Citation Nr: 21069241 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 15-44 414 DATE: November 17, 2021 ORDER An evaluation in excess of 60 percent for prostate cancer is denied. A compensable evaluation of for left ilio-inguinal nerve disability is denied. An evaluation in excess of 20 percent for residuals of a right scapula shell fragment wound to Muscle Group III is denied. An evaluation in excess of 10 percent for residuals of a right scapula shell fragment wound to Muscle Group I is denied. Beginning October 4, 2018, entitlement to special monthly compensation based on statutory housebound criteria is granted. FINDINGS OF FACT 1. Residuals of prostate cancer manifests as a voiding dysfunction for which the Veteran is currently assigned the highest evaluation. Renal dysfunction is not present. 2. A left ilio-inguinal nerve disability is wholly sensory in nature and manifest as no more than moderate severity. 3. A right scapula shell fragment wound to Muscle Group III manifests as no more than a moderate injury. 4. A right scapula shell fragment wound to Muscle Group I manifest as no more than a moderate injury 5. Beginning October 4, 2018, the Veteran's TDIU can be awarded based only upon his acquired psychiatric disorder. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 60 percent for prostate cancer have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.115b, Diagnostic Code (DC) 7528. 2. The criteria for a compensable evaluation percent for left ilio-inguinal nerve disability have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. § 4.1, 4.3, 4.7, 4.123, 4.124a, Diagnostic Code 8630. 3. The criteria for an evaluation in excess of 20 percent for residuals of a right scapula shell fragment wound to Muscle Group III have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.73, Diagnostic Code (DC) 5303. 4. The criteria for an evaluation in excess of 10 percent for residuals of a right scapula shell fragment wound to Muscle Group I have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.73, Diagnostic Code (DC) 5301. 5. Beginning October 4, 2018, the criteria for entitlement to special monthly compensation based on statutory housebound status have been met. 38 U.S.C. § 1114(s)(1). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1968 to May 1970. In addition, he has Reserve service from June 1974 to June 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). A Board decision in June 2019 denied the Veteran's increased rating claims and awarded entitlement to a total disability rating based upon individual unemployability. The Veteran thereafter appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in July 2020, the Court granted a Joint Motion for Remand (JMR) by the Veteran and VA General Counsel, to vacate the Board's decision and remand the case for readjudication in accordance with the JMR. In January 2021, the Board remanded the issues for additional development. The case has now been returned to the Board. The Board finds there was substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board directed the AOJ to: ask the Veteran to identify and provide authorization to obtain any outstanding, relevant treatment records for all his service-connected disabilities; obtain all outstanding VA treatment records with respect to all service-connected conditions since September 29, 2015; obtain any outstanding service treatment records (STRs) associated with the Veteran's August 1969 shell fragment wound, including records of any inpatient treatment at a hospital in or associated with the 3rd Medical Battalion in Vietnam from in August 1969; afford the Veteran a VA skin condition examination; and obtain medical opinions with regard to whether the Veteran has impairment of motor function and whether the Veteran's itching is a symptom of a nerve vs. a skin disorder. In compliance with these remand directives, the AOJ sent a January 2021 letter to the Veteran asking the Veteran to identify and provide authorizations for private medical records. In March 2021, the Veteran submitted an authorization for records from the VA healthcare system. Next, the AOJ obtained updated VA treatment records. Next, in February 2021, the AOJ made a request through the Personnel Information Exchange System (PIES) for complete medical/dental records and the entire personnel file at the National Personnel Records Center. Extensive military personnel records were sent. The March 2021 PIES response stated that all available STRs were mailed and a response to a prior request also furnished STRs. VA also afforded the Veteran a VA skin condition examination and a VA peripheral nerves examination. The nerves examination identifies whether there is impairment of motor function. VA also obtained a medical opinion with regard to whether the Veteran's itching is a symptom of a nerve vs. a skin disorder. The examiner described the disability in sufficient detail to enable a fully informed rating. As to the medical opinion the VA examiner reviewed the evidence of record and considered the Veteran's actual history and statements. The examiner rendered opinions with reasoned medical explanations and analysis. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Therefore, the Board finds that the Veteran has been provided an adequate medical examination in conjunction with his claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Rating 1. An evaluation in excess of 60 percent for prostate cancer. The Veteran seeks an evaluation higher than 60 percent for the residuals of his prostate cancer. The Veteran had a radical prostatectomy for prostate cancer in September 2009. He filed his claim for an increased evaluation in June 2013, after having withdrawn an appeal as to the evaluation assigned in the January 2011 rating decision. The evaluation of the disability has been assigned under Diagnostic Code 7528. Diagnostic Code 7528 evaluates malignant neoplasms of the genitourinary system, and it assigns a 100 percent rating for active malignancy. An evaluation for residuals is assigned following active malignancy under the appropriate criteria based on whichever genitourinary dysfunction predominates. A note after Diagnostic Code 7528 provides that, following the cessation of surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105 (e). If there has been no local reoccurrence or metastasis, the disability is to be rated on residuals, such as voiding dysfunction or renal dysfunction, whichever is predominant. See 38 C.F.R. § 4.115b, Diagnostic Code 7528, Note. In this case, the evidence indicates that the date for evaluation of residuals, i.e. six months after surgery and cessation of therapeutic procedures, was prior to June 2012 (the start of the appeal period). Therefore, the 100 percent evaluation for active malignancy was not warranted during the appeal period. The Veteran has been assigned a maximum evaluation under the provision for a voiding dysfunction. 38 C.F.R. § 4.115a. A 60 percent rating for voiding dysfunction is assigned when there is continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. Id. Therefore, in order to qualify for a higher evaluation, the disability would need to be rated as renal dysfunction. An 80 percent rating for renal dysfunction is warranted when there is persistent edema and albuminuria with blood urea nitrogen (BUN) 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Id. The Board finds that the Veteran's disability does not manifest as a renal dysfunction. The Veteran's complaints are of urine leakage and urinary frequency. The December 2013 and August 2021 VA examiners found kidney infections were not present and the examiners did not diagnose the Veteran with renal dysfunction when conducting a specific examination for the residuals of prostate cancer. There is no other indication of renal dysfunction. The Veteran has not asserted that his residuals of prostate cancer manifest as renal dysfunction. Accordingly, an evaluation higher than 60 percent is not warranted. The Board acknowledges the Veteran's report that he suffers from extreme irritation and itching caused by urine laying against his skin and the use of pads. For the reasons discussed in the section below regarding the nerve disability, a separate evaluation for a skin disability is not warranted. 2. An evaluation for left ilio-inguinal nerve disability. The Veteran seeks a compensable evaluation for left ilio-inguinal nerve neuralgia. At the October 2018 Board hearing, the Veteran reported itching so intensely he scratches until it bleeds. He also reported pain deep under the skin. The Veteran questioned whether the assigned diagnostic code was appropriate since it references paralysis. The Veteran's disability is evaluated under Diagnostic Code 8630 for neuritis of the ilio-inguinal nerve. Neuritis is characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating. 38 C.F.R. § 4.123. Peripheral nerve neuralgia is characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve. 38 C.F.R. § 4.124. The Diagnostic Codes for peripheral nerves contemplate sensory involvement and motor involvement, such as is the case here. See 38 C.F.R. § 4.124a. Therefore, these regulations and diagnostic codes describe nerve disorders where paralysis is not present and are appropriate. The Board finds that the Diagnostic Codes applicable to the ilio-inguinal nerve are most appropriate based on the relevant medical history, diagnosis, and demonstrated symptomatology. The history and symptoms relate to a disorder of the nerve, rather than of the skin. For instance, the April 2011 and January 2012 private providers diagnosed the nerve disability, as does the August 2021 VA examiner. The diagnoses by more than one provider of an ilio-inguinal nerve disorder are especially probative, as are the Veteran's reports that the irritation is felt deep inside. The Board notes that evaluations for neuritis and neuralgia may apply to wholly sensory involvement without complete or incomplete paralysis. The Board now turns to the severity of the disability. Paralysis of the ilio-inguinal is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8527. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8630 and 8730. Under these criteria, mild to moderate paralysis is rated as noncompensable. Moderate to complete paralysis is rated as 10 percent disabling. 38 C.F.R. § 4.124a. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). On this record, at the December 2013 VA peripheral nerves examination, the Veteran reported constant pain, numbness, and burning on the medial side of the upper thigh and scrotum for which he took Gabapentin. Symptoms were found to be mild pain, mild paresthesias and/or dysesthesias, and mild numbness. Muscle strength was normal in the lower extremities. Atrophy was not present. Reflexes were normal. Sensation was normal. Trophic changes were not present. The examiner found there to be mild incomplete paralysis of the left ilio-inguinal nerve. The August 2021 VA peripheral nerves examination showed a diagnosis of "peripheral neuropathy, left ilio-inguinal nerve disability / left ilio-inguinal nerve neuralgia." Symptoms were numbness and pain to the left genital and inguinal area. Muscle strength was normal. Atrophy was not present. Reflexes were normal. For the areas tested, sensation was normal. Nonetheless, the Board acknowledges that the testing may not have been performed on the precise area where the Veteran has symptoms. The examiner found moderate incomplete paralysis of the ilio-inguinal nerve. At the October 2018 Board hearing, the Veteran testified to pain after surgery in the fold of his left leg that never went away. He reported having sharp pain on some activities, such as sharply moving his left leg over his right. The pain will wake him up. If his dog's tail hits him on that spot, it doubles him over. He has to bend over "slight, real slow, because [he doesn't] know if [he's] compressing something." He further testified that it was constant pain and a burning sensation. He testified that walking or standing for long periods of time worsens it. He testified to scratching in his sleep, including as due to irritation and itching from urine contacting the skin through the absorbent materials he uses for his voiding dysfunction. He reported scratching to the point of bleeding, but that "there's nothing I can itch. It's way down under the skin surface." The Veteran's wife testified that he's had injections and that he has had some kind of topical cream to try to calm it down. He takes oral nerve medication, and still gets no relief. The Board cannot consider ameliorative effects of medication. However, because the Veteran has credibly stated that his medication does not help relieve his condition, there are no ameliorative effects to discount. Based on the above, the Board finds that the disability is primarily manifest by sensory disturbance such as pain, numbness, itching and burning. The Veteran's reports regarding bending over and worsening pain, burning, and compression with prolonged standing or walking, which the JMR characterized as indicating some impairment of motor function, are expressly considered by the Board. The Veteran's actual description shows that he avoids certain activities or performs them carefully so as to avoid triggering additional pain, itching, and burning. These are wholly sensory symptoms. The evidence of record is against a finding that the disability is manifest by trophic changes, loss of reflexes, muscle atrophy, weakness, and paralysis (either incomplete or complete). Therefore, at most the moderate degree of impairment may be awarded. Under the Diagnostic Codes for the ilio-inguinal nerve, moderate impairment warrants only a non-compensable evaluation. Next, the Board considers whether a separate compensable evaluation is warranted for the Veteran's nerve symptoms that cause him to scratch so intensely that it bleeds. In the October 2018 Board hearing, the Veteran and his wife described that this pain caused him to scratch in his sleep until he bled through his underwear and the bed sheets, and that he required the use of topical cream and injections, but that they did not work. As noted above, there are no ameliorative effects to consider because the medications do not change the severity of the disability because the do not provide relief. Initially, the Board evaluates whether the Veteran in fact has a separate skin disability. In that regard, the Board finds that he does not. In August 2021, the Veteran underwent VA prostate cancer and skin examinations. In the resulting opinion, the examiner stated that the genital area itches all the time, even right after a shower and is aggravated by urine incontinence and sweat, but is not caused by urine or sweat. The examiner found no rash or erythema. The Board notes that "erythema" is the "redness of the skin produced by congestion of the capillaries." Dorland's Illustrated Medical Dictionary 643 (32d ed. 2012). The examiner further found no skin disorder present. Instead, the examiner stated that stated this is a type of neuropathy that is due to his radical prostatectomy surgery. The examiner found that the nerve symptoms of pruritis were not related to urinary incontinence. The examiner found that the peripheral neuropathy is a residual of the prostate cancer surgery. The Veteran is already in receipt of a separate evaluation for the peripheral nerve disorder as a residual of the prostate cancer surgery, so the examiner's connecting the two is not necessary. The examiner's opinion as to a separate skin condition is probative and based on the Veteran's lay report of symptoms. A January 2012 statement from Dr. Q.H. from Texas Tech Pain Management Center reported that he had been treating the Veteran since July 2011 for left groin pain. The clinician stated that two ileoinguinal nerve blocks were performed. An August 2014 VA urology followup note reported that the Veteran has itching on his scrotum. There was some redness on the right groin and scrotum. Clotrimazole cream was prescribed. The VA medical opinion and treatment records showing no rashes or other external symptoms such as lesions on the Veteran's left groin shows there is no separate skin disorder of the left ileo-inguinal area. Having found no separate skin disorder diagnosis, the Board evaluates whether one is warranted as to the symptoms only. In that regard, the Board finds that the Veteran's itching is a natural result of the sensory disturbances contemplated by the rating schedule for nerve disabilities under 38 C.F.R. § 4.124 and §124a. See Spellers v. Wilkie, 30 Vet. App. 211 (2018). Thus, itching to the point of bleeding is also a consequence of the symptom contemplated by the rating schedule. Unfortunately, the Board cannot award a higher evaluation for the nerve disability because there are only sensory manifestations of it. Alternatively, the Board has considered evaluating the symptoms analogous to the skin disability diagnostic codes under 38 C.F.R. § 4.118 as symptoms only, without a diagnosis, under Saunders v. Wilkie. 886 F.3d 1356 (2018) ("pain alone can serve as a functional impairment and therefore qualify as a disability"). The Board evaluates the Veteran's symptoms under an appropriate Diagnostic Code for the skin. The Veteran's itching and use of topical cream suggests a disability analogous to dermatitis under Diagnostic Code 7806. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the pre-August 13, 2018, regulations because the Veteran's scratching and bleeding symptoms do not more nearly approximate at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the August 13, 2018, regulations because the Veteran's scratching and bleeding symptoms do not more nearly approximate characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy required for a total duration of less than 6 weeks over the past 12- month period. The August 2021 VA skin examination showed no symptoms. Nonetheless, based on the Veteran's description that he scratches the fold of his left leg, the Board can estimate that the area affected is less than five percent of total body area. Furthermore, there is no indication topical cream was a systemic immunosuppressive or corticosteroid. The clotrimazole cream prescribed in August 2014 VA is an antifungal. See Dorland's Illustrated Medical Dictionary, 375 (32nd ed. 2012). This topical medication does not operate by impacting the body as a whole and instead is applied to the area where the symptoms occur. Additionally, the record does not show, nor does the Veteran assert, that the clotrimazole cream produced side effects outside of the area where it was applied. The nerve block was prescribed to treat the nerve disability for which the Veteran is already compensated. Finally, the Board notes the Veteran is compensated at 30 percent for his scars that include anterior and posterior trunk scars. The June 2019 Board decision increased the rating to 30 percent for 3 scars that are painful and unstable, based on the Veteran's testimony in the October 2018 Board hearing that the scars were tender to the touch and the skin over them peels. To the extent there is a skin peeling disorder, the Veteran has already been compensated for it. To compensate for it again would be impermissible pyramiding. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for an evaluation in excess of a compensable rating. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. An evaluation in excess of 20 percent for residuals of a right scapula shell fragment wound to Muscle Group III. 4. An evaluation in excess of 10 percent for residuals of a right scapula shell fragment wound to Muscle Group I The Veteran seeks an evaluation in excess of 20 percent for the residuals of a right scapula shell fragment wound and in excess of the 10 percent evaluation previously awarded in the Board's June 2019 decision. The Veteran reports that shrapnel has come to the surface in the past. He also reports increased pain as he ages, some of which may have been from spurs on his rotator cuff, which he had removed arthroscopically many years after service. The Veteran also believes he had a fractured right shoulder. The Veteran's shell fragment wound is currently evaluated under 38 C.F.R. § 4.73, Diagnostic Code 5303, for a Group III muscle disability and under Diagnostic Code, 5301, for a Group I muscle disability. Muscle disabilities are rated as slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56. 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). An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56 (a). A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56 (b). A moderately severe muscle disability is evidenced by a through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. There should be hospitalization for a prolonged period for treatment of wound and a record of consistent complaint of cardinal signs and symptoms of muscle disability and, if present, evidence of inability to keep up with work requirements. 38 C.F.R. § 4.56 (d)(4)(i), (ii). A severe muscle injury is a through and through or deep penetrating wound due to high-velocity missile, or 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, where there was hospitalization for a prolonged period for treatment of the wound. There should be a record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. 38 C.F.R. § 4.56 (d)(4)(i), (ii). Moderately severe disability of muscles requires entrance and (if present) exit scars indicating track of missile through one or more muscle groups, indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side, and tests of strength and endurance compared with the sound side demonstrating positive evidence of impairment. 38 C.F.R. § 4.56 (d)(3)(iii). Severe disability of the muscles requires ragged, depressed and adherent scars, loss of deep fascia or muscle substance or soft flabby muscles in the wound area, and severe impairment on tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side. 38 C.F.R. § 4.56 (d)(4)(iii). If present, the following are also signs of severe muscle disability: (a) x-ray evidence of minute multiple scattered foreign bodies; (b) adhesion of the scar; (c) diminished muscle excitability on electrodiagnostic 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; or (g) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56 (d)(4)(iii). Diagnostic Code 5303, Muscle Group III, involves the intrinsic muscles of the shoulder girdle, including the pectoralis major I (clavicular) and the deltoid. For the dominant arm, a 20 percent disability rating is warranted for moderate injury. A 30 percent rating is warranted for moderately severe injury. 38 C.F.R. § 4.73, Diagnostic Code 5303. A maximum 40 percent rating is warranted for severe injury. Diagnostic Code 5301 addresses injuries to Muscle Group I. Muscle Group I involves the extrinsic muscles of the shoulder girdle: (1) trapezius; (2) levator scapulae; and (3) serratus magnus. Under Diagnostic Code 5301, for a dominant arm, a slight disability warrants a noncompensable rating, a moderate disability warrants a 10 percent rating, a moderately severe disability warrants a 30 percent rating, and a severe disability warrants a 40 percent rating, the highest rating available under the diagnostic code. The December 2013 VA examiner found that the shell fragment wounded muscle groups I, III and IV. Diagnostic Code 5304, Muscle Group IV, includes the supraspinatus, infraspinatus, teres minor, subscapularis, and coracobrachialis muscles associated with the functions of which include stabilization of the shoulder against injury in strong movements, holding the head of the humerus in socket, abduction, and outward rotation and inward rotation of the arms. For a Muscle Group IV injury in a dominant limb, a 0 percent rating is appropriate for slight impairment, a 10 percent rating is appropriate for moderate impairment, and a 20 percent rating is appropriate for moderately severe impairment, and a 30 percent rating is for severe impairment. Because there are separate muscle groups involved, the Board may assign separate evaluations for each muscle group as long as the functional impairment is not overlapping. Under what is commonly known as the rule against pyramiding, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14. The Board now turns to the analysis of whether a separate evaluation for Muscle Group IV is warranted. In the December 2013 VA examination, the Veteran reported pain between first and second posterior ribs. He reported that he cannot raise his arm above his shoulder blade or swing his arm behind his back. Cardinal signs and symptoms were reported as consistent fatigue-pain and uncertainty of movement to all muscle groups affected. The examiner found the Veteran has problems with pain and limitation of movement from the strained muscle involved. The examiner also found limitation of right shoulder flexion was to 70 degrees and abduction was to 80 degrees. Normal flexion and abduction were to 180 degrees. Muscle strength tests were normal. Atrophy was not present. The Board finds the Veteran's disabilities correspond to muscle group functions as follows: the inability to raise his arm above his shoulder blade corresponds to muscle group I (elevation of arm above shoulder level), but not to muscle group III, which limits the evaluation of the function to the "elevation and abduction of arm to level of shoulder." (Emphasis added). It also corresponds to "abduction" in muscle group IV. The inability to swing his arm behind his back corresponds to the "forward and backward swing of the arm" in muscle group III and the "outward and inward rotation of arm" in muscle group IV. The limitation of motion disability corresponds to the group I function of "elevation of arm above shoulder level" and "abduction" in group IV. As there are overlapping symptoms between groups I and IV and groups III and IV, the assignment of a separate evaluation for group IV would constitute impermissible pyramiding. Next, the Board reviews the severity of the injury to each muscle group in terms of whether it is slight, moderate, moderately severe, or severe based on the criteria described above. A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56 (b). Here, muscle group III has already been assigned a 20 percent evaluation, corresponding to moderate disability. Muscle group I must be assigned at least a 10 percent evaluation for moderate disability. The Board finds a through-and-through injury was present based on the presence of two scars, which were noted in the December 2013 VA examination. As to whether moderately severe or severe evaluations are warranted, the December 2013 VA examiner found tenderness on the right scapular area, but normal strength, no atrophy, and normal light touch sensation. X-rays were negative for retained metallic fragments. The cardinal signs and symptoms were consistent fatigue-pain and consistent uncertainty of movement. Service treatment records for August 1969 describe treatment for a through-and-through wound on the surface of the right shoulder. The wound was cleaned out and irrigated daily until the fourth day at which time the wound was closed with sutures. The initial note indicated "fx right shoulder," which generally means a fracture occurred. However, there are no subsequent references to a fracture. A September 1969 treatment record noted the wound became infected and that the Veteran now had pain when lifting the arm. The note showed that all muscle groups had good strength, there was full range of motion in the shoulder, and no sensory deficit in the arm. The Board concludes that the Veteran's muscle group injuries were no more than moderate. The service treatment records do not show debridement took place. Debridement is defined as "the removal of...contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed." See Dorland's Illustrated Medical Dictionary, 473 (32 ed., 2012). Although the Veteran's wound was cleaned, irrigated and sutured, there is no indication that tissue was removed. Additionally, there was no prolonged infection, or sloughing of soft parts, and intermuscular scarring. Here, there was evidence of infection, but it was not prolonged, as there was only one reference to a history of the infection after suturing. In the record noting the infection, the Veteran was placed on light duty. These notations and the short time between them contradict a finding of a prolonged infection. Evidence also shows no prolonged hospitalization, if any hospitalization at all. A note in mid-August 1969 states the Veteran was to return to the clinic in one week. Therefore, he was not hospitalized as of about five days after the wound. Additionally, the VA examination results found no indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side, and tests of strength and endurance compared with the sound side were normal. For these reasons, the wound does not meet the criteria for a moderately severe rating. The Board also concludes that the Veteran does not have a severe muscle injury to either muscle group. Although there may have been a fracture of the scapula, the treatment record noting a fracture did not indicate any shattering of bone or open comminuted fracture. As noted above, there was no debridement, prolonged infection, sloughing of soft parts or prolonged hospitalization. Furthermore, intermuscular binding and scarring was not shown. Scars are not ragged, depressed and adherent. There is no loss of deep fascia or muscle substance or soft flabby muscles in the wound area, and there was no severe impairment on tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side. 38 C.F.R. § 4.56 (d)(4)(iii). X-rays were negative for minute multiple scattered foreign bodies, although the Veteran reported having shrapnel removed in his remote history. For these reasons, the muscle groups do not warrant a severe rating. The Board has considered other residuals of the gunshot wound such as limitation of motion of the shoulder. In this case, a rating for limitation of motion of the shoulder under Diagnostic Code 5201 cannot be awarded separately. The symptoms of limited motion overlap with the muscle group injury symptoms, in particular, the Veteran's inability to raise his arm above his shoulder. Nonetheless, if different evaluations are available for the same disability, the Board is required to award the higher of the evaluations. Under Diagnostic Code 5201, a 20 percent rating is warranted for limitation at the shoulder level and a 30 percent rating is warranted for limitation to midway between the side and shoulder level for the major extremity. For the major shoulder, a 40 percent rating is provided where limitation is to 25 degrees from the side. Under this Diagnostic Code, the Veteran would qualify only for a 20 percent evaluation because the VA examination shows he is able to raise his arm to shoulder level. Functional limitation due to pain and fatigue would not more nearly approximate limitation of motion midway between the side and shoulder level or to 25 degrees from the side. Therefore, the evaluations for muscle group injuries is more favorable to the Veteran. The Board has also considered Diagnostic Code 5203 for impairment of the scapula. There the maximum evaluation is 20 percent, which is no higher than what the Veteran has already been assigned. This evaluation could not be awarded separately because symptoms of impairment overlap with that of limited motion in this case because the Veteran has described mainly symptoms of limitation of motion. In sum, a higher evaluation for Muscle Groups I and III is not warranted. 5. Entitlement to special monthly compensation based on 38 U.S.C. section 1114(s). On remand from the Court, the Board is instructed to consider whether the Veteran's award of a TDIU could be based upon a single service-connected disability. If so, the Veteran qualifies for special monthly compensation (SMC) under the statutory housebound criteria. Entitlement to special monthly compensation based on housebound status will be granted when a veteran has a single service-connected disability rated as 100 percent and, (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s). The criteria in subsection (1) is referred to as statutory housebound criteria. A veteran is permanently housebound when he is substantially confined as a direct result of service-connected disabilities to his dwelling and the immediate premises. 38 C.F.R. § 3.350 (i). There is no indication in this case that the Veteran is substantially confined to his dwelling or immediate premises. As to whether a TDIU could be based upon a single service-connected disability, the Board finds that the Veteran's acquired psychiatric disorder alone prevents him from securing and following a substantially gainful occupation beginning October 3, 2018, the date of the Board hearing and subsequent evidence from his family. Prior to that, the TDIU cannot be based on one disability alone. In the June 2013 VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability, the Veteran reported being unable to work due to residuals of the prostatectomy including his nerve disability, shoulder muscle damage, and a mood disorder/PTSD. December 2012 and December 2013 VA examinations show the Veteran last worked in August 2012 as a substitute teacher. He stated that he had not been able to work since that time due to health problems. The Veteran stated that a typical day is to watch ESPN, help with the housework, read, nap for about 2 to 3 hours, help cook dinner, and look after his autistic 5 year-old grandson. After dinner, he would read and play games or watch football games. He enjoys gardening as well. He was not prescribed any psychotropic medication. Symptoms included depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. May 2013 to June 2015 VA mental health treatment notes depression or mood disorder and PTSD by history. The Veteran also attended family counseling with his wife and anger management group therapy. Symptoms indicative of an inability to secure or follow a substantially gainful occupation were not reported. In September 2015 mental health treatment, the Veteran reported that he had been substitute teaching and had a meltdown, triggered by a young boy who was physically disfigured. The foregoing symptoms are not sufficient to support a TDIU on their own as far as psychiatric disabilities are concerned. Furthermore, the evidence shows the Veteran was able to perform some substitute teaching at least until September 2015. Although he had a "meltdown" at that time, there is insufficient evidence to show that there were further meltdowns. At the October 2018 Board hearing, the Veteran described several factors contributing to his inability to work. Most relevant to this time period, the Veteran stated that the last time he taught was four or five years ago, and stopped because he could not do all the standing. This indicates a cause other than his psychiatric disorder. It is not until the October 2018 Board hearing and the subsequent statements from the Veteran's family that there is evidence showing near continuous depression affecting the ability to function effectively, outbursts of anger and irritability with yelling, difficulty in adapting to stressful circumstances including work or a worklike setting, poor appetite, fatigability, social isolation, crying easily, and easy startling. The October 2018 statement from the Veteran's granddaughter reports that the Veteran's symptoms were drastically worsened "more recently." As to prostate cancer residuals, the Board finds the functional impairment prior to October 2018 did not render the Veteran unable to secure or follow a substantially gainful occupation on their own. In that regard, at the Board hearing, he stated when he was diagnosed with prostate cancer, he stopped teaching. However, records show, he continued to teach until at least September 2015. The March 2011 VA genitourinary examination showed the Veteran was teaching and had to change his pad three times in school and a minimum of five times daily due to his urinary incontinence. April 2011 private treatment records show the Veteran changes his pads four times per day and had "mild urinary stress incontinence." The Board finds this limitation to be challenging, but on its own did not prevent the Veteran from securing or following a substantially gainful occupation. The January 2013 VA nerves examination showed the Veteran's nerve pain was substantial, and that the pain increased with walking and standing. Nonetheless, the Veteran was able to teach on a substitute basis at least until September 2015. Furthermore, his VA Form 21-8940 is probative evidence that his multiple disabilities, rather than one, contributed to the inability to work. Thus, the Board finds that at least up until September 2015, although he had more pain when walking or standing with teaching, it alone did not prevent him from securing or following a substantially gainful occupation. Because the evidence is insufficient to find that, prior to October 4, 2018, the Veteran was unable to secure or follow a substantially gainful occupation due to one service-connected disability, SMC based on statutory housebound status is not warranted prior to that date. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Rocktashel, 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.