Citation Nr: 21066018 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 15-14 053 DATE: October 28, 2021 ORDER Service connection for a left knee disability is granted. An increased rating for service-connected left upper extremity fractured ulna and radius status post open reduction internal fixation (ORIF), currently noncompensable, is denied. An initial increased rating for service-connected left upper extremity muscle herniation with scars, currently noncompensable through July 29, 2021, and 30 percent beginning July 30, 2021, is denied. REMANDED Service connection for left ear hearing loss is remanded. Service connection for tinnitus is remanded. FINDINGS OF FACT 1. The arthritis component of the Veteran's current left knee disability did not manifest within his first post-service year and is not related to his service in any manner, but the meniscal tear component of his current left knee disability is due to him injuring that knee during service. 2. During the period on appeal, the Veteran's left upper extremity fractured ulna and radius status post ORIF did not manifest flexion limited to 100 degrees or less, extension limited to 45 degrees or more, supination to 30 degrees or less, or pronation motion lost beyond the last quarter of arc with the hand not approaching full pronation. 3. Through July 29, 2021, the Veteran's left upper extremity muscle herniation with scars more nearly approximated a slight muscle disability. It already has been determined to more nearly approximate a severe disability, which is the highest level of severity, as of July 30, 2021. At no point have the Veteran's scars been larger than 39 square centimeters, unstable, painful, or functionally limiting. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 4.71A Diagnostic Code 5003. 2. The criteria for a compensable rating, whether an increased rating or separate rating, for service-connected left upper extremity fractured ulna and radius status post ORIF have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.400, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.69, 4.71, 4.71A Diagnostic Codes 5206, 5207, 5208, and 5213. 3. The criteria for a compensable initial rating through July 29, 2021, whether an increased rating or separate rating, for service-connected left upper extremity muscle herniation with scars have not been met. There are no criteria for an initial increased rating beginning July 30, 2021, for this disability, and the criteria for a separate compensable initial rating have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.56, 4.59, 4.69, 4.73 Diagnostic Codes 5305 and 5307, 4.118 Diagnostic Codes 7801-7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1985 to January 1993. This matter is on appeal from a January 2014 rating decision. Despite requesting it, the Veteran failed to appear for a hearing when it was scheduled for April 2018. He also did not provide good cause for this failure, so his request is considered withdrawn. 38 C.F.R. § 20.704(d). In a September 2018 decision, the Board of Veterans' Appeals (Board) reopened service connection for a left knee disability and then remanded it for additional development. An increased rating for service-connected left upper extremity fractured ulna and radius status post ORIF and an initial increased rating for service-connected muscle herniation with scars also were remanded for additional development. Service connection for bilateral hearing loss and for tinnitus finally were denied. The United States Court of Appeals for Veterans Claims vacated the denials for left ear hearing loss and tinnitus in a March 2020 Memorandum Decision, however. Those issues accordingly were returned to the Board for readjudication. In November 2020, the Board remanded them for additional development. The Board once again remanded them, along with each of the other aforementioned issues comprising this matter, for additional development in June 2021. This development resulted in an August 2021 rating decision which granted an increased initial rating of 30 percent for the Veteran's service-connected muscle herniation with scars. As this determination constitutes a grant for only part of the period on appeal, this matter continues to encompass an increased initial rating for that disability. AB v. Brown, 6 Vet. App. 35, 38 (1993). Service Connection Direct service connection is established when there is a nexus between a current disability and an injury or disease incurred or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). When the current disability is a chronic disease, service connection is presumed under certain circumstances for veterans. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303(b), 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The claimant is afforded the benefit of the doubt on any point when there is an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Finally, although all evidence must be considered, only the most relevant evidence must be discussed. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Left Knee Disability The Veteran contends he has a left knee disability attributable to injuries sustained to his knee during service. It is undisputed that he has a current left knee disability. 2012 and 2013 private treatment records include X-rays showing degenerative or osteoarthritis changes in his left knee. Left knee degenerative joint disease (DJD) accordingly was diagnosed. This diagnosis does not resolve, as indicated by it being repeated in a May 2015 letter from the Veteran's private physician as well as at an October 2020 VA medical examination (signed by the examiner in November 2020). A left knee meniscal tear also was diagnosed at this examination, and he further was noted to have undergone a partial meniscectomy in 2005. This corresponds to 2005 private treatment records, which note no arthritis but a tear visible with magnetic resonance imaging (MRI). The Veteran has a left knee meniscal tear, status post partial meniscectomy, in other words. Next, it also is undisputed the Veteran injured his left knee during service. Service treatment records (STRs) document his complaint of pain in this knee after stepping off a box in September 1987. He was diagnosed with a contused (bruised) knee. In October 1987, he complained of twisting his left knee. The diagnosis made was left knee strain. Left knee pain once again was the Veteran's complaint after a reinjury while playing basketball in late November 1987. As no abnormalities were found then or in December 1987, only left knee pain was diagnosed. The Veteran's lower extremities, which includes his knees, were found to be normal at his December 1992 separation examination. Yet he complained of a trick or lock knee at that time, noting that his left knee slips. The Veteran continued to complain of left knee symptoms, primarily giving out and catching, at October 1993 and August 1994 VA medical examinations after service. Although it was felt that he probably had some mild degenerative disease at the former examination, X-rays were not taken to confirm this. The Veteran was diagnosed with a healed left knee injury at the latter examination, however, as contemporaneous X-rays were normal. That they did not show degenerative or osteoarthritis changes is significant. Indeed, arthritis generally is established by X-ray. 38 C.F.R. § 4.71A, Diagnostic Code 5003. Arthritis, which is another term for degeneration, is a chronic disease. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a); Greyzck v. West, 12 Vet. App. 288 (1999). Yet it must manifest within the first post-service year for service connection to be presumed. 38 U.S.C. § 1112(a)(1); 38 C.F.R. § 3.307(a)(3). That did not happen here. Turning back to direct service connection, the only remaining requirement is nexus. The Veteran's private physician stated in the May 2015 letter that left knee DJD could manifest years after trauma. Yet no opinion was provided as to whether the Veteran's was related to his service, given the physician's lack of awareness as to what this service entailed and the left knee injured he sustained then. Only one other opinion exists concerning his arthritis. This opinion, rendered in December 2020 as part of the October 2020 VA medical examination, is against a nexus to service essentially because the Veteran's left knee arthritis was not present for years after service. The opinion is probative because it was expressed clearly, explained, and was based on accurate facts. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Indeed, STRs and all other evidence which includes the May 2015 letter was reviewed before it was rendered. The October 2020 VA medical examination also included another nexus opinion concerning the Veteran's left knee meniscal tear status post partial meniscectomy, also rendered in December 2020. Unlike the opinions for DJD/arthritis, this opinion is for a nexus to service. That the Veteran has reported continued symptoms ever since injuring his left knee while playing sports during service (this was noted to have occurred in 1988, a minor discrepancy with STRs that confirm it was 1987) was highlighted. Indeed, this is in agreement with his service separation examination, the October 1993 and August 1994 VA medical examinations, and a November 2005 private treatment record in which he continued complaining of left knee catching, locking, and sliding out and indicated this had been ongoing for a number of years. Next, it was noted that there is no interim injury to account for the Veteran's left knee meniscal tear. He has not reported a left knee injury before his separation from service and late 2005 when the tear was discovered. There also is no documentation of a left knee injury during this timeframe. As such, the opinion concluded that the tear has existed since the in-service injury but was missed when it was treated. How this could have occurred was not discussed. Nevertheless, that STRs did not include MRI or other diagnostic testing is notable in this regard. So is the fact that the Veteran was characterized as 'rather stoical" at the August 1994 VA medical examination. The opinion for a left knee meniscal tear, even without discussing these points, was expressed clearly, explained, and based on accurate facts. It therefore is probative. Nieves-Rodriguez, 22 Vet. App. at 304. A nexus between the Veteran's left knee meniscal tear, now status post partial meniscectomy, and his in-service left knee injury therefore has been established. This means the three criteria for direct service connection have been met. That conclusion is made based upon the preponderance of the evidence, without resort to resolving the benefit of the doubt in the Veteran's favor. Service connection for a left knee disability is granted. Increased Rating and Initial Rating Ratings represent as far as practicably can be determined the average impairment in earning capacity due to a disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A rating is assigned under the Rating Schedule by comparing the extent to which a disability impairs the ability to function under the ordinary conditions of daily life, as demonstrated by symptoms, with the criteria for that disability. Id.; 38 C.F.R. § 4.10; Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The disability's history and all other relevant evidence is to be considered. 38 C.F.R. §§ 4.1, 4.6. Examinations are to be interpreted and, if necessary, reconciled. 38 C.F.R. § 4.2. When two ratings may be applicable, the higher is assigned only if the criteria for it are more nearly approximated. 38 C.F.R. § 4.7. Any reasonable doubt on this or any other point is resolved in the claimant's favor. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Different ratings may be assigned for different periods. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The period under consideration begins one year prior to the claim for an increased (but not an initial increased) rating. 38 U.S.C. § 5110(b)(3); 38 C.F.R. § 3.400(o)(2). A few regulations are useful to understand a musculoskeletal disability, after which a rating is assigned under 38 C.F.R. §§ 4.71A or 4.73. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). Important factors include pain on movement, weakened movement, more or less movement than normal, excess fatigability, incoordination, swelling, deformity, and atrophy. 38 C.F.R. §§ 4.40, 4.45, 4.59. Consideration must be given to functional loss, to include during flare-ups and after repeated use over a period of time, caused by these factors. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 205-207 (1995). There is functional loss when the factor(s) affects some aspect of the normal working movements of the body. Id.; Mitchell v. Shinseki, 25 Vet. App. 32, 43-44 (2011). Left Upper Extremity Fractured Ulna and Radius Status Post ORIF 38 C.F.R. § 4.71A addresses musculoskeletal disabilities. The Veteran's left upper extremity fractured ulna and radius status post ORIF currently has a noncompensable rating pursuant to Diagnostic Code 5299-5206 thereunder. Hyphenated Diagnostic Codes are used when a disability identified by first set of numbers is rated based on a residual identified by the second set of numbers. 38 C.F.R. § 4.27. Here, Diagnostic Code 5299 signifies that the disability is musculoskeletal but unlisted. It is rated by analogy to limitation of flexion of the forearm, the subject of Diagnostic Code 5206. Ratings for arm disabilities vary depending on whether the disability is to the major, or dominant, arm or to the minor, or non-dominant, arm. All indications are that the Veteran's left upper extremity is his minor arm. 38 C.F.R. § 4.69. Under Diagnostic Code 5206, flexion limited to 110 degrees in the minor arm merits a noncompensable rating. A 10 percent rating requires flexion limited to 100 degrees, while a 20 percent rating is for flexion limited to 90 degrees or to 70 degrees. Flexion limited to 55 degrees results in a 30 percent rating. The maximum rating of 40 percent is reserved for flexion limited to 45 degrees. Under Diagnostic Code 5207, which concerns limitation of extension of the forearm, a 10 percent rating is assigned for extension limited to 45 degrees or to 60 degrees in the minor arm. A 20 percent rating in this arm requires extension limited to 75 degrees or 90 degrees. Extension limited to 100 degrees merits a 30 percent rating, while extension limited to 110 degrees merits the maximum rating of 40 percent. Diagnostic Code 5208 assigns a 20 percent rating for the minor arm when flexion is limited to 100 degrees and extension is limited to 45 degrees. Normal range of motion is from 0 degrees extension to 145 degrees flexion. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5213 finally pertains to impairment of supination and pronation. Limitation of supination to 30 degrees of less receives a 10 percent rating for the minor arm. For limitation of pronation, motion lost beyond the last quarter of the arc, where the hand does not approach full pronation, as well as motion lost beyond the middle of the arc is assigned a 20 percent rating with respect to this arm. A 20 percent rating also is assigned for loss (bone fusion) when the hand is fixed near the middle of the arc or moderate pronation or when the hand is fixed in full pronation. The maximum rating of 30 percent is reserved for when the hand is fixed in supination or hyperpronation. Normal range of motion is from 0 to 80 degrees pronation and from 0 to 85 degrees supination. 38 C.F.R. § 4.71, Plate I. During the period on appeal, the Veteran has reported intermittent left forearm pain, difficulty, and weakness triggered by rigorous activity like lifting, pushing, and pulling using that arm. At no point have these factors been sufficient to justify an increased rating under Diagnostic Code 5206 or a separate compensable rating under Diagnostic Code 5207, however. There indeed is no indication that the Veteran's flexion ever was limited to 100 degrees or less or that his extension ever was limited to 5 degrees or more. His left elbow range of motion upon VA medical examination in December 2013 initially was from 0 to 120 degrees without pain. He could flex to 120 degrees and extend to 0 degrees, in other words. At an October 2020 VA medical examination (signed by the examiner in November 2020), his range of motion initially was from 0 to 145 degrees without pain during flexion or extension. There was no change after three repetitions at either examination. Both found that the Veteran had normal strength. Examinations should test a joint and the opposite undamaged joint for pain on both active and passive motion as well as in weight-bearing and nonweight-bearing. Correia v. McDonald, 28 Vet. App. 158, 168 (2016) (citing 38 C.F.R. § 4.59). Both of the aforementioned examinations evaluated the Veteran's right elbow as well as his left elbow. The only notable finding was that flexion initially was more limited in his right elbow than in his disabled left elbow at the former examination. While weight-bearing and nonweight-bearing were not discussed at this examination, the latter found pain during each as well as during passive motion. Range of motion, however, was measured only during active motion at both examinations. This is standard, and it typically represents the worst-case scenario. The Veteran actively moving his elbow indeed should be more limiting than the examiner passively moving it for him because he experiences his pain and/or other limiting factors whereas the examiner does not experience them. Next, motion during flare-ups and following repeated use over time is to be measured or at least estimated. Sharp v. Shulkin, 29 Vet. App. 26, 33-35 (2017). Nothing of the sort was provided with respect to flare-ups at the December 2013 VA medical examination or at the October 2020 VA medical examination. Yet this is inconsequential, since the Veteran denied flare-ups at both. Regarding repeated use over time, the former examination is silent. Yet the latter examination estimated his range of motion would remain from 0 to 145 degrees in flexion and extension despite pain. There is no indication from any source of a significant change over time, such that this estimated consistency would not also have been present at the former examination. Substantial compliance, in sum, with examination requirements has been achieved. To the extent it has not been achieved, it is not prejudicial to the Veteran. Reliance therefore can be placed on both examinations. Each of these examinations clearly conveys that even the lowest compensable rating of 10 percent is not warranted under Diagnostic Codes 5206 and 5207. The Veteran's left elbow flexion was not normal. At worst, to include following repeated use over time, it was to 120 degrees. This is significantly greater than the 100 degrees required for the next highest rating of 10 percent under Diagnostic Code 5206. Indeed, it merits only the currently assigned noncompensable rating. The Veteran's left elbow extension always was normal. This includes following repeated use over time. This is significantly greater than the 45 degrees required for a separate 10 percent rating under Diagnostic Code 5207. Since the Veteran's flexion is not limited to 100 degrees or less and his extension is not limited to 45 degrees or more, it follows that a 20 percent rating under Diagnostic Code 5208 is not warranted. Regarding Diagnostic Code 5213, a separate compensable rating also is not warranted. The December 2013 VA medical examination did not include supination or pronation measurements. The Veterans left forearm supination and pronation range of motion initially was from 0 to 75 degrees with pain at the October 2020 VA medical examination. There was no change after three repetitions. After repeated use over time, it was estimated that pain would further limit range of motion from 0 to 70 degrees. That reliance is properly placed on the aforementioned examination is reiterated. It shows that his supination, even at worst following repeated use over time, was far greater than the 30 degrees or less required for a 10 percent rating. At worst, his pronation approached full (70 degrees, which is 7/8 of the normal 80 degrees) and therefore does not satisfy the requirements for a 20 percent rating. Both examinations accordingly found no impairment of supination and pronation. A February 2021 VA treatment record documents the Veteran's denial of pronation problems and his complaint of being unable to fully supinate his left hand. This is interpreted to mean he cannot fully supinate his left forearm, since supination is not a direction of movement for the wrist. 38 C.F.R. § 4.71, Plate I. No supination or pronation measurements were taken, however. Nevertheless, the treatment records is consistent with the October 2020 examination. The examination indeed revealed some supination range of motion loss (15 degree loss at worst) which was more significant than the range of motion loss with respect to pronation (10 degree loss at worst). Other Diagnostic Codes lastly pertain to the elbow and forearm (5205 for elbow ankylosis, 5210 for other impairment of the elbow flail joint, 5122 for ulna impairment, and 5212 for radius impairment). However, there is no indication whatsoever that any is potentially applicable in considering the Veteran's disability. In conclusion, the preponderance of the evidence shows that the criteria for an increased rating under Diagnostic Code 5206 have not been met. The preponderance of the evidence also shows that the criteria for a separate compensable rating under other potentially applicable Diagnostic Codes have not been met. A compensable rating, whether an increased rating or a separate rating, for service-connected left upper extremity fractured ulna and radius status post ORIF accordingly is denied. Left Upper Extremity Muscle Herniation with Scars 38 C.F.R. § 4.73 concerns muscle injuries. The Veteran's service-connected left upper extremity muscle herniation with scars currently has a noncompensable initial rating pursuant to Diagnostic Code 5305 thereunder through July 29, 2021. Effective July 30, 2021, his initial rating was increased to 30 percent via Diagnostic Code 5307. Such a change in Diagnostic Code generally is permissible as long as it is explained. Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011); Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The only exception is a protected rating, one in effect for 20 or more years. 38 C.F.R. § 3.951(b). Here, the Veteran's rating has been in effect only since September 2013. Diagnostic Code 5305 is for muscle Group V, which includes the biceps, brachialis, and brachioradialis. Their function is elbow supination (long head of biceps is stabilizer of shoulder joint) and elbow flexion. A noncompensable rating is assigned for a slight muscle disability in the non-dominant arm. A 10 percent rating requires a moderate disability of this arm, while a moderately severe disability receives a 20 percent rating. The maximum rating of 30 percent is reserved for a severe disability. Diagnostic Code 5307 pertains to muscle Group VII, which includes the muscles arising from the internal condyle of humerus as well as flexors of the carpus, long flexors of the fingers and thumb, and the pronator. Their function is flexion of the wrist and fingers. A noncompensable rating is assigned for a slight muscle disability in the non-dominant arm. A 10 percent rating requires a moderate disability of this arm, while a moderately severe disability receives a 20 percent rating. The maximum rating of 30 percent is reserved for a severe disability. For rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). A slight muscle disability results from a simple wound of muscle without debridement or infection. STRs should document a superficial wound with brief treatment and return to duty, healing with good functional results, and no cardinal signs and symptoms. Objective findings should include minimal scarring and no fascial defects, atrophy, or impaired tonus. There also should be no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(1). A moderate muscle disability results from a through and through or deep penetrating wound of short track from a single bullet, small shell, or shrapnel fragment without the explosive effect of a high velocity missile, the residuals of debridement, or prolonged infection. STRs or other records of such should document treatment for the wound and consistent complaints of one or more cardinal signs and symptoms, particularly lower threshold of fatigue after average use, affecting the functions controlled by the injured muscles. Objective findings should include small or linear entrance and (if present) exit scars indicating the short track of the missile through muscle tissue, some loss of deep fascia or muscle substance or impairment of muscle tonus, and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). Next, a moderately severe muscle disability results from a through and through or deep open penetrating wound by a small high velocity missile or a large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts and intermuscular scarring. STRs or other records should document hospitalization for a prolonged period for treatment of the wound, consistent complaints of cardinal signs and symptoms, and, if present, evidence of an inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups and indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). A severe muscle disability results from a through and through or deep penetrating wound due to a high velocity missile, a large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. STRs or other records should document hospitalization for a prolonged period for treatment of the wound, consistent complaints of cardinal signs and symptoms worse than those shown for moderately severe muscle injuries, and, if present, evidence of an inability to keep up with work requirements. Objective findings of a severe muscle disability should include ragged, depressed, and adherent scars indicating wide damage to muscle groups in the missile track. It also should include palpation showing loss of deep fascia or muscle substance, soft flabby muscles in the wound area, and abnormal muscle swelling and hardening in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side should indicate severe impairment of function. 38 C.F.R. § 4.56(d)(4). Additionally, the following are signs of severe muscle damage: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile, (B) adhesion of the scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle, (C) diminished muscle excitability to pulsed electrical current in electro-diagnostic tests, (D) visible or measurable atrophy, (E) adaptive contraction of an opposing group of muscles, (F) atrophy of muscle groups not in the track of the missile, and (G) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4). That the medical evidence is in conflict as to which of the Veteran's muscle groups is impacted by his service-connected left upper extremity muscle herniation with scars is notable at the outset. Specifically, a December 2013 VA medical examination found that muscle Group V was impacted. A July 2021 VA medical examination, however, found that muscle Group VII was impacted. Resolution of this conflict is unnecessary since doing so would not impact this decision. Indeed, Diagnostic Code 5305 for muscle Group V and Diagnostic Code 5307 for muscle Group VII have the same criteria for noncompensable, 10 percent, 20 percent, and 30 percent ratings in the non-dominant arm. The rating criteria applicable to the Veteran's disability are the same regardless of which muscle group is impacted, in other words. Regarding the type of injury the Veteran sustained, a slight disability is strongly suggested. There is no indication in his STRs of a through and through or deep penetrating wound. Those dated in October 1992 instead reveal his complaints of pain and swelling in his left forearm after being thrown off a bull while riding it. Some deformity was found, and X-rays showed transverse mid-shaft fractures of his radius and ulna with marked displacement and angulation of the bone fragments. No mention was made of a shattering bone fracture or open comminuted fracture, however. ORIF surgery, with fixation from plates and screws, was performed. There was no evidence of complication, whether infection or otherwise. Reference finally was not made to any debridement, sloughing of soft parts, intermuscular scarring, or intermuscular binding. The history of the Veteran's injury also is most indicative of a slight disability. STRs document that he spent 4 to 5 days, a relatively brief time, in a private hospital for the aforementioned surgery. Upon his return to military care, he was noted to be healing well. There is nothing suggesting he was unable to keep up with his duties. His cast came off in November 1992. He had decreased range of motion and decreased strength, also known as the cardinal sign and symptom of weakness, for which he was referred to occupational therapy. This therapy ended in mid-December, given his imminent separation. Yet he also seemingly no longer needed it. At his mid-December 1992 separation examination, his upper extremities indeed were found to be normal. He further did not report any relevant symptoms related to breaking his left arm. Upon VA medical examination in October 1993 and August 1994, the Veteran further denied such symptoms except for occasionally when the weather changes. It follows that he did not consistently make complaints, whether of cardinal signs and symptoms or otherwise. While the Veteran's left forearm range of motion and strength were not assessed at this former examination, both were normal when assessed at the latter. There was a slight, non-painful, soft, compressible, and easily reducible bulge of muscle during flexion in the line of one of the two scars stemming from the ORIF procedure, however. It was thought to be a small hernia, likely from separation of fascia. Yet overall, no functional impairment was found. The Veteran both did not manifest any cardinal signs or symptoms and was functioning well despite this bulge, in other words. During the period on appeal through July 29, 2021, he similarly did not manifest any cardinal signs and symptoms. No relevant complaints were made in this regard by him at the December 2013 VA medical examination. It additionally specifically was determined that he did not have any such signs and symptoms. Regarding weakness, the only sign and symptom temporarily found in the past, his left forearm strength was normal. Complaints during the period on appeal through July 29, 2021, accordingly are in agreement with type of injury and history, to include history of complaints, in indicating that the Veteran's disability is only slight. All that remains is to consider objective findings during the period on appeal through July 29, 2021. They also are indicative of only a slight disability. No muscle atrophy or fascial defect was present at the December 2013 examination. There also was no functional problem attributed to the muscle body herniations under the Veteran's scars, which were characterized as minimal, when his muscles are flexed. His left forearm function indeed was full and normal. As such, no affect was detected as to his muscle substance or to his muscle function. No relevant evidence exists after the aforementioned examination. Treatment records during the period on appeal through July 29, 2021, are silent regarding the Veteran's left forearm. The July 2021 VA medical examination further took place on the 30th, the day after this period ended. In conclusion, the type of injury, history including of complaints, current complaints, and objective findings all convey a slight disability through July 29, 2021. A slight disability thus was more nearly approximated by the preponderance of the evidence during this period. This means that the criteria for an initial increased rating have not been met. A compensable rating for service-connected left upper extremity muscle herniation with scars through July 29, 2021, is denied. Beginning July 30, 2021, it already has been determined that a severe disability was more nearly approximated. There is no greater severity than severe. As such, there are no criteria for an initial increased rating higher than 30 percent. Such a rating beginning July 30, 2021, accordingly is denied for the Veteran's service-connected left upper extremity muscle herniation with scars. The August 2021 rating decision setting forth the determination to increase the Veteran's initial rating from noncompensable to 30 percent was based primarily on the July 2021 VA medical examination findings of soft flabby muscles in the wound area, some impairment of muscle tonus, and some loss of power. However, that muscle fascia was found not intact also is noteworthy. So are the Veteran's complaints of relevant symptoms. No basis exists to award an earlier effective date for the initial increased rating, since there is no indication of these findings or complaints prior to the examination. The Veteran's representative objects to the fact that it was performed by a nurse practitioner, without any specialty in orthopedics or dermatology. This objection is moot with respect to an initial increased rating beginning July 30, 2021, under the muscle injuries Diagnostic Codes, since no such rating is allowable. For a separate initial rating under the scars Diagnostic Codes, the Veteran's representative did not explain why the examiner should have special expertise. The rating criteria require determinations as to location of the scars, their area, whether they are unstable or painful, and whether or not there is associated underlying damage. These are relatively simple and straightforward to do. The findings made at the July 2021 VA medical examination lastly are largely in agreement with those made at the December 2013 VA medical examination and an October 2020 VA medical examination (signed by the examiner in November 2020), which were performed respectively by an internal medicine physician and a general practice physician. Reliance on the July 2021 examination, in addition to these other examinations, is appropriate for these reasons. Each of them conveys that a separate compensable initial rating for the Veteran's scars is not warranted at any point during the period on appeal. 38 C.F.R. § 4.118 concerns skin disabilities. 10 percent ratings are established under Diagnostic Codes 7801 and 7802 for scars not of the head, face, or neck that are at least 39 square centimeters if associated with underlying soft tissue damage and at least 929 square centimeters if not associated with such damage. One or two unstable or painful scars also receives a 10 percent rating under Diagnostic Code 7804. Finally, Diagnostic Code 7805 directs that other disabling effects of scars be rated under an appropriate Diagnostic Code. The December 2013 and July 2021 examinations indicated that the Veteran has two scars, while the October 2020 examination noted only one. This middle examination found underlying soft tissue damage, whereas the others did not. In any event, all found that the scarred area is less than 39 square centimeters. All also found that the scars were not unstable or painful and did not limit the Veteran's function. No indication to the contrary exists from him or from treatment records. The preponderance of the evidence, in conclusion, shows that the criteria for a separate initial compensable rating for scars are not met. Such a rating thus is denied. REASONS FOR REMAND Readjudication of service connection for left ear hearing loss and for tinnitus unfortunately cannot occur until more additional development is completed. The Board's September 2018 decision denying service connection for left ear hearing loss relied on a December 2013 VA medical examination. However, the Court's March 2020 Memorandum Decision deemed the opinion portion inadequate because the possibility that the Veteran's hearing loss had delayed onset following his loud noise exposure during service was not addressed. Compliance with the Court is mandatory. Forcier v. Nicholson, 19 Vet. App. 414, 425 (2006). As such, the Board remanded to obtain a new, adequate VA medical examination in November 2020. When completed in February 2021, the opinion portion did not address the possibility that the Veteran's left ear hearing loss is of delayed onset. The Board accordingly remanded a second time in June 2021. Yet the opinion portion of the resultant August 2021 VA medical examination once again did not address the possibility that the Veteran's left ear hearing loss is of delayed onset. A third remand for an adequate opinion thus is required. To ensure it is fully informed, efforts first must be made to obtain updated VA treatment records and, if identified by him or his representative, any outstanding relevant private treatment records. The Court additionally noted that service connection for tinnitus is inextricably intertwined with service connection for left ear hearing loss in its March 2020 Memorandum Decision. Indeed, the February 2021 and August 2021 examinations have included the finding that the Veteran's tinnitus is at least as likely as not a symptom associated with his left ear hearing loss. Service connection for left ear hearing loss, in sum, must be adjudicated before service connection for tinnitus. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). In remanding both issues, the Board makes no makes no expressed or implied determination as to the credibility of any statements of record. The aforementioned issues are REMANDED for the following action: 1. Follow established procedure for obtaining: (a) the Veteran's updated VA treatment records and (b) any private treatment records identified by him or his representative as concerning his left ear hearing loss or tinnitus. 2. After completing paragraph 1, arrange for a new VA medical opinion to be rendered concerning the Veteran's left ear hearing loss. Whether another examination is needed is left to this examiner's discretion. The examiner specifically shall review the claims file and opine as to whether there is at least an approximate balance of positive and negative evidence that the Veteran's disability is related: (a) to his loud noise exposure during service or (b) to his service otherwise. To support this opinion, a detailed explanation is required. This means that relevant medical principles and/or medical literature should be discussed as it relates specifically to the Veteran, as shown by the medical and lay (non-medical) evidence. In this regard, the possibility that he had delayed onset hearing loss following his loud noise exposure during service must be addressed. Comment should be made on the medical articles cited by the Veteran's representative in an April 2021 Appellant's Post-Remand Brief in doing so. 3. Then readjudicate service connection for left ear hearing loss. Readjudicate service connection for tinnitus thereafter. Follow established procedure for returning any issue that remains denied to the Board. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Becker 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.