Citation Nr: 18160315 Decision Date: 12/26/18 Archive Date: 12/26/18 DOCKET NO. 09-44 649 DATE: December 26, 2018 ORDER Entitlement to an initial rating in excess of 20 percent for left acromioclavicular joint arthritis, status post Mumford surgery with scar, is denied. FINDING OF FACT The Veteran’s left shoulder motion of the left arm is not limited to 25 degrees from the side of the Veteran’s body. CONCLUSION OF LAW The criteria for entitlement to an initial rating in excess of 20 percent for left acromioclavicular joint arthritis, status post Mumford surgery with scar, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4.71a, DC 5003-5201, DC 5202 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from March 1982 to April 2008. This matter comes before the Board of Veterans’ Appeals (the Board) from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. The June 2008 rating decision, in pertinent part, granted service connection for left acromioclavicular joint arthritis, status post Mumford surgery with scar and assigned an initial 10 percent disabling rating effective May 1, 2008. In May 2017, the Board remanded the issue on appeal for additional development. The Board’s remand included an instruction that left shoulder range of motion testing should note the point at which the Veteran experiences pain and to include a discussion of the Veteran’s symptoms, including symptoms during flare-ups. Pursuant to the May 2017 Board remand instructions, the Veteran was afforded a VA examination in September 2017 to assist in determining the severity of his service-connected left shoulder disability. The Board finds that the May 2017 VA examination report is thorough and adequate and incompliance with the remand instructions. Further, a Supplemental Statement of the Case (SSOC) was issued re-adjudicating the claim currently in appellate status. As such, there has been substantial compliance with the prior Board remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97 (2008). In October 2015, the Veteran testified at a hearing before the undersigned Veterans Law Judge in a Videoconference Board Hearing to present testimony on the issue of the initial rating for the Veteran’s left acromioclavicular joint arthritis, status post Mumford surgery, with scar, as well as issues not presently on appeal. A transcript of the hearing if of record. A July 2018 rating decision granted a 20 percent disability rating for the service-connected left acromioclavicular joint arthritis, status post Mumford surgery with scar disability effective May 1, 2008 (the date of the initial evaluation determination), thereby, not creating a “staged” initial disability rating. 1. Entitlement to an initial rating in excess of 20 percent for left acromioclavicular joint arthritis, status post Mumford surgery, with scar 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 (2012); 38 C.F.R. § 4.1 (2017). All potentially applicable rating criteria and regulations must be considered. 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 (2017). All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 4.3 (2017). Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Where, as in this case, the question for consideration is the propriety of the initial ratings assigned, evaluation of the all evidence and consideration of the appropriateness of staged ratings is required whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. The determination of whether an increased disability rating is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In its claim adjudication, the RO did not assign a “staged” rating to the claim on appeal. Rather, as noted above, the July 2018 rating decision increased the initial disability evaluation from 10 to 20 percent disabling with the same effective date of May 1, 2008. The Board has considered, and found inappropriate, the assignment of “staged” ratings for any part of the initial rating period for the remainder of the disability decided herein. 38 C.F.R. §§ 4.40, 4.45 and 4.59 require the Board to consider a veteran’s pain, swelling, weakness, and excess fatigability when determining the appropriate evaluation for a disability using the limitation of motion diagnostic codes. See Johnson v. Brown, 9 Vet. App. 7, 10 (1996); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). 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). 38 C.F.R. § 4.59 also requires consideration of painful motion, specifying that the intent of the rating schedule is to recognize painful motion with joint pathology as productive of disability and 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 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When analyzing lay evidence, the Board should assess the evidence and determine whether the disability claimed is of the type for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313 Fed Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Board considers not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2017). However, the evaluation of the same “disability” or the same “manifestations” under various diagnoses is not allowed. See 38 C.F.R. § 4.14 (2017). A claimant may not be compensated twice for the same symptomatology as “such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity.” See 38 U.S.C. § 1155 (2012); Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran’s service-connected left acromioclavicular joint arthritis, status post Mumford surgery with scar, is currently rated as 20 percent disabling under diagnostic codes (DC) 5003-5201. This hyphenated coding indicates that the rating is for arthritis (DC 5003) based upon limitation of motion of the shoulder joint (DC 5201). Specifically, the diagnostic code for degenerative arthritis states that where arthritis is established by x-ray findings, it is to be rated based on limitation of motion under the appropriate DC for the specific joint involved. When limitation of motion is noncompensable under the appropriate DC, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a (2017), DC 5003. In this instance, the Regional Office has assigned a 20 percent rating based upon the Veteran’s painful motion of the shoulder with x-ray evidence of degenerative arthritis, including consideration of functional loss under the holding of DeLuca v. Brown and others discussed above. See Rating Decision(s), June 2008, July 2018. The Board now considers whether an initial rating in excess of 20 percent under DC 5003-5201 for the Veteran’s service-connected left acromioclavicular joint arthritis, status post Mumford surgery with scar, is warranted. First, the Board has considered all other diagnostic codes referable to the shoulder and arm (DCs 5200-5203), but finds none is more applicable than that currently in use. Thus, the Board finds DC 5003-5201 to be most relevant to the symptomatology and impairment described by the Veteran. Limitation of motion of the arm is evaluated under DC 5201. 38 C.F.R. § 4.71a (2017), DC 5201. Ratings assigned pursuant to this code may differ depending on whether the extremity at issue is considered the major (dominant) extremity or the minor (non-dominant) extremity. As the Veteran in the case at hand is right-handed, his left shoulder condition affects his minor extremity, and will be evaluated accordingly. For DC 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, rate as follows: a 10 percent evaluation is assigned for painful or limited motion of a major joint or group of minor joints and may also be applied once to multiple joints if there is no limited or painful motion. A 20 percent is assigned for X-ray evidence that shows involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. Note (1): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a (2017). Under DC 5201, a 20 percent disability rating is assigned for limitation of an arm at the shoulder level, whether it is the major or minor extremity. A 30 percent disability rating is assigned for the major extremity when motion is limited to midway between the side and shoulder level. A 40 percent disability rating is assigned for the major extremity when motion is limited to 25 degrees from the side. See 38 C.F.R. § 4.71a (2017). Normal ranges of shoulder flexion and abduction are from 0 to 180 degrees, and external and internal rotation are from 0 to 90 degrees. See 38 C.F.R. § 4.71, Plate I (2017). In determining whether the Veteran has limitation of motion to shoulder level, it is necessary to consider forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-316 (2003). Lastly, the Veteran is not entitled to ratings under DC 5200, ankylosis of scapulohumeral articulation, or DC 5203, impairment of the clavicle or scapula, as there is no ankylosis of the left shoulder joint noted in any medical examination, and there is no impairment of the left shoulder clavicle or scapula. 38 C.F.R. § 4.71a (2017). Throughout the course of the appeal, the Veteran has contended generally that the left shoulder disability has been manifested by more severe symptoms than those contemplated by the 20 percent initial disability rating assigned. In the hearing with the undersigned VLJ in October 2015, the Veteran testified that his left shoulder condition was worse since his last VA examination in April 2014. Thereafter, in an October 2018 Informal Hearing Presentation (IHP) the Veteran’s representative argues that the Veteran should have been entitled to a staged rating, claims that the evidence demonstrates a greater degree of impairment that what the current rating demonstrates. In November 2007, the Veteran complained of chronic neck pain/stiffness and numbness in the left hand during the day, at night bilateral numbness; he was given a provisional diagnosis of radiculopathy and referred for a cervical magnetic resonance imaging (MRI) diagnostic. See VA Outpatient Treatment Records, November 2007. The Veteran underwent a retirement physical exam in December 2007. He reported impaired use of his arms [] …, pain in both left and right shoulders, histories his left shoulder Mumford surgery in 2000, reported difficulty raising his arms, and indicated he cannot perform a military press. See Medical Treatment Records, December 2015. Following his pre-service separation claim, dated August 2007, for service-connection for his left shoulder disability the Veteran received a VA examination in December 2007. The examiner noted the Veteran’s diagnosis of AC joint arthritis and Mumford surgery in November 2000, where distal clavicle resection was done. The examiner noted that the Veteran’s symptoms improved, but he still complains of on and off pain to the AC joint and the back of the shoulder, which is more with motion. No aggravating activities were reported. The Veteran reported using Motrin as needed. An objective examination found the Veteran’s left shoulder possessed a full range of motion, noted pain, weakness, fatigue or incoordination following repetitive use or flare-ups, which decreased range of motion when shoulder pain flares up, and found positive tenderness to palpation to AC joint area, pain with cross arm adduction, negative apprehension test, pain with Hawkins Impingement test. It was noted that there was no deformity, and a well healed 3-inch scar to the AC joint for the previous shoulder surgery. The examiner indicated that the Veteran’s left shoulder AC joint arthritis, status post Mumford surgery with scar, affects his ability to do overhead lifting when shoulder pain flares-up. Thereafter, outpatient treatment records from the 121st Combat Support Hospital from January 2008 report joint pain, localized in the shoulder, notably the records fail to specify which shoulder is affected. In a January 2009 written statement, the Veteran disagreed with the July 2008 rating decision, and relied on an independent medical evaluation, which found crepitus of both shoulders, 4/5 strength left shoulder all planes, left rotation 45/45, left external rotation 45/45, left forward flexion 0-90/0-90, and left abduction 0-90/0-90. See Private Medical Treatment Record, Dr. C.N.B, Neuro-Radiology, December 2008. In his report, Dr. C.N.B. opined that the Veteran is underrated and assigned an incorrect diagnostic code because he entered service fit for duty, has significant left upper extremity weakness, pain with decreased ranged of motion, had service time injuries to this area. He noted that the Veteran reported that he cannot throw a football or baseball due to pain, he sleeps on his right side, wakes up with shoulder throbbing, arm numb, and cannot return to sleep until pain subsides. The Veteran also reported that his left forearm down through his hand is numb all the time, cannot hold a telephone for any length of time without it becoming severely painful and arm becoming numb. Dr. C.N.B. concluded that the Veteran’s records do not support another more likely etiology for his current left shoulder disability. Complaints of left shoulder pain arise next in July 2009, when the Veteran reported doing certain movements caused sharp pain, especially when pulling inward and pushing outward, and whenever raising his left arm over shoulder level. Notably, treatment records from November 2010 focus on the Veteran’s lumbar spine condition and are negative for any left shoulder condition. VA Outpatient Treatment Records show that as of December 2014 the Veteran’s active health problems listed Gastroesophageal Reflux Disease, Low Back Pain, but did not include any left shoulder condition. See Medical Treatment Record, December 2015. Private physical therapy treatment records from 2015 show the Veteran was evaluated and received therapeutic treatment for his cervicalgia condition; during his evaluation he reported functional limitations include driving, lifting, opening objects and sleeping, but he did not relate these limitations were caused by his left shoulder condition. Nonetheless, the Board notes that although the evaluator did not record upper extremities range of motion, the therapist did note the Veteran’s manual muscle test for the left shoulder as flexion 4/5, abduction 4/5, external rotation 4/5, and internal rotation 4-/5. The left shoulder was noted as tender to palpation, but not clinical remarks were made regarding his joint mobility. He was assessed with severe limitations in cervical range of motion, decreased upper extremities strength and multiple tender points; a plan was developed provide him with an extensive home exercise program. See Private Physical Therapy Treatment Records, Back in Motion Physical Therapy, J.D. DPT, March 2015; see also physical therapy records, April, August, October 2015 (denoting a history of lumbago, cervicalgia, cervical disc herniation, facet syndrome, and radiculitis; negative treatment history for any shoulder condition). A Physical Therapy Progress Note from July 2015, reports the Veteran went fly fishing in Alaska for 11 days, but reported he could only fly fish for 20 minutes at a time, reported he would get spasms in between his shoulder blades; returned with left side of low back bothering him. See Private Physical Therapy Treatment Records, Back in Motion Physical Therapy, J.D. DPT, July 2015. A VA Shoulder and Arm Conditions Disability Benefits Questionnaire (DBQ) dated April 2015, noted that the left shoulder had abnormal or outside of normal range of motion, left shoulder flexion was noted at 140/180 degrees, abduction 140/180 degrees, external and internal rotation normal at 90 degrees. The examiner noted that the abnormal range of motion contributed to a functional loss due to limited motion; noted pain on examination which caused functional loss, pain with weight bearing, but no objective evidence of localized tenderness or pain on palpation of the joint or associated tissue and no evidence of crepitus. The examiner also remarked on the evidence of pain, weakness, fatigability or incoordination which limited the left shoulder functional ability with repeated use over a period of time. The examiner indicated that the Veteran was examined during a flare-up. The Veteran’s arthroscopic Mumford surgery in 2000 was noted. The examiner concluded that the left shoulder had less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-ups, contracted scars, etc.) No muscle strength reduction was noted, no muscle atrophy, no ankylosis, no suspected rotator cuff condition, no shoulder instability, dislocation or labral pathology suspected, no clavicle, scapula, acromioclavicular joint or sternoclavicular joint condition suspected, and no evidence of loss of head (flail shoulder), nonunion (false fail shoulder), or fibrous union of the humerus. The Examiner remarked that an x-ray of the Veteran’s left shoulder was abnormal, showing incidental finding of old granulomatous calcification, and recommended follow with primary care provider. Also, the examiner remarked that imaging studies of the left shoulder did not document degenerative or traumatic arthritis. Nonetheless, the examiner indicated that he Veteran experiences functional impact due to pain with activity, but he did not specify which shoulder. Outpatient treatment record from 2015 denote the Veteran’s active health problems, including chronic neck pain, back pain, hemorrhoids, etc., but the record is negative for an entry for any left shoulder condition. See Medical Treatment Records, Dr. W.C.R., October 2015; see also Sentara Medical Group, Dr. A.V., September 2015. Private outpatient records from November 2015, show the Veteran was receiving treatment at the Virginia Spine Institute for his cervical pain and limited range of motion. During one session he complained of neck pain, left arm numbness/tingling, lower back pain, and leg weakness, but there is no indication that he was being treated for the claimed left shoulder condition. In fact, the clinical notes indicate the Veteran has positive Tinel’s and cubital tunnel in the left arm, he was advised to try night splinting to relieve his symptoms; no additional treatment or comments were made regarding any other left shoulder condition. The active problems list does not mention any left shoulder condition. See Private Treatment Records, Virginia Spine Institute, Dr. B.R.S., January, September, November 2015. See also Private Outpatient Treatment Records, Clinical Progress Notes, January, June, September, October 2013, (denoting treatment for lumbar postlaminectomy syndrome, low back pain, cervicalgia, cervical spondylosis, and cervical facet syndrome; negative for any mention of a left shoulder condition). In December 2015, the Veteran submitted a letter in support of his claim from his physical therapist, who provides a detailed history of the various conditions for which she has provided rehabilitative care for the Veteran since October 2012, including bilateral shoulder pain. The therapist goes not to indicate that the Veteran’s primary conditions are cervicalgia and lumbago, which have resulted in chronic pain and as well as severe limitations in range of motion (cervical and lumbar), decreased muscle strength, impaired posture, numbness and tingling, joint hypomobility, muscle spasms and low endurance. In addition, reports functional limitations due to an inability to stand or sit for longer than five minutes without increase in low back pain and inability to lift or carry heavy objects without increase in pain and fatigability. See Back in Motion Physical Therapy Letter, D.J., DPT, October 2015. The Veteran received another VA examination for his left shoulder disability in September 2017, which required the examiner to evaluate the current level of severity of the Veteran’s service-connected left acromioclavicular joint arthritis, status post Mumford surgery with scar, to include range of motion testing on the left shoulder, address symptoms during flare-ups, and to address any functional loss and additional limitations in active and passive range of motion due to pain, weakness, fatigability or incoordination. The examiner noted the Veteran’s Mumford surgery in 2000, which the Veteran reported improved after surgery, but recurred 5-6 years ago, gradually worsening. The Veteran was noted as being right hand dominant, and experiencing flare-ups of the shoulder that cause functional loss or impairment of the joint or extremity; the Veteran reported difficulty with several activities of daily living that involve using shoulders, especially reaching overhead, like hanging a light bulb. Range of motion testing was conducted, indicating flexion to 110 degrees, abduction to 50 degrees, internal rotation of 90 degrees, and external rotation of 90 degrees. The examiner remarked that the abnormal range of motion, caused by pain, contributes to functional loss which limits the Veteran’s ability to bend, twist, and turn the left shoulder. Pain was noted with flexion and abduction movements; however, there was no objective evidence localized tenderness or pain on palpation of the joint or associated soft tissue. No objective evidence of crepitus. After repetitive testing, the Veteran could perform repetitive-use testing with at least three repetitions, no evidence of pain on passive range of motion testing. Positive evidence of pain when the left joint is used in non-weight bearing. The joints were deemed abnormal. Range of motion on repetitive use indicating flexion to 85 degrees, abduction to 50 degrees, internal rotation of 90 degrees, and external rotation of 90 degrees. The examiner noted that pain on motion would also cause functional loss. Other functional impacts described include fatigue, weakness, and lack of endurance for the left shoulder. No muscle atrophy or ankylosis of the left upper extremity was noted. No objective evidence of loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus, no malunion of the humerus or marked deformity. The examiner opined that the humerus condition does not affect the range of motion of the shoulder (glenohumeral joint). Testing was done for possible damage to the left shoulder rotator cuff, but was found to be negative. Nonetheless, due to the positive cross-body adduction test of the left shoulder (passively adduct arm across the patient’s body toward the contralateral shoulder) the examiner remarked that an acromioclavicular (AC) joint joint condition was suspected. The examiner summarized the functional impact of the Veteran’s left shoulder disability by remarking the Veteran has decreased range of motion and strength with instability to the left shoulder which impacts his occupational tasks, mainly, the Veteran was deemed to have difficulty reaching and changing a light bulb due to pain, but the can perform light physical and sedentary activities. For the left shoulder disability rated under Diagnostic Codes 5003-5201, the Board finds that a rating in excess of 20 percent is not warranted for the entire period under appeal. A 20 percent evaluation is assigned for painful motion of the shoulder. 38 C.F.R. § 4.59 allows for functional loss due to painful motion to be rated at least the minimum compensable rating for a particular joint. For DC 5201, limitation of motion at the shoulder level for both major and minor extremities is rated at 20 percent. Here, the medical evidence demonstrates the Veteran’s painful motion of the arm at the shoulder, based on his diagnosis of degenerative joint disease of the left shoulder, determined from X-ray evidence. A higher evaluation of 30 percent is not warranted for limitation of motion of the shoulder unless there is limitation of motion to 25 degrees from the side. 38 C.F.R. § 4.71a (2017). The weight of the evidence does not demonstrate that there is limitation of motion to 25 degrees from the side as show above from the evidence of record. The Board considered the possibility of staged ratings for the Veteran’s left shoulder disability, but at no time during the period on appeal has the disability warranted more than the assigned rating after a review of the claims file. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board has considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.10, 4.40, and 4.45 would warrant a higher rating. See Spurgeon v. Brown, 10 Vet. App. 194 (1997); and DeLuca. While evidence shows that the Veteran had symptoms, e.g., pain, during left shoulder motion, as well as other symptoms upon activity, the weight of the evidence does not demonstrate additional functional loss and/or limitation of motion during flare-ups or with normal use that is not otherwise considered in the rating criteria. Accordingly, even with consideration of the doctrine of the favorable resolution of doubt, ratings in excess of 20 percent for the service-connected left shoulder disability are not warranted. Therefore, the Board finds that the preponderance of evidence is against assigning ratings in excess of 20 percent for the Veteran’s left acromioclavicular joint arthritis, status post Mumford surgery, with scar, disability. See 38 C.F.R. § 4.71 (a), Diagnostic Codes 5003-5201, 5202 (2017); see also 38 U.S.C. § 5107 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD E. Steele, Associate Counsel