Citation Nr: 0006874 Decision Date: 03/14/00 Archive Date: 03/17/00 DOCKET NO. 95-36 995 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for arthritis, claimed as secondary to service-connected disorders of the left thigh, left foot, and left arm. 2. Entitlement to an increased evaluation for residuals of a shell fragment wound to the left thigh, Muscle Group XIII, currently evaluated as 30 percent disabling. 3. Entitlement to an increased evaluation for residuals of a shell fragment wound to the left foot, Muscle Group X, currently evaluated as 20 percent disabling. 4. Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The veteran and his wife ATTORNEY FOR THE BOARD S. J. Janec, Associate Counsel INTRODUCTION The veteran had active military service from March 1941 to December 1945. This matter comes before the Board of Veterans' Appeals (Board) from a January 1995 rating decision of the Columbia, South Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA) which denied service connection for arthritis, claimed as secondary to service-connected disorders of the left thigh, left foot, and left arm; granted an increased evaluation of 30 percent for residuals of a shell fragment wound to the left thigh, Muscle Group XIII; granted an increased evaluation of 20 percent for residuals of a shell fragment wound to the left foot, Muscle Group X; and denied a rating in excess of 10 percent for PTSD. In an August 1996 rating decision, the RO granted an increased evaluation of 30 percent for PTSD. The veteran properly appealed all four issues to the Board. In April 1998, the Board remanded the case to the RO for further development. Most of the requested development was accomplished; however, the issue of entitlement to service connection for arthritis, claimed as secondary to service- connected disorders of the left thigh, left foot, and left arm, must be returned to the RO for further action. In the April 1998 Remand the Board noted that, in May 1997, the veteran had submitted a claim seeking entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU); and, in September 1997, he had submitted a claim seeking entitlement to non-service-connected disability pension benefits, including special monthly compensation based on the need for regular aid and attendance. We further noted that neither of those claims had been developed for appellate review, and referred them to the RO for appropriate action. Upon close review of the claims file, it appears that the RO denied the veteran's TDIU claim in a June 1997 rating decision. It also appears that the veteran did not file a Notice of Disagreement related to that decision. Nevertheless, in a December 1999 statement, the veteran again raised the issue of TDIU. Therefore, that issue is again directed to the RO's attention for appropriate development. FINDINGS OF FACT 1. The veteran's residuals of a shell fragment wound to the left thigh, Muscle Group XIII, result in moderately severe disability to that muscle group; severe disability has not been demonstrated. 2. The evidence is in approximate balance as to whether the residuals of a shell fragment wound to the left foot, Muscle Group X, should be considered to be comparable to disability that would be associated with a severe foot injury. 3. The veteran's PTSD is manifested by definite impairment in his ability to establish and maintain effective or favorable relationships with people or occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; it is not shown that his PTSD results in considerable impairment in his ability to obtain or retain employment, or in occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for an increased rating for residuals of a shell fragment wound to the left thigh, Muscle Group XIII, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.73, Diagnostic Code 5313 (1999). 2. Giving the benefit of the doubt to the veteran, the criteria for a 30 percent rating for a left foot disability (formerly designated as residuals of a shell fragment wound of the left foot, Muscle Group X) have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.102, 4.3, 4.71a, Diagnostic Code 5284 (1999). 3. The criteria for a rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.16, 4.18, 4.132, Diagnostic Code 9411 (1996), 4.130, Diagnostic Code 9411 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background Pertinent service medical records indicate that the veteran sustained a shell fragment wound to the left thigh while in combat with enemy forces on June 6, 1944. In later action in April 1945, he sustained penetrating shell fragment wounds to the medial surface of the lower third of the right leg, the posterior surface of the middle third of the left arm, and the dorsum of the left mid-foot. The left third metatarsal was fractured. The wounds were debrided and the foreign bodies were removed. The left foot was placed in a cast. X- rays in November 1945 showed that the bone was healing. At a VA orthopedic examination in September 1946, it was noted that there was a scar on the dorsum of the left foot, extending from the proximal third of the second metatarsal obliquely downward to the distal third of the fourth metatarsal. The scar was well-healed, nonadherent, and nontender. No swelling or limitation of motion was present. Examination of the left thigh revealed a one-inch scar over the lateral aspect of the middle third, which was well-healed and nonadherent. Another two-inch scar was seen over the medial aspect of the middle third, which was also well-healed and nonadherent. X-rays showed an incomplete, well-healed fracture of the first cuneiform of the left foot, with a large metallic body present at the fracture site. At a VA examination of the muscles in November 1994, the veteran related that he had sustained several shell fragment wounds in service during World War II, and that shrapnel had lodged in the left dorsal area of his left foot. It remained there, and was painful. He also complained of bilateral leg cramps. He had difficulty walking because of the left foot disability, and used crutches at times to maintain his balance. Clinical evaluation revealed that muscle strength of the left thigh, knee, and foot was 4/5. His gait was abnormal, with slight stiffness in the left lower extremity, and the left hip showed limited inversion and eversion. There was mild tissue loss compared to the right extremity where the entrance wound existed, with depression into the muscle group on the left thigh. The scars were well-healed, and there were no adhesions. There was no tendon damage. The assessment was status post injury to the left thigh and left foot, with evidence of tissue damage at the entrance and exit wounds, chronic pain, mild atrophy, and loss of strength of the left lower extremity. At a VA psychiatric examination in November 1994, the veteran's wife related that the veteran had begun having memory problems 10 to 15 years previously, and his difficulties had recently worsened. He was able to shave and feed himself, but he easily got lost and became upset when he was in strange places. He had begun being followed by VA three to four years ago. He was prescribed Haldol, which greatly relieved some of the rage reactions he experienced at night. The veteran related that he often had dreams about the war and became very depressed. He also experienced a great deal of pain in his legs and arms. Clinical evaluation revealed that there was considerable psychomotor retardation. He had difficulty recalling the year, his age, his birthday, and his present location. He also had considerable difficulty recalling past dates and events. His affect was flat, and his mood demonstrated evidence of depression. His thinking was slightly concrete, but there were no loosening of associations, blocking, or rambling. He admitted auditory and visual hallucinations, and he was extremely paranoid with delusions of persecution. The diagnoses were PTSD, by history; Alzheimer's type dementia; and dysthymia disorder. VA outpatient treatment records, dated from July 1995 to May 1999, indicate that the veteran was seen for various physical and mental complaints, including PTSD and pain related to his left thigh and foot disabilities. Dementia was not noted. At a personal hearing before a hearing officer at the RO in July 1996, the veteran testified that he had constant pain in his left thigh and foot. He was unable to stand unassisted on just his left leg, and he believed he had significant muscle loss. He took medication on a regular basis for his PTSD. He said was unable to continue many activities, including fishing, and household chores. His wife testified that the veteran continued to have nightmares and flashbacks, and that he avoided crowds in public places. At a VA joints examination in July 1998, the veteran related that he was ambulating with a cane and was able to walk less than a block. He described constant pain in the left mid- foot medially and dorsally, as well as weakness and increased pain with activity. He treated the problem with new foot wear, and had not had any further surgical intervention. Clinical evaluation revealed that there were well-healed wounds over the anterior medial and anterior lateral sides of the left leg. There was no evidence of erythema, induration, drainage, or tenderness. The left foot lacked toenails over the first two toes. The feet were plantigrade and pulses were palpable. There was loss of motion, bilaterally, with no active dorsiflexion; plantar flexion to 35 degrees; inversion to 5 degrees; and eversion to 5 degrees. The heels were in valgus. There were no intractable plantar keratoses, but there were scars over the left third metatarsal in the left second toe and the plantar aspect of the left foot. The Achilles was significantly tight on the left, and strength was approximately 4/5 in the quadriceps and tibialis anterior. Sensation was diffusely diminished. It was noted that previous X-rays showed metallic foreign bodies in the medial cuneiform. X-rays of the left thigh showed some diffuse osteopenia. The impression was status post open fracture of the left foot with residual pain, dysfunction, and diminished strength, particularly at the extensor hallucis longus, as a result of injury in service. The examiner noted that the foreign bodies in the medial cuneiform were very close to where the extensor hallucis longus would function. Neurologically, there was some diminished sensation, but the examiner opined that this was not equated with the service-connected injury. The bones of the foot were damaged; however, the foot was plantigrade and did not show any areas of focal wear. The quadriceps dysfunction and weakness was thought most likely related to the injury in service. At a VA psychiatric examination in July 1998, the veteran related some of his experiences in World War II. On D-Day, he had sustained wounds to his left thigh. He was hospitalized and returned to duty. While in Germany, he was cut off from his unit and pinned down by a German unit. He subsequently sustained shell fragment wounds to the left foot, right leg, and left arm. After the war, he had several jobs, but was never able to keep them because of his nerves. He was very paranoid and could not stand being around people. He said he had last worked approximately three to four years prior. The veteran's wife reported that, since his return from the war, the veteran had continued to have nightmares and dreams of his experiences. He often believed there were enemies in their backyard. He was unable to participate in any significant activities; he experienced significant periods of irritability, difficulty concentrating, and hypervigilance with an exaggerated startle response. The examiner noted that the veteran had begun to receive psychiatric treatment at VA five years ago, and was diagnosed with PTSD and dementia. He was treated with Haldol and Ativan, which he continued to take. His wife indicated that she had to assist him with most activities. Clinical evaluation revealed that the veteran was neat, clean, and appropriately dressed. He had poor eye contact and demonstrated significant psychomotor retardation. His speech was nonspontaneous and brief. His mood was dysphoric and his affect was flat. His thought processes seemed to be logical and goal directed; thought content was without any auditory or visual hallucinations. He admitted having nightmares. He was alert and oriented to person and place only. His immediate memory was 0/3 and his thinking was very concrete. He could not do any mathematical calculations or serial 7's, and he could not spell backwards. Insight and judgment were limited. The diagnoses were Alzheimer's type dementia and PTSD. His GAF was reported to be 35. The examiner concluded that, while the veteran did have symptoms related to PTSD, his current symptomatology was dominated by dementia, which was evident from the significant cognitive impairments noted. The veteran submitted a VA outpatient treatment record, dated in May 1999, directly to the Board. In his October 1999 Written Brief Presentation, the veteran's representative waived RO review of this evidence in accordance with 38 C.F.R. § 20.1304. The record indicates that the veteran was seen for complaints that his "PTSD was real bad." He said he cannot be in crowds and is unable to hold a job. His wife related that he struggled with employment and social impairments. The assessment was multiple health problems, including PTSD. II. Analysis Initially, the Board finds that the veteran's claims for increased ratings are well grounded within the meaning of 38 U.S.C.A. § 5107(a). The Court of Appeals for Veterans Claims has held that, when a veteran asserts that a service- connected disability has increased in severity, the claim for an increased rating is generally well grounded. See Jackson v. West, 12 Vet.App. 422, 428 (1999), citing Proscelle v. Derwinski, 2 Vet.App. 629 (1992). Furthermore, after reviewing the record, the Board is satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required to comply with the duty to assist him mandated by 38 U.S.C.A.§ 5107(a). In general, disability evaluations are assigned by applying a schedule of ratings which represent, as far as can practicably be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155. Although the regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history, 38 C.F.R. §§ 4.1, 4.2, 4.41, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, it is the present level of disability which is of primary concern. Francisco v. Brown, 7 Vet.App. 55 (1994). Cf. Powell v. West, 13 Vet.App. 31 (1999) (holding that earlier findings may be used if the most recent examination is inadequate). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (1999). Therefore, under the reasonable doubt doctrine, where we find an approximate balance of positive and negative evidence on the merits of the claim, the benefit of the doubt shall be given to the veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). The Court of Appeals for Veterans Claims has also held that, where a pertinent law or regulation changes after a claim has been filed or reopened but before the administrative and/or judicial appeal process has been concluded, the version most favorable to the appellant will apply unless Congress provided otherwise or permitted the Secretary of Veterans Affairs to do otherwise and the Secretary has done so. See Fischer v. West, 11 Vet.App. 121, 123 (1998), quoting Karnas v. Derwinski, 1 Vet.App. 308, 312-313 (1991). See also Baker v. West, 11 Vet.App. 163, 168 (1998); Dudnick v. Brown, 10 Vet.App. 79 (1997) (per curiam order). During the pendency of the veteran's claims, VA issued new regulations for evaluating disability due to muscle injuries, effective July 3, 1997. 62 Fed. Reg. 30,235-30,240 (1997). Likewise, the rating criteria for psychiatric disorders were amended, effective on November 7, 1996. 61 Fed. Reg. 52,700 (1996). The RO has, and the Board will, consider the criteria most favorable to the veteran in rating his claims. A. Residuals of Shell Fragment Wounds Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little-used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. 38 C.F.R. § 4.40 (1999). As regards the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight- bearing are related considerations. 38 C.F.R. § 4.45 (1999). The conception of disability of a muscle or muscle group is based on the ability of the muscle to perform its full work and not solely on its ability to move a joint. A muscle which can barely move its bony lever but which has no substantial excess of power or endurance to enable it to perform work by that movement is in effect a useless muscle for occupational efficiency. Tests for ability to move adjacent joints are useless for estimation of the disability in cases of muscle injuries unless all the movements are required to be made against varying resistance (for example, with gravity, against gravity, against moderate resistance, against strong resistance) and compared with the sound side. Comparative tests of endurance and of coordination are also needed. Muscle injuries alone do not necessarily limit the movements of adjacent joints and these movements may be freely carried out by very weak muscles, or even by gravity alone without muscular participation as in extension of the elbow and in dropping the arm to the side. 38 C.F.R. § 4.51 (1997). The factors used for consideration in the rating of muscle injuries, particularly as they relate to residuals of gunshot and shell fragment wounds, are set forth in 38 C.F.R. § 4.56, which was amended in 1997. Under the old version, 38 C.F.R. § 4.56 provided that moderate disability of a muscle would be characterized by a through and through or deep penetrating wound of relatively short track, by a single bullet or a small shell or shrapnel fragment. There would be an absence of the explosive effect of a high velocity missile, and of residuals of debridement or of prolonged infection. The service medical records would show a record of hospitalization in service for treatment of the wound. In addition, there would be records following service of consistent complaints of one or more of the cardinal symptoms of muscle wounds, particularly fatigue and fatigue-pain after moderate use, affecting the particular functions controlled by the injured muscles. Objectively, the medical evidence would show a moderate injury to a muscle group manifested by an entrance and (if present) exit scar, linear or relatively small and so situated as to indicate a relatively short track of the missile through tissue; signs of moderate loss of deep fasciae or muscle substance or impairment of muscle tonus, and definite weakness on comparative tests. 38 C.F.R. § 4.56(b) (1997). Also under the old version of 38 C.F.R. § 4.56, moderately severe disability of a muscle would be characterized by a through and through or deep penetrating wound by a high velocity missile of small size or a large missile of low velocity, with debridement or with prolonged infection or with sloughing of soft parts, and intermuscular cicatrization. The service medical records would show a record of hospitalization for a prolonged period in service for treatment of the wound of severe grade. In addition, there would be records following service of consistent complaints of cardinal symptoms of muscle wounds. There might also be evidence of unemployability because of an inability to keep up with the work requirements. Objectively, the medical evidence would show a moderately severe injury to a muscle group manifested by an entrance and (if present) exit scar relatively large and so situated as to indicate a track of the missile through important muscle groups. Further, there would be indications, on palpation, of moderate loss of deep muscle substance or moderate loss of normal firm resistance of muscles compared with the sound side. Tests of strength and endurance of muscle groups involved would give positive evidence of marked or moderately severe loss. 38 C.F.R. § 4.56(c) (1997). In addition, the old version of 38 C.F.R. § 4.56 provided that severe disability of a muscles would be characterized by a through and through or deep penetrating wound due to a high velocity missile or large or multiple low velocity missiles, or the explosive effect of high velocity missile, or a shattering bone fracture with extensive debridement or prolonged infection and sloughing of soft parts, intermuscular binding, and cicatrization. The service medical records would show a record of hospitalization for a prolonged period in service for treatment of the wound of severe grade. In addition, there would be records following service of consistent complaints of cardinal symptoms of muscle wounds. There might also be evidence of unemployability because of an inability to keep up with the work requirements. Objectively, the medical evidence would show a severe injury to a muscle group manifested by extensive ragged, depressed, and adherent scars of skin so situated as to indicate wide damage to muscle groups by the track of the missile. X-rays might show minute, multiple, scattered foreign bodies, indicating the spread of intermuscular trauma and the explosive effects of the missile. Palpation would reveal moderate or extensive loss of deep fasciae or muscle substance, with soft or flabby muscles in the wound area. Tests of strength, endurance compared with the sound side, or coordinated movements would show positive evidence of severe impairment of function. Reaction of degeneration would not be present in electrical tests, but a diminished excitability to faradic current, compared with the sound side, may be present. Visible or measured atrophy may be present, with adaptive contractions or the opposing groups of muscles, if present, indicating severity. Adhesion of the scar to one of the long bones, scapula, pelvic bones, sacrum, or vertebra, with epithelial sealing over the bone without true skin covering, in an area where bone is normally protected by muscle, indicates the severe type of muscle damage. Atrophy of muscle groups not included in the track of the missile, particularly of the trapezius and serratus in wounds to the shoulder girdle (traumatic muscular dystrophy), and induration and atrophy of an entire muscle following simple piercing by a projectile (progressive sclerosing myositis), may be included in the severe group if there is sufficient evidence of severe disability. 38 C.F.R. § 4.56(d) (1997). Under the new version of the rating criteria, the introductory portion of 38 C.F.R. § 4.56 provides that: (a) an open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal; (b) a through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged; (c) for VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement; and (d) under diagnostic codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe, or severe. The Board notes that the remainder of the new version of 38 C.F.R. § 4.56 is otherwise basically the same as the old version, in its description of the relative serevity of muscle disabilities. Also, the current provisions of 38 C.F.R. § 4.56(a) and (b) were formerly contained in 38 C.F.R. § 4.72, as in effect prior to June 3, 1997. However, for the sake of clarity and in order to show that both versions have been fully considered by the Board, we will set forth the new version. Under the new version of the rating criteria at 38 C.F.R. § 4.56(d), moderate disability of muscles is described as: (i) Type of injury: through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection; (ii) History and complaint: service department record or other evidence of in-service treatment for the wound; record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles; (iii) Objective findings: entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2) (1999). Also under the new version of the rating criteria, moderately severe disability of muscles is described as: (i) Type of injury: 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; (ii) History and complaint: service department record or other evidence showing hospitalization for a prolonged period for treatment of wound; record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements; (iii) Objective findings: entrance and (if present) exit scars indicating track of missile through one or more muscle groups; indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side; tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3) (1999). Finally, under the new version of the rating criteria, severe disability of muscles is described as: (i) Type of injury: through and through or deep penetrating wound due to high- velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring; (ii) History and complaint: service department record or other evidence showing hospitalization for a prolonged period for treatment of wound; record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements; (iii) Objective findings: ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track; palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area; muscles swell and harden abnormally in contraction; tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) Visible or measurable atrophy; (E) Adaptive contraction of an opposing group of muscles; (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4) (1999). Scars which are tender and painful on objective demonstration, or poorly nourished with repeated ulceration, are rated 10 percent disabling. 38 C.F.R. § 4.118, Diagnostic Codes (DC) 7803, 7804 (1999). Separate ratings may be assigned for the separate and distinct manifestations of the same injury. Esteban v. Brown, 6 Vet.App. 259 (1994). 1. Muscle Group XIII The veteran's residual disability from a shell fragment wound to the left thigh, Muscle Group XIII, is currently evaluated as 30 percent disabling under the criteria for impairment of that muscle group. The functions affected by Muscle Group XIII include extension of the hip and flexion of the knee; outward and inward rotation of flexed knee; acting with rectus femoris and sartorius synchronizing simultaneous flexion of hip and knee and extension of hip and knee by belt-over-pulley action at knee joint. It involves the posterior thigh group, and the hamstring complex of two-joint muscles: (1) biceps femoris; (2) semimembranosus; and (3) semitendinosus. Moderately severe disability of Muscle Group XIII is assigned a 30 percent disability rating. Severe disability of Muscle Group XIII warrants a 40 percent disability rating. 38 C.F.R. § 4.73, DC 5313 (1997, 1999). Based upon a review of the record before us, the Board finds that an increased rating is not warranted. Service medical records show that the veteran sustained a penetrating shell fragment wound to the left thigh in 1944. There is no indication that the femur was fractured or broken. Upon VA orthopedic examination in September 1946, no significant disability of the thigh was indicated, and the scars were noted to be well-healed and nonadherent. VA examinations in November 1994, and in July 1998, revealed decreased muscle strength in the left thigh, with mild tissue loss and depression into the muscle group. In addition, the left hip demonstrated limited inversion and eversion. These findings are not suggestive of severe muscle disability to Muscle Group XIII. Therefore, the Board concludes that the current 30 percent rating adequately reflects the level of disability associated with this injury. The Board further notes that, as the scars were reported to be well-healed, nontender, and nonadherent, a separate rating under DC 7803 or 7804 may not be assigned. See Esteban, supra. 2. Muscle Group X The veteran's left foot disability is currently evaluated as 20 percent disabling under the criteria for impairment of Muscle Group X (dorsal). 38 C.F.R. § 4.73, DC 5310. Muscle Group X includes the muscles of the foot on the plantar and dorsal sides. The plantar side includes the: (1) flexor digitorum brevis; (2) abductor hallucis; (3) abductor digiti minimi; (4) quadratus plantae; (5) lumbricales; (6) flexor hallucis brevis; (7) adductor hallucis; (8) flexor digiti minimi brevis; and (9) dorsal and plantar interossei. The functions affected by these muscles include movement of the forefoot and toes, and propulsion thrust in walking. Moderately severe plantar dysfunction is assigned a 20 percent disability rating. To warrant a 30 percent rating, the plantar dysfunction must be severe. The dorsal side involves the: (1) extensor hallucis brevis; and (2) extensor digitorum brevis. Other important dorsal structures include: cruciate, crural, deltoid, and other ligaments; tendons of long extensors of toes and peronei muscles. Severe dorsal dysfunction is assigned a 20 percent disability rating. This is the maximum rating under DC 5310 for dorsal dysfunction, in both the 1997 and 1999 versions. Under a diagnostic code which can be applied to any foot disorder, irrespective of the specific degree of muscle damage, moderate foot injuries may be assigned a 10 percent disability rating. A 20 percent rating will be assigned if a foot injury is moderately severe. Severe foot injuries warrant a 30 percent disability rating. 38 C.F.R. § 4.71a, DC 5284 (1997, 1999). Based upon a review of the evidence of record, the Board concludes that, although the evidence may not preponderate in the veteran's favor, it permits us to exercise the doctrine of reasonable doubt to find that the veteran's left foot disability now warrants an increased rating. It is clear that the original shell fragment wounds caused considerable damage on the dorsal side of the foot, and in fact, he is currently receiving the maximum rating under DC 5310. The medical evidence does not indicate that the injury involved the plantar side of the foot. Therefore, a 30 percent rating for severe muscle disability pursuant to that portion of DC 5310 would not be appropriate. Nevertheless, the Board finds that the veteran's overall left foot disability has recently increased in severity. Upon VA examination in July 1998, it was noted that he ambulated with a cane and was only able to walk a very short distance. The left ankle demonstrated no dorsiflexion, and the examiner stated that there was diffusely diminished strength in the left foot. X-rays demonstrated that foreign bodies in the medial cuneiform were present, and interfered with the foot's functioning. Accordingly, the Board finds that there is an approximate balance in the evidence, as to whether veteran's residuals of a shell fragment wound to the left foot may be characterized as a severe foot injury under DC 5284. Therefore, resolving reasonable doubt in the veteran's favor, a 30 percent rating for this disability is warranted. This represents the maximum rating available for this disability under the rating schedule. In addition, the Board notes that, the residual scars from this injury have been reported to be well-healed and non-tender. Therefore, a separate rating under DC 7803 or 7804 may not be granted. See Esteban, supra. B. PTSD Under the old provisions, in evaluating impairment resulting from mental disorders, social inadaptability was to be evaluated only as it affected industrial adaptability. The principle of social and industrial inadaptability, the basic criterion for rating disability from a mental disorder, contemplated those abnormalities of conduct, judgment, and emotional reactions which affect economic adjustment, i.e., the impairment of earning capacity. 38 C.F.R. § 4.129 (1996). The severity of disability was based upon actual symptomatology as it affected social and industrial adaptability. Two of the most important determinants of disability were time lost from gainful employment and decrease in work efficiency. The regulation emphasized that VA should not underevaluate the emotionally sick veteran with a good work record, nor overevaluate his or her condition on the basis of a poor work record not supported by the psychiatric disability picture. It was for that reason that great emphasis was placed upon the full report of the examiner which was descriptive of actual symptomatology. The record of the history and complaints was only preliminary to the examination. The objective findings and the examiner's analysis of the symptomatology were the essentials. 38 C.F.R. § 4.130 (1996). When evaluating a mental disorder under the new criteria, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (1999). The veteran is currently assigned a 30 percent disability rating for his service-connected PTSD. Under the General Rating Formula for Psychoneurotic Disorders, effective prior to November 7, 1996, a 30 percent rating was assigned when the evidence demonstrated definite impairment in the ability to establish or maintain effective and wholesome relationships with people, and where the psychoneurotic symptoms resulted in such reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. A 50 percent rating was warranted when the evidence demonstrated that the ability to establish or maintain effective or favorable relationships with people was considerably impaired, and, by reason of psychoneurotic symptoms, the reliability, flexibility, and efficiency levels were so reduced as to result in considerable industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). Under the current criteria, a 30 percent rating requires evidence of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130 (1999). Based upon a review of the evidence, the Board finds that an increased rating for the veteran's PTSD is not warranted, under either the old or the new rating criteria. Upon VA examinations in November 1994 and July 1998, it was noted that the veteran's current psychiatric symptomatology was caused primarily by his Alzheimer's-type dementia, not PTSD. Therefore, the significant cognitive impairment that resulted from the non-service-connected dementia may not be used in rating the PTSD. It was also noted that the veteran's PTSD symptoms did not appear to be severe. Based on these clinical assessments, the Board finds that the 30 percent rating currently in effect adequately reflects the level of impairment associated with that disability. Therefore, an increased rating is not warranted. See 38 C.F.R. § 4.132, DC 9411 (1996); 38 C.F.R. § 4.130, DC 9411 (1999). The Board notes that the veteran's wife and representative have asserted that the record does not indicate the presence of dementia prior to the veteran's July 1998 VA examination, and that his psychiatric impairment results solely from his PTSD. However, the Board would respectfully point out that the veteran was also noted to suffer from Alzheimer's-type dementia on VA examination in November 1994. While the outpatient treatment reports may not mention the veteran's dementia, the information from the two VA examinations is not in conflict. Furthermore, questions of medical diagnosis or causation require medical expertise. The Board does not doubt the sincerity of the beliefs of the veteran's wife and his representative; however, as laypersons they are not competent to offer medical opinions. See Routen v. Brown, 10 Vet.App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (1998), cert. denied, 119 S. Ct. 404 (1998). See also Espiritu, supra; Moray v. Brown, 5 Vet.App. 211 (1993). ORDER An increased rating for residuals of a shell fragment wound, Muscle Group XIII, is denied. A 30 percent rating for a left foot disability (formerly rated as residuals of a shell fragment wound to the left foot, Muscle Group X) is granted, subject to the regulations governing the payment of monetary awards. An increased rating for PTSD is denied. REMAND It appears that the issue of service connection for arthritis, claimed as secondary to the service-connected disorders of the left thigh, left foot, and left arm, has been returned to the Board for decision despite the fact that the evidentiary development requested in the April 1998 Remand has not been fully accomplished. The veteran's representative noted this fact in his October 1999 Written Brief Presentation. The United States Court of Appeals for Veterans Claims has definitively held that the Board must remand any case in which there has been a failure to comply with directions in an earlier Board remand. Stegall v. West, 11 Vet.App. 268 (1998). The RO clearly made an effort to fulfill all the development requested by the Board in the April 1998 remand. However, the Board directed the RO to more fully develop the issue of entitlement to service connection for arthritis, by scheduling an examination, including X-rays, and requesting an opinion as to the etiology of the veteran's arthritis disorder, if present. The examination was scheduled and conducted in July 1998. However, as noted by the veteran's representative, the requested X-rays were not accomplished, and a medical opinion was not expressed. Therefore, this issue must be returned to the RO for further evidentiary development. Accordingly, the case is REMANDED to the RO for the following action: 1. The RO should obtain copies of any recent records of VA hospitalization or treatment that have not been associated with the veteran's claims file. 2. The veteran should be scheduled for a VA examination which includes indicated X-ray studies. After the examination and a review of the medical record, the examiner should clearly indicate whether or not the veteran has arthritis, and, if so, should specify the joints affected. The examiner should also express an opinion, based upon the history and examination of the veteran, as to whether any diagnosed arthritis disorder is etiologically related to the veteran's service-connected disabilities involving the left thigh, foot, and arm. 3. When the above development has been completed, and all evidence obtained has been associated with the file, the claim for service connection for arthritis, claimed as secondary to the service-connected disabilities involving the left thigh, foot and arm, should be readjudicated by the RO. If the decision remains adverse to the veteran, he and his representative should be furnished with a Supplemental Statement of the Case and afforded a reasonable opportunity to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further consideration if appropriate. The veteran need take no action until he is informed. However, the veteran is advised that he has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet.App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. ANDREW J. MULLEN Member, Board of Veterans' Appeals