Citation Nr: 22017641 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 16-42 309 DATE: March 25, 2022 ORDER 1. Entitlement to service connection for residuals of a traumatic brain injury (TBI) is denied. 2. Entitlement to service connection for lumbar spine disability with radiculopathy is denied. 3. Entitlement to service connection for a right hip disability is denied. 4. Entitlement to service connection for a left hip disability is denied. 5. Entitlement to increases in the (10 percent prior to June 29, 2009, and 20 percent from that date) staged ratings assigned for diabetes mellitus type II is denied. 6. Entitlement to increases in the (20 percent prior to April 6, 2017, and 50 percent from that date) for residuals of a shell fragment wound (SFW) to Muscle Group (MG) XVII, left side is denied. 7. Entitlement to increases in the (0 percent prior to December 14, 2021, and 10 percent from that date) staged ratings assigned for SFW of the left wrist (MG VIII) is denied. 8. Entitlement to a rating in excess of 10 percent for a left buttock scar is denied. 9. Entitlement to a compensable rating for a left forearm scar is denied. FINDINGS OF FACT 1. The Veteran is not shown to have a TBI residual disability. 2. Lumbar spine arthritis with radiculopathy was not manifested during service or within a year following the Veteran's separation from active duty service; and his current lumbar spine arthritis with radiculopathy is not shown to be etiologically related to his service/injury therein. 3. A chronic right or left hip disability was not manifested during service; right or left hip arthritis was not manifested within a year following the Veteran's separation from active duty service; and any current right and left hip disabilities are not shown to be etiologically related to his service/injury therein. 4. Prior to June 29, 2009, the Veteran's diabetes mellitus type II is not shown to have required insulin and restricted diet, or oral hypoglycemic agent and restricted diet; from that date, it is not shown to have required regulation of activities at any time. 5. Prior to April 6, 2017, the Veteran's residuals of a SFW to MG XVII, left side, are not shown to have had objective findings of more than a moderate injury; from that date, the 50 percent rating assigned is the maximum schedular rating provided for a MG XVII disability, and separately ratable complications of MG XVII symptoms or impairment not encompassed by the schedular criteria are not shown or alleged. 6. Prior to December 14, 2021, the Veteran's SFW of the left wrist (MG VIII) is not shown to have objective findings of more than a slight injury; from that date, it is not shown to have objective findings of more than a moderate injury. 7. The Veteran's left buttock scar is not shown to have been manifested by three or four unstable or painful scars, and it is not shown to be unstable as well as painful, deep or nonlinear, of at least 144 square inches in area, or to cause any functional limitations. 8. The Veteran's left forearm scar as residual of a SFW is not shown to be unstable or painful, deep and nonlinear and at least 6 square inches in area, superficial and nonlinear and at least 144 square inches in area, or to cause any functional limitations. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of TBI are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for service connection for a lumbar spine disability with radiculopathy are not met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). 3. The criteria for service connection for right and left hip disabilities are not met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). 4. Entitlement to ratings in excess of 10 percent prior to June 29, 2009, and in excess of 20 percent as of June 29, 2009, for diabetes mellitus are not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.119, Diagnostic Code 7913. 5. Entitlement to ratings in excess of 20 percent prior to April 6, 2017, and in excess of 50 percent as of April 6, 2017, for residuals of a shell fragment wound to Muscle Group XVII on the left side are not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.10, 4.21, 4.55, 4.56, 4.71a, Diagnostic Code 5317. 6. Entitlement to ratings in excess of 0 percent prior to December 14, 2021, and in excess of 10 percent as of December 14, 2021, for a shell fragment wound of the left wrist involving Muscle Group VIII are not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.10, 4.21, 4.55, 4.56, 4.71a, Diagnostic Code 5308. 7. Entitlement to a rating in excess of 10 percent for a left buttock scar is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.7, 4.21, 4.31, 4.55(a), 4.118, Diagnostic Codes 7801, 7802, 7804, 7805. 8. Entitlement to a compensable rating for left forearm scar is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.7, 4.21, 4.31, 4.55(a), 4.118, Diagnostic Codes 7801, 7802, 7804, 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from August 1965 to June 1968. These matters are before the Board on appeal from a March 2009 Department of Veterans Affairs (VA) rating decision. In January 2013 and May 2019, the matters were remanded for additional development. The Board's previous remand also addressed claims for service connection for left upper extremity peripheral neuropathy, right upper extremity peripheral neuropathy, right lower extremity radiculopathy or peripheral neuropathy, and erectile dysfunction. An August 2021 rating decision established service connection for left upper extremity peripheral neuropathy, right upper extremity peripheral neuropathy, and erectile dysfunction; and a December 2021 rating decision established service connection for right lower extremity peripheral neuropathy. Those decisions constitute a full grant of benefits sought on appeal with regard to the issues of entitlement to service connection for left and right upper extremity peripheral neuropathy, right lower extremity peripheral neuropathy, and erectile dysfunction. Therefore, those issues are no longer before the Board. AB v. Brown, 6 Vet. App. 35 (1993). Service Connection Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disability first diagnosed after separation from service may be service-connected if all the evidence establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Certain chronic diseases listed in 38 C.F.R. § 3.309(a), to include arthritis, may be presumed to be service-connected if manifested to a compensable degree within one year following separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Lay evidence may be competent evidence to establish incurrence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 1. Entitlement to service connection for residuals of TBI is denied. The Veteran contends that he sustained a TBI in service, as a result of a concussive blast from a 500-pound bomb that detonated very near to his position in Vietnam in November 1967. The fact that the explosion occurred is not in dispute, and the Veteran is presumed to have been in close proximity to that detonation and having sustained a head injury in that explosion. The service medical records do not show complaints, findings, treatment, or diagnosis of any head injury, residuals of any head injury, or TBI. At a June 1968 service separation examination, the head was normal on clinical evaluation. On contemporaneous report of medical history, the Veteran denied any history of head injury, frequent or severe headache, dizziness or fainting spells, loss of memory or amnesia, or periods of unconsciousness. At an October 1968 VA examination, the Veteran was noted to have received various shell fragment wounds in service when a 750 pound bomb went off nearby. On physical examination, a 0.75 inch scar was noted on the vertex of the scalp with probable retained shell fragment on palpation. The head was otherwise normal, and skull X-rays were normal. At a May 2006 VA examination, the examiner noted that a January 2006 VA neurology visit report stated that the Veteran had an MRI scan of the brain which was unremarkable. May 2006 skull X-rays were unremarkable. The Veteran reported receiving shrapnel fragments to the top of the head toward the occipital area with retained shrapnel. He reported having tenderness to that area, and that a few days a week, he had some swelling which could also cause headache. The diagnoses included shrapnel injury of the scalp with retained fragments. The examiner opined that the headaches were most likely tension in nature and not likely caused by or a result of a shrapnel fragment wound to the scalp. At a February 2009 VA neuropsychological assessment, the Veteran was able to describe events leading up to the November 1967 injuries during an extended battle in Vietnam, suggesting no significant retrograde amnesia. He reported being unconscious for about two minutes and then felt confused for about 15 to 20 minutes. The provider opined that the Veteran's report suggested that he had a mild concussion, based on the brief period for which he was unconscious and limited amount of amnesia surrounding the injury. The Veteran reported that he was unable to recall much about the four days between his injuries and when he was evacuated. The provider noted that gangrene had developed in the Veteran's wound and he was not eating or drinking so he may have had some mild delirium. He had also been diagnosed with PTSD, so there may have been some psychogenic amnesia or dissociation occurring at that time. The Veteran reported having had problems with postconcussion symptoms since the injury. The provider noted there is no documentation of those complaints until fairly recently. The Veteran did not begin receiving VA treatment until 2004, and on December 2004 neurology consult, he reported experiencing lightheadedness and dizziness only during discrete episodes of numbness and weakness in the extremities. The neurologist noted that the Veteran denied headache, blurred vision, diplopia, or auditory changes, and reported mild photophobia during those discrete episodes. The provider noted that March 2005 neurological testing was normal with intact cognition. The provider noted that the Veteran's report of daily headaches for years with some photophobia and nausea on October 2008 treatment was the first documentation of any problems with headaches. On current evaluation, the Veteran reported problems with memory, speech, balance, headaches, depression, and sleep. He reported having a mild concussion at work about eight years prior. Following testing, the provider opined that the pattern of cognitive difficulties together with the history described was more consistent with the likelihood that the psychiatric problems accounted for the difficulties. The provider opined that it was unlikely that the history of mild TBI that the Veteran experienced was currently causing cognitive or neuropsychiatric difficulties. June 2009 MRI results of the brain found no acute intracranial process. There were a few scattered foci of abnormal signal involving the periventricular and subcortical white matter which were nonspecific, but most commonly seen in the setting of chronic small vessel ischemic disease. Other etiologies including migraine headaches and hypertension should be considered in the differential. There were several areas of susceptibility artifact involving the scalp, most prominently overlying the left frontal vertex which the provider opined may represent sequela of prior traumatic injury. VA treatment records from November 2013 to June 2016 include assessments of TBI, mild neurocognitive disorder due to TBI, and personality change due to a medical condition of TBI. On September 2015 VA neurology consult, the provider opined that the Veteran's headaches appeared to be the result of TBI during service. On November 2020 VA treatment, the previous medical history active problems included "cognitive disorder, mild, likely small vessel disease. Neuropsychiatric examination was stable, and the examiner opined that the Veteran may have old underlying TBI." At a May 2021 VA TBI examination, the examiner, a physiatrist, noted the Veteran's history of being "blown unconscious" after a jet dropped a bomb in his defense perimeter. He reported being transported to a hospital base four days later to be treated for gangrene in the left buttock and leg. He never sought medical attention for TBI because the other wounds were more serious. His reported symptoms included hearing loss, tinnitus, headaches, memory loss, and vertigo. The criteria supporting the Veteran's TBI claim included alteration in mental state at the time of the injury; neurological deficits after the event that may or may not be transient; receipt of combat decorations as documented in the service separation form with reported loss of consciousness due to an in-combat injury. The examiner noted that the Veteran has been diagnosed with PTSD. The examiner cited the February 2009 neuropsychological evaluation finding that, despite the obviously stressful incidents he suffered during service in Vietnam, the Veteran was able to function in his roles as father, husband, and worker before the onset of difficulties about five years ago; and that there was no documentation of postconcussion syndrome symptoms until fairly recently, with VA treatment beginning in 2004. The examiner opined that it was unlikely that a mild concussion in 1967 would only start to cause significant symptoms in 2004. Therefore, by default, all emotional and behavioral signs and symptoms would be parts of the Veteran's co-existing mental disorder, PTSD, and prior alcohol abuse, and none would represent residuals of a TBI. The examiner opined that the Veteran's medical records did not support that any currently diagnosed conditions related to traumatic brain injury were at least as likely as not (50 percent or greater probability) incurred in or caused by the impact with the ground from the bomb detonation during service. The examiner noted that the Veteran complained of five main symptoms: hearing loss, tinnitus, headaches, memory loss, and vertigo. The examiner opined that none of those symptoms would be at least as likely as not (50 percent or greater probability) related to a head or brain injury. The VA examiner opined that hearing loss would not be related to the TBI, noting that according to a May 2006 audiology note, the Veteran had comprehensive audiology in November 1968 at the Pittsburgh VA. At that time, the ears were clear, the eardrums were okay, and hearing bilaterally was in the normal sensitivity range. The examiner opined that if bomb detonation had caused the hearing loss, it would be expected to be present to some degree in 1968. The examiner noted that tinnitus was not evaluated and it was beyond the scope of the review, and it had been evaluated on other examinations. The VA examiner opined that headaches would not be related to TBI, noting that although the Veteran stated that headaches had been present since the bomb exposure, he did not seek treatment for any symptoms from VA until 2004, or possibly 2000 at the earliest. The examiner noted that the Veteran suffered only a mild concussion at the time of the explosion and only a brief loss of consciousness. He had been classified as having suffered only a mild concussion, and he carried no specific diagnosis other than "headache, unspecified". The examiner opined that it was unlikely that a mild concussion suffered in 1967 would be a source of worsening headaches which did not start significantly until at least 2000. The VA examiner opined that memory loss would not be related to TBI, noting that the Veteran had normal memory on examination, according to a February 2012 neuropsychological evaluation. The mild cognitive deficits were due to age-related changes. The provider at that time noted, "The etiology of his difficulties is likely related to cerebrovascular disease identified on brain imaging. His pattern of performance across tests is consistent with that typically seen in persons with chronic small vessel ischemic disease. It is also possible that the topiramate he is currently taking may have some impact on his cognitive function, particularly on verbal fluency and word finding." The VA examiner opined that the Veteran's complaints of dizziness and vertigo would not be related to a November 1967 concussion, noting that a May 2006 comprehensive audiology consult showed the ears were clear, eardrums were okay, and hearing bilaterally was in the normal sensitivity range. A December 2004 neurology note indicated no frank vertigo. A brain MRI had shown no definite structural abnormality which would account for vertigo. The post-service medical evidence did not otherwise show any complaint, finding, treatment, or diagnosis of TBI or residuals thereof. As TBI residual disability was not manifested in service, service connection for a TBI residual disability on the basis that it became manifest in service and persisted is not warranted. Furthermore, the threshold requirement that must be met with respect to this claim is that there must be competent evidence that the Veteran currently has, or during or contemporary to the pendency of the claim has had, the disability for which service connection is sought, of TBI or residuals. 38 U.S.C. § 1110. The Board finds that the evidence is persuasively against a finding that the Veteran currently has residuals of a TBI in service. Treatment records associated with the record do not include any assessment or confirmed diagnosis or treatment of TBI. The February 2009 provider who conducted a neuropsychological assessment of the Veteran opined that the pattern of cognitive difficulties together with the history described was more consistent with the likelihood that his psychiatric problems account for his difficulties, and that it is unlikely that the history of mild TBI he experienced in service is currently causing cognitive or neuropsychiatric difficulties. The May 2021 VA examiner found that the Veteran does not meet the criteria for a diagnosis of TBI. There is no medical opinion in the record that shows a diagnosis of TBI based on a thorough evaluation for such. The providers of the VA opinions are medical professionals competent to determine whether or not the Veteran has, or has had, a valid diagnosis of TBI residual disability. Their opinions stating he does not have, and has not had, such diagnosis cite to supporting clinical and other factual data, and they invoke medical principles by citing to testing (both scores and their significance) he was provided to determine whether he has cognitive or memory impairment residual from a TBI. Their opinions are probative evidence and persuasive. The Veteran has not identified any physician or other medical provider who has assigned the Veteran a diagnosis of residuals of a TBI in service with an adequate explanation of rationale that expresses awareness of the entire factual record. The Board notes that VA treatment records from November 2013 to June 2016 include assessments of TBI, mild neurocognitive disorder due to TBI, and personality change due to a medical condition of TBI. On September 2015 VA neurology consult, the provider opined that the Veteran's headaches appeared to be the result of TBI during service. On November 2020 VA treatment, the previous medical history active problems included "cognitive disorder, mild, likely small vessel disease. Neuropsychiatric examination was stable, and the examiner opined that the Veteran may have old underlying TBI." However, the Veteran has established service connection for PTSD, and what was listed as a cognitive disorder had been found by other examiners to be part of the service-connected PTSD. The Board finds those opinions more persuasive because they explained why the mental disorder, cognitive disorder, or personality change was related to PTSD, rather than noting or speculating about a relationship to TBI. While the September 2015 treatment provider stated that headaches could be due to TBI, the most recent VA examiner persuasively explained why the headaches were not at least as likely as not related to TBI. The Board finds that opinion, with rationale, more persuasive than the recording opinion without rationale in September 2015. The Board concludes that a TBI residual disability is simply not shown. As weight of the evidence is against a finding that there are any current TBI residuals, the Board finds that the evidence is not in relative equipoise and there is no reasonable doubt to be resolved in favor of the Veteran. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Therefore, the appeal must be denied. 2. Entitlement to service connection for a lumbar spine disability with radiculopathy is denied. The service medical records do not show complaint, finding, treatment, or diagnosis regarding the lumbar spine. On June 1968 service separation examination, the spine was normal on clinical evaluation. On contemporaneous report of medical history, he denied any history of arthritis or recurrent back pain. On October 1968 and September 1973 VA examinations, X-rays of the lumbosacral spine were normal. The post-service medical evidence does not complaint, finding, treatment, or diagnosis regarding a back disability until a January 2006 VA treatment record, when the Veteran reported having experienced severe back and lower extremity pain in the past. May 2006 lumbosacral spine X-rays were unremarkable. On November 2007 treatment, the Veteran reported left buttock and left low back pain with radiation to the left knee. The assessments included low back and left hip pain. Lumbar spine MRI results showed a large L4-L5 left posterior extrusion impinging the traversing left L4 nerve root, and moderate L4-L5 spinal stenosis and minimal bilateral L4-L5 neural foraminal narrowing. On December 2007 treatment, the assessments included lumbar spinal stenosis, chronic, new, and radiculopathy. At a March 2008 VA examination, the Veteran reported that in November 2007, he came home from work with extreme pain in the lower back and left hip, and he was unable to walk due to the severe pain. He reported that his primary care practitioner put him on prednisone and prescribed pain pills, and he was later diagnosed with lumbar stenosis with radiculopathy down the left leg. He reported receiving spinal injections with some relief. Following a physical examination, the diagnoses included lumbar disk disease with bilateral radiculopathy, worse on the left. At a November 2008 VA examination, the Veteran reported having problems with the lower back since a shrapnel injury to the left buttock in service. He reported that he was issued a cane in May 2008 during physical therapy. He reported constant back pain with daily stiffness. May 2008 lumbar spine MRI was noted to show degenerative facet disease at L4-L5 with mild to moderate spinal canal narrowing and moderate bilateral neural foraminal narrowing, left greater than right. Following a physical examination, the diagnosis was degenerative arthritis of the lumbar spine with radiculopathy. The examiner noted that the Veteran had a shrapnel injury to the left buttock during combat, and the shrapnel was removed. The examiner opined that the Veteran did not have a deep enough shrapnel injury to have caused degenerative changes to the lumbar spine. The examiner noted that the Veteran has diffuse changes, whereas the shrapnel injury was an isolated injury, and opined that therefore the lumbar spine arthritis was not secondary to the service-connected shrapnel injury to the left buttock. In September 2013 VA treatment and subsequent treatment records, the assessments included low back pain with a history of surgical repair. On February 2016 VA treatment, the Veteran was noted to have had an acute low back strain. In a May 2019 remand, the Board noted that there was no medical opinion record regarding whether a lumbar spine disability was related to the impact with the ground from the bomb blast itself. The Board noted that the Veteran experienced a concussive blast from a 500-pound bomb that detonated very near to his position during service, and remanded the matter for an examination and medical opinion to address that particular theory of entitlement. At an August 2021 VA back examination, the Veteran reported the onset of back pain after service, sometime in the 1980s, at about the time he retired; he reported that his back hurt so much he could not work anymore, and right leg pain ensued. He reported that he went to the pistol range for his job as a federal police officer and by the end of the day he could not walk due to pain; he sought care and had a laminectomy and fusion after this episode. Following a physical examination, the diagnoses included degenerative arthritis (May 2008), degenerative disc disease other than intervertebral disc syndrome (November 2007), intervertebral disc syndrome (August 2021), spinal stenosis (November 2007), right lumbar radiculopathy (2008), and status post lumbar laminectomy and fusion with pain (April 2009). The examiner opined that the claimed low back conditions were less likely than not (less than 50 percent probability) caused by impact with the ground from the bomb detonation during service. The examiner noted that the clinical record cover sheet from the hospital in November 1967 at the time of the injury in question states "wounds, fragments, multiple, open, head, arms and right buttock, without nerve or artery involvement"; there was no back injury documented at that time. The examiner noted that the report of medical history at separation from service is negative for a back injury, diagnosis or symptoms, and imaging of the lumbar spine from 1968 to 2006 was normal. The examiner noted the Veteran's work history at a steel mill for a short time, at the post office for a short time, and then as a federal policeman for over 30 years, with retirement in September 2008. The examiner noted the Veteran's report that he retired shortly after the onset of back pain after work in 2007, and that he was able to work a very physical and active career that left ample opportunity for injury from the 1967 blast injury to the November 2007 work-reported back pain, when he reported extreme lower back and left hip pain after getting in and out of his car all night responding to emergencies and patrolling. It is not in dispute that the Veteran has a current lumbar spine disability of degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome, intervertebral disc syndrome, spinal stenosis, right lumbar radiculopathy, and status post lumbar laminectomy and fusion with pain were diagnosed on VA examination. However, a chronic lumbar spine injury or disease in service is not shown, and arthritis of the lumbar spine is not shown to have been manifested within a year following his separation from service. The earliest notation of a low back complaint documented in the claims file is in January 2006. Consequently, service connection for a lumbar spine disability on the basis that it became manifest in service, or on a chronic presumptive basis for arthritis manifesting within one year following separation from service is not warranted. Considering the earliest post-service documentation of low back complaints in 2006, continuity of a lumbar spine disability is not shown, and service connection based on continuity of symptomatology is also not warranted. A November 2008 VA examiner opined that the Veteran did not have a deep enough shrapnel injury to have caused degenerative changes to the lumbar spine. He had diffuse changes whereas the shrapnel injury was an isolated injury. Therefore the examiner opined that the lumbar spine arthritis was not secondary to a service-connected shrapnel injury to the left buttock. The August 2021 VA examiner opined that the low back disability was less likely than not caused by impact with the ground from the bomb detonation during service, noting that there was no back injury documented at that time. The report of medical history at separation from service was negative for a back injury, diagnosis or symptoms, and imaging of the lumbar spine from 1968 to 2006 was normal. The examiner noted the Veteran's report that he retired shortly after the onset of back pain after work in 2007, and that he was able to work a very physical and active career that left ample opportunity for injury from the 1967 blast injury until the November 2007 work-reported back pain. The examiners are medical professionals and the opinions are probative evidence in this matter. The opinion indicates familiarity with the Veteran's medical history and includes a rationale that cites to supporting evidence. They are the most probative competent evidence in this matter, and the Board finds them persuasive. Whether the Veteran's lumbar spine disability is related to an injury or activities in service is a medical question beyond the scope of common knowledge and incapable of resolution by lay observation; it requires medical expertise. The Veteran is a layperson. Consequently, his opinion is not competent evidence in these matters. The Veteran has not submitted a medical opinion with adequately explained rationale in support of the claim or identified any medical provider who has offered such an opinion. The Board finds that the weight of the evidence is against a finding that a lumbar spine disability was incurred in or aggravated by service, or manifested as arthritis within one year following separation from service. The Board finds that the evidence is not in relative equipoise and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the appeal must be denied. 3. Entitlement to service connection for right and left hip arthritis is denied. The service medical records do no show complaints, findings, treatment, or diagnosis of any left or right hip disability. At the June 1968 service separation examination, the lower extremities were found to be normal on clinical evaluation. On contemporaneous report of medical history, the Veteran denied any history of swollen or painful joints; arthritis or rheumatism; bone, joint, or other deformity; or lameness. The post-service medical evidence does not show complaint, finding, treatment, or diagnosis regarding a disability of either hip until a November 2007 treatment record, when the Veteran reported aching and stiffness over the hip girdle. On December 2007 treatment, he reported ongoing severe left leg and hip pain and an inability to walk. At a March 2008 VA examination, the Veteran reported having extreme left hip pain in November 2007 that left him unable to walk. He reported that the left leg was weak from the hip to the knee. He reported having pain, tenderness, and stiffness in both hips. He reported a feeling like electricity running up and down the left leg from the toes to the hips. Bilateral hip X-rays were normal. Following a physical examination, there was no diagnosis regarding either hip. The examiner noted that the Veteran claimed arthritis of the bilateral hips secondary to the injury to the left buttock, noted that no hip arthritis was shown on X-rays, and opined that it was not secondary to the injury to the left buttock. On June 2010 and February 2013 VA treatment, the Veteran reported bilateral hip pain. On March 2015 VA treatment, there was no hip pain on right lower extremity examination. On February 2016 treatment, he reported bilateral hip pain. Subsequent VA treatment records include notations of hip pain. An October 2016 VA scars examination; April 2017 VA muscle injuries, scars, and peripheral nerve conditions examinations; August 2021 VA back, scars, elbow and forearm conditions, and peripheral nerve conditions examinations; and December 2021 muscle injuries, scars, and wrist conditions examinations do not show any findings regarding a disability of either hip. The Board finds that right or left hip arthritis was not manifested in service or within one year following separation from service. Therefore, service connection for right or left hip arthritis on the basis that either became manifest in service, or that hip arthritis manifested within one year following separation from service is not warranted. Considering the earliest post-service documentation of left or right hip complaints in 2007, continuity of a left or right hip disability is not shown, and service connection based on continuity of symptomatology is also not warranted. While the Veteran may substantiate the claims by competent medical evidence that he currently has right or left hip arthritis that is etiologically related to his service, he has presented no such evidence. There is no credible evidence of a related disease or injury in service, and therefore no possibility of a probative positive nexus opinion based on the current record in these matters. The Board finds that the weight of the evidence is against a finding that any right or left hip disability was incurred in or aggravated by service, or manifested as arthritis within one year following separation from service. The Board finds that the evidence is not in relative equipoise and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the appeal must be denied. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity caused by the given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate ratings may be assigned for separate periods of time, based on the facts found. The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability for the time period beginning one year before the claim was filed until VA makes a final decision on the claim. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When a question arises as to which of two ratings applies, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding degree of disability will be resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. 4. Entitlement to increased ratings for diabetes mellitus is denied. At March 2008 treatment, the assessments included new diabetes mellitus type II. At April 2008 VA treatment, the Veteran reported that he had recently been diagnosed with borderline diabetes and was started on metformin. AT May 2008 treatment, he reported having dizziness since being on Glucophage (metformin), and he had stopped taking it. He was not prescribed insulin or a different oral hypoglycemic agent. At a January 2009 VA diabetes examination, the Veteran was noted to have had non-insulin dependent diabetes mellitus for the past year. He denied any issues of ketoacidosis or hypoglycemic reactions, or any hospitalization for ketoacidosis or hypoglycemic reactions. He was restricted in many activities due to spinal stenosis of the lower back and possibly cervical spine, not due to the diabetes. He did not have to avoid strenuous activity to prevent hypoglycemic reactions. He had been initially started on metformin as a hypoglycemic medication but was unable to tolerate it secondary to gastrointestinal issues. At the time of examination, his diabetes was diet and exercise controlled and did not need any oral medication. He was also on gabapentin. He saw his diabetic provider every six months. The examiner opined that the neurological complaints were inconsistent with diabetic neuropathy and were most likely secondary to spinal and cervical stenosis. No diabetic eye disease or other diabetic complications were found. Based on that evidence, a March 2009 rating decision established service connection for diabetes mellitus and assigned a 10 percent rating, effective March 17, 2008. VA treatment records show that the Veteran was first prescribed glyburide, an oral hypoglycemic agent, on June 29, 2009. In a December 2012 diabetes mellitus disability benefits questionnaire (DBQ), the provider stated that the Veteran was prescribed an oral hypoglycemic agent and did not require regulation of activities as part of the medical management of diabetes mellitus. The Veteran reported that he visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month. He had no episodes of ketoacidosis or hypoglycemia requiring hospitalization over the previous 12 months. He had no progressive unintentional weight loss or progressive loss of strength attributable to diabetes mellitus. He had no diabetic peripheral neuropathy, renal dysfunction, or retinopathy. The diabetes mellitus did not impact the ability to work. At a May 2013 VA diabetes examination, the Veteran's diabetes mellitus was noted to be managed by restricted diet and prescribed oral hypoglycemic agent. He did not require regulation of activities as part of medical management of diabetes mellitus. The Veteran reported that he visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month. He had no episodes of ketoacidosis or hypoglycemia requiring hospitalization over the previous 12 months. He had no progressive unintentional weight loss or progressive loss of strength attributable to diabetes mellitus. He had no known diabetic eye disease or other diabetic complications. The examiner opined that diabetes mellitus did not impact the Veteran's ability to work. Based on this evidence, an August 2016 rating decision assigned an increased rating of 20 percent for diabetes mellitus, effective June 29, 2009. At an August 2021 VA diabetes examination, the diagnoses included diabetes mellitus with diabetic cataract, and diabetic peripheral neuropathy of the upper and lower extremities. The diabetes mellitus was noted to be treated with prescribed oral hypoglycemic agent specified a Ozempic, which is an injectable non-insulin hypoglycemic agent. The Veteran did not require regulation of activities as part of the medical management of diabetes mellitus. He visited a diabetic care provider for episodes of ketoacidosis or hypoglycemia less than two times per month, and had no hospitalizations for episodes of ketoacidosis or hypoglycemic reactions over the previous 12 months. There was no progressive unintentional weight loss and loss of strength attributable to diabetes mellitus. Erectile dysfunction was noted to be secondary to diabetes mellitus. Additional VA and private treatment records show symptoms and impairment essentially similar to those noted on the VA examinations. The Board notes that the Veteran is already service-connected for bilateral cataracts, and peripheral neuropathy of the bilateral upper and lower extremities. Diabetes mellitus is rated under Diagnostic Code 7913. A 10 percent rating is warranted for diabetes manageable by restricted diet only. A 20 percent rating is warranted for diabetes requiring insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. 38 C.F.R. § 4.119. The criteria for rating diabetes are in the conjunctive and progressive, and to warrant the higher of two ratings, the additional criteria required for the higher rating (in addition to those for the lower rating) must be satisfied. Prior to June 29, 2009, it is not shown that the Veteran's diabetes mellitus met the criteria for a 20 percent schedular rating. Although he was initially prescribed metformin upon diagnosis of diabetes, he stopped taking it after a short time due to unpleasant side effects, and he was not prescribed an alternative medication. On January 2009 VA examination, the diabetes was under control without oral medication or insulin. Therefore, it is not shown that the diabetes required insulin or an oral hypoglycemic agent, in addition to restricted diet, to manage the disability prior to June 29, 2009. Under those circumstances, a 10 percent rating is to be assigned. The Board has considered the Metformin was prescribed and then discontinued. However, the Board finds that the disability was controlled without oral hypoglycemic agent. Therefore, a higher rating was not warranted. Continuing the analysis, there is no evidence that at any time under consideration, the Veteran's diabetes met the criteria for a 40 percent schedular rating. At no time is it shown that the diabetes required regulation of activities in addition to insulin or an oral hypoglycemic agent and a restricted diet. No medical provider of record has indicated that regulation of his activities is required to maintain management of his diabetes. Therefore, a rating in excess of 20 percent is not warranted. Furthermore, additional complications of diabetes besides the service-connected bilateral cataracts and peripheral neuropathy of the bilateral upper and lower extremities are not shown. A separate 10 percent rating for cataracts is not warranted unless there is visual impairment to a compensable degree. That level of visual impairment due to cataracts is not shown. The Board finds that the weight of the evidence is against a finding that any higher or separate ratings are warranted for diabetes mellitus. The Board finds that the evidence is not in relative equipoise and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the appeal must be denied. 5. Entitlement to increased ratings for residuals of a shell fragment wound to Muscle Group XVII on the left side is denied. The service medical records show that the Veteran was wounded in November 1967 when a bomb exploded very near his location. He sustained a fragment wound to the buttock on November 19, 1967, with no nerve or artery involvement. After admission to an evacuation hospital on November 21, the grossly infected wound was debrided under spinal anesthesia on November 22. A 15 centimeter by 5 centimeter open granulating wound was noted on hospitalization on November 26, and a delayed primary closure was done on November 27. There was some cellulitis and separation of the wound edges after the sutures were removed on December 12, but at the time of discharge he had healed and was taking physical therapy. At a March 2008 VA examination, the Veteran reported having developed pain, numbness, and tingling radiating down the legs. He reported being sent for nerve conduction studies, which showed damage in the left leg, although the neurologist could not specify the cause. He reported that in November 2007, he came home from work with extreme pain in the lower back and left hip, and he was unable to walk due to the severe pain. He reported that his primary care practitioner put him on prednisone and prescribed pain pills, and he was later diagnosed with lumbar stenosis with radiculopathy of the left leg. He reported receiving spinal injections with some relief. He complained that the left leg was weak from the hip to the knee. He reported having pain, stiffness, and tenderness in the lower back, left buttock, left leg, and right hip, with weakness and instability attributed to the pain. He reported feeling weak like the left leg was going to collapse. He reported feeling that the symptoms of pain in the lower back and radiating up and down the left leg, numbness in both legs, and sharp jabbing electrical sensations over the previous five years had always been centered on the wound in the left buttock. On physical examination, no muscle spasms were noted. The Veteran had pain with palpation along the paravertebral muscles, and tenderness with palpation of the left hip. He had decreased sensation to monofilament in both feet, greater on the left, and decreased vibratory sensation in the left great toe. He had an antalgic gait with a left limp. Left lower extremity strength was 4/5. Straight leg raises on the left produced numbness radiating down to the midthigh with no change with dorsiflexion of the left foot. There was obviously underlying tissue damage in the area of the depression of the left buttock wound, with no adherence to underlying tissue. There was evidence on the EMG or nerve conduction studies that the Veteran had an unobtainable left peroneal sensory response of unclear origin which the examiner opined was most likely related to the previous gunshot injury in the left buttock area, representing residual of the sciatic neuropathy which mostly affected the peroneal component, and would be at least as likely as not secondary to the shell fragment wound of the left buttock. Based on that evidence, a March 2009 rating decision continued a 20 percent rating for the Muscle Group XVII injury with scars. The medical evidence shows that in June 2013, the Veteran was sleeping on his couch, apparently with a handgun in his lap and awoke after shooting himself in the left leg. He underwent urgent repair of what he reported to be a lacerated femoral artery, with compartment syndrome of the calf requiring fasciotomy. At an April 6, 2017, VA muscle injuries examination, the Veteran was noted to have had a left buttock injury from shrapnel that required resection due to secondary infection. He was noted to have associated peroneal neuropathy secondary to the original injury and a non-painful scar as residuals. Symptoms of the muscle group injury included numbness type of pain into the left buttock, constant and rated as 8 of 10 in severity at baseline, and worse at 9 of 10 with sitting or standing for more than a few minutes. He reported that the pain in the left buttock radiated into the left hip area. Some loss of deep fascia caused by the muscle injury was noted, in addition to soft flabby muscles in the wound area and visible or measurable atrophy of the left buttock, muscle group XVII. The atrophy was not amenable to circumference testing due to location. There was no X-ray evidence of retained metallic fragments. The examiner opined that muscle weakness in the left lower extremity was attributable to injuries sustained from the gunshot wound in 2013, not due to the previously service-connected injury to muscle group XVII. At an April 6, 2017, VA peripheral nerve conditions examination, the Veteran reported loss of sensation in the left lower leg that was longstanding, preceding his unrelated gunshot wound and subsequent surgeries in 2013. Symptoms included moderate left lower extremity paresthesias and/or dysesthesias and numbness. Sensory testing was decreased at the left thigh and knee and lower leg and ankle. His gait was markedly antalgic with slowed pace requiring cane for support, due to unrelated gunshot wound in 2013 with extensive leg injury. Mild incomplete paralysis of the left superficial peroneal nerve was indicated. The examiner opined that an unobtainable left peroneal sensory response was of unclear origin, but most likely related to the previous injury in the left buttock area representing residual of the sciatic neuropathy which mostly affected the peroneal component. The examiner opined that the muscle strength loss in the left lower leg is secondary to muscle injury, femur injury in the left leg from 2013 gunshot wound, and not secondary to the peroneal nerve injury. A December 2021 VA muscle injuries examination did not address this disability. Based on that evidence, a December 2021 rating decision assigned an increased rating of 50 percent for shell fragment wound of Muscle Group XVII, effective April 6, 2017. Diagnostic Code 5317, used for rating disability of Muscle Group XVII, applies to the pelvic girdle group, gluteus maximus, gluteus medius, and gluteus minimus, responsible for extension of the hip, abduction of the thigh, elevation of the opposite side of the pelvis, tension of the fascia lata and iliotibial (Maissiat's) band, and acting with Muscle Group XIV in postural support of the body steading the pelvis upon the head of the femur and condyles of the femur on the tibia. Injuries to Muscle Group XVII are assigned a 20 percent rating for moderate injury, a 40 percent rating for moderately severe injury, and a 50 percent rating for severe injury. 38 C.F.R. § 4.73, Diagnostic Code 5317. For rating muscle disabilities, slight disability includes a simple wound of the muscle without debridement or infection. Service department records would show a superficial wound with brief treatment and return to duty, healing with good functional results, and no cardinal signs or symptoms of muscle disability as defined in 4.56(c). Objective findings would show minimal scar, no evidence of fascial defect or atrophy or impaired tonus, and no impairment of function or metallic fragments retained in the muscle tissue. Moderate disability includes a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of a high velocity missile, residuals of debridement, or prolonged infection. Service department records or other evidence would show in-service treatment for the wound. The record would show consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in 4.56(c), particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objective findings would 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. Moderately severe disability included a through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. Service department records or other evidence would show hospitalization for a prolonged period for treatment of the wound. The record would show consistent complaint of cardinal signs and symptoms of muscle disability and, if present, evidence of inability to keep up with work requirements. Objective findings would show entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups; indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side; and tests of strength and endurance compared with the sound side would demonstrate positive evidence of impairment. Severe disability includes a through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, and intermuscular binding and scarring. Service department records or other evidence would show hospitalization for a prolonged period for treatment of the wound. The record would show consistent complaint of cardinal signs and symptoms of muscle disability as defined in 4.56(c) worse than those shown to moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings would show ragged, depressed and adherent scars indicating wide damage to muscle groups in the missile track; palpation would show loss of deep fascia or muscle substance, or soft flab by muscles in the wound area; muscles would swell and harden abnormally in contraction; tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side would indicate severe impairment of function. Other signs of severe muscle disability could include X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; 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; diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; visible or measurable atrophy; adaptive contraction of an opposing group of muscles; atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; or induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56. The Board finds that, prior to the April 6, 2017, VA examinations, the criteria for a higher, moderately severe, disability rating are not met with respect to Muscle Group XVII, so as to warrant a 40 percent or higher rating. Although the March 2008 VA examiner found obvious underlying tissue damage in the area of the depression of the left buttock wound, with no adherence to underlying tissue, the examination reports and treatment records prior to April 6, 2017, do not show that the Muscle Group XVII injury residuals resulted in indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side; tests of strength and endurance compared with the sound side demonstrating positive evidence of impairment. Therefore, a rating in excess of 20 percent is not warranted prior to April 6, 2017. The assignment of the maximum schedular rating for the disability as of April 6, 2017, raises a question of whether referral of the claim for increase to the Director of Compensation for consideration of an extraschedular rating is warranted. The Board's review of the evidence of record in the matter found that referral is not necessary. There is no evidence showing or allegation of symptoms or functional impairment not encompassed by the schedular criteria. VA examiners have not opined that the Veteran has frequent hospitalization or marked interference with employment due to the service-connected Muscle Group XVII injury residuals, or that the symptoms he has reported are not all encompassed by the schedular rating criteria. Consequently, separate ratings for complications are not warranted, and referral for extraschedular consideration is not warranted. The Board notes the lay statements submitted by the Veteran in support of this claim. They describe the types of problems that result from the disability. The symptoms he describes are consistent with the criteria for the 20 percent and 50 percent ratings assigned, and do not support that any higher rating is warranted. The Board finds that the weight of the evidence is against a finding that any higher or separate ratings are warranted for the disability. The Board finds that the evidence is not in relative equipoise and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the appeal must be denied. 6. Entitlement to increased ratings for shelf fragment wound of the left wrist Muscle Group VIII is denied. The service medical records show that the Veteran sustained small fragment wounds of the forearm and elbow, without nerve or artery involvement, when a bomb exploded very near his location in November 1967. At a November 2008 VA examination, the Veteran indicated that he only needed a lumbar spine exam and did not need an examination for increase for the shrapnel fragment of the left wrist or any scars. Based on that evidence, a March 2009 rating decision continued a 0 percent rating for shell fragment wound of the left wrist. An April 2017 VA muscle injuries examination report notes that the Veteran had never had an injury to a muscle group of the forearm or hand. At an August 2021 VA elbow and forearm conditions examination, the Veteran was noted to have incurred a left upper extremity cut in the soft tissue, residual of shrapnel in 1967. In 2006, he was diagnosed with mild degenerative joint disease of the elbows. There were no symptoms of the left healed shrapnel wound. The examiner opined that the reported bilateral elbow pain was due to arthritis due to wear and tear, related to age. The diagnoses included left forearm superficial laceration due to shrapnel with residual scar, and degenerative arthritis other than posttraumatic. At a December 14, 2021, VA muscle injuries examination, the Veteran was noted to have sustained a left wrist injury due to a shrapnel fragment from a friendly fire incident while in Vietnam in 1967. He removed the shrapnel from the left wrist himself while still in the combat field. He reported that the condition had remained the same since onset. He reported symptoms of left hand and arm numbness and tingling and chronic pain to the left wrist. Involvement of muscle groups VII, VIII, and IX of the forearm or hand was indicated. A minimal scar was noted, with no known fascial defects or affected muscle substance or function. Loss of power, weakness, and fatigue and/or pain were noted to muscle groups VII, VIII, and IX. Muscle strength testing was 4/5 for wrist flexion and extension. There was no muscle atrophy. The examiner opined that the muscle injury impacted the Veteran's ability to work due to difficulty with opening bottles and jars and difficulty with grasping and holding onto objects. At a December 14, 2021, VA wrist conditions examination, left wrist dorsiflexion was to 60 degrees, palmar flexion was to 70 degrees, ulnar deviation was to 35 degrees, and radial deviation was to 20 degrees. Pain was noted on all ranges of motion. Passive range of motion was the same as active motion, with pain in all directions. There was evidence of pain in weight-bearing and in non-weight-bearing, on active and passive motion, and on non-movement; the pain did not result in or cause functional loss. There was no objective evidence of crepitus or pain on palpation. There was no additional loss of function or range of motion after repetitive use testing. There was no muscle atrophy or ankylosis. A May 2006 wrist X-ray was noted to show mild degenerative changes. Based on that evidence, a December 2021 rating decision assigned an increased rating of 10 percent for shell fragment wound of the left wrist, effective December 14, 2021. Diagnostic Code 5308, used for rating disability of Muscle Group VIII, applies to the muscles arising mainly from the external condyle of the humerus, responsible for extension of the wrist, fingers, and thumb. Injuries to Muscle Group VIII warrant a 0 percent rating for slight injury to the non-dominant arm, a 10 percent rating for moderate injury to the non-dominant arm, and a 20 percent rating for moderately severe injury or severe injury to the non-dominant arm. The Board finds that, prior to the December 14, 2021, VA examinations, the criteria for a higher, moderate, disability rating are not met with respect to Muscle Group VIII, so as to warrant a 10 percent or higher rating. The August 2021 VA examiner opined that there were no symptoms of the left forearm healed shrapnel wound, and previous examiners noted that the Veteran had no history of an injury to a muscle group of the left forearm. The examinations and treatment records prior to December 14, 2021, do not show that a Muscle Group VIII injury residuals resulted in one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles, 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. Therefore, a rating in excess of 0 percent is not warranted prior to December 14, 2021. The evidence also does not show pain on use that would warrant a compensable rating. 38 C.F.R. § 4.59. The Board finds that the criteria for a higher, moderately severe, disability rating are not met with respect to the left wrist shell fragment wound at any time, so as to warrant a 20 percent or higher rating. Although the December 14, 2021, VA examinations showed loss of power, weakness, and fatigue and/or pain to muscle group VIII, the examinations and treatment records do not show that the Muscle Group VIII injury residuals resulted in consistent complaint of cardinal signs and symptoms of muscle disability, indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side; and tests of strength and endurance compared with the sound side demonstrating positive evidence of impairment. Therefore, the Board fins that a rating in excess of 10 percent is not warranted at any time. The Board notes the lay statements submitted by the Veteran in support of this claim. They describe the types of problems that result from this disability. The symptoms he describes are consistent with the criteria for the 0 percent and 10 percent ratings assigned, and do not support a finding that any higher rating is warranted. The evidence is persuasively against the assignment of a rating in excess of 0 percent prior to December 14, 2021, and in excess of 10 percent from that date, for a shell fragment wound of the left wrist. The Board finds that the weight of the evidence is against a finding that any higher or separate ratings are warranted for the disability. The Board finds that the evidence is not in relative equipoise and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the appeal must be denied. 7. Entitlement to a rating in excess of 10 percent for a left buttock scar is denied. 8. Entitlement to a compensable rating for a left forearm scar is denied. At a March 2008 VA examination, the left forearm was noted to have a 2 millimeter white dot that the Veteran claimed was from shrapnel. There was no inflammation, ulcer, edema, or keloid formation. There was no adherence to underlying tissue or underlying tissue damage. The scar was superficial in nature. The examiner noted a scar on the left buttock that was crescent-shaped, 10 centimeters long, 1.5 centimeters wide, and with a 1 centimeter depression. There was no inflammation, ulceration, edema, or keloid formation. There was no adherence to underlying tissue. There was obviously underlying tissue damage in the area of the depression of the wound, and the scar was tender to touch. Based on that evidence, a March 2009 rating decision continued a 0 percent rating for a left forearm scar. Based on that evidence, an August 2016 rating decision assigned a 0 percent rating for left buttock scar, effective November 23, 2007, the date of receipt of the claim for the disability. An October 2016 VA scars examination report does not address the service-connected scars of the left forearm or left buttock. At an April 2017 VA scars examination, the Veteran was noted to have had an injury to muscle group XVII with a resulting scar to the left buttock. The residual scarring was stable, superficial, and not painful. The examination report notes that the left upper extremity was not affected by scarring. At an August 2021 VA scars examination, a left forearm scar was noted without a retained fragment. It measured 2 centimeters by 0.5 centimeters, with approximate total area of 1 square centimeters. The scar was not tender to palpation, unstable upon inspection, or with underlying soft tissue damage. It did not result in limitation of function. The left buttock scar was not addressed. At a December 2021 VA scars examination, a scar to the left medial anterior aspect of the left wrist was noted to have stayed the same since onset. There were no current symptoms. The scar was not painful or unstable. It measured 1 centimeter by 1 centimeter. There was no underlying tissue damage. The scar did not result in limitation of function. Additional VA treatment records throughout show symptoms largely similar to those found on the VA examinations described above. Under Diagnostic Code 7801, a 10 percent rating is warranted for scars that are deep and nonlinear with an area or areas of at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters), a 20 percent rating is warranted for areas of at least 12 square inches (77 square centimeters) but less than 72 square inches (465 square centimeters), and a 30 percent rating is warranted for areas of at least 72 square inches (465 square centimeters) but less than 144 square inches (929 square centimeters). Under Code 7802, a 10 percent rating is warranted for scars that are superficial and nonlinear with an area or areas of at 144 square inches (929 square centimeters) or greater). Under Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful, a 20 percent rating is warranted for three or four scars that are unstable or painful, and a 30 percent rating is warranted for five or more scars that are unstable or painful. Under Code 7805, scars are rated under an appropriate Code for any disabling effects not considered in a rating under Codes 7800 to 7804. The Board finds that the evidence does not show that the left buttock scar warrants a rating in excess of 10 percent under any applicable rating criteria. On VA examinations, there was one painful scar; the scar was superficial, not unstable, measured 10 by 1.5 centimeters, and did not cause any limitation of function or disabling effects not considered in a rating under any other Code. Therefore, a rating in excess of 10 percent for the left buttock scar is not warranted. The evidence does not show that the left arm scar warrants a compensable rating under any applicable rating criteria. On VA examinations, the scar was superficial, not unstable or painful, measured 2 by 0.5 centimeters or 1 by 1 centimeters (less than 39 square centimeters), and did not result in limitation of function or impact the Veteran's ability to work. Therefore, a compensable rating for the left arm SFW scar is not warranted. The Board finds that the weight of the evidence is against a finding that any higher or separate ratings are warranted for the scars. The Board finds that the evidence is not in relative equipoise and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the appeal must be denied. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Schechner, 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.