Citation Nr: 1312834 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 08-36 882 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an increased initial rating greater than 10 percent for a left elbow disability rated under limitation of flexion prior to June 3, 2009. 2. Entitlement to an increased initial rating greater than 20 percent for a left elbow disability rated under limitation of flexion beginning June 3, 2009. 3. Entitlement to a separate compensable initial rating of 20 percent for a left elbow disability rated under limitation of extension. 4. Entitlement to a separate compensable initial rating of 20 percent for a left elbow disability rated under limitation of pronation. 5. Entitlement to an initial rating greater than 10 percent for ulnar neuropathy of the left arm. 6. Entitlement to an initial rating greater than 10 percent for scars of the face and scalp. 7. Entitlement to a separate compensable initial rating of 20 percent for four painful scars. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran, spouse ATTORNEY FOR THE BOARD H.J. Baucom, Associate Counsel INTRODUCTION The Veteran had active service from August 1953 to September 1957. These matters come before the Board of Veterans' Appeals (Board) on appeal from three rating decision of several Department of Veterans Affairs (VA) Regional Offices (ROs). In a November 2007 rating determination, the Cleveland, Ohio, RO granted service connection for a left elbow condition with a 10 percent rating, and granted service connection for scars of the face and scalp with a noncompensable rating. In March 2009 the Montgomery, Alabama, RO, issued a rating decision increasing the initial noncompensable rating for scars of the face and neck to 10 percent. As this is not a full grant of benefits the issue remains on appeal. In a January 2010 rating decision, the RO increased the left elbow disability to 20 percent effective June 3, 2009 and reclassified it as osteoarthritis of the left elbow. The rating decision also granted service connection for ulnar neuropathy of the left arm with a 10 percent initial rating effective July 25, 2009. In June 2012 a Board hearing was held at the RO before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In October 2012 the Board remanded the issues for further development which has been completed. The "virtual VA" file has been reviewed by the Board. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The RO is reminded to consider the amputation rule of 38 C.F.R. § 4.68 when combining the ratings for multiple disabilities associated with the left arm. FINDINGS OF FACT 1. During the entire time period on appeal the limitation of flexion of the left elbow has been manifested by the functional equivalent of 80 degrees. 2. During the entire time period on appeal the limitation of extension of the left elbow has been manifested by the functional equivalent of 75 degrees. 3. During the time period on appeal the left elbow has had limited pronation as manifested by the inability of the left hand to approach full pronation. 4. During the time period on appeal the left arm ulnar neuropathy is manifested by moderate incomplete paralysis. 5. The scars of the face and scalp are manifested by surface contour depressed on palpation. 6. There are four painful scars on the face and scalp. CONCLUSIONS OF LAW 1. The criteria for the assignment of a 20 percent initial rating, but no more, for a left elbow disability under limitation of flexion prior to June 3, 2009 have been met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.71a, Diagnostic Code 5206 (2012). 2. The criteria for the assignment of a 20 percent initial rating, but no more, for a left elbow disability under limitation of flexion beginning June 3, 2009 have been met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.71a, Diagnostic Code 5206 (2012). 3. The criteria for the assignment of a separate 20 percent initial rating, but no more, for a left elbow disability under limitation of extension have been met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.71a, Diagnostic Code 5207 (2012). 4. The criteria for the assignment of a separate 20 percent initial rating, but no more, for a left elbow disability under limitation of pronation have been met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.71a, Diagnostic Code 5213 (2012). 5. The criteria for the assignment of an initial 20 percent rating, but no more, for an ulnar neuropathy of the left arm have been met. 38 U.S.C.A. §§ 1155, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.71a, Diagnostic Code 8516 (2012). 6. The criteria for the assignment of an initial rating greater than 10 percent for scars of the face and scalp have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.118, Diagnostic Code 7800 (2012). 7. The criteria for the assignment of a separate initial rating of 20 percent for four painful scars, but not higher, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.118, Diagnostic Code 7804 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Ratings In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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 importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as "staged" ratings." Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The assignment of a particular diagnostic code is completely dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. The Schedule provides for consideration of additional functional impairment due to pain, weakness, fatigue, incoordination, and lack of endurance when assigning evaluations. 38 C.F.R. § 4.40, 4.45, 4.59; see DeLuca v. Brown, 8 Vet. App. 202 (1995). Left elbow disability At the October 2007 VA examination the Veteran reported that he fractured his left elbow in 1956 in service and it has become progressively more stiff and has lost more and more range of motion as time has passed. The Veteran reported joint symptoms of pain, stiffness, and weakness with no deformity, giving way, instability, or episodes of dislocation or subluxation. Upon physical examination the active flexion was 40 to 124 degrees, passive flexion was 40 to 130 degrees, active extension 124 to 40 degrees, and passive extension 130 to 40 degrees. Pronation was 0 to 60 degrees for active and passive. Supination was 0 to 45 degrees for active and 0 to 50 degrees passive. No pain was reported for any of the ranges of motion. X-ray diagnosed mild moderate osteoarthrosis. The Veteran reported no incapacitating episodes of arthritis. At a June 2009 joint examination the Veteran reported that his left elbow has gotten worse with problems bruising, decreased range of motion and weakness in the hand since the last VA examination in 2007. The Veteran reported symptoms of pain, stiffness, weakness, incoordination, decreased speed of joint motion and weekly moderate to severe flare ups lasting two days. The Veteran denied any incapacitating episodes of arthritis. Range of motion testing revealed flexion from 86 to 114 degrees, extension 86 to 86 degrees, pronation 40 to 70 degrees, and supination of 40 to 70 degrees. There was no objective evidence of pain with active motion. There was no joint ankylosis. X-ray revealed moderate degenerative joint disease of the humero-ulnar joint which has progressed since the previous study. The Veteran reported that his left elbow disability affects his usual daily activities. At a January 2013 VA examination the Veteran denied flare ups. Range of motion testing revealed flexion to 120 degrees with painful motion at 80 degrees, and extension to 80 degrees. Range of motion measurements were the same after repetitive testing. The examiner found the Veteran to have functional loss and/or functional impairment of the elbow and forearm due to less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement. The Veteran reported pain on palpation. Muscle strength was 4/5 for flexion and extension. The examiner found no ankylosis of the elbow. There was no flail joint, joint fracture and/or impairment of supination or pronation. X-ray studies document arthritis. The examiner noted that the Veteran's elbow/forearm condition would prevent employment of a physical but not sedentary nature; however the Veteran has reported that he is retired and has not claimed to be unemployable due to his service connected disability. TDIU is found not be found to be indicated to be raised based on this record. The Veteran's left arm disability is currently rated under Diagnostic Code (DC) 5205-5010. However DC 5205 is not the proper Diagnostic Code for rating purposes as there is no ankylosis of the elbow. The disability is more accurately rated under the DC 5003 for arthritis which is rated as limitation of motion of the joint. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). DCs 5206, 5207 and 5213 are for limitation of flexion, extension, and supination and pronation of the forearm. Separate ratings for each of the limitations of motions is permissible as the elbow, similar to the knee, is rated based upon limitations in planes of movement, where each limitation is a separate distinct disability and not considered to be the "same disability." 38 C.F.R. § 4.71a; See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); VAOPGCPREC 09-04. The issue regarding the elbow has not been directly addressed by the Courts. The Veteran's left elbow disability is rated as arthritis which is based upon limitation of motion of the affected joint. The Veteran testified that his left arm is his minor arm and it will be rated accordingly with only the rating percentages for the minor side identified. 38 C.F.R. § 4.69. DC 5206 provides ratings for limitation of flexion of minor forearm. Flexion limited to 110 degrees is noncompensable, flexion limited to 100 degrees is 10 percent, limited to 90 degrees is 20 percent, limited to 70 degrees is 20 percent, limited to 55 degrees is 30 percent, limited to 45 degrees is 40 percent. Flexion was limited to 114 degrees at the most prior to the January 2013 VA examination however at the January 2013 examination the examiner found the Veteran to have pain beginning at 80 degrees extension, and affirmatively noted that there was additional functional loss and impairment of the elbow and forearm due to less movement than normal, weakened movement, excess fatigability, incoordination and pain on movement. Such functional loss is considered in the impairment level. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). As such a 20 percent rating under DC 5206 for limitation of flexion of the minor forearm is warranted. A higher rating is not warranted as there is no evidence of flexion limited to 55 degrees or less. DC 5207 provides ratings for limitation of extension of the minor forearm. Extension limited to 45 degrees is noncompensable, limited to 60 degrees is 10 percent, limited to 75 degrees is 20 percent, limited to 90 degrees is 20 percent, limited to 100 degrees is 30 percent, and limited to 110 degrees is 40 percent. At the October 2007 VA examination passive and active extension was limited to 40 degrees, at the June 2009 examination extension was limited to 86 degrees, and at the January 2013 examination extension was limited to 80 degrees at the most. A separate 20 percent rating under DC 5207 for limitation of extension of the minor forearm is warranted. A higher rating is not warranted as there is no evidence of limitation of extension to 100 degrees or more. DC 5208 provides a 20 percent rating for a forearm with flexion limited to 100 degrees and extension to 45 degrees. A separate rating under DC 5208 would be pyramiding and is not permissible as flexion and extension are already rated under DC 5206 and 5207. DC 5209 provides ratings for other impairment of the elbow. However as there is no impairment of the flail joint; joint fracture, with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius, DC 5209 does not apply. As there is no impairment of the ulna or radius, DC 5210, 5211, and 5212 do not apply. DC 5213 provides ratings for impairment of supination and pronation. Loss of supination and pronation (bone fusion): The hand fixed in supination or hyperpronation is 30 percent; the hand fixed in full pronation is 20 percent; the hand fixed near the middle of the arc [40degrees] or moderate pronation is 20 percent. Limitation of pronation with motion lost beyond middle of arc [40degrees] is 20 percent; motion lost beyond last quarter of arc [60degrees], the hand does not approach full pronation [80degrees] is 20 percent; and limitation of supination to 30 degrees or less is 10 percent. As the Veteran's left hand does not approach full pronation a separate 20 percent rating under DC 5213 for limitation of pronation is warranted. A higher rating is not warranted as there is no evidence that the hand is fixed and there is no limitation of supination. Separate 20 percent initial ratings under DCs 5206, 5207 and 5213 are warranted for the left elbow disability for the entire time period. The Veteran has consistently reported that his left elbow disability was worse then the rating initially assigned and his contentions were reflected in later VA examinations. The Veteran is granted the benefit of the doubt, and the Board finds that his left arm disability symptomatology and rating level has been present since the initial rating. Staged ratings are not warranted as the next higher criteria under DCs 5206, 5207 and 5213, separately, have not been met. Again, the RO is reminded to consider the amputation rule of 38 C.F.R. § 4.68 when combining the ratings for multiple disabilities associated with the left arm. Left ulnar neuropathy The Board notes that the Veteran is separately service connected, and a 10 percent rating assigned, for left hand disability which was rated by analogy under DC 5003-8516 however the issue of an increased rating for the left hand disability is not on appeal at this time. Diagnostic Code 8516 provides ratings for paralysis of the ulnar nerve. Diagnostic Code 8516 provides that mild incomplete paralysis is rated 10 percent on the minor side; moderate incomplete paralysis is rated 20 percent on the minor side; and severe incomplete paralysis is rated 30 percent on the minor side. Complete paralysis of the ulnar nerve, the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers, cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened, is rated 50 percent on the minor side. Diagnostic Code 8616 provides a rating for neuritis of the ulnar nerve. Diagnostic Code 8716 provides a rating for neuralgia of the ulnar nerve. The term "incomplete paralysis" with this and other peripheral nerve injuries 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. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. At the July 2009 peripheral nerves exam the Veteran reported a history of left arm pain and impaired function beginning in 1990 which has gotten progressively worse. The examiner noted severe motor function limitation of left elbow extension due to flexion contracture. Sensory function found normal response to vibration, pain, light touch, with decrease in position sense. A physical examination revealed diffuse mild loss of bulk muscle of left upper and forearm. Electrophysiological findings from nerve conduction studies were compatible with mild left ulnar neuropathy only however the examiner diagnosed median and ulnar neuropathy. At a January 2013 VA examination the examiner diagnosed left ulnar neuropathy only. No other nerve condition or neuropathy was identified. The Veteran reported weakness and strength issues with some pain and sensation loss. He had nerve conduction testing which confirmed ulnar neuropathy. The Veteran reported symptoms of moderate pain, mild paresthesias and/or dysesthesias and mild numbness. Muscle atrophy over the hypothenar muscles was present with decreased sensation in the left hand or fingers. The examiner concluded that there was moderate incomplete paralysis of the ulnar nerve. The examiner also found that the periphery nerve condition would prevent employment of a physical but not sedentary nature. However, as discussed above, the Veteran has not reported that he is unemployable due to his neuropathy, nor there is any evidence to suggest any interference with employment, physical or sedentary, as the Veteran is currently retired. A higher 20 percent initial rating is warranted for left arm ulnar neuropathy based upon moderate incomplete paralysis of the ulnar nerve. A higher rating is not warranted as there is no evidence of severe incomplete paralysis or complete paralysis of the ulnar nerve, the "griffin claw" deformity at any time. The Veteran has consistently reported that his left arm ulnar neuropathy was worse then the rating initially assigned and his contentions are reflected in the later VA examination. The Veteran is granted the benefit of the doubt, and the Board finds that his left arm ulnar neuropathy symptomatology and rating level has been present since the initial rating. Again, the RO is reminded to consider the amputation rule of 38 C.F.R. § 4.68 when combining the ratings for multiple disabilities associated with the left arm. Scars of the face and scalp The Veteran's service-connected scars of the face and scalp are currently rated as 10 percent disabling under DC 7800. Diagnostic Code 7800 provides that a skin disorder with one characteristic of disfigurement of the head, face, or neck is rated 10 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, is rated 30 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement, is rated 50 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement, is rated 80 percent disabling. Note (1) to Diagnostic Code 7800 provides that the 8 characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, are: Scar 5 or more inches (13 or more cm.) in length. Scar at least one-quarter inch (0.6 cm.) wide at widest part. Surface contour of scar elevated or depressed on palpation. Scar adherent to underlying tissue. Skin hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). Underlying soft tissues missing in an area exceeding six square inches (39 sq. cm.). Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Note (2) to Diagnostic Code 7800 provides that tissue loss of the auricle is to be rated under Diagnostic Code 6207 (loss of auricle), and anatomical loss of the eye under Diagnostic Code 6061 (anatomical loss of both eyes) or Diagnostic Code 6063 (anatomical loss of one eye), as appropriate. Note (3) provides that unretouched color photographs are to be taken into consideration when rating under these criteria. Note (4): Separately evaluate disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply § 4.25 to combine the evaluation(s) with the evaluation assigned under this diagnostic code.). For example, a 10 percent evaluation may be assigned for a superficial scar which is unstable or painful. 38 C.F.R. § 4.118, Code 7804. Note (5): The characteristic(s) of disfigurement may be caused by one scar or by multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. 38 C.F.R. § 4.118. The criteria for evaluation of scars was amended effective October 23, 2008, during the pendency of this appeal. While the criteria under DC 7800 were not changed, the criteria under DC 7803 and 7804 did change. Under the old criteria superficial unstable scars warranted 10 percent under DC 7803, with a separate 10 percent for superficial painful scars under DC 7804. 38 C.F.R. § 4.118 Diagnostic Codes 7803, 7804 (prior to October 23, 2008). The new criteria combined the two old rating codes into the new DC 7804 as follows. Diagnostic Code 7804 provides that one or two scars that are unstable or painful are rated 10 percent disabling. Three or more scars that are unstable or painful are rated 20 percent disabling. Five or more scars that are unstable or painful are 30 percent disabling. Note (1) to Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under diagnostic codes 7800, 7891, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118. (emphasis added) At a November 2007 scars examination the Veteran reported a history of motor vehicle accident in service resulting in several facial abrasions and laceration to the lower lip. Upon physical examination the examiner noted the first scar to be a mid lower lip scar 14mm wide, 26 mm length with no tenderness on palpation, adherence to underlying tissue, limitation of motion or loss of function, underlying soft tissue damage, skin ulceration or breakdown over scar, underlying tissue loss, depression of scar, disfigurement of head, face or neck; or induration or inflexibility. The scar was elevated with the same texture and color as normal skin. The second scar was on the anterior aspect of right mandibular ramus and was 3 mm wide, 37 mm long, with no tenderness on palpation, adherence to underlying tissue, limitation of motion or loss of function, underlying soft tissue damage, skin ulceration or breakdown over scar. The third scar was on the inferior aspect of right anterior ramus mandible and 8 mm in wide, 5mm in length, with no tenderness on palpation, adherence to underlying tissue, limitation of motion or loss of function, underlying soft tissue damage, skin ulceration or breakdown over scar, underlying tissue loss, depression of scar, disfigurement of head, face or neck; or induration or inflexibility. Scar was elevated, same color as normal skin but texture was abnormal for the entire scar, 8mm x 5mm. At a January 2013 VA examination four scars were noted, on over the chin, right lip and two over left eyebrow. The examiner noted that the Veteran had a large scar between his eyebrows but it was not from service but from a cancer removed within the past two years. The examiner reported that all four scars were painful but none were unstable. The first scar was horizontal over the chin and measured 6.5 by .1cm. The second scar was vertical over the right lip and measured 1cm by .1cm. The third scar was over left eyebrow vertical in the hair and 1 by .1cm. The fourth scar was also over left eyebrow vertical in the hair and measured 1.5 by .1cm. All four scars had surface contour depressed on palpation and were hyperpigmented. Although the examiner noted "yes" to gross distortion or asymmetry of facial features or visible palpable tissue loss of the chin, there was no description provided. No limitation of function was noted. The January 2013 VA examination found four scars with surface contour depression on palpation. Therefore an initial rating higher than 10 percent under DC 7800 is not warranted as there is only one characteristic of disfigurement. An additional separate 20 percent rating for the four painful, but not unstable, scars is warranted under the new DC 7804. The new criteria is more favorable as it assigns a 20 percent rating for three or four painful (in this case) or unstable scars, and the old criteria would assign only a 10 percent rating for painful scars. A higher rating than 20 percent is clearly not warranted. The service and post-service medical records would only provide highly probative evidence against such a finding. Extraschedular The Board has considered Mittleider v. West, 11 Vet. App. 181 (1998), holding that the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition. The Veteran's service connected symptoms have been considered in connection with his claims for increased ratings for left elbow disability, ulnar neuropathy and scars. Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, a determination must be made as to whether the schedular criteria reasonably describe a veteran's disability level and symptomatology. Id. At 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, referral for extraschedular consideration is not required and the analysis stops. Id. If the schedular rating criteria do not reasonably describe a veteran's level of disability and symptomatology, a determination must be made as to whether an exceptional disability picture includes other related factors, such as marked interference with employment and frequent periods of hospitalization. Id. At 116. If an exceptional disability picture including such factors as marked interference with employment and frequent periods of hospitalization exists, the matter must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Veteran's complaints associated with his left elbow disability include limited of extension of the forearm, limited flexion of the forearm, and limited pronation. The schedular rating criteria specifically contemplate ratings based on limitation of motion, including as due to DeLuca factors of pain, weakness, excess fatigability, incoordination, pain on movement, swelling, or atrophy and consideration of additional functional impairment due to pain under Mitchell. The complaints or findings associated with the service- connected ulnar neuropathy include moderate incomplete paralysis of the ulnar nerve, pain and sensation loss. Findings associated with the service connected scars include four painful scars with surface contour depressed on palpation. The Board finds that the schedular rating criteria in this case is adequate to rate the Veteran's left elbow disabilities of limitation of flexion, extension and pronation, ulnar neuropathy of the left arm, and scars of the face and scalp. In the absence of evidence that the schedular rating criteria is inadequate to rate the Veteran's disability, the Board is not required to remand this case to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See also Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Notice and Assistance VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). An August 2007 letter satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Although not required as to the issues of higher initial ratings, the notification letter did notify the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records and VA medical treatment records have been obtained; he did not identify any additional private or VA treatment records pertinent to the appeal. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration based on disability. 38 C.F.R. § 3.159 (c) (2). VA examinations were conducted in October 2007, June 2009, July 2009 and January 2013; the Veteran has not argued, and the record does not reflect, that these examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The examinations were adequate as the examiners evaluated the Veteran's current disability level and provided findings to allow for proper application of the rating criteria. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). ORDER An increased initial rating of 20 percent for a left elbow disability rated under limitation of flexion prior to June 3, 2009 is granted subject to laws and regulations governing the payment of monetary benefits. An increased initial rating greater than 20 percent for a left elbow disability rated under limitation of flexion beginning June 3, 2009 is denied. A separate compensable initial rating of 20 percent for a left elbow disability rated under limitation of extension is granted subject to laws and regulations governing the payment of monetary benefits. A separate compensable initial rating of 20 percent for a left elbow disability rated under limitation of pronation is granted subject to laws and regulations governing the payment of monetary benefits. An initial rating greater than 10 percent for ulnar neuropathy of the left arm is granted subject to laws and regulations governing the payment of monetary benefits. A separate compensable initial rating of 20 percent for four painful scars is granted subject to laws and regulations governing the payment of monetary benefits. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs