Citation Nr: 1804229 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 16-08 537 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 10 percent for degenerative changes of the thoracic spine. 2. Entitlement to a rating in excess of 10 percent for shell fragment wound residuals of the left knee. 3. Entitlement to an initial compensable rating for left knee scars, status-post shell fragment wound. 4. Entitlement to a compensable rating for malaria residuals. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD E. Redman, Counsel INTRODUCTION The Veteran served on active duty from October 1945 to February 1947 and from December 1948 to September 1967. He was awarded the Purple Heart. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). When the case was previously before the Board in March 2017, the issues of entitlement to an increased rating for left knee scars, entitlement to an increased rating for left knee shell fragment wound residuals and entitlement to an increased rating for malaria residuals were remanded for additional development. Additionally, in March 2017 the Board denied the Veteran's claims of entitlement to an increased rating for degenerative changes of the thoracic spine, entitlement to an increased rating for left hip degenerative changes, entitlement to an increased rating for right anterior chest wall scar and entitlement to an increased rating for right ankle second degree burn residuals. The Veteran appealed the Board's March 2017 denials of the increased rating claims to the United States Court of Appeals for Veterans Claims (Court). In August 2017 the Court granted a Joint Motion for Partial Remand which dismissed the appeals of the increased rating claims involving the left hip, right anterior chest wall scar and right ankle burn residuals, and vacated/remanded the issue of entitlement to a rating in excess of 10 percent for degenerative changes of the thoracic spine. In a September 2017 rating decision the Appeals Management Center (AMC), in pertinent part, granted service connection for injury to Muscle Group XI, left lower extremity associated with left knee shell fragment wound residuals, and assigned a 30 percent rating effective May 10, 2011 (the date the claim for an increased rating was received), and granted service connection for left knee arthroplasty associated with left knee shell fragment wound residuals and assigned a 30 percent rating effective May 10, 2011. The Veteran did not appeal any aspect of this decision. As such, these issues are not currently before the Board. The issue of entitlement to a rating in excess of 10 percent for degenerative changes of the thoracic spine is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's shell fragment wound residuals of the left knee are manifested by pain on flexion, weakness, fatigability, effusions, and stiffness; flexion is limited to 100 degrees; extension is full; there is no instability or subluxation and no neurological involvement. 2. The Veteran has four left knee scars, two linear and two non-linear/deep; none of the scars are painful or unstable. The area of the deep scars is 28.76 sq. cm. 3. The Veteran's service-connected malaria is not shown to be currently active or productive of residual liver impairment, spleen impairment, or other significant and non-transient residuals. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for left knee shell fragment wound residuals have not been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.71a, Diagnostic Codes 5256-5263 (2017). 2. The criteria for a rating in excess of 10 percent for left knee scars, status-post shell fragment wound, have not been met. 38 U.S.C. §§ 1155, 5103A, 5107 (2012); 38 C.F.R. §§ 4.7, 4.14, 4.20, 4.118, Diagnostic Code 7804 (2017). 3. The criteria for a compensable rating for malaria residuals have not been met. U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.20, 4.31, 4.88b, Diagnostic Code 6304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, the Board is satisfied as to compliance with the instructions from its March 2017 remand. Specifically, the March 2017 remand instructed the AOJ to afford the Veteran VA examinations to determine the current severity of his service-connected left knee scars, left knee shell fragment wound residuals and malaria residuals. The requested VA examinations were conducted in April 2017. In sum, the Board finds that the RO has complied with the Board's instructions and that the April 2017 VA examination reports substantially comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Legal Analysis Left Knee Shell Fragment Wound Residuals Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations, which are potentially applicable, based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. 589 (1991). It is not expected that all cases will show all findings specified; however, findings sufficiently characteristic to identify the diseases and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. 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 closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2017). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 do not apply to ratings under Diagnostic Code 5257. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). The final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Pursuant to Correia, "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 38 C.F.R. § 4.59." Correia v. McDonald, 28 Vet. App. 158 (2016). Compliance with Correia is addressed below. The normal range of motion for the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2017). The Veteran's left knee shell fragment wound residuals are rated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5257. He asserts that a higher rating is warranted. As previously noted, in a September 2017 rating decision, a separate 30 percent rating was granted for Muscle Group XI injury associated with the left knee shell fragment wound residuals and a separate 30 percent rating was granted for left knee arthroplasty associated with the left knee shell fragment wound residuals pursuant to Diagnostic Code 5055. The Veteran did not appeal this decision; therefore, these issues are not currently before the Board. Diagnostic Code 5257 provides for a 10 percent rating when there is slight recurrent subluxation or lateral instability; a 20 percent rating when there is moderate recurrent subluxation or lateral instability; and a 30 percent rating when there is severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Limitation of motion of the knee is addressed in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is limited to 60 degrees; 10 percent rating where flexion is limited to 45 degrees; 20 percent rating where flexion is limited to 30 degrees; and 30 percent rating where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to 5 degrees; 10 percent rating where extension is limited to 10 degrees; 20 percent rating where extension is limited to 15 degrees; a 30 percent rating where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). The General Counsel subsequently clarified that for a knee disability rated under Diagnostic Code 5257 to warrant a separate rating for arthritis based on x-ray findings and limitation of motion, limitation of motion under Diagnostic Code 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on x-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998). The General Counsel further held that separate ratings could also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Prosthetic replacement of a knee joint, for one year following implantation of the prosthesis warrants a 100 percent rating. With chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent evaluation will be assigned. With intermediate degrees of residual weakness, pain or limitation of motion, the knee replacement is rated by analogy to 38 C.F.R. Part 4, Diagnostic Codes 5256, 5261, or 5262. 38 C.F.R. § 4.71, Diagnostic Code 5055. The minimum rating assigned will be 30 percent. A May 2011 VA examination report reflects that the Veteran had left knee total replacement in 1996. Reported symptoms included pain and stiffness. Deformity, giving way, instability, weakness, incoordination, decreased speed of joint motion, dislocation, subluxation, effusions and inflammation were not reported. Gait was normal. There was no evidence of abnormal weight-bearing. On examination there was guarding of movement. There was no crepitation, clicks or snaps, grinding, instability, patellar abnormality, meniscus abnormality, or mass behind the knee. Range of motion was from zero to 120 degrees, without any pain on motion. On repetitive testing, range of motion was unchanged, and no pain, fatigue, weakness, or incoordination was noted. It was noted that the Veteran cannot stand for more than 15 to 30 minutes; he can walk more than a quarter of a mile but less than a full mile. A September 2014 VA treatment record reflects range of motion from zero to 100 degrees. An April 2015 VA treatment record reflects range of motion from zero to 105 degrees. The April 2017 VA examination report reflects that the Veteran's left knee disability has progressed; he experiences significant knee pain, effusions and decreased range of motion. He requires a walker for ambulation. He reported weekly flare-ups that cause increased pain and decreased motion. During flare-ups the Veteran reported significant difficulty bending, kneeling and stooping. He is unable to walk more than 40 or 60 feet or stand for more than five minutes without experiencing pain and weakness. Active and passive range of motion were the same, from zero to 120 degrees with pain on flexion. (The same range of motion was found for the right knee, but with pain on both flexion and extension.) The examiner opined that the limitation of flexion the Veteran displayed would limit bending, kneeling, and stooping, and climbing a ladder or stools. There was no localized tenderness or pain on palpation of the joint or associated soft tissue. There was evidence of pain with weight bearing. There was no crepitus. There was no additional loss of function or range of motion after three repetitions. The examiner noted that the examination was not performed immediately after repetitive use over time, but opined that the examination was neither medical consistent nor inconsistent with the Veteran's statements regarding functional loss with repetitive use over time. The examiner opined that pain, weakness, and fatigability (but not incoordination or lack of endurance) significantly limit functional ability with repeated use over time; however, the examiner was unable to describe such limitation in terms of loss of range of motion because it would be speculative to do so, as the examination was not conducted after repeated use over time. The examiner noted that the examination was not conducted during a flare-up and as such it would be speculative to state whether pain, weakness, fatigability, or incoordination would significantly limit functional ability with flare-ups. Similarly, because the examination was not conducted during a flare-up it would be speculative to quantify functional loss during a flare-up in terms of range of motion. Additional contributing factors of disability were less movement than normal, more movement than normal, weakness, disturbance of locomotion, interference with sitting, and interference with standing. It was specifically noted that swelling, deformity, atrophy of disuse and instability of station were not additional contributing factors of locomotion. Muscle strength testing for the knees was 4/5. Atrophy was not present. There was no ankylosis, instability or recurrent subluxation. There is a history of recurrent effusions. There is no evidence of patellar dislocation or shin splints. The Veteran does not have, nor has he ever had, a meniscal/semilunar cartilage condition. The Veteran regularly uses a walker. X-ray studies of the knees from 2014 revealed left knee arthroplasty, small joint effusion, and vascular calcifications. The examiner stated that knee pain was not demonstrated in non-weight bearing (when seated). The pertinent evidence of record, as summarized above, shows that the Veteran's service-connected left knee shell fragment wound residuals do not warrant a rating in excess of the current 10 percent rating. While instability has not been shown at any point during the period of the claim, the Veteran's 10 percent rating under Diagnostic Code 5257 has been in effect since September 20, 1976 and as such, it is protected under 38 C.F.R. § 3.951(b). In this regard, the provisions of 38 C.F.R. § 3.951 (b) provide that a rating that has been in effect continuously for 20 years may not be reduced except by a showing of fraud. The evidence of record does not demonstrate that a rating in excess of 10 percent under Diagnostic Code 5257 is warranted (all tests for joint stability have been normal; instability has not been objectively found), or that a higher or separate rating under any other diagnostic code is warranted. Notably, the Veteran has not shown, at any point, a degree of limited flexion or extension in his left knee that meets even the noncompensable criteria under the respective diagnostic codes. At the worst, the Veteran has demonstrated 100 degrees of flexion. Extension has consistently been full and without pain. The Veteran has described pain upon movement, and pain was objectively found (on flexion) at the April 2017 examination. (No pain on motion was found on examination in May 2011.) However, the fact that a veteran experienced pain, even if experienced throughout the range of motion on examination, does not by itself warrant a higher rating under the Diagnostic Codes providing ratings for limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, it is the functional limitation, i.e., the additional limitation of motion, caused by pain or the other DeLuca factors that must be considered in determining whether a higher rating is warranted. In that regard, the evidence does not reflect that pain or any of the other DeLuca factors resulted in limitation of motion that more nearly approximated even the noncompensable ratings for flexion or extension pursuant to Diagnostic Codes 5260 and/or 5261. At both of the VA rating examinations the Veteran demonstrated that he was able to perform repetitive-use testing and showed no additional limitation of motion following such testing. Any additional functional loss due to pain, weakness, and fatigability in the left knee joint, while significant, would not suffice to reduce extension, which has consistently been full, to 5 degrees or more, or to reduce flexion, which has been no worse than to 100 degrees, to even 60 degrees, particularly when examination consistently revealed that after three repetitions the range of motion of the left knee did not change at all. Also, while the Veteran has complained of flare-ups, as explained by the April 2017 VA examiner, it would be mere speculation to estimate the range of motion during a flare-up. In this regard, the Board's March 2017 remand sought to obtain findings that would permit it to evaluate his disability as required by DeLuca, and the provisions of 38 C.F.R. § 4.40 and 4.45. However, the April 2017 VA examiner professed an inability to estimate the limitation of motion during flare-ups (or after repetitive use) without speculation because the examination was not being conducted during a flare-up (or after repeated use of the knee). (The examiner added that this was neither consistent or inconsistent with the examination findings and went on to profess an inability to say whether there was significant impairment during flare-ups.) This is precisely the type of opinion that the Court has recently found to be inadequate. Sharp v. Shulkin, No. 16-1385 (U.S. Vet. App. Sept. 6, 2017). Therefore, the April 2017 VA examination report does not reflect strict compliance with the holding in Correia. However, given that the Veteran is in receipt of a 30 percent rating for Muscle Group XI injury related to the left knee shell fragment wound residuals, a 30 percent rating for left knee arthroplasty under Diagnostic Code 5055 and a 10 percent rating for shell fragment wound residuals of the left knee (the rating currently on appeal), that he does not meet the criteria for even the compensable ratings for limitation of flexion and extension, and that any pain, loss of range of motion/additional functional loss is already contemplated in the 30 percent rating assigned under Diagnostic Code 5055, the Board finds that another remand for strict compliance with Correia in this particular case would result in a further and unnecessary delay and would be of little to no benefit to the Veteran. The Board has considered the Veteran's statements in this regard and other symptoms in his left knee in conjunction with the objective medical findings of record. Although the Board finds that the Veteran's assertions as to his increased knee symptomatology are competent, i.e., to the extent that he personally experiences such symptoms, the Board is persuaded by the results of various tests during the VA examinations. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board has considered the provisions of Diagnostic Code 5258 for dislocation of semilunar cartilage with frequent episodes of locking, pain, and effusion. Although he has effusions, the clinical evidence confirms that he does not have dislocation of semilunar cartilage/meniscus. Thus, a higher evaluation under Diagnostic Code 5258 is not warranted. Moreover, the evidence does not show ankylosis of the left knee (Diagnostic Code 5256); impairment of the tibia or fibula (Diagnostic Code 5262); traumatic acquired genu recurvatum [a backward curving or hyperextended knee, see 68 Fed. Reg. 7017 (February 11, 2003)] with objectively shown weakness and insecurity in weight-bearing (Diagnostic Code 5263); or left knee ankylosis (Diagnostic Code 5256) which is joint immobility and consolidation; thus, a higher evaluation under these Diagnostic Codes is not warranted. As noted, the Veteran is already in receipt of a separate rating for Muscle Group XI injury, left lower extremity associated with shell fragment wound, under Diagnostic Code 5311. Further, the medical evidence of record reflects that there is no neurological impairment as part of the shell fragment wound residuals. As such, a separate rating on this basis is not warranted. In sum, the Board finds that the evidence of record does not warrant a higher rating than the current 10 percent disability rating assigned for left knee shell fragment wound residuals under Diagnostic Code 5257. The preponderance of the evidence is against assignment of a higher or separate rating on any basis; the claim is denied. 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). Left Knee Scars The Veteran asserts entitlement to a compensable rating for his left knee scars, currently rated under 38 C.F.R. § 4.118, Diagnostic Code 7804 for unstable or painful scars. He has not specifically alleged any symptoms or other reasons why he feels a compensable rating is warranted. Under Diagnostic Code 7804, one or two scars that are unstable or painful are rated 10 percent disabling. Three or more scars that are unstable or painful are rated 20 percent disabling. Five or more scars that are unstable or painful are 30 percent disabling. Note (1) to Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that 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. Note (3) provides that scars evaluated under Diagnostic Codes 7800, 7891, 7802, or 7805 may also receive an evaluation under this Diagnostic Code, when applicable. 38 C.F.R. § 4.118. In considering alternate Diagnostic Codes, Diagnostic Code 7801 provides ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. Scars that are deep or that cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 sq. cm.) are rated 20 percent disabling. Scars in an area or areas exceeding 72 square inches (465 sq. cm.) are rated 30 percent disabling. Scars in an area or areas exceeding 144 square inches (929 sq.cm.) are rated 40 percent disabling. Note (1) to DC 7801 provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Note (2) provides that if multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Combine the separate evaluations under 38 C.F.R. § 4.25. Qualifying scars are scars that are nonlinear, deep, and are not located on the head, face, or neck. 38 C.F.R. § 4.118. Under Diagnostic Code 7802, burn scars and scars of other causes not of the head, face, or neck, that are superficial and nonlinear and have an area or areas of 144 square inches (929 square centimeters) or greater warrant a 10 percent rating. 10 percent is the only rating assignable under Diagnostic Code 7802. 38 C.F.R. § 4.118, Diagnostic Codes 7802. Diagnostic Code 7802 includes two note provisions: Note (1): A superficial scar is one not associated with underlying soft tissue damage. Note (2): If multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign, a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Combine the separate evaluations under § 4.25. Qualifying scars are scars that are nonlinear, superficial, and are not located on the head, face, or neck. Diagnostic Code 7805 provides that any other scars (including linear scars) and other disabling effects of scars should be evaluated even if not considered in a rating provided under Diagnostic Codes 7800-7804 under an appropriate Diagnostic Code. 38 C.F.R. § 4.118. The Veteran was afforded a VA scar examination in May 2011. At that examination the Veteran was diagnosed with a single scar on the lateral aspect of the left knee. It was noted to be 5 inches in length and 0.5 inches wide. The examiner noted that the scar is not painful. There is no skin breakdown. There is also no underlying soft tissue damage or loss, elevation or depression of the scar, or hyperpigmentation. The texture of the scar area is normal and the scar does not have induration or inflexibility. Finally, the examiner determined that the Veteran's scar does not result in any limitation of function and does not impact the Veteran's ability to work. The Veteran was afforded another VA scar examination in April 2017. The examination report reflects a diagnosis of four scars from the left knee shell fragment wound. The scars are not painful or unstable. Two of the scars are linear and two are deep/non-linear. The first linear scar measures 27.8 cm in length and 0.4 cm wide. The second linear scar measures 8.2 cm in length and 0.8 cm wide. The first deep, non-linear scar right measures 7.2 cm in length and 2.4 cm wide. The second deep, non-linear scar right measures 8.2 cm in length and 1.4 cm wide. The total area of the deep, non-linear scars is 28.76 sq. cm. The treatment records contained in the claims file do not provide evidence contrary to that obtained at the VA examinations. After review, the Board finds that the evidence is against a compensable evaluation for the Veteran's left knee scars. As none of the Veteran's left knee scars are painful or unstable, a compensable rating is not warranted under Diagnostic Code 7804. Additionally, the Veteran's deep scars do not exceed 6 square inches (39 sq. cm.) and his scars do not cause functional limitation. The criteria for a higher rating under Diagnostic Codes 7801 or 7805 are therefore not met. 38 C.F.R. § 4.118. Further, the Veteran does not have any superficial, non-linear scars. As such, a 10 percent rating under Diagnostic Code 7802 is not warranted. Lastly, Diagnostic Code 7800 does not provide an avenue for a higher evaluation as it only pertains to scars of the head, face, or neck. 38 C.F.R. § 4.118. Additionally, in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report and observe the scars on his body and his pain. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran's competent belief that his scars disability is worse than the assigned noncompensable rating, however, is outweighed by the competent and credible medical examinations that evaluated the extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints (to the extent the Veteran has made such complaints). For these reasons, greater evidentiary weight is placed on the physical examination findings. Also, as stated above, the rating criteria are specific in indicating that some of the criteria must be objectively demonstrated. In sum, the preponderance of the evidence is against a compensable rating for the Veteran's left knee shell fragment wound scars throughout the entire appeal period. As the preponderance of evidence weighs against the Veteran's claim for a higher evaluation, the benefit of the doubt rule is not applicable to the Veteran's appeal and the appeal must therefore be denied. See 38 U.S.C. § 5107 (b). Malaria The Veteran contends that a higher (compensable) rating is warranted for his service-connected malaria because it is more severe than contemplated by the current noncompensable rating. However, a review of the record reflects that the Veteran has not provided any specific argument as to what symptoms he currently experiences as a result of his malaria or otherwise why he feels his malaria warrants a compensable rating. The RO has evaluated the Veteran's disability under 38 C.F.R. § 4.114, Diagnostic Code 6304, malaria. Pursuant to Diagnostic Code 6304, a 100 percent rating for malaria is assigned when there is an active disease process. Relapses must be confirmed by the presence of malarial parasites in blood smears. Thereafter, malaria is to be rated on the basis of residuals such as liver or spleen damage under the appropriate system. A Mat 2011 VA examination report notes that the Veteran's malaria is asymptomatic. It was noted that all tests for malaria were negative and all possible symptoms were not present. Further, it was noted that there was no history of relapse. An April 2017 VA malaria examination report reflects that the Veteran developed malaria in Okinawa in service in 1949. He was treated on an outpatient basis. He had a recurrence in service in 1950 and was hospitalized for four days. He had no further recurrences during service. The examiner noted that the malaria has been inactive since 2011 and the Veteran currently had not significant complaints. June 2011 lab results revealed negative smears and negative plasmodium antigen test. The examiner noted that the liver cyst, which is only documented in a single February 2015 VA treatment record, could not be verified by further CT scan or ultrasound, and if it exists, it is asymptomatic. An April 2017 VA liver examination report reflects that the Veteran currently has no signs or symptoms of liver disease. The VA treatment records do not contradict the VA examination reports. After review of the record, the Board finds that the clinical evidence of record does not demonstrate any verified relapses. Specifically, there is no evidence that the Veteran was ever hospitalized for a relapse of malaria, nor is there evidence that a relapse was confirmed by the presence of malarial parasites in blood smears. Additionally, there is no clinical evidence demonstrating either liver or spleen damage secondary to malaria, such that residuals of malaria could be rated under the appropriate system. To the extent that the Veteran believes that he has experienced recurrences of malaria since service, the Board notes that the Veteran is competent to provide testimony concerning factual matters of which he has first-hand knowledge and experiences through his senses. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). However, as to whether certain symptoms represent recurrences or residuals of malaria, such assessment of the origin of symptoms is a medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Thus, although the Veteran has not alleged that he has experienced any specific symptoms or a relapse, the Board ultimately affords the objective medical evidence of record greater probative weight than any such lay statements. Further, the April 2017 VA examiner specifically indicated that the Veteran's liver cyst, if it exists, is asymptomatic. Thus, even if it were related to his malaria, it is asymptomatic and does not warrant a compensable rating. In sum, the weight of the competent evidence demonstrates that the Veteran's malaria does not warrant a compensable disability rating pursuant to Diagnostic Code 6304. 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 compensable rating, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. ORDER Entitlement to an initial compensable rating for scars of the left knee, status-post shell fragment wound of the left knee is denied. Entitlement to a rating in excess of 10 percent for shell fragment wound residuals of the left knee is denied. Entitlement to a compensable rating for malaria residuals is denied. REMAND Pursuant to the directives of the Joint Motion for Partial Remand, the March 2017 Board decision improperly relied on the May 2011 VA examination report insofar as the report failed to adequately address functional loss due to limitation of motion of the thoracolumbar spine during flare-ups or after repeated use as set forth in Mitchell v. Shinseki, 25 Vet. App. 32 (2011). As such, a remand is required in order to schedule the Veteran for a new VA examination. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Schedule the Veteran for a VA spine examination in order to determine the current severity of his service-connected degenerative changes of the thoracic spine. The claims file should be made available to and reviewed by the examiner in conjunction with the examination. All necessary testing should be conducted. Range of motion testing should be undertaken for the thoracolumbar spine. The examiner is to report the range of motion measurements in degrees. The examiner is asked to indicate the point during range of motion testing that motion is limited by pain. Range of motion should be tested actively and passively, in weight bearing, and after repetitive use. The examiner should consider whether there is likely to be additional range of motion loss due to any of the following: (1) during flare-ups; and, (2) as a result of pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. If possible, the examiner should provide an opinion regarding whether, during a flare-up, the Veteran's range of motion is limited by 50 percent, as noted (and apparently reported by the Veteran) in the May 2011 VA examination report. 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 explain why that is so. A rationale for all stated opinions must be provided. 2. When the development requested has been completed, the case should be reviewed by the AOJ on the basis of additional evidence. If the benefits sought are not granted, the appellant and her representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ Kristin Haddock Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs