Citation Nr: 1324384 Decision Date: 07/31/13 Archive Date: 08/07/13 DOCKET NO. 07-34 359 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to an increased disability rating for service-connected gunshot wound of the left medial thigh, currently rated 30 percent disabling, to include whether additional separate ratings are warranted for involvement of multiple muscle groups. REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Barone, Counsel INTRODUCTION The Veteran had active duty service from February 1969 to May 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2006 determination by a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was previously before the Board in August 2011 and in September 2012, when it was remanded for additional development. The August 2011 VA examination report (and subsequent evidence) has specifically clarified that the gunshot wound of the left thigh involved multiple muscle groups of the left thigh. The Board's September 2012 remand accordingly recharacterized the issue on appeal to contemplate the broader scope of left thigh muscular disability under consideration in this case. During the pendency of this appeal, a June 2012 RO rating decision partially granted the Veteran's claim on appeal by awarding a 30 percent disability rating for the left thigh gunshot wound disability effective from September 5, 2006; a 10 percent rating for the disability is in effect prior to that date. This appeal now includes the Veteran's claim of entitlement to higher disability ratings for both periods. The Board observes that during the course of this appeal, a June 2009 RO rating decision granted service connection for left knee instability with degenerative joint disease as secondary to the gunshot wound of the left thigh. The Board also observes that during the processing of the Board's August 2011 remand, a June 2012 RO rating decision granted service connection for scars associated with the left thigh gunshot wound. During the processing of the Board's September 2012 remand, a February 2013 RO rating decision granted service connection for a right Achilles tendon tear, left lower extremity varicose veins, and right knee instability all secondary to the left thigh gunshot wound on appeal. The Veteran has not appealed any aspect of the assignments of separate disability ratings for scarring, vascular problems, or knee impairment. No appeal of such ratings has been prepared for Board review at the Agency of Original Jurisdiction, and those ratings are not currently before the Board in this case. The Veteran testified at a Board hearing in January 2011. A transcript of this hearing is of record. FINDINGS OF FACT 1. Prior to August 4, 2006, the Veteran's service-connected residuals of gunshot wound of the left medial thigh were productive of moderate impairment to Muscle Group XIV and Muscle Group XV, but not greater impairment. 2. From August 4, 2006, the Veteran's service-connected residuals of gunshot wound of the left medial thigh were productive of moderately severe impairment to Muscle Group XIV and Muscle Group XV, but not greater impairment. CONCLUSION OF LAWS 1. For the period prior to August 4, 2006, the criteria for a rating in excess of 10 percent for residuals of gunshot wound of the left medial thigh involving Muscle Group XIV have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.56, 4.73, Diagnostic Code 5314 (2012). 2. For the period from August 4, 2006, the criteria for a 30 percent rating (but no higher) for residuals of gunshot wound of the left medial thigh involving Muscle Group XIV have been met; the criteria for a rating in excess of 30 percent for disability of Muscle Group XIV have not been met at any time. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.56, 4.73, Diagnostic Code 5314 (2012). 3. For the period prior to August 4, 2006, the criteria for a separate 10 percent rating (but no higher) for residuals of gunshot wound of the left medial thigh involving Muscle Group XV have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.56, 4.73, Diagnostic Code 5315 (2012). 4. For the period from August 4, 2006, the criteria for a separate 20 percent rating (but no higher) for residuals of gunshot wound of the left medial thigh involving Muscle Group XV have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.56, 4.73, Diagnostic Code 5315 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Duty to Notify The record shows that a letter dated May 2006 informed the appellant of the information and evidence necessary to warrant entitlement to the benefits sought on appeal. The appellant was also advised of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The United States Court of Appeals for Veterans Claims' decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. In this case, the May 2006 VCAA letter provided notice prior to the August 2006 RO rating decision on appeal. The VCAA notice was therefore timely. Further, the notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). To the extent pertinent to the present appeal, the Board notes that the May 2006 letter provided notice of the types of evidence necessary to establish a disability rating and effective date for the disability on appeal. In sum, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. The record in this case includes all pertinent identified medical records, including VA treatment records. The Veteran was afforded VA examinations in June 2006, March 2009, August 2011, August 2012, and December 2012. The Board finds that the set of VA examination reports addressing the increased rating issue on appeal now present a sufficiently thorough and complete discussion of the pertinent history, current findings, symptom complaints, and expert determinations informed by review of the claims file and direct examination of the Veteran such that the reports (read together) present adequate and probative evidence in this case. The Board observes that in April 2009 the RO issued a formal finding of unavailability documenting that treatment records "for 1982 from Tucson, Arizona VA Medical Center are unavailable for review." The Veteran's contentions pertinent to this appeal, which features a rating period that begins more than two decades after 1982, do not direct significant attention to matters of treatment in 1982. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. The Board finds that the actions directed by the prior remands have been completed in substantial compliance with the terms and purposes of those remands. In this regard, the Board notes that the August 2011 and December 2012 VA examination reports reflect that the directed VA examinations were accomplished and the reports adequately address the appeal in accordance with the Board's directives. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the claimant. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ clearly discussed the matter of identifying the issue on appeal as well as identifying additional claims the Veteran wished to raise which were not in appellate status. The Veteran was assisted at the hearing by an accredited representative from his service representative Colorado Division of Veterans Affairs. The VLJ granted the Veteran's motion to hold the record open for 60 days to permit the submission of additional medical evidence. After the hearing, the Board has twice remanded this appeal for the purpose of ensuring adequate development of the medical evidence pertinent to this appeal; significantly, the Board's decision at this time involves a partial but substantial grant of the appeal for increased disability compensation. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) nor identified any prejudice in the conduct of the Board hearing. The Veteran's representative and the VLJ asked questions to draw out the evidence which related to the severity and symptomatology of the Veteran's residuals of gunshot wound to the left thigh. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that any error in notice provided during the Veteran's hearing constitutes harmless error. In any event, as (1) the Board has already twice remanded this matter for additional development of the medical evidence and (2) the evidence supports a substantial partial grant of the increased disability compensation sought consistent with the symptoms described by the Veteran, the Board finds that to send the Veteran a letter and ask him to submit more evidence detailing his left thigh disability manifestations would be "an idle and useless formality." NLRB v. Wyman-Gordon Co., 394 U.S. 759, 766 n. 6 (1969). VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision at this time. Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file (including the Virtual VA electronic claims file), 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 claim. The Board notes that some of the pertinent evidence in this case is found in the Virtual VA paperless claims processing system; this evidence has been reviewed and is discussed below where appropriate. The Veteran contends that the severity of his service-connected left thigh gunshot wound residuals warrants higher disability ratings than those currently assigned under 38 C.F.R. § 4.73, Diagnostic Code 5314. The ratings on appeal feature a 10 percent rating for the period prior to September 5, 2006, and a 30 percent rating effective from that date. The appeal arises from a claim filed in March 2006. Initially, it should be noted that VA regulations allow for the assignment of an increased rating up to one year prior to receipt of a formal claim for increase, when it is factually ascertainable that an increase in disability had occurred. 38 C.F.R. §§ 3.157, 3.400(o)(2). In this case, VA must review the evidence of record from March 2005 (a year prior to the March 2006 claim leading to this appeal), to determine if there was an ascertainable increase in the Veteran's left thigh gunshot wound residuals. In so doing, the Board must also consider all potentially applicable regulations pertaining to rating left thigh disability. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order 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 v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). 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). Nevertheless, the Board acknowledges that 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 in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. It should be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. However, merely having pain throughout the entire range of motion of a major joint, or groups of minor joints, does not warrant a maximum rating. Rather, any such painful motion must be shown to produce actual functional limitation. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In sum, Mitchell held that pain on motion is not, itself, "functional loss," but "may result in functional loss ... only if it limits the ability 'to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance'." Id. at 38 (quoting 38 C.F.R. § 4.40). The Board notes that the service-connected pathology involved with this issue is complex and involves application of multiple rating codes with several different simultaneous disability ratings currently in effect. However, the single issue currently remaining on appeal features only the left thigh gunshot wound residuals and not any secondary disabilities for which claims of entitlement to secondary service connection have been separately adjudicated. Service connection has been separately established for disabilities of the right Achilles, left lower extremity varicose veins, left knee instability and degenerative joint disease, right knee instability, and scars on the left lower extremity associated with the gunshot wound. There has been no appeal of the ratings separately assigned for these disabilities; the ratings assigned for these separately recognized service-connected disabilities are not before the Board at this time. Accordingly, the Board's analysis of the left thigh disability at issue in this case shall not focus upon associated scarring, vascular problems, or knee limitation to the extent that these matters are contemplated in separate disability ratings that have not been appealed. The Board's analysis in this case focuses upon the injuries of muscle groups shown to be directly involved in the gunshot wound injury to the left thigh, with attention also to potentially pertinent neurological or left hip manifestations of the same disability. The gunshot wound of the left medial thigh has been rated by the RO under the provisions of 38 C.F.R. § 4.73, Diagnostic Code 5314, which pertains to impairment of Muscle Group XIV. Such group affects the function of extension of the knee, simultaneous flexion of the hip and flexion of the knee, tension of the fascia lata and iliotibial band, acting with Muscle Group XVII in postural support of the body, and acting with the hamstrings in synchronizing hip and knee. Group XIV involves the anterior thigh group muscles (1) sartorious, (2) rectus femoris, (3) vastus externus, (4) vastus intermedius, (5) vastus internus, and (6) tensor vaginae femoris. Under this code, a noncompensable rating is assigned for a slight muscle injury, a 10 percent rating when moderate, a 30 percent rating when moderately severe, and a 40 percent rating when there is a severe injury. 38 C.F.R. § 4.73, Diagnostic Code 5314. The Board is required to consider all evidence of record and to consider, and discuss in its decision, all "potentially applicable" provisions of law and regulation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The provisions of Diagnostic Code 5315 pertain to Muscle Group XV. Such group affects the function of adduction of the hip, flexion of the hip, and flexion of the knee. Group XV involves the mesial thigh group (1)adductor longus, (2) adductor brevis, (3) adductor magnus, (4) gracilis. Under this code, a noncompensable rating was assigned for a slight muscle injury, a 10 percent rating when moderate, a 20 percent rating when moderately severe, and a 30 percent rating when there is a severe injury. 38 C.F.R. § 4.73, Diagnostic Code 5315. Except as otherwise provided in the rating schedule, all disabilities, including those arising from a single disease entity, are to be rated separately, so long as the symptomatology for the disabilities is not "duplicative of or overlapping with the symptomatology" of any of the other disabilities. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Court of Appeals for Veterans Claims (CAVC) has determined that a veteran that suffers a through-and-through injury with muscle damage is, as a matter of law, entitled to have "each group of muscles damaged" rated as no less than a moderate injury. Jones v. Principi, 18 Vet. App. 248, 258 (2004). Muscle injuries are evaluated pursuant to criteria at 38 C.F.R. §§ 4.55, 4.56, and 4.73. For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions. 38 C.F.R. § 4.55(b). The specific bodily functions of each group are listed at 38 C.F.R. § 4.73. Generally, a muscle injury rating will not be combined with a peripheral nerve paralysis rating for the same body part, unless the injuries affect entirely different functions. 38 C.F.R. § 4.55(a); see also 38 C.F.R. § 4.14. The severity of the muscle disability is determined by application of criteria at 38 C.F.R. § 4.56. First, an open comminuted fracture with muscle or tendon damage will be rated as severe, unless (for locations such as the wrist or over the tibia) the evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(a). A through and through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(b). 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). Under Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe. 38 C.F.R. § 4.56 (d). The type of injury associated with a moderate muscle disability 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. A history with regard to this type of injury should include service department evidence or other evidence of in-service treatment for the wound and consistent complaints of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use affecting the particular functions controlled by the injured muscles. Objective findings should include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue and 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 associated with a moderately severe muscle disability is a through and through or deep penetrating wound by a small high-velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. A history with regard to this type of injury should include prolonged hospitalization in service for treatment of wound, consistent complaints of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups, and indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). The type of injury associated with a severe muscle disability is a through and through or deep penetrating wound by a small 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, and intermuscular binding and scarring. A history with regard to this type of injury should include prolonged hospitalization in service for treatment of wound, consistent complaints of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings should include ragged, depressed, and adherent scars indicating wide damage to muscle groups in missile track, and indications on palpation of loss of deep fascia, muscle substance, or soft flabby muscles in wound area. Also, muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side should indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X- ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of missile; (B) adhesion of scar to one of the long bones, scapula, pelvic bone, sacrum, or vertebrae, with epithelial sealing over the bone, rather than true skin covering in an area where bone is normally protected by muscle; (C) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) visible or measurable atrophy; (E) adaptive contraction of an opposing group of muscles; (F) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (G) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4). The Veteran has been afforded several VA examinations in connection with the evaluation of the disability on appeal in this case. Each of the corresponding examination reports presents pertinent clinical findings from medical professionals informed by interview and direct inspection of the Veteran. For compensable muscle group injuries which are in the same anatomical region 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. 38 C.F.R. § 4.55(e). In every instance where the schedule does not provide a zero percent evaluation for a Diagnostic Code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. A June 2006 VA examination report, in pertinent part, discusses the left thigh disability on appeal in this case. The report discusses that the Veteran was a helicopter pilot during service over Cambodia when he was in the line of fire and was hit in the left thigh (and also the upper arm). The "bullet in the thigh entered and exited." Medics "did debridement of this left thigh wound and left it open." They "sutured the entrance wound and the exit wound of the left thigh, but they apparently did a debridement of another wound on the anterior aspect of his left thigh." The service medics "left the anterior wound of his thigh open for a week, and then resutured it...." The June 2006 VA examination report shows that the Veteran reported that the "only symptoms" at the time of examination were "periods of severe cramps causing pain from time to time, and this would occur about 3-4 times a year only.... they would last for at least 30 minutes at a time." The examiner commented that "[t]he point of importance here is that any cramps in his legs would be 3-4 times a year, lasting not more than 30 minutes." The report also notes that "he tends to feel that his left thigh is somewhat slightly weaker than his right leg." The Veteran "denies any problems with any joint involvement, per se." The physical examination revealed an entrance wound on the medial aspect of his left thigh that was 10 centimeters long and 1 centimeter wide; there was an exit wound of 4 centimeters length and 1 centimeter width. The examination report noted an open wound, due to shrapnel, in the middle of his thigh, measuring 12 centimeters long and 3 centimeters wide. The examiner explained that the last wound was left open for three to four weeks and consequently healed with a much wider scar than any of the other wounds. The examiner noted "no evidence of any muscle wasting or any muscle damage per se," and that it "appears that there was no evidence to suggest that there was any." The examiner explained that "there does not appear to have been any obvious damage to muscle, tendon, nerve, or bone," and "there is no evidence of any difference between the 2 thighs, except for the scars." The June 2006 VA examination report provides detailed findings regarding the scarring, but as the Veteran's scarring has been separately service connected and assigned a rating that has not been appealed, the Board shall not recount all of these details in this decision concerning muscle injury. The Board notes, however, that the examiner found that "[t]he scars appear superficial," and "[i]t does not appear that these scars attach to any deep muscle or deep tissue, or are causing any muscle damage." The examiner noted that the only joint involved in the pertinent disability was the left hip, which had "perfectly normal range of motion." The examiner noted that all sensory modalities were grossly intact, except for loss of sensation to touch and pinprick over the scar areas of the wounds on the thigh ... only localized to the actual scar tissue." The examiner's final analysis was that the gunshot wound of the left thigh caused "a lot of pain and discomfort, for which I think we should allocate him at least a 10-degree loss in forward flexion of his left hip movement, since the spasm would cause problems with movements of his left hip." The examiner reiterated that there is no evidence to suggest any muscle damage or obvious muscle wasting or any tendon, bone, or nerve damage. The examiner noted that X-ray study revealed "no definite metallic shrapnel." The examiner commented that, aside from what has been discussed, there was "no change in active or passive range of motion during repeat testing against resistance, and no additional losses of range of motion are recommended for his left thigh ... due to painful motion, weakness, impaired endurance, incoordination, or acute flares...." The Board notes that a VA treatment report dated in August 2006 shows that the Veteran described that "his activities have had to be adjusted because of thigh weakness / cannot play basketball / bowl / do vigorous activities with grandkids because of thigh weakness...." The VA medical assessment at that time included: "thigh weakness ... is limited in activities because of this weakness...." A March 2009 VA examination report updates and adds pertinent medical information concerning this issue. In pertinent part, the March 2009 VA examination report indicates that the Veteran "works as a real estate investor and developer." The report describes that the in-service left thigh injuries "were through and through injuries affecting the soft tissues. It did not affect the bone. No fractures were noted." The Veteran reported that "he always felt like he has reduced thigh muscle mass in the leg as a result of that problem, reduced muscle tone and reduced muscle volume." The Veteran reported developing knee symptoms over the previous 10 to 15 years after service. The Veteran reported the knee symptoms included a feeling of giving way and a buckling sense when doing a lot of lifting, bending or exercise; there with no pain, locking, or catching noted. (The Veteran's left knee disability is service connected separately and the rating for that disability is not currently on appeal; accordingly, the Board shall not further detail the examiner's discussion specific to the left knee.) The Veteran reported that he had been able to function in his usual occupation and had not missed any work time because of the leg disability. The Veteran reported that his gait was abnormal with limping on his left side at times; the Veteran did not use any assistive devices. Physical examination findings in the March 2009 report indicate no gross muscle tissue loss beneath the entry or exit scars. Examination of the thigh showed a "very mild quadricep atrophy in the left thigh as compared to the right, mild atrophy is seen." The Veteran had fully normal (5/5) extension strength and flexion strength in the knee as well as fully normal (5/5) extension, flexion, and abduction strength of the hip. (Findings particular to the left knee joint disability and findings particular to scarring of the skin are presented, but such disabilities are separately rated and are not currently part of this appeal concerning muscle injury.) The examiner noted no increased pain with repetitive resisted motion and no pain with range of motion testing; the examiner found that there was no weakness, incoordination, or easy fatigability noted to DeLuca style testing done three times against resistance. The March 2009 VA examination report's diagnostic conclusions, following X-ray study, indicate that the examiner found "old gunshot injury to the left thigh" and that "a very mild quadricep weakness and atrophy is seen...." The examiner referred to "a quadricep bridge in the left thigh" and "[r]etained metallic fragments in soft tissues on 6/2/06." The examiner also made a separate diagnosis of degenerative joint disease of the left knee, with discussion mostly pertinent to that separately service-connected and separately rated disability; however, with this diagnosis the examiner includes a comment that "this patient has lost some degree of quadricep tone and girth and this can give patients a sense of buckling and giving way which is exactly what this veteran feels." An August 2011 VA examination report updates and adds pertinent medical information concerning this issue. The Veteran reported that he had not missed any work in the last year due to the left thigh disability; he had missed work due to his right leg giving out; service connection has recently been separately established for right leg disabilities and those ratings are not part of the current appeal. The August 2011 VA examination report's account of the occurrence of the gunshot wound to the left thigh is consistent with prior accounts in all pertinent respects. The Veteran reported having "ongoing muscle atrophy in the left leg" and that he had been "unable to do sports after leaving the military." The Veteran described a remote history of experiencing looseness of the left knee requiring him to wrap the leg and keep it stiff, eventually leading to right leg problems; the Veteran reported that in approximately 1996 a VA medical provider told him that he had a loose kneecap. At the time of the August 2011 VA examination, the Veteran reported "spasms in the left leg and it is weak." The Veteran reported being unable to run since the original injury, being unable to do a 100 yard man carry, and having to climb ladders very slowly to avoid having his left knee give out and because he does not trust his left leg to not cramp. The Veteran reported that the knee problem "isn't as bad as it used to be." The Veteran denied having any problems dressing or getting into or out of a shower. The Veteran described using handles in a tub for stability. The Veteran reported no problems driving an automatic. The Veteran explained that he avoided stairs and did not believe he could go up more than two flights. He described that he could stand without much difficulty but could walk only one quarter to one half of a mile without hills. The Veteran described experiencing pain with stairs throughout the anterior and medial thigh, but no increased pain with walking on a level surface. The Veteran described that he experiences spasms in the left anterior and medial thigh "a couple of times per month with pain of "7-8/10 with spasms, or at least 3-5/10." The August 2011 VA examination report indicates that the Veteran's left knee and hip were "negative for pain, locking, stiffness, swelling and instability now." The report indicates "[n]o flares or assistive device." Following review and extensive discussion of the contents of the claims-file, the examiner presented current examination findings including: "slightly stiff gait, but can do heel walking, toe walking," "half squatting causes RIGHT quadriceps fasciculations," pertinent deep tendon reflexes were normal "2+" and symmetric, and there was decreased pinprick sensation of the left medial and anterior thigh." Strength was a normal "5/5" in the bilateral ankle dorsiflexors, extensor hallucis longus and hamstrings (with some cramping in the hamstrings). Strength was 4/5 for the left hip abductors as compared to 5/5 on the right, tested in sidelying position. Furthermore, "[h]ip abductors on the left were <3 tested in left sidelying, about 2/5 (right side 5/5). Hip flexors and knee extensors were 5-/5 on the left, 5/5 on the right." Proximal left thigh circumference, measured at the level of the groin, was decreased at "60.5 cm compared to 64.5 cm on the right." Distal left thigh circumference, measured 15 cm above the knee, was "54 cm on the left and 55 cm on the right." There was "visually decreased muscle bulk on the left in the rectus femoris, vastus medialis, and adductor longus." The examiner noted extensive and large varicose veins in the left medial thigh but none on the right. Additional findings are presented concerning the knee and scarring more pertinent to separately service-connected issues not on appeal. The August 2011 examination report discusses that diagnostic imaging of the left femur revealed that "[t]wo punctate metallic foci overlie the soft tissues in the upper/mid-thigh medial to the femur on the AP view, not seen on the orthongal projection suggesting artifact." The hip and knee joint alignment as well as the femur were intact. The report references the June 2006 diagnostic imaging report showing "[n]o definite metallic shrapnel identified"; the humerus was intact as was alignment of visualized joints. The August 2011 VA examiner diagnosed: "Gunshot wound left thigh with residual scars, muscle weakness, and muscle atrophy. Muscle Groups XIV (particularly involving the rectus femoris, vastus lateralis (externus), vastus intermedius, TFL or tensor vaginae femoris) and XV (adductors) are involved." The examiner found that the "[s]everity of atrophy and weakness are moderate." The examiner also found "mild sensory involvement in the distribution of the obturator and intermediate and medial cutaneous nerves of the thigh." In September 2012, after the Board had undertaken appellate review of this case, a VA examination report was added to the record presenting evidence pertinent to the issue on appeal. The VA examination was conducted in August 2012. The record of the VA examination was added to Virtual VA during September 2012. As discussed in the Board's September 2012 remand of this issue, this VA examination report is substantially inconsistent with the rest of the evidentiary record and, furthermore, introduces critical uncertainty and ambiguity. The earlier August 2011 VA examination report specifies that Muscle Group XIV and Muscle Group XV were involved in the through-and-through gunshot wound, and presented detailed findings concerning the nature and severity of the left thigh disability. Separate claims, not on appeal, appear to have led to the development of the August 2012 VA examination report which features a completed Disability Benefits Questionnaire report directly evaluating muscle injuries. It is not entirely clear whether the August 2012 VA examination report was intended to be focused upon the scope of the left thigh gunshot wound residuals or, rather, intended to encompass a broader scope. The August 2012 report begins by diagnosing a left leg gunshot wound with a set of other related diagnoses specific to the left leg. The report goes on to indicate involvement of Muscle Groups XIII, XIV, XV, XVI, and XVIII for both legs. The report also indicates involvement of Muscle Groups XI and XII for the right leg only. The prior evidence, including the August 2011 VA examination report, had only suggested or indicated involvement of the left thigh's Muscle Groups XIV and XV. As discussed in the Board's September 2012 remand, the August 2012 VA examination report's substantial expansion of the number of Muscle Groups involved is highly confusing to the extent that the findings are so inconsistent with the findings in prior evidence, without explanation, and because the report does not explain the nature of the involvement of the numerous additional Muscle Groups. The inclusion of a number of Muscle Groups of the right leg, when the gunshot is established to have penetrated only the left thigh and when the only identified diagnoses in the report are specifically limited to the left leg, strongly suggests that the report is including Muscle Groups that are not directly associated with the gunshot injury on appeal (even if they may be secondary consequences resulting from the original gunshot wound due to such factors as compensation, altered gait, or other secondary pathologies). The issue on appeal concerns rating the gunshot injury itself, while separate claims that are not on appeal have concerned additional disabilities that may be secondary to the residuals of the original gunshot wound. Significantly, the Veteran has been separately awarded service-connected benefits for disabilities secondary to the gunshot wound, including right leg disability, during the pendency of this appeal. As discussed by the Board's September 2012 remand, to the extent that the August 2012 VA examination report may be listing together all impaired Muscle Groups of the lower extremities without distinguishing between those directly affected by the gunshot wound and those affected only by secondary but distinct pathology subject to separate claims, greater clarity and specificity was required. In order to appropriately apply examination findings to the rating criteria, the Board must be able to determine which findings are to be rated as residuals of the gunshot wound currently on appeal. The August 2012 VA examiner's remarks merely indicate that various left leg diagnoses (not further discussing Muscle Groups or the right leg) are related to the Veteran's left knee disability, which itself has been service-connected as secondary to the left thigh gunshot wound but is a distinct secondary disability. Additionally, the August 2012 VA examination report presents indications of "Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track" with "loss of deep fascia," "Soft flabby muscles in wound area," "Induration or atrophy of an entire muscle following history of simple piercing by a projectile," and "Adaptive contraction of an opposing group of muscles" among other findings that present a remarkable contrast to all other VA examination report findings. The Board remanded the matter in September 2012 to develop additional medical evidence with clarification as to (1) whether these findings pertain specifically to the Muscle Groups associated with the specific pathology at issue in this appeal (once those Muscle Groups have been adequately identified), (2) which Muscle Group disability features are manifested in each Muscle Group, and (3) whether each finding is likely a significant recent increase in the severity of the disability or, rather, reflects this examiner's characterization of features of disability that are likely longstanding characteristics of the gunshot wound damage (and which prior medical reports perhaps overlooked). As a result, in December 2012 the Veteran was re-examined by the author of the August 2011 VA examination report. This VA examiner explained that the intervening August 2012 VA examination report was prepared by a provider who "will not provide this addendum, as we are no longer using that contract company." The December 2012 VA examination report was informed by re-examination of the Veteran and review of the claims-file, including noting that the August 2011 VA examination report was "confusing." The December 2012 VA examination report attempts to address, clarify, and reconcile the confusing indications raised by the August 2011 VA examination report. The Board finds that the December 2012 VA examination report presents clear information allowing the Board to determine the correct disability features actually pertinent to the specific disability on appeal; the December 2012 VA examination report thoroughly addresses the contents of the August 2012 VA examination report; the Board finds that the August 2012 VA examination report is essentially inadequate for rating purposes and that its pertinent information is clarified and reconciled with the rest of the evidence by the discussion in the December 2012 VA examination report. The December 2012 VA examiner noted that the Veteran's "occupational history has not changed." The Veteran reported that "[h]e thinks he tore a muscle in the medial thigh about 8 months ago because he woke up with his medical thigh blue down to the calf, his groin muscle 'balled up' proximally, and difficulty walking and controlling his leg." The Veteran reported that he "wrapped his thigh tightly for [] 2 months" and "he did not see a doctor." The Veteran described that he can walk through a big store without problems but "he thinks he would be uncomfortable by the end of one month." The Veteran reported that he experienced "Charley horses" in both thighs, anterior and posterior, after going up hills or walking faster than usual. He has to "tighten" the left leg and is cautious with it when he walks to avoid the feeling of instability at the knee. The Veteran explained that there was "no pain in the left thigh unless he gets a charley horse." There were "[s]till no problems with the left hip." The December 2012 VA examination report's physical examination findings show that gait was "a little stiff L>R and he locks his L knee slightly at heel strike." The gait was "mildly wide based." The Veteran was able to demonstrate normal heel walking, but toe walking was somewhat limited on the right side. Three-quarter squats caused "mild" tremors in the left quadriceps (and pain in the right Achilles region). Deep tendon reflexes were "2-3+" at the patellar and Achilles tendon, slightly brisker on the right at the knee and at the left ankle "likely due to GSQ to L quads and R Achilles tear." Sensation was decreased to pinprick in the left medial and anterior thigh. Motor strength findings included a note that "EDB bulk" was "slightly" diminished on the left compared to the right, with the examiner noting this has "no clinical relevance to this particular exam." The Veteran could do 10 full toe raises on the left. Hip flexion, knee extension, and hamstrings were all "5 on the R, 5- on the L." Gluteus medius tested in side lying were "4+ to 5- bilaterally due to deconditioning (most individuals do not strengthen this particular muscle)." Glut maximus was 5- bilaterally, "also from deconditioning." Hip adductors were "<3 bilaterally (which is different from my 2011 exam, and is likely due to the fact that this muscle is hard to isolate for testing side to side, and recent adductor injury is likely affecting both sides)." Report of examination of extremities included a comment that the examiner previously thought "there was more valgus in the left knee than right," but upon further consideration found that there is actually 10 degrees valgus bilaterally at the knees. Squeeze of either calf caused plantar flexion, greater on the left. The examiner noted "Ely's positive for hip flexor tightness." There was crepitus of the left knee patella, but no other pertinent findings associated with the knee. There was "[s]till no pain with L hip internal rotation." There had been no change in left thigh atrophy compared to the right since the 2011 examination, and there had been no change in the scarring since the 2011 examination. The December 2012 VA examiner diagnosed a gunshot wound to the left thigh with residual scars, muscle weakness, and muscle atrophy. The VA examiner specifically reiterated: "Muscle Groups XIV and XV are involved." The VA examiner specified that the "[s]everity of atrophy and weakness remain moderate." The examiner commented that "[m]ild sensory involvement of left obturator and intermediate and medial cutaneous nerves of the thigh unchanged." Significantly, the December 2012 VA examiner reviewed and compared the confusing August 2012 VA examination report to the August 2011 and December 2012 findings. The December 2012 VA examiner commented that the August 2012 report used a Disability Benefit Questionnaire which may have been confusing to the contracted medical professional "as it is worded in such a way that examiner may easily add other disabilities outside the muscle injury conditions which are the focus" of the appeal. The December 2012 VA examiner's impression was that "[i]t appears this is part of what happened with the [August 2012 VA] exam." The December 2012 VA examiner explains the discrepancies between the August 2012 VA examination report and the rest of the indications of record. The December 2012 VA examiner explains that "[i]n regards to the additional weakness which was noted [by the August 2012 VA examination report] in muscle groups XIII, XVI, and XVIII, the veteran reports today that his low back was giving him a lot of trouble when he went to the [August 2012] exam and this could certainly cause him to give less effort bilaterally due to pain." The December 2012 VA examiner states: "Regardless, today and in August 2011, there was only very mild weakness on the left in muscle groups XIV and moderate weakness in XV." The December 2012 VA examiner goes on to explain that the "[m]ild, symmetric gluteus maximus and medius weakness is a very common finding in individuals who are not working out or training those muscles regularly, and is not of significance on this exam." Furthermore, the "[m]inimal left knee flexion weakness can be explained by adductor magnus involvement from recent injury (which, given location and prior weakness of this muscle, is as likely as not due to the original GSW in service) and is not a separate Muscle Group XIII problem." Also, the "[m]ild left hip flexor weakness is explained by quadriceps/rectus femoris weakness, and is not a separate problem with muscle group XVI." The December 2012 VA examiner discusses that the "anterior thigh surgical scar has atrophied and spread out a little over time, giving it ragged edges," but explains that examination of the area reveals "[t]here is not significant evidence of loss of tissue in the missile track." The examiner further explains that "[t]here is no palpable herniation of muscle tissue through fascia thus there is no way to prove there is loss of deep fascia." The examiner acknowledged "[s]oft flabby muscles" and "extra subcutaneous tissue," but explains that there is no loss of neural innervation causing decreased tone in the muscles "as was determined by having the veteran fire his quads and adductors and palpating those muscles. All sections of the muscle bulk were firing, even though there is some diminished volume of these muscles (atrophy)." The examiner also stated "no induration or atrophy of an entire muscle was noted" and "I did not detect adaptive contraction of an opposing group of muscles." The examiner found that "hamstrings are not firing continually," and "[h]ip flexors are tight bilaterally and this is relatively symmetric, common in individuals with back pain, and not an indicator of the GSW." The examiner concluded that: "Other than the recent severe adductor strain and partial tear on the left there is no exacerbation of the veteran's disability as compared to August 2011." The December 2012 VA examination report further contains a completed Disability Benefits Questionnaire worksheet which presents the examiner's findings and conclusions through answers substantially consistent with the explanations and analysis discussed just above. The examiner's findings included involvement of the left sided Muscle Groups XIV and XV only, with cardinal signs and symptoms featuring consistent loss of power, consistent weakness, occasional lowered threshold of fatigue, and muscle atrophy. The examiner also indicated that the Veteran's muscle injuries do not impact his ability to work. The claims-file additionally contains lay statements from the Veteran and other witnesses concerning a wide range of issues and the remote history of his left thigh disability. To the extent that the lay testimony in this case contains information specifically pertinent to the left thigh disability rating issue on appeal, this information is essentially consistent with the account of symptoms and features of the disability discussed in the detailed VA examination reports informed by the Veteran's descriptions and objective medical findings. To the extent that the Veteran's contentions have additionally referenced corroborative photographs, the Board notes that all of the Veteran's contentions and symptom reports have been considered and accounted for by the VA examination reports of record as well as by the Board analysis in applying the rating criteria to the shown disability features in this case. This claim arises from a claim filed by the Veteran in March 2006. For the period on appeal prior to September 2006, a 10 percent rating is in effect under Diagnostic Code 5314. A June 2012 RO rating decision has assigned a 30 percent rating under Diagnostic Code 5314 effective from September 5, 2006. The basis for the selection of September 5, 2006, as the effective date for the 30 percent rating was explained in the RO rating decision to be a determination that this was the earliest date upon which weakness of the left thigh was shown in VA treatment reports; reading the entirety of the June 2012 RO decision, it appears that the RO reasoned that the earliest showing of left thigh weakness reasonably evidenced a manifestation of the later-shown muscle atrophy meeting the criteria for a 30 percent rating. The Board notes that an August 4, 2006, VA treatment report shows a medical assessment of "thigh weakness/awaiting addl rating ... is limited in activities because of this weakness." It appears that this August 4, 2006, report presents the information the RO attributed to a date in September 2006. Under the circumstances of this case, the Board finds the most reasonable action is to find that the 30 percent rating under Diagnostic Code 5314 is warranted from August 4, 2006, because this is the correct date of the record the RO cited as the basis for its assignment of the 30 percent rating. The Board finds that the preponderance of the evidence is against assignment of any rating in excess of 10 percent under Diagnostic Code 5314 during the period prior to August 4, 2006. The 10 percent rating assigned contemplates "moderate" disability; assignment of a higher rating would require that the evidence show at least "moderately severe" disability. The June 2006 VA examination report shows that the Veteran reported that the "only symptoms" at that time were "periods of severe cramps causing pain from time to time, and this would occur about 3-4 times a year only.... they would last for at least 30 minutes at a time." Although the report noted the Veteran "tends to feel that his left thigh is somewhat slightly weaker than his right leg," such loss of power or lowered threshold of fatigue is contemplated in the 10 percent rating for "moderate" disability. The June 2006 VA examination report clearly shows that there was "no evidence of any muscle wasting or any muscle damage per se," that "there does not appear to have been any obvious damage to muscle, tendon, nerve, or bone," and "there is no evidence of any difference between the 2 thighs, except for the scars." These findings are simply not consistent with "moderately severe" disability under the terms of 38 C.F.R. § 4.56(d)(3). Neither the June 2006 VA examination report, nor any other evidence from the period prior to August 4, 2006, shows "moderately severe" muscle disability meeting the criteria for a 30 percent rating under Diagnostic Code 5314. No rating in excess of 10 percent under Diagnostic Code 5314 is warranted prior to August 4, 2006. The Board further finds that no rating in excess of the currently assigned 30 percent is warranted for the period from August 4, 2006, onward. The 30 percent rating contemplates "moderately severe" disability; assignment of a higher rating would require that the evidence show "severe" disability. Although some conflicting indications are introduced by the August 2012 VA examination report, the evidence does not show severe impairment of function. The Board finds that the inconsistencies between the August 2012 VA examination report and the findings of the rest of the evidence are persuasively reconciled by the December 2012 VA examination report which, informed by the examiner's multiple direct inspections of the Veteran (before and after the August 2012 examination), persuasively explains (1) that the August 2012 VA examination report appears to have included findings not pertinent to the disability on appeal due to confusion with the VA questionnaire form, and (2) that the objective indications and the Veteran's subjective report present a symptom picture that is not consistent with the findings in the August 2012 report. The most probative evidence, including the only evidence addressing the inconsistent findings in the August 2012 VA examination report, leads the Board to conclude that the August 2012 VA examination report presents a less accurate reflection of the disability symptoms than do the other pertinent items of medical evidence of record. In this light, the most probative medical evidence does not support finding "severe" muscle disability. The most probative evidence does not show abnormal muscle swelling or hardening in contraction nor indications of severe functional impairment of the thigh muscles. Although the March 2009 VA examination report suggests that the examiner observed metallic fragments in the June 2006 X-ray imaging, the Board finds that the most probative evidence indicates that there are no retained metallic fragments associated with the gunshot injury. The June 2006 VA examination report associated with the June 2006 X-ray imaging in question shows that it was interpreted as showing "no definite metallic shrapnel." The August 2011 examination report discusses that diagnostic imaging of the left femur revealed "[t]wo punctate metallic foci," but clearly explained that, in context, these findings were likely imaging "artifact" rather than actual metallic fragments (because the foci were "not seen on the orthongal projection"). The August 2011 report also references the June 2006 diagnostic imaging report showing "[n]o definite metallic shrapnel identified." The March 2009 suggestion that the June 2006 imaging showed retained metallic fragments is contradicted by the other medical evidence, including the probative report of the June 2006 X-ray study itself and the August 2011 VA examination report explaining why the appearance of metal foci actually suggest imaging artifacts rather than actual retained fragments. The Board finds that the probative evidence does not show X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of missile consistent with "severe" muscle disability. The evidence does not show adhesion of a scar with epithelial sealing over the bone. The evidence does not show diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. The evidence does not show atrophy demonstrative of "severe" muscle disability; the loss of muscle substance that is shown (in that the left thigh has become somewhat smaller than the right thigh) is consistent with the description of "moderately severe" muscle disability contemplated by the 30 percent rating. The evidence does not show adaptive contraction of an opposing group of muscles nor atrophy of muscle groups not in the track of the missile, nor induration or atrophy of an entire muscle following simple piercing by a projectile. The Board finds that the preponderance of the evidence is against finding that the criteria for a rating in excess of 30 percent is warranted for the disability of Muscle Group XIV at any time. The Board has also considered the applicability of Diagnostic Code 5315 for injury and disability of Muscle Group XV. The VA examination reports beginning with the August 2011 report clearly indicate that Muscle Group XV is directly involved in the gunshot wound; the features of injury and disability of Muscle Group XIV are indicated to be essentially shared by Muscle Group XV in all pertinent respects. With consideration of the nature of a gunshot wound injury which was incurred long before the period on appeal, the Board accepts that this evidence essentially indicates that disability of Muscle Group XV has been part of left thigh disability on appeal throughout the appeal period (indeed, since the incurrence of the gunshot wound). The Court of Appeals for Veterans Claims (CAVC) has determined that a veteran that suffers a through-and-through injury with muscle damage is, as a matter of law, entitled to have "each group of muscles damaged" rated as no less than a moderate injury. Jones v. Principi, 18 Vet. App. 248, 258 (2004). This holding instructs as to how to apply 38 C.F.R. § 4.56(b), dictating that a through and through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. Accordingly, the Board finds that a separate rating for disability of Muscle Group XV under Diagnostic Code 5315 is warranted in this case. As noted above, for compensable muscle group injuries which are in the same anatomical region 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. 38 C.F.R. § 4.55(e). The Board finds that 38 C.F.R. § 4.55(e) does not apply in this case, because Muscle Groups XIV and XV do act on the same joints. The evidence essentially indicates that Muscle Groups XIV and XV share the same features of muscle disability, without any meaningful distinction indicating that one Muscle Group is more severely affected than the other. Accordingly, the Board finds that, like Muscle Group XIV, Muscle Group XV manifested "moderate" disability for the period prior to August 4, 2006, and manifested "moderately severe" disability for the period from August 4, 2006, onward; these characterizations apply, and no characterizations of greater severity apply, for the same reasons as discussed above with regard to Muscle Group XIV. Applying Diagnostic Code 5315, then, a separate 10 percent rating is warranted prior to August 4, 2006, and a separate 20 percent rating is warranted from that date. For the reasons discussed above (concerning the details of muscle disability to both Muscle Groups XIV and XV), no higher ratings are warranted under Diagnostic Code 5315 during the period on appeal. A question arises as to whether the Veteran would be entitled to a higher rating on the basis of the nerve injury than for the muscle injury. The Board must answer this question in the negative. The evidence shows no neurological deficit prior to August 2011, and only "mild sensory involvement in the distribution of the obturator and intermediate and medial cutaneous nerves of the thigh." The Diagnostic Codes for paralysis of the obturator nerve (8528), the external cutaneous nerve of thigh (8529), and the ilio-inguinal nerve (8530) all provide noncompensable ratings for mild or moderate paralysis. See 38 C.F.R. § 4.124a. There is no evidence that suggests a greater level of disability for any pertinent nerve at any time. Hence, a higher rating would not be warranted given the shown symptomatology. The Board now turns to see if a higher rating is warranted under ratings of the musculoskeletal system set forth in 38 C.F.R. § 4.71a. Disabilities of the hips and thighs are set forth in Diagnostic Codes 5250 through 5255. Diagnostic Code 5250 is not applicable in the instant case because there has been no medical record indicating ankylosis of the left hip. Diagnostic Code 5254 is not for application because there has been no medical evidence showing that the Veteran has a flail hip joint. Lastly, Diagnostic Code 5255 is not applicable because there is no medical evidence of current impairment of the femur. Normal ranges of motion of the hip include hip flexion from 0 degrees to 125 degrees, and hip abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. The applicable Diagnostic Codes for limitation of motion of the hip are 38 C.F.R. § 4.71a, Diagnostic Codes 5251, 5252 and 5253. A 10 percent disability rating is warranted where extension of the thigh is limited to 5 degrees (Diagnostic Code 5251); or where flexion is limited to 45 degrees (Diagnostic Code 5252). 38 C.F.R. § 4.71a. A 20 percent disability rating is assigned where flexion is limited to 30 degrees; a 30 percent disability rating is assigned where flexion is limited to 20 degrees; and a 40 percent disability rating is assigned where flexion is limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. A 10 percent disability rating is also warranted for limitation of rotation of the thigh if the affected leg cannot toe-out more than 15 degrees; a 10 percent rating is warranted where adduction is limited such that legs cannot be crossed; and a 20 percent rating is assigned for limitation of abduction of the thigh with motion lost beyond 10 degrees. 38 C.F.R. § 4.71a , Diagnostic Code 5253. Where limitation of motion of either hip is noncompensable under Diagnostic Codes 5251, 5252, or 5253, a rating of 10 percent may be assigned where there is X-ray evidence of arthritis combined with limitation of motion objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003. The greatest extent of limitation of motion of the hip/thigh in this case is the June 2006 VA examination report's indication that the left hip had a "perfectly normal range of motion," but recommended that "we should allocate him at least a 10-degree loss in forward flexion of his left hip movement, since the spasm would cause problems with movements of his left hip." The June 2006 VA examiner explained that "no additional losses of range of motion are recommended for his left thigh ... due to painful motion, weakness, impaired endurance, incoordination, or acute flares...." With this evidence presenting the most severe indication of left hip limitation pertinent to the ratings of the musculoskeletal system set forth in 38 C.F.R. § 4.71a, there is simply no basis for assignment of any schedular rating under these provisions which could be more favorable to the Veteran than the ratings assigned under the Diagnostic Codes for muscular injury/disability. In light of the discussion above, the Board has now assigned: a 10 percent rating under Diagnostic Code 5314 and a 10 percent rating under Diagnostic 5315 prior to August 4, 2006; and a 30 percent rating under Diagnostic Code 5314 and a 20 percent rating under Diagnostic Code 5315 from August 4, 2006, onward. The Board finds that the ratings now assigned accurately depict the severity of the disability during each portion of the rating period on appeal, including the one year period prior to receipt of the claim for increase, and there is no basis for higher staged ratings. Accordingly, no further increased evaluation is warranted. To that extent, the preponderance of the evidence is against assignment of any further increases and there is no doubt to be resolved. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1991). Conclusion and Extraschedular Consideration In this decision, the Board has found that the evidence discussed above is highly probative evidence with regard to evaluating the severity of the Veteran's disability on appeal in this case. The evidence features the Veteran's statements, VA examination reports, and medical evidence presenting professional medical impressions and the Veteran's own account of symptom details. The reports specifically document and address the Veteran's symptom complaints, document the pertinent specialized clinical findings, and present competent medical examiners' assessments of the disability informed by direct interview and inspection of the Veteran together with consideration of the pertinent history. The Board has reviewed the entirety of the evidence of record, including the Veteran's testimony and additional treatment records (including service treatment records); the Board acknowledges that the claims-file contains additional medical treatment records with discussion of the Veteran's history and treatment of the disabilities on appeal consistent with the information presented in the highly detailed examination reports throughout the period on appeal discussed above. The Board finds that none of the evidence of record probatively contradicts the findings discussed above, nor does any of the evidence of record otherwise probatively show that the criteria for further increased ratings are met in this case. The Board acknowledges that the Veteran, in advancing this appeal, suggests that the disabilities on appeal may have been more severely disabling than the assigned disability ratings reflect. The Board has carefully considered the Veteran's contentions and testimony, including as presented in written statements, hearing testimony, and in his responses to the inquiries of VA examiners. Lay testimony is competent to describe such complaints as the frequency and nature of symptoms such as pain, and perceivable interference with activities. The Board has considered the Veteran's testimony in such respects, yet the decisive questions presented by the rating criteria in this case are medical in nature, as discussed above. The probative evidence supports the ratings assigned by the Board in this decision as discussed above; the preponderance of the most probative evidence does not support assignment of any further increased ratings in this case. Finally, in making these determinations, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence with regard to any adverse determination in this decision. The benefit-of-the- doubt doctrine does not apply and any further increased ratings sought in this appeal must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). The Board also recognizes that the Veteran and the record refer to the impact of the service-connected disabilities on the Veteran's functioning, including work functioning. In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe a veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate a veteran's level of disability and symptomatology, then either the RO or the Board must determine whether a veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, the symptoms described by the Veteran fit squarely within the criteria found in the relevant Diagnostic Codes for the disability at issue. In short, the rating criteria contemplate not only his symptoms but the severity of his disability. The manifestations of the Veteran's left thigh disability are consistent with the schedular criteria, which describe the features of the gunshot wound in great detail including the 'through and through' nature of the gunshot wound, loss of muscle substance, atrophy, and loss of power. Other rating criteria considered in this case also contemplate limited motion and pain associated with the left hip as well as neurological sensory deficit. There is no objective evidence that the manifestations of his left thigh disability are unusual or exceptional. In sum, there is no indication that the average industrial impairment from the service-connected left thigh disability would be in excess of that contemplated by the assigned ratings. For these reasons, referral for extraschedular consideration is not warranted. Lastly, the Court has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a Veteran or reasonably raised by the record, 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, if the disability upon which a claim of entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In the instant case, the March 2009, August 2011, and December 2012 VA examination reports all indicate that the Veteran's own account of his occupational functioning indicated no time missed from his ongoing regular employment due to the left thigh disability on appeal in this case; the most recent VA examination report from December 2012 expressly reiterates that the left thigh disability still does not impact the Veteran's employability. The Veteran appears to have been employed throughout the appeal period, and there is no substantial indication that the Veteran believes or contends that he is unemployable due to the disability involved in this appeal. An unemployability claim has not been reasonably raised by the record. In light of the discussion above, the Board has now assigned: a 10 percent rating under Diagnostic Code 5314 and a 10 percent rating under Diagnostic 5315 prior to August 4, 2006; and a 30 percent rating under Diagnostic Code 5314 and a 20 percent rating under Diagnostic Code 5315 from August 4, 2006, onward. The Board finds that the ratings now assigned accurately depict the severity of the disability during each portion of the rating period on appeal, including the one year period prior to receipt of the claim for increase, and there is no basis for higher staged ratings. Accordingly, no further increase in disability ratings is warranted. ORDER Entitlement to a disability rating of in excess of 10 percent for disability of Muscle Group XIV is not warranted prior to August 4, 2006. To this extent, the appeal is denied. Entitlement to a 10 percent rating (but no higher) for disability of Muscle Group XV is warranted prior to August 4, 2006. To this extent, the appeal is granted, subject to laws and regulations governing payment of VA monetary benefits. Entitlement to a 20 percent rating (but no higher) for disability of Muscle Group XV is warranted from August 4, 2006. To this extent, the appeal is granted, subject to laws and regulations governing payment of VA monetary benefits. Entitlement to a 30 percent rating (but no higher) for disability of Muscle Group XIV is warranted from August 4, 2006. To this extent, the appeal is granted, subject to laws and regulations governing payment of VA monetary benefits. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs