Citation Nr: 1800459 Decision Date: 01/04/18 Archive Date: 01/19/18 DOCKET NO. 10-04 103 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a compensable rating for residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye prior to September 29, 2016. 2. Entitlement to a rating in excess of 30 percent for residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye after September 29, 2016. 3. Entitlement to a rating in excess of 20 percent for residuals of shell fragment wounds to the left shoulder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Matthew Miller, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1967 to August 1969. He is the recipient of the Combat Infantryman Badge and a Purple Heart among his awards and decorations. This matter initially came to the Board of Veterans' Appeals (Board) on appeal of a rating decision of the Department of Veteran's Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The matter was remanded to the Appeals Management Center (AMC) in Washington, D.C. While in remand status, the AMC granted a disability evaluation of 20 percent for residuals of shell fragment wounds to the left shoulder, characterized as a deltoid strain. The Veteran initially indicated satisfaction with his appeal, but a short time later raised the issues of increased ratings for some of the shell fragment wounds. Thus, this issue was subsequently returned to the Board. The Veteran testified at a May 2012 Travel Board hearing before the undersigned. A transcript of that hearing is of record. In November 2013 and June 2016, the Board remanded the appeal for additional evidentiary development. The appeal has since returned to the Board for further consideration. The Board notes that during evidentiary development, evidence was received that pertains to a possible claim of entitlement to service connection for tinea pedis. See September 2016 VA examination. The Veteran and his representative are advised that he must submit a claim for this issue on the application form prescribed by the Secretary. 38 C.F.R. §§ 3.1(p), 3.155, 3.160 (2017). See also 79 Fed. Reg. 57660 (Sep. 25, 2014) (All claims governed by VA's adjudication regulations must be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises.) As such, this potential issue is not before the Board at this time. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. Any future consideration of this appellant's case should take into account the existence of these records. FINDINGS OF FACT 1. For the period prior to September 29, 2016, there was no objective evidence of pain on examination of the Veteran's residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye. 2. For the period after September 29, 2016, the probative evidence of record shows objective evidence of pain on examination on 5 or more scars of the Veteran's residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye. These scars have not been shown to be both painful and unstable, nor have they been shown to be manifested by limitation of function. 3. The probative evidence of records shows that residuals of shell fragment wounds to the left shoulder have not been productive of moderately severe or severe injury to Muscle Group III. The Veteran is right handed. CONCLUSIONS OF LAW 1. For the period prior to September 29, 2016, the criteria for a compensable rating for residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.118, Diagnostic Codes 7804, 7805 (2017). 2. For the period after September 29, 2016, the criteria for a rating in excess of 30 percent for residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.118, Diagnostic Codes 7804, 7805. 3. The criteria for a rating in excess of 20 percent for residuals of shell fragment wounds to the left shoulder, Muscle Group III, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.73, Diagnostic Code 5303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C. §§ 5100, 5102, 5103A, 5107, 5126 (2012) sets forth VA's duties to notify and assist a claimant with the evidentiary development of a claim for compensation or other benefits. See also 38 C.F.R. §§ 3.102, 3.159 and 3.326 (2017). VCAA notice must, upon receipt of a complete or substantially complete application for benefits, inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is expected to provide; and (3) that VA will obtain on his behalf. The Veteran has been provided satisfactory and timely VCAA notice in advance of the rating decision on appeal. VA has also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claim, and, as warranted by law, affording VA examinations. Currently, there is no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. The Veteran's statements in support of the claim are of record, including testimony provided at the hearing before the undersigned Veterans Law Judge. The Board hearing focused on the elements necessary to substantiate his claim and the Veteran, through his testimony and his representative's statements, demonstrated that he had actual knowledge of the elements necessary to substantiate the claim for benefits. Thus, the material issues on appeal were fully developed in accordance with 38 C.F.R. § 3.103(c) (2017). Pursuant to the Board's December 2016 remand, the Agency of Original Jurisdiction (AOJ) attempted to retrieve outstanding service treatment records and provided the Veteran with VA examinations and opinions which were responsive to the questions asked of the examiner. A supplemental statement of the case was later issued in March 2017. Based on the foregoing actions, the Board finds that there has been substantial compliance with the Board's prior remand. Stegall v. West, 11 Vet. App. 268 (1998). Finally, in reaching this determination, the Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claim, and what the evidence in the claims file shows, or fails to show, with respect to this claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Legal Principles - Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14 (2017); Esteban v. Brown, 6 Vet. App. 259, 262 (1994). While it is necessary to consider the complete medical history of the Veteran's condition in order to evaluate the level of disability and any changes in condition, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); Francisco v. Brown, 7 Vet. App. 55 (1994). In deciding the Veteran's increased evaluation claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and 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. Factual Background The Veteran's service treatment records reveal that he was wounded twice. First, in May 1968, an explosion in combat left shrapnel wounds in his left wrist and upper arm, and broke his left shoulder. He was treated at an Army Evac Hospital at DaNang, and eventually transferred to Cam Ranh Bay for rehabilitation. Second, in August 1968, another explosion in combat left shrapnel wounds under his right eye, and in his left calf and knee. He was initially treated for these wounds at the 27th Surgical Hospital, and then transferred to the 2nd Surgical Hospital at Chu Lai. See August 1968 Clinical Record Cover Sheet. Other than the August 1968 clinical record cover sheet and a brief mention in service treatment records and military records, the claims file contains no records of his treatment for these combat wounds. In its June 2016 remand, the Board instructed the AOJ to make additional attempts to retrieve these records. However, these attempts were unsuccessful and any future attempts would likely be futile. As such, the Board will proceed with the merits of the appeal. According to the available service treatment records, the Veteran's left forearm was wounded during a May 1968 mortar attack. The wound was initially debrided and left open. The Veteran received convalescent treatment for approximately 13 days. As for the second injury, it appears that his right eye, left knee, and left calf were injured in an August 1968 ambush. As noted above, the Veteran's service treatment records are limited, but he was hospitalized for 1 day and also received a temporary eye patch. The Board notes that the Veteran has received some VA and private treatment for his claimed conditions. The Veteran underwent a VA examination in August 2009. The VA examination results showed that there is no muscle, nerve, bone, or tendon damage due to the shell fragment wounds sustained to his left arm, right eye, left knee, and left calf. Evidence showed multiple (7) well-healed scars on the left arm which are all superficial and non-tender. The examiner noted no limitation of function with these scars. A corresponding VA eye examination showed visual acuity of 20/25 bilaterally, with mild increase in vision due to presbyopia. The examiner indicated that there is a slight area of scar tissue in the Veteran's right macula due the shrapnel wound sustained in service, but it is not visually significant. As a result of this examination, a noncompensable rating was continued for these residuals. In May 2012, the Veteran testified that he was wounded twice while in service. The Veteran stated that he had a superficial shrapnel wound in his left calf, and a shrapnel wound in his left knee. He further testified to having left knee problems such as buckling and swelling. He also reported popping in his left ankle. According to the Veteran, his scars from these shell fragment wounds were sometimes painful. The Veteran underwent another VA examination in January 2014 for his shell fragment wounds. The examiner noted multiple (eight) scars from the upper left arm through the forearm, and indicated that they were neither painful nor unstable. The examiner further indicated that no other extremity, including the left leg, was affected by scarring. In April 2014, the Veteran underwent a VA examination for the residuals of shell fragment wounds to his left arm. The examiner diagnosed "right deltoid strain" affecting the left side, and later referred to "left deltoid strain." The examiner also indicated the Veteran had never had an injury to a muscle group of the forearm or hand, or the foot or leg, but noted x-ray evidence of shrapnel in the left forearm. The examiner conducted muscle strength testing and did determine the left deltoid strain was the natural progression of shell fragment wounds in the left arm. However, the examiner did not conduct any range of motion testing. During another VA eye examination, the Veteran was diagnosed with mild cataracts and the examiner opined that they were not related to his right eye shell fragment wounds or otherwise etiologically related to service. Pursuant to the Board's June 2016 remand, the Veteran was afforded additional VA examinations to clarify and evaluate his residuals in September 2016, which will be summarized below. A VA elbow and forearm examination revealed a diagnosis of left elbow osteoarthritis, dated 2016. The Veteran was listed as right hand dominant. Range of motion testing was normal. Right elbow strength was 5/5 and left elbow strength was 4/5. A VA shoulder and arm examination revealed a diagnosis of left shoulder impingement syndrome, dated 2016. The Veteran complained of additional pain and limited range of motion. Right shoulder range of motion testing was normal, but left shoulder range of motion testing was abnormal. Specifically, flexion was 0 to 100 degrees, abduction 0 to 100 degrees, but external and internal rotation was 0 to 90 degrees. Right arm muscle strength was also 5/5, but left arm muscle strength was 4/5. No ankylosis was noted. The examiner stated that the diagnosed impingement syndrome is most likely proximately due to the muscle injuries/residuals of blast exposure. A VA muscle examination revealed a diagnosis of retained shrapnel. The Veteran was again listed as right hand dominant. The examiner reported muscle injuries to shoulder girdle and arm as Group III (intrinsic muscles of the shoulder girdle: pectoralis major, deltoid) on the left side, Group V (flexor muscles of the elbow: biceps, brachialis, brachioradialis) on the left side, and Group VI (extensor muscles of the elbow: triceps) on the left side. A muscle injury to the forearm and hand was reported as Group VII (muscles of the forearm: flexors of the wrist, fingers, and thumb) on the left side. Muscle injury to the foot and leg was listed as Group XI (muscles of the foot, ankle, and calf: gastrocnemius, soleus, tibalis posterior, peroneus longus, peroneus brevis, flexor hallucis longus, flexor digitorum longus) on both sides. The Veteran was reported to have entrance and exit scars associated with his muscle injuries. The examiner noted that the Veteran's injuries caused some impairment of muscle tonus. The Veteran reported consistent fatigue and muscle pain. A VA scars/disfigurement examination revealed a diagnosis of multiple residual scars of head, face or neck, dated 1968. The examiner noted that the Veteran has 5 or more scars of the trunk or extremities that are painful, but also noted that these scars were not unstable. The examiner recorded 8 deep and non-linear scars on the Veteran's left upper arm and forearm. These scars measured 3.7 x 0.7cm, 6.5 x 0.8cm, 4 x 0.4cm, 1.8 x 0.5cm, 3.9 x 0.8cm, 1.4 x 0.8cm, 2.5 x 0.7cm, and 0.5 x 0.4cm, respectively. The examiner also recorded 1 superficial and non-linear scar on the Veteran's right calf, measuring 2.5 x 0.6cm, along with 2 superficial and non-linear scars on the left calf, measuring, 4.5 x 0.2cm and 1 x 0.5cm. In total, superficial non-linear scars of the right lower extremity approximated a total area of 1.5 square cm, and scars of the left lower extremity approximated a total area of 1.4 square cm. Deep, non-linear scars of the left upper extremity approximated a total area of 16.54 square cm. A VA foot examination showed a diagnosis of bilateral tinea pedis, dated 1969 (per Veteran). The Veteran complained of foot sores and rough scaly skin, but did not suggest that his feet were impacted by his in service wounds. The examiner determined that the Veteran's bilateral tinea pedis is at least as likely as not caused by service. The examiner explained that the Veteran reported frequent fungal infections in service, such as jungle rot or foot sores and that the Veteran was unaware that he could seek medical help or VA treatment for his condition. A VA neck (cervical spine) examination showed a diagnosis of degenerative arthritis of the spine, dated 2009. The Veteran described his initial shoulder wound and reported pain radiating through his neck and down his arm. Range of motion testing, strength testing, and reflex testing were normal. The examiner determined that the Veteran's cervical degenerative disc disease is less likely as not caused by service. The examiner noted that the Veteran's condition did not onset until 2009, which is nearly 40 years after service and there Veteran had not received any in service treatment for neck pain or complaints. A VA knee and lower leg examination showed a diagnosis of left knee/left calf shrapnel injury, dated 1968. The Veteran complained of shrapnel in his knees and calves. Range of motion and muscle strength testing were normal. No ankylosis was reported, and there was no history of recurrent subluxation, lateral instability, or effusion. Joint stability testing was also normal. The examiner reported subjective tenderness of the Veteran's left knee and calf, but it was an otherwise normal examination. A VA ankle examination showed no diagnosis. All ankle testing was reported as normal, and the examiner noted that the Veteran complained of mild ankle tenderness and lower extremity edema, but it was an otherwise normal examination. A VA peripheral nerves examination showed a diagnoses of left arm peripheral nerve injury, status post shrapnel injury. The Veteran stated that he has felt decreased sensation in his left arm since his injury and additional arm weakness. Moderate paresthesias and/or dyesthesias were reported in his left arm, along with mild numbness. Muscle strength testing of the right arm was 5/5 and the left arm was 4/5. The Veteran was noted to have mild incomplete paralysis of the left radial nerve, median nerve, circumflex nerve, upper radicular group nerve, middle radicular group nerve. He also was noted to have moderate incomplete paralysis of the left musculocutaneous nerve and left long thoracic nerve. Mild incomplete paralysis was also listed for the left sciatic nerve and left external popliteal nerve. A VA hand and fingers examination showed a diagnosis of left hand shrapnel fragments. The Veteran complained of left hand and wrist weakness, with additional problems grasping objects. Range of motion testing was normal. Grip strength testing was 5/5 for the right hand and 4/5 for the left hand. No ankylosis was noted. A VA wrist examination showed a diagnosis of left wrist shrapnel wound. The Veteran complained of wrist weakness and difficulty lifting heavy objects. Left wrist range of motion testing was abnormal, with palmar flexion 0 to 40 degrees, dorsiflexion 0 to 20 degrees, ulnar deviation 0 to 30 degrees, and radial deviation 0 to 20 degrees. Left wrist muscle strength testing was 4/5. Muscle atrophy was reported at 4 cm above the wrist. Circumference of the more normal side was reported as 17 cm, with the atrophied side as 16 cm. Another VA elbow and forearm examination showed a diagnosis of shrapnel wounds to the left arm. The Veteran complained of locking or clicking in his elbow, along with numbness and pain. Left elbow range of motion testing was abnormal, with flexion 0 to 130 degrees, extension 145 to 0 degrees, forearm supination 0 to 50 degrees, and forearm pronation 0 to 80 degrees. The examiner noted that this limited arm movement is related to his in service injury. Left elbow muscle strength testing was 4/5. Muscle atrophy was reported at 12 cm below the lateral epicondyle of the right wrist. Circumference of the more normal side was reported as 23 cm, with the atrophied side as 21 cm. A VA eye examination showed no diagnosis. The Veteran reported that his right eye was hit by shrapnel, which injured his cornea. He stated he now uses glasses to aid his vision. The examiner provided the following statement: There is no corneal, scleral, conjunctival, or retinal scar noted. [The Veteran] is able to see well at distance and near with his glasses. The cornea is clear and so is the retina. There are no residual [scars] noted in either of the eyes today. Therefore there is no eye condition noted in either of the eyes which was at least as likely not incurred or caused by (during) the service. There were no further remarks. Noncompensable rating for residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye prior to September 29, 2016 The Veteran's residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye were initially rated as noncompensable under Diagnostic Code 7805, effective April 27, 1987. During evidentiary development, Diagnostic Code 7804 was applied to result in the 30 percent rating, effective September 29, 2016 (and will be discussed in the next section). Of particular importance is the date of the Veteran's claim. The schedule for rating disabilities of the skin was initially revised effective August 30, 2002 and was codified under 38 C.F.R. § 4.118, Diagnostic Codes 7800 - 7833. The criteria for rating scars were revised again, effective October 23, 2008. However, the introductory paragraph to 38 C.F.R. § 4.118 notes that a Veteran that was rated under Diagnostic Codes 7800, 7801, 7802, 7803, 7804 or 7805 before October 23, 2008, can request review under diagnostic codes 7800, 7801, 7802, 7804, and 7805, irrespective of whether the Veteran's disability has increased since the last review. Here, the Veteran's initial claim for benefits was received after October 23, 2008 and he has not raised a theory of an increased rating under the older criteria and the older criteria are not beneficial to his claim. Accordingly, the Board will utilize the revised schedular rating criteria in this decision. Pursuant to the rating schedule, a 10 percent rating is assigned for one or two scars that are unstable or painful. A 20 percent rating is assigned for three or four scars that are unstable or painful. A 30 percent rating is assigned for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. at Note (1). If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. at Note (2). Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. Id. at Note (3). According the August 2009 VA examination, the results showed that there is no muscle, nerve, bone, or tendon damage due to the shell fragment wounds sustained to his left arm, right eye, left knee, and left calf. Evidence showed multiple (7) well-healed scars on the left arm which are all superficial and non-tender. Then in May 2012, the Veteran testified that his scars were multiple and painful. He underwent another VA examination in January 2014 for his shell fragment wounds. The examiner noted multiple (eight) scars from the upper left arm through the forearm, and indicated that they were neither painful nor unstable. The examiner further indicated that no other extremity, including the left leg, was affected by scarring. In light of the above, the Board finds that prior to September 29, 2016, there was no objective evidence of painful scars. While the Veteran is competent to report about pain, multiple VA examiners during this period reported that while the Veteran did have multiple scars, they were neither painful nor unstable. In other words, his reports do not outweigh the objective evidence of record. On review, the objective findings are contemplated in the noncompensable rating currently assigned under Diagnostic Code 7804 and 7805 for this period. There is no probative evidence during this period of limitation of function or further disabling effects due to the service-connected residual scars. In sum, the Board finds that the preponderance of the evidence is against a compensable rating for residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher evaluation, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Rating over30 percent rating for residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye after September 29, 2016 As discussed above, Diagnostic Code 7804 was applied to the Veteran's residual scars to result in the 30 percent rating, effective September 29, 2016. This date corresponds with the date of the most recent and pertinent VA scar examination. According to the September 2016 VA scars examination, the examiner noted that the Veteran has 5 or more scars of the trunk or extremities that are painful, but also noted that these scars are not unstable. The examiner recorded 8 deep and non-linear scars on the Veteran's left upper arm and forearm. The examiner also recorded 1 superficial and non-linear scar on the Veteran's right calf along with 2 superficial and non-linear scars on the left calf. In total, superficial non-linear scars of the right lower extremity approximated a total area of 1.5 square cm, and scars of the left lower extremity approximated a total area of 1.4 square cm. Deep, non-linear scars of the left upper extremity approximated a total area of 16.54 square cm and no additional scars were recorded. With regard to Diagnostic Code 7805, the Board notes that the Veteran's scars do not result in limitation of motion or loss of function. The Board is cognizant of the potential for additional diagnostic codes to apply, but the results of the VA examinations detailed above show that the Veteran is either already separately compensated for additional disability due to his residuals, or that an additional rating would be impermissible pyramiding. These examiners also considered whether the Veteran's residuals could include arthritis, but a negative etiological opinion was provided. A negative etiological opinion was also provided with respect to any claimed eye injury. While the Veteran clearly has multiple scars and residuals related to shrapnel wounds, testing of the joints associated with his claimed injuries does not show any disabling effects due to the scars themselves, and a separately compensable rating is not warranted when considering Diagnostic Code 7805. The Board has also considered other diagnostic codes pertaining to scars. Under current diagnostic criteria for scars, a compensable rating requires a deep, nonlinear scar that is at least 6 square inches in size, (39 square cm), a superficial non-linear scar of at least 144 square inches, or a scar that is unstable. 38 C.F.R. § 4.118, Diagnostic Codes 7801-7804. The Veteran's scars are not shown to be unstable or are too small in size to warrant an additional or separate rating. In sum, the Board finds that the preponderance of the evidence is against a higher rating for residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher evaluation, that doctrine is not applicable. See 38 U.S.C. § 5107(b). Rating over 20 percent rating for residuals of shell fragment wounds to the left shoulder (minor extremity) The Veteran appeals the denial of a rating in excess of 20 percent for residuals of shell fragment wounds to the left shoulder, Muscle Group III. Throughout his appeal, he has been rated under Diagnostic Code 5303. Diagnostic Code 5303 involves the intrinsic muscles of the shoulder girdle, including the pectoralis major I (clavicular) and the deltoid. For the nondominant arm, a 20 percent disability rating is warranted for moderate or moderately severe injury. 38 C.F.R. § 4.73 , Diagnostic Code 5303. A maximum 30 percent rating is warranted for severe injury. Muscle injuries are evaluated pursuant to the criteria at 38 C.F.R. §§ 4.55, 4.56, and 4.73 (2017). 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. The severity of the muscle disability is determined by application of criteria at 38 C.F.R. § 4.56. First, an open comminuted fracture with muscle or tendon damage will be rated as severe, unless (for locations such as the wrist or over the tibia) the evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(a). 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). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). Under Diagnostic Codes 5301 to 5323, 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 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. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2017). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 (2017) are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2017). Here, service treatment records reveal that the Veteran suffered a left shoulder injury during a mortar attack and he was subsequently hospitalized. In April 2014, the Veteran underwent a VA examination for the residuals of shell fragment wounds to his left arm. The examiner diagnosed "right deltoid strain" affecting the left side, and later referred to "left deltoid strain." The examiner also indicated the Veteran had never had an injury to a muscle group of the forearm or hand, or the foot or leg, but noted x-ray evidence of shrapnel in the left forearm. The examiner conducted muscle strength testing and did determine the left deltoid strain was the natural progression of shell fragment wounds in the left arm. Pursuant to the Board's December 2016 remand, the Veteran was afforded another VA shoulder and arms examination. Left shoulder range of motion testing was noted as abnormal. Right arm muscle strength was 5/5, but left arm muscle strength was 4/5. No ankylosis was noted. The examiner stated that the diagnosed left shoulder impingement syndrome is most likely proximately due to the muscle injuries/residuals of blast exposure. An analogous VA muscle examination revealed a diagnosis of retained shrapnel. The Veteran was listed as right hand dominant. The examiner reported muscle injuries to shoulder girdle and arm as Group III (intrinsic muscles of the shoulder girdle: pectoralis major, deltoid) on the left side, Group V (flexor muscles of the elbow: biceps, brachialis, brachioradialis) on the left side, and Group VI (extensor muscles of the elbow: triceps) on the left side. Compensable impairment of the elbow or wrist has not been shown. The Board acknowledges that some of Veteran's VA treatment records reveal additional complaints of pain associated his left shoulder injury. After a thorough review of the evidence of record, the Board finds against the claim for an increased rating. To that end, moderately severe wounds consist of a through-and-through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, as well as intermuscular scarring. There must be evidence in the file showing hospitalization for a prolonged period for treatment of the wound, a record of consistent complaint of cardinal signs and symptoms of muscle disability, and if present, evidence of inability to keep up with work requirements. Here, evidence shows normal muscle substance, function, and strength. There is also no motion of any joint limited by muscle disease or injury that has not been separately rated or accounted for. While the Board acknowledges the Veteran's complaints of pain, the evidence does not reflect findings of loss of deep fascia or muscle substance, soft, flabby muscles in the wound area, adaptive contraction of an opposing group of muscles, or visible or measurable atrophy. Furthermore, the clinical evidence does not indicate that the Veteran had a lowered threshold of fatigue, impairment of coordination, or uncertainty of movement. Therefore, his symptoms are not shown to be moderately severe. The Board has also considered the Veteran's left shoulder injury under the musculoskeletal diagnostic codes. However, an increased evaluation greater than 20 percent is not warranted under the shoulder and arm diagnostic codes. See 38 C.F.R. § 4.71a , Diagnostic Codes 5200-5203 (2017). There is no evidence of any left shoulder ankylosis, fibrous union of the humerus, nonunion of the humerus, or loss of head of the humerus. 38 C.F.R. § 4.71a , Diagnostic Codes 5200, 5202 (2017). Accordingly, an increased evaluation is not warranted under the musculoskeletal disorder diagnostic codes. The Board has also considered whether a separate evaluation is warranted for the Veteran's service-connected disability under diagnostic codes governing scarring. However, the Board observes that the Veteran is separately service-connected residuals of multiple scars and has been discussed in the previous section. Accordingly, another separate rating is not warranted for the scarring. Last, the Board has considered entitlement to a separate evaluation for peripheral nerve impairment. A muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. 38 C.F.R. § 4.55(a) (2017). Here, the Veteran has been diagnosed with left arm peripheral nerve injury, which essentially impacts the same body part and functions. Accordingly, a separate evaluation for peripheral nerve impairment is not warranted. In sum, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for residuals of shell fragment wounds to the left shoulder. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher evaluation, that doctrine is not applicable. See 38 U.S.C. § 5107(b). ORDER Entitlement to a compensable rating for residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye prior to September 29, 2016 is denied. Entitlement to a rating in excess of 30 percent for residuals of shell fragment wounds, to include, but not limited to, scars of the left arm, left leg, left knee, and right eye after September 29, 2016 is denied. Entitlement to a rating in excess of 20 percent for residuals of shell fragment wounds to the left shoulder is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs