Citation Nr: 1735652 Decision Date: 08/28/17 Archive Date: 09/06/17 DOCKET NO. 06-31 961 ) DATE ) ) On appeal from the Department of Veterans Affairs Pittsburgh Foreign Cases Regional Office THE ISSUES 1. Entitlement to an initial compensable rating for residuals of a left forearm fracture. 2. Entitlement to an initial rating higher than 10 percent for fascial herniation bulge, left forearm. 3. Entitlement to an initial rating higher than 10 percent for left wrist strain. 4. Entitlement to an initial compensable rating for scars arising from a left forearm fracture. ATTORNEY FOR THE BOARD L. Edwards Andersen, Counsel INTRODUCTION The Veteran had active service from October 1984 to October 2004. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a November 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. In January 2008, the Board remanded this claim for additional development. The Veteran requested a hearing before the Board, but canceled his request in September 2011; therefore, the Veteran's request for hearing is deemed withdrawn. In a February 2011 rating decision, the RO granted service connection and assigned a 10 percent rating for a fascial herniation bulge of the left forearm and for a strained left wrist. He was also awarded noncompensable service connection for scars associated with his left forearm surgery. As noted in a previous remand, the Veteran has not expressly appealed the ratings assigned for the above conditions; nevertheless, the Board considers it significant that each of these conditions represents a distinct manifestation of the Veteran's left forearm fracture. See 38 C.F.R. §4 14, Esteban v. Brown, 6 Vet. App. 259 (1994). Significantly, the Veteran has not limited his appeal with respect to that service-connected disability and, thus, the Board must consider all of its underlying manifestations including the newly rated conditions detailed above. See AB v. Brown, 6 Vet. App. 35 (1993) (noting that, on a claim for an original or an increased rating, the claimant is generally presumed to be seeking the maximum benefit allowed by law and regulation, and such a claim remains in appellate status where a subsequent rating decision awarded a higher rating, but less than the maximum available benefit). Accordingly, the Board finds that the separately assigned ratings for these conditions are properly on appeal, as reflected on the title page of this remand. In May 2012, the Board remanded these claims for additional development. That development having been completed, the claims are now ready for appellate review. FINDINGS OF FACT 1. The Veteran is right-hand dominant. 2. The Veteran's residuals of a left forearm fracture are manifested by arthritis confirmed on x-ray, and objectively confirmed limited motion due to pain and weakness. 3. The Veteran's fascial herniation bulge, left forearm does not more nearly approximate a moderately severe muscle injury. 4. The Veteran's left wrist strain is not manifested by favorable or unfavorable ankylosis, loss of use of the left hand, or loss of use of or ankylosis of any individual or multiple digits of his left hand. 5. Throughout the period on appeal, the Veteran's scars arising from a left forearm fracture have been asymptomatic and have not covered an area greater than 6 square inches, or an area of 144 square inches. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 10 percent, but no higher, for residuals of a left forearm fracture are met. 38 U.S.C.A. §§ 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Codes 5003, 5010, 5299-5213 (2016). 2. The criteria for an initial rating higher than 10 percent for fascial herniation bulge, left forearm, are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.56, 4.73, Diagnostic Codes 5307, 5308, 5326 (2016). 3. The criteria for an initial rating higher than 10 percent for a left wrist strain have not been met. 38 U.S.C.A. §§ 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Codes 5003 - 5215 (2016). 4. The criteria for an initial compensable rating for scars arising from a left forearm fracture have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.118, Diagnostic Code 7805 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As set forth in the Veterans Claims Assistance Act of 2000 (VCAA), the Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2014). The Board notes that where the underlying claim for service connection has been granted and there is disagreement regarding a downstream issue, such as entitlement to a higher initial rating, the claim as it arose in its initial context has been substantiated and there is no need to provide additional VCAA notice concerning the downstream issue. Goodwin v. Peake, 22 Vet. App. 128, 134 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Rather, the provisions of 38 U.S.C.A. § 7105 (d) require VA to issue a statement of the case (SOC) concerning the downstream issue if the disagreement is not resolved. The Veteran received SOC's in September 2006 and February 2017. The VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records, pertinent medical records and providing an examination when necessary. Bernard v. Brown, 4 Vet. App. 384 (1993). Service treatment records are associated with the claims file, as are post-service treatment records and VA examinations. There is no indication that there are any outstanding pertinent documents or records that have not been obtained, or that are not adequately addressed in documents or records contained within the claims folder. While the Board notes the Court's holding in Correia v. McDonald, 28 Vet. App. 158 (2016), the Board finds that here, it is not applicable to the issues on appeal. The Court in Correia held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. However, the Veteran is already receiving the highest maximum rating available for his fascial herniation and his left wrist sprain, and his scars have not been noted to affect limitation of motion in any way. Furthermore, for the Veteran's residuals of left forearm fracture, although the more recent examinations do not provide range of motion in weight bearing and non-weight bearing and active and passive motion, the Board finds that it may nonetheless proceed to adjudication of the claim. A new examination would not reveal such range of motion findings present in prior examinations. Additionally, the Board notes that the Veteran lives outside of the United States; scheduling examinations have been a difficult and lengthy process. Importantly, the Veteran indicated in a September 2011 statement that he wished to have a decision made based on the evidence already of record; he has not challenged the adequacy of the VA medical examinations. Thus, the Board finds that a remand for an examination that complies with Correia would not provide any additional benefit to the Veteran. In May 2012, the Board remanded these claims to afford the Veteran a VA examination to determine the severity of his disabilities. The Veteran was afforded VA examinations for these disabilities in September 2016. As such, the evidence indicates that there has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The VA's duty to assist in the development of the claims is complete, and no further notice or assistance to the Veteran is required to fulfill the duty. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). In light of the foregoing, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103 (a), § 5103A, or 38 C.F.R. § 3.159, and that the Veteran will not be prejudiced by the Board's adjudication of the claims. II. Increased Ratings The Veteran seeks entitlement to initial increased ratings for his residuals of a left forearm fracture, fascial herniation bulge of the left forearm, left wrist strain, and scars arising from a left forearm fracture. Disability evaluations are determined by application of criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found), is required. See Fenderson, 12 Vet. App. at 126. The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40. Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the Diagnostic Codes; "functional loss" may occur as a result of weakness, fatigability, incoordination or pain on motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). VA must consider any part of the musculoskeletal system that becomes painful on use to be "seriously disabled." Under 38 C.F.R. §§ 4.40 and 4.45, a Veteran's pain, swelling, weakness, and excess fatigability must be considered when determining the appropriate evaluation for a disability using the limitation of motion Diagnostic Codes. See Johnson v. Brown, 9 Vet. App. 7, 10 (1996). The Court held in DeLuca that all complaints of pain, fatigability, etc., shall be considered when put forth by a Veteran. Therefore, consistent with DeLuca and 38 C.F.R. § 4.59, the Veteran's complaints of pain have been considered in the Board's review of the Diagnostic Codes for limitation of motion. The Board has considered the entire record, including the Veteran's VA clinical records and private treatment records. These show complaints and treatment, but will not be referenced in detail. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Therefore, the Board will discuss the evidence pertinent to the rating criteria and the current disability. By way of history, the Veteran fell off a training facility in 1985 and suffered left radius/ulnar and wrist fractures. He underwent an open reduction internal fixation (ORIF) with placement of screws and plates in the radius/ulna and wrist. The Board notes that the Veteran is right hand dominant, so the ratings applicable to the nondominant extremity will be used for the Veteran's service-connected left wrist/forearm disabilities. See August 2016 VA examination. A. Entitlement to an Initial Compensable Rating for Residuals of a Left Forearm Fracture Service connection for residuals of a left forearm fracture was established by a November 2004 rating decision, at which time a noncompensable rating was assigned, effective from November 1, 2004. The Veteran is currently rated noncompensably under Diagnostic Code 5299-5213. VA regulations provide that conditions not listed in the rating schedule will be rated by analogy and coded with the first two numbers of the schedule provisions for the most closely related body part and "99." 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 a hyphen. 38 C.F.R. § 4.27 (2016). Diagnostic Codes beginning with "52" generally refer to bones. Diagnostic Code 5213 refers to impairment of supination and pronation of the elbow and forearm and provides a 10 percent rating for limitation of supination to 30 degrees or less; a 20 percent rating for limitation of pronation with motion lost beyond last quarter of arc, the hand does not approach full pronation or motion lost beyond middle of arc; and a 20 percent rating for the hand fixed near the middle of the arc or moderate pronation or the hand fixed in full pronation; and a 30 percent rating for the hand fixed in supination or hyperpronation. In all the forearm and wrist injuries codes 5205 through 5213, multiple impaired finger movements due to tendon tie-up, muscle or nerve injury, are to be separately rated and combined not to exceed the rating of loss of use of hand. See Note, The Elbow and Forearm. Normal range of motion of the elbow is from 0 degrees extension to 145 degrees flexion. Normal forearm pronation is from 0 to 80 degrees, and normal supination is from 0 to 85 degrees. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5206 provides that limitation of flexion warrants a noncompensable evaluation when limited to 110 degrees, a 10 percent evaluation when limited to 100 degrees, a 20 percent evaluation when limited to 90 degrees, a 20 percent evaluation when limited to 70 degrees, a 30 percent evaluation when limited to 55 degrees, and a 40 percent evaluation when limited to 45 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5207 provides that limitation of extension warrants a 10 percent evaluation when limited to either 45 or 60 degrees, a 20 percent evaluation when limited to 75 degrees, a 20 percent evaluation when limited to 90 degrees, a 30 percent evaluation when limited to 100 degrees, a 40 percent evaluation when limited to 110 degrees. Id. The Veteran was afforded a VA examination in August 2004, at which time the Veteran's in-service injury was discussed. On examination, the Veteran had full extension of his left elbow, and flexion was 142 degrees on active motion, and 145 degrees on passive motion, with no pain. The examiner stated that the Veteran's range of motion was normal for his body structure and muscle mass. X-rays demonstrated possible mild degenerative changes at the radial carpal joint. The Veteran was afforded a VA examination in April 2010. He reported left forearm pain with motion, especially with lifting and when he rests his left forearm on a desk. He described it as a stretching type pain with an intensity level of 7-8/10. He treated the pain with Motrin 3 times a week, and the pain level decreased to 6/10. He also used warm rubs 1 to 2 times a month. He did not use any assistive devices for the left forearm pain and he denied any flare-ups. He reported that he was able to perform his job without any difficulties due to forearm pain. Examination revealed radial deviation was 0 to 13 degrees with pain throughout motion, 0 to 14 degrees with pain throughout motion, and 0 to 10 degrees with pain throughout motion. There was an additional loss of 3 degrees motion/joint function with use due to pain with repeated testings. Ulnar deviation was 0 to 16 degrees with pain throughout motion, 0 to 15 degrees with pain throughout motion, and 0 to 15 degrees with pain throughout motion. There was an additional loss of 1 degree motion/joint function with use due to pain with repeated testings. Left forearm range of motion was 0 to 80 degrees pronation. Supination was 0 to 50 degrees. X-rays revealed a subtle 5 millimeter (mm) ossific density adjacent to the ulnar styloid process, which may represent sequela from a prior old traumatic injury. He received a diagnosis of left forearm fracture, with pain and limitation of motion. The Veteran was afforded a VA examination in August 2016. The Veteran was diagnosed with traumatic arthritis of the left elbow. The Veteran had a left elbow flexion of 0 to 145 degrees, extension 145 to 0 degrees, supination of 0 to 85 degrees, and pronation to 0 to 85 degrees. The Veteran was noted to have weakened movement. The examiner noted that the Veteran did not have flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation, or ankylosis. Given the above range of motion findings, the Board finds that even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as DeLuca and Mitchell the Veteran's functional losses does not equate to the criteria required for compensable ratings under Diagnostic Codes 5206, 5207, 5208, or 5213. There is also no evidence of ankylosis (Diagnostic Code 5205), impairment of flail joint (Diagnostic Code 5209), nonunion of radius and ulna with fail false joint (Diagnostic Code 5210), or impairment of the ulna (Diagnostic Code 5211) or radius (Diagnostic Code 5212). Of note, however, traumatic arthritis under Diagnostic Code 5010, is to be rated under Diagnostic Code 5003 for degenerative arthritis. 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 the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. Id. In the absence of limitation of motion, a 20 percent rating is assigned for arthritis when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. If there are no incapacitating exacerbations, a 10 percent rating is assigned. Id. In application of Diagnostic Code 5003, the Court has held that "painful motion of a major joint . . . caused by degenerative arthritis, where the arthritis is established by x-ray, is deemed to be limited motion and entitled to a minimum 10-percent rating, per joint, combined under Diagnostic Code 5003, even though there is no actual limitation of motion." See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991); see also 38 C.F.R. § 4.59. In Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011), the Court held that although painful motion is entitled to a minimum 10 percent rating under Lichtenfels and Diagnostic Code 5003, it does not follow that the maximum rating is warranted under the applicable diagnostic code pertaining to range of motion simply because pain is present throughout the range of motion. Rather, the pain must actually affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance under 38 C.F.R. § 4.40 in order to constitute functional loss warranting a higher rating. Here, as noted, the Veteran does not have compensable limitation of motion of the left forearm/elbow under any of the Diagnostic Codes pertaining to range of motion. The Veteran was, however, diagnosed with left forearm fracture with pain and limitation of motion in April 2010, and weakened movement with traumatic arthritis of the left elbow during the August 2016 VA examination. Therefore, in the absence of compensable limitation of motion under the above Diagnostic Codes, a separate 10 percent rating is warranted under Diagnostic Code 5010, for arthritis of the left elbow with painful and limited motion. The Board notes the Veteran is competent to speak to certain symptoms of his disability, such as pain. The Board accepts his reports of pain and weakness and has assigned a 10 percent rating on the basis of those reports, as well as the objective findings of arthritis and painful motion noted on examinations. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that a rating of 10 percent, but no higher, throughout the entire period of appeal is warranted. However, the Board finds that the preponderance of the evidence is against the assignment of any higher rating. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2016). B. Entitlement to an Initial Rating Higher than 10 Percent for Fascial Herniation Bulge, Left Forearm Service connection for fascial herniation bulge of the left forearm was established by a February 2011 rating decision, at which time a 10 percent rating was assigned, effective from November 1, 2004. The Veteran is currently in receipt of a 10 percent rating under Diagnostic Code 5326, the maximum rating allowed for an extensive muscle hernia without other injury to the muscle. 38 C.F.R. § 4.73, Diagnostic Code 5326. Because the Veteran is in receipt of the maximum rating under Diagnostic Code 5326, the Board will also consider other potentially applicable Diagnostic Codes. Muscle injuries are evaluated pursuant to criteria at 38 C.F.R. §§ 4.55, 4.56, and 4.73. For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions. 38 C.F.R. § 4.55 (b). The specific bodily functions of each group are listed at 38 C.F.R. § 4.73. In this case, the affected muscles, flexors and extensors of the wrist, fingers and thumb are part of Group VII and VIII and are rated under Diagnostic Codes 5307 and 5308. Under Diagnostic Code 5307, a slight disability is rated as noncompensable, a moderate disability is rated 10 percent, a moderately severe disability is rated 20 percent, and a severe disability is rated 30 percent. 38 C.F.R. § 4.73, Diagnostic Code 5307. Under Diagnostic Code 5308, a slight disability is rated as noncompensable, a moderate disability is rated as 10 percent, a moderately severe disability is rated as 20 percent, and a severe disability is rated as 20 percent. Muscle injury disabilities are rated as slight, moderate, moderately severe or severe according to criteria based on the type of injury, the history and complaint, and objective findings. 38 C.F.R. § 4.56 (d). A slight muscle disability is one where the injury was a simple wound of muscle without debridement or infection. The service department record would show a superficial wound with brief treatment and return to duty. There would be healing with good functional results. There are no cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c). Objectively, there would be a minimal scar, with no evidence of fascial defect, atrophy, or impaired tonus. There would be no impairment of function, or metallic fragments retained in muscle tissue. A moderate muscle disability is one where the injury was either through and through, or a deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without the effect of high velocity missile, residuals of debridement, or prolonged infection. The service department record (or other evidence) would show in service treatment for the wound. There would be a consistent complaint of one or more of the cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56 (c), particularly a lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objectively, the entrance (and if present, exit) scars would be small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance, or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side would be present. 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. 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 and 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. The cardinal signs or symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56 (c). The Veteran was afforded a VA examination in August 2004. It was noted that the Veteran complained of occasional discomfort when lifting heavy objects with his left non-dominant hand, but nonetheless the Veteran completed a successful career as an infantryman without difficulty. The Veteran developed a fascial herniation as a consequence of the surgery and has a fascial hernia, which on recent orthopedic examination was felt to have a very low possibility of incarceration or strangulation. On examination, there was a 10 centimeters (cm) area of fascial defect with muscle herniation present on the extensor surface of the forearm. There was no incarceration or tenderness and neurovascular status of the hand and arm was normal. The Veteran was afforded a VA examination in April 2010. He was noted to have a left forearm fascial herniation bulge that was 10.0 cm long and 3.0 cm wide. Strength was 4+/5 on the left arm. The Veteran was afforded a VA examination in August 2016. The examiner stated the Veteran had a non-penetrating muscle injury during service. The Veteran reported he was told he had a dehiscence of the tissue between the muscles of the forearm, but no repair was recommended. The Veteran reported intermittent painless bulging of the tissue in and around the left forearm surgical site, but denied pulsation or pain in this site. The examiner stated that muscle groups VII and VIII were affected, and that palpation showed a loss of deep fascia; however, the injury did not affect muscle substance or function. It was also noted that the Veteran had consistent weakness, fatigue-pain, and left wrist flexion and extension were 4/5 on muscle strength testing. There was no muscle atrophy. The examiner commented that the Veteran's disability had a mild impact on his ability to use the left wrist and forearm for prolonged dorsi/palmar flexion and lifting heavy objects (more than 30 pounds) due to pain, weakness and fatigue. Based on the above, the Veteran's symptoms of fascial herniation bulge, left forearm, do not warrant a rating higher than the current 10 percent. The Veteran's symptoms include pain and decreased muscle strength. Again, 10 percent is the maximum rating available under Diagnostic Code 5326 for muscle hernia. 38 C.F.R. § 4.73. Higher ratings are available under Diagnostic Code 5307 or 5308 for injuries to muscle group VII or VIII that are at least moderately severe. However, the Veteran's muscle injury was not a through and through or deep penetrating wound as required for more than a moderate muscle injury. See 38 C.F.R. § 4.56. While loss of power of the muscle is shown, the amount of loss was found to be slight, 4/5. Similarly, while palpation showed a loss of deep fascia, the injury did not affect muscle substance or function, and the August 2016 examiner indicated that the Veteran's disability had a mild impact on his ability to use the left wrist and forearm. The August 2016 VA examiner specifically stated that the Veteran's injury was moderate in nature and not severe, as he still had 4/5 strength. When assessing the actual objective findings and lay complaints, however, the overall muscle disability is slight at best under the criteria for evaluating muscle disabilities which warrants a noncompensable evaluation under Diagnostic Codes 5307 and 5308. The Board considered whether separate ratings may be assigned for muscle groups VII and VIII identified in the August 2016 VA examination. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Effective from July 3, 1997, 38 C.F.R. §§ 4.55 and 4.56 no longer preclude separate ratings for muscle group disabilities to the same anatomical region where those muscle group disabilities act on the same joint. Currently, "[a] through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged." 38 C.F.R. § 4.56 (b) (2016). 38 C.F.R. § 4.55 (d) now provides that "[t]he combined evaluation of muscle groups acting upon a single unankylosed joint must be lower than the evaluation for unfavorable ankylosis of that joint, except in the case of muscle groups I and II acting upon the shoulder." In Jones v. Principi, the United States Court of Appeals for Veterans Claims (Court) held that, pursuant to the post-1997 version of 38 C.F.R. § 4.56 (b), a Veteran is entitled to separate ratings for "'each group of muscles damaged' as a result of "'[a] through-and-through injury with muscle damage.'" 18 Vet. App. 248, 258 (2004) (quoting 38 C.F.R. § 4.56 (b)). Here, however, the Board notes that the Veteran's injury was not a through-and-through injury; the August 2016 VA examiner described it as a non-penetrating muscle injury. Furthermore, even if considered a through-and-through injury, the Board notes that the August 2016 VA examiner stated that although muscle groups VII and VIII were affected, there was overlapping symptomatology between the two muscle groups, as both groups affected the forearm flexors and caused a weakened wrist flexion. The examiner stated that the Veteran's disability was not accompanied by any muscle injury other than the fascial herniation bulge. Although muscle group VII and VIII were affected, the Board finds that separate ratings for each muscle group are not warranted, as the medical evidence indicates that both groups affect the forearm flexors and cause the same symptom of a weakened wrist flexion. As noted, the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Here, the symptomatology is overlapping, as specifically noted by the August 2016 VA examiner, and therefore, the Veteran does not have separate and distinct manifestations from the same injury which would permit separate ratings for each muscle group in addition to the ratings for the fascial herniation bulge, limitation of forearm motion, and left wrist impairment. In conclusion, there are no higher or alternative ratings under different Diagnostic Codes which can be applied to the Veteran's claim. See Schafrath, 1 Vet. App. at 593. The preponderance of the evidence is against the Veteran's claim for an increased rating. As such, the benefit of the doubt doctrine is inapplicable and the Veteran's appeal is denied. 38 C.F.R. § 4.3. C. Entitlement to an Initial Rating Higher than 10 Percent for a Left Wrist Strain Service connection for a left wrist strain was established by a February 2011 rating decision, at which time a 10 percent rating was assigned, effective from November 1, 2004. The Veteran is currently rated as 10 percent disabled under 38 C.F.R. § 4.71a, Diagnostic Code 5215. Under Diagnostic Code 5215, a 10 percent rating for the wrist is warranted for either limitation of palmar flexion in line with the forearm or limitation of dorsiflexion to less than 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5215. The 10 percent disability rating is the maximum evaluation under Diagnostic Code 5215. The Board first notes that no higher disability evaluation under Diagnostic Code 5215 may be assigned for the Veteran's left wrist disability, as 10 percent is the maximum evaluation possible under that Diagnostic Code. Furthermore, a higher rating for limitation of dorsiflexion or palmar flexion is not warranted, as Diagnostic Code 5215 already contemplates the effects of limitation of motion. In evaluating musculoskeletal disabilities, the VA must determine whether the joint in question exhibits weakened movement, excess fatigability, incoordination, and whether pain could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. See DeLuca, 8 Vet. App. at 206-207; See also 38 C.F.R. §§ 4.40, 4.45. However, where a musculoskeletal disability is currently evaluated at the maximum schedular rating based on limitation of motion, DeLuca consideration is not applicable. See Johnston, 10 Vet. App. at 85. Therefore, no higher rating based on limitation of motion of the Veteran's left wrist is possible. The Board has considered the application of Diagnostic Code 5003, which allows for a separate 10 percent rating for limitation of motion, where there is radiographic evidence of arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board notes that the Veteran was diagnosed with degenerative joint disease of the radiocarpal joint in the August 2016 VA examination. However, a separate 10 percent rating under Diagnostic Code 5003 is not warranted for the left wrist because it applies only where limitation of motion under an applicable Diagnostic Code is non-compensable. In the present case, the Veteran is in receipt of a compensable rating for limitation of movement in his left wrist. Thus, a separate or increased rating is not warranted under Diagnostic Code 5003 for the Veteran's left wrist disability, at any time during the period on appeal. Furthermore, under 38 C.F.R. § 4.45 (f), for the purpose of rating disability from arthritis, the only major joints are the shoulder, elbow, wrist, hip, knee and ankle. Additionally groups of multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities; the interphalangeal, metatarsal and tarsal joints of the lower extremities; the cervical vertebrae; the dorsal vertebrae; and the lumbar vertebrae, are considered groups of minor joints, ratable on parity with major joints. 38 C.F.R. § 4.45 (f). This implies that the Veteran's wrists are considered to be one joint. Therefore, in order to warrant a higher rating, the medical evidence must demonstrate that the Veteran has no range of motion within his left wrist or that he has effectively lost the functioning of his left hand. For example, Diagnostic Code 5214 offers a higher rating where there is medical evidence of ankylosis of the wrist. Ankylosis is defined as the "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). Under Diagnostic Code 5214, a 20 percent rating is warranted for favorable ankylosis of the minor (non-dominant) wrist in 20 to 30 degrees of dorsiflexion. A 30 percent rating is warranted for any other position, except favorable of the minor wrist; and a maximum 40 percent rating requires unfavorable ankylosis of the minor wrist in any degree of palmar flexion or with ulnar or radial deviation. A review of the Veteran's medical records fails to show any diagnosis and/or evidence of ankylosis. Furthermore, these records fail to show that the Veteran's left wrist disability was of such condition that it was the functional equivalent of ankylosis; the August 2016 VA examiner specifically indicated that this was not the case. While August 2004, April 2010 and August 2016 VA examinations document chronic wrist pain with reduced range of motion, there is no indication that the Veteran's wrist is ankylosed; in fact, the August 2016 VA examiner specifically noted that there was no left wrist ankylosis. Additionally, the Board finds no evidence that would support the award of a 60 percent rating for loss of use of the left hand. Loss of use of a hand is present when no effective function remains other than that which could be equally well served by an amputation stump at the site of election below elbow with use of a suitable prosthetic appliance. 38 C.F.R. § 3.350 (a)(2). However, the medical evidence does not show a loss of the Veteran's left hand. For example, the August 2016 noted a reduction in grip strength, but strength was still classified as 4/5 and there was no muscle atrophy. Finally, as noted above, the medical evidence does not report findings indicating the Veteran experienced the loss of use of or ankylosis of any individual or multiple digit of his left hand. As such, there can be no award of an increased rating under those Diagnostic Codes. 38 C.F.R. § 4.71a, Diagnostic Codes 5126-5156, 5216-5130. In conclusion, there are no higher or alternative ratings under different Diagnostic Codes which can be applied to the Veteran's claim. See Schafrath, 1 Vet. App. at 593. The preponderance of the evidence is against the Veteran's claim for an increased rating. As such, the benefit of the doubt doctrine is inapplicable and the Veteran's appeal is denied. 38 C.F.R. § 4.3. D. Entitlement to an Initial Compensable Rating for Scars Arising From a Left Forearm Fracture Service connection for scars arising from the left forearm fracture was established by a February 2011 rating decision, at which time a noncompensable rating was assigned, effective from November 1, 2004. During the pendency of the Veteran's claim and appeal, amendments were made to the criteria for rating the skin, effective October 23, 2008. See 73 Fed. Reg. 54,710 (Sept. 23, 2008). These amendments only apply to applications received by VA on or after October 23, 2008, or if the Veteran expressly requests consideration under the new criteria, which the Veteran here has not done. The Veteran's claim was received in 2004, therefore, the Board has no authority to consider these revisions in deciding this claim and they will not be discussed herein. See 38 U.S.C.A. § 5110 (g); VAOPGCPREC 3-00. The Veteran is currently rated noncompensably under Diagnostic Code 7805. See 38 C.F.R. § 4.118, Diagnostic Code 7805. Diagnostic Code 7805 states to rate scars on limitation of function of affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (in effect prior to October 23, 2008). Diagnostic Code 7800 pertains to scars of the head, face or neck, and as such, is not applicable here. Diagnostic Code 7801 rates scars, other than the head, face or neck that are deep or that cause limited motion. Under this diagnostic code, evaluations of 10, 20, 30 and 40 percent are warranted for scars with an area between 6 square inches (39 sq. cm.) and 12 square inches (77 sq. cm.), between 12 square inches and 72 square inches (465 sq. cm.), between 72 square inches and 144 square inches (929 sq. cm.), and exceeding 144 square inches, respectively. 38 C.F.R. § 4.118, Diagnostic Code 7801 (in effect prior to October 23, 2008). Note one to Diagnostic Code 7801 reads that scars in widely separated areas, such as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note two reads that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 (in effect prior to October 23, 2008). Diagnostic Code 7802 rates scars, other than head, face or neck, that are superficial and that do not cause limited motion. Under this diagnostic code a 10 percent evaluation is warranted for a scar with an area of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802 (in effect prior to October 23, 2008). Note one to Diagnostic Code 7802 reads that scars in widely separated areas, such as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note two reads that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802 (in effect prior to October 23, 2008). Diagnostic Code 7803 provides a 10 percent evaluation for scars that are superficial and unstable. Note one to this diagnostic code reads that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note two reads that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7803 (in effect prior to October 23, 2008). Diagnostic Code 7804 provides a 10 percent evaluation for scars that are superficial and painful on examination. Note one to this diagnostic code reads that a superficial scar is one not associated with underlying soft tissue damage. Note two reads that in this case a 10 percent evaluation will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable evaluation. 38 C.F.R. § 4.118, Diagnostic Code 7804 (in effect prior to October 23, 2008). The Veteran was afforded a VA examination in August 2004. He was noted to have multiple surgical scars present over his left forearm. The examiner stated he had long scars on the flexor and extensor surfaces of his forearm, representing previous extensive surgery. There was also a healed scar representing a carpal tunnel release performed at the time of his original surgery. The Veteran was afforded a VA examination in April 2010. He reported postoperative scars on the left wrist and forearm area. He indicated that they are not painful and there was no skin breakdown over the scar. The Veteran reported that he is cosmetically embarrassed by the scar even though it is well healed. Examination revealed three scars. Scar number one was located on the left anterior forearm. It was a vertical scar, measuring 13.2 cm long and 0.8 cm wide. Scar number two was located on the posterior aspect of the forearm, and was a vertical scar that measured 15.7 cm long and 0.4 cm wide. Scar number three was located at the anterior left wrist, and was a vertical scar that measured 7.5 cm long and 0.2 cm wide. All three scars were described as superficial, nontender and nonpainful. The scars had no adherence to underlying tissue, no irregular texture, no atrophy, no shininess, no scaliness, no instability, no ulceration, no skin breakdown, no elevation or depression on palpation, no hypopigmentation, no hyperpigmentation, no induration, no inflexibility, no limitation of motion or function caused by scar, no keloid, no edema, no inflammation, no disfigurement distortion, or asymmetry. The Veteran was afforded a VA examination in August 2016. The examiner noted that there were no scars that were both painful and unstable. The Veteran was noted to have three scars on the anterior and posterior left forearm and wrist. Scar one was 12.0 cm by 0.4 cm, scar two was 16.0 cm by 0.3 cm, and scar three was 6.0 cm x 0.2 cm. The examiner stated that the scars did not result in limitation of motion. The examiner indicated that the Veteran had fascial diathesis with muscle herniation of the left forearm, which is a failure of the scarring process, and part of the scar, and affects his ability to lift and carry heavy objects. The Board notes, however, that the Veteran is separately service connected for the muscle herniation. As noted above, the Veteran's scars are currently rated as noncompensable under Diagnostic Code 7805, which provides that scars are to be rated based on limitation of motion of the affected part. 38 C.F.R. § 4.118. The Board finds the noncompensable rating appropriate. The VA examinations of record do not reflect that the Veteran's scars result in any limitation of motion or loss of function. In fact, the evidence shows his scars have been asymptomatic throughout the pendency of the claim. As the evidence throughout the appeal period does not show any disabling effects due to the scars, a compensable rating is not warranted under Diagnostic Code 7805. Id. The Board considered other potentially applicable diagnostic codes for rating the Veteran's scars, but finds no higher rating is assignable under any other diagnostic code. To that end, his scars have been asymptomatic during the entire pendency of the claim, thus compensable ratings are not warranted under Diagnostic Code 7803 (scars, superficial, unstable) or Diagnostic Code 7804 (scars, superficial, painful on examination). Moreover, the scars do not exceed six square inches to warrant application of Diagnostic Code 7801 (scars, other than head, face, or neck, that are deep or that cause limited motion) or affect an area of 144 square inches to warrant application of Diagnostic Code 7802 (scars, other than head, face, or neck, that are superficial and do not cause limited motion). Based on the foregoing, the Veteran is not entitled to a compensable rating for his scars. As detailed above, there is no evidence that the Veteran's scars are deep or nonlinear, unstable or painful, or that the affected area is greater than 6 square inches or an area of 144 square inches. Further, the evidence of record does not show that the Veteran's service-connected scars cause functional impairments of the left upper extremity. As the preponderance of evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. The Board notes that in Rice v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that entitlement to a total disability rating based on individual unemployability (TDIU) may be considered part and parcel of an increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran has not raised a claim for TDIU and the evidence does not indicate that he is unemployable due to the disabilities on appeal. See, e.g., April 2010 and August 2016 VA examinations. Accordingly, the Board finds that Rice is not applicable in this case. ORDER Entitlement to an initial rating of 10 percent, but no higher, for residuals of a left forearm fracture is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial rating higher than 10 percent for fascial herniation bulge, left forearm, is denied. Entitlement to an initial rating higher than 10 percent for a left wrist strain is denied. Entitlement to an initial compensable rating for scars arising from a left forearm fracture is denied. ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs