Citation Nr: 1331698 Decision Date: 10/02/13 Archive Date: 10/07/13 DOCKET NO. 13-00 218A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a disability rating higher than 30 percent for peripheral neuropathy of the right median nerve. 2. Entitlement to a disability rating higher than 10 percent for residuals of a shell fragment wound of the right arm. 3. Entitlement to a disability rating higher than 10 percent for residuals of a shell fragment wound of the right thigh. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Cheryl E. Handy, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1944 to November 1945. He received two Purple Heart Medals and the Combat Infantryman Badge, among other decorations. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions in June 2008, April 2010, and September 2010 of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which continued a 30 percent disability rating for paralysis of the right median nerve and a 10 percent disability rating for residuals of shell fragment wound of the right thigh, denied entitlement to TDIU, and continued a 10 percent disability rating for residuals of a shell fragment wound of the right arm, respectively. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to an increased rating for the residuals of shell fragment wound right thigh and entitlement to TDIU are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the appeal period, peripheral neuropathy of the Veteran's right median nerve impairment have been manifested by no more than moderate incomplete paralysis of the median nerve. 2. Throughout the appeal period, the Veteran's other residuals of a shell fragment wound in the right arm have consisted of a moderate injury to Muscle Group IX with weakness and loss of power, but no loss of muscle fascia, no compensable loss of motion of the fingers, and asymptomatic scarring. 3. A 10 percent rating for moderate injury to Muscle Group VII has been in effect form more than 20 years. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 30 percent for peripheral neuropathy of the median nerve of the right arm have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.159, 3.321(b)(1), 3.655(b), 4.1, 4.10, 4.124a, Diagnostic Code 8515 (2013). 2. The criteria for a disability rating higher than 10 percent for residuals of shell fragment wound of the right arm manifested by damage to Muscle Group VII have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.17, 4.40, 4.56, 4.71a, 4.73, Diagnostic Codes 5307, 5228, 5229; 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7803 (2008 & 2013). 3. The criteria for a separate rating of 10 percent for residuals of shell fragment wound of the right arm manifested by damage to Muscle Group IX have been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.17, 4.40, 4.56, 4.71a, 4.73, Diagnostic Codes 5309, 5228, 5229 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Duty to Notify Proper notice from VA must inform the claimant of any information and medical or lay 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In a claim for increase, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the Veteran was sent letters in September 2007 and March 2009 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Complete notice was not issued prior to the adverse determination on appeal. However, fully compliant notice was later issued in the March 2009 letter, and the claim was thereafter readjudicated in December 2012. Accordingly, any timing deficiency has here been appropriately cured. Mayfield, 444 F.3d 1328 (Fed. Cir. 2006). Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of relevant service and post-service treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All necessary development has been accomplished. The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. The Board has reviewed the Veteran's statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. The Veteran was provided with VA examinations for his right arm disabilities in June 2008, September 2010, and August 2012. A medical opinion is adequate "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet. App. 102, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When an examination is provided, the examiner must support his or her conclusions with an analysis that is adequate for the Board to consider and weigh against contrary opinions. Id. at 124-25. Thus, ""a] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The VA examinations and opinions discussed the Veteran's history, including his reports and other lay statements as well as prior examinations. It was also supported by reasons based on an accurate record. 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). For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Assigning Disability Ratings A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007); Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). Facts and Analysis The Veteran has argued on several occasions that when he first separated from service he was given a 50 percent disability rating for his right arm disability resulting from shell fragment wound in service. That rating was assigned based on a convalescent status and was later reduced to 20 percent under the legal guidelines then in place. 38 C.F.R. § 4.28 (2013). He has stated that his primary interest in seeking an increased disability rating is to return to a disability rating of 50 percent for the right arm. The Board notes that the Veteran is right hand dominant, and his right arm would therefore be his major arm for rating purposes. The Veteran's right arm disability resulting from the shell fragment wound in service has resulted in two separate ratings, both of which are on appeal here. At present, the nerve damage to the right arm, classified as peripheral neuropathy or partial paralysis of the median nerve, is assigned a 30 percent disability rating. The other residual effects of the shell fragment wound include skin scarring, which is not rated as compensable, and muscle damage, which is currently assigned a 10 percent disability rating. Under the rule against pyramiding, 38 C.F.R. § 4.14, the evaluation of the same disability or the same manifestation of a disability, under different diagnostic codes is to be avoided. See 38 C.F.R. § 4.55(a) (2013) (prohibiting separate ratings for muscle injury and peripheral never paralysis of the same body part unless the injuries affect entirely different functions). Muscle injuries are rated under the following criteria contained in 38 C.F.R. § 4.56: (a) An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. (b) A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. (c) For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. (d) Under diagnostic codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows: (1) Slight disability of muscles-- (i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles-- (i) Type of injury. 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. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. 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. (3) Moderately severe disability of muscles-- (i) Type of injury. 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. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. 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. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles-- (i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56. The Veteran's service treatment records show that he sustained a machine gunshot wound of the right forearm in March 1945. The wound was initially described as severe. The wound was debrided, treated with sulfa, and placed in an arm cast. Examination indicated that he could move all of his fingers but not his thumb and his fingers were warm. X-rays showed no fracture of the arm or elbow and no evidence of a foreign body. The wound was found to be penetrating. There was an entrance wound was 6 cm. below the below the elbow and the exit wound was at the level of level of the medial epicondyle. During his recovery he had some stiffness of the elbow and slight limitation of supination with paresthesias and hypoesthesias along the superficial radial and ulnar distribution of the hand. He was treated with physical therapy and diagnosed with incomplete paralysis of the median nerve. In May 1946, he was evacuated to a hospital in the zone of the interior. It appears that he remained hospitalized until receiving a certificate for disability discharge from service. The first examination after service separation, in April 1946, noted that the Veteran's right arm tired easily and ached constantly. The Veteran reported that after working for three months in a butcher shop he had left that job because of difficulty with prolonged standing and the strain on his right arm. He had been employed as a clerk at VA. Physical examination showed slight weakness of grip in his right hand and weakness of the opponens policis and of flexion of the terminal phalanx of the thumb. He had anesthesia of the dorsum of the right hand in the median nerve distribution, but no other motor loss or sensory change. Entrance and exit wound scars were not adherent or extensive. The diagnosis of mild partial paralysis of the right median nerve was confirmed. In August 1946, it was reported that the Veteran remained an employee of the RO. There are no reports of treatment for the Veteran's injuries for several decades following service. The Veteran's next VA examination took place in August 2002, when the Veteran reported increasing pain over the last 10 years. The Veteran remained able to accomplish activities of daily living with his right hand, but reported continuous numbness and frequently dropping objects. On examination there was slight weakness in the right hand. There was no apparent fixation of underlying tissue and scars were not tender to palpation. The wound, including scars, was described as well healed. Private treatment records dated in June 2007 show that the Veteran complained of chronic pain in his right arm, inability to grasp items reliably with his right hand, and spasmodic-type pain combined with areas of loss of sensation in his right hand. On physical examination the strength in his right hand was 4/5 compared to 5/5 on the left, and sensory examination showed decreased sensation on the posterior of the right arm and hand. On a June 2008 VA examination, the Veteran reported stiffness in the right forearm, decreased grip strength and weakness in picking up objects. He had pain ranging from 5 to 8 out of 10 in intensity and numbness in the first, second, and third fingers as well as in the thenar prominence. He was unable to pick up a coffee cup with just his right hand, but needed to use two hands to do so. He reported that at times he was unable to write two or three words in a row without stopping to rest his hand. Physical examination showed mild wasting of the thenar eminence and there was decreased strength in the right arm, particularly in the elbow flexors, extensors, and finger flexor for first, second, and third digits. He had decreased sensation to pinprick in the median nerve distribution and the medial ante-brachial cutaneous nerve distribution. His scars were described as a round scar 1.5 cm in diameter on the lateral aspect of the right forearm and a 2 cm linear scar on the inner elbow. All scars were flat, nontender on palpation, hypopigmented, moved freely with the surrounding skin without induration or ulceration, and were atrophic in nature. In a statement submitted in September 2009, the Veteran reported that he had lost a "good amount" of the motor skills in his right arm which were necessary to do any type of work or writing. He found it hard to do things like hold a cup or sign his name to a credit card receipt. On an April 2010 VA examination, the Veteran reported residual symptoms in his right arm as constant daily pain at 7/10 and numbness with increasing weakness and more instance of dropping things from his right hand. He also had difficulty writing. He had reduced strength on the right side compared to the left side and impaired sensation to pinprick and right hand. Range of motion in the right arm was described as flexion to 140 degrees, extension to 0degrees, forearm supination to 85 degrees, and pronation to 80 degrees. The right wrist range of motion was dorsiflexion to 50 degrees, palmar flexion to 80 degrees, radial deviation to 15 degrees, and ulnar deviation to 35 degrees, with negative Tinel's and Phalen's testing. Right hand and fingers showed intact opposition and normal fisting to the transverse crease, with ranges of motion of 90 degrees in the metacarpal phalangeal joints, 110 degrees in the proximal interphalangeal joints, and 70 degrees in the distal interphalangeal joints. On a September 2010 VA examination, the Veteran complained of daily pain and increasing weakness in the right arm. He had problems writing and dropped things occasionally. He had paresthesias and fatigue in the first, second, and third fingers of the right hand and aspects of the forearm overlaying the median nerve. Physical examination showed reduced grip strength and strength against resistance of 4/5 in the right hand and arm compared with 5/5 in the left. He had impaired sensation to pinprick and light touch on the forearm and hand in distribution of the median nerve. Range of motion in his elbows, wrists, and hands was normal and symmetrical, and there was no evidence of painful motion, tenderness, spasms, edema, or fatigability. The examiner noted the presence of right median nerve peripheral neuropathy but no objective findings of muscular defect. A private examination in March 2012 noted that there was evidence of mild nerve entrapment at the cubital tunnel on the right hand as well as mild-to-moderate carpal tunnel syndrome. Previous examinations had shown a negative median nerve compression test, negative Tinel's sign, and a negative Phalen's test on the right side. Physical examination showed decreased sensation in the right arm in all dermatomal distributions. Motor testing was essentially unchanged in the right arm and his left arm had no so significant weakness although there was slight weakness in left wrist flexion. On VA examination in August 2012, the Veteran reported difficulty tying his shoes because of a non-service-connected back disability and problems cleaning himself due to right hand weakness. He stated that he had difficulty in his job as a maintenance worker at the golf course because it was hard to lift the one gallon containers of sand used to cover divots. The Veteran said he had notified his employers he would be quitting his job because of this physical impairment. Physical examination showed a non-linear scar on the right forearm which was 2 cm by one cm and another that was 2 cm by 0.3 cm. The scars were deep but not tender on examination, did not result in any limitation of motion or function, and were not disfiguring. There was no loss of tone or atrophy and the Veteran's strength testing showed as 5/5. The examiner noted range of motion of both elbows as 0-140 degrees, with forearm supination at 80 degrees and pronation at 75 degrees, limited by age. Range of motion in both wrists was dorsiflexion to 60 degrees, palmar flexion to 70 degrees, radial deviation to 15 degrees, and ulnar deviation to 35 degrees, all limited by age. Range of motion in the hands and fingers was measured as 0 to 90 degrees in the metacarpal phalangeal joints, to 100 degrees in the proximal interphalangeal joints, to 60/70 degrees in the distal interphalangeal joints, with intact opposition and normal fisting to the transverse crease. EMG and NCV testing in January 2012 was note to be consistent with mild to moderate bilateral carpal tunnel syndrome. The examiner diagnosed peripheral neuropathy of the right median nerve with mild functional limitation and bilateral carpal tunnel syndrome, also with mild functional limitation. Residuals of the shell fragment wound of the right forearm were noted to include moderate functional limitation of Muscle Group IX. The examiner noted there was no effect on muscle substance or function and no evidence of fascial defects. The signs and symptoms of muscle disability were loss of power and lowered threshold of fatigue in Muscle Group IX of the right arm. Muscle strength testing again showed decreased strength of 4/5 in all right-sided muscle groups compared to 5/5 strength in the left side. The examiner indicated that the injury did not involve other muscle groups in the right upper extremity. Peripheral nerve symptoms were described as mild paresthesias or dysesthesias and mild numbness in the right arm, but no intermittent pain or constant pain. There was decreased sensation in the right inner and outer forearm and the right hands and fingers. The radial, ulnar, and musculocutaneous nerves were diagnosed as normal, but there was mild incomplete paralysis of the right median nerve. Nerve Damage Paralysis of the median nerve is rated under Diagnostic Code 8515. Under this criteria, a 10 percent evaluation is warranted for a minor or major extremity with mild incomplete paralysis of the median nerve; a 30 percent rating is warranted for a major extremity with moderate incomplete paralysis of the median nerve; a 50 percent rating is warranted for a major extremity with severe incomplete paralysis of the median nerve; and a 70 percent rating is warranted for a major extremity with complete paralysis of the median nerve. Symptoms of complete paralysis of the median nerve include the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of the thenar eminence, and the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. 38 C.F.R. § 4.124a, Diagnostic Code 8515. The Veteran's disability picture includes diminished strength and diminished grip, decreased sensation in the arm and fingers, and occasionally dropping objects. He is not able to lift heavier objects one-handed and has recurrent pain in his right arm. This is consistent with a moderate disability in the major hand/arm, or a 30 percent disability rating. A higher disability rating of 50 percent is not warranted, as the evidence does not reflect any additional symptoms which would be characterized as severe incomplete paralysis. The Veterans impairments have been characterized as mild or slight weakness in hand grip, deep tendon reflexes have been intact and Tenel's sign has been negative. The records dating from the time of the initial injury in service do not contain any findings of severe disability. Muscle Injury Muscle Group injuries are rated under criteria set forth in 38 C.F.R. § 4.73. The Board notes that the listed Diagnostic Code of record for the Veteran's right arm residuals is Diagnostic Code 5307, which rates impairment to Muscle Group VII. Muscle Group VII involves the muscles arising from the internal condyle of the humerus, to include the flexors of the carpus and long flexors of fingers and thumb and the pronator, and its functions include the flexion of wrist and fingers. 38 C.F.R. § 4.73, Diagnostic Code 5307. The August 2012 VA examination indicates that the Muscle Group affected by the shell fragment wound is actually Muscle Group IX, which would be rated under Diagnostic Code 5309. The Board will evaluate the Veteran's specific disability picture and symptomatology under both Diagnostic Codes 5307 and 5309 and will apply whichever rating criteria result in a more favorable outcome for the Veteran. There is no indication that a separate disability rating under each Diagnostic Code is warranted. A rating decision dated in August 2002, shows that the rating under Diagnostic Code 5307 had been in effect since October 29, 1946. The rating under Diagnostic Code 5307 is now protected, because it was in effect for more than 20 years. Murray v. Shinseki, 24 Vet. App. 420 (2011); 38 C.F.R. § 3.951(b) (2013). Under Diagnostic Code 5307, applicable to Muscle Group VII, a noncompensable rating is assigned when impairment is slight, a 10 percent rating is assigned when impairment is moderate, a 30 percent rating is assigned for the dominant hand when impairment is moderately severe, and a 40 percent rating is assigned when impairment of the dominant hand is severe. 38 C.F.R. § 4.73. An increased rating under Diagnostic Code 5307 is not warranted, because there is no current evidence of impairment of that muscle group. Diagnostic Code 5309 rates Muscle Group IX. Muscle Group IX involves the intrinsic muscles of the hand, including the thenar eminence, the short flexor, opponens, abductor, and adductor of the thumb, hypothenar eminence, the short flexor, opponens, and abductor of the little finger, 4 lumbricales, and 4 dorsal and 3 palmar interossei. Muscle Group IX functions to supplement the strong grasping movements of the forearm muscles with delicate manipulative movements. 38 C.F.R. § 4.73, Diagnostic Code 5309. As the hand is so compact a structure, isolated muscle injuries are rare, and these injuries are rated based on limitation of motion, with a minimum rating of 10 percent. 38 C.F.R. § 4.73, Diagnostic Code 5309, Note. Limitation of motion of the various digits (fingers and thumb) is rated under Diagnostic Codes 5228, 5229, and 5230. Limitation of motion of the thumb, first or second (index or long) fingers, with a gap of less than one inch (2.5 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, is rated as noncompensable (0 percent); with a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers is assigned a 10 percent rating; and a 20 percent rating is assigned for a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. See 38 C.F.R. § 4.71a, Diagnostic Codes 5228, 5229. Limitation of the ring or little finger (third or fourth finger) is not compensable. Diagnostic Code 5230. Under Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe. Inasmuch as the Veteran's shell fragment wound of the right arm was a through-and-through injury, it is to be considered at least a moderate injury for the specific muscle group in question. 38 C.F.R. § 4.56 A review of the history of the injury shows that the bullet wound was penetrating and through and through; although he did have debridement and prolonged hospitalization, there was no prolonged infection or sloughing of soft body parts. His scars have consistently been described as non-adherent and there is no evidence of intramuscular scarring. The post-service examination noted that he suffered mostly from decreased threshold of pain and fatigue pain in the right arm. While he reported leaving a job as a butcher due in part to the strain on his arm, there is nothing to indicate he could not keep up with work requirements, and the Veteran also attributed his change in employment to difficulty with prolonged standing. The record does not indicate that he had any sloughing of the soft parts, intramuscular scarring, loss of deep fascia or muscle substance. Based on the initial history of the injury, a moderate disability of the right arm muscles was demonstrated. Currently, the Veteran does not have compensable limitation of motion of any of the fingers under Diagnostic Codes 5309 and 5228-5230. As rating under Diagnostic Code 5307 is appropriate, because there is evidence of a muscle group injury which impacted the muscles which operate the flexors of the fingers and thumbs. The injury, as noted, was a through-and-through injury, and is to be rated as at least moderate under the provisions of 38 C.F.R. § 4.56. Examiners have described the Veteran as exhibiting some, but not all, of the cardinal signs and symptoms of muscle group injury, specifically weakness, loss of power and lowered threshold of fatigue. This is consistent with a moderate muscle group injury and a 10 percent disability rating. The Veteran's symptomatology is not consistent with a still higher disability rating, such as one for moderately severe muscle group injury. There is no evidence of loss of deep fascia or muscle substance, and no evidence of the original injury including debridement or prolonged infection with sloughing of the soft parts and intramuscular cicatrization. While there is evidence that the Veteran's strength and endurance of the muscle groups is slightly decreased when compared with the sound side, this symptomatology is included in the consideration for the 30 percent disability rating assigned for partial incomplete paralysis of the median nerve. As such, it may not be considered again here under 38 C.F.R. § 4.17. In any event a 10 percent rating is required under Diagnostic Code 5309, because the medical evidence shows that the Veteran's right arm bullet wound is moderate and involved that muscle group. The separate rating does not violate any of the restrictions on combined ratings for muscle injuries contained in 38 C.F.R. § 4.55 (2013). Scars During the course of the Veteran's appeal, VA revised the rating criteria for evaluating scars, effective October 23, 2008. See 73 Fed. Reg. 54710 (October 23, 2008). The amendments are effective for claims filed on or after October 23, 2008, unless a claimant requests consideration under the amended criteria. In this case, while the RO has not indicated whether it considered the Veteran's scars under the old or the new rating criteria, the Board notes that the Veteran's residuals other than nerve damage, that is, his scars were rated as noncompensable prior to the inclusion of the muscle injury considerations discussed above. The Veteran's claim for an increased disability rating was initially filed prior to the effective date of the amendments. The Veteran has not specifically requested adjudication under the new rating criteria. Nonetheless, the Board has opted to afford the Veteran the full benefits of consideration of both criteria, although any rating under the new criteria could be effective only as of October 23, 2008. 38 C.F.R. § 4.118 (2013) (providing that the new criteria cannot be applied prior to October 23, 2008). Prior to October 2008, Diagnostic Code 7801 provided ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. Scars that are deep or that cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) were rated 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 sq. cm.) were rated 20 percent disabling. Note (2) provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic Code 7802 provided ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, were rated 10 percent disabling. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic Code 7803 provided a 10 percent rating for superficial unstable scars and Diagnostic Code provided a 10 percent rating for superficial scars that are painful on examination. As the Veteran's scars are neither unstable nor painful on examination, these rating criteria are not applicable. The new rating criteria applicable to scars, effective October 23, 2008 provide ratings based on location of the scars and their appearance. Under Diagnostic Code 7801, scars affecting areas other than the head, face, or neck, that are deep and nonlinear affecting areas of at least 6 square inches or 39 square centimeters, but less than 12 square inches or 77 square centimeters, are assigned a 10 percent rating. Diagnostic Code 7802 assigns a 10 percent disability rating for scars in areas other than the head, face, or neck, that are superficial and nonlinear and equal to or greater than 144 square inches or 929 square centimeters in area. Diagnostic Code 7804 assigns ratings for scars that are unstable or painful. As noted, the Veteran's scars are not unstable or painful, so these criteria do not apply. In reviewing the description of the Veteran's scars from the shell fragment wound of the right arm, it is clear that a separate compensable rating for scars is not warranted under either the old or the new criteria. The Veteran's scars are smaller than any of the size measurements needed for a compensable rating, being 2 cm by 1 cm and 2 cm by 0.3 cm in area. There was no soft tissue damage, as required for a deep scar under the rating criteria, they were not unstable or painful, and they did not result in any limitation of function or motion. As such, under 38 C.F.R. § 4.118, no compensable disability rating is warranted for the Veteran's scars. Extraschedular Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2008). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). As noted above, the Veteran's scars are essentially asymptomatic and there are no manifestations that are not contemplated by the rating schedule. The median nerve and muscle injury symptoms are contemplated by the rating schedule and provide ratings based on the overall level of disability. There are no indications of manifestations outside the rating schedule. The weight of the evidence is against higher ratings than have been awarded in this decision. Reasonable doubt does not provide a basis for increased ratings other than as awarded in this decision. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.321(b), 4.7, 4.21. ORDER Entitlement to a disability rating higher than 30 percent for peripheral neuropathy of the right median nerve is denied. Entitlement to a disability rating higher than 10 percent for residuals of a shell fragment wound of the right arm involving scarring and Muscle Group VII is denied. Entitlement to a 10 percent rating for residuals of a shell fragment wound of the right arm involving scarring and Muscle Group IX is granted. REMAND The Veteran filed a timely notice of disagreement with a June 2008 rating decision that denied an increased rating for residuals of a right thigh wound. A statement of the case has not been issued. The Board is required this issue so that a statement of the case can be provided. Manlincon v. West, 12 Vet. App. 238 (1999). A VA examiner has opined on two occasions that the Veteran would be capable of sedentary employment, notwithstanding his service connected disabilities, but she has not provided reasons for the opinion. The Veteran was reported to be working part-time at a golf course, but it is unclear whether this employment is marginal. In a statement received at the Board in September 2013, the Veteran reported that he had had a stroke affecting his right side and that the service connected injuries to the right side prevented him from fully recovering. This is construed as a claim for service connection. The issue is inextricably intertwined with the TDIU issue. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. Issue a statement of the case with regard to entitlement to a higher disability rating for residuals of a shell fragment wound of the right thigh. This issue should not be certified to the Board unless the Veteran submits a sufficient substantive appeal. 2. Adjudicate the issue of entitlement to service connection for residuals of a stroke, to include the question of entitlement to service connection on a secondary basis. 3. Ask the Veteran to provide information as to his annual earnings from employment since 2006. 4. Provide the Veteran with a VA examination to determine whether the his service connected disabilities; PTSD, hearing loss, tinnitus, and gunshot wound residuals; would combine to prevent him from obtaining and maintaining gainful employment for which his education and occupational experience would otherwise qualify him. The examiner should provide reasons for this opinion. The examiner should also state whether the opinion would be different if the residuals of the stroke were considered service connected. 4. If any issue perfected for appeal remains denied, issue a supplemental statement of the case and return the case to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs