Citation Nr: 1318870 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 07-14 599 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to an evaluation in excess of 10 percent for residuals of a shell fragment wound (SFW) to the right anterior chest. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Rutkin, Joshua M. INTRODUCTION The Veteran served on active duty from April 1969 to April 1970, and from August 1990 to July 1991. The Veteran also served in the Air Force Reserves. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The Veteran testified before a Decision Review Officer (DRO) in March 2009, and testified at a Board hearing in November 2009. Transcripts of both hearings are of record. The Veterans Law Judge who conducted the November 2009 Board hearing is no longer employed at the Board. The Veteran was notified of this fact in an August 2012 letter and offered an opportunity to testify at another Board hearing before a member of the Board. He declined this offer. Therefore, no additional action is needed. The Board denied this claim in a May 2011 decision. However, in February 2012 the United States Court of Appeals for Veterans Claims (Court) issued an Order that granted a joint motion for remand, vacated the Board's May 2011 decision, and remanded the claim for compliance with the instructions in the joint motion. The Board remanded this claim in March 2010 and February 2013 for further development. It now returns for appellate review. The Veteran submitted additional private treatment records after this claim was last adjudicated in an April 2013 Supplemental Statement of the Case, and waived his right to initial consideration of this evidence by the agency of original jurisdiction (AOJ) in accordance with 38 C.F.R. § 20.1304(c) (2012) (providing that any pertinent evidence accepted directly at the Board must be referred to the AOJ for initial review unless this procedural right is waived by the appellant). Therefore, the Board may proceed with appellate review. See id. FINDINGS OF FACT 1. The Veteran's residuals of a multiple shell fragment wound, right chest wall area, affect only one muscle group, most likely the thoracic muscle group (Muscle Group XXI), are productive of intermittent pain three or four times per week triggered by certain movements and activities, associated spasming, and fatigue, and overall are no more than moderate in nature in terms of the history of the wound, the objective clinical findings, and the Veteran's reported symptoms and functional impairment. 2. There are shrapnel fragments in the subcutaneous tissue of the chest wall, including one in the anterior chest wall between the fifth and sixth ribs which is outside the rib cage and does not affect the lung; these shrapnel fragments have not been shown to produce additional disability or further injury. 3. The preponderance of the evidence shows that there are no lung, respiratory, or neurologic disorders associated with the Veteran's shell fragment wound. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for residuals of shrapnel fragment wound, right anterior chest area, Muscle Group XXI, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.56, 4.73, Diagnostic Code 5321 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104(d)(1) (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. See id. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. When the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must weigh against a claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). I. The Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002), sets forth VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In order to satisfy its duty to notify the claimant under the VCAA, the United States Court of Appeals for Veterans Claims (Court) held that 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; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). All notice under the VCAA should generally be provided prior to an initial decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, a delay in timing of the notice is "cured," and therefore harmless, when a fully compliant VCAA notification letter is followed by readjudication of the claim (such as through issuing a statement of the case or supplemental statement of the case) after the claimant has had an opportunity to submit additional evidence. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). In order to satisfy the first notice element in a claim for an increased rating for a service-connected disability, VA must notify the claimant that he needs to provide or request VA to obtain medical or lay evidence demonstrating a worsening or increase in severity of the disability at issue. Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 97-103 (2010) (Vazquez-Flores III); Vazquez-Flores v. Peake, 22 Vet. App. 37, 43 (2008) (Vazquez-Flores I), overruled in part sub. nom. Vazquez-Flores/Wilson v. Shinseki, 580 F.3d 1270, 1280-81 (Fed. Cir. 2009) (Vazquez-Flores II). Further, the claimant must be notified that 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. Finally, the notice must provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Id. Except when VCAA notice as to how to substantiate an increased-rating claim is not provided at all, it is the claimant's burden to show that he was prejudiced by any deficiency in the notice provided. See Vazquez-Flores, 24 Vet. App. at 106-07. During the pendency of this appeal, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that, for increased rating claims, notice provided to the Veteran under 38 U.S.C.A. § 5103(a) need not be "veteran specific," and that VA is not required to notify the Veteran of the rating criteria applicable to the disability at issue or to inform him that he may submit evidence of the effect of his disability on daily life. See Vazquez-Flores/Wilson, 580 F.3d at 1280-81. Here, a March 2006 letter satisfied all the above notice requirements and was sent to the Veteran prior to the initial rating decision in this matter. Accordingly, the duty to notify is satisfied. See Vazquez-Flores, 24 Vet. App. at 97-10; 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA's duty to assist under the VCAA includes helping the claimant to obtain service treatment records and other pertinent records, as well as providing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Here, the Veteran's service treatment records, VA medical records, and Social Security Administration (SSA) records are in the claims file. Private medical records identified by the Veteran have also been associated with the claims file. The Veteran was also sent a letter in March 2013 asking him to identify additional treatment for his SFW residuals, and either to provide VA with sufficient information and authorization to request records of such treatment on his behalf, or to submit these records himself. He responded by submitting additional private treatment records from the Rheumatology Specialty Center. He has not identified any other records or evidence that remains outstanding. Thus, the duty to assist with respect to obtaining relevant records on the Veteran's behalf is satisfied. See 38 C.F.R. § 3.159(c). The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a), 3.327 (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). In increased rating claims, where the evidence of record does not reflect the current state of the veteran's disability, a new VA examination must be conducted. See 38 C.F.R. § 3.327(a); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, a VA muscle examination was performed most recently in March 2013. The examination report is adequate for rating purposes, as the examiner reviewed the claims file and medical history, examined the Veteran, and described the Veteran's disability in sufficient detail to enable the Board to make a fully informed decision on this claim. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (quoting Green, 1 Vet. App. at 124). Moreover, the examiner's conclusion that the Veteran did not have muscle damage is consistent with May 2006 and April 2009 VA examinations which also did not yield findings of muscle damage. Thus, the examiner's conclusion after reviewing the pertinent medical history and examining the Veteran that there was no residual muscle damage is sufficient for deciding this claim. See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion" even when the rationale does not explicitly "lay out the examiner's journey from the facts to a conclusion") (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)); see also D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). As will be discussed below, the evidence shows that at most the Veteran has some muscle damage to the thoracic muscle group which is no more than moderate in nature. In this regard, a February 2012 VA Disability Benefits Questionnaire (DBQ) filled out by the Veteran's private treating physician reflects a finding of injury to the upper thoracic muscle group (Group XII), and that there was "maybe" some atrophy on the right breast area when compared to the left. An August 2010 VA examination report also shows a finding of muscle damage to the right external oblique muscle. However, the disparate findings among the VA examination reports and the September 2012 DBQ filled out by the private physician suggest that the Veteran's muscle injury is so subtle as to be difficult to observe on examination. What is clear is that at most only one muscle group is affected, most likely the thoracic group as found by the private treating physician, and that the resulting disability is no more than moderate in nature, as discussed below. Thus, a remand for another opinion to try to reconcile the conflicting reports is not warranted, as such a reconciliation (assuming one were even possible) would not result in a higher or separate rating even if it could be confirmed that the Veteran does in fact have residual muscle damage, which is already compensated with a 10 percent evaluation. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). The Veteran has not stated and there is no other evidence indicating that there has been a material change in the severity of his SFW residuals since he was last examined in March 2013. See 38 C.F.R. § 3.327(a). Additional diagnoses including Tietze's disease and costochondritis reflected in the private treatment records and September 2012 DBS were made prior to the March 2013 VA examination, and thus do not indicate a worsening of disability since the Veteran was last examined by VA. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007); VAOPGCPREC 11-95 (April 7, 1995). Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion is satisfied. 38 C.F.R. § 3.159(c)(4); Barr, 21 Vet. App. at 312. In sum, VA's duty to notify and assist under the VCAA has been satisfied. The Veteran has had ample opportunity to participate in the development of his claim. See Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011) (citing Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that any error depriving a claimant of "a meaningful opportunity to participate effectively in the processing of his or her claim . . . . must be considered prejudicial")). Any defect in the notice or assistance provided did not affect the outcome of this claim or compromise the "essential fairness of the adjudication," as shown in the above discussion. See Mayfield v. Nicholson, 19 Vet. App. 103, 116 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, any error in the notice or assistance provided was harmless, and no prejudice exists. See Shinseki v. Sanders 556 U.S. 396, 407, 410 (2009) (holding that the "rule of prejudicial error" requires a case-by-case determination as to whether the error in question was harmless, and that it is the burden of the claimant to show that the error was harmful by at least providing an explanation as to how the error caused harm); see also 38 U.S.C.A. § 7261(b)(2) (West 2002). Accordingly, the Board may proceed with appellate review. II. Procedural Due Process A. Compliance with Board's Remand Directives The Board remanded this claim in February 2013 for further development. In Stegall v. West, 11 Vet. App. 268, 271 (1998), the Court held that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Here, the Board's remand directives to afford the Veteran a VA examination assessing whether he has a separate injury to the external oblique muscle as a result of the SFW, to send the Veteran a letter requesting him to identify additional relevant treatment records, and then to readjudicate the claim and issue a Supplemental Statement of the Case have been satisfied. In this regard, as the examiner found that the Veteran did not have any residual muscle injury, there was no need for the examiner to specifically state that the Veteran did not have an injury to the external oblique muscle. As discussed above with regard to VA's duty to assist, further opinion on this issue is not warranted as the preponderance of the evidence clearly shows that the Veteran does not have injuries to multiple muscle groups, thereby rendering further inquiry into this matter moot in terms of any benefit that might accrue to him from such an investigation. Accordingly, there has been substantial compliance with the Board's remand directives. See id. B. Compliance with Hearing Officer's Duties under Bryant As noted above, the Veteran testified at a DRO hearing in March 2009 and at a hearing before the Board in November 2009. Under 38 C.F.R. § 3.103(c)(2) (2012), it is the responsibility of the hearing officer to explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the hearing officer has two distinct duties under section 3.103(c)(2). First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id. at 496 (finding that a hearing officer's inquiries regarding the existence of a current disability and a nexus to service did not equate to explaining to the claimant that these issues were material to substantiating the claim). Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id., at 496-97. Importantly, the Court observed that the rule of prejudicial error applies in assessing any deficiency with respect to the hearing officer's duties under section 3.103(c). See id. at 498. Citing Sanders, 556 U.S. at 407, 410, the Court noted in this regard that the rule of prejudicial error requires a case-by-case determination as to whether the error in question was harmless. Id. Thus, in Bryant, 23 Vet. App. at 498-99, the Court held that although the hearing officer did not explicitly lay out the material issues of medical nexus and current disability, the "clarity and completeness of the hearing record was intact" and the purpose of section 3.103(c)(2) fulfilled because the record reflected that these issues were developed by VA, including the provision of a VA examination, and there was no indication that the appellant had any additional information to submit. Here, the outstanding issue is whether the Veteran's residuals of an SFW are more severe than contemplated by the 10 percent evaluation currently assigned, to include whether separate ratings are warranted for injuries to separate muscle groups (i.e. Muscle Groups XIX and XII) and whether there are other separately compensable residuals as a result of remaining shell fragments. Although the hearing officers did not explicitly identify this issue for the Veteran, the Veteran had an opportunity to describe his symptoms and functional impairment at the hearings, and his testimony is consistent with the medical records and examination reports in the file. Moreover, any deficiencies in the hearings under section 3.103(c)(2) were not prejudicial. Specifically, VA has otherwise developed this claim, including obtaining records on the Veteran's behalf and providing a VA examination which addresses the outstanding issue in this case, namely the nature and severity of his muscle injury, as discussed above with regard to VA's duty to assist under the VCAA. The Veteran has also submitted private treatment records and examination reports addressing his SFW residuals. Furthermore, the Veteran did not raise any new issues pertaining to his claim at the hearings, and there is no indication of any outstanding evidence that may have been overlooked. See id. at 499. Thus, given the development undertaken by VA with respect to this claim, and in light of the Veteran's testimony at the hearings, the "clarity and completeness of the hearing record [is] intact" and the purpose of section 3.103(c)(2) to develop the record has been fulfilled. Id. at 498-99. Accordingly, the Veteran's right to a Board hearing has been satisfied and no prejudicial error exists with regard to the hearing officer's duties under section 3.103(c)(2). See id.; see also Sanders, 556 U.S. at 407, 410. III. Increased Rating VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R., Part IV. 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 (2012). The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2012). Otherwise, the lower rating will be assigned. Id. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The schedule recognizes that disability from distinct injuries or diseases may overlap. See 38 C.F.R. § 4.14 (2012). However, the evaluation of the same disability or its manifestation under various diagnoses, which is known as pyramiding, is to be avoided. Id. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). The provisions of 38 C.F.R. § 4.56(d) provide that disabilities resulting from muscle injuries under diagnostic codes 5301 through 5323, shall be classified as "slight," "moderate," "moderately severe," or "severe." The type of injury contemplated by "slight disability of muscles" is a simple wound of muscle without debridement or infection. This type of injury is evidenced by service department record of superficial wound with brief treatment and return to duty; healing with good functional results; and no cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c). Objective findings of this type of injury include a minimal scar; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(1). The type of injury contemplated by "moderate disability of muscles" is a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. This type of injury is evidenced by service department record or other evidence of in-service treatment for the wound or a record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objective findings of this type of injury include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue; some loss of deep fascia or muscle substance; or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). The type of injury contemplated by "moderately severe disability of muscles" is a through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. This type of injury is evidenced by service department record or other evidence showing hospitalization for a prolonged period for treatment of wound; a record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c); and, if present, evidence of inability to keep up with work requirements. Objective findings of this type of injury include entrance and (if present) exit scars indicating track of missile through one or more muscle groups; indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side; and tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). The type of injury contemplated by "severe disability of muscles" is a 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. This type of injury is evidenced by service department record or other evidence showing hospitalization for a prolonged period for treatment of wound, or a record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings of this type of injury include ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track; palpation showing loss of deep fascia or muscle substance, or soft flabby muscles in wound area; muscles that swell and harden abnormally in contraction; and tests of strength, endurance, or coordinated movements that indicate severe impairment of function when compared with the corresponding muscles of the uninjured side. If present, the following are also signs of severe muscle disability: (1) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; (2) adhesion of a 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 the bone is normally protected by muscle; (3) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (4) visible or measurable atrophy; (5) adaptive contraction of an opposing group of muscles; (6) atrophy of muscle groups not in the tract of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (7) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56. Evaluation of muscle injuries as slight, moderate, moderately severe, or severe, is based on the type of injury, the history and complaints of the injury, and objective findings. 38 C.F.R. § 4.56(d). The Court has held that 38 C.F.R. § 4.56(d) is essentially a "totality-of-the-circumstances" test and that no single factor is per se controlling. Tropf v. Nicholson, 20 Vet. App. 317 (2006) (citing Robertson v. Brown, 5 Vet. App. 70 (1993)). Thus, the criteria under 38 C.F.R. § 4.56 are only guidelines for evaluating muscle injuries from gunshot wounds or other trauma, and such guidelines are to be considered with all factors in the individual case. Robertson, 5 Vet. App. 70. The Veteran's SFW residuals have been assigned a 10 percent rating under 38 C.F.R. § 4.73, Diagnostic Code (DC) 5321. Diagnostic Code 5321 pertains to the muscles of respiration or the thoracic muscle group. Id. Under DC 5321, a severe or moderately severe injury is assigned a 20 percent rating, a moderate injury is assigned a 10 percent rating, and a slight injury is assigned a 0 percent rating. Id. The service treatment records show that in February 1969, the Veteran sustained a penetrating shell fragment wound to the right chest when shot by an M-79 fragment while on the rifle range. There was no nerve or artery involvement. The wound was debrided and he remained hospitalized for two days. It was recommended that he be placed on light duty for fifteen days. Thereafter, he returned to duty with no change in his physical profile. The sutures were removed a week later. His March 1970 separation physical examination report noted normal clinical findings with regard to the lungs and chest with no reference to the shell fragment wound. However, in the accompanying Report of Medical History, the Veteran stated that he experienced occasional chest pains, and it was noted on the back of this form that he had sustained a shrapnel wound to the right chest. A VA medical examination was performed in June 1970. The Veteran gave a history of the February 1969 shell fragment wound injury. He complained of a "jabbing like pain" of the chest over the area of the scar with discomfort and shooting pains, at times. Physical examination revealed the presence of a one-inch scar over the right anterior hemothorax four finger-widths below the nipple. The scar was tender to pressure palpation. There was no fixation of the scar to the underlying musculature. A chest X-ray film report noted a solitary metallic foreign body overlying the anterior right lower chest, measuring 2 millimeters (mm) in diameter. The assessment was residuals of shell fragment wound, right chest with retained foreign body. After he submitted this claim, the Veteran wrote in a March 2006 statement that he experienced chest pressure on occasion. He stated that on a cold day or when he physically exerts himself, such as shoveling or lifting in a certain way, he can feel pressure. He also reported he sometimes got a feeling of cramping on his right side under his rib cage, and was forced to stop what he was doing or try to twist every which way to work away the cramping feeling. Over the past few years he had tried to ignore the feeling and work around it. In a May 2006 VA examination report, the examiner noted that the Veteran had suffered a "superficial" shrapnel wound of the anterior chest. The Veteran reported that he had been employed as a fireman for the past thirty-four years, but in the last few years had a sedentary job. An examination of the chest was "unremarkable," and the examiner did not find any injury to the respiratory muscles (the examiner actually wrote "muscles of restoration," but almost certainly meant "respiration" rather than "restoration" in light of DC 5321). The Veteran was capable of deep breathing. The skin was normal except for a scar of the right anterior chest below and lateral to the nipple. A January 2008 private treatment record reflects that the Veteran did not have chest pain or shortness of breath on the day he was seen for treatment, but reported occasional right-sided chest pain with cold weather or activity such as shoveling snow which he described as a cramping pain. A July 2008 private chest x-ray report shows that the Veteran had reported shortness of breath and this symptom was the indication for the chest x-ray. The x-ray study showed a generalized increase in interstitial vascular markings which were found to be compatible with congestive heart failure. The Veteran was diagnosed with congestive heart failure. There was no mention of retained shell fragments or residuals of an SFW in this record. At the March 2009 DRO hearing, the Veteran stated that he felt pressure over the site of his SFW. He stated that it bothered him on cold days, and when he had to shovel snow or do any kind of twisting motion. He would have to stop and take a break for about 10 minutes at these times. He stated he did not take pain medication, and that the feeling was more of a pressure sensation. An April 2009 VA examination report states that the Veteran retired in January 2007 from his job with the fire department due to length of service. The examiner reviewed the claims file and noted that there had been surgical closure of the Veteran's shell fragment wound during active service, but there was no lung involvement and the chest cavity was not penetrated. The Veteran stated that he felt a weakness in the area "at times." For example, he related that when he had been asked to hold a piece of drywall to a ceiling, he felt an abnormality in the area of the former wound. On examination, there was a 1.5 inch long horizontal scar in the right inframammary area which was not tender or painful. The scar was superficial, "meaning that [the examiner could] palpate no underlying soft tissue damage." There was no limitation of motion or other limitation of function caused by the scar. An examination of the lungs showed that they were clear with no decreased breath sounds or other right-sided pulmonary abnormality. The examiner diagnosed a superficial scar of the right inframammary area. An X-ray study performed at this time showed a small piece of shrapnel in the anterior/inferior portion of the right lung, with no rib fractures or other rib abnormality seen. Multiple BB's were also shown in the region of the right eighth, ninth, and tenth ribs. At the November 2009 Board hearing, the Veteran stated that he had a pressure and weakness in his chest, as if someone was pressing on it. He further testified that he experienced cramping to the point where if he was doing anything like shoveling snow or an activity with some sort of twisting motion to it, he had to stop and take a break. A June 2010 private treatment record shows that the Veteran reported fluctuating symptoms and described the severity level as moderate. He reported a burning, piercing and sharp pain that radiates to the front of the chest. He described it as a bullet and shrapnel injury. He also stated his pain was aggravated by lifting and movement, and relieved by rest and stretching. Associated symptoms included spasms. He denied bruising, crepitus, decreased mobility, and difficulty going to sleep, numbness, popping, swelling, tenderness, and weakness. Upon physical examination, the examiner noted full range of motion of all major joints including the right shoulder and elbow. The treating physician referred to a recent CT scan of the chest which revealed that the object was outside the lung parenchyma. The Veteran reported frequent and random spasms of the anterior chest wall which hindered his ability to perform strenuous physical jobs, and the examiner suggested muscle relaxants to reduce motor junction excitability. The assessment was spasm of muscle, moderate. At an August 2010 VA examination, the Veteran stated that he had persistent episodes of right chest wall pain which occurred primarily when he was reaching for or pulling items. He described the pain as being located in a three-centimeter area immediately below and slightly medial to the right nipple that is associated with a cramping pressure pain. The most serious episode occurred when shoveling snow and lasted for about ten minutes. Reaching or stretching also provoked pain, although these episodes usually resolved in one or two minutes. The episodes of chest pain occurred approximately three or four times per week. They did not limit the motion of the shoulder joint and did not limit his physical activity. In this regard, the examiner noted that although the Veteran would discontinue activity after having an episode of chest pain, he had not tried to continue working to determine whether the pain would return. At the examination, the Veteran expressed concern that the shrapnel might be migrating to his lung. The examiner stated that he had reviewed the x-ray studies from April 2009 and found four individual pieces of shrapnel. One piece was overlying the anterior chest wall between the fifth and sixth rib, one was immediately superior to the seventh rib, one was overlying the eighth rib, and one was overlying the fifth rib on the right. The examiner stated that all of the pieces of shrapnel moved away from the chest wall except for the one lying between the fifth and sixth ribs. It was not clear whether this lesion was inside or outside of the thoracic cage. However, the examiner noted that the Veteran reported that a CT scan performed in January 2010 was reviewed by his rheumatologist, who found that it clearly showed the shrapnel to be superficial to the ribs. Indeed, as noted above, the June 2010 private treatment record does show a finding that the shrapnel was outside the lung parenchyma based on a recent CT scan. On physical examination, there was a well-healed transverse scar overlying the fifth rib anteriorly. It was freely moveable over the subcutaneous tissues. There was some irregularity palpable between the fourth and fifth rib which was not tender. When the Veteran was asked to abduct his arm and reach posteriorly, the soft tissue of the chest wall moved smoothly over the ribs. However, there was a defect in the chest wall palpable immediately inferior to the right nipple which was 1 centimeter superior and 1 centimeter lateral to the midpoint of the shrapnel scar. This area was mildly tender. Further stretching caused the pain to become more severe. There was no palpable spasm or mass. The examiner found that the defect appeared to be most consistent with a tear of an external oblique muscle between the fourth and fifth ribs. The defect did not affect the strength or mobility of the shoulder on the right side, and there was no associated shortness of breath (dyspnea), although the Veteran did report that with deep inspiration the pain became more severe. There were no other palpable abnormalities of the chest wall, and none of the shrapnel pieces were palpable. The examiner noted that the Veteran's pain was not associated with movement of the shrapnel, and the shrapnel fragments were unlikely to present further problems in the future. The examiner rendered a diagnosis of muscle injury with fibrosis and a separation from the fifth rib. The examiner found that the Veteran was unlimited in his activities of daily living. An October 2010 private treatment record reflects that the Veteran was unable to lift, twist, and raise his arms above his shoulder due to penetrating sharp pain associated with the shrapnel wound residuals. The treating physician noted that the Veteran's pain had worsened in the last several months and now was moderately severe in intensity. The pain was described as an aching, sharp, and deep pain which radiated to the anterior chest. The pain was aggravated by bending, lifting, movement, pushing, and twisting, and was worse at night. The pain was relieved by medications and with rest. Associated symptoms included decreased mobility, difficulty going to sleep, night pain, spasms, and tenderness. A September 2012 VA Disability Benefits Questionnaire (DBQ) for muscle injuries filled out by the Veteran's private treating physician, E. Eisner, M.D., reflects diagnoses of an acquired chest deformity and costochondritis. Doctor Eisner indicated that the Veteran had an injury to Muscle Group XXI, which pertains to the muscles of respiration, otherwise known as the thoracic muscle group, and specifically noted that the injury was to the upper thorax. She did not check the box corresponding to injuries of Muscle Group XIX, which include the external oblique muscle, or any other muscle group. Doctor Eisner further indicated that the Veteran had a minimal scar and no fascial defects, including loss of deep fascia. However, she did note visible or measurable atrophy, although in describing this atrophy later in the DBQ (on page 5) she stated "Maybe -[right] breast area [decreased] compared to [left breast]." In other words, the atrophy was barely noticeable and possibly not even present, as denoted by the word "maybe." The treating physician also indicated that the Veteran had some fatigue and pain in the pectoral muscle, but did not describe its frequency or severity. Dr. Eisner further indicated that the Veteran had slightly decreased strength of right shoulder abduction and right hand grip (5-/5), but did not state whether this decrease was related to the Veteran's muscle injury. The treating physician stated that it was unknown whether there were any other pertinent physical findings, complications, conditions, signs and/or symptoms associated with the Veteran's muscle injury. In the section addressing whether the Veteran's muscle injury impacts his ability to work, the treating physician wrote that the Veteran stated he was "unemployable" due to his symptoms, and put the word unemployable in quotation marks in emphasis that she was merely recording the Veteran's statement and not necessarily making such a finding herself. A March 2013 private treatment record authored by the same physician who filled out the September 2012 VA DBQ reflects an assessment of chronic Tietze's disease. In the comments below this diagnosis, it was noted that the Veteran had ongoing chest wall symptoms, some coughing, and "some suggestion of interstitial prominence" on a chest x-ray. Dr. Eisner also diagnosed an acquired deformity of the chest and rib, and postinflammatory pulmonary fibrosis. In the March 2013 VA examination report, the examiner noted that the Veteran had multiple physicals and medical examinations prior to his discharge from the Reserves in June 2005. The examination reports dated in October 1984, April 1988, April 1995, and April 2001 all reflected normal findings with regard to the chest and lung. At the examination, the Veteran reported intermittent pain in the right mid chest region. The baseline pain at the time of onset was a 6 on a scale of 0 to 10, and worsened with stretching and twisting on the right side, at which point the pain increased to a 9. The pain resolved spontaneously in 5 to 10 minutes. The Veteran reported a 30 percent limitation of function in his daily activities during flare-ups. He stated that the flare-ups occurred one to two times per week and resolved spontaneously in about 5 to 15 minutes. He took a prescribed muscle relaxant (Skelaxin) which helped alleviate the pain. On physical examination, the examiner noted a superficial scar which was not elevated or depressed and not adherent to underlying tissue. There was no exit wound in the right chest region. The examiner also found no muscle involvement from the shrapnel fragment wound, as well as no joint or nerve involvement. There was no loss of muscle function in the right chest wall region. On examination of the lungs, there was no restriction of movement of air to inspiration and expiration in both lung fields. The examiner found that the right chest wall condition had no effect on the Veteran's activities of daily living, and had not affected his occupational functioning as a firefighter. The examiner concluded that there was no evidence of a muscle injury on examination. The examiner further opined that there was a mild residual of a shrapnel fragment wound in the anterior/inferior portion of the right lung based on the April 2009 x-ray report. However, the Board notes that, as discussed above, it had since been found by a CT scan study that the shell fragment is outside the lung, as noted in the June 2010 private treatment record and August 2010 VA examination report. The Veteran's SSA records show that he was granted disability benefits in October 2009 with a primary diagnosis of diabetes and a secondary diagnosis of posttraumatic stress disorder (PTSD). In the decision, it was found that the Veteran had obesity and poorly controlled diabetes mellitus which caused chronic fatigue and shortness of breath, as well as peripheral neuropathy in the lower extremities. It was also noted that he suffered from intermittent chest pain, which the Veteran attributed to the residuals of the shrapnel fragment wound. The evidence discussed above shows that the Veteran's SFW residuals of the right anterior chest wall most nearly approximate a 10 percent rating under DC 5321. As discussed above, a moderately severe injury or severe muscle injury is generally evidenced by a history of hospitalization for a prolonged period of time for treatment of the wound, or a record showing consistent complaint of cardinal signs and symptoms of muscle disability, such as loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. See 38 C.F.R. § 4.56(d), (c). In this case, the fact that the Veteran was hospitalized for only two days, and was able to return to active service after only fifteen days of being put on light duty weighs against a moderately severe or severe injury. Further, although there is credible evidence that the Veteran experienced occasional chest pain since service, as shown in the March 1970 Report of Medical History, the June 1970 VA examination report, and the Veteran's March 2006 written statement, the Veteran has not stated and there is no evidence otherwise showing that he had a history of consistent cardinal signs and symptoms of muscle disability, including loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of incoordination, or uncertainty of movement. See 38 C.F.R. § 4.56(c). The fact that he worked as a firefighter for thirty-four years weighs against such a history. In short, the history of the Veteran's SFW to the right chest weighs against a moderately severe or severe injury in terms of the guidelines set forth in section 4.56(d). Present clinical findings further weigh against a moderately severe or severe injury. There is no evidence of intermuscular scarring, ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track, loss of deep fascia or muscle substance, or loss of normal firm resistance of muscles compared with the sound side. See id. There is also no evidence that the Veteran's right chest wall muscles swell and harden abnormally in contraction, or that tests of strength, endurance, or coordinated movements indicate severe impairment compared with the sound side. See id. Finally, there is no evidence that the Veteran was unable to keep up with work requirements due to his chest wound residuals. See id. Moreover, there are no other signs of a severe muscle injury. While there is x-ray evidence of multiple shell fragments, there is no evidence of intermuscular trauma or that such fragments even involve the muscle. There is also no evidence of adhesion of the scar with epithelial sealing over the bone rather than true skin covering in an area where the bone is normally protected by muscle, diminished muscle excitability to pulsed electrical current in electrodiagnostic tests, adaptive contraction of an opposing group of muscles, induration or atrophy of an entire muscle, or atrophy of muscle groups not in the tract of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. See id. While the September 2012 DBQ states that the Veteran had some visible atrophy on the right side compared with the left side of the chest, the preponderance of the evidence weighs against visible or measurable atrophy, as such atrophy has not been noted or observed in any of the other VA examinations or treatment records dated prior to and after the September 2012 DBQ, and the DBQ itself is equivocal with regard to this finding, as indicated by the word "maybe." Thus, the Board finds that the Veteran does not have visible or measurable atrophy of the right chest compared with the left chest. In short, the Veteran's SFW residuals do not exhibit any of the signs or findings associated with moderately severe or severe injuries as set forth in section 4.56(d). The objective clinical findings reflected in the VA examination reports and the private DBQ indicate that the Veteran's muscle injury is no more than moderate in nature. The June 1970, May 2006, April 2009, and March 2013 VA examination reports are all negative for findings of any muscle injury, and the May 2006 and March 2013 VA examination reports affirmatively state that no muscle damage was found on examination. Rather, the VA examination reports only show that the Veteran had a superficial scar and some retained shrapnel fragments. Notably, there is no x-ray or other diagnostic imaging showing any muscle injury. The only findings of muscle injuries are reflected in the August 2010 VA examination report and the September 2012 VA DBQ filled out by Dr. Eisner, and neither of these reports indicates that the muscle injury was moderately severe or severe. The fact that muscle damage has not always been observed on physical examination indicates that such damage must be fairly subtle, and thus weighs against a moderately severe or severe injury. The Veteran's reported symptoms and functional limitations also do not support a moderately severe or severe muscle injury. He has consistently reported intermittent chest pain that is triggered by cold weather and certain movements, and which generally resolves after a few minutes. It appears that it is only with more rigorous physical activity, such as shoveling snow or holding up drywall to a ceiling, that he experiences chest pain significant enough for him to have to discontinue the activity in which he was engaged. As noted by the August 2010 VA examiner, the Veteran did not try to resume the activity when the pain resolved after a few minutes, thus suggesting that it could not be determined whether continuing the activity at such times would produce further pain. While the October 2010 private treatment record describes worsening pain that prevented the Veteran from lifting, twisting, and raising his arms above shoulder level, the VA examinations and private treatment records dated both before and after this treatment record are negative for such findings. Rather, they show intermittent chest wall pain triggered by the cold and triggered by certain movements. The June 2010 private treatment record, dated about four months prior to the October 2010 private treatment record, shows that he denied bruising, crepitus, decreased mobility, and difficulty going to sleep, numbness, popping, swelling, tenderness, and weakness. Upon physical examination, the examiner noted full range of motion of all major joints including the right shoulder and elbow. Likewise, the August 2010 VA examination report, dated just two months prior to the October 2010 private treatment record, states that the Veteran was unlimited in his activities of daily living and is negative for findings of limited range of motion. Moreover, as recently as the March 2013 VA examination, the Veteran did not report being unable to lift or twist, or raise his arms above shoulder level, but rather described intermittent pain that worsened with stretching and flare-ups that occurred one or two times per week which resolved spontaneously in about 5 to 15 minutes. There are no findings of limited range of motion either in this examination report or in the September 2012 DBQ filled out by his private treating physician, or in the subsequent treatment records. Thus, the preponderance of the evidence shows that the overall level of disability is not characterized by an inability of the Veteran to do basic movements such as lift his arms above shoulder level, and there is no objective evidence that the Veteran's SFW residuals had otherwise worsened for any meaningful length of time. Although the Veteran apparently stated that he was "unemployable" when examined in September 2012 by Dr. Eisner, his treating physician did not state this as an objective finding (underscored by the fact that she put the word in quotation marks, thus emphasizing that she was only noting the Veteran's statement), and there is no other evidence or findings indicating that the Veteran cannot work or has occupational impairment due to his chest wound residuals. In short, the preponderance of the evidence shows that the Veteran has occasional symptoms of chest pain, spasms, and weakness, which resolve after a few minutes and are aggravated by certain twisting movements or more rigorous physical activity. Such symptoms more nearly approximate a moderate injury given their intermittent nature, given the fact that they do not affect his activities of daily living, given the fact that they did not affect his thirty-four year career as a firefighter, and given the fact that generally they have not been shown to produce functional impairment except during short flare-ups lasting only a few minutes one or two times per week. The 10 percent rating currently assigned compensates for such symptoms. The Board has also considered the diagnosis of Tietze's disease in the March 2013 private treatment record and the diagnosis of costochondritis in the September 2012 DBQ. However, even assuming that the Veteran has Tietze's disease or costochondritis associated with his SFW of the right anterior chest, there are no findings in the March 2013 DBQ or the September 2012 DBQ with regard to symptoms, functional impairment, or the objective presentation of the Veteran's SFW to suggest additional disability not already compensated by the 10 percent evaluation under DC 5321. In other words, there is no evidence that the mere diagnosis of Tietze's disease or costochondritis represents findings in addition to those already reflected in the VA and private treatment records. Importantly, the evaluation of the same disability or its manifestations under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Thus, the mere notation of such diagnoses without any mention of their clinical significance or other evidence of additional symptoms or impairment does not support a finding of a moderately severe or severe muscle injury. Likewise, they do not warrant a separate rating in the absence of evidence that such diagnoses in fact represent manifestations of the Veteran's SFW distinct from those already contemplated in the 10 percent evaluation currently assigned. See id. In this regard, it is notable that the March 2013 VA examination report, which is dated after the Veteran was diagnosed with Tietze's disease and costochondritis, does not show additional disability but rather is consistent with the earlier VA examination reports and also with the Veteran's earlier statements with regard to his symptoms and the objective presentation of his SFW residuals. Thus, separate or higher ratings are not warranted merely because the Veteran has been diagnosed with Tietze's disease or costochondritis. Finally, the Board has considered whether separate ratings are warranted for injuries to other muscle groups or for the remaining shell fragments, as directed in the joint motion for remand. Specifically, in the joint motion, the parties agreed that the Board should determine whether a separate rating is warranted for an injury to Muscle Group XIX given the August 2010 VA examiner's finding that the Veteran had muscle damage to the external oblique muscle, which is a part of that muscle group. The joint motion also directed the Board to determine whether a separate rating was warranted for any lung impairment associated with a shrapnel fragment. For the following reasons, the Board finds that separate ratings are not warranted. Under 38 C.F.R. § 4.55(e) (2012), for compensable muscle group injuries which are in the same anatomical location but do not act on the same joint, the evaluation for the most severely injured muscle group will be increased by one level and used as the combined evaluation for the affected muscle groups. Under 38 C.F.R. § 4.55(f), for muscle group injuries in different anatomical regions which do not act upon ankylosed joints, each muscle group injury shall be rated separately and the ratings combined under the provisions of 38 C.F.R. § 4.25 (2012). Muscle Group XIX is evaluated under DC 5319, which indicates that this muscle group governs the support and compression of the abdominal wall and lower thorax as well as the flexion and lateral motions of the spine, and functions as synergists in the strong and downward movements of the arm. 38 C.F.R. § 4.73. This muscle group consists of the muscles of the abdominal wall, including the rectus abdominis, the external oblique, the internal oblique, the transversalis, and the quadratus lumborum. See id. Under DC 5319, a 50 percent rating is assigned severe injuries of this muscle group, a 30 percent rating is assigned moderately severe injuries, a 10 percent rating is assigned moderate injuries, and a 0 percent rating is assigned slight injuries. Id. The preponderance of the evidence shows that the Veteran's SFW residuals do not affect more than one muscle group. While the August 2010 VA examiner found that the Veteran's external oblique muscle was affected, which would fall under Group XIX, he did not find injury to other muscle groups, including the muscles of inspiration or thoracic muscle group (Group XXI). By contrast, the Veteran's treating physician, Dr. Eisner, indicated in the September 2012 DBQ that it was the Veteran's upper thoracic muscle in Group XXI that was injured, and did not check the box corresponding to Muscle Group XIX. Finally, as shown above, the majority of the VA examinations are negative for any muscle injury at all. Thus, at most, the Veteran has a moderate injury to one muscle group, and the difference in findings as to which muscle group, or as to whether a muscle defect exists at all, simply underscores its lack of severity. Thus, as there is no evidence showing that two muscle groups are affected, but rather simply conflicting findings as to the location (and existence) of the muscle defect, separate ratings are not warranted under 38 C.F.R. § 4.55. Moreover, because a 10 percent rating is assigned moderate injuries with respect to either Muscle Group XIX or Muscle Group XXI, a higher rating would not be available even if it were determined that the defect is located in Muscle Group XIX, as the Veteran's muscle injury is no more than moderate in nature. See id., DC's 5319, 5321. Finally, there is no evidence showing that the remaining shell fragments produce additional disability. There are no clinical findings by VA examiners or treating physicians suggesting that the shell fragments actually produce any physical impairment. Although the April 2009 VA x-ray was interpreted as showing a small piece of shrapnel in the anterior/inferior portion of the right lung, a subsequent CT scan showed that the fragment was not in the lung, as reflected in the June 2010 private treatment record and August 2010 VA examination report. Moreover, although the Veteran has expressed concern that the shell fragment might migrate to his lung, he has not stated that it currently has affected his lung. The evidence also does not show that the Veteran has lung or respiratory problems associated with his SFW residuals. Rather, the July 2008 private chest x-ray report states that the Veteran's interstitial vascular markings were compatible with congestive heart failure, and the October 2009 SSA decision found that the Veteran had obesity and poorly controlled diabetes mellitus which caused chronic fatigue and shortness of breath. Thus, his shortness of breath is not associated with his SFW residuals. Finally, there is no evidence of neurological impairment associated with the SFW residuals. Accordingly, the preponderance of the evidence shows that the Veteran's SFW residuals of the right anterior chest more nearly approximate the criteria for a 10 percent rating for moderate muscle injuries under DC 5321. See 38 C.F.R. § 4.73. There is no evidence showing that the Veteran's SFW residuals have met the criteria for a rating in excess of 10 percent at any point since his claim for an increased evaluation, for the reasons discussed above. Thus, staged ratings are not appropriate for the relevant time frame. See Hart, 21 Vet. App. at 509-10. The Board has considered whether to the address the issue of a total disability rating based on individual unemployability (TDIU). See 38 C.F.R. §§ 3.340, 4.16 (2012). In Rice v. Shinseki, 22 Vet. App. 447, 453 (2009), the Court held that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or as part of a claim for increased compensation. If the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel of that claim for an increased rating is the issue of whether a total rating based on individual unemployability as a result of that disability is warranted. Id. at 455. As the Veteran is already in receipt of a TDIU, whether a TDIU is warranted based on the Veteran's SFW residuals is moot. The Board has also considered whether the Veteran's claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2012); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun, 22 Vet. App. at 114. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue 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). In Thun, 22 Vet. App. at 115, the Court held that the determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. First, as a threshold factor, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. In this regard, the Board must compare the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. See id. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular criteria are found to be inadequate to evaluate the claimant's disability, the Board must determine whether the exceptional disability exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. If so, then under the third step of the inquiry the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the claimant's disability picture requires the assignment of an extraschedular rating. Id. Here, referral for extraschedular consideration is not warranted. Specifically, a comparison of the Veteran's SFW residuals of the right anterior chest and the rating criteria does not show "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). His disability is primarily manifested by a superficial scar, a possible muscle defect, and intermittent pain, fatigue, and weakness. These symptoms and clinical presentation are expressly set forth in 38 C.F.R. § 4.56(c) and (d). His reported functional limitations, including weakness and pain with certain movements causing him to discontinue the pain-triggering activity (such as shoveling snow), are concomitants of the symptoms already compensated under the applicable diagnostic codes and thus are within the purview of the schedular criteria, even if such criteria are not couched in terms of functional limitations. See 38 C.F.R. § 4.1 (providing that the degrees of disability specified in the General Rating Criteria are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability). There is no indication that the Veteran's pain on movement is unusual or in excess of the limitations contemplated by the rating criteria. There are also no symptoms that have been left uncompensated or unaccounted for by the assignment of a schedular rating. See Thun, 22 Vet. App. at 115. As noted in Thun, the rating criteria are averages and need not account for each individual circumstance in order to be adequate for evaluation purposes. Rather, the disability must be "exceptional" or "unusual." Consequently, the available schedular evaluations are adequate to rate this disability. In the absence of this threshold finding, there is no need to consider the second step of the inquiry, namely whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). Nevertheless, apart from the Veteran's one-time statement of being "unemployable" due to his SFW residuals in the September 2012 DBQ, there is no competent or credible evidence of marked interference with employment or frequent hospitalization. Further inquiry into this issue, however, is moot since the threshold requirement of an exceptional or unusual disability picture has not been satisfied. See id. Therefore referral for extraschedular consideration is not warranted. See id. Accordingly, the preponderance of the evidence is against the Veteran's claim. Therefore, the benefit-of-the-doubt rule does not apply, and a rating in excess of 10 percent for residuals of a shell fragment wound to the right anterior chest is denied. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. ORDER Entitlement to an evaluation in excess of 10 percent for residuals of a shell fragment wound (SFW) of the right anterior chest is denied. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs