired insight and judgment, and possible panic attacks.  The symptoms of his residuals of a gunshot wound to the right index finger include loss of sensation, numbness, deformity, arthritis of the distal interphalangeal joint, swelling, pain, stiffness, tenderness, limitation of index finger motion, a scar, and impaired strength and dexterity of the right hand.  The symptoms of his residuals of a gunshot wound to the left thigh include left buttock pain, a limp, tenderness, muscle atrophy, numbness, left knee and hip pain, left knee crepitus, limitation of motion of the left hip, muscle loss, intermuscular scarring, left thigh scars, and fatigue, stiffness, and weakness of the left thigh, hip, and knee.  All of these symptoms are contemplated by the appropriate diagnostic criteria as set forth above.  Thus, referral for consideration of an extraschedular evaluation for the disability addressed herein is not warranted.  38 C.F.R. § 3.321(b)(1).


ORDER

A 50 percent rating (but not more), prior to March 1, 2008, and a 70 percent rating (but not more), since March 1, 2008, for PTSD is granted, subject to the laws and regulations governing the payment of monetary awards.

A 10 percent rating (but not more) for residuals of a gunshot wound to the right index finger is granted.

A separate 10 percent rating (but note more) for peripheral neuropathy of the right upper extremity is granted.

A rating in excess of 30 percent for residuals of a gunshot wound to the left thigh is denied.


REMAND

The Court has held that in the case of a claim for a TDIU, the duty to assist requires that VA obtain an examination that includes an opinion on what effect a veteran's service-connected disability has on his ability to work.  Friscia v. Brown, 7 Vet. App. 294, 297 (1994).  Although there are several opinions of record pertaining to the individual impacts of some of the Veteran's service-connected disabilities on his employability, the evidence of record does not contain a specific single opinion as to whether all of the Veteran's service-connected disabilities, in combination, prevent him from securing and following employment for which his education and occupational experience would otherwise qualify him.  Thus, a remand is necessary to afford the Veteran a new VA examination to obtain the necessary opinion.  On remand, the AOJ will also be able to take into consideration the higher ratings award that were granted by the Board herein when readjudicating the TDIU claim.

Accordingly, this issue is REMANDED for the following actions:

1.  Schedule the Veteran for a VA examination with a VA medical professional with appropriate expertise to determine whether his service-connected disabilities prevent him from securing and following employment for which his education and occupational experience would otherwise qualify him.  All indicated tests and studies shall be conducted.

The claims folder, including this remand and any relevant records contained in the Virtual VA system, must be sent to the examiner for review.  

The examiner shall answer the following question:

Is it at least as likely as not (50 percent probability or more) that the Veteran's service-connected disabilities (residuals of a gunshot wound to the left thigh (including muscle, orthopedic, and neurologic impairments and scars), PTSD, tinnitus, residuals of a gunshot wound to the right index finger with osteoarthritis of the distal interphalangeal joint (including orthopedic and neurologic impairments and a scar), and bilateral hearing loss) would singularly, or in combination, and without regard to any nonservice-connected disabilities, be sufficient to preclude him from securing and following substantially gainful employment for which his education and occupational experience would otherwise qualify him?

In formulating the above opinion, the examiner shall comment on the significance, if any, of the Veteran's reports that his employment on the family farm is sheltered employment that is not gainful.   

The examiner must provide reasons for each opinion given.  The examiner is advised that the Veteran is competent to report his symptoms and history, and such statements by the Veteran must be specifically acknowledged and considered in formulating any opinions.  If the examiner rejects the Veteran's reports regarding symptoms, the examiner must provide a reason for doing so.  

If the examiner determines that he or she cannot provide an opinion without resorting to speculation, the examiner shall explain the inability to provide an opinion, identifying precisely what facts could not be determined.  In particular, he or she shall comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion.  Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). (The AOJ shall ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.)

2.  Review the examination report to ensure that it contains the information and opinion (i.e. a single opinion as to the combined impact of all the Veteran's service-connected disabilities on his employability) requested in this remand and is otherwise complete.

3.  If the benefit sought on appeal remains denied, issue a supplemental statement of the case.  After the Veteran is given opportunity to respond, the case shall be returned to the Board.

The Veteran has the right to submit additional evidence and argument on the matter 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 or by the Court 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).



______________________________________________
RYAN T. KESSEL
Acting Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs