Citation Nr: 21021434 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 09-20 961 DATE: April 13, 2021 ORDER Entitlement to a 40 percent evaluation, but no higher, for fragment wound residuals of the right upper thigh with loss of tissue and atrophy for the time period from March 13, 2006, to the present is granted. Entitlement to an evaluation in excess of 10 percent from March 13, 2006, and in excess of 20 percent from September 14, 2020, for shell fragment wounds of the right foot is denied. FINDINGS OF FACT 1. From March 13, 2006, fragment wound residuals of the right upper thigh with loss of tissue and atrophy were productive of severe impairment in Muscle Groups XIII and XV. 2. From March 13, 2006, shell fragment wounds of the right foot were not productive of more than moderate impairment in Muscle Group X. 3. From September 14, 2020, shell fragment wounds of the right foot were not productive of more than moderately severe impairment in Muscle Group X. CONCLUSIONS OF LAW 1. The criteria for entitlement to an evaluation of 40 percent, but no higher, for fragment wound residuals of the right upper thigh with loss of tissue and atrophy from March 13, 2006, to the present have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.55, 4.56, 4.73, Diagnostic Codes 5313, 5315 (2020). 2. The criteria for entitlement to an evaluation in excess of 10 percent from March 13, 2006, and in excess of 20 percent from September 14, 2020, for shell fragment wounds of the right foot have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.55, 4.56, 4.73, Diagnostic Code 5310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1966 to October 1968. His awards include the Combat Infantryman Badge. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2006 rating decision, wherein the Agency of Original Jurisdiction (AOJ) increased the Veteran’s rating for his service-connected fragment wounds of the right foot to 10 percent, effective March 13, 2006 (the date of the Veteran’s claim for an increased rating). In a September 2013 rating decision, the AOJ increased the Veteran’s rating for residual fragment wound of the right upper thigh with loss of tissue and atrophy to 30 percent, effective April 16, 2012. Additionally, in an October 2017 rating decision, the AOJ increased the Veteran’s rating for his service-connected fragment wound of the right upper thigh to 30 percent, effective March 13, 2006. In an October 2020 rating decision, the AOJ increased the Veteran’s rating for his service-connected fragment wounds of the right foot to 20 percent, effective September 14, 2020 (the date of the VA examination). As those increases do not represent the maximum benefit for those disabilities, the Veteran’s appeal was not abrogated, and the issues remain on appeal. AB v. Brown, 6 Vet. App. 35 (1993). In March 2012, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The Board remanded these matters in May 2013. In February 2016, the Board issued a decision denying the issues on appeal. The Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). In October 2016, the Court issued an Order granting a Joint Motion for Remand (Joint Motion) and remanding the appeal for action consistent with the terms of the Joint Motion. In March 2017, December 2017, and May 2020, the Board remanded these matters for additional development. Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2020). Evidence of record, including service treatment records, showed that the Veteran sustained fragment wounds in both legs from shrapnel in June 1967, which resulted in injuries in his right foot, leg, knee, and right upper thigh. These injuries were treated with surgical debridement and removal of the shrapnel, requiring weeks of hospitalization. The Veteran has muscle injuries due to his fragment wound residuals of the right upper thigh with loss of tissue and atrophy as well as shell fragment wounds of the right foot. In March 2006, the Veteran filed increased rating claims for his right upper thigh and right foot fragment wound disabilities. Muscle injuries are evaluated pursuant to criteria at 38 C.F.R. §§ 4.55, 4.56, and 4.73. For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions, which include 3 muscle groups for the foot and leg (Diagnostic Codes 5310 through 5312) and 6 muscle groups for the pelvic girdle and thigh (Diagnostic Codes 5313 through 5318). 38 C.F.R. § 4.55(b). For compensable muscle group injuries which are in the same anatomical region but do not act on the same joint, the evaluation for the most severely injured muscle group will be increased by one level and used as the combined evaluation for the affected muscle groups. 38 C.F.R. § 4.55(e). For VA 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 disability of muscles consists of simple wound of muscle without debridement or infection. Objective findings include minimal scar; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(1). A moderate muscle disability comprises of a through-and-through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. Objective findings should include entrance and (if present) exit scars; small or linear, indicating short track of 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). A moderately severe muscle disability comprises of 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. There should be a history of hospitalization for a prolonged period for treatment of the wound, with a record of consistent complaints of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating track of 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 contemplates through-and-through or deep penetrating wounds 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. There should be a history of hospitalization for a prolonged period for treatment of the wound, with consistent complaints 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. Objective findings should include ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track; palpable loss of deep fascia or muscle substance, or soft flabby muscles in 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 indicate severe impairment of function. 38 C.F.R. § 4.56(d)(4). If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of 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 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, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56. The Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Use of terminology such as severe by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. 1. Entitlement to a 40 percent evaluation, but no higher, for fragment wound residuals of the right upper thigh with loss of tissue and atrophy for the time period from March 13, 2006, to the present is granted. The Veteran is currently assigned a 30 percent evaluation for his service-connected fragment wound residuals of the right upper thigh with loss of tissue and atrophy under Diagnostic Code 5315. He now seeks a higher evaluation. Diagnostic Code 5313 pertains to a disability of Muscle Group XIII, which is comprised of the posterior thigh group and hamstring complex of 2-joint muscles: 1) biceps femoris, 2) semimembranosus, and 3) semitendinosus. The functions of Muscle Group XIII include: extension of hip and flexion of knee; outward and inward rotation of the flexed knee; and, acting with the rectus femoris and sartorius, synchronizing simultaneous flexion of hip and knee and extension of hip and knee by belt-pulley action at the knee joint. A slight disability warrants a noncompensable rating. A moderate disability warrants a 10 percent disability rating. A moderately severe disability warrants a 30 percent disability rating. A severe disability warrants a 40 percent rating, the highest rating available under the diagnostic code. 38 C.F.R. § 4.73, Diagnostic Code 5313. Under Diagnostic Code 5315, injury of Muscle Group XV, the Pelvic Girdle and Thigh, governing movements of the adduction of the hip, flexion of the hip, and flexion of the knee, as to the mesial thigh muscles warrants the maximum assignment of a 30 percent rating when severe. 38 C.F.R. § 4.73, Diagnostic Code 5315. Initially, the Board finds that residuals of the right thigh fragment wound involve injury to Muscle Groups XIII and XV, which are in the same anatomical region (i.e., pelvic girdle and thigh) and act upon different joints (i.e., hip and knee); therefore, the rating for the most severely injured muscle group will be used as the combined evaluation for the affected muscle groups per 38 C.F.R. § 4.55(e). Based on evidence of record during the time period from March 13, 2006, (including lay assertions from the Veteran, VA and private treatment records, and VA examination reports/medical opinions dated from 2006 to 2020), the Board has determined that the disability was productive of severe impairment. In an April 2006 VA examination report, the examiner noted that the Veteran’s right lower extremity showed a large defect and scar that measured 12x12 centimeters over the inner aspect of the right thigh with partial debridement of the hamstring musculature and adduction musculature. Scars were also shown over the proximal anterior tibia and medial tibia. None of the scars had excessive tenderness to palpation and were all well healed without any evidence of breakdown. Range of motion of the right hip was 110 degrees (flexion), 30 degrees (extension), 25 degrees (adduction), 35 degrees (abduction), 60 degrees (external rotation), and 60 degrees (internal rotation). Range of motion of the right knee was 120 degrees (flexion) and 0 degrees (extension). The extremes of motion were limited by pain without evidence of fatigability, lack of coordination, weakness, or dysfunction with repetitive use. Sensation over the leg was normal with 4/5 strength for hamstring and abductor muscles of the leg. A May 2006 VA X-ray report revealed multiple small fragments of shrapnel in the posterior aspects of the right leg as well as a few scattered pieces of shrapnel along the lateral aspects of the distal leg. Additional VA treatment records noted findings of hip arthralgia with pain on rotation of the hip. Private treatment records from 2007 detailed right sided adductor weakness secondary to wounds and right hip osteoarthritis. The provider listed an assessment of mild/mild to moderate arthrosis about the right hip with multiple shrapnel fragments. Generally painless range of motion of the right hip with noted. In a December 2008 VA examination report, the examiner noted extensive right lower extremity retained foreign bodies with no lateral tenderness to palpation at the hip. There was a right medial thigh soft tissue defect consistent with previous split-thickness skin graft measuring 10x10 centimeters. Range of motion of the right hip was 90 degrees (flexion), 0 degrees (extension), 45 degrees (external rotation), and 30 degrees (internal rotation). In April 2012 VA examination reports as well as a September 2013 VA addendum medical opinion, the Veteran was noted to have a muscle injury to Muscle Group XIII and Muscle Group XV. Positive findings in Muscle Group XV included ragged depressed and adherent scars indicating wide damage to muscle groups in missile track, fascial defects including palpation showing loss of deep fascia, and visible loss of entire muscle of the upper inner thigh. His muscle substance or function for Muscle Group XV was affected with some impairment of muscle tonus, loss of muscle substance, soft flabby muscles in the wound area, adaptive contraction of an opposing group of muscles, and visible measurable atrophy. Cardinal signs and symptoms of muscle disability of Group XV were consistent at a more severe level loss of power, consistent weakness, consistent lowered threshold of fatigue, and consistent fatigue-pain. The Veteran exhibited full muscle strength, muscle atrophy affecting Group XV right upper thigh, and radiologic evidence of minimal DJD of right hip joint as well as retained metallic fragments of the right lower extremity with minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. The examiner noted findings of posttraumatic arthritis, s/p grenade injury with retained shrapnel. The examiner clarified that Muscle Group XV was the most severe and that the remaining affected muscle groups would be mild. Range of motion of the right hip was 100 degrees of flexion, greater than 5 degrees of extension, abduction not lost beyond 10 degrees, adduction not limited such that Veteran cannot cross legs, and rotation not limited such the Veteran cannot toe out more than 15 degrees. Functional loss was listed as less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, and interference with sitting/standing/weight-bearing. Muscle strength testing was 4/5 in all ranges of hip motion. Range of motion of the right knee was 90 degrees of flexion and 0 degrees of extension. Functional loss was listed as less movement than normal, weakened movement, excess fatigability, pain on movement, and interference with sitting/standing/weight-bearing. Muscle strength testing was 4/5 on knee flexion and 5/5 on knee extension. The examiner noted that muscle tissue missing from the medial and posterior right thigh muscles affected mobility of the right hip and right knee. Right knee X-rays revealed minimal narrowing of the medial knee joint compartment and shrapnel fragment projecting over the proximal tibia. In an April 2017 VA addendum medical opinion, the examiner clarified that the Veteran’s Muscle Group XV corresponds to a severe level of severity in accordance with VA regulations. The examiner reviewed extensive medical history and examination findings, concluding that Muscle Groups XIII and XVII were not part of the service-connected fragment wound residuals. Debridement of the hamstring and abductor muscles were acknowledged at the time of the initial injury. However, post-service VA examination findings indicated the Veteran’s ability to run, have normal gait, and ability to walk on toes and heels without impairment with no loss of motion in the lower extremities. In a September 2020 VA thigh examination report, the examiner indicated that there was less movement than normal in the right hip secondary to pain and reduction in muscle strength (4/5 on right hip extension). Range of motion of the right hip was 110 degrees (flexion), 10 degrees (extension), 10 degrees (adduction), 20 degrees (abduction), 20 degrees (external rotation), and 30 degrees (internal rotation). Range of motion contributed to functional loss, with moderately increased time required to complete, as well as inability to perform frequently, certain occupational tasks such as climbing, stooping, kneeling, and crouching as well as decreased standing and ambulation potential secondary to pain. Range of motion of the right hip with functional loss due to pain was 100 degrees (flexion), 5 degrees (extension), 10 degrees (adduction), 15 degrees (abduction), 15 degrees (external rotation), and 20 degrees (internal rotation). The examiner concluded that the right thigh injury was severe in severity, primarily based upon the medical record evidence of retained fragments in that area. The examiner detailed that the right thigh revealed evidence of both atrophy and loss of the muscle substance of the right hip adductor and right medial hamstring musculature on examination, which in itself represented severe pathology not even considering the weakness (hip extension and adduction) on manual motor testing and medical record evidence of retained shrapnel. In September 2020 and December 2020 VA muscle injury examination reports, the examiner indicated the Veteran had a penetrating muscle injury to Group XIII and Group XV in the right thigh categorized as severe in nature. Positive findings included entrance and (if present) exit scars indicating track of missile through one or more muscle groups (September 2020 examiner) and ragged, depressed, and adherent scars indicating wide damage to muscle groups in missile track (December 2020 examiner). There were fascial defects including palpation showing loss of deep fascia and some loss of deep fascia. His muscle substance or function was affected with some impairment of muscle tonus, some loss of muscle substance, and visible measurable atrophy. Cardinal signs and symptoms of muscle disability in Muscle Group XIII and Muscle Group XV were consistent loss of power, consistent weakness, consistent lowered threshold of fatigue, and consistent fatigue-pain. There was muscle atrophy of right hip adductors and medial hamstring proximal thigh. In a December 2020 VA thigh examination report, the examiner indicated that there was no pain on hip movement and no reduction in muscle strength. Range of motion of the right hip was 125 degrees (flexion), 30 degrees (extension), 25 degrees (adduction), 45 degrees (abduction), 60 degrees (external rotation), and 40 degrees (internal rotation). Given the objective findings of a penetrating right thigh muscle injury to Muscle Group XIII and Muscle Group XV categorized as severe in nature with objective findings of consistent loss of power, consistent weakness, consistent lowered threshold of fatigue, consistent fatigue-pain, palpable loss of deep fascia, impairment of muscle tonus, loss of muscle substance, soft flabby muscles in the wound area, adaptive contraction of an opposing group of muscles, and visible measurable atrophy, the Board finds that Muscle Group XV is the most severely injured muscle group. The maximum 30 percent rating is currently assigned under Diagnostic Code 5315 for severe disability of Muscle Group XV. However, multiple VA examiners clearly outlined additional severe fragment wound residuals in Muscle Group XIII. Increased by one level and used as the combined evaluation for the affected muscle groups, a 40 percent rating, the maximum rating allowable, can be assigned as the combined rating for Muscle Groups XIII and XV under 38 C.F.R. § 4.55(e). In view of the foregoing, the Board concludes that a rating of 40 percent, the maximum rating allowable, for fragment wound residuals of the right upper thigh involving Muscle Groups XIII and XV with tissue loss and atrophy is warranted under 38 C.F.R. § 4.73, Diagnostic Codes 5313, 5315. The Veteran’s hip flexion was, at worse, to 90 degrees, and knee flexion was, at worse, to 90 degrees. The Board is cognizant that thigh extension was shown to be limited to 5 degrees by functional loss due to pain in an isolated instance in September 2020. However, additional findings dated both before and after September 2020 clearly showed that right thigh extension was not limited to 5 degrees. As overall evidence of record did not show limitation of range of motion to a compensable degree, a higher rating for any loss of range of motion is not warranted. Similarly, there is no evidence of ankylosis of the hip or knee, hip flail joint, or femur fracture. Accordingly, a higher rating under Diagnostic Codes 5250 to 5263 for orthopedic manifestations is not warranted. The Board has considered whether separate ratings are assignable under the rating criteria that relate to limitation of motion of the right hip and/or knee, to include Diagnostic Code 5003, which pertains to degenerative arthritis. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not “duplicative of or overlapping with the symptomatology” of the other condition. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. 38 C.F.R. § 4.14; Esteban, 6 Vet. App. at 261-62. In this case, the Board finds that the diagnostic codes in question overlap, as they all contemplate limitation of function, including motion, of the affected joints. Diagnostic Code 5003, specifically addresses painful limitation of motion of the hip and/or knee, while Diagnostic Codes 5313-5315 contemplate loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement in the muscle groups affecting the hip and knee. Accordingly, although the Board notes the X-ray evidence of degenerative changes of the right hip and knee, the Board finds that separate evaluations would constitute pyramiding (the Veteran would be compensated twice for the same symptoms). The Veteran has therefore been rated under the criteria that afford the higher schedular rating under Diagnostic Codes 5313-5315. 2. Entitlement to an evaluation in excess of 10 percent from March 13, 2006, and in excess of 20 percent from September 14, 2020, for shell fragment wounds of the right foot is denied. The Veteran is currently assigned a 10 percent evaluation from March 13, 2006, and 20 percent evaluation from September 14, 2020, for his service-connected shell fragment wounds of the right foot under Diagnostic Code 5310. He now seeks higher evaluations. Under Diagnostic Code 5310, injury of Muscle Group X, the Foot and Leg, governing movements of the forefoot and toes, and propulsion thrust in walking, as to the plantar muscles warrants the assignment of a 10 percent evaluation when moderate; a 20 percent evaluation when moderately severe; and a 30 percent evaluation when severe. 38 C.F.R. § 4.73, Diagnostic Code 5310. Based on evidence of record during the time period from March 13, 2006, to September 13, 2020 (including lay assertions from the Veteran, VA and private treatment records, and VA examination reports/medical opinions dated from 2006 to 2019), the Board has determined that the disability was not productive of more than moderate impairment. In an April 2006 VA examination report, there were no scars over the right foot. A May 2006 VA X-ray report revealed a few scattered pieces of shrapnel along the lateral aspects of the right midfoot as well as minimal degenerative changes of the ankle mortise. The Veteran complained of right foot and ankle pain as well as swelling, especially with exercising. He was noted to have a history of a shrapnel injury as well as to be status post excision of right foot neuroma. Private treatment records from 2007 detailed chronic right ankle pain and strain with full muscle strength in the lower extremities. In a December 2008 VA examination report, the examiner noted extensive right lower extremity retained foreign bodies with no significant tenderness to palpation of the right foot or ankle. There was no plantar skin abnormality and no significant toe malalignment. VA treatment notes dated in 2011 showed findings of a plantar cyst. Physical examination findings reflected palpable pedal pulses, pedal skin with good texture and turgor, grossly intact protective sensation, pain with palpation to the lateral and anterior-lateral as well as with dorsiflexion of right ankle, and full muscle strength in all planes. In April 2012 VA examination reports and a September 2013 VA addendum medical opinion, the Veteran was noted to have a muscle injury to Muscle Group X with full muscle strength in the right ankle. X-rays revealed right ankle degenerative or traumatic arthritis with multiple shrapnel fragments projecting over the lateral aspect of the right ankle and right lower leg. The examiner listed diagnoses of metatarsalgia and residual shrapnel from grenade blast, marking in the report that the Veteran had a moderately severe right foot injury (referencing rating criteria from Diagnostic Code 5284). X-rays revealed minimal DJD of first MTP joint with minimal narrowing as well as multiple small shrapnel fragments in the right foot and ankle. It was noted that residual shrapnel was embedded in multiple areas of the foot with some plantar and some dorsal components involved and that the scattering of the shrapnel most likely affected all of the muscles of the foot in some way. In an April 2017 VA addendum medical opinion, the examiner clarified that the Veteran’s Muscle Group X (muscles associated with the shrapnel injury to the foot with retained shrapnel) corresponds to a moderate level of severity in accordance with VA regulations. It was noted that the Veteran’s examination supported more than a penetrating wound to the foot with radiographic evidence of multiple small shrapnel fragments still remaining in the soft tissues. There was no objective evidence of cardinal signs and symptoms of Muscle Group X disability. The shrapnel pieces retained in the foot were noted to at least as likely as not contribute to non-specific pain in the muscles affected but were not likely to affect overall function since the overall function of the foot was intact. The examiner reiterated that Muscle Group X injury was of moderate severity, as the only cardinal sign regarding the muscles of the right foot was pain. There was also no objective involvement of Muscle Groups XI or XII. In a February 2018 VA addendum medical opinion, the examiner clarified that there were no physical findings on examination involving Muscle Group X other than sub-centimeter scars (reflecting entry/exit wounds that would be minimal and very small) and radiographic evidence of retained shrapnel. The examiner found that the Veteran’s symptomatology would be consistent with slight impairment. For Muscle Group X, specifically the right foot, there was no loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, or uncertainty of movement. The examiner indicated that plantar and dorsal muscles of the right foot were affected by radiographic evidence of the presence of the shrapnel. The plantar muscles were likely equally affected as the dorsal muscles without any objective evidence of loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, or uncertainty of movement in either of these muscle groups. Again, the examiner concluded that there was currently only slight functional impairment of the right foot muscle groups. During this time period, the Board finds that evidence overall reflects that residuals of shell fragment wounds of the right foot have manifested as no more than moderate disability. Muscle Group X disability was characterized by small penetrating entrance wounds due to missile fragments and shrapnel removal, radiologic evidence of retained fragments, and consistent pain, which approximates no more than the currently assigned 10 percent rating. The Board recognizes that the examiner in the April 2012 VA foot examination characterized the Veteran’s right foot injury (grenade explosion, fracturing ankle, and residual shrapnel) as moderately severe. Use of terminology such as moderately severe by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. Here, objective physical findings concerning the right foot more nearly approximates moderate disability of Muscle Group X under the rating criteria for muscle injuries. In fact, multiple VA examiners specified that there was no objective evidence of cardinal signs and symptoms of Muscle Group X disability other than complaints of pain. Based on evidence of record during the time period from September 14, 2020 (including lay assertions from the Veteran, VA treatment records, and VA examination reports dated in September 2020 and December 2020), the Board has determined that the disability was not productive of more than moderately severe impairment. In a September 2020 VA foot examination report, the examiner described the Veteran’s foot injury as moderate, noting that it did not compromise weight-bearing or require orthotics. Functional loss was listed as pain on weight-bearing, pain on nonweight-bearing, disturbance of locomotion, and interference with standing. During flare-ups and repetitive use, there was mild to moderately decreased standing and ambulation potential secondary to pain. The examiner concluded that the right foot injury was moderate in severity, primarily based upon the medical record evidence of retained fragments in that area. It was not unreasonable to believe that ambulation with retained shrapnel fragments represent a significant functional impairment and would necessitate a moderate designation. The examiner detailed that if there had been evidence of right foot intrinsic muscle atrophy/loss, recurrent surgical intervention, loss of toes due to the wound, fracture healed in mal-alignment or other significant shrapnel sequelae, then it would be more reasonable to consider that the injury was severe in nature. In a September 2020 VA muscle injury examination report, the examiner indicated the Veteran had a penetrating muscle injury to Group X in the right foot categorized as moderate in nature. Positive findings included entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Cardinal signs and symptoms of muscle disability in Group X were consistent lowered threshold of fatigue and consistent fatigue-pain. In a December 2020 VA foot examination report, the examiner noted the Veteran’s foot injury did not compromise weight-bearing or require orthotics. During this time period, the Board finds that evidence overall reflects that residuals of shell fragment wounds of the right foot have manifested as a moderately severe disability. Muscle Group X disability was characterized by small penetrating entrance wounds due to missile fragments and shrapnel removal with retained fragments, consistent lowered threshold of fatigue, and consistent fatigue-pain, which approximates the currently assigned 20 percent rating. Additional findings reflective of a severe muscle injury, such as atrophy or palpable loss of deep fascia or muscle substance, have not been shown. A higher rating under Diagnostic Codes 5276 to 5284 for orthopedic manifestations is not warranted. Additional right foot findings of plantar cyst and neuroma during the appeal period were also not shown to be related to the Veteran’s service-connected fragment wound residuals. Although the Board notes the X-ray evidence of degenerative changes of the right foot, the Board finds that a separate evaluation based on degenerative arthritis would constitute pyramiding (the Veteran would be compensated twice for the same right foot symptoms). The Veteran has been rated under the muscle injury criteria that afford higher schedular ratings under Diagnostic Code 5310. Additional Considerations The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has impairment associated with any other muscle groups. The Veteran has also been assigned separate evaluations for right lower extremity scar residuals. He has not challenged those ratings and evidence of record, including VA scar examinations dated in April 2012, May 2019, September 2020, and December 2020, does not indicate that the assignment of any increased evaluation is warranted. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. The Board acknowledges that the Veteran is competent to report observable symptoms such as pain and numbness. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). He is not, however, competent to identify a specific level of disability. Competent evidence concerning the nature and extent of the Veteran’s service-connected right thigh and right foot disabilities has been provided by VA medical professionals who have examined him. The medical findings adequately address the criteria under which the disabilities are evaluated and clearly demonstrate the degree of impairment attributable to each service-connected disability. The Board accords these findings greater weight than the Veteran’s complaints as to right thigh and right foot symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Accordingly, the Veteran’s contention that he is entitled to increased evaluations for his right thigh and right foot disabilities is outweighed by the objective medical findings of record. That is, the Board assigns greater probative value to the pertinent objective findings in the VA examination reports than to the Veteran’s general belief that he is entitled to higher ratings. In this case, evidence of record showed no distinct periods of time during the appeal period when the Veteran’s service-connected fragment wound residuals of the right upper thigh with loss of tissue and atrophy varied to such an extent that a rating greater or less than the 40 percent rating currently assigned would be warranted. Evidence of record also showed no distinct periods of time during the appeal period when the Veteran’s service-connected shell fragment wounds of the right foot varied to such an extent that ratings greater or less than the 10 percent and 20 percent ratings currently assigned would be warranted. Hart v. Mansfield, 21 Vet. App. 505 (2007). In sum, the Board concludes that the symptomatology noted in the medical and lay evidence has been adequately addressed by the current ratings and that the Veteran’s service-connected fragment wound residuals of the right upper thigh with loss of tissue and atrophy do not meet the applicable criteria for an evaluation in excess of the 40 percent rating now assigned. The Veteran’s service-connected shell fragment wounds of the right foot do not meet the applicable criteria for evaluations in excess of the 10 percent and 20 percent ratings assigned. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s increased rating claims, the doctrine is not for application. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 4.3, 4.7 (2020); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. D. Deane, 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.