Citation Nr: 1803390 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 13-28 111A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada THE ISSUES 1. Entitlement to service connection for a bilateral knee disability. 2. Entitlement to an initial rating in excess of 20 percent for rotator cuff tear, subluxation bicipital tendon, left shoulder. 3. Entitlement to a rating in excess of 10 percent for synovial cyst, left thumb, status post cystectomy and metacarpophalangeal joint fusion with residual scar. 4. Entitlement to an initial, compensable rating for residual scar status post iliac crest bone graft for left hand. 5. Entitlement to an initial, compensable rating for residual scar status post left wrist bone graft for left thumb. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. D. Simpson, Counsel INTRODUCTION The Veteran served on active duty from November 1996 to March 2006. This appeal to the Board of Veterans' Appeals (Board) arose from a March 2013 rating decision in which the RO in Phoenix, Arizona denied service connection for a bilateral knee condition; granted service connection for rotator cuff tear of the subluxation bicipital tendon of the left shoulder (assigned an initial 10 percent rating), and, for residual scar of the left wrist, status post bone graft donation for left thumb (assigned an initial zero percent (noncompensable rating), and for residual scar status post iliac crest bone graft for left hand, assigning an initial noncompensable rating, each effective December 30, 2010; as well as denied a rating in excess of 10 percent for synovial cyst of the left thumb, status post cystectomy and metacarpophalangeal joint fusion with residual scar. Because the Veteran disagreed with the initial ratings assigned following the awards of service connection for left shoulder, iliac crest, and left wrist disabilities, the Board has characterized these claims in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability).By contrast, the claim involving the left thumb disability is an increased rating claim. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Francisco v. Brown, 7 Vet. App. 55 (1994). In March 2013, the Veteran filed a notice of disagreement (NOD) with respect the higher initial ratings and increased rating claims. In August 2013, the Veteran filed a NOD with respect to the denial of service connection for a bilateral knee disability. In September 2013, the RO issued a statement of the case (SOC) covering all the issues on appeal. In October 2013, the Veteran filed a substantive appeal, via a VA Form 9, Appeal to the Board of Veterans' Appeals for all issues. The Board notes that jurisdiction over these claims was transferred to the RO in Reno, Nevada, which has certified the appeal to the Board. In May 2016, the Veteran was afforded a Board hearing before the undersigned Veterans Law Judge at the Las Vegas, Nevada satellite office of the Reno RO. A copy of the hearing transcript is of record. In August 2016, the Board remanded the claims on appeal for additional development. After accomplishing further action, in September 2016, the Appeals Management Center (AMC) assigned a higher initial 20 percent rating for service-connected rotator cuff tear, subluxation bicipital tendon, left shoulder. However, as higher schedular ratings are available, and the Veteran is presumed to seek the maximum available benefit for a disability, the claim for a higher rating remains viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board's decisions on the claims for higher initial ratings for scars and for an increased rating for a left thumb disability are set forth below., The claims for service connection for a bilateral knee disability and for an increased rating for a left shoulder disability are addresses in the remand following the order; these matters are hereby remanded to the agency of original jurisdiction (AOJ). VA will notify the Veteran when further action, on his part, is required. As a final preliminary matter, the Board again notes, as noted in the August 2016 remand, that the Veteran raised a claim for an increased rating for service-connected gastric ulcers in the August 2013 NOD. To date, this matter still not been adjudicated by the AOJ, hence, it is not properly before the Board, and it is, again, referred to the AOJ for appropriate action. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 2. At no time pertinent to the December 2010 claim for increase has the Veteran's service-connected left thumb disability been shown to result in a gap of more than two inches between the thumb pad and the fingers; limitation of motion of other digits or interference with overall function of the hand; or symptoms approximating left thumb amputation. 3. Competent, probative evidence indicates that the two left upper extremity scars and left iliac crest scar are not painful or unstable; deep and nonlinear, or superficial and nonlinear; do not exceed 39 square centimeters in total area; and are not shown to result in other disabling characteristics, including limited motion. 4. The schedular criteria are adequate to evaluate the Veteran's two left upper extremity scars, left iliac crest scar and left thumb disability at all points pertinent to the current claim. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for synovial cyst, left thumb, status post cystectomy and metacarpophalangeal joint fusion with residual scar are not met. 38 U.S.C.. § 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5224, 5228 (2017). 2. The criteria for a compensable rating for residual scar status post iliac crest bone graft for left hand are not met. 38 U.S.C.. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.31, 4.118, DCs 7801-7805 (2017). 3. The criteria for a compensable rating for residual scar status post left wrist bone graft for left thumb are not met. 38 U.S.C. §§ 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321,4.1, 4.2, 4.3, 4.7, 4.31, 4.118, DCs 7801-7805 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). After a complete or substantially complete application for benefits is filed, the notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C. § 5103 (a) and 38 C.F.R. § 3.159 (b)). VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ. Id; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. Here, in January 2011and February 2013 letters issued prior to the March 2013 rating decision on appeal, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate claims for service connection and increased rating, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The letters also provided general information pertaining to VA's assignment of disability ratings and effective dates (in the event service connection is granted), as well as the type of evidence that impacts those determinations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With respect to the higher initial rating claims , after the award of service connection, and the Veteran's disagreement with each rating assigned, no additional notice for the downstream, initial rating issues was required under 38 U.S.C. § 5103A. See VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). However, the SOC set forth the criteria for higher ratings for each disability(the timing and form of which suffices for Dingess/Hartman), The record also reflects that, consistent with applicable duty-to-assist provisions, VA has made reasonable efforts to develop the Veteran's claims herein decided, to include obtaining or assisting in obtaining all relevant records and other evidence pertinent to the matters herein decided. Pertinent medical evidence associated with the claims file consists of service treatment records, VA treatment records and September 2016 VA examination reports. There is no indication that the severity of any pertinent service-connected disability has materially increased since September 2016. Also of record and considered in connection with the appeal is the transcript of the Board's May 2016 hearing, along with various written statements from the Veteran and his representative. The Board finds that no further action on any claim herein decided, prior to appellate consideration, is required. As for the May 2016 Board hearing, the transcript reflects that, during the hearing, the undersigned identified the issues on appeal and pertinent testimony was elicited regarding the nature and etiology of, and treatment for the Veteran's left shoulder, left thumb and scars of the back and left wrist. Although the undersigned did not explicitly suggest the submission of any specific, additional evidence, the Board subsequently sought further development of the claims based, in part, upon the Veteran's hearing testimony. The hearing was legally sufficient. See 38 C.F.R. 3.103(c)(2) (2016); Bryant v Shinseki, 23 Vet. App. 488 (2010). The Board also finds substantial compliance with the August 2016 Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that substantial, rather than strict, compliance with remand directives is required). Pursuant to the prior remand, the AOJ obtained updated Phoenix and Las Vegas VA Medical Center (VAMC) treatment records for the Veteran. The AOJ also sent him an August 2016 letter requesting that he identify and submit any additional medical evidence; no such records have been identified or received. The Veteran was afforded appropriate VA examinations in September 2016. Also, as directed, after the receipt of additional evidence, the AOJ readjudicated the claims (as reflected in the September 2016 SSOC). With respect to the adequacy of the examination reports of record, the Board acknowledges the decision of the United States Court of Appeals for Veterans Claims (Court) in Correia v. McDonald, 28 Vet. App. 158 (2016), in which the Court discussed 38 C.F.R. § 4.59. Specifically, the Court held that to be adequate, a VA examination of the joints must, wherever possible, include the results of range of motion testing on both active and passive motion, in weight-bearing and non weight-bearing, and, if possible, with the range of the opposite undamaged joint. Correia, 28 Vet. App. 169-70. The examination findings for the Veteran's left thumb do not reflect that testing of the undamaged right thumb, presumably for comparison purposes, or passive motion study was performed. The Board points out, however, that the thumb is not a weight-bearing joint. In this regard, the Board notes that the Veteran's thumb is rated based on whether it is ankylosed and/or the measureable gap between the thumb and the fingers upon attempted opposition. Determining the measurable gap on the undamaged left thumb would not alter the interpretation of the measurable gap on the service-connected right thumb disability in a way which would benefit the Veteran. As for passive motion, the rating criteria for the thumb specifically contemplate active motion for the next higher rating. 38 C.F.R. § 4.71a, DC 5228 ("attempting to oppose . . ."). Moreover, the Veteran's range of motion would naturally be greater under passive movement (i.e. when it is being moved for him by the physician) than with active motion; thus, the more accurate range of motion upon which to rate the Veteran, and that which could potentially provide him with the highest level of compensation, is the active movement, which is noted in the record. The Veteran has not alleged any difference in his left thumb passive range of motion from the recorded active range of motion. Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (discussing claimant's obligation to identify violations of VA's duty to assist before the Board)). In sum, there is no evidence indicating that the Veteran's right thumb motion or passive range of motion for the left thumb would reveal any more restricted range of motion which would allow for the assignment of a higher rating. For these reasons, a remand of this claim for further examination to obtain ese claims . See 38 C.F.R. § 3.159(d). See also Sabonis v. Brown, 6 Vet. App. 426 (1994), citing; Soyini v. Derwinski, 1 Vet. App. 540 (1991) (remand not required when it would impose unnecessary burdens on VA adjudication system with no benefit flowing to the Veteran); cf. Shade v. Shinseki, 24 Vet. App. 110, 123-24 (2010) (Lance, J., concurring) ("reopening [a] claim only to deny it without providing assistance would be a hollow, technical decision. There is no reason to expend agency resources on a semantic determination that is not tied to a meaningful procedural duty."). In sum, there is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required in connection with any of these claims. Accordingly, the Veteran is not prejudiced by the Board proceeding to a decision on each claim herein decided, at this juncture. II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Where 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 award 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. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Likewise, in determining the present level of a disability for any increased rating claim, the Board must consider the applicability of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings may be warranted. A. Synovial cyst, left thumb, status post cystectomy and metacarpophalangeal joint fusion with residual scar Historically, the Veteran underwent a cystectomy and metacarpophalangeal joint (MCP) fusion on his left thumb in 2004. Service treatment records from January 2005 indicate that the Veteran did not have any postoperative complications. Currently, the Veteran's service-connected synovial cyst, left thumb, status post cystectomy and MCP fusion with residual scar is rated as 10 percent disabling under DC 5228. 38 C.F.R. § 4.71a, DC 5228. DC 5228 provides for a 10 percent rating where there is a gap of one to two inches (2.5 to 5.1 cm) between the thumb pad and fingers, with the thumb attempting to oppose the fingers, and a 20 percent rating if there is a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Id. The Board notes that, when evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which a claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare- ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; Deluca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). August 2011 VA primary care records include complaints about left thumb pain. The clinician noted the surgical history for it. The Veteran denied any recent trauma, but reported it was worsening with use. He also reported numbness. The clinician assessed left thumb pain and recommended conservative treatment. X-rays of the left thumb revealed postoperative residuals, mild hypertrophy and punctate calcification. September 2012 VA primary care records include complaints about intermittent numbness and tingling of the left hand. Neurological findings reflected full strength and intact sensation through both upper extremities. The clinician assessed left hand numbness and paresthesia. She recommended electromyogram (EMG) testing. October 2012 VA EMG report confirmed left ulnar neuropathy at the elbow and left moderate median sensorimotor neuropathy at the wrist, as consistent with carpal tunnel syndrome (CTS). There was no evidence of left radial sensory neuropathy or left cervical radiculopathy. In March 2013, the Veteran was afforded a VA examination for his left thumb. The examiner diagnosed left thumb synovial cyst, status post cystectomy and MCP fusion. The Veteran reported persistent, intermittent left thumb pain with numbness. He was left hand dominant. The examiner reported that there was no gap between the left thumb pad and fingers. Repetitive motion did not further diminish movement. Hand grip strength was complete bilaterally. No ankylosis was observed. The examiner noted that X-ray revealed degenerative arthritis of the left hand. For functional impact, the examiner listed reports about difficulty writing with the left hand, gripping objects, and repetitive grasping. The Veteran was currently unemployed, but had worked about a week ago as a maintenance worker through a temporary staffing agency. At the May 2016 hearing, the Veteran reported that he had a cyst removed from his left thumb and MCP fusion. He had pain where the cyst was removed. He was left hand dominant. His left hand was weak. He had difficulty grasping and lifting objects with his left hand because of his left thumb. In September 2016, the Veteran was afforded a VA examination for his left hand. The examiner listed a diagnosis of left thumb fusion. He reported that the Veteran was left hand dominant. No flare-ups of the condition were reported. Range of motion (ROM) for the MCP was extension to 5 degrees and flexion to 0 degrees. ROM for the interphalangeal joint (IP) was extension to 0 and flexion to 40 degrees. There was no gap between the pad of the thumb and fingers. There was no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. However, the examiner noted pain on use with the left hand and localized tenderness or pain on palpation of the joint for the left thenar. Repetitive motion upon clinical evaluation did not cause any additional functional loss. However, the examiner determined that repeated use over time caused functional loss from pain. Estimated ROM for repeated use over time for MCP was extension to 5 degrees and flexion to 5 degrees. For IP joint, estimated ROM for repeated use over time for extension was to 0 degrees and for flexion was to 35 degrees. The estimated gap between the left thumb pad and fingers was 1 cm. There was no estimated gap between the finger and proximal transverse crease of the hand on maximal finger flexion. The examiner noted reduction in muscle strength from the left thumb fusion. No muscle atrophy was found. The examiner reported that the left thumb MCP was ankylosed in extension. However, the ankylosed joint did not interfere with overall function of the hand. For functional impact, the examiner commented the disability would decrease ability to lift and carry objects. Considering the pertinent evidence of record in light of the applicable rating criteria and rating considerations, the Board finds that the claim for a rating in excess of 10 percent for his service-connected left thumb disability must be denied, The evidence does not show that the gap measured between the thumb pad and finger is to at least two inches (5.1 cm), which would warrant a 20 percent rating under DC 5228. Id. The Board has also considered the Veteran's lay statements regarding the functional impact of his service-connected left thumb disability. The Veteran is competent to report his own observations with regard to the severity of his left thumb impairment, including reports of pain and decreased mobility. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). He has stated that he has pain in his left thumb that makes it difficult to carry or grip objects. While the statements are credible, they are also consistent with the rating assigned. The occurrence of pain or increased difficulty while performing activities is not an additional symptom, but rather the practical effect of the symptoms of pain and limited range of motion which have been clinically observed. The Veteran's disability also is not shown to involve any other factor(s) warranting evaluation under any other provision(s) of VA's rating schedule. To the extent that the Veteran argues that his symptomatology is more severe than shown on evaluation, as noted, in evaluating the severity of the Veteran's left thumb disability, the Board has considered the Veteran's assertions regarding his symptoms, the presence, nature and frequency of which he is competent to assert. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support a higher rating requires measurements and clinical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective clinical findings which, as indicated above, do not support assignment of a higher rating. The Board notes the September 2016 VA examination report confirmed MCP ankylosis. However, the rating criteria under DC 5224 for ankylosis of the thumb only contemplate the carpometacarpal and IP joints. 38 C.F.R. § 4.71a, DC 5224. They do not include the MCP joint. Id. Here, only the left thumb MCP is noted as ankylosed. There is no ankylosis of either the carpometacarpal and IP joints. Further consideration of DC 5224 is not warranted. Id. For all the foregoing reasons, the Board finds that there is no basis for staged rating, and that the claim for a rating in excess of 10 percent for service-connected synovial cyst, left thumb, status post cystectomy and metacarpophalangeal joint fusion must be denied. In reaching these is conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; as the preponderance of the evidence is against assignment of an increased rating, it is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert . B. Residual scars status post iliac crest bone graft for left hand and status post left wrist bone graft for left thumb The Veteran is service-connected for postoperative scars pertaining to the iliac crest and left wrist. Each scar has an initial noncompensable rating under Diagnostic Code (DC) 7805. 38 C.F.R. § 4.118, DC 7805. Under the applicable scar rating criteria, DC 7801 governs burn scars, other than the head, face, or neck, that are deep and nonlinear. It provides a 10 percent evaluation when the area or areas exceed six square inches (sq. in) (39 square centimeters (sq. cm.)). A 20 percent evaluation is assignable when the area or areas exceed 12 sq. in. (77 sq. cm). 38 C.F.R. § 4.118, DC 7801. Scars in widely separated areas, 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 of this part. A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801, Note (1), (2). DC 7804 provides a 10 percent rating for one or two scars that are unstable and painful on examination. A 20 percent rating applies to three or four scars that are unstable or painful. A 30 percent rating is for five or more scars that are unstable or painful. Note (1) to DC 7804 provides that a superficial scar is one not associated with underlying soft tissue damage. Note (2) provides that 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. Note (3) provides that scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an rating under this DC when applicable. 38 C.F.R. § 4.118, DC 7804. Under DC 7805, other types of scars will be rated based on limitation of function of affected part. 38 C.F.R. § 4.118, DC 7805. August 2011 VA primary care records show that the Veteran presented to establish care. He complained about various arthralgias. Clinical evaluation was grossly normal. The assessment did not include any findings pertinent to either scar. In March 2013, the Veteran was afforded a VA examination. As relevant, the clinical findings included an assessment of well healed scars from left thumb surgery and bone grafts. The left thumb dorsal aspect revealed a 6 cm by 1 millimeter (mm) scar. The left dorsal wrist had a 3.5 cm by 1 mm scar. The left anterior hip had a 5 cm by 1 mm scar. The examiner characterized the scars as nontender. At the May 2016 hearing, the Veteran reported that the left wrist scar limited his left wrist motion. He reported occasional pain with his left wrist, but was unsure as to whether it was due to the scar. He reported that the iliac crest scar was tender. In September 2016, the Veteran was afforded another examination for his scars. The examiner reviewed the claims folder and recited the 2002 bone graft surgery. Clinical examination confirmed two left upper extremity linear scars of 2.5 cm and 6 cm. The left iliac crest was notable for a superficial nonlinear scar measuring 6 cm by 0.5 cm, which covered an approximate total area of 3 sq. cm. The examiner stated that none of the scars resulted in limitation of function or had any functional impact. The Veteran contends that compensable initial ratings are warranted for service-connected scars. However, considering the above-cited medical and lay evidence of record evidence in light of the applicable criteria, the Board finds that a compensable rating for the left upper extremity scars and left iliac crest scar is not warranted at any point pertinent to the current claim, as explained below. 38 C.F.R. § 4.118, DCs 7801-7805. Medical records, particularly, the March 2013 and September 2016 VA examination reports, document that the Veteran's scars were not painful or productive of any limitation of function. The Board notes the Veteran's subjective reports of occasional pain or tenderness at the scar sites and limited left wrist movement at the May 2016 hearing. However, objectively, no pain or restricted joint movement associated with any scars was shown at the VA examinations in March 2013 and September 2016. These findings are consistent with the VA treatment records spanning from August 2011 to July 2017 that are entirely silent for complaints associated with any scar. It is reasonable to infer that he has not been experiencing ongoing problems with his service-connected scars. See Kahana v. Shinseki, 24 Vet. App. 428, 438-41 (2011) (Lance, J., concurring) (discussing the distinction between cases in which there is a complete absence of any evidence to corroborate or contradict the testimony, as opposed to cases in which there is evidence that is relevant either because it speaks directly to the issue or allows the Board, as factfinder, to draw a reasonable inference). As such, the VA examination reports, along with VA treatment records dating since 2011 weigh against any finding that the Veteran has been experiencing pain or other problems with his left upper extremity scars and left iliac crest scar. Id.; Caluza, 7 Vet. App. at 510-511. The Board has considered the applicability of other potentially applicable criteria for evaluating the Veteran's left upper extremity scars and left iliac crest scar, but finds that a compensable rating is not assignable. Disfigurement of the head, face, or neck is not shown by the evidence of record; the scars are not deep and nonlinear, or superficial and nonlinear; they do not exceed 39 square centimeters in total area; and the scars are not shown by the evidence to have or to result in other disabling characteristics, such as limited motion, adherence, or tissue loss. Therefore, a higher rating for scars is not warranted under DCs 7800, 7801, or 7802. In conclusion, the Board finds the Veteran's left upper extremity scars and left iliac crest scar are properly rated as noncompensable under DC 7805. See 38 C.F.R. § 4.31 (authorizing the assignment of a 0 percent (noncompensable) rating in every instance in which the rating schedule does not provide for such a rating and the requirements for a compensable rating are not met); 38 C.F.R. § 4.118, DCs 7801-7805. The evidence weighs against the assignment of a compensable initial rating for residual scar status post iliac crest bone graft for left hand and for residual scar status post left wrist bone graft for left thumb, and these claims must be denied. Id. C. All Disabilities The above determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point pertinent have the Veteran's residual scars or left thumb disability been shown to present so exceptional or so unusual a picture as to render the applicable criteria inadequate, and to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding on the part of the AOJ or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the AOJ or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, 22 Vet. App. 111. In this case, the Board finds that the applicable schedular criteria are adequate to rate the Veteran's residual scars and left thumb disability at all points pertinent to this appeal. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than that assigned based on more significant functional impairment. Significantly, there is no medical indication or argument that the applicable criteria are otherwise inadequate to rate these disabilities. The Board further notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. Here, however, the Veteran has not asserted, and the evidence of record does not suggest, that this appeal involves any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. Yancy v. McDonald, 27 Vet. App. 484, 495 (Fed. Cir. 2016) ("the Board is required to address whether referral for extra-schedular consideration is warranted for a veteran's disabilities on a collective basis only when that issue is argued by the claimant or reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities"). As such, further discussion of the holding in Johnson is unnecessary. As the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321 (b)(1) is not met, referral of any claim for extra-schedular consideration is not required. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, the Board notes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which a higher rating is sought, then part and parcel to that claim for a higher rating is the matter of whether a total disability rating based on individual unemployability (TDIU) due to that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this regard, the Veteran's employment status is unclear. The Veteran was furnished a VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability in April 2015. He did not complete the application and the RO summarily denied his TDIU claim in June 2015 based upon his failure to do so. It also informed him that if an application was received by May 13, 2016 his TDIU claim would be reconsidered. To date, the Veteran has not filed a TDIU claim. The record does not otherwise indicate that his service-connected scars and left thumb disability are productive of unemployability. Under these circumstances, the Board finds that the matter of the Veteran's entitlement to a TDIU due to one or more of the disabilities under consideration has not been raised, and need not be addressed in conjunction with the higher initial and increased rating claims herein decided. For all of the foregoing reasons, the Board finds that there is no basis for staged rating of any disability herein addressed and that the preponderance of the evidence is against assignment higher rating at any pertinent point. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A rating in excess of 10 percent for synovial cyst, left thumb, status post cystectomy and metacarpophalangeal joint fusion with residual scar is denied. An initial, compensable rating for residual scar status post iliac crest bone graft for left hand is denied. An initial, compensable rating for residual scar status post left wrist bone graft for left thumb is denied. REMAND Unfortunately, the Board finds that further AOJ action on the issues of service connection for a bilateral knee disability and a higher initial rating for a left shoulder disability is warranted, even though such will, regrettably, further delay an appellate decision on these matters. A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). With respect to the claim for service connection for bilateral knee disability, the August 2016 Board remand requested a medical etiology opinion with consideration of the January 2000 service treatment records (STRs) documenting a right knee injury and the Veteran's reports about exertive activities in service. The September 2016 VA examiner provided negative medical opinion with a cursory rationale. The rationale essentially rejected a military nexus based upon an absence of medical treatment in service. The Board finds the September 2016 VA medical opinion for the bilateral knee disability to be unresponsive to the specific remand instructions given in the August 2016 Board remand. The examiner makes no reference to the January 2000 STRs rationale and does not consider the Veteran's competent and credible reports concerning exertive military activity. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). For these reasons, the September 2016 VA medical opinion regarding service connection for a bilateral knee disability did not substantially comply with the Board's August 2016 remand directives. Thus, another remand of this matter is required to ensure such compliance. Stegall, supra.; See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall where the Board's remand instructions were substantially complied with). With respect to higher initial rating for a left shoulder disability, in August 2016, the Board remanded the claim, in part, to afford the Veteran a left shoulder examination that was complaint with the Court's decision in Correia. However, the report of the September 2016 VA left shoulder examination accomplished on remand does not include joint testing for pain in passive motion, weight-bearing and non-weight-bearing and testing of the range of motion of the opposite undamaged joint. As such, the September 2016 examination is not in compliance with the August 2016 Board remand instructions. Thus, another remand of this matter is required to ensure such compliance. Stegall, supra.; See also D'Aries, 22 Vet. App. at 105; Dyment, 13 Vet. App. at 146-47 (remand not required under Stegall where the Board's remand instructions were substantially complied with). The Veteran is hereby notified that failure to report to any scheduled examination(s), without good cause, may well result in denial of his claim(s). See 38 C.F.R. § 3.655 (2017). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. Prior to arranging for the Veteran to undergo further examination, to ensure that all due process requirements are met, and the record is complete, the AOJ should give the Veteran another opportunity to provide additional information and/or evidence pertinent to the claim on appeal (to include as regards private (non-VA) records), explaining that he has a full one-year period for response. See 38 U.S.C. § 5103(b)(1) (2012); but see also 38 U.S.C. § 5103(b)(3) (clarifying that VA may make a decision on a claim before the expiration of the one-year notice period). Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2016). However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted prior to adjudicating the remaining claims on appeal. Accordingly, these matters are hereby REMANDED for the following action: 1. Furnish to the Veteran and his representative a letter requesting that the Veteran provide information and, if necessary, authorization, to obtain any additional evidence pertinent to the claims on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate, authorization to obtain any outstanding, pertinent private (non-VA) records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 2. If the Veteran responds, obtain all identified records, following the procedures set forth in 38 C.F.R. § 3.159 (2016). All records and responses received should be associated with the file. If any records sought are not obtained, notify the Veteran and his representative of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 3. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange to obtain an addendum opinion regarding service connection for a bilateral knee disability from an appropriate physician-preferably, one who had not previously examined him in connection with his appeal. Only arrange for the Veteran to undergo further VA examination if one is deemed necessary in the judgment of the physician designated to provide the addendum opinion. The contents of the entire, electronic claims file (in VBMS or Virtual VA (Legacy Content Manager), to include a complete copy of this REMAND, must be made available to the designated individual, and the addendum opinion/examination report should include discussion of the Veteran's documented history and lay assertions. Based on a review of all pertinent lay and medical evidence, the examiner should render an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any knee disorder: had its onset in, or is otherwise medically-related to the Veteran's military service to specifically include: (a) right knee injury documented in January 2000 service treatment records and/or (b) the Veteran's reports of exertive activity during service. The examiner should not focus on the absence of records for knee medical treatment in service. Rather, the examiner should review all of the records and explain, in detail, why the Veteran's current knee disabilities may or may not be related to the documented January 2000 right knee injury in service or competent and credible reports about general exertive activity during military service. The examiner is reminded that that merely stating a conclusory opinion that the Veteran's bilateral knee disability is not related to service is not sufficient. An explanation is required that takes into account the record and pertinent medical principles and the examiner's rationale should include citation to pertinent evidence and/or medical principles relied upon to form that opinion. All examination findings/testing results, along with a complete, clearly-stated rationale for the conclusions reached, must be provided. 4. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo a VA examination of his left shoulder by an appropriate medical professional. The contents of the entire, electronic claims file (in VBMS and Virtual VA (Legacy Content Manager)), to include a complete copy of this REMAND, must be made available to the designated examiner, and the examination report should include discussion of the Veteran's documented medical history and assertions. All appropriate tests and studies should be accomplished (with all results made available to the requesting examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The examiner should conduct range of motion testing of the left shoulder (expressed in degrees) on both active motion and passive motion and in both weight-bearing and non-weight-bearing (as appropriate). The examiner should also conduct range of motion testing of the right shoulder , for comparison purposes If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly so state and explain why. The examiner should render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination. If pain on motion is observed, the examiner should indicate the point at which pain begins. Also, if the examination is not conducted during a flare-up, based on examination results and the Veteran's documented history and assertions, the examiner should indicate whether, and to what extent, the Veteran experiences likely functional loss due to pain and/or any of the other symptoms noted above during flare-ups and/or with repeated use; to the extent possible, the examiner should express any such additional functional loss in terms of additional degrees of limited motion. The examiner should specifically indicate whether the Veteran is able to raise his left arm above shoulder level. Furthermore, based on the examination results and review of the record, the examiner should also clearly indicate whether the claims file reflects any change(s) in the severity of the left shoulder disability since the effective date of the award of service connection and, if so, the approximate date(s) of any such change(s), and the severity of the disability as of each date. All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. 5. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 6. After completing the requested actions, and any additional notification and/or development action deemed warranted, adjudicate the remaining claims on appeal in light of all pertinent evidence (to include all that added to the electronic claims file since the last adjudication) and legal authority. 7. If any benefit(s) sought on appeal remain(s) denied, furnish to the Veteran and his representative an appropriate supplemental SOC that includes clear reasons and bases for all determinations, and afford them an appropriate time period for response. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether any benefit requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs