Citation Nr: 1633392 Decision Date: 08/23/16 Archive Date: 08/31/16 DOCKET NO. 08-31 721 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for residuals of partial hysterectomy. 2. Entitlement to an initial rating in excess of 10 percent for left wrist arthritis. 3. Entitlement to an initial rating in excess of 10 percent for left shoulder arthritis. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant is represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The appellant is a veteran (the Veteran) who had active duty service from November 1987 to November 2007. This appeal comes before the Board of Veterans' Appeals (Board) from a December 2007 rating decision of the RO in Salt Lake City, Utah. In November 2010 and October 2013, the Board remanded the above issues for additional evidentiary development, to include obtaining the Veteran's Vocational Rehabilitation records. The appeal has since been returned to the Board for further appellate action. In November 2010, the Board also granted service connection for a right wrist disorder and denied service connection for a hernia scar. In October 2013, the Board also denied increased ratings for right lung scarring, a left breast scar, and a right forearm scar. The Board's decision with respect to those matters is final. See 38 C.F.R. § 20.1100 (2015). FINDINGS OF FACT 1. The Veteran's hysterectomy residuals have been manifested by a painful residual scar. 2. The Veteran's left wrist arthritis has been manifested by painful and stiffened motion with X-ray evidence of arthritis; in no instance has wrist dorsiflexion been limited to less than 15 degrees or has wrist palmar flexion been limited in line with the forearm. 3. The Veteran's left shoulder arthritis has been manifested by a painful surgical scar, and by painful and stiffened motion of the shoulder with X-ray evidence of arthritis; in no instance has shoulder flexion been limited at shoulder level. 4. Pertinent to this appeal, the Veteran has been actually employed in a substantially gainful occupation, the schedular criteria for TDIU have not been met, and the Veteran's service-connected disabilities have not rendered her unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for hysterectomy residuals have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.116 (Diagnostic Code 7618) (2015), 4.118, Diagnostic Codes 7800-7815 (2008). 2. The criteria for a rating in excess of 10 percent for left wrist arthritis have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215 (2015). 3. The criteria for a rating in excess of 10 percent for left shoulder arthritis have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (2015). 4. The criteria for a separate rating of 10 percent for a painful left shoulder surgical scar are met; the criteria for a rating in excess of 10 percent have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10 (2015), 4.118, Diagnostic Codes 7800-7815 (2008). 5. The criteria for TDIU have not been met for any period. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Schedular Rating Consideration Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, her present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Hysterectomy Residuals This appeal arises from a claim of entitlement to service connection for hysterectomy residuals received on July 20, 2007. In a December 2007 rating decision, the RO granted service connection for partial hysterectomy residuals consisting of complete removal of the uterus and resulting scar, and assigned an initial rating of 30 percent under Diagnostic Code 7618, effective December 1, 2007, the day after service separation. Under Diagnostic Code 7618 (uterus, removal of, including corpus), a 100 percent rating is assigned for three months after removal. Thereafter, a 30 percent rating is assigned. 38 C.F.R. § 4.116, Diagnostic Code 7618. Diagnostic Code 7617 addresses the complete removal of the uterus and both ovaries, which is not demonstrated here. As the service-connected condition inherently involves a surgical scar, also potentially applicable are the criteria for skin disabilities. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. These criteria were revised during this appeal, in 2008. The applicability of the 2008 amendment is specified as follows: "This amendment shall apply to all applications for benefits received by VA on or after October 23, 2008. A veteran whom VA rated before such date under diagnostic codes 7800, 7801, 7802, 7803, 7804, or 7805 of 38 CFR 4.118 may request review under these clarified criteria, irrespective of whether his or her disability has worsened since the last review." See 73 Fed. Reg. 54708-01. As the Veteran's claim was received prior to October 23, 2008, and she has not requested that her disabilities be evaluated under the revised criteria, the Board will apply the pre-2008 criteria consistent with the above instructions. In a letter dated January 5, 2009, the Veteran reported experiencing chronic pain. She reported that her doctors tell her that they cannot find anything. She reported that medications do not work. At times, it hurts so bad she cannot get out of bed. Sometimes this goes on for weeks or months. Sometimes it itches. She reported that the scar measures four inches. It bothers her most when she tries to work out doing sit ups. A May 2011 VA examination reveals that the hysterectomy scar was midline and linear. It measured 15 x 0.5 centimeters (cm). It was hypopigmented, flat, nontender, mobile, nonadherent, superficial, and without signs of inflammation, induration, or keloid formation. There was no breakdown of skin. The texture of the scar was irregular. The scar was completely healed with no residuals. After a review of all of the evidence, the Board finds that a disability rating in excess of 30 percent for hysterectomy residuals is not warranted. At all times pertinent to this appeal, three months had expired since the hysterectomy, which was performed in service in 2003. Therefore, there is no basis under the Diagnostic Code 7618 to assign any higher rating. Regarding the ratings for skin disabilities, Diagnostic Code 7800 requires involvement of the head, face, or neck, none of which are at issue here. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). The version of Diagnostic Code 7801 in effect from August 30, 2002, to October 23, 2008, applies to scars, other than head, face, or neck, that are deep or that cause limited motion. That code provides a 40 percent rating for scars exceeding 144 square inches (929 square cm). Here, the Veteran has asserted that her scar measures four inches and the May 2011 examination showed that it measured 15 x .5 centimeters. That equates to 7.5 square inches. Accordingly, the criteria for the 40 percent rating are not met. Diagnostic Code 7805 applies to scars that cause limited function. Such scars are to be rated in accordance with the functions that are limited. In light of the Veteran's report of pain with bending, the Board has considered rating by analogy to a thoracolumbar spine disability. However, the Board finds that this would be inappropriate as, notwithstanding the potential applicability of the skin rating criteria, there is a specific diagnostic code for the disability in question, i.e. hysterectomy residuals. When a condition is specifically listed in the rating schedule, it may not be rated by analogy. Copeland v. McDonald, 27 Vet. App. 333, 338 (2015). The Board finds that rating the hysterectomy scar by analogy to a thoracolumbar spine disability is beyond what is contemplated by the rating schedule and is not appropriate. None of the other diagnostic codes pertinent to the skin and scars provides a rating in excess of 30 percent. Diagnostic Code 7804 applies to scars that are superficial and painful on examination. While certainly applicable here, only a single 10 percent rating is available under that code. Even under the current rating schedule, which contemplates the assignment of more than one rating under Diagnostic Code 7804, such multiple ratings must be based on the existence of multiple scars, which is not demonstrated here. See 38 C.F.R. § 4.118, Diagnostic Code 7804 (2016). The Board has considered whether separate ratings may be assigned for hysterectomy residuals and the surgical scar. However, in this case, it appears that the surgical scar is the primary hysterectomy residual. The Board finds that pyramiding would be inherent and unavoidable in the assignment of separate ratings for hysterectomy residuals and the surgical scar. In sum, the Veteran's hysterectomy residuals are manifested by a painful residual scar. Neither the schedule for evaluating hysterectomy residuals nor the schedule for rating skin disabilities provide or contemplate a rating in excess of 30 percent for the symptomatology demonstrated here. Consideration of Special Monthly Compensation is addressed below. To the extent any higher level of compensation is sought, the preponderance of the evidence is against the claim. Accordingly, the Board concludes that a rating in excess of 30 percent for hysterectomy residuals is not warranted. Left Wrist Arthritis This appeal arises from a claim of entitlement to service connection for a left wrist disorder received on July 20, 2007. In a December 2007 rating decision, the RO granted service connection for left wrist arthritis and assigned an initial rating of 0 percent under Diagnostic Code 5003-5215, effective December 1, 2007, the day after service separation. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent rating is provided with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent rating is provided with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. However, these ratings will not be combined with ratings based on limitation of motion and will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Diagnostic Code 5215 provides ratings specifically for the wrist joint. A maximum 10 percent rating is provided for limitation of dorsiflexion of the wrist, with dorsiflexion limited to less than 15 degrees; a maximum 10 percent rating is provided for limitation of palmar flexion, with palmar flexion limited in line with the forearm, whether the dominant or minor wrist. 38 C.F.R. § 4.71a, Diagnostic Code 5215. A September 2007 VA examination reveals that flexion (palmar) was measured to 80 degrees and extension (dorsiflexion) to 70 degrees. Ulnar deviation was measured to 45 degrees and radial deviation was measured to 20 degrees. X-rays confirmed the presence of degenerative joint disease. There were no other objective findings. The examiner noted that activities of daily living remained intact and that there was no ankylosis. In a letter dated January 5, 2009, the Veteran reported that she experiences pain in the left wrist and that medications only ease the pain for about two hours. She is not able to put pressure on the wrist. A May 2011 VA examination reveals continuing complaint of pain in the left wrist and stiffness. The pain was aggravated by rotational movements and flexion/extension movements. She was treating with Tylenol and this was effective. The pain was intermittent but she also reported early morning stiffness that would last about 30 minutes. The pain would occur with long-distance driving, wringing out rags or clothes, and during cooking. The pain could last about 30 minutes and seemed more like stiffness than actual pain. The discomfort could radiate into the metacarpal bones. She ranked the pain as 0-3 out of 10. On the job, she could work with and through the stiffness; however, she had lost a couple days from her job in the prior five months. While she reported discomfort while driving a long distance, she was able to perform her usual activities of daily living. She was noted to be right-hand dominant. On examination, there was no tenderness with palpation of the left wrist. Dorsiflexion was measured from 0 to 55 degrees before, and 0 to 70 degrees after, repetitive movements. Palmar flexion was measured from 0 to 75 degrees before, and from 0 to 70 degrees after, repetitive movements. Ulnar deviation was measured from 0 to 20 degrees before, and from 0 to 35 degrees after, repetitive movements. Radial deviation was measured from 0 to 20 degrees before and after repetitive movements. The Veteran voiced pain with movements and no pain after repetitive movements. There was no evidence of fatigue, weakness, or lack of endurance, after repetitive movements. Muscle strength of the upper extremities was rated at 5 out of 5 with good bulk and tone of the muscles. A VA examination of the right wrist in April 2014 also contained pertinent evidence for the left wrist. Left palmar flexion was measured to 80 degrees or greater with onset of pain at 70 degrees or greater. Dorsiflexion was not reported. Radial deviation was from 0 to 20 degrees and ulnar deviation was from 0 to 45 degrees. There was no additional functional loss after repetitive testing. Strength was normal (5 out of 5) on flexion and extension. There was no pain, weakness, fatigue, incoordination, or lack of endurance with range of motion after three repetitions. There was no ankylosis. After a review of all of the evidence, the Board finds that a rating in excess of 10 percent is not warranted for the left wrist arthritis. In no instance has dorsiflexion been limited to less than 15 degrees or has palmar flexion been limited in line with the forearm. The current rating is assigned on the basis of painful motion with X-ray evidence of arthritis. The Board acknowledges the pain experienced by the Veteran. She is competent to report the experience of pain and stiffness. However, the current 10 percent rating fully contemplates the presence of pain. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance, in order to constitute functional loss. Id. at 38; see 38 C.F.R. § 4.40. While the provisions of 38 C.F.R. § 4.59 establish that the Veteran is entitled to at least the minimum compensable evaluation for her symptoms, evaluations in excess of the minimum compensable rating must be based on demonstrated functional impairment. The Board acknowledges the presence of arthritis in the left wrist. However, there is no additional rating contemplated for the presence of arthritis. A noncompensable disability under Diagnostic Code 5215 is a prerequisite for compensation under the second or third parts of Diagnostic Code 5003. Only when arthritic pain does not cause limitation of motion, or causes a limitation of motion that does not rise to a compensable level, will a 10 percent rating under Diagnostic Code 5003 be appropriate. In sum, the Veteran's service-connected left wrist disability is manifested by painful and stiffened motion with X-ray evidence of arthritis. In no instance has dorsiflexion been limited to less than 15 degrees or has palmar flexion been limited in line with the forearm. To the extent any higher level of compensation is sought, the preponderance of the evidence is against the claim. Accordingly, the Board concludes that a rating in excess of 10 percent is not warranted. Left Shoulder Arthritis This appeal arises from a claim of entitlement to service connection for a left shoulder disorder received on July 20, 2007. In a December 2007 rating decision, the RO granted service connection for arthritis of the left shoulder and assigned an initial rating of 10 percent under Diagnostic Code 5003-5201, effective December 1, 2007, the day after service separation. The criteria for Diagnostic Code 5003 are set out above. Under Diagnostic Code 5201, limitation of motion of the shoulder warrants a 40 percent rating for the major arm (30 percent minor) where limited to 25 degrees from the side, a 30 percent rating for the major arm (20 percent minor) where limited midway between the side and shoulder level, and a 20 percent rating for either arm where limited at shoulder level. 38 C.F.R. § 4.71a, Diagnostic Code 5201. A September 2007 VA examination reveals activities of daily living, to include bathing, toileting, and eating remained intact. The disability limited her in that she could not lift greater than five pounds, do push-ups, or work over head greater than 10 minutes at time. Ankylosis was not present. Range of flexion and abduction was measured from 0 to 150 degrees (out of 180 degrees) with 3 out of 10 pain from 0 to 150 degrees. External and internal rotation were each measured from 0 to 90 degrees with 2 out of 10 pain in that range. The only objective findings for the shoulders were tenderness to palpation. In a letter dated January 5, 2009, the Veteran reported her surgical scars are beginning to give her problems; they itch badly and they turn red and get hard. There are times when she cannot pick up items because the soreness from scratching and itching. A May 2011 VA examination reveals that the shoulder continued to give her problems. She had pain if she lifted anything over her head. Even combing her hair and bathing aggravated the pain. The pain was intermittent, occurring daily, and could last anywhere from 15 minutes to all day. She had been prescribed many different pain medications but none seemed to help. If she had intense pain she would take Tylenol 500 mg. The Tylenol was effective in reducing the pain and she denied any side effects. The pain radiated down from the shoulder to the fingertips of the left hand. She ranked her pain 0-6 out of 10. She was able to do her job in food services but had to adapt to carrying heavy things in the right hand and arm because of the pain in the left hand. She missed about 10 days from work over the prior year. There was no effect on her activities of daily living and no shoulder dislocation. Examination findings included no unusual tenderness with palpation of the left shoulder area. Shoulder range of motion revealed flexion form 0 to 180 degrees before and after repetitive movements. Abduction was measured from 0 to 180 degrees before and after repetitive movements. Internal rotation was measured from 0 to 70 degrees before repetitive movements, and from 0 to 80 degrees after repetitive movements. External rotation was measured from 0 to 60 degrees before repetitive movements, and from 0 to 70 degrees after repetitive movements. The Veteran voiced pain with movements but no increased pain after repetitive movements. There was no evidence of fatigue, weakness, or lack of endurance after repetitive movements. Muscle strength of the upper extremities was 5 out of 5 with good bulk and tone of the muscles. An October 2012 examination by private physician R.H. Lewis, MD, reveals complaint of increased pain and decreased range of motion. The diagnosis was moderately-severe left shoulder subacromial bursitis (VBMS record 11/25/2013). After a review of all of the evidence, the Board finds that a rating in excess of 10 percent is not warranted for the left shoulder. In no instance has flexion been limited at shoulder level. All measurements (flexion and abduction) exceeded this point. The current rating was assigned on the basis of painful motion with X-ray evidence of arthritis. The Board acknowledges the pain experienced by the Veteran. She is competent to report the experience of pain. However, the current 10 percent rating fully contemplates the presence of pain. Mitchell, 25 Vet. App. at 37. Evaluations in excess of the minimum compensable rating must be based on demonstrated functional impairment. The Board acknowledges the presence of arthritis and/or bursitis in the left shoulder. However, there is no additional rating contemplated for the presence of either condition. Both conditions are to be rated on the basis of limitation of motion. A noncompensable disability under Diagnostic Code 5201 is a prerequisite for compensation under the second or third parts of Diagnostic Code 5003. While the Board understands the Veteran's central concern that she has a disabling shoulder disability, it is important for the Veteran to also understand that, without some problems associated with her shoulder there would be no basis for the current 10 percent rating. This is also true with respect to the left wrist. In this regard, it is important to note that the range of motion testing would not meet the requirements of a 10 percent evaluation, let alone a higher evaluation. Without consideration of the problems she has cited, and the pain and other issues she experiences, the current evaluation could not be justified. Regarding the Veteran's competent complaint of an itchy and irritated surgical scar, the Board finds that a separate rating of 10 percent is warranted under Diagnostic Code 7804 as the equivalent of a painful scar. The criteria for skin disabilities are set out above. As 10 percent is the maximum rating available under that code (pre-2008 version), a rating in excess of 10 percent is not warranted. As the scar does not involve disfigurement of the head, face, or neck, Diagnostic Code 7800 is not for application. There is no evidence that the scar is deep; and to the extent that it causes limited motion, this is compensated under Diagnostic Code 5003. Accordingly, Diagnostic Codes 7801 and 7805 are not for application. Diagnostic Codes 7802 and 7803 provide no more than a 10 percent rating. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (in effect from 2002-2008). In sum, the Veteran's service-connected left shoulder disability is manifested by a painful surgical scar, as well as painful and stiffened motion with X-ray evidence of arthritis. In no instance has flexion been limited at shoulder level. While a separate rating of 10 percent is warranted for the irritated scar, to the extent any higher level of compensation is sought, the preponderance of the evidence is against the claim. Accordingly, the Board concludes that a rating in excess of 10 percent for left shoulder arthritis is not warranted and a rating in excess of 10 percent for the painful surgical scar is not warranted. Extraschedular Consideration The Board has considered whether an extraschedular evaluation is warranted for the issues on appeal. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. The Board finds that the first Thun element is not satisfied with respect to the musculoskeletal disabilities. The Veteran's service-connected wrist and shoulder disabilities are manifested by signs and symptoms such as pain, stiffness, fatigability, and lack of endurance, which impairs her ability to lift and manipulate objects with her left upper extremity. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to disabilities of the wrist and shoulder provide disability ratings on the basis of limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5201, 5215. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell, 25 Vet.App. at 37. For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss including those reported here. The Board finds that the first Thun element is not satisfied with respect to the hysterectomy residuals or surgical scar (left shoulder), which are manifested by a painful scar. The criteria under Diagnostic Code 7618 contemplate all residuals of a hysterectomy, and the criteria for skin disorders contemplate the Veteran's symptoms of a painful scar. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, hysterectomy residuals, and skin disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is manifested by impairment in use of her left upper extremity and by pain in the area of her hysterectomy scar. In short, there is nothing exceptional or unusual about the Veteran's disabilities because the rating criteria reasonably describe her disability level and symptomatology. Thun, 22 Vet. App. at 115. In this regard and consistent with the reasoning presented above, the Board finds that the rating schedule is adequate, even in regard to the collective and combined effect of all of the Veteran's service connected disabilities, and that referral for extraschedular consideration is not warranted under the circumstances of this case. Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. Aug. 6, 2014). In so finding, the Board notes that the Veteran has not identified how her disability picture renders the rating schedules for musculoskeletal disabilities and disabilities of the skin and gynecologic conditions inadequate. Special Monthly Compensation Consideration The Board has considered whether the Veteran's disability picture warrants any additional level of Special Monthly Compensation (SMC). See 38 U.S.C.A. §§ 1114; 38 C.F.R. §§ 3.350, 3.352. The Veteran is currently in receipt of SMC under 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a) on account of anatomical loss of a creative organ, effective December 1, 2007. The evidence demonstrates that, while she has multiple upper extremity disabilities, she does not have such impairment as approximates loss of use of either upper extremity. 38 U.S.C. § 1114(k), (m), (n), (o); 38 CFR § 3.350(a), (c), (d), (e). She has also not been found to be housebound or in need of the aid and attendance of another. 38 U.S.C. § 1114(l), (s), (r) 38 CFR § 3.350(b), (i), (h). Her combined disability rating is 50 percent since December 1, 2007, and 60 percent since November 25, 2013, including with the additional 10 percent rating assigned in this decision. 38 U.S.C. § 1114(p), (s) 38 CFR § 3.350(f), (i). Under the circumstances here, the Board concludes that no additional SMC is warranted. TDIU Consideration It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a)(1), 4.15 (2015). The term substantially gainful occupation is not specifically defined for purposes of the regulations governing TDIU. However, marginal employment is not considered substantially gainful employment. Marginal employment includes situations in which an individual's annual income does not exceed the poverty threshold for one person. Employment may be marginal even when the individual's earned income exceeds the poverty threshold if such individual is employed in a protected environment such as a family business or sheltered workshop. 38 C.F.R. § 4.16(a). A total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a). A claim for a total disability rating based upon individual unemployability presupposes that the rating for the service-connected disability is less than 100 percent, and only asks for TDIU because of subjective factors that the objective rating does not consider. Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In evaluating a veteran's employability, consideration may be given to her level of education, special training, and previous work experience in arriving at a conclusion, but not to her age or impairment caused by non service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2015). Here, the Veteran's combined disability rating is currently 60 percent with multiple service-connected disabilities, none of which is rated at 40 percent or more. Accordingly, the schedular criteria for TDIU are not met. Pursuant to 38 C.F.R. § 4.16(b), when a claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), such case shall be submitted for extraschedular consideration in accordance with 38 C.F.R. § 3.321. For a veteran to prevail on a claim for a total compensation rating based on individual unemployability on an extraschedular basis, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Here, the Veteran has been employed for the entire period on appeal. She has never specifically contended that she was not actually employed or that her employment was not substantially gainful. She has not actually filed a claim of entitlement to TDIU. The Board inferred the issue in October 2013 remand. As noted above, the Veteran reported that she was employed in the food service industry in May 2011. In the April 2014 VA examination, the Veteran reported that she was working as an environmental specialist with physical duties consisting of sweeping, taking out the trash, and things of that nature. She reported having difficulty with lifting something heavy, which does not have to do often. In Faust v. West, 13 Vet. App. 342 (2000), the United States Court of Appeals for Veterans' Claims (Veterans Court) held that where an individual became employed at a substantially gainful occupation, irrespective of the number of hours or days that individual actually works and without regard to her earned annual income prior to her having been awarded TDIU, such employment constitutes, as a matter of law, a substantially gainful occupation and thus "actual employability" for the purposes of 38 C.F.R. § 3.343(c)(1). The Veteran's Vocational Rehabilitation records have also been reviewed. A memorandum dated April 14, 2016, indicates that she is expecting to graduate in December 2016 with a degree in Business Management and was maintaining a grade-point average of 3.05. This is probative evidence that the Veteran is able to perform the tasks and training necessary to secure and follow a substantially gainful occupation. As the evidence demonstrates that the Veteran has been employed during the appeal period, and as there is no assertion that her employment is not substantially gainful, the Board finds that the Veteran's service-connected disabilities have not rendered her unable to secure or follow a substantially gainful occupation. Therefore, referral for extraschedular consideration is not warranted. As the schedular criteria for TDIU are not met, and as the criteria for extraschedular referral are not met, the Board finds that a preponderance of the evidence is against this claim. Accordingly, the Board concludes that TDIU is not warranted. Duties to Notify and Assist VA's duty to notify was satisfied by a letter in May 2008, June 2008, December 2010, and April 2011. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The RO has obtained pertinent medical records including the service treatment records, VA outpatient treatment reports, and private treatment reports identified by the Veteran. The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of these claims that has not been obtained. The RO has also obtained a thorough medical examination regarding the claims, as well as medical opinions. The Veteran has made no specific allegations as to the inadequacy of any opinion. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). As noted above, this appeal involves a remand by the Board for additional evidentiary development. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). While substantial compliance is required, strict compliance is not. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In this case, the RO substantially complied with the Board's remand instructions by obtaining the Veteran's Vocational Rehabilitation records. ORDER A rating in excess of 30 percent for a hysterectomy scar is denied. A rating in excess of 10 percent for left shoulder arthritis is denied. A rating in excess of 10 percent for left wrist arthritis is denied. A separate rating of 10 percent, but not higher, for the left shoulder surgical scar is granted. TDIU is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs