Citation Nr: 21030630 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 07-06 642A DATE: May 19, 2021 ORDER A compensable disability rating prior to December 18, 2020, and a disability rating greater than 10 percent thereafter, for shell fragment wound (SFW) with residual scar of the left ankle is denied. A compensable disability rating for SFW with residual scar of the left knee is denied. A compensable disability rating prior to September 25, 2019, and a disability rating greater than 10 percent thereafter, for SFW with retained foreign body of the left buttock is denied. A compensable disability rating prior to December 18, 2020, and a disability rating greater than 10 percent thereafter, for SFW with retained foreign body of the left hip is denied. A compensable disability rating prior to September 25, 2019, and a disability rating greater than 10 percent thereafter, for SFW with retained foreign body of the back is denied. A compensable disability rating for abdominal laparotomy scar is denied. An initial compensable disability rating for right clavicle scar is denied. A total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to November 10, 2008, to include on an extraschedular basis is denied. FINDINGS OF FACT 1. Prior to December 18, 2020, the Veteran's SFW with residual scar of the left ankle was manifested by a 4.5 centimeter (cm) linear tannish scar at the insertion of the Achilles tendon with very slight amount of tissue loss. It was not deep, unstable, or painful; did not lose its covering repeatedly; did not cover an area of 144 square inches or greater; nor did it adversely affect any function. 2. Beginning December 18, 2020, the Veteran's SFW with residual scar of the left ankle has been manifested by complaints of a dull, aching pain and tenderness to palpation. 3. For the entire appeal period, the Veteran's SFW with residual scar of the left knee has been manifested by a scar no larger than 3 x 2 cm which is not deep, unstable, or painful; does not lose its covering repeatedly; does not cover an area of 144 square inches or greater; nor does it adversely affect any function. 4. Prior to September 25, 2019, the Veteran's SFW with retained foreign body of the left buttock was manifested by two separate scars no larger than 4.5 x 1.5 cm each. These scars were not deep, unstable, or painful; did not lose its covering repeatedly; did not cover an area of 144 square inches or greater; nor did it adversely affect any function. 5. Beginning September 25, 2019, the Veteran's SFW with retained foreign body of the left buttock has been manifested by lowered threshold of fatigue as well as fatigue-pain. 6. Prior to December 18, 2020, the Veteran's SFW with retained foreign body of the left hip was manifested by two separate scars no larger than 5.5 x 3.5 cm each. These scars were not deep, unstable, or painful; did not lose its covering repeatedly; did not cover an area of 144 square inches or greater; nor did it adversely affect any function. 7. Beginning December 18, 2020, the Veteran's SFW with retained foreign body of the left hip has been manifested by complaints of a dull, aching pain and tenderness to palpation. 8. Prior to September 25, 2019, the Veteran's SFW with retained foreign body of the back was manifested by approximately four separate scars no larger than 6 x 1.5 cm. These scars were not deep, unstable, or painful; did not lose its covering repeatedly; did not cover an area of 144 square inches or greater; nor did it adversely affect any function. 9. Beginning September 25, 2019, the Veteran's SFW with retained foreign body of the back has been manifested by lowered threshold of fatigue as well as fatigue-pain. 10. For the entire appeal period, the Veteran's abdominal laparotomy scar has been manifested by five separate scars, the first four being no longer than 1 cm in length and the second measuring no more than 20 x 0.35 cm. These scars are not deep, unstable, or painful; do not lose their covering repeatedly; did not cover an area of 144 square inches or greater; nor did they adversely affect any function. 11. Since the grant of service connection, the Veteran's right clavicle scar has been manifested by two separate scars, each measuring no more than 4 x 0.25 cm. These scars are not deep, unstable, or painful; do not lose their covering repeatedly; did not cover an area of 144 square inches or greater; nor did they adversely affect any function. 12. Prior to November 10, 2008, the Veteran did not meet the minimum percentage requirements for consideration of a schedular TDIU rating as set forth under 38 C.F.R. § 4.16(a). 13. Prior to November 10, 2008, the evidence of record did not show that the Veteran's service-connected disabilities precluded him from securing and following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a compensable disability rating for SFW with residual scar of the left ankle prior to December 18, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Codes (DCs) 7804-7805 (prior to October 23, 2008). 2. The criteria for a disability rating greater than 10 percent for SFW with residual scar of the left ankle beginning December 18, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DCs 7805-7805 (prior to October 23, 2008). 3. The criteria for a compensable disability rating for SFW with residual scar of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DCs 7804-7805 (prior to October 23, 2008). 4. The criteria for a compensable disability rating for SFW with retained foreign body of the left buttock prior to September 25, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DCs 7804-7805 (prior to October 23, 2008). 5. The criteria for a disability rating greater than 10 percent for SFW with retained foreign body of the left buttock beginning September 25, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DCs 7805-7805 (prior to October 23, 2008). 6. The criteria for a compensable disability rating for SFW with retained foreign body of the left hip prior to December 18, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DCs 7804-7805 (prior to October 23, 2008). 7. The criteria for a disability rating greater than 10 percent for SFW with retained foreign body of the left hip beginning December 18, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DCs 7805-7805 (prior to October 23, 2008). 8. The criteria for a compensable disability rating for SFW with retained foreign body of the back prior to September 25, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DCs 7804-7805 (prior to October 23, 2008). 9. The criteria for a disability rating greater than 10 percent for SFW with retained foreign body of the back, beginning September 25, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DCs 7805-7805 (prior to October 23, 2008). 10. For the entire appeal period, the criteria for a compensable disability rating for abdominal laparotomy scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DC 7805 (prior to October 23, 2008). 11. Since the grant of service connection, the criteria for a compensable disability rating for right clavicle scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, DC 7805 (prior to October 23, 2008). 12. Prior to November 10, 2008, the criteria for a TDIU rating, to include on an extra-schedular basis, were not met. 38 U.S.C.§ 1155; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1963 to September 1968, February to October 1969, August 1972 to August 1975, January to April 1977, and from May to July 1981, to include combat service in the Republic of Vietnam. He also had additional periods of unverified active service in the Reserves and National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2006 and June 2007 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. Specifically, the January 2006 rating decision, in pertinent part, continued a combined 10 percent disability rating for SFWs, multiple sites, with retained foreign bodes on left ankle and left knee and denied service connection for retained foreign bodies of the left hip and left buttocks. The June 2007 rating decision, in pertinent part, granted service connection for a right clavicle scar, assigning a noncompensable disability rating effective March 14, 2006, and continued a noncompensable disability rating for abdominal laparotomy scar. The Veteran testified at a Board videoconference in January 2008 before a Veterans Law Judge who is no longer at the Board and a copy of the hearing transcript has been added to the record. In March 2009, the Board remanded the above claims for additional development. Subsequently, in a December 2012 rating decision, the agency of original jurisdiction (AOJ) recharacterized the Veteran's service connection claims for retained foreign bodies of the left hip and left buttocks as increased rating claims for SFWs with retained foreign bodies in the left hip and left buttocks. The AOJ noted that, historically, a July 1979 rating decision had assigned a noncompensable disability rating for SFWs in the left ankle, left knee, left buttock, left hip, and back. The AOJ also noted that, historically, a September 1991 rating decision had combined all of the Veteran's service-connected SFWs in multiple areas into a single disability and assigned a 10 percent rating for retained foreign bodies in the soft tissue of the left ankle, knee, and back. The AOJ concluded that the September 1991 rating decision was not the most beneficial way to compensate the Veteran for his service-connected SFWs in multiple anatomical regions. Accordingly, the AOJ concluded in the December 2012 rating decision that the Veteran was entitled to consideration of increased (compensable) ratings for SFW with residual scar of the left ankle, SFW with residual scar of the left knee, SFW with retained foreign body of the left buttock, SFW with retained foreign body of the left hip, and for SFW with retained foreign body of the back and denied each of these claims. The Veteran testified at another Board videoconference in December 2013 before the undersigned Veterans Law Judge and a copy of the hearing transcript also has been added to the record. In April 2014, the Board again remanded the case to the AOJ for additional development. Also, in an April 2014 rating decision, the AOJ concluded that the Veteran was incompetent to handle disbursement of VA funds and a fiduciary needed to be appointed for him. It appears that his wife subsequently was appointed his fiduciary for purposes of disbursing VA disability compensation benefits. This case was most recently before the Board in July 2017 at which time the Board again remanded the case to the AOJ for additional development. The Board also noted that, the Veteran was in receipt of a TDIU from November 10, 2008, to August 19, 2011, and was also in receipt of a 100 percent scheduler rating effective August 19, 2011, for his service-connected posttraumatic stress disorder (PTSD). As such, the Board found that the issue of entitlement to a TDIU after November 10, 2008, is moot and characterized the TDIU claim as stated on the title page. General Legal Criteria Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a "staged" rating are required. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. The Court since has extended this practice even to established ratings, not just initial ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Analysis The Veteran seeks a higher disability rating for his service-connected scars, both prior to and beginning December 18, 2020. By way of history, service treatment records show that the Veteran sustained SFWs to his body resulting in scars of the left ankle, left knee, left hip, left lateral chest wall, left buttocks, left sacral area, and left lumbar area in January 1968. X-rays confirmed evidence of metallic bodies in the back and left leg. Service treatment records also show that the Veteran had an exploratory laparotomy performed at that time and was hospitalized from January to June 1968 in order to recover from his surgery. As above, by rating decision dated in July 1979, the AOJ granted service connection for SFWs in the left ankle, left knee, left buttock, left hip, and back, assigning a noncompensable disability rating effective February 9, 1978. The AOJ also granted service connection for a laparotomy scar, assigning a noncompensable disability rating effective February 9, 1978. Subsequently, by rating decision dated in September 1991, the AOJ combined all of the Veteran's service-connected SFWs in multiple areas into a single disability and assigned a 10 percent rating for retained foreign bodies in the soft tissue of the left ankle, knee, and back. In May 2005, the Veteran submitted a formal claim for a TDIU and, in connection with this claim, by rating decision dated in January 2006, the AOJ continued a combined 10 percent disability rating for SFWs, multiple sites, with retained foreign bodes on left ankle and left knee and denied service connection for retained foreign bodies of the left hip and left buttocks. Subsequently, by rating decision dated in June 2007, the AOJ, in pertinent part, granted service connection for a right clavicle scar, assigning a noncompensable disability rating effective March 14, 2006, and continued a noncompensable disability rating for abdominal laparotomy scar. The Veteran disagreed with this decision and perfected this appeal. The Veteran disagreed with this decision and perfected this appeal. As above, by rating decision dated in December 2012, the AOJ concluded that the September 1991 rating decision was not the most appropriate way to compensate the Veteran for his service-connected SFWs in multiple anatomical regions. Accordingly, the AOJ concluded in the December 2012 rating decision that the Veteran was entitled to consideration of increased (compensable) ratings for SFW with residual scar of the left ankle, SFW with residual scar of the left knee, SFW with retained foreign body of the left buttock, SFW with retained foreign body of the left hip, and for SFW with retained foreign body of the back and denied each of these claims. The diagnostic criteria for disorders of the skin are found at 38 C.F.R. § 4.118, DCs 7801-7805. The Board notes that on September 23, 2008, VA amended the criteria for evaluating scars. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). The amendments are only effective, however, for claims filed on or after October 23, 2008, although a claimant may request consideration under the amended criteria. In this case, the Veteran submitted his claim in 2005/2006 and has not requested such consideration. Therefore, the Board will only consider the claim under the old criteria. Prior to September 23, 2008, DC 7801 provided ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. Scars that are deep or that cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Note (1) to DC 7802 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7802 provided ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. Note (1) to DC 7802 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7803 provided a 10 percent rating for superficial unstable scars. Note (1) to DC 7803 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. DC 7804 provided a 10 percent rating for superficial scars that are painful on examination. Note (1) to DC 7804 provides that a superficial scar is one not associated with underlying soft tissue damage. Note (2) provides that a 10 percent rating will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable rating. 38 C.F.R. § 4.118. DC 7804 also directs the rater to see 38 C.F.R. § 4.68 (amputation rule). 38 C.F.R. § 4.118. DC 7805 provided that other scars are to be rated on limitation of function of affected part. 38 C.F.R. § 4.118. Evidence relevant to the current level of severity of the Veteran's service-connected scars includes VA examination reports dated in July 2005, April 2007, August 2011, September 2019, and December 2020. During the July 2005 VA general examination, the Veteran reported occasional soreness of his left ankle and daily intermittent pain of the left knee but it appears that these complaints were related, primarily, to the Veteran's separately service connected left ankle/knee joint disabilities. The Veteran denied any problems with his laparotomy scar. X-ray examination in December 2004 revealed retained soft tissue SFWs of the left knee and left ankle. The impression, in pertinent part, was sarcoidosis with mild restrictive disease and left knee/ankle degenerative changes with retained shrapnel. Significantly, the examiner noted that there was no problem with the Veteran's laparotomy scarring. During the April 2007 VA scars examination, the examiner noted the following scars: Location Description Findings Back - proximal lumbosacral spine area 6 centimeter (cm) brown colored linear scar; depressed approximately 1 cm no ulceration, keloid formation, adherence to underlying tissue, restriction of range of motion related to the scar. warmth, redness, tenderness on palpation Back - left of the lumbar midline 3.5 x 1 cm oval brown colored scar; slightly rough in texture but no depression or loss of underlying tissue no warmth, swelling, or tenderness on palpation Back further off the midline and inferiorly reddish, brown patch of discoloration of the skin; appeared to be a patch of discoloration of skin but with no other changes no loss of tissue, changes to skin texture, tenderness on palpation, warmth, swelling, redness, loss of range of motion, restriction of major motion, and/or loss of underlying tissue Back - left lateral chest wall 2.5 x 1.5 oval scar; brown in color, slightly raised, and rough in texture no adherence to underlying tissue, loss of underlying tissue, and/or restriction of range of motion related to this scar Left Buttock - superior fold of the left gluteal muscle linear keloid formation with no ulceration no ulceration, adherence to underlying tissue, loss of underlying tissue, swelling, redness, warmth on palpation, tenderness on palpation, and/or other changes Left Buttock - lateral buttock area 4.5 x 1.5 cm brownish oval scar; very slight depression no adherence to underlying tissue, restriction of range of motion related to this scar, keloid formation, warmth, tenderness, and/or swelling noted on palpation of the scar Left hip lateral hip area 5.5 x 3.5 cm oval brownish scar with very slight depression no warmth, swelling, tenderness on palpation, adherence to underlying tissue, restriction of range of motion related to this scar Left hip left lateral thigh 3 x 2 cm oval brown scar no tissue loss, swelling, warmth, tenderness on palpation, adherence to underlying tissue, loss of range of motion related to this scar Left ankle left lateral heel area 4.5 cm linear tannish scar at the insertion of the Achilles tendon very slight amount of tissue loss but no redness, swelling, tenderness/warmth on palpation, restriction of range of motion, and/or adherence to underlying tissue Right clavicle superior aspect of the manubrium from biopsy of the mediastinum 4 cm tannish linear well-healed surgical scar which is slightly raised no adherence to underlying tissue, loss of underlying tissue, ulcerations, significant keloid formation, and/or other changes Right clavicle base of the right sternocleidomastoid muscle at the right base of the neck 4 cm whitish linear surgical scar from further biopsy of a lymph node in this area; flat and smooth no loss of underlying tissue, adherence to underlying tissue, ulcerations, and/or restriction of movement related to the scar Abdomen four scars of the abdomen each measuring 1 cm in length; flat (from the clamps used to perform laparoscopic surgery no loss of underlying tissue, adherence to underlying tissue, restriction of movement, keloid formation, ulceration, and/or other changes Abdomen mid upper abdomen down the midline around the umbilicus, extending inferiorly to the pubic symphysis 22 cm brown, colored linear well-healed surgical scar no loss of underlying tissue, adherence to underlying tissue, restriction of movement, ulceration, keloid formation, and/or other changes Significantly, it was noted that December 2004 VA X-rays showed retained soft tissue shrapnel fragments projecting posteriorly and laterally at the level of the distal femur, within the left Achilles tendon and laterally at the level of the left talus/left subtalar joints, and soft tissue of the left mid thoracic back. The impression was residual scarring, as described above, with retained metal fragments. During the August 2011 VA scars examination, the examiner noted the following scars: Location Description Findings Left hip 1 cm linear scar and 4.5 x 2.5 cm superficial non-linear scar no complaints of breakdown, secondary infections, pain, and/or tenderness Left knee 2 x 2 cm superficial non-linear no complaints of breakdown, secondary infections, pain, and/or tenderness Abdominal laparoscopy 19 x 0.25 superficial non-linear scar no complaints of breakdown, secondary infections, pain, and/or tenderness Right clavicle 1 cm linear scar no complaints of breakdown, secondary infections, pain, and/or tenderness Superior to Sternal Notch (center of chest) 4 cm linear scar no complaints of breakdown, secondary infections, pain, and/or tenderness Left buttock x 2 4 cm and 3 cm linear scars no complaints of breakdown, secondary infections, pain, and/or tenderness Thoracic scars x 2 5 cm and 3 cm linear scars no complaints of breakdown, secondary infections, pain, and/or tenderness Significantly, the August 2011 VA skin examiner indicated that none of the Veteran's scars were painful. In total, the Veteran had superficial non-linear scars of the left lower extremity with an approximate total area of 7.5 cm squared, anterior trunk with an approximate total area of 20 cm squared, and the posterior trunk with an approximate total area of 15 cm squared. During a September 2019 VA muscles examination, the examiner diagnosed mid-line lumbar spine SFW with underlying muscle damage, left lumbar SFW with underlying muscle damage, and SFW, residual scar and retained foreign body of the buttock with underlying muscle damage. These injuries affected Muscle Groups XIII and XX and resulted in ragged, depressed, and adherent scars indicating wide damage to muscle groups in missile track. Significantly, the flexion of the left hip was slightly weakened due to muscle injury to the left buttock. These muscle injuries resulted in consistent lowered threshold of fatigue as well as fatigue-pain. Muscle strength testing was normal with the exception of the left hip, which was described as "less than normal strength." There was no muscle atrophy. The examiner noted that there was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. There were no other pertinent physical findings. With regard to functional impact, the examiner wrote that the Veteran's muscle injuries impacted his ability to work due to an inability to keep up with work requirements, specifically the Veteran was unable to complete work related tasks requiring frequent high stepping due to Group XIII and Group XX muscle fatigue/weakness. During a December 2020 VA scars examination, the Veteran reiterated his history of in-service SFWs and complained of stiffness causing difficulty with bending, lifting, standing, walking, or sitting for too long of a time. He treated the pain with medication. Significantly, it was noted that two of his scars are painful (the left hip and the left ankle scars) but that none of his scars were unstable with frequent loss of covering of skin. The examiner noted the following scars: Location Description Findings Left pelvis (hip) 5 x 2 cm Dull aching pain, tender to palpation Left knee/thigh 3 x 1.8 cm Back midline and left paraspinal 5.5 x 0.35 cm, 3 x 1 cm, and 1 x 0.2 cm Left ankle 2.5 x 0.2 cm Dull aching pain, tender to palpation Right clavicle, right scalene node biopsy scar right upper chest and mediastinoscopy scar chest wall anteriorly 2.5 x 0.25 cm and 4 x 0.25 cm Laparotomy 20 x 0.35 cm Buttock x 2 3 x 0.25 cm and 5 x 2 cm In total, the Veteran had scars without underlying tissue damage of the left lower extremity with an approximate total area of 15.9 cm squared, anterior trunk with an approximate total area of 8.5 cm squared, and the posterior trunk with an approximate total area of 15.825 cm squared. None of the Veteran's cars resulted in limitation of function (to include limitation of motion) of the affected area. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms associated with the scars and the examiner found that the Veteran's scars did not impact his ability to work. Also of record are VA and private treatment records dated through September 2020 which pertain, primarily, to disabilities other than the Veteran's scars. 1. A compensable disability rating prior to December 18, 2020 and a disability rating greater than 10 percent thereafter for SFW with residual scar of the left ankle is denied. As above, the Veteran is currently in receipt of service connection for a scar of the left ankle since June 25, 2005, but is not in receipt of a compensable disability rating for his left ankle scar until December 18, 2020, the date of the most recent VA scar examination showing a painful left ankle scar. As such, there are two periods of time at issue here: prior to December 18, 2020, while the Veteran's left ankle scar was rated as noncompensable; and from December 18, 2020 to the present while the Veteran's left ankle scar has been rated as 10 percent disabling. The Board will consider the proper rating to be assigned for both periods. See Hart, 21 Vet. App. at 505. As for the period prior to December 18, 2020, the Board finds that a compensable disability rating is not warranted. Significantly, the Veteran denied any problems with his scars during the July 2005 VA general examination and the April 2007 VA scar examination report shows that the Veteran's left ankle scar was manifested by a 4.5 centimeter (cm) linear tannish scar at the insertion of the Achilles tendon with very slight amount of tissue loss but no pain, redness, swelling, tenderness/warmth on palpation, restriction of range of motion, and/or adherence to underlying tissue. An increased disability rating under DCs 7801 or 7802 is not warranted as the Veteran's left ankle scar did not exceed 77 square centimeters. An increased evaluation is also not warranted under DC 7803 as the Veteran's left ankle scar was not shown to be unstable. Similarly, an increased evaluation is not warranted under DC 7804 as there was no evidence that the Veteran's left ankle scar was superficial or painful. Finally, as to DC 7805, the Board notes that there was no evidence of limitation of function of the left ankle due to the scar, rather any limitation of function can be attributed to the Veteran's separately service-connected left ankle disorder. Thus, the Veteran is not entitled to a compensable disability rating for his left ankle scar prior to December 18, 2020. As for the period beginning December 18, 2020, the Board finds that a disability rating greater than 10 percent is not warranted as the record does not show that the Veteran's left ankle scar is deep and nonlinear for an area of at least 6 square inches or superficial and 144 square inches, or that the scar is both painful and unstable, meaning that there is frequent loss of covering of skin over it. 38 C.F.R. § 4.118, DC 7801, 7804. Moreover, there is no evidence that the Veteran's left ankle scar causes any other impairment. See 38 C.F.R. § 4.118, DC 7805. 2. A compensable disability rating for SFW with residual scar of the left knee is denied. Upon review of the above evidence, the Board finds that a compensable disability rating is not warranted for the Veteran's left knee scar. Significantly, the Veteran denied any problems with his scars during the July 2005 VA general examination. The April 2007 VA scar examination report shows that the Veteran's left knee scar was manifested by 3 x 2 cm oval brown scar with no tissue loss, swelling, warmth, tenderness on palpation, adherence to underlying tissue, loss of range of motion related to this scar. The August 2011 VA scar examination report shows that the Veteran's left knee scar was manifested by a 2 x 2 cm superficial non-linear scar no complaints of breakdown, secondary infections, pain, and/or tenderness. The September 2019 VA muscle examination report pertains only to the left buttock and back. And the December 2020 VA scar examination report shows that the Veteran's left knee scar was manifested by a 3 x 1.8 cm scar which was neither painful nor unstable with frequent loss of covering of skin. An increased disability rating under DCs 7801 or 7802 is not warranted as the Veteran's left knee scar does not exceed 77 square centimeters. An increased evaluation is also not warranted under DC 7803 as the Veteran's left knee scar is not shown to be unstable. Similarly, an increased evaluation is not warranted under DC 7804 as there was no evidence that the Veteran's left knee scar is superficial or painful. Finally, as to DC 7805, the Board notes that there is no evidence of limitation of function of the left knee due to the scar, rather any limitation of function can be attributed to the Veteran's separately service-connected left knee disorder. Thus, the Veteran is not entitled to a compensable disability rating for his left knee scar. 3. A compensable disability rating prior to September 25, 2019 and a disability rating greater than 10 percent thereafter for SFW with retained foreign body of the left buttock is denied. As above, the Veteran is currently in receipt of service connection for a scar of the left buttock since June 25, 2005 but is not in receipt of a compensable disability rating for his left buttock scar until September 25, 2019, the date of a VA muscle examination showing lowered threshold of fatigue as well as fatigue-pain. As such, there are two periods of time at issue here: prior to September 25, 2019, while the Veteran's left buttock scar was rated as noncompensable; and from September 25, 2019 to the present while the Veteran's left buttock scar has been rated as 10 percent disabling. The Board will consider the proper rating to be assigned for both periods. See Hart, 21 Vet. App. at 505. As for the period prior to September 25, 2019, the Board finds that a compensable disability rating is not warranted. Significantly, the Veteran denied any problems with his scars during the July 2005 VA general examination. The April 2007 VA scar examination report shows that the Veteran's left buttock scar was actually two scars, the first at the superior fold of the left gluteal muscle manifested by linear keloid formation and the second, a 4.5 x 1.5 cm brownish oval scar; very slight depression. Neither of these scars were manifested by ulceration, adherence to underlying tissue, loss of underlying tissue, restriction of range of motion related to the scars, keloid formation, swelling, redness, warmth, and/or tenderness on palpation, and/or other changes. The August 2011 VA scar examination report shows that the Veteran's left buttock scar was manifested by two 4 cm and 3 cm linear scars with no complaints of breakdown, secondary infections, pain, and/or tenderness. Considering the evidence of record, particularly the July 2005, April 2007, and August 2011 VA examination reports, an increased disability rating under DCs 7801 or 7802 is not warranted as the Veteran's left buttock scar did not exceed 77 square centimeters. An increased evaluation is also not warranted under DC 7803 as the Veteran's left buttock scar was not shown to be unstable. Similarly, an increased evaluation is not warranted under DC 7804 as there was no evidence that the Veteran's left buttock scar was superficial or painful. Finally, as to DC 7805, the Board notes that there was no evidence of limitation of function of the left buttock due to the scar, rather any limitation of function can be attributed to the Veteran's separately service-connected left hip disorder. Thus, the Veteran is not entitled to a compensable disability rating for his left buttock scar prior to September 25, 2019. As for the period beginning September 25, 2019, the Board finds that a disability rating greater than 10 percent is not warranted as the record does not show that the Veteran's left buttock scar is deep and nonlinear for an area of at least 6 square inches or superficial and 144 square inches, or that the scar is both painful and unstable, meaning that there is frequent loss of covering of skin over it. 38 C.F.R. § 4.118, DC 7801, 7804. Moreover, there is no evidence that the Veteran's left buttock scar causes any other impairment. See 38 C.F.R. § 4.118, DC 7805. 4. A compensable disability rating prior to December 18, 2020 and a disability rating greater than 10 percent thereafter for SFW with retained foreign body of the left hip is denied. As above, the Veteran is currently in receipt of service connection for a scar of the left hip since June 25, 2005 but is not in receipt of a compensable disability rating for his left hip scar until December 18, 2020, the date of the most recent VA scar examination showing a painful left hip scar. As such, there are two periods of time at issue here: prior to December 18, 2020, while the Veteran's left hip scar was rated as noncompensable; and from December 18, 2020 to the present while the Veteran's left hip scar has been rated as 10 percent disabling. The Board will consider the proper rating to be assigned for both periods. See Hart, 21 Vet. App. at 505. As for the period prior to December 18, 2020, the Board finds that a compensable disability rating is not warranted. Significantly, the Veteran denied any problems with his scars during the July 2005 VA general examination and the April 2007 VA scar examination report shows that the Veteran's left hip scar was manifested by a 5.5 x 3.5 cm oval brownish scar with very slight depression with no warmth, swelling, tenderness on palpation, adherence to underlying tissue, restriction of range of motion related to this scar. The August 2011 VA scar examination report shows that the Veteran's left hip scar was manifested by two separate scars, a 1 cm linear scar and a 4.5 x 2.5 cm superficial non-linear scar with no complaints of breakdown, secondary infections, pain, and/or tenderness. Considering the evidence of record, particularly the July 2005, April 2007, and August 2011 VA examination reports, an increased disability rating under DCs 7801 or 7802 is not warranted as the Veteran's left hip scar did not exceed 77 square centimeters. An increased evaluation is also not warranted under DC 7803 as the Veteran's left hip scar was not shown to be unstable. Similarly, an increased evaluation is not warranted under DC 7804 as there was no evidence that the Veteran's left hip scar was superficial or painful. Finally, as to DC 7805, the Board notes that there was no evidence of limitation of function of the left hip due to the scar, rather any limitation of function can be attributed to the Veteran's separately service-connected left hip disorder. Thus, the Veteran is not entitled to a compensable disability rating for his left hip scar prior to December 18, 2020. As for the period beginning December 18, 2020, the Board finds that a disability rating greater than 10 percent is not warranted as the record does not show that the Veteran's left hip scar is deep and nonlinear for an area of at least 6 square inches or superficial and 144 square inches, or that the scar is both painful and unstable, meaning that there is frequent loss of covering of skin over it. 38 C.F.R. § 4.118, DC 7801, 7804. Moreover, there is no evidence that the Veteran's left hip scar causes any other impairment. See 38 C.F.R. § 4.118, DC 7805. 5. A compensable disability rating prior to September 25, 2019 and a disability rating greater than 10 percent thereafter for SFW with retained foreign body of the back is denied. As above, the Veteran is currently in receipt of service connection for a scar of the back since June 25, 2005 but is not in receipt of a compensable disability rating for his back scar until September 25, 2019, the date of a VA muscle examination showing lowered threshold of fatigue as well as fatigue-pain. As such, there are two periods of time at issue here: prior to September 25, 2019, while the Veteran's back scar was rated as noncompensable; and from September 25, 2019 to the present while the Veteran's back scar has been rated as 10 percent disabling. The Board will consider the proper rating to be assigned for both periods. See Hart, 21 Vet. App. at 505. As for the period prior to September 25, 2019, the Board finds that a compensable disability rating is not warranted. Significantly, the Veteran denied any problems with his scars during the July 2005 VA general examination. The April 2007 VA scar examination report shows that the Veteran's back scar was actually four separate scars: (1) proximal lumbosacral spine area measuring 6 cm, brown in color, linear, and depressed approximately 1 cm, (2) left of the lumbar midline measuring 3.5 x 1 cm, oval shaped, brown in color, and slightly rough in texture, (3) further off the midline and inferiorly, reddish/brown patch of discoloration of the skin, and (4) left lateral chest wall measuring 2.5 x 1.5 cm, oval shaped, brown in color, slightly raised, and rough in texture. These scars did not demonstrate ulceration, keloid formation, adherence to underlying tissue, loss of tissue, changes to skin texture, tenderness on palpation, warmth, swelling, redness, loss of range of motion, and/or restriction of major motion. The August 2011 VA scar examination report shows that the Veteran's back scars were manifested by two 5 cm and 3 cm linear scars with no complaints of breakdown, secondary infections, pain, and/or tenderness. Considering the evidence of record, particularly the July 2005, April 2007, and August 2011 VA examination reports, an increased disability rating under DCs 7801 or 7802 is not warranted as the Veteran's back scars did not exceed 77 square centimeters. An increased evaluation is also not warranted under DC 7803 as the Veteran's back scars were not shown to be unstable. Similarly, an increased evaluation is not warranted under DC 7804 as there was no evidence that the Veteran's back scars were superficial or painful. Finally, as to DC 7805, the Board notes that there was no evidence of limitation of function of the back due to the scar, rather any limitation of function can be attributed to the Veteran's separately service-connected back disorder. Thus, the Veteran is not entitled to a compensable disability rating for his back scar prior to September 25, 2019. As for the period beginning September 25, 2019, the Board finds that a disability rating greater than 10 percent is not warranted as the record does not show that the Veteran's back scars are deep and nonlinear for an area of at least 6 square inches or superficial and 144 square inches, or that the scar is both painful and unstable, meaning that there is frequent loss of covering of skin over it. 38 C.F.R. § 4.118, DC 7801, 7804. Moreover, there is no evidence that the Veteran's back scars cause any other impairment. See 38 C.F.R. § 4.118, DC 7805. 6. A compensable disability rating for abdominal laparotomy scar is denied. Upon review of the above evidence, the Board finds that a compensable disability rating is not warranted for the Veteran's abdominal laparotomy scar. Significantly, the Veteran denied any problems with his scars during the July 2005 VA general examination. The April 2007 VA scar examination report shows that the Veteran's abdominal laparotomy scar was manifested by five different scars of the abdomen, the first four each measuring 1 cm in length; flat (from the clamps used to perform laparoscopic surgery) and the fifth measuring 22 cm, brown in color, linear, and well-healed. None of these scars resulted in loss of underlying tissue, adherence to underlying tissue, restriction of movement, ulceration, keloid formation, and/or other changes. The August 2011 VA scar examination report shows that the Veteran's abdominal laparotomy scar was manifested by a 19 x 0.25 superficial non-linear scar with no complaints of breakdown, secondary infections, pain, and/or tenderness. The September 2019 VA muscle examination report pertains only to the left buttock and back. And the December 2020 VA scar examination report shows that the Veteran's abdominal laparotomy scar was manifested by a 20 x 0.35 cm scar which was neither painful nor unstable with frequent loss of covering of skin. An increased disability rating under DCs 7801 or 7802 is not warranted as the Veteran's abdominal laparotomy scar does not exceed 77 square centimeters. An increased evaluation is also not warranted under DC 7803 as the Veteran's abdominal laparotomy scar is not shown to be unstable. Similarly, an increased evaluation is not warranted under DC 7804 as there was no evidence that the Veteran's abdominal laparotomy scar is superficial or painful. Finally, as to DC 7805, the Board notes that there is no evidence of limitation of function of the abdomen due to the scar, rather any limitation of function can be attributed to the Veteran's separately service-connected sarcoidosis. Thus, the Veteran is not entitled to a compensable disability rating for his abdominal laparotomy scar. 7. An initial compensable disability rating for right clavicle scar is denied. Upon review of the above evidence, the Board finds that an initial compensable disability rating is not warranted for the Veteran's right clavicle scar. Significantly, the Veteran denied any problems with his scars during the July 2005 VA general examination. The April 2007 VA scar examination report shows that the Veteran's right clavicle scar was manifested by two different scars: (1) a 4 cm tannish linear well-healed surgical scar which was slightly raised at the superior aspect of the manubrium from biopsy of the mediastinum and (2) a 4 cm whitish linear surgical scar from further biopsy of a lymph node in this area which was flat and smooth at the base of the right sternocleidomastoid muscle at the right base of the neck. Neither of these scars resulted in loss of underlying tissue, adherence to underlying tissue, restriction of movement, ulceration, keloid formation, and/or other changes. The August 2011 VA scar examination report shows that the Veteran's right clavicle scar was manifested by a 1 cm linear scar with no complaints of breakdown, secondary infections, pain, and/or tenderness. The September 2019 VA muscle examination report pertains only to the left buttock and back. And the December 2020 VA scar examination report shows that the Veteran's right clavicle scar was manifested by two different scars: (1) right scalene node biopsy scar (measuring 2.5 x 0.25 cm) and right upper chest and mediastinoscopy scar chest wall anteriorly (measuring 4 x 0.25 cm) which were neither painful nor unstable with frequent loss of covering of skin. An increased disability rating under DCs 7801 or 7802 is not warranted as the Veteran's right clavicle scars do not exceed 77 square centimeters. An increased evaluation is also not warranted under DC 7803 as the Veteran's right clavicle scars are not shown to be unstable. Similarly, an increased evaluation is not warranted under DC 7804 as there was no evidence that the Veteran's right clavicle scars are superficial or painful. Finally, as to DC 7805, the Board notes that there is no evidence of limitation of function of the clavicle due to the scar, rather any limitation of function can be attributed to the Veteran's separately service-connected sarcoidosis. Thus, the Veteran is not entitled to a compensable disability rating for his right clavicle scar. 8. A TDIU prior to November 10, 2008, to include on an extraschedular basis, is denied. The Veteran first filed a formal claim for a TDIU in May 2005. At that time, he wrote that he had been unable to work full time as a driver since June 2004, due to his service-connected disabilities. Specifically, in May 2005 correspondence the Veteran wrote that he was unable to maintain suitable employment due to his psychiatric disabilities, hypertension, gout, prostate, and sleep apnea (to include medications used to treat these disabilities). According to the Veteran, he was unable to work for eight straight hours due to the effects of these disabilities. By rating decision dated in January 2012, the RO granted a TDIU effective November 10, 2008. However, the Veteran's claim for a TDIU had been pending since May 2005. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340 and 4.16(a). If, however, there is only one such disability, it shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Further, TDIU may be granted on an extraschedular basis, pursuant to 38 C.F.R. § 4.16(b), for Veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). This means that in exceptional cases, where the evaluations provided by the rating schedule are found to be inadequate, a TDIU claim may be referred for extraschedular consideration. 38 C.F.R. § 3.321(b). The Board does not have jurisdiction to assign an extraschedular rating in the first instance. VAOPGCPREC 6-96 (Aug. 16, 1996); Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Rather, consideration of whether an extraschedular rating is assignable must be referred to the RO, who requests such consideration by the Under Secretary for Benefits or by the Director of Compensation Service. Entitlement to a total rating must be based solely on the impact of the Veteran's service-connected disabilities on his ability to keep and maintain substantially gainful employment. See 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). While medical examiners are responsible for providing a full description of the effects of disability upon the person's ordinary activity, 38 C.F.R. § 4.10; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013), the ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one; rather, that determination is for the adjudicator. 38 C.F.R. § 4.16(a); Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Prior to November 10, 2008, the Veteran was service-connected for posttraumatic stress disorder (PTSD) and major depression (evaluated as 30 percent disabling beginning October 27, 1999), sarcoidosis (evaluated as noncompensably disabling beginning February 9, 1978 and 30 percent disabling effective March 14, 2006), SFWs with retained foreign bodies of the left back, left flank, left buttocks, let knee, and left ankle (evaluated as 10 percent disabling from October 4, 1989 to June 25, 2005), a left knee disability (evaluated as 10 percent disabling effective June 25, 2005), a left ankle disability (evaluated as 10 percent disabling effective June 25, 2005), a low back disability (evaluated as 10 percent disabling effective March 14, 2006), and various scars (each evaluated as noncompensably disabling). As above, by rating decision dated in January 2012, the RO granted a TDIU effective November 10, 2008. It appears that this award was due, at least in part, to the Veteran's service-connected psychiatric disability being increased from 30 to 70 percent disabling effective November 10, 2008. As of November 10, 2008, the Veteran met the schedular requirements for a TDIU under 38 C.F.R. § 4.16(a). However, prior to November 10, 2008, the Veteran did not meet the schedular criteria for a TDIU as he only had a combined 40 percent rating effective October 27, 1999, a combined 50 percent rating effective June 25, 2005, and a combined 60 percent rating effective March 14, 2006. Even so, he may be entitled to a TDIU on an extra-schedular basis prior to such date if the evidence demonstrates that his service-connected disabilities rendered him unable to secure or follow a substantially gainful occupation. Therefore, the remaining inquiry is whether it is factually ascertainable that the Veteran's service-connected disabilities, rendered him unable to secure or follow a substantially gainful occupation in light of his educational and employment history prior to November 10, 2008. A review of the pertinent evidence of record includes a July 2005 VA psychiatric examination report. At that time, the examiner noted that the Veteran was currently unemployed but also noted that the Veteran's current level of psychiatric symptomatology did not render the Veteran unemployable as he was totally independent with all activities of daily living, to include management of financial needs in his best interest. Significantly, it was noted that the Veteran's psychiatric medications had been somewhat helpful in managing his symptomatology. His daily routine reportedly included getting out of bed at approximately 7am, having breakfast, and spending time checking messages or playing card games on his computer. He took regular walks, cleaned his apartment, and did additional household chores (like laundry). He spent his evenings on his computer. An April 2007 VA respiratory examination shows that the Veteran had been unemployed since 2006, when he moved to Arkansas, and was self-employed as a chauffeur from 2003 to 2006. Significantly, the Veteran reported that he was unable to pass a DOT physical due to his use of psychiatric medications. During the January 2008 Board hearing, the Veteran testified that he was unable to work, primarily, due to medications used to treat his service-connected psychiatric disabilities. Based on the foregoing, despite the Veteran's allegations of an inability to work solely as a result of his service-connected disabilities prior to November 10, 2008, the evidence of record fails to support such contention. Significantly, the medical evidence shows that while the Veteran's psychiatric disability made employment more difficult due to his limitations, the condition did not preclude employment prior to November 10, 2008. Even though the Veteran may have had difficulty getting certain types of jobs prior to November 10, 2008, there is no evidence that he could not get any job. As above, the July 2005 VA psychiatric examiner opined that the Veteran's psychiatric symptomatology did not render the Veteran unemployable as he was totally independent with all activities of daily living, to include management of financial needs in his best interest. Therefore, the Board finds that the Veteran's service-connected disabilities, while disruptive and uncomfortable, did not render him unable to secure or follow a substantially gainful occupation in light of his educational and employment history prior to November 10, 2008. Accordingly, the Board finds that the preponderance of the evidence is against the award of a TDIU prior November 10, 2008. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against a TDIU prior to November 10, 2008. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board April Maddox, 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.