Citation Nr: 1313192 Decision Date: 04/19/13 Archive Date: 05/02/13 DOCKET NO. 07-06 391A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a rating in excess of 30 percent for a left great toe disability (to include entitlement to extension of the temporary total (convalescence) rating beyond February 28, 2007). 2. Entitlement to a rating in excess of 10 percent for a left femur donor site scar. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from August 1987 to July 1988. These matters are before the Board of Veterans' Appeals (Board) on appeal from June 2004 and November 2005 rating decisions of the Montgomery, Alabama Department of Veterans Affairs (VA) Regional Office (RO) that, respectively, granted a 10 percent rating for left femur donor site scar effective March 31, 1997 and continued a 20 percent rating for left great toe disability (hallux valgus of the left great toe, status post bunionectomy and osteotomy with degenerative joint disease (DJD) and elevated metatarsal).. An interim (November 2007) decision review officer (DRO) decision increased the rating for the left great toe disability to 30 percent, effective March 10, 2005. In March 2010 the Board remanded the case for a Travel Board hearing. In October 2011, a hearing was held before the undersigned; a transcript of the hearing is associated with the claims file. At the hearing the issues were acknowledged to be as stated on the preceding page. Also at the hearing the Veteran submitted additional evidence with a waiver of RO initial consideration. In April 2012 the case was remanded for additional development. The April 2012 Board remand referred to the RO the matter of entitlement to a temporary total (convalescence) rating following a surgical procedure in March 2011. A March 2012 rating decision (while the case was at the Board, and unbeknownst to the Board) granted such benefit. The Veteran has not filed a notice of disagreement with that determination, and that matter is not before the Board. [The Veteran has a service connected left foot scar which is separately rated 10 percent; the rating for that scar is not at issue herein.] FINDINGS OF FACT 1. At no time during the period under consideration (excluding from October 2, 2006 through February 28, 2007 and from March 9, 2011 through April 30, 2011, during which times a total rating was assigned) is the Veteran's left great toe disability shown to have been manifested by more than severe symptoms; loss of use of the left foot is not shown. 2. Convalescence following a surgical procedure for the Veteran's service-connected left great toe disability in October 2006 was not required beyond February 28 , 2007. 3. The Veteran's left femur donor site scar is not shown to be unstable, or painful, or to cause limitation of motion or any other function; while it may reasonably be characterized as deep, it does not exceed 12 square inches. CONCLUSIONS OF LAW 1. A rating in excess of 30 percent for a left great toe disability is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.30, 4.71a, Diagnostic Codes (Codes) 5280, 5283, 5284, 5165, 5167 (2012). 2. Extension of a temporary total (convalescence) rating beyond February 28, 2007 is not warranted. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.30 (2012). 3. A rating in excess of 10 percent for a left femur donor site scar is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.118, Codes 7801, 7802, 7803, 7804, 7805 (as in effect for claims filed prior to October 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claims. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran has been advised of VA's duties to notify and assist in the development of his claims. Regarding the increased rating claim for his left great toe disability, the Veteran received VCAA notice in April 2005, prior to the initial RO adjudication of the claim in November 2005. Regarding the claim for an increased rating for s left femur donor site scar, the Veteran received post-adjudication VCAA notice by a September 2008 letter (addressing both matters). The April 2005 and September 2008 letters provided essential notice prior to the readjudication of his claims. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Specifically, these letters provided notice of what was needed to substantiate an increased rating claim and explained the evidence VA was responsible for providing and the evidence he was responsible for providing. Various supplemental statements of the case (SSOCs), most recently in January 2013, readjudicated the matters after the Veteran and his representative responded and further development was completed. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (VCAA timing defect may be cured by the issuance of fully compliant notification followed by readjudication of the claim); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (discussing the rule of prejudicial error). The Veteran's pertinent private and VA treatment records have been secured. VA treatment records from April 2009 to April 2012 were obtained and associated with the Veteran's Virtual VA record (VA electronic data storage system). At the October 2011 Travel Board hearing before the undersigned, the Veteran was advised of what is still needed to substantiate his claims; his testimony reflects that he is aware of what remains necessary. The RO arranged for VA examinations in June 2007, November 2007, September 2008, and April 2012. The Board notes that the reports from these VA examinations contain sufficient clinical findings and informed discussion of the pertinent history and features of the disabilities on appeal to provide probative medical evidence adequate for rating purposes. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide these matters, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background and Analysis Initially, Board notes that it has reviewed all of the evidence of record, to include in the Veteran's claims file and in Virtual VA, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. In general, disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity caused by a given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath, 1 Vet. App. at 594. However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis herein is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.10, 4.40, 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disease. 38 C.F.R. § 4.45. Left Great Toe Disability The Veteran asserts that the symptoms and impairment from his left great toe disability are not fully reflected by the 30 percent schedular rating assigned. There is a specific diagnostic code for unilateral hallux valgus. Under 38 C.F.R. § 4.71a, Code 5280, if such disability is postoperative with resection of metatarsal head, or severe (if equivalent to amputation of great toe, a (maximum) 10 percent rating is to be assigned. The RO has found that Code 5280 does not reflect the full extent of the disability, and the left great toe disability is rated under 38 C.F.R. § 4.71a, Codes 5283 (for malunion or nonunion of tarsal/metatarsal bones) and 5284 (for other foot injuries). Code 5283 provides for a (maximum) 30 percent rating for severe disability. Code 5284 provides for a (maximum) 30 percent rating for severe disability. 38 C.F.R. §4.71a. Under Code 5167, loss of use of a foot warrants a 40 percent rating. Amputation of a leg at a lower level (permitting prosthesis) warrants a 40 percent rating under Code 5165. 38 C.F.R. § 4.71a. Loss of use of a foot will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function and whether acts such as balance and propulsion could be accomplished equally well by an amputation stump with prosthesis. 38 C.F.R. § 3.350(a)(2). The Veteran filed an increased rating claim for his left great toe hallux valgus, disability in March 2005. In November 2005, the RO received notification that he had failed to report for a VA examination scheduled to evaluate the disability. A May 2006 VA treatment record notes the Veteran was seen with a history of a toe injury sustained in 1998 in a parachute jump. He had a history of a total of four surgeries for the disability. On physical examination the left foot had a hypertrophic nodule along the surgical scar nodule 1st metatarsal. The assessment was foot pain. May 2006 X-rays of the left foot revealed two arthrodesis screws traversing the great toe metatarsophalangeal (MTP) joint. One of the screws extended beyond the proximal phalanx cortex into the adjacent soft tissues laterally. There was no evidence of hardware loosening. A June 2006 VA podiatry clinic report notes the Veteran complained of left foot pain. On examination he had limited dorsiflexion of the hallux at the metatarsophalangeal joint (MPJ) and a bony prominence at the met cuneiform joint. The assessment was fusion of the first MPJ causing pain, and bony exostosis causing pain. Surgical intervention was suggested. June 2006 X-rays of the left foot showed two arthrodesis screws traversing the great toe MTP joint. There was no acute fracture or dislocation. There were mild pes planus and mild degenerative changes in the mid foot and talocalcaneal joint. Other images of the left foot taken the same month shows no evidence of loosening of the great toe MTP arthrodesis hardware. The MTP joint itself was largely ankylosed with only minimal joint space lucency seen peripherally. The remainder of the forefoot was unremarkable. The impression was stable postoperative appearance of the great toe. In October 2006 the Veteran underwent a procedure to remove retained hardware from his left foot. December 2006 X-rays of the left foot show there were no fractures or dislocation. The Veteran was status post fusion at the 1st MTP joint. Hypertrophic changes were noted at the 1st tarsometatarsal joint. No periosteal reaction or lytic destruction was noted. Joint spaces were well maintained and there was no radiopaque foreign body. The impression was no acute bony injury. Status post fusion at 1st MTP joint with degenerative changes at first tarsometatarsal joint. A January 2007 podiatry consult report notes the Veteran's complaints of left big toe pain since 1996 when he had fusion of the 1st MPJ due to traumatic arthritis/fracture. He described the pain as stabbing/aching, rated 8/10. The pain is aggravated by weight-bearing and alleviated by rest. On examination muscle strength was +5/5 for all lower groups tested. Range of motion of the left hallux was fixed at MPJ. Ranges of motion for all lower extremity joints were fluent, pain-free, and without crepitation. There was a bony exostosis at the dorsum of the left 1st met-cuneiform joint. The assessment was status post fusion left 1st MPJ and hardware removal, and degenerative joint disease of the left 1st tarsomet joint. On June 2007 podiatry clinic follow-up for left foot pain, the Veteran reported there was no improvement in pain, but indicated that he had not yet received his prescribed orthotics. He denied any other pedal complaints. On objective examination, he ambulated in extra depth shoes and socks. There was no motion at the left 1st metatarsophalangeal joint (MTPJ). There was a palpable bump noted at the 1st met-cuneiform left. The assessment was left 1st MTPJ fusion, exostosis 1st met-cuneiform joint, and degenerative joint disease of the left foot. On June 2007 VA examination, it was noted that the pain at the base of the Veteran's left great toe kept increasing until 1996 when he had it evaluated by VA. A MTP and tarsometatarsal (TMT) fusion was completed with no postoperative complications; it was repeated (by VA) in 1997. The procedure was debridement of nonunion with open reduction and internal fixation of the left great toe, left distal femoral bone grafting and Akin interphalangeal ostomy of the proximal metatarsal. Two 40 mm screws were placed in the tarsometatarsal joint. Postoperatively there were no complications. The Veteran was sore over the surgical site only. He reported that in October 2006 he was seen by VA's orthopedic department because he redeveloped pain of a 3-4/10 level, and VA attempted to remove the screws in his toe and one of the screws broke as it was being extracted; there was no further attempt to remove the remaining part of the screw. He stated that he still has pain in the foot most of the time that is 3/(on a scale of 10), but with cold weather or prolonged walking the pain would increase to a 6/10. He stated that in January 2007 the pain had increased to 8/10. Surgical options were discussed, but it was felt that an attempt to remove the remaining part of the screw in the left great toe could cause more damage than help. He was given orthopedic gel soft inserts and was to be followed in podiatry on a six-month basis. He stated that his condition does not interfere with normal daily activity. However, he could not engage in stressful or running sport activities. He had not worked in the past year so it did not interfere with work activities. On physical examination, the Veteran was able to walk from the waiting room to the examining room with a normal gait for the rest of the way to the examining room. He stated he was having 3/10 pain in the left foot at the time of the examination. The left foot showed left great toe fixed with no range of motion present. There was an old surgical scar 6 cm long and 1 cm wide. There was mild tenderness with palpation of the scar which was superficial, the scar was moveable. Some keratotic changes were present in the midline of the scar. All the other toes of the left foot had full range of motion with no deformities noted. Sensation of all left foot toes was normal using cotton swab as testing device. On September 2008 VA examination, the Veteran reported increasing pain and a "knot" in his left foot from the retained pin from previous surgery that was getting bigger. He stated that there was more swelling especially after prolonged walking, along with pain, stiffness, heat, and sometimes redness. He stated that he is able to only walk maybe a block at a time before he has to rest. He described the pain as continuous and achy, increased by touching at the surgical site. The pain is usually decreased by elevating [the leg] and taking pain medications/sleeping pills at night. He took Percocet and Motrin for pain, and used a cane for stability. He did not work currently because of his foot problem but did go to school for computer networking. He stated that his disability does not interfere with normal daily activity. He stated that he did not engage in stressful or running sport activities. He had not worked in the past year so it did not interfere with work activities. On physical examination his stance and gait were erect and steady, he had a limp and had to use a cane. There was no erythema, swelling, inflammation, or ecchymosis of the soft tissue of the left foot. There was a widened 6 cm scar which was nontender without any inflammation, swelling, erythema, hypertrophy, or keloid formation on the lateral aspect of the MTP joint area. There was tenderness at the 1st metatarsal-phalangeal joint, which was immobile, but he was able to move the toes in flexion and extension at the interphalangeal joint. The initial assessment was status post left 1st metatarsal and metatarso-phalangeal joint surgery (bunionectomy and osteotomy) with residual retained pin with constant pain at the surgical site and surrounding soft tissue of the foot; and 1st metatarsal joint immobility. The final assessment was hallux valgus deformity of the left MTP joint - status post left bunionectomy and osteotomy with resultant nonunion and subsequent fusion and immobility of the 1st metatarsal-phalangeal joint, retained pin (not mentioned in 2006 X-ray report, but film reviewed by examiner) and degenerative changes with constant worse pain from last year, and instability, resulting in an abnormal gait. October 2008 X-rays showed the Veteran was post fusion of the left 1st MTP joint. There was a single screw identified. There was solid bony bridging across the joint space. There was mild, patch sclerosis within the left first metatarsal bone proximally, in the metadiaphyseal region, of uncertain clinical significance. There was no evidence of bony destruction or aggressive periosteal reaction. There was a dorsal osteophyte noted in the left foot on the lateral view, at the tarsometatarsal junction. The impression was post fusion of the left 1st MTP joint, and mild sclerosis within the left 1st metatarsal bone proximally, of uncertain clinical significance. On April 2009 podiatry outpatient note, the Veteran complained of left foot pain. He rated his left foot pain as 9/10 and stated he had taken Percocet and Ibuprofen for it in the past. He stated that the pain had flared recently as he had to walk a lot more. He admitted to having orthotics and extra depth shoes, which helped relieve the foot pain, but he did not have them at that time. Objective examination revealed muscle strength +5/5 all pedal groups, but guarding was evident for the left foot. The left foot was exquisitely tender to palpation with pain extending from just distal to the 1st MTP joint to proximal to the level of the 1st metatarsal/cuneiform joint. There was limited range of motion of the 1st MTP joint left foot; range of motion of medial column of the foot was not assessed due to guarding. There was palpable exostosis of the medial cuneiform, left foot. There were no masses, and no effusions bilaterally. X-rays of the left foot were remarkable for joint space narrowing of the 1st metatarsal/cuneiform joint and dorsal exostosis. The assessments were exostosis, pain in limb, and osteoarthritis. July 2011 X-rays of the left foot revealed the Veteran had undergone prior surgery with a threaded rod traversing the 1st metatarsophalangeal joint, which appeared to have been recontoured medially. The impression was that there was no change in the postoperative appearance of the left foot. At the October 2011 hearing The Veteran testified that he now has to walk with a cane. He stated that he is unable work in his previous employment; he was an automobile diesel mechanic, and now cannot carry the auto diesel wheels. He stated that he has had six surgeries on the left foot. He related that he has a retained fixation screw in his left because the head of it broke, they could not get it out. He noted that it is painful because it is rubbing against the nerves. On a scale of one to ten, he stated that his pain is a 10 every day. On April 2012 VA examination, the Veteran reported that since he had an additional surgery of the left great toe in March 2011 for painful exostosis of the 1st MTP cuneiform joint. The pain is constant and worse with weightbearing. It was noted that the Veteran had severe symptoms of the left foot due to his hallux valgus disorder. He did not have acquired claw foot (pes cavus). There was no malunion or non-union of tarsal or metatarsal bones. He used a cane. There was no functional impairment of the left foot such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The diagnosis was left foot great toe surgery with residuals. Regarding whether convalescence beyond March 1, 2007 was required, the evidence shows that the Veteran underwent surgery of the left great toe in October 2006 for hardware removal due to increasing pain. A second screw could not be removed. In November 2006 he moved and started receiving care at a local VA medical center. He was seen in January 2007. He reported that he performed physical therapy at home for seven to eight months post-surgery, but that was not confirmed in progress notes. As to whether convalescence beyond March 1, 2007was required, the examiner noted that it did not appear so based on review of medical records. Orthotics and new shoes were prescribed. Applying the above-outlined rating criteria to the facts of the case, the Board notes that because the Veteran's left great toe/foot disability is now rated at the maximum (30 percent) rating afforded under Codes 5283, 5284 the analysis must proceed to a determination under any alternate criteria that provide for a rating in excess of 30 percent. Essentially, such criteria are those in Code 5167 (for loss of use of the foot) and those in Code 5165 (for amputation of a leg at a lower level permitting use of a prosthesis. The preponderance of the evidence is against a finding that the Veteran has disability analogous to amputation or loss of use of his left foot. Examinations and treatment records have consistently shown that while the left foot becomes painful with use, the Veteran is able to use foot, albeit with limited motion. On September 2008 VA examination, he stated that he is able to walk maybe a block at a time before he has to rest. He reported that while he uses a cane for stability; the foot disability does not interfere with normal daily activity. At his April 2009 podiatry outpatient visit, he stated that the pain had flared recently as he had to walk a lot more. Orthotics and extra depth shoes helped relieve the foot pain. At the October 2011 hearing he testified that he walks with a cane; there is no report of inability to use the left foot. The April 2012 VA examiner specifically found that the Veteran's left foot does not have functional impairment, such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The Board finds that medical opinion to be probative and persuasive evidence in the matter; it is consistent with the Veteran's self-reports. Left Femur Donor Site Scar The Veteran's left distal femur donor site scar is currently rated 10 percent by analogy to Code 7804 . The criteria for rating skin disabilities were revised, effective October 23, 2008 (during the pendency of this claim/appeal). 73 Fed. Reg. 54,708 (Sept. 23, 2008). The announcement of the final regulation specifically states that the new criteria apply "to all applications for benefits received by VA on or after October 23, 2008" and that a Veteran rated under the skin criteria in effect prior to that date may request review under the clarified criteria. As neither the Veteran nor his representative has requested such review, and his claim was received prior to October 23, 2008, it is not necessary to consider the revised criteria. Under the pre-October 23, 2008 criteria, scars, other than those on the head, face, or neck, are rated under 38 C.F.R. § 4.118, Codes 7801-7805. A 10 percent rating is warranted for a scar (not on the head, face, or neck) when it is: a deep scar (one associated with underlying tissue damage) or one that causes limited motion, and involves an area or areas exceeding 6 square inches (39 sq. cm.) or greater; a 20 percent rating is warranted when it involves an area or areas exceeding 12 square inches (77 sq. cm.). 38 C.F.R. § 4.118, Code 7801. A superficial scar (other than head, face, or neck) that does not cause limited motion and involves an area or areas of 144 square inches (929 sq. cm.) or greater also warrants a 10 percent rating (Code 7802). A note following Code 7802 provides that a superficial scar is one not associated with underlying soft tissue damage. A 10 percent rating is also authorized for superficial, unstable scars. (Code 7803). A note following Code 7803 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar. Under Code 7804, a 10 percent rating is authorized for superficial scars that are painful on examination. 38 C.F.R. § 4.118. Code 7805 provides that other scars will be rated on limitation of motion of the affected part. 38 C.F.R. § 4.118. On June 2007 VA examination, there were no findings regarding the left femur donor site scar. On November 2007 VA examination for scars, a 10 cm scar at the left lateral knee was noted. There were no further findings regarding the left femur donor site scar. On September 2008 VA foot examination for feet, it was noted that the Veteran had a MTP and TMT [tarsometatarsal] fusion in 1997 in which a debridement of a nonunion bone with open reduction and internal fixation of the left great toe, left distal femoral bone grafting and an Akin interphalangeal osteotomy of the proximal metatarsal. There were no notations regarding the left femur donor site scar. On April 2012 VA examination, a left distal femur donor site scar was noted. The Veteran reported a history of the scar being painful. On physical examination the scar was linear; it was located at the left distal femur. It measured 4.5x0.25 cm. The examiner noted there were no superficial or deep non-linear scars. There was no limitation of function due to the scar. The Veteran did not have any other pertinent physical findings, complications, conditions, signs and/or symptoms (such as muscle or nerve damage) associated with the left femur donor scar. It was noted that the Veteran's scar had no impact on his ability to work. As the left femur donor site scar is already rated 10 percent, the Board must look to those applicable rating criteria, outlined above, that provide for a rating in excess of 10 percent (as the scar is not shown to limit motion or any other function). In essence, this limits consideration to the pre-October 23, 2008 Code 7801, which provides for a 20 percent rating for a deep scar that exceeds 12 square inches (as the other applicable codes provide for a maximum 10 percent rating).. The Veteran's left thigh scar may reasonably be described be described as deep. As it was created by the extraction of a bone fragment from the thigh for grafting in the foot there logically would have been some involvement of soft tissue below the skin at the thigh donor site for the bone fragment to be harvested. The determinative question then becomes whether the dimensions of the scar warrant an increase in the rating. The only evidence in the record that definitively provides the dimensions of the left thigh/femur donor site scar is the report of the April 2012 VA examination when the scar was described as 4.5 cm by .25 cm. As this falls far short of the more than 12 square inches (77 sq. cm.) required for a 20 percent rating, the Board must find that the criteria for the next higher, 20 percent , rating are neither met nor approximated (see 38 C.F.R. § 4.7), and that a rating in excess of 10 percent is not warranted. The Board has also considered whether referral of either of these matters for consideration of an extraschedular rating is indicated. There is no objective evidence, or even allegation, of symptoms or impairment that are not encompassed by the criteria for the 30 percent and 10 percent schedular ratings assigned. Therefore, the schedular criteria are not inadequate, and referral of the claims for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111 (2008). Finally, the record shows that the Veteran has been unemployed since approximately 2007 or 2008. The United Stated Court of Appeals for Veterans Claims (Court) has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for service-connected disability or disabilities, and therefore is part and parcel of a claim for increased compensation. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the Veteran filed a specific claim for TDIU rating, and the RO adjudicated and denied such claim by a December 2007 rating decision which the Veteran did not appeal. Consequently, the question before the Board now is whether the matter of entitlement to a TDIU rating has been re-raised in the context of the instant claims for increase. While the Veteran has reported (both on examinations and in hearing testimony) that he is currently unemployed and incapable of engaging in his prior employment due to his foot disabilities, he has also indicated that he is attending school and receiving computer training (to improve qualifications for sedentary employment). Accordingly, the record does not now suggest that by virtue of his service-connected disabilities the Veteran is precluded from engaging in any substantially gainful employment; and the Board concludes that the matter of entitlement to a TDIU rating is not re-raised by the record requiring remand for development and readjudication. Entitlement to extension of a temporary total (convalescent) rating beyond February 28, 2007. A June 2007 rating decision assigned the Veteran a temporary total rating for the left great toe disability based on surgical or other treatment necessitating convalescence, effective from October 2, 2006 to March 1, 2007. The Veteran has expressed disagreement with the length of the temporary total rating and seeks an extension. A temporary total (100 percent) disability rating for convalescence purposes will be assigned, for up to three months, without regard to other provisions of the Rating Schedule, when it is established that treatment of a service-connected disability results in: (1) Surgery necessitating at least one month of convalescence. (2) Surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight bearing prohibited). 3) Immobilization by cast, without surgery, of one major joint or more. 38 C.F.R. § 4.30. Extensions of temporary convalescent ratings, for up to three months beyond the initial three months are available for items (1), (2), and (3) above; and approval may be obtained for extensions of one or more months, up to six months beyond the initial six-month period, for items (2) or (3) above. 38 C.F.R. § 4.30(b). In October 2006 the Veteran underwent surgery for his service-connected left great toe disability (surgical removal of the retained hardware in the left foot). In November 2006, VA furnished the Veteran with a "Return to Work/School Status" document that noted that he would be ready to return to work in January 2007. Subsequently, in January 2007, the RO received a "Return to Work" slip from the Veteran's primary care physician that noted that he was under her care and would be able to return to work on March 1, 2007. The evidence shows that following his October 2006 surgery the Veteran's convalescence was characterized by progressive improvement. A November 2006 VA orthopedic progress note notes the incision was healing well with no drainage or signs of infection; he was continuing to progress to regular shoes. On January 2007 VA podiatry consult, he reported pain with weight bearing. He was ambulating in athletic shoes with a cane. On examination, muscle strength was +5/5 in all lower groups tested; range of motion of the left hallux was fixed at the MPJ. As is noted, the Veteran's primary care provider expressly indicated that he could return to work as of March 1, 2007. Finally, an April 2012 VA examiner concluded, based on review of the medical records, that convalescence beyond March 1, 2007 for the October 2006 surgical procedure for the left great toe disability was not required. The examiner noted that the Veteran had orthotics and new shoes prescribed (and presumably was using them, as there is no objective evidence to the contrary). In summary, all medical evidence in the record regarding the Veteran's convalescence following the October 2006 surgery is to the effect that after February 28, 2007, convalescence was no longer needed. The record does not show that after February 2007 there were any severe postoperative residuals such as incompletely healed surgical wounds, immobilization of one major joint or more, immobilization equivalent to a body cast, or that the Veteran was confined to his house for needed continued use of a wheelchair or crutches (with regular weight bearing prohibited-see prescription of orthotics/shoes). The clinical findings outweigh the Veteran's lay assertions regarding the severity of his postoperative residuals. Hence, an extension (beyond February 28, 2007) of the convalescence temporary total rating is not warranted. ORDER A rating in excess of 30 percent for a left great toe disability is denied. A rating in excess of 10 percent for a left femur donor site scar is denied. The appeal seeking extension of a temporary total (convalescence) rating beyond February 28, 2007 is denied. ____________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs