Citation Nr: 1339783 Decision Date: 12/03/13 Archive Date: 12/18/13 DOCKET NO. 09-06 214 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to a rating in excess of 20 percent for residuals of a shrapnel wound of the left upper extremity at the elbow, Muscle Group V (minor). 2. Entitlement to a rating in excess of 20 percent for neuropathy of the median and ulnar nerves of the left upper extremity (minor). REPRESENTATION Appellant represented by: Michael J. Brown, attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from April 1967 to April 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2008 decision of the Philadelphia, Pennsylvania, Regional Office (RO) of the Department of Veterans Affairs (VA). In April 2013, the Board remanded the claims for the scheduling of a hearing before the Board. In October 2011, the Veteran was afforded a Board hearing at the RO. In July 2013, the Veteran was afforded a videoconference hearing before the undersigned Acting Veterans Law Judge who is rendering the determination in this claim and was designated by the Chairman of the Board to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 2002). FINDINGS OF FACT 1. The Veteran's service-connected residuals of a shrapnel wound of the left upper extremity at the elbow, Muscle Group V (minor) has been shown to be productive of complaints of pain, and some limitation of motion, but not more than a moderately severe muscle disability. 2. The Veteran's service-connected left arm disability has been shown to be productive of complaints of pain, and some decreased strength, but not by severe incomplete neuritis, or neuralgia of the ulnar nerve. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for the Veteran's service-connected residuals of a shrapnel wound of the left upper extremity at the elbow, Muscle Group V (minor) have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.40, 4.45, 4.56, 4.71a, 4.73, Diagnostic Code 5305 (2013). 2. The criteria for a rating in excess of 20 percent for the Veteran's service-connected neuropathy of the median and ulnar nerves of the left upper extremity (minor) have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.124a, Diagnostic Codes 8515, 8516 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Ratings The Veteran asserts that he is entitled to increased ratings for his service-connected residuals of a shrapnel wound of the left upper extremity at the elbow, Muscle Group V (minor), and neuropathy of the median and ulnar nerves of the left upper extremity (minor). During his hearing, held in July 2013, the Veteran testified that he has painful and limited motion, with numbness and weakness. The Board notes that in February 2011, the RO granted a total rating on the basis of individual unemployability due to service-connected disability (TDIU), effective October 21, 2005. As for the history of the disabilities at issue, see 38 C.F.R. § 4.1 (2013), the Veteran's service treatment reports show that in March 1968, during service in Vietnam, he sustained shrapnel wounds to his left upper anterior extremity, with a contusion of the left medial nerve. He was hospitalized for over three weeks, with no operations and a benign hospital course. In July 1968, he was noted to have symptoms that included left hand hypesthesia with intact median and ulnar nerves. The impression was contusion left median nerve. In November 1968, he was noted to report decreased motor and sensory functions in his left hand, and numbness of the first and second fingers of the left hand. In 1969 and 1970, he reported occasional paresthesias and pain, with a good range of motion in the left arm noted in May 1969, and no atrophic changes. A March 1970 report notes that the left median nerve was apparently transected and was repaired, but the Veteran continued to have paresthesia down the arm and muscle weakness. On examination, there was no atrophy, normal strength, and virtually a full return of sensation. The report states that no profile was indicated. The Veteran's separation examination report, dated in January 1970, shows that his upper extremities were clinically evaluated as normal. The associated "report of medical history" noted a history of shrapnel wound, with pain in the left hand and arm. As for the post-service medical evidence, an April 1971 VA examination report shows a complaint of pain from the left elbow to the thumb and index finger, and X-rays of the left humerus and elbow showed normally outlined bone and joint structures. The diagnosis was neuropathy, partial, median and ulnar nerves, left, manifested by sensory changes. An April 1990 VA examination report showed a very weak left thumb and index finger, with sensory impairment chiefly in the distribution of the median nerve, and to a minor extent, distribution of the left ulnar nerve. A May 2005 private X-ray report for the left elbow shows that it was normal. A January 2006 VA examination report shows 4/5 left arm strength and grip, with no loss of dexterity. It contains diagnoses that included median neuropathy and partial ulnar neuropathy of the arms, left side, moderate to severe in severity with restrictions. In May 1970, the RO granted service connection for an injury to the radial and ulnar nerve of the left hand, evaluated as 20 percent disabling, with an effective date of April 25, 1970. In May 1971, the RO granted a separate 20 percent rating for partial neuropathy of the median and ulnar nerves. In June 1990, the RO increased the Veteran's evaluation for partial neuropathy of the median and ulnar nerves to 40 percent, with an effective date of March 21, 1990. In August 2006, the RO reduced the Veteran's evaluation for his partial neuropathy of the median and ulnar nerves to 20 percent, with an effective date of November 1, 2006. A timely notice of disagreement as to the August 2006 rating decision was received, and in May 2007, a statement of the case was issued. However, a timely appeal was not received and the RO's decision became final. See 38 U.S.C.A. § 7105(c) (West 2002). In January 2008, the Veteran filed a claim for an increased rating. In May 2008, the RO denied the claim. The Veteran has appealed. The Board first notes that the evidence indicates that the Veteran is right-handed. See e.g., November 2012 VA Disability Benefits Questionnaire (DBQ). In this regard, to the extent the Veteran's representative expressed concern during the most recent hearing that the Veteran's disability of the left arm had been characterized as "minor," the Board points out that this was a reference to the fact that the Veteran's left arm is considered his non-dominant arm, and that it is not a characterization of the severity of his disability. Disability evaluations are determined by comparing the veteran's symptomatology with the criteria set forth in the VA's Schedule for Ratings Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4. The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). A. Residuals, Shrapnel Wound, Left Upper Extremity, Muscle Group V (minor) Muscle injuries are evaluated pursuant to criteria at 38 C.F.R. §§ 4.55, 4.56, and 4.73 (2013). For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions. 38 C.F.R. § 4.55(b). The specific bodily functions of each group are listed at 38 C.F.R. § 4.73. A muscle injury evaluation will not be combined with a peripheral nerve paralysis evaluation of the same body part unless the injuries affect entirely different functions. 38 C.F.R. § 4.55(a). Residuals of gunshot and shell fragment wounds are evaluated on the basis of the following factors: The velocity, trajectory and size of the missile which inflicted the wounds; extent of the initial injury and duration of hospitalization; the therapeutic measures required to treat the disability; and current objective clinical findings. 38 C.F.R. § 4.56. 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, and disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe. 38 C.F.R. § 4.56(c), (d) Under 38 C.F.R. § 4.56(d): A moderately severe muscle disability is one where the injury was either through and through, or a deep penetrating wound by a small high velocity missile or large low velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intramuscular scarring. The service department record (or other evidence) would show hospitalization for a prolonged period for treatment of the wound. There would be a consistent complaint of cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), and, if present, an inability to keep up with work requirements. Objectively, the entrance (and if present, exit) scars would indicate the track of missile through one or more muscle groups. There would be 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. 38 C.F.R. § 4.56(d)(3). A severe muscle disability is one where the injury was either through and through, or a deep penetrating wound due to a high velocity missile, or large or multiple low velocity missiles, or one with a shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intramuscular binding and scarring. The service department record (or other evidence) would show hospitalization for a prolonged period for treatment of the wound. There would be a consistent complaint of cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), which would be worse than that shown for moderately severe injuries, and, if present, an inability to keep up with work requirements. Objectively, there would be ragged, depressed and adherent scars, indicating wide damage to muscle groups in the missile track. Palpation would show loss of deep fascia or muscle substance, or soft flabby muscles in the wound area. Muscles would swell or harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side would indicate severe impairment of function. If they happen to be present, the following would also be signs of severe muscle injury: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intramuscular trauma and explosive effect of 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 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(d)(4). Normal motion of an elbow is from 0 degrees extension to 145 degrees of flexion, 0 to 80 degrees of forearm pronation, and 0 to 85 degrees of forearm supination. 38 C.F.R. § 4.71, Plate I. The Veteran's left arm condition has been evaluated under 38 C.F.R. § 4.73, Diagnostic Code (DC) 5305, which provides that Muscle Group V is defined as including the flexor muscles of the elbow, including the biceps, brachialis, and brachioradialis. The function of these muscle groups is listed as elbow supination (long head of biceps as stabilizer of the shoulder joint), and flexion of the elbow. Under DC 5305, a 20 percent rating is warranted for moderately severe disability (of the non-dominant upper extremity), and a 30 percent rating is warranted for severe disability (of the non-dominant upper extremity). The relevant medical evidence is summarized as follows: A VA examination report, dated in February 2008, shows that the Veteran had no complaints or impairments in regard to his left elbow, and that he declined to have it examined. He complained of moderate, constant left arm muscle pain, which was worse with pulling and lifting more than 15 pounds. It was relieved with use of Tylenol and Codeine every six hours for pain, and gabapentin at bedtime, 600 milligrams (mg.). He also reported that his pain radiated to the fingers of his left hand with constant moderate numbness and burning. The impaired muscles affected the biceps and triceps. There were no complaints involving the bone. On examination, there was minimal tissue loss. There was no tendon, bone, or joint damage. There was no evidence of muscle herniation. Dexterity was clinically normal. Left arm strength, and grip strength, were 4/5. The diagnosis noted median neuropathy and partial ulnar neuropathy of the left arm, moderately to severely active. An August 2008 report from N.P., M.D., notes that the Veteran has muscle weakness, fatigue, and numbness and tingling of his injury arm. A VA examination report, dated in July 2009, shows that the Veteran complained of left upper arm weakness, and constant, "achy" pain. He stated that he dropped things with his left hand. On examination, there was weakness of the median and ulnar nerves involving the forearm and the forearm muscle "of severe variety." The diagnoses noted severe ulnar and median neuropathy involving the left upper extremity. A VA scar examination report, dated in December 2011, shows that the Veteran had 5/5 strength on left elbow flexion, supination, and pronation. The left elbow had flexion to 110 degrees, and extension to 0 degrees. Supination was from 0 to 70 degrees, and pronation was from 0 to 85 degrees. After repetitive use (3 repetitions), flexion was decreased by five degrees (to 105 degrees), supination was decreased by 10 degrees (0 to 60 degrees), and pronation was unchanged. The decrease was due to pain, and not due to fatigue, weakness, or lack of endurance. The diagnosis noted a limitation of motion of the left elbow due to impairment of Muscle Group V. A VA neurological examination report, dated in December 2011, shows that on examination, left grip strength was 4/5, and there was diminished weakness of the flexor Capri ulnaris (4/5). There was a positive Tinel sign over the median and ulnar nerves, bilaterally. There was a positive Phalen sign of the left hand. There was no atrophy. Deep tendon reflexes were 1+ and symmetrical. The diagnoses were mild ulnar neuropathy, and moderate degree of median nerve neuropathy of the left hand. There was no significant concern for fluctuations, and he was still independent in his activities of daily living. Treatment reports from Virtual Health Berlin, covering private treatment provided between December 2011 and January 2012, show treatment for hypoxic respiratory failure. They note the following: the upper extremities had a normal range of motion, intact sensation, and motor strength in all extremities was strong and equal. The Veteran denied paresthesias, and numbness or tingling. They show that a neurological examination revealed no focal motor deficits, or focal sensory deficits. A VA DBQ, dated in November 2012, shows that the examiner stated that the Veteran's claims file was not available. The diagnosis was shrapnel injury to Muscle Group V of the left upper extremity with residual of scar. The Veteran complained of pain while extending the left forearm or elbow. He reported that he had a work history as a bus driver for 35 years, until he retired in 2005 due to a heart condition. He stated that he took over-the-counter medicines or nonsteroidal medications for pain. His pain was aggravated by cold weather. He reported mild decreased strength in the area of Muscle Group V which does not limit his activities. The examiner stated that no other Muscle Groups, other than Muscle Group V, were involved. There was no history of muscle hernia. The muscle substance was affected; there was some soft, flabby muscle in the wounded area. The function of the muscles was fully intact. There was no impairment of function of the muscles. There was no induration or atrophy. There was no adaptive contraction of opposing groups of muscles, and no impairment of muscle tonus. There was a loss of muscle substance. He had a lower threshold of fatigue; the severity of frequency was occasional. Muscle strength for elbow flexion was 4/5. The remaining effect of function of the extremities was not so diminished that amputation with prosthesis would serve the Veteran. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to his diagnosis. VA progress notes, dated between 2007 and 2012, include an October 2007 report which notes that sensation and strength were intact. An EMG (electromyogram) report for the upper extremities, dated in October 2009, shows that the Veteran complained of bilateral hand numbness, and reduced grip strength. The conclusion was that there was an abnormal study, with electrophysiologic evidence of a bilateral median neuropathy at the wrist, severe on the right, and moderate-to-severe on the left. A December 2009 report shows that the Veteran complained of bilateral hand pain, worse on the right, and right hand numbness. He was noted to have bilateral hand calluses, and no thenar atrophy. An EMG was noted to show bilateral CTS (carpal tunnel syndrome). The assessment was stable bilateral CTR (carpal tunnel release, or repair). A January 2010 report shows that he underwent a carpal tunnel release on the right. The reports note that he "moves all extremities well," except for the right wrist, due to carpal tunnel syndrome. A June 2010 report shows that on examination, he moved his upper extremities grossly WFL (within full limits). Reports, dated between 2011 and 2012, show that he was repeatedly noted to have CTS. The Board notes that records from the Social Security Administration (SSA) have been obtained which show that in February 2006, the SSA determined that the Veteran was disabled as of October 2005, with a primary diagnosis of coronary artery disease, and a secondary diagnosis of degenerative changes lumbosacral spine and hips. In the supporting documents, the Veteran was noted to have been a bus driver. The Board finds that the claim must be denied. The Veteran's left arm disability has been evaluated as 20 percent disabling, and the Board finds that the evidence of record is insufficient to show that the Veteran's residuals of a shrapnel wound of the left upper extremity at the elbow, Muscle Group V (minor) are shown to have been productive of a severe injury. There is some evidence that the Veteran's in-service wound is consistent with a severe injury, specifically, the Veteran's wound was through-and-through, and he has been found to have soft flabby muscles in the wound area. See 38 C.F.R. § 4.56(d)(4). However, overall, the Veteran's in-service wound is not shown to be consistent with a severe injury. See Tropf v. Nicholson, 20 Vet. App. 317 (2006) (38 C.F.R. § 4.56(d) is essentially a totality-of-the-circumstances test and no single factor is per se controlling). For example, the evidence is insufficient to show that the Veteran has such symptoms as wide damage to muscle groups in the missile track, abnormal swelling or hardening of the muscles in contraction, a severe impairment of strength, endurance, or coordinated movements when the left arm is compared with the corresponding muscles of the uninjured side, X-ray evidence of minute multiple scattered foreign bodies, visible or measurable atrophy, adaptive contraction of an opposing group of muscles, atrophy of muscle groups not in track of the missile, or induration or atrophy of an entire muscle following simple piercing by a projectile. In addition, during his February 2008 VA examination, he was noted to have minimal tissue loss, no tendon, bone, or joint damage, no evidence of muscle herniation, and clinically normal dexterity. Throughout the course of the appeal, left arm strength, and grip strength, are shown to have been 4/5, or 5/5, with another finding expressed as "motor strength in all extremities was strong and equal." In July 2009, he was noted to have weakness of the median and ulnar nerves involving the forearm and the forearm muscle "of severe variety." In December 2011, he was noted to have 5/5 strength on left elbow flexion, supination, and pronation, with other findings of 4/5 left grip strength 4/5 strength at the flexor Capri ulnaris. The left elbow had flexion to 110 degrees, and extension to 0 degrees. The diagnoses were mild ulnar neuropathy, and moderate degree of median nerve neuropathy of the left hand. Private treatment reports, covering treatment provided between December 2011 and January 2012, show a normal range of motion in the upper extremities, with intact sensation, and that motor strength in all extremities was strong and equal. A neurological examination revealed no focal motor deficits, or focal sensory deficits. The November 2012 VA DBQ notes mild decreased strength in the area of Muscle Group V which does not limit his activities, and some soft, flabby muscle in the wounded area, but fully intact function of the muscles, with no impairment of function of the muscles, no induration or atrophy, no adaptive contraction of opposing groups of muscles, and no impairment of muscle tonus. Elbow flexion strength was 4/5. In summary, the evidence does not support a conclusion that the criteria for a 30 percent evaluation have been met, and the findings are insufficient to show more than a moderately severe injury. To the extent that the Veteran's symptoms have been characterized at various times from "mild" to "severe," the Board has based its conclusions on the findings of record, which it regards as the most probative evidence on these matters. See 38 C.F.R. §§ 4.2, 4.6. As the preponderance of the evidence indicates that the Veteran's disability is not more than moderately severe, the Board concludes that the disability picture for service-connected residuals of a shrapnel wound of the left upper extremity at the elbow, Muscle Group V (minor) does not more nearly approximate the criteria for a 30 percent evaluation under DC 5305. The Board has considered whether an initial compensable evaluation is warranted under any other potentially applicable diagnostic code. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, there is no evidence of ankylosis of the elbow, a limitation of flexion to 100 degrees, a limitation of extension to 45 degrees, impairment of the flail joint, a nonunion of the radius and ulna with false flail joint, a nonunion of the upper half of the ulna, a nonunion of the lower half of the radius, or a limitation of supination to 30 degrees or less, to support an initial compensable evaluation under 38 C.F.R. § 4.71a, DC's 5205-5213 (2013). The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45. To the extent that these provisions are applicable to the Diagnostic Codes considered in this case, the evidence is insufficient to show additional functional loss due to pain, incoordination on use, weakness or fatigue beyond that already contemplated by the schedular diagnostic criteria, such that an evaluation in excess of 20 percent is warranted under 38 C.F.R. § 4.71a, DC's 5206-5208. In this regard, the December 2011 VA scar examination report shows that the left elbow had flexion to 110 degrees, and extension to 0 degrees, supination was from 0 to 70 degrees, and pronation from 0 to 85 degrees. After repetitive use (3 repetitions), flexion was decreased by five degrees (to 105 degrees), supination was decreased by 10 degrees (0 to 60 degrees), and pronation was unchanged. The decrease was due to pain, and not due to fatigue, weakness, or lack of endurance. The December 2011 VA neurological examination report shows that the examiner stated that there was no significant concern for fluctuations, and that the Veteran was still independent in his activities of daily living. The November 2012 VA DBQ shows that the Veteran reported mild decreased strength in the area of Muscle Group V which does not limit his activities, that the function of the muscles was fully intact, and that there was no impairment of function of the muscles. See Deluca v. Brown, 8 Vet. App. 202 (1995). Accordingly, the claim must be denied. B. Neuropathy, Median and Ulnar Nerves, Left Upper Extremity (Minor) A note in the Rating Schedule pertaining to "Diseases of the Peripheral Nerves" provides that the term "incomplete paralysis" indicates a degree of lost or impaired function which is substantially less than that which results from complete paralysis of these nerve groups, whether the loss is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a , DC's 8510 through 8540 (2013). Neuritis of the peripheral nerves, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum rating equal to severe, incomplete, paralysis. The maximum rating that may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123 (2013). Neuralgia of a peripheral nerve characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. The term incomplete paralysis, with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124 (2013). The RO has evaluated this disability under 38 C.F.R. § 4.124a, DCs 8516-8515. See 38 C.F.R. § 4.27 (2013) (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen). These hyphenated diagnostic codes may be read to indicate that impairment of the ulnar nerve is a service-connected disorder (DC 8516), as is the impairment of the median nerve under DC 8515. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Court has held that a claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). Here, separate ratings are not warranted for the median and ulnar nerves. The evidence indicates that the median nerve is more impaired that the ulnar nerve. See e.g., April 1990 VA examination report (noting sensory impairment chiefly in the distribution of the median nerve, and to a minor extent, distribution of the left ulnar nerve); December 2011 VA neurological examination report (noting mild ulnar neuropathy, and a moderate degree of median nerve neuropathy of the left hand). In addition, the Veteran is already being compensated for all of his left upper extremity impairment, and no left upper extremity symptoms have been dissociated from his service-connected ratings. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). The VA examiners made no attempt to differentiate these nerves in terms of function or impairment, and the Board is precluded from drawing such an independent medical conclusion. See Colvin v. Derwinski, 1 Vet. App. 171, 172 (1991). Consequently, the Board finds that awards of separate ratings for these functionally indistinguishable nerves would violate VA's rule against pyramiding. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1994). The criteria for evaluating the severity or impairment of the median nerve is set forth under 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8615, and 8715. Under DC 8515, a 20 percent rating requires moderate incomplete paralysis of the ulnar nerve in the minor extremity. A 40 percent rating requires severe incomplete paralysis of the median nerve in the minor extremity. Diagnostic Codes 8616 and 8716 address the criteria for evaluating neuritis and neuralgia of the median nerve, respectively. The criteria are consistent with the criteria for evaluating degrees of paralysis as set forth above. 38 C.F.R. § 4.124a, DC's 8515, 8615, and 8715 (2013). The Board's discussion of the medical evidence in Part I is incorporated herein. Briefly stated, throughout the course of the appeal, left arm strength, and grip strength, are shown to have been 4/5, or 5/5, with another finding expressed as "motor strength in all extremities was strong and equal." His upper extremity deep tendon reflexes are shown to be 1+. In February 2008, dexterity was found to be clinically normal. Private treatment reports from Virtual Health Berlin, covering treatment provided between December 2011 and January 2012, show that a neurological examination revealed no focal motor deficits, or focal sensory deficits. The November 2012 VA DBQ show that the Veteran reported mild decreased strength in the area of Muscle Group V which does not limit his activities. On examination, the function of the muscles was fully intact, and there was no impairment of function of the muscles. There is no muscle atrophy. Given the foregoing, the Board finds that the Veteran's condition is not shown to have been manifested by severe incomplete paralysis of the median nerve, such that a rating in excess of 20 percent is warranted for the Veteran's neuropathy of the median and ulnar nerves of the left upper extremity (minor) under DC 8515. Overall, the medical evidence does not contain objective evidence of such findings as muscle atrophy, weakness, or sensory impairment to the required degree. To the extent that the Veteran's symptoms have been characterized from "mild" to "severe," the Board has based its conclusions on the findings of record, which it regards as the most probative evidence on these matters. See 38 C.F.R. §§ 4.2, 4.6. Based on the foregoing, the Board finds that the evidence does not show that the Veteran's neuropathy of the median and ulnar nerves of the left upper extremity (minor) is shown to have been manifested by symptomatology that more nearly approximates the criteria for an evaluation in excess of 20 percent under DC 8515, and that the preponderance of the evidence is against a rating in excess of 20 percent. The Board also concludes that the evidence does not demonstrate that the Veteran's condition is manifested by severe incomplete neuritis, or neuralgia, such that a rating in excess of 20 percent is warranted under DC's 8615 or 8715. Specifically, given the aforementioned medical evidence, to include the findings (or lack thereof) as to muscle atrophy, weakness and sensory impairment, the Board finds that it is not shown that the Veteran's neuropathy of the median and ulnar nerves of the left upper extremity (minor) is manifested by severe incomplete neuritis, or neuralgia of the ulnar nerve, as contemplated by these diagnostic codes. Accordingly, the criteria for a rating in excess of 20 percent have not been met under DC's 8615 or DC 8715. C. Conclusion In Esteban v. Brown, 6 Vet. App. 259, 262 (1994), the Court held that evaluations for distinct disabilities resulting from the same injury could be combined so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. In this case, the evidence does not show that a separate compensable rating is warranted for his left arm scars, or any other problem associated with the service-connected disorders. The evidence does not show that the Veteran's left arm scars are deep, cause limited motion, have an area exceeding 6 square inches (39 sq. cm.), that they are unstable, or painful on examination, or that they cause a limitation of function. See e.g., November 2012 VA DBQ (noting two nontender, not unstable, left arm scars of 5 cm. x 1 cm.); December 2011 VA scar examination (noting well-healed nontender, non-adherent scars, 21/2-inch x 3/4 to 1-inch and 3-inch x 3/4-inch, that did not cause a limitation of motion or function); February 2008 VA examination report (noting two nontender, non-adherent scars, 10 cm. x 1-2 cm., and 12 cm. x 1-2 cm., that were not productive of a limitation of function). The Board therefore finds that the Veteran does not have compensable manifestations of his left arm scars under 38 C.F.R. § 4.118, DC's 7801-7805, and that the assignment of a separate 10 percent evaluation for scarring is not warranted. In deciding the Veteran's increased rating claims, the Board has considered the Court's decision in Hart v Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. The evidence of record supports the conclusion that the Veteran's disabilities have consistently approximated the criteria for no more than a 20 percent rating throughout the appeal period, and that separate rating periods are not in order. Consideration has also been given to whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2013); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1) (2013); Thun, 22 Vet. App. at 116. The schedular evaluations in this case are not inadequate. When comparing the Veteran's disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that manifestations of the service-connected left arm disabilities are congruent with the disability picture represented by the disability ratings assigned herein. The criteria for the 20 percent ratings currently assigned more than reasonably describe the Veteran's disability levels and symptomatology. The Veteran is shown to have some decreased strength and increased limitation of motion, with pain, with no post-service history of surgery. The rating schedule contemplates functional loss, which may be manifested by, for example, decreased motion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). The schedular criteria for muscle injuries, and nerve impairment, contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for the Veteran's disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is primarily manifested by some impairment of strength, and limitation of motion. In short, there is nothing exceptional or unusual about the Veteran's left arm disabilities because the rating criteria reasonably describe his disability levels and symptomatology. Thun, 22 Vet. App. at 115. With respect to the second Thun element, the evidence does not suggest that any of the "related factors" are present. In particular, the Veteran does not contend, and the evidence of record does not suggest, that his left arm disabilities have caused him to miss work, or have resulted in any hospitalizations. The evidence indicates that the Veteran is retired, and that he was determined to be disabled as of 2005, due to a heart disability. The Board finds, therefore, that the Veteran's service-connected left arm disabilities do not result in marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). Thus, even if his disability picture was exceptional or unusual, referral would not be warranted. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with his employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. In reaching these decisions, the Board has considered the oral and written testimony of the Veteran. The Board points out that, although a lay person is competent to testify only as to observable symptoms, see Falzone v. Brown, 8 Vet. App. 398, 403 (1995), a layperson is not, however, competent to provide evidence that the observable symptoms are manifestations of chronic pathology or diagnosed disability, unless such a relationship is one to which a lay person's observation is competent. See Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). In this case, the Board has determined that the medical evidence is more probative of the issues, and that it outweighs the lay statements. Accordingly, the Veteran's claims must be denied. III. Duties to Notify and Assist The Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2013). The notification obligation in this case was accomplished by way of letters from the RO to the Veteran dated in February 2008, and May 2009. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran's service treatment reports, and VA and non-VA medical records, and SSA records, have been obtained, and the Veteran has been afforded several examinations. The Veteran and his representative have not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and have not argued that any error or deficiency in the accomplishment of the duty to assist has prejudiced him in the adjudication of his appeal. See Mayfield, 19 Vet. App. at 103. In April 2013, the Board remanded these claims. The Board directed that the Veteran be afforded a hearing, and in July 2013, this was done. Under the circumstances, the Board finds that there has been substantial compliance with its remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). In July 2013, the Veteran was provided an opportunity to set forth his contentions during a Board hearing. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims recently held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the July 2013 hearing, the issues on appeal were identified. Information was solicited regarding the severity of his disabilities. The Veteran has been afforded several examinations. The testimony did not reflect that there were any outstanding medical records available that would support his claim. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. Bryant, 23 Vet. App. at 497. As such, the Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. 3.103(c)(2) have been satisfied, and that it may proceed to adjudicate the claims based on the current record. Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). ORDER A rating in excess of 20 percent for residuals of a shrapnel wound of the left upper extremity at the elbow, Muscle Group V (minor), is denied. A rating in excess of 20 percent for neuropathy of the median and ulnar nerves of the left upper extremity (minor), is denied. ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs