Citation Nr: 1334547 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 10-08 488 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for right shoulder disability. 2. Entitlement to service connection for residuals of burns of the left hand. 3. Entitlement to service connection for testicular pain. 4. Entitlement to service connection for left knee disability. 5. Entitlement to an initial disability rating higher than 10 percent for low back disability. 6. Entitlement to an initial disability rating higher than 0 percent for hypertension. 7. Entitlement to an initial disability rating higher than 0 percent for a scar residual to removal of a cyst on the back. 8. Entitlement to an initial disability rating higher than 0 percent for recurrent abscess on the scrotum. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from December 1988 to December 2008. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions by the Louisville, Kentucky Regional Office (RO) of the United States Department of Veterans Affairs (VA). In a June 2009 rating decision the RO granted service connection for hypertension and assigned a 0 percent disability rating. The RO denied service connection for right shoulder disability, residuals of burns of the left hand, testicular pain, and left knee disability. In a February 2010 rating decision the RO granted service connection for a low back disability manifested by chronic pain and assigned a 10 percent disability rating, granted service connection for a scar residual to removal of a cyst on the back and assigned a 0 percent disability rating, and granted service connection for recurrent abscess on the scrotum and assigned a 0 percent disability rating. The Board has reviewed both the Veteran's paper claims file and the Veteran's file on the Virtual VA electronic file system, to ensure a total review of the evidence. FINDINGS OF FACT 1. Right shoulder impairment manifested by pain and limitation of motion began during service and has continued after service. 2. Burns of the left hand sustained in service in 1993 were treated and resolved in service without residual pathology. 3. Post-service intermittent rashes on the left index finger are not residual to 1993 burns of the finger and other parts of the hands. 4. Testicular pain that arose during service at the same time as an abscess on the scrotum is a manifestation of the service-connected disorder described as abscess on the scrotum, and there is no separate testicular disorder. 5. Left knee injuries during service, including medial collateral ligament (MCL) injury in 2002, have produced recurrent left knee pain and functional limitation during and since service. 6. From separation from service, low back disability has been manifested by pain and limitation of motion, without limitation of forward flexion to 60 degrees or less or limitation of the combined range of motion to 120 degrees or less, without muscle spasm or guarding severe enough to result in an abnormal gait, without abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, and without incapacitating episodes. 7. Before and since separation from service, hypertension has had a history of diastolic pressure predominantly 100 or more, and has required continuous medication for control. 8. A scar residual to removal of a cyst on the back is superficial, has an area less than 929 square centimeters, is not unstable or painful, and does not produce any other compensably disabling effect. 9. Disability related to recurrent abscess on the scrotum has been manifested by episodes of testicular pain that is not chronic and by intermittent groin area rashes that cover less than 5 percent of the body and have not required any systemic therapy such as corticosteroids or other immunosuppressive drugs. CONCLUSIONS OF LAW 1. Right shoulder disability manifested by pain and limitation of motion was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 2. There is no current disability that is residual to burns of the left hand during service. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 3. Current testicular pain is a manifestation of service-connected abscess on the scrotum; no testicular pain-related disorder separate from abscess on the scrotum was incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 4.14 (2013). 4. Current left knee disability was incurred in injuries, including MCL injury, during service. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 5. From separation from service, low back disability has not met the criteria for a disability rating higher than 10 percent. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2013). 6. From separation from service, hypertension has met the criteria for a 10 percent disability rating. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.104, Diagnostic Code 7101 (2013). 7. A scar residual to removal of a cyst on the back has not met the criteria for a disability rating higher than 0 percent. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.118, Diagnostic Codes 7802, 7804, 7805 (2013). 8. Disability related to recurrent abscess on the scrotum has not met the criteria for a disability rating higher than 0 percent. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.115b, 4.118, Diagnostic Codes 7806, 7525 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim for VA benefits. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has stated that the requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). VA provided the Veteran with VCAA notice in July 2008 and April 2009, before the initial unfavorable decision on these claims. In the notices the RO addressed the information and evidence necessary to substantiate claims for service connection. The RO informed the Veteran how VA assigns increased disability ratings and effective dates. The notices also addressed who was to provide the evidence. The record regarding the Veteran's claims (including the paper claims file and information in electronic form) contains service treatment records, records of post-service treatment and examinations, and statements from the Veteran. The Veteran has had a VA medical examination performed by a qualified clinician who reviewed the claims file. The examiner explained his findings and conclusions. The examination and the examination report are adequate for addressing these claims. With respect to the disabilities for which the Veteran has appealed for higher ratings, he has not alleged that any of those disabilities has worsened since the most recent VA examination, which was performed in 2009. In fact, there have been no allegations from the Veteran in over four years referencing treatment, worsening symptoms, etc. The mere passage of time between the examination and the Board's review does not, in and of itself, trigger a remand for another more contemporaneous examination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (holding that a remand was not required solely due to the passage of time since the most recent VA examination); VAOPGCPREC 11-95 (1995). The Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claims, as well as the avenues through which he might obtain such evidence, and the allocation of responsibilities between him and VA in obtaining such evidence. The Veteran actively participated in the claims process by providing evidence and argument. Thus, the Veteran was provided with a meaningful opportunity to participate in the claims process, and he has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication nor to have caused injury to the Veteran's interests. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless, and does not prohibit consideration of the claims on their merits. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Right Shoulder Disability The Veteran contends that he has right shoulder disability that began during service. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection also may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis, may be established based upon a legal presumption by showing that it manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1112, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). The Court has explained that, in general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative means of establishing service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Some of the Veteran's service treatment records include lists of the Veteran's problems. In records from August 2007 forward those lists include "joint pain, localized in the shoulder." The Veteran filed a claim for VA disability compensation in July 2008, while he was preparing for retirement from service. The claimed disorders include chronic right shoulder pain. Medical history and examinations were obtained in August and September 2008 in preparation for the Veteran's retirement from service. In a medical history the Veteran reported having continuous right shoulder pain. On the report of an examination the examiner checked normal for the condition of the Veteran's upper extremities. A summary of defects and diagnoses included right shoulder pain. On VA medical examination in November 2009 the examiner reported having reviewed the Veteran's claims file including his service treatment records. The Veteran reported that in 2000 he began experiencing right shoulder pain after road marching with a rucksack on his back. He reported that he was seen and treated with pain medication and ice packs. He reported that the pain recurred a number of times, and that he was last seen for the pain in about 2007. He stated that at present he experienced right shoulder pain only if he slept on it. He indicated that his current joint symptoms included right shoulder pain. He reported that he took nonprescription pain medication as needed for right shoulder pain. On x-rays the Veteran's right shoulder appeared normal. On examination, forward flexion of the right shoulder was possible to 180 degrees, abduction was limited to 145 degrees, internal rotation was possible to 90 degrees, and external rotation was limited to 80 degrees. There was pain on motion with abduction, internal rotation, and external rotation. The left shoulder had full ranges of motion without pain. With respect to the Veteran's chronic right shoulder pain, the examiner stated that at present there was "insufficient clinical evidence to warrant a diagnosis of any acute or chronic disorder or residuals thereof." The examiner indicated that the right shoulder pain had effects on the Veteran's activities, including severe effects on chores, shopping, exercise, recreation, traveling, bathing, and dressing, and prevention of participation in sports. In an August 2013 statement the Veteran asserted through his representative that a right shoulder disability began during service and continued through the present. The Veteran's service treatment records and separation history document his reports of chronic right shoulder pain in 2007 and 2008 and around the time of his retirement from service. The Veteran is competent to report symptoms such as pain. The Board finds that the evidence adequately establishes that the Veteran had right shoulder pain during service. The Veteran has reported ongoing right shoulder pain since separation from service. The VA clinician who examined the Veteran in 2009 found that the evidence did not warrant a diagnosis regarding the right shoulder. However, the examination showed limitation of motion in some directions and pain on motion in some directions. The Veteran's statements and the examination findings are sufficient to show that the right shoulder symptoms that the Veteran experienced during service continued or recurred after service. As the Veteran had chronic right shoulder pain during service that continued after service, the evidence at least equivocally supports that he has functional impairment of the shoulder that began during service, even though the pathology producing that impairment has not been diagnosed. Giving the benefit of the doubt to the claimant, the Board grants service connection for right shoulder disability manifested by pain and limitation of motion. Residuals of Burns of the Left Hand The Veteran sustained burns to his left hand during service in 1993. He is seeking service connection for residuals of those burns. His service treatment records show that in March 1993 he had emergency room treatment after his left hand was burned by hot cooking oil. He sustained first and second degree burns on the dorsum of the thumb and second and third fingers. The burns were dressed and checked the day of the injury and on follow-up over approximately a week. No signs of infection were seen. Records of treatment after March 1993 do not show any further treatment for the burns. In the Veteran's July 2008 claim for VA disability compensation he included a history of burns of the left hand. At separation from service in 2008 the Veteran reported a history of burn injury of a hand, and a history of a rash along the inside of a leg. A clinician who examined the Veteran checked normal for the condition of his skin and upper extremities. On VA examination in November 2009 the Veteran reported that having received treatment for burns to the hand sustained in the early 1990s. He stated that he had not had treatment for the hand since it healed. He indicated that since sustaining the burns he experienced a rash on his index finger in the summer when the hand sweated. On skin examination the examiner observed that the skin on the left hand where the Veteran was burned was normal. Musculoskeletal, circulatory, and neurological functions in the left hand were normal. The examiner's diagnosis was first and second degree burns of three fingers of the left hand in 1993 with no objective evidence of residuals. In an August 2013 statement the Veteran asserted through his representative that he incurred left hand burns during service and continued to have effects from those burns through the present. The 1993 burns of the Veteran's left hand were treated in 1993. Through the remaining fifteen years of his service he did not report tenderness, scarring, rashes, or any other symptoms involving the areas that were burned. After separation from service he has asserted that an intermittent rash on the left index finger is related to the burns during service. The VA physician who examined him in 2009 noted his report of the rash, but concluded that there was no objective evidence of residuals of the burns. The Veteran is competent to observe that a rash sometimes occurs on that finger. As he is not a medical professional, his statement that the rash is related to the 1993 burns is not competent medical evidence of such a relationship. The VA examiner's conclusions are competent medical opinion. The examiner's conclusion that the evidence does not show residuals of the burns is persuasive. By the preponderance of the evidence, then, the rash is not residual to the burns, and there is no current disorder residual to the burns. As the evidence is against the existence of a current disability that is residual to the burns, the Board denies service connection for disability of the left hand residual to the burns. Testicular Pain In his July 2008 claim the Veteran sought service connection for testicular pain on the left side and for recurrent abscess on the scrotum. In the June 2009 rating decision the RO denied service connection for both of those claimed disorders. The Veteran's appeal included the denial of both claims. In the February 2010 rating decision, the RO granted service connection for recurrent abscess on the scrotum. The Veteran continues to seek service connection for testicular pain. He essentially contends that service connection is warranted for testicular pain as a condition separate from or in addition to the service-connected disorder described as recurrent abscess of the scrotum. During service, in February 1997, the Veteran sought treatment for pain on the left side of his testicle. A clinician noted a semi-hard boil on the left testicle, and observed evidence of pain with standing and movement. On urology consultation the clinician noted a pustule on and induration of the left hemiscrotum. The clinician described the disorder as an abscess. The abscess was incised and drained and antibiotic medication was started. The following day improvement was observed. In an August 2008 medical history the Veteran reported a history of a cyst on his scrotum. In an August 2008 service separation examination the examiner checked normal for the condition of the Veteran's external genitalia. In the November 2009 VA examination the examiner reported having reviewed the Veteran's claims file. The Veteran recounted that in the 1990s he had left testicular pain and a scrotal abscess was incised and drained. He related having had a number of recurrences of pain and swelling since then. He stated that with those recurrences he had been seen and treated with antibiotics. He reported that in 2003 he was hospitalized for a very inflamed rash in the groin area. He indicated that he was treated most recently in about 2005. He reported that currently he had left testicular pain after walking about one and a half miles or standing for more than an hour. He stated that he had rashes in the groin area intermittently during summers. On genitourinary examination the structures appeared normal. An echogram of the scrotum was unremarkable, with no evidence of abscess, mass, torsion, or epididymitis. The examiner provided a diagnosis of recurrent abscess on scrotum with normal examination. The examiner stated that with respect to left sided testicular pain there was "insufficient clinical evidence at the present to warrant a diagnosis of any acute or chronic disorder or residuals thereof." In an August 2013 statement the Veteran asserted through his representative that left testicular pain began during service and recurred intermittently during and after service, through the present. The RO granted service connection for recurrent abscess of the scrotum. The service treatment records show that in 1997 abscess of the scrotum was found and diagnosed when the Veteran sought treatment for left testicular pain. The Veteran later reported that the condition that was manifested in 1997 by pain and abscess recurred a number of times during and after service. The medical records and other evidence tend to show that the testicular pain and scrotal abscess occurred at the same time and are manifestations of the same disorder. There is no medical finding or opinion that the testicular pain is a manifestation of a disorder separate from the service-connected condition described as scrotum abscess. In establishing compensation for service-connected disability, pyramiding, or evaluation of the same disability under various diagnoses, is to be avoided. 38 C.F.R. § 4.14. The Board concludes that the scrotal abscess and the testicular pain each are manifestations of the same disability. The Board therefore denies establishment of service connection for testicular pain as a separate disability. The Veteran's testicular pain should be considered in evaluating his scrotal abscess disability. The rating for that disability is on appeal before the Board and will be addressed in this decision, below. Left Knee Disability The Veteran sustained left knee injury during service. He contends that current left knee disability is related to injury in service. The Veteran's service treatment records reflect that he sustained left knee injury in March 2002. During combat training a fellow soldier fell on the Veteran's knee, and the knee twisted and popped. On initial treatment the clinician observed that the Veteran had obvious discomfort in the knee. The clinician's impression was medial collateral ligament (MCL) strain or tear. On follow-up the next day a clinician recommended profiles, for considerable limits on duties for fourteen days, followed by lesser limits on duties for fourteen more days. In May 2008 the Veteran sustained a knee injury that included abrasion. He was placed on a limited duty profile for two weeks. In his July 2008 VA disability claim the Veteran included among his disabilities chronic left knee pain. On the report of an August 2008 examination of the Veteran for separation from service, the examiner checked normal for the condition of the Veteran's lower extremities. In an August 2008 medical assessment the Veteran expressed concern about his knees. In a September 2008 medical history the Veteran reported a history of knee trouble. He related having abnormality, including locking, in his left knee. He indicated that he had pain in both knees. On a September 2008 physical profile report, diagnoses included bilateral knee pain. On VA examination in November 2009 the Veteran reported having sustained a left knee injury in service in 2002 or 2003. He stated that he received treatment with Motrin and ice packs. He related having recurring left knee pain after that, and being seen for the pain a number of times. He stated that in 2008 he fell while going down stairs and injured his left knee. He indicated that he was treated with pain medication, a knee brace, and physical therapy. He reported that at present he had left knee pain when going up or down two flights of stairs. He stated that he last had left knee pain in August 2009. He indicated that his left knee had pain, swelling, limited motion, and instability. He reported that symptoms occurred weekly and lasted for hours. The examiner found that the Veteran's left knee was tender to palpation. The left knee had motion from 0 to 135 degrees, and there was evidence of pain on motion. The right knee had motion from 0 to 140 degrees without pain on motion. The left knee appeared normal on x-rays. With respect to the Veteran's left knee pain, the examiner stated that there was "insufficient clinical evidence at that time to warrant a diagnosis of any acute or chronic disorder or residuals thereof." The examiner found that the left knee pain had effects on many of the Veteran's daily activities, including severe effects on chores, shopping, exercise, recreation, traveling, bathing, dressing, toileting, and driving, and prevention of participation in sports. In an August 2013 statement the Veteran asserted through his representative that his left knee disability began during service and continued through the present. Records from the time of the Veteran's service are consistent with his reports of left knee injuries on two occasions in service, including MCL injury in 2002. Those records show that he reported chronic left knee pain during the period immediately preceding his separation from service. The separation examination report did not relate any knee disorder, but also did not contain detailed assessment of any of the symptoms the Veteran reported around the time of that examination. The Veteran is competent to report his left knee symptoms during and since service. His accounts have been reasonably consistent and thus are fairly credible. He reports recurrent and chronic left knee pain during and since service. The VA clinician who examined the Veteran in 2009 found that the evidence did not warrant a diagnosis regarding the left knee. However, that examination report showed limitation of motion of the left knee compared to the right, pain on motion of the left knee, and limitations of activities due to left knee pain. The Veteran's statements and the examination findings are sufficient to show that his left knee injuries and ongoing symptoms during service were followed by ongoing symptoms after service. Even in the absence of a diagnosis regarding his current left knee impairment, the evidence at least equivocally indicates that he has functional impairment of the left knee that began during service and recurred and continued after service. Giving the benefit of the doubt to the claimant, the Board grants service connection for left knee disability residual to MCL injury and manifested by pain and limitation of motion. Low Back Disability The Veteran appealed the initial 10 percent disability rating that the RO assigned for his low back disability. VA assigns disability ratings by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. If two ratings are potentially applicable, the higher rating 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. When evaluation of a musculoskeletal disability is based on limitation of motion, VA regulations provide, and the Court has emphasized, that evaluation must include consideration of impairment of function due to such factors as pain on motion, weakened movement, excess fatigability, diminished endurance, or incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59; see DeLuca v. Brown, 8 Vet. App. 202 (1995). In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. The Court has held that, at the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). As the Veteran appealed the initial rating that the RO assigned, the Board will consider the evidence for the entire period since January 1, 2009, which is the day after his separation from service and the effective date of service connection. The Board will consider whether a higher rating is warranted for any part of that period. The RO described the Veteran's low back disability as chronic lower back pain, also claimed as McKenzie posterior derangement syndrome. The RO evaluated the disability under 38 C.F.R. § 4.71a, Diagnostic Code 5237, for lumbosacral strain. The rating schedule provides for evaluating spine strain and other spine disabilities under a General Rating Formula for Diseases and Injuries of the Spine, and for evaluating intervertebral disc syndrome under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, Diagnostic Codes 5242, 5243 (2013). Under the General Rating Formula for spine disabilities, a 20 percent evaluation is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula. Normal thoracolumbar spine forward flexion is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion is the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, General Rating Formula, Note (2); 38 C.F.R. § 4.71a, Plate V. Under the rating criteria for intervertebral disc syndrome, a 20 percent evaluation is assigned for incapacitating episodes having a total duration of at least 2 week but less than 4 weeks during the past 12 months, a 40 percent evaluation is assigned for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months, and a maximum 60 percent evaluation is assigned for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, General Rating Formula, Note (1). On VA medical examination in November 2009 the Veteran reported that during service he received treatment for chronic low back pain and a clinician diagnosed McKenzie posterior derangement syndrome. He stated that treatment had included pain medication and physical therapy. He indicated that he was last seen for low back pain early in 2008. At the time of the 2009 examination, he reported that he was not employed. He stated that three to four times a week he experienced mild low back pain. He related that about twice a week he experienced severe low back pain that lasted until he laid down at night. He indicated that the low back symptoms had become progressively worse since onset. He reported that he was limited due to low back pain. He stated that he could not walk more than one to three miles or stand more than one hour. The examiner found evidence of tenderness to palpation of the lumbar spine. The ranges of motion of the lumbar spine were to 65 degrees of forward flexion, 25 degrees of extension, 25 degrees of lateral flexion to each side, and 30 degrees of rotation to each side. There was evidence of pain with motion in all directions. After three repetitions there ranges of motion remained the same. On x-rays the lumbar spine appeared essentially normal. The examiner's diagnosis was lumbar strain. The examiner indicated that the low back disability prevented the Veteran from participating in sports, had severe effects on exercise, recreation, traveling, bathing, and driving, and had moderate effects on chores, shopping, dressing, toileting, and grooming. The ranges of motion shown on the 2009 examination do not meet the criteria for a disability rating higher than 10 percent. There is no evidence that the Veteran's low back has muscle spasm or guarding severe enough to result in an abnormal gait, or has an abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. It is not clear whether the McKenzie posterior derangement syndrome of the Veteran's low back is related to or accompanied by any intervertebral disc pathology. In any case, there is no evidence that the Veteran's low back disability has produced any incapacitating episodes, that is, any periods of acute signs and symptoms that require bed rest prescribed by a physician and treatment by a physician. The evidence, including medical findings and the Veteran's accounts, shows low back disability that does not meet the criteria for a rating higher than 10 percent. The Board therefore denies a rating higher than 10 percent. When there is an exceptional disability picture, such that the rating schedule criteria do not reasonably describe a claimant's disability level and symptomatology, an RO may refer a case to the VA Under Secretary for Benefits or to the Director of the VA Compensation and Pension Service for consideration of an extraschedular rating. See 38 C.F.R. § 3.321(b)(1) (2012); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008). Extraschedular ratings are limited to cases in which it is impractical to apply the regular standards of the rating schedule because there is an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment. 38 C.F.R. § 3.321(b)(1). The Veteran's low back disability has not required frequent hospitalizations. There is evidence that the Veteran's low back disability has affects on some activities. However, the Veteran has not asserted, and clinicians who have seen him have not indicated, that his low back disability markedly interferes with his capacity for employment. The General Rating Formula for Diseases and Injuries of the Spine provides ratings based on limitation of motion and other impairment with or without pain, stiffness, or aching. The rating criteria thus address the manifestations of the Veteran's low back disability, including the pain and limitation of motion. The rating criteria provided for higher ratings for disability greater than is present in this case. The regular rating criteria thus are adequate to evaluate the Veteran's low back disability. It is not necessary to refer the rating of that disability for consideration of extraschedular ratings. The Court has indicated that in claims for increased ratings the Board must consider whether the record raises the issue of unemployability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, there is no evidence suggesting that the Veteran's low back disability, with or without his other service connected disabilities, makes him unable to secure or follow a substantially gainful occupation. The record does not directly or indirectly raise a TDIU claim. Hypertension The Veteran appealed the initial 0 percent disability rating that the RO assigned for his hypertension. As the Veteran appealed the initial rating that the RO assigned, the Board will consider whether a higher rating is warranted for any part of the period since the January 1, 2009, effective date of service connection for hypertension. The rating schedule provides for evaluating hypertension under 38 C.F.R. § 4.104, Diagnostic Code 7101, as follows: Diastolic pressure predominantly 130 or more .. 60 percent Diastolic pressure predominantly 120 or more .. 40 percent Diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more ............. 20 percent Diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control ............... 10 percent The Veteran was diagnosed with and treated for hypertension during service. His service treatment records show that from the late 1990s forward some readings showed elevated blood pressure. Hypertension was diagnosed and medication was first prescribed in or before 2004. Records from the remainder of his service reflect that sometimes he was on medication for hypertension and sometimes he was not. Over several months in mid to late 2007 his diastolic pressure was predominantly over 100. In 2008 a clinician reported that his hypertension was controlled on medication. On VA examination in November 2009 the Veteran reported that he was last seen for his blood pressure in 2008. He stated that he had been off of medication since February 2009 because he had run out of it. In the examination blood pressure readings were 150/110, 150/104, and 140/100. The examiner found that the Veteran's hypertension did not have effects on his daily activities. In an August 2013 statement the Veteran asserted through his representative that his hypertension met the criteria for a higher rating. Over the one to two years preceding the Veteran's retirement from service, there was a several month period when his diastolic pressure was predominantly 100 or more, followed by a period when his hypertension was controlled on continuous medication. At the time of the earliest post-service source of data, the November 2009 VA examination, his medication supply had lapsed, and his diastolic readings were predominantly 100 or more. From soon before separation from service through the post-service examination, the Veteran's hypertension has met the criteria for a 10 percent rating. The Board therefore grants a 10 percent rating effective from separation from service. There is no evidence that the Veteran has ever had diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more; so the Veteran's hypertension does not meet the criteria for a rating higher than 10 percent. The Veteran's hypertension has not required frequent hospitalizations. There is no evidence that his hypertension markedly interferes with his capacity for employment. The rating criteria for hypertension, including those for the 10 percent rating granted in this decision, contemplate the Veteran's blood pressure levels and his need for antihypertensive medication. The rating criteria provide for higher ratings for higher blood pressure levels than are shown in this case. The regular rating criteria thus are adequate to evaluate the Veteran's hypertension. It is not necessary to refer the rating of that disability for consideration of extraschedular ratings. There is no evidence suggesting that the Veteran's hypertension, with or without his other service connected disabilities, makes him unable to secure or follow a substantially gainful occupation. The record does not directly or indirectly raise a TDIU claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Scar Residual to Removal of a Cyst on the Back During service the Veteran had an epidermal inclusion cyst on his back. In 2007 a clinician surgically removed the cyst. The Veteran has appealed the initial 0 percent rating that the RO assigned for a scar residual to removal of the cyst. The Board will consider whether a higher rating is warranted for any period since separation from service. The rating schedule at 38 C.F.R. § 4.118 provides criteria for evaluating scars. Diagnostic Code 7800 addresses scars on the head, face, or neck, and Diagnostic Codes 7801, 7802, and 7804 address scars that are not on the head, face, or neck. The scar for which the Veteran seeks a higher rating is on his back and not on his head, face, or neck. Such a scar, when it is deep and nonlinear, warrants a compensable (10 percent or higher) rating if the area is at least 6 square inches or 39 square centimeters. 38 C.F.R. § 4.118, Diagnostic Code 7801. Such a scar when superficial and nonlinear is assigned a 10 percent rating if the area is at least 144 square inches or 929 square centimeters. 38 C.F.R. § 4.118, Diagnostic Code 7802. Unstable or painful scars are rated at 30 percent for five or more such scars, 20 percent for three or four such scars, and 10 percent for one or two such scars. 38 C.F.R. § 4.118, Diagnostic Code 7804. An unstable scar is one where there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1). If linear scars or other scars have any disabling effects that are not considered under Diagnostic Codes 7800-7804, those disabling effects are to be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. The Veteran underwent excision of a cyst on his low back in September 2007. The cyst was found to be an epidermal inclusion cyst. On follow-up two weeks later a clinician removed sutures. The Veteran had an itchy rash, diagnosed as allergic contact dermatitis, around the wound where topical medications had been applied. A clinician discontinued those medications. Subsequent service treatment notes were silent regarding the skin in the area from which the cyst was removed. In a September 2008 medical history the Veteran reported the removal of a cyst from his back in 2007. On VA examination in November 2009 the Veteran reported that presently he had a small lump at the location of the cyst that was removed in 2007. He stated that he sometimes experienced mild pain there when he wore a belt over it. He indicated that he usually wore his belt above or below it. The examiner observed a surgical scar on the right lower back that was 2.5 centimeters by 0.3 centimeters. The examiner described the scar as barely discernible, with no depression, tissue loss, adherence, or palpable nodule. The examiner found no tenderness and no skin breakdown at the scar. The VA examination was performed by a physician. The Board finds that the examiner was qualified to describe the scar and that his findings are credible. The examination revealed that the cyst excision scar is superficial and is smaller than 929 square centimeters, so it does not warrant a compensable rating under Diagnostic Code 7802. The examination did not show the scar to be unstable and the Veteran has not reported that it is unstable. The examiner did not find evidence that the scar was painful at the time of the examination. The Veteran reported that he sometimes experienced mild pain when he wore a belt over the scar, and that he usually wore any belt so that it was located above or below the scar. The Board accepts the Veteran's accounts that he has mild pain in the scar when a belt is worn over it, and that this belt position and resulting mild pain are usually avoidable. The reported occasional mild symptoms do not seem sufficiently uncomfortable, frequent, or persistent for the scar to be characterized as a painful scar, such as would warrant a 10 percent rating under Diagnostic Code 7804. The Veteran's account and examiner's findings do not show that the cyst removal scar has any other disabling effects that warrant compensation. The Board therefore denies a compensable rating. The cyst removal scar on the Veteran's back has not required frequent hospitalizations. There is no evidence that the scar markedly interferes with his capacity for employment. The rating criteria for scars contemplate the characteristics and effects of the Veteran's scar, and provide for higher ratings for scars with more disabling characteristics and effects. Thus, the regular rating criteria thus are adequate to evaluate the Veteran's cyst removal scar, and it is not necessary to refer the rating of that scar for consideration of extraschedular ratings. There is no evidence suggesting that the Veteran's cyst removal scar, with or without his other service connected disabilities, makes him unable to secure or follow a substantially gainful occupation. The record therefore does not directly or indirectly raise a TDIU claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Abscess on the Scrotum During service the Veteran was seen for pain in the area of his scrotum and testicles. A clinician diagnosed an abscess on the left side of the scrotum. The Veteran received treatment for that disorder. The Veteran sought service connection for recurrent genital region pain. The RO established service connection for a disorder described as recurrent abscess on the scrotum. The Veteran has appealed the initial noncompensable disability rating the RO assigned. He reports that he has episodes of testicular pain and groin area rashes. As noted above, claimed recurrent testicular pain is part of the service-connected disorder the RO described as recurrent abscess of the scrotum. The Board will consider whether a compensable rating is warranted for all manifestations of the current disorder including any abscess, pain, rashes, or other manifestations affecting the genital region. The RO evaluated the disorder described as recurrent abscess under 38 C.F.R. § 4.118, Diagnostic Codes 7899 and 7806, as a skin disorder analogous to dermatitis or eczema. Under Diagnostic Code 7806, a compensable, 10 percent rating is assigned if at least 5 percent of the entire body or other exposed areas of the body is affected, or if the disorder required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. The rating schedule also provides for evaluating testicular, scrotal, and genital region disorders, including scrotum, testicle, and epididymis area inflammation described as epididymo-orchitis. 38 C.F.R. § 4.115b, Diagnostic Code 7525. Epididymo-orchitis may be rated only if it is chronic. Diagnostic Code 7525. As noted above, during service the Veteran received treatment for scrotal and testicular symptoms in February 1997. He reported pain on the left side of his testicle. A clinician noted a semi-hard boil on the left testicle, and observed evidence of pain with standing and movement. On urology consultation the clinician noted a pustule on and induration of the left hemiscrotum. The clinician described the disorder as an abscess. The abscess was incised and drained and antibiotic medication was started. The following day improvement was observed. In an August 2008 medical history the Veteran reported a history of a cyst on his scrotum. In an August 2008 service separation examination the examiner checked normal for the condition of the Veteran's external genitalia. In the November 2009 VA examination the Veteran related the history of left testicular pain and incision and drainage of a scrotal abscess in the 1990s. He reported having had a number of recurrences of pain and swelling since then. He stated that with those recurrences he had been seen and treated with antibiotics. He reported that in 2003 he was hospitalized for a very inflamed rash in the groin area. He indicated that he was treated most recently in about 2005. He reported that currently he had left testicular pain after walking about one and a half miles or standing for more than an hour. He stated that he had rashes in the groin area intermittently during summers. On genitourinary examination the structures appeared normal. An echogram of the scrotum was unremarkable, with no evidence of abscess, mass, torsion, or epididymitis. The examiner provided a diagnosis of recurrent abscess on scrotum, with normal examination. The examiner stated that with respect to left sided testicular pain there was "insufficient clinical evidence at the present to warrant a diagnosis of any acute or chronic disorder or residuals thereof." In an August 2013 statement the Veteran asserted through his representative that left testicular pain began during service and recurred intermittently during and after service, through the present. The Veteran has not indicated that, after the completion of treatment of the scrotum abscess in 1997, he has had any further abscess, nor any scar at the location of the incised abscess. He reports that since 1997 he has experienced intermittent symptoms of testicular pain and groin area rash. On a service examination in 2008 and a post-service examination in 2009 there was no evidence of any current disorder or symptoms affecting the testicles, scrotum, other genital structures, or skin in that area. As the Veteran's testicular or scrotal area pain, by his accounts, is not chronic, it does not warrant a rating under Diagnostic Code 7525. The intermittent groin area rash that he has reported has not been observed by a clinician. In any case, his statement that the rash when present is in the groin area tends to indicate that it does not cover at least 5 percent of his body. He has not indicated that the groin area has ever required treatment with systemic therapy such as corticosteroids or immunosuppressive drugs. Thus, there is not a basis for a compensable rating for the groin area disorder as a skin disorder. In summary, the testicular pain episodes and intermittent groin rash that are the reported residuals of the genital region pain and abscess treated during service do not warrant a compensable rating. The service-connected scrotal abscess disability (including the testicular pain and groin rash manifestations) has not required frequent hospitalizations. There is no evidence that the disability markedly interferes with the Veteran's capacity for employment. There are rating criteria that address rashes and genital pain, and those criteria provide for higher ratings for disorders that are more disabling than those present. Thus, the regular rating criteria thus are adequate to evaluate the genital region disability, and it is not necessary to refer the rating of that disability for consideration of extraschedular ratings. There is no evidence suggesting that the Veteran's genital region disability (characterized as recurrent scrotal abscess), with or without his other service connected disabilities, makes him unable to secure or follow a substantially gainful occupation. The record therefore does not directly or indirectly raise a TDIU claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Entitlement to service connection for right shoulder disability is granted. Entitlement to service connection for residuals of burns of the left hand is denied. Entitlement to service connection for testicular pain, as a disorder separate from abscess on the scrotum, is denied. Entitlement to service connection for left knee disability residual to MCL injury is granted. Entitlement to a disability rating higher than 10 percent for low back disability is denied. Entitlement to an initial 10 percent disability rating for hypertension is granted, subject to the laws and regulations controlling the disbursement of monetary benefits. Entitlement to a disability rating higher than 0 percent for a scar residual to removal of a cyst on the back is denied. Entitlement to a disability rating higher than 0 percent for recurrent abscess on the scrotum is denied. ______________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs