Citation Nr: 21004337 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 11-16 663 DATE: January 26, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for a scar on the left arm, characterized as painful, is denied. Entitlement to an initial rating in excess of 10 percent for a scar on the left arm, characterized as deep and non-linear, is denied. Entitlement to a rating of 70 percent for residuals of crush injuries to the left arm, characterized as damage to muscle groups V and VI, damage to the brachial artery, and damage to the median, ulnar, and radial nerves, is granted. For the period prior to July 8, 2104, an initial rating in excess of 20 percent for a left shoulder disability is denied. Since July 8, 2014, a rating of 30 percent, but no higher, for the left shoulder disability is granted. Entitlement to an initial rating in excess of 10 percent for a left wrist disability is denied. FINDINGS OF FACT 1. The Veteran’s left arm scar is characterized as painful. 2. The Veteran’s left arm scar is deep and non-linear, and covers less than 77 centimeters squared. 3. The Veteran’s left arm is his major extremity. 4. The Veteran’s residuals of crush injuries to the left arm, characterized as damage to muscle groups V and VI, damage to the brachial artery, and damage to the median, ulnar, and radial nerves, is characterized by complete paralysis. 5. For the period prior to July 8, 2014, the evidence reflects that the Veteran’s service-connected left shoulder disability was manifested by limitation of flexion to 90 degrees. 6. Since July 8, 2014, the Veteran’s left shoulder disability is characterized by limitation of motion from midway between the side of the body and shoulder level; limitation of motion to 25 degrees from the side of the body is not shown. 7. The Veteran’s service-connected left wrist disability has been productive of decreased motion and pain. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for the scar on the left knee characterized as painful have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, Diagnostic Code 7801. 2. The criteria for a rating in excess of 10 percent for the scar on the left knee characterized as deep and non-linear have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, Diagnostic Code 7804. 3. The criteria for a rating of 70 percent for residuals of crush injuries to the left arm, characterized as damage to muscle groups V and VI, damage to the brachial artery, and damage to the median, ulnar, and radial nerves, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.124A, Diagnostic Code 8512. 4. Prior to July 8, 2014, the criteria for an initial rating in excess of 20 percent for a left shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201. 5. Since July 8, 2014, the criteria for a rating of 30 percent, but no higher, for a left shoulder disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201. 6. The criteria for an initial rating in excess of 10 percent for a left wrist disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.118, Diagnostic Code 5215. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1985 to November 1986. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared for a Board hearing in April 2018. A copy of the transcript has been associated with the claims file. In July 2018, the Board previously remanded these claims for additional development and adjudication. Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the disabilities presently on appeal all arise from the same injury during service, which involved a motor vehicle accident. As such, due to some overlap in the evidence discussing the various symptomology during the relevant appeals period and for the sake of brevity, the Board will provide a recitation of the relevant facts pertaining to only the claimed disabilities, and then focus on separate analyses for each disability below. Factual Analysis During service, a jeep rolled over the Veteran and crushed his left arm. His service treatment records show that he suffered a compound fracture of the left humerus. He was immediately hospitalized and underwent debridement of the wound and open reduction with internal fixation of the left humerus fracture. He also underwent surgical repair of the brachial artery with a saphenous vein interposition graft and primary repair of the median nerve. A post-surgery physical examination showed decreased muscle strength to the triceps, brachioradialis, wrist extensors, and finger extensors; and absent function of the median nerve. A summary of diagnoses at that time included open fracture of the left humerus, laceration of the left brachial artery, laceration of the left median nerve, and laceration of the left radial nerve. A later in-service examination performed in September 1986 showed some return of median nerve motor function, but function of the radial nerve was absent. The ulnar nerve at that time was intact. The impression was recovering median nerve function and healing fracture of the humerus. The Veteran sought service connection for the residuals of the motor vehicle accident, including left arm injury, in December 1986. At the March 1987 VA examination, the Veteran reported occasional pain in his left arm and noted that he “could not use” his arm. The VA examiner noted that the Veteran’s left arm was very nearly amputated in the accident. X-rays taken as part of the March 1987 VA examination showed a metallic plate in mid-shaft of the humerus, and the impression was well-healed left humeral fracture. A physical examination of the left upper extremity in March 1987 showed a long, healed scar along the entire one half of the left arm, left shoulder limitation of flexion and abduction to 90 degrees, 25 percent restriction of internal rotation and external rotation of the left shoulder, atrophy of the forearm, loss of radial and median nerve function, loss of strength in the ulnar nerve distribution, and no grip of the left hand. The examiner stated that there was “no functional use” of the left arm, but noted good sensation in the ulnar nerve distribution. The examiner also noted a decrease of left arm range of motion to 25 degrees passively. The March 1987 VA examiner’s diagnosis was crushed left arm laterally with median, ulnar, and radial nerve and brachial artery damage with “functionless” left upper extremity. A September 1989 VA examination noted that the Veteran had a damaged left radial nerve, greater than the ulnar nerve. Function of the left upper extremity was impaired. Range of motion of the shoulder was normal, and muscle strength was 5/5. A September 1991 treatment record noted full range of motion of the left shoulder. There were healed wounds over the anterior and medial aspects of the left arm. The treating physician noted no active extension of the left wrist, and no ulnar deviation on flexion. The Veteran was examined by VA in June 2008. At that time, the Veteran reported constant residual pain in the left arm and shoulder at the site of the surgical scars, rated at a 7/10 or 8/10. He also reported weakens, stiffness intermittent, swelling, heat, redness, instability of the left arm, and popping of the left wrist. Aggravating factors included the use of the arm. The Veteran reported pain on the medial aspect of the left upper extremity that shoots down to the wrist and fingers, with constant heaviness of the arm and decreased range of motion of all joints. Physical examination of the left upper arm revealed a scar measuring 15 inches in length and 5 inches in width. The examiner found the scar to have hyperpigmentation on the inner aspect of the left upper arm and hypopigmentation on the anterior aspect. There was muscle atrophy underneath the depressed part of the scar, and tenderness to palpation. The left upper extremity was noted to be in a semi-prone position at the elbow, with evidence of atrophy of the intrinsic muscles of the left hand. His grip strength was reduced to 3/5, and he was unable to make a fist with his hand or oppose his thumb to any fingers. As for the left wrist, there was decreased range of motion noted to be 5 degrees of dorsiflexion and 5 degrees of palmar flexion. Radial and ulnar deviation were not possible, both actively and passively. A physical examination of the left shoulder revealed flexion to 90 degrees, abduction to 90 degrees, extension to 20 degrees, adduction to 20 degrees, internal rotation to 50 degrees, and external rotation was not possible. The examiner noted that the Veteran was unable to touch the back of his head with his left hand. X-rays confirmed degenerative changes of the acromioclavicular (AC) joint. Further, electromyography (EMG) findings noted severe left median and radial nerve neuropathy. In July 2014, the Veteran was scheduled for a VA Muscles Injuries Disability Benefits Questionnaire (DBQ). At that time, it was noted that he had a non-penetrating muscle injury. The Veteran reported fairly constant sharp pain in the left arm from the shoulder to the hand, and numbness and weakness of the arm. Upon physical examination, muscle groups V and VI were identified as the injured muscles, which include the flexor muscles of elbow (biceps, brachialis, and brachioradial) and the extensor muscles of the elbow (triceps), respectively. The examiner noted some loss of deep fascia, some impairment of muscle tonus, and some loss of muscle substance. Consistent weakness and loss of power due to the muscle group injuries identified were found on examination. Reduced muscle strength and muscle atrophy were also present. In July 2014, the Veteran was also scheduled for a VA peripheral nerves DBQ. At that time, ulnar and radial nerve damage was noted, as well as left median neuropathy. The Veteran reported constant weakness, and numbness and tingling in the left arm, forearm, and hand. He had constant sharp pain in the left upper extremity that was provoked by lying on the arm and letting the arm hang. The examiner reported the peripheral neuropathy symptoms to be of moderate severity. There was evidence of decreased muscle strength, muscle atrophy, and deep tendon reflexes were decreased. The examiner determined that the peripheral neuropathy was best characterized as moderate incomplete paralysis of the radial, median, and ulnar nerves. In a July 2014 VA scars DBQ, the Veteran reported he had frequent tenderness in the left upper extremity scar. The Veteran reported intermittent prickly, shooting, and fleeting pain in the scar of the left arm. Upon examination, the left arm scar was found to be deep and non-linear, measuring 28 centimeters (cm) by 1.5 cm, totalling 42 cm squared. No other disfiguring characteristics were noted. In a July 2014 VA shoulder and arms conditions DBQ, the Veteran reported achy shoulder pain with certain movements such as abduction and extension, but was able to flex without much pain. He denied flare-ups. Range of motion testing revealed flexion to 40 degrees, and abduction to 90 degrees, with no evidence of pain on motion. The Veteran was able to perform repetitive use testing with no decrease in range of motion. However, additional limitation was noted in less movement than normal. Pain on palpation was noted, but there was no evidence of guarding. Muscle strength was normal, and there was no evidence of ankylosis. The examiner noted the Veteran was unable to perform the Hawkins Impingement Test, Empty-Can Test, and the Lift-Off Subscapularis Test due to limitations in ranges of motion. There was no evidence of recurrent subluxation. Cross-body adduction was negative. No other physical findings were noted. The examiner concluded that the Veteran had some weakness in the shoulder from deconditioning related to the left arm muscle and nerve damage, and he reported having some pain, weakness and fatigability as noted above, which may limit functional ability but not necessarily when the joint is used repeatedly over a period of time. Instead, the functional ability is limited by the service-connected nerve damage with resultant muscular weakness and neuropathy affecting the entire left upper extremity. Thus, the left shoulder degenerative joint disease was not a factor that affected functional ability in this case. Finally, the July 2014 wrist conditions DBQ noted the Veteran’s reports that he was unable to "rotate" the wrist very well, had generalized pain in the whole left upper extremity that was related to the service-connected nerve condition, and denied any other complaints related to the wrist. He denied experiencing flare-ups. Palmar flexion was noted to be 80 degrees or higher, and dorsiflexion was to 0 degrees, with no evidence of pain on motion for either movement. The Veteran was able to perform repetitive use testing, with no additional loss in range of motion for the left wrist. Additional function loss resulted in less movement than normal for the left wrist. There was evidence of pain on palpation. Decreased muscle strength was noted as a 4/5 for flexion and 0/5 for extension. Radial and ulnar deviations were found to be to 0 degrees, and there was no evidence of pain on motion. Finally, the examiner noted there was no wrist condition causing pain, weakness, fatigability, or incoordination that limits functional ability when the joint is used repeatedly over a period of time In September 2019, the Veteran was again examined by VA as it pertains to his left shoulder disability, left wrist disability, and scar on the left arm. Turning first to the findings in the September 2019 VA shoulder conditions DBQ, the Veteran reported pain in the left shoulder, worse at night and morning, or when lying down. During a flare-up, he experiences no decrease in range of motion, but he reported he had functional impairment with “everything” and could not do anything involving overhead reaching and lifting. Range of motion testing revealed flexion to 30 degrees, abduction to 30 degrees, and internal and external rotation to 90 degrees, each. Pain was noted for flexion and abduction, with functional limitations in overhead lifting. The Veteran was able to perform repetitive use testing with no decrease or change in range of motion. Additionally, there was no change in range of motion of the left shoulder following repeated use or during a flare-up. The examiner did indicate that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time or during a flare-up. Pain on palpation was noted, but there was no evidence of guarding or pain on weight-bearing. Muscle strength was normal, and there was no evidence of muscle atrophy or ankylosis. The examiner noted the Veteran was unable to perform the Hawkins Impingement Test, Empty-Can Test, and the Lift-Off Subscapularis Test due to limitations in ranges of motion. Additionally, the Crank apprehension and relocation test for stability was not able to be performed. No other physical findings were noted. The September 2019 VA scars DBQ noted that the left upper extremity scar measured 28 cm by 1.5 cm. Underlying tissue damage was found to be 42 cm squared. The scar was described as non-linear, tender, and painful. No other physical findings were noted. The September 2019 VA wrist conditions DBQ noted the Veteran’s report of limitation of motion of the left wrist, resulting in the inability to wash his face; limitations with lifting, carrying, pushing, and pulling; and being unable to hold his granddaughter or change a diaper. He denied experiencing flare-ups. Palmar flexion was noted to be 80 degrees or higher, and dorsiflexion was to 0 degrees, with evidence of pain on motion resulting in functional loss. Radial deviation was to 20 degrees, and ulnar deviation was to 45 degrees. There was no evidence of pain on weight-bearing, evidence of crepitus, or pain on palpation. Pain was found to be present with passive range of motion. The Veteran was able to perform repetitive use testing, with no additional loss in range of motion for the left wrist. Pain, weakness, fatigability or incoordination were not found to significantly limit functional ability with repeated use over a period of time. Decreased muscle strength was noted as a 3/5 for flexion and 0/5 for extension, and found to be entirely due to this disability. There was no evidence of muscle atrophy or ankylosis. In October 2020, the Veteran was provided a VA peripheral nerves conditions DBQ. At that time, the Veteran reported left shoulder and left arm pain at a 10 out of 10, with the pain alleviating if he is standing. He reported the pain increased if the arm hangs down, along with increased tingling and numbness. Upon examination, pain, paresthesias/ dysesthesias, and numbness were found to be severe. Muscle strength was decreased at the wrist and elbow, and absent with grip and pinch. Reflexes and sensory exemptions were decreased in the medial nerve distribution, and sensory was absent in the left hand radial nerve distribution. The examiner found severe incomplete paralysis of the radial and ulnar nerves, and moderate incomplete paralysis of the median nerve. The Veteran declined EMG testing at the time of the October 2020 VA examination. Finally, the Veteran underwent a VA muscle injuries DBQ in October 2020. At that time, it was noted that he has a non-penetrating muscle injury. The Veteran reported fairly constant sharp pain in the left arm from the shoulder to the hand, and numbness and weakness of the arm. Upon physical examination, muscle groups V and VI were identified as the injured muscles, which include the flexor muscles of elbow (biceps, brachialis, and brachioradial) and the extensor muscles of the elbow (triceps), respectively. The examiner noted some loss of deep fascia, some impairment of muscle tonus, some loss of muscle substance, and visible or measurable atrophy; tests of endurance or coordinated movements compared with the corresponding muscles of the uninjured side indicated severe impairment of function. Weakness, loss of power, pain, lowered threshold of fatigue, and impairment of coordination were noted to be consistent at a more severe level due to the muscle group injuries identified. Reduced muscle strength and muscle atrophy were also present. 1. Left arm scar The Veteran is seeking initial ratings higher than 10 percent for his left arm scar. Presently, the Veteran has two separate ratings for his left arm scar. He is rated at 10 percent for a deep, non-linear scar under Diagnostic Code 7801, and also at 10 percent for pain under Diagnostic Code 7804. By way of history, the Veteran was granted a 10 percent rating for his left arm scar under Diagnostic Code 7804 in an April 2010 rating decision, effective from March 10, 2008, the date of receipt of his claim. In a July 2014 rating decision, the RO granted a separate rating of 10 percent for the left arm scar under Diagnostic Code 7801, also effective from March 10, 2008, the date of receipt of the claim. During the pendency of this appeal, VA published a final rule amending its regulations on skin disabilities effective August 13, 2018. Where a law or regulation changes after the claim has been filed, but before the administrative or judicial process has been concluded, the version most favorable to the veteran applies unless Congress provided otherwise or permitted VA to do otherwise and VA did so. See VAOGCPREC 7-2003. The Board will therefore evaluate the Veteran’s scars under both the old and new criteria, keeping in mind that the revised criteria may not be applied to any time period before the effective date of the change. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000 (Apr. 10, 2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Board will discuss both periods of regulations in order to determine if a compensable rating is warranted under the applicable scar criteria during that time period. Under the scar regulations in effect prior to August 13, 2018, scars that, as here, do not impact the head, face, or neck are rated under 38 C.F.R. § 4.118, Diagnostic Codes 7801 to 7805. Under Diagnostic Code 7801, a 10 percent rating is assigned when a scar, not of the head, face, or neck, is deep and nonlinear, and covers an area of at least 6 square inches (39 sq. cm.), but less than 12 square inches (77 sq. cm.). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 (in effect from October 23, 2008 to August 13, 2018). Under Diagnostic Code 7802, a 10 percent rating is assigned when a scar, not of the head, face, or neck, is superficial and nonlinear, and covers an area of at least 144 square inches (929 sq. cm.). 38 C.F.R. § 4.118, Diagnostic Code 7802 (in effect from October 23, 2008 to August 13, 2018). Under Diagnostic Code 7804, a 10 percent rating is assigned for one or two scars that are unstable or painful. A 20 percent rating is assigned for three or four scars that are unstable of painful. A 30 percent rating is assigned for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804 (in effect from October 23, 2008 to August 13, 2018). Under Diagnostic Code 7805, any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-7804 should be evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805 (in effect from October 23, 2008 to August 13, 2018). Under the scar regulations in effect since August 13, 2018, Diagnostic Code 7801 provides ratings for scars, other than the head, face, or neck, that are associated with underlying soft tissue damage. Scars that are associated with underlying soft tissue damage in an area or areas exceeding 6 square inches (39 square centimeters) are rated as 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 square centimeters) are rated as 20 percent disabling. Scars in an area or areas exceeding 72 square inches (465 square centimeters) are rated as 30 percent disabling. Scars in an area or areas exceeding 144 square inches (929 square centimeters) are rated as 40 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7801 (in effect since August 13, 2018). Diagnostic Code 7802 provides ratings for scars, other than the head, face, or neck, that are not associated with underlying soft tissue damage. A scar that is not associated with underlying soft tissue damage in an area or areas of 144 square inches (929 square centimeters) or greater is rated as 10 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7802 (in effect since August 13, 2018). Diagnostic Code 7804 provides ratings for scars that are unstable or painful. One or two scars that are unstable or painful are rated as 10 percent disabling. Three or more scars that are unstable or painful are rated as 20 percent disabling. Five or more scars that are unstable or painful are rated as 30 percent disabling. Note (1) to DC 7804 provides that an unstable scar was one where, for any reason, there was frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7804 (in effect since August 13, 2018). 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 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805 (in effect since August 13, 2018). Based on the evidence as discussed above, a rating higher than 10 percent under Diagnostic Code 7801, pursuant to either the version in effect prior to August 13, 2018 or since, for a deep, non-linear scar, is not warranted. Specifically, the left arm scar has been consistently characterized as deep and adhering to underlying tissue in the total amount of 42 cm. squared. See July 2014 and September 2019 VA scar conditions DBQs. At no point during the appeal period does the evidence suggest the left arm scar exceeds 77 cm. squared. Similarly, a rating higher than 10 percent under Diagnostic Code 7804, pursuant to either the version in effect prior to August 13, 2018 or since, is not warranted. Specifically, the Veteran has been found to only have one scar that is characterized as painful. Regardless, in order to receive the next higher 20 percent rating, he would have to have at least 3 scars, which the evidence simply does not support. The Veteran’s treatment records do not document any complaints or treatment for his left arm scar during the pendency of this appeal, noting only the existence of the scar. Thus, the Veteran’s medical records do not document a scar that exceeds 77 cm. squared, or more than one left arm scar. The Board also does not find the Veteran is entitled to a rating in excess of 10 percent at any point during the appeals period, either under Diagnostic Code 7805 or under a different code, for which there are ratings in excess of 10 percent available. The objective findings noted in the VA examination reports, treatment records, and lay statements do not warrant higher ratings under Diagnostic Codes 7801 or 7804, either prior to or since August 13, 2018, as the scars are not of an area or areas exceeding 12 square inches (77 square centimeters), nor does the Veteran have more than one scar, respectively. The Board has carefully reviewed and considered the Veteran’s statements regarding the severity of his left arm scar. To that end, the Board acknowledges that the Veteran, in advancing this appeal, believes that his scar is more severe than the assigned disability ratings reflect. The Board is likewise aware of the Veteran’s contentions that his left arm scar is intermittent prickly, shooting, and results in fleeting pain. See July 2014 VA scar conditions DBQ; see also April 2018 Board Hearing Transcript. Moreover, the Board notes that the Veteran is competent to report observable symptoms such as pain and limitation of motion. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In this case, however, the competent medical evidence offering detailed, specific, and specialized determinations pertinent to the rating criteria, namely, determinations as to the characteristics of his left arm scarring are most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The medical evidence also largely contemplates the Veteran’s descriptions of his symptoms, including his reports of pain. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board has considered whether staged ratings are appropriate in this case. The evidence of record shows that the symptoms of the left arm scar has not fluctuated materially during the course of this appeal. As such, a staged rating is not warranted. Thus, under the regulations in effect prior to and since August 13, 2018, the Veteran is appropriately in receipt of 10 percent ratings for a deep and non-linear scar, and a painful scar. Finally, the Board acknowledges that the Veteran testified as to the painful nature of the scar on his thigh. However, this matter is not on appeal, and the Board has no jurisdiction to consider the current level of severity of this scar. As the preponderance of the evidence is against the claims for ratings in excess of 10 percent, the benefit-of-the-doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Residuals of crush injuries of the left arm The Veteran is seeking a rating higher than 60 percent pursuant to Diagnostic Code 8512 for the residuals of crush injuries to the left arm, characterized as damage to muscle groups V and VI, damage to the brachial artery, and damage to the median, ulnar, and radial nerves. The Board notes the Veteran is in receipt of a 60 percent rating, which is the highest rating available under Diagnostic Code 8512 for the minor extremity. A 70 percent rating is warranted for under this diagnostic code for the major extremity. Therefore, a threshold determination is required to identify the Veteran’s major and minor extremities. Here, the record reflects that a June 1986 service treatment record indicates the Veteran is right hand dominant, while the record reflects the Veteran has consistently asserted he is ambidextrous. See June 2008, July 2014, and September 2019 VA Shoulder and Wrist Conditions DBQs; October 2020 VA Muscle Conditions DBQ; and October 2020 VA Peripheral Nerves Conditions DBQ. The injured extremity, or the most severely injured extremity, of an ambidextrous individual will be considered the dominant hand for rating purposes. The Board will resolve doubt in the favor of the Veteran and find that his left extremity is the dominate extremity. Thus, the left upper extremity is the dominant, as his left upper extremity is rated higher than the right upper extremity. See 38 C.F.R. § 4.69. Given such, the applicable rating will be assigned under the “Major” rating. Thus, the Veteran is entitled to the higher 70 percent rating for the neurological residuals of the crush injury to the left upper extremity lower radicular group for the entire period on appeal, so from March 10, 2008, the date of receipt of his claim for an increased rating. As the Veteran is now in receipt of the highest disability rating available under the Diagnostic Code, the remaining question is whether the Veteran is entitled to separate disability ratings. The Board finds, however, that the Veteran is already in receipt of a rating that contemplates all of the neurological symptoms associated with his crush injuries for the lower radicular group, and separate ratings would constitute prohibited pyramiding. 38 C.F.R. § 4.14. The Board must next consider whether the Veteran is entitled to separate compensable ratings under Diagnostic Code 5305 or 5306 for injuries to Muscle Groups V and VI. However, VA regulations mandate that a muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. 38 C.F.R. § 4.55(a). Thus, separate ratings are not available under these diagnostic codes. Moreover, as the Veteran’s now assigned 70 percent rating is higher than the ratings pertaining to muscle injuries, recharacterizing the Veteran’s disability is not in his favor. Finally, the Board acknowledges that the Veteran’s attorney has raised the applicability of VA’s amputation rule. Here, the amputation rule does not come into play as the rating provided for the arm is now 70 percent, which is less than any of the listed amputation options for the arm. See 38 C.F.R. § 4.68, 4.71a, Diagnostic Codes 5120, 5121, 5122. Therefore, resolving all reasonable doubt in the Veteran’s favor, a rating of 70 percent, but no higher, is warranted for the entire period on appeal. Musculoskeletal Disabilities Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity, or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is asserted due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45 but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination, or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). In Sharp v. Shulkin, the United States Court of Appeals for Veterans Claims (Court) decision addressed what constitutes an adequate explanation for an examiner’s inability to estimate motion loss in terms of degrees during periods of flare-ups. 29 Vet. App. 26 (2017). The Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. 3. Left shoulder disability The Veteran is seeking entitlement to a rating in excess of 20 percent for his left shoulder disability, diagnosed as degenerative joint disease. Here, service connection for this disability was granted in the January 2009 rating decision presently on appeal, and an initial rating of 20 percent, effective from March 10, 2008, was assigned. However, in a July 2020 Board decision, the Board determined there was clear and unmistakable error (CUE) in a prior April 1987 rating decision and determined the left shoulder disability warrants a separate rating from November 29, 1986. Therefore, the applicable appeals period is from the grant of the date of service connection for this disability, so from November 29, 1986. Disabilities of the shoulder and arm are rated under Diagnostic Codes 5200 through 5203. The Federal Circuit has held that the plain language of 38 C.F.R. § 4.71(a) confirms that a veteran is only entitled to a single disability rating under Diagnostic Code 5201 for each arm that suffers from limited motion at the shoulder joint. The diagnostic code does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to “limitation of motion of” the arm. Yonek v. Shinseki, 722 F.3d 1355 (Fed. Cir. 2013). Diagnostic Codes 5200-5203 distinguish between the major (dominant) extremity and the minor (non-dominant) extremity. See 38 C.F.R. § 4.69. As discussed above, the Board has determined that the Veteran’s left extremity is his dominate extremity. Given such, the applicable rating will be assigned under the “Major” rating. Diagnostic Code 5201 provides that limitation of motion of the arm at shoulder level warrants a 20 percent rating. Limitation of motion of the arm from midway between the side and shoulder level warrants a 30 percent rating for a major extremity. Limitation of motion to 25 degrees from the side warrants a 40 percent rating for a major extremity. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 degrees to 180 degrees, abduction from 0 degrees to 180 degrees, external rotation from 0 degrees to 90 degrees, and internal rotation from 0 degrees to 90 degrees.  38 C.F.R. § 4.71, Plate I. The Board finds that the Veteran’s symptoms of his left shoulder disability most closely approximate the criteria for the currently assigned 20 percent rating for the period prior to July 8, 2014, and a rating of 30 percent thereafter. Period Prior to July 8, 2014 Turning first to the period prior to July 8, 2014, the evidence of record shows the Veteran’s range of motion of the left shoulder was noted be normal in a July 1989 VA examination and again in a September 1991 treatment record. A June 2008 VA examination shows flexion to 90 degrees and abduction to 90 degrees, with pain. While he has also consistently reported left shoulder pain, limitation of motion, and an inability to perform overhead activities or lift his arms, the Board notes that the evidence does not demonstrate that limitation of the left arm was midway between his side and shoulder level at any point during the period prior to July 8, 2014, such that the next higher 30 percent rating is warranted. The Board has also considered whether a higher rating is warranted under any other diagnostic code for the shoulder. In this respect, an evaluation in excess of 20 percent is available if there is ankylosis of the scapulohumeral articulation, recurrent dislocation of the humerus with frequent episodes and guarding of all arm movements, fibrous union of the humerus, nonunion of the humerus (false flail joint), loss of head of the humerus (flail shoulder), or malunion of the humerus with marked deformity. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202. The Board notes, however, that the Veteran’s left shoulder is not productive of ankylosis of scapulohumeral articulation or impairment of the humerus. The VA examinations specifically note no ankylosis, no shoulder instability, and no impairment of the humerus. Thus, the Board finds that Diagnostic Codes 5200 and 5202 are not for application. The Board also finds that even when considering the Veteran’s reported left shoulder symptomatology including pain and limitation of motion, the reported symptomatology does not, when viewed in conjunction with the medical evidence, tend to establish additional limitations of motion to the degree that would warrant a rating in excess of 20 percent at any point during the appeal period under 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holding in DeLuca. Here, the evidence of record prior to July 8, 2014 does not include any additional limitations due to pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. In fact, there is no indication in either the examinations of record or the VA treatment records that the Veteran’s left arm range of motion was ever limited to below shoulder level, or less than 90 degrees. In addition, the discussion above reflects that all the symptoms of the Veteran’s service-connected left shoulder disability are contemplated by the applicable rating criteria. The various functional loss factors of his disability, including pain, weakness, and lack of endurance have been fully considered and are contemplated in the rating schedule. That is, the Board finds that these symptoms are contemplated under the relevant rating criteria and under the DeLuca criteria, including §§ 4.40 and 4.45, which compensate for limitation of motion, and symptoms such as pain, weakness, and instability producing functional limitations.  38 C.F.R. §§ 4.40, 4.45, 4.59; Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Period Since July 8, 2014 However, on VA examination dated July 8, 2014, the Veteran’s flexion of the left shoulder was shown to be to 40 degrees. The September 2019 VA examiner also noted flexion to 30 degrees. Therefore, resolving reasonable doubt in favor of the Veteran, the Board finds the range of motion of the left shoulder more closes resembles motion limited to midway between the side and shoulder level. He has also reported left shoulder pain, limitation of motion, an inability to perform overhead activities or lift his arms. See July 2014 and September 2019 VA shoulder and arm conditions DBQs. The Board notes that the Veteran has only reported flare-ups during the September 2019 VA examination. Nevertheless, the evidence does not demonstrate limitation of the left arm is to 25 degrees from the side at any time during the pendency of this appeal. Id. As such, the next higher 40 percent rating is not warranted. The Board has also considered whether a higher rating is warranted under any other diagnostic code for the shoulder. In this respect, an evaluation in excess of 30 percent is available if there is ankylosis of the scapulohumeral articulation, recurrent dislocation of the humerus with frequent episodes and guarding of all arm movements, fibrous union of the humerus, nonunion of the humerus (false flail joint), loss of head of the humerus (flail shoulder), or malunion of the humerus with marked deformity. 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202. The Board notes, however, that the Veteran’s left shoulder is not productive of ankylosis of scapulohumeral articulation or impairment of the humerus. The VA examinations specifically note no ankylosis, no shoulder instability, and no impairment of the humerus. Thus, the Board finds that Diagnostic Codes 5200 and 5202 are not for application. The Board also finds that, even when considering the Veteran’s reported left shoulder symptomatology including pain and limitation of motion, the reported symptomatology does not, when viewed in conjunction with the medical evidence, tend to establish additional limitations of motion to the degree that would warrant a rating in excess of 30 percent at any point this period under 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holding in DeLuca. Here, the July 2014 VA examiner found no additional limitations due to pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. However, even when the September 2019 VA examiner noted that pain, weakness, and lack of endurance were found to be contributing factors after repetitive use, there were no additional functional limitations due to pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use testing. In addition, the discussion above reflects that all of the symptoms of the Veteran’s service-connected left shoulder disability are contemplated by the applicable rating criteria. The various functional loss factors of his disability, including pain, weakness, and lack of endurance, have been fully considered and are contemplated in the rating schedule. That is, the Board finds that these symptoms are contemplated under the relevant rating criteria and under the DeLuca criteria, including §§ 4.40 and 4.45, which compensate for limitation of motion, and symptoms such as pain, weakness, and instability producing functional limitations.  38 C.F.R. §§ 4.40, 4.45, 4.59; Correia v. McDonald, 28 Vet. App. 158 (2016). The Board considered the notation in the September 2019 examination report indicating that the Veteran suffers from flare-ups that result in decreased range of motion and increased pain. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the United States Court of Appeals for Veterans Claims (Court) noted that for a joint examination to be adequate, the examiner “must express an opinion on whether pain could significantly limit” a veteran’s functional ability, and that determination “should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups.” However, the examiner indicated there was no decrease in the limitation of motion during a flare-up or after a repeated use over a period of time. Notably, the Veteran denied having flare-ups during the prior to the September 2019 examination but instead reported achy shoulder pain during the July 2014 VA examination. Thus, even with consideration of the Veteran’s reported symptoms during a flare-up or following repetitive use and the symptoms found on examination, the evidence does not suggest that his motion on flare-up or after repeated use has been limited to 25 degrees or less on flexion or abduction at any time during the pendency of the claim. Notably, to the extent that there has been any decrease in muscle strength, this residual has been contemplated in the 70 percent rating discussed above for neurological and muscle group residuals. The Board has carefully reviewed and considered the Veteran’s statements regarding the severity of his left shoulder disability. To that end, the Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. The Board is likewise aware of the Veteran’s contentions that his left shoulder disability impacts his daily activities and results in pain and limitation of motion. Moreover, the Board notes that the Veteran is competent to report observable symptoms such as pain and limitation of motion. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In this case, however, the competent medical evidence offering detailed, specific, and specialized determinations pertinent to the rating criteria, namely, determinations as to range of motion of the left shoulder, functional impairment, and incapacitating episodes are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The medical evidence also largely contemplates the Veteran’s descriptions of his symptoms, including his reports of impairment with respect to physical activities, such as lifting his arms above his head. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In sum, the evidence deemed most probative by the Board establishes that for the period prior to July 8, 2014, the Veteran’s left shoulder disability more nearly approximated the criteria for the assigned 20 percent rating, and a higher rating is not warranted. Since the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). However, for the period since July 8, 2014, a 30 percent rating, and no higher, is warranted. 4. Left wrist disability The Veteran is seeking entitlement to an initial rating in excess of 10 percent for residuals of a left wrist disability. By way of history, the rating decision currently on appeal granted service connection for this disability and assigned an initial rating of 10 percent, effective from March 10, 2008, the date of receipt of the claim for service connection. The Veteran’s left wrist disability is evaluated under Diagnostic Code 5215, which provides for the assignment of a 10 percent disability rating with dorsiflexion less than 15 degrees or palmar flexion limited in line with forearm. 38 C.F.R. § 4.71a. Normal ranges of motion of the wrist are dorsiflexion from 0 degrees to 70 degrees, and palmar flexion from 0 degrees to 80 degrees. 38 C.F.R. § 4.71, Plate I (2020). The Veteran is currently in receipt of the maximum schedular disability rating available under Diagnostic Code 5215. 38 C.F.R. § 4.71a. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. These provisions are not applicable where, as in this case, the maximum rating for limitation of motion has been awarded. Johnston, 10 Vet. App. at 84-5; 38 C.F.R. § 4.59. The Board has considered the application of other Diagnostic Codes in an effort to determine whether a higher rating may be warranted for the Veteran’s left wrist disability, but finds none are raised by the medical evidence. In particular, Diagnostic Code 5214 provides ratings for ankylosis of the wrist. Ankylosis was not demonstrated by the Veteran’s ranges of motion of the left wrist, albeit limited, during any of the VA examinations. Further, there are no medical treatment records of record which would document that the Veteran’s left wrist was ankylosed so as to warrant a higher disability rating. While the Board has considered the Veteran’s lay contentions, the competent medical evidence offering detailed, specific, and specialized determinations pertinent to the rating criteria, namely determinations as to range of motion of the left wrist and functional impairment, constitutes the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The medical evidence also largely contemplates the Veteran’s descriptions of his symptoms, including his reports of impairment with respect to physical activities. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In sum, as the preponderance of the evidence is against the award of an initial rating in excess of 10 percent, the benefit-of-the-doubt doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b). In reaching the above determinations, the Board notes that this appeal raises no additional rating issues. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017). Notably, the Veteran reported during his April 2018 hearing that he was working, and he has had a combined 100 percent evaluation, with no single evaluation in excess of 70 percent, since April 5, 2011. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Berry, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.