Citation Nr: 0001896 Decision Date: 01/24/00 Archive Date: 02/02/00 DOCKET NO. 98-06 061 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a shell fragment wound to the jaw and gum. 2. Entitlement to an increased evaluation for a healed fracture of the left elbow with a residual operative scar, a history of paresthesias of the left arm, and x-ray evidence of degenerative disc disease (minor), currently rated as 10 percent disabling. 3. Entitlement to an increased evaluation for a partial collapse of L1 and narrowing of the intervertebral base at T12-L1, currently evaluated as 10 percent disabling. 4. Entitlement to a compensable evaluation for a healed fracture of the left tibia and fibula with shortening of the left leg. 5. Entitlement to a compensable evaluation for a shell fragment wound to the right leg. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Odlum, Associate Counsel INTRODUCTION The veteran had active military service from January 1968 to November 1980. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 1996 rating decision from the Waco, Texas Department of Veterans Affairs (VA) Regional Office (RO). The veteran raised a claim, in pertinent part, of service connection for a right ear injury in February 1981. During the August 1999 hearing before a travel Member of the Board, the veteran indicated that his left ear was partially torn off while he was serving in the Republic of Vietnam, and that his hearing had been slightly impaired as a result. He testified that he had suffered partial deafness in his left ear as a result of noise from transmission right next to his left ear. Transcript, p. 10. The Board concludes that the veteran has raised claims of service connection for disabilities to the right and left ears. As theses issue have been neither procedurally developed nor certified for appellate review, the Board is referring them to the RO for initial consideration and appropriate action. Godfrey v. Brown, 7 Vet. App. 398 (1995). The veteran testified to having shrapnel wounds to the throat and the side of the neck which he sustained while in the military. Tr., p. 11. He also contended that he had suffered injuries to his knees secondary to his service connected left leg injury with shortening of the left leg. Tr., p. 3. As the issues of service connection for shrapnel wounds to the throat and side of the neck and service connection for injuries to the knees as secondary to his healed fracture of the left tibia and fibula with shortening of the left leg have been neither procedurally developed nor certified for appellate review, the Board is referring them to the RO for initial consideration and appropriate action. Godfrey, supra. The Board notes that the veteran testified during the August 1999 hearing to having difficulty with maintaining employment as a result of his service-connected disabilities. It has been held that, in an appealed claim for an increased rating, the Board has jurisdiction to consider entitlement to a total disability rating based on individual unemployability (TDIU) when that issue is raised, either by assertion or reasonably indicated by the evidence, even though the RO did not expressly address the issue. See VAOPGCPREC 6-96; Caffrey v. Brown, 6 Vet. App. 377, 382 (1994); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). However, it has also been held that the question of a TDIU entitlement may be considered a component of an appealed increased rating claim only if the TDIU claim is based solely upon the disability or disabilities which are the subject of the increased rating claim. VAOPGCPREC 6-96. In the case at hand, the veteran has also indicated that disabilities that have not been service-connected and are not part of the current appeal (knee problems) have caused a major portion of his problems with his employers. Transcript, p. 4. Because the veteran's allegations concerning his difficulty with maintaining employment include a non-service connected disability not currently on appeal, the Board concludes that it does not have jurisdiction to address the issue of entitlement to a TDIU. See VAOPGCPREC 6-96. Accordingly, the issue of entitlement to a TDIU which has neither been procedurally prepared nor certified for appellate review, and is otherwise not properly before the Board at this time, is referred to the RO for initial consideration and appropriate action. Godfrey, supra. FINDINGS OF FACT 1. The claim of entitlement to service connection for a shell fragment wound to the jaw and gum is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 2. All relevant evidence necessary for an equitable disposition of the increased rating claims has been obtained. 3. The left elbow disability is not manifested by ankylosis, marked cubitus varus or cubitus valgus deformity, nonunion of the radius or ulna, or malunion of the ulna or radius, with bad alignment. 4. The spinal disability at T12-L1 is manifested by limitation of motion with demonstrable deformity of a vertebral body, and additional functional loss due to pain. 5. The left tibia and fibular disability is manifested by malunion with a slight ankle disability. 6. The shell fragment wound to the right leg is not manifested by moderate disability to Group XI muscle functioning. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for a shell fragment wound to the jaw and gum is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The criteria for a rating in excess of 10 percent for a healed fracture of the left elbow with a residual operative scar, a history of paresthesias of the left arm, and x-ray evidence of degenerative disc disease (minor) have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010- 5207 (1999). 3. The criteria for an increased rating of 30 percent for a partial collapse of L1 and narrowing of the intervertebral base at T12-L1 have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.25, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5285-5292 (1999). 4. The criteria for a 10 percent rating for a healed fracture of the left tibia and fibula with shortening of the left leg have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5262 (1999). 5. The criteria for a compensable rating for a shell fragment wound to the right leg have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.73, Diagnostic Code 5311 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection for Shell Fragment Wounds to the Jaw and Gum Factual Background Available service medical records show no documentation of a shell fragment wound to the jaw and gum. Dental records indicate that some teeth were removed, but they do not specifically document an injury or other impairment involving the jaw or gum. There is no documented diagnosis regarding the jaw or gums on separation examination. The mouth and throat were described as being normal. In a report of medical history on separation examination, the veteran reported sustaining a head injury; however, he denied having severe tooth or gum trouble. VA examination in March 1981 indicated, in pertinent part, that examination of the head, face, neck, mouth, and throat were normal. On examination at the New Orleans VA Outpatient Clinic in March 1984, a past medical history of scars on the chin was noted. On examination, there was a three centimeter (cm), well-healed, and non-adherent scar on the inferior chin area, and a 2 cm, well-healed and non-adherent scar on the left chin area. It was also indicated that there were three missing teeth. The diagnosis was, in pertinent part, scars of the chin. In February 1995 the veteran submitted a VA Form 21-4138, specifically alleging, in pertinent part, service connection for a shell fragment wound to the jaw and gum. In a statement dated from October 1996, the veteran contended that he still had a scar on his chin where a fragment hand gone through and cut his gum. He stated that he was "medivaced" from the 93rd EVAC Hospital in Bien Hoa, Vietnam to the 106th Medivac Hospital in Japan, then to Letterman Hospital in California. He reported that his gum had to be sewn back together to keep his teeth in place, but that it was necessary to have two teeth removed as a result of this. He reported that he was presently having a problem with his teeth falling out. In December 1997 the veteran reported that he had been informed that there was no record of his conditions from Letterman General Hospital due to a fire in 1975. In August 1999 a hearing before the undersigned Member of the Board was conducted. During the hearing, the veteran testified, in pertinent part, to having an iron plate go up through his chin, tearing out all of the gum, which had to be removed. Transcript, p. 3. He testified that his teeth were sewn in, leaving just skin over the teeth. He stated he was told that he would be losing his teeth. Tr., p. 3. He testified that his teeth were dropping out, but that he had been able to get treatment for it because he was not covered "by any of this." Id. The veteran testified that these problems began while he was in service. Transcript, p. 4. He reported that his teeth began falling out while he was in the service and that it was increasing lately because of the gap in the teeth. Tr., p. 5. Criteria Pursuant to 38 U.S.C.A. § 5107(a), a person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well-grounded. The United States Court of Appeals for Veterans Claims (Court) has held that a well-grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of § [5107(a)]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The Court has also held that although a claim need not be conclusive, the statute provides that it must be accompanied by evidence that justifies a "belief by a fair and impartial individual" that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 610 (1992). The Court has held that "where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is 'plausible' or 'possible' is required." Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993) (citing Murphy, at 81). The Court has held that a well-grounded claim requires competent evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). See Epps v. Brown, 126 F.3d. 1464, 1468 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). In order to establish service connection for a claimed disability the facts must demonstrate that a disease or injury resulting in current disability was incurred in active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Where there is a chronic disease shown as such in service or within the presumptive period under § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (1999). This rule does not mean that any manifestation in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt doctrine in resolving each such issue shall be given to the veteran. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Analysis Section 5107 of Title 38, United States Code unequivocally places an initial burden upon the veteran to produce evidence that his claim is well grounded; that is, that his claim is plausible. Grivois v. Brown, 6 Vet. App. 136, 139 (1994); Grottveit v. Brown, 5 Vet. App. 91, 92 (1993). Because the veteran has failed to meet this burden, the Board finds that his claim of entitlement to service connection for a shell fragment wound to the jaw and gum must be denied as not well grounded. The Board reiterates the three requirements for a well grounded claim: (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in- service incurrence or aggravation of a disease or injury; and, (3) medical evidence of a nexus between the claimed inservice injury or disease and a current disability. See Caluza, supra. The veteran has contended that he suffered a shell fragment wound to his jaw and gum while in the service. The record shows that the veteran was diagnosed with scars on his chin in 1984. The record also shows that the veteran has missing teeth. However, there are no documented medical opinions or other competent evidence of record linking the veteran's current disability to military service. In addition, there is no evidence that the veteran manifested a chronic disease pertaining to the jaw or gums in service. Nor is there medical evidence of a relationship between the veteran's current disability and his alleged continuity of symptomatology. See Voerth v. West, 13 Vet. App. 117 (1999); McManaway v. West, 13 Vet. App. 60 (1999); Savage v. Gober, 10 Vet. App. 488 (1997). The veteran's own opinions and statements will not suffice to well-ground his claim. While a lay person is competent to provide evidence on the occurrence of observable symptoms during and following service, such a lay person is not competent to make a medical diagnosis or render a medical opinion, which relates a medical disorder to a specific cause. Espiritu v. Derwinski, 2 Vet. App. 492, 494-495 (1992). Neither is the Board competent to supplement the record with its own unsubstantiated medical conclusions as to whether the veteran's current disability is related to a disease or injury incurred during service. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The Board notes that the veteran has referred to being treated at Letterman General Hospital for a lacerated chin and gums while in the service. He has stated that, following his in-service injury, he was evacuated from the 93rd EVAC Hospital in Bien Hoa, Vietnam to the 1206th Medivac Hospital, and from there to Letterman General Hospital in California. Pursuant to 38 U.S.C.A. § 5103(a), if VA is placed on notice of the possible existence of information that would render the claim plausible, and therefore well grounded, VA has the duty to advise the veteran of the necessity to obtain the information. McKnight v. Gober, 131 F.3d 1483, 1484-1485 (Fed. Cir. 1997); Robinette v. Brown, 8 Vet. App. 69, 80 (1995). In this case, the Board finds that the duty to inform does not attach to the above-mentioned evidence because there is no indication that it would well-ground his claim, i.e., provide a nexus between a current disability and service, or between a current disability and his alleged continuity of symptomatology, as these records pertain to in-service treatment and not to treatment of a current disability which could help provide competent medical evidence of a nexus between a current disability and service or between a current disability and his alleged continuity of symptomatology. In addition, the Board notes that it has been indicated that such records could not be obtained because of a fire at Letterman Hospital. See Franzen v. Brown, 9 Vet. App. 235 (1996) The Board therefore finds that the RO has advised the veteran of the evidence necessary to establish a well grounded claim, and the veteran has not indicated the existence of any evidence that has not already been obtained that would well ground his claim. McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Brown, 9 Vet. App. 341, 344 (1996), aff'd sub nom. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). Because there is no competent medical evidence of a nexus between the veteran's current disability and service, the Board finds that his claim of entitlement to service connection for a shell fragment wound to the jaw and gum must be denied as not well grounded. The Board views its foregoing discussion as sufficient to inform the veteran of the elements necessary to complete his application to reopen this claim. See Graves v. Brown, 8 Vet. App. 522 (1996); Robinette v. Brown, 8 Vet. App. 69, 77-78 (1995); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). As the veteran's claim for service connection of a shell fragment wound to the jaw and gum is not well grounded, the doctrine of reasonable doubt has no application to his claim. Increased Rating Claims: Left Elbow, Back, Left Tibia and Fibula, and Right Leg Factual Background The pertinent evidence of record shows that the veteran was seen at the Biloxi VA Medical Center (VAMC) in January 1993 with complaints of, in pertinent part, chronic low back pain and problems with his left elbow, including occasional numbness in his left arm. Physical examination revealed mild discomfort in both hips and discomfort in the left elbow. X- rays of the lumbosacral spine revealed wedging of L1 consistent with an old healed compression fracture. X-rays of the left elbow were interpreted as revealing post- operative changes with deformity of the olecranon consistent with an old healed fracture, without arthritis. In April 1993, a VA examination was conducted. Examination of the left elbow revealed 150 degrees flexion and 10 degrees lacking from terminal extension. X-rays of the left elbow revealed an old trauma and post-surgical changes of the olecranon with resulting degenerative disease and probable calcifications in the tendon with no actual complication. Examination of the left tibia revealed a prominence representing the fracture site. It was noted that there was a one half to three quarters of an inch shortening of the left leg. In August 1993, the RO assigned a 10 percent rating for the left elbow disability in view of the limitation of motion and the degenerative changes found in the elbow on x-ray examination. A 10 percent rating was assigned for the back disability based on the observation that there was a demonstrable deformity of a vertebral body. In February 1995 the veteran was seen at the Temple VAMC for complaints of, in pertinent part, low back pain. It was indicated that the veteran did not want to wait for an examination, and he was scheduled for an appointment. In February 1995 the veteran raised, in pertinent part, claims of increased ratings for his service-connected spine, left elbow, left leg, and right leg disabilities. VA outpatient records from June 1996 show that the veteran was seen at that time with complaints of, in pertinent part, chronic low back pain and an inability to extend his left elbow with intermittent numbness. Examination revealed a deformity of the left elbow with extension limited to 80 degrees. There was paravertebral tenderness at T4-5 and spasm tenderness at L5-S1. The assessment was mechanical low back pain and degenerative joint disease of the thoracic spine. A note from these VA records indicates that the veteran was found to have the following problems, in pertinent part: traumatic arthritis of the lumbar spine, status post fracture of the left tibia-fibula with shortening of the left leg, and recurring episodes of numbness in the left forearm and hand. In May 1998 the veteran underwent a VA examination of the bones. With respect to the healed left elbow fracture, the veteran reported that there was no pain but that he could twist the arm a sudden way and lose all feeling and strength below the elbow, and that heavy lifting was bothersome. He stated that his service-connected spinal disability required that he make frequent position changes because prolonged sitting, standing, or walking would bother the back. He stated that lifting was bothersome but that there was no radiation of pain in the lower extremities. As for the healed fracture of the left tibia and fibula, the veteran was noted as indicating that there was some shortening of the left leg and that his leg was bothered by prolonged periods of weight bearing. He reported that his right leg disability bothered him with weather changes and that he would experience cramping pain at times; otherwise, he was noted as reporting that he could stand and walk "okay" on the right leg. On physical examination, the veteran was noted as moving about the room without difficulty and no definite limp appreciated. Limb lengths were measured and there was noted to be a half inch shortening of the left leg. Range of motion of both knees was from 0 to 145 degrees. The right lower leg had several small scars on the lateral aspect. The left leg revealed a large bony prominence at the junction of the mid and distal one-third of the tibia representing the fracture site. The leg was found to be in otherwise good alignment. He was able to heel and toe walk, and squat and arise again. There was 5/5 strength in both lower extremities, and both quadriceps measured 33 centimeters (cm) at a point of three finger breadths above the superior patella border. Calf measurements were 32 cm bilaterally. Reflexes and sensation were intact in the lower extremities. X-rays of the left tibia and fibula were interpreted as showing healed fracture deformities of the mid-shafts of the tibia and fibula with no apparent complications. Examination of the left elbow revealed a well-healed surgical scar on the posterior lateral aspect. The veteran was noted as being right hand dominant. The left elbow lacked 15 degrees in terminal extension and had 140 degrees of flexion. It was noted that there was no pain on motion, and no swelling or tenderness. He made a good fist and the right hand could oppose the thumb and remaining fingertips satisfactorily. There was 5/5 strength in the upper extremities. Upper extremity measurements were found to be 24 cm bilaterally. Proximal forearm measurements were 24 cm on the right and 23 cm on the left. Reflexes and sensation were found to be intact. X-rays of the left elbow were interpreted as showing a deformity of the olecranon, compatible with a healed trauma. Examination of the back revealed that the veteran was able to stand erect. There was 70 degrees of flexion, 30 degrees of extension, and 30 degrees of right and left lateral bending. There was pain on extremes of extension and left lateral bending. X-rays of the lumbar spine revealed anterior compression of the L1 vertebral body compatible with an old trauma. No other abnormalities were found to be evident. The diagnoses were post-operative residuals of a left elbow injury with a healed fracture, limitation of motion, and paresthesias by history with an unremarkable neurological examination; chronic lumbar syndrome (a history of a partial collapse of L1 with narrowing at T12-L1 secondary to an old injury); residuals of a healed fracture of the left tibia and fibula with limb length shortening and limitation of motion in the left ankle; and shell fragment wounds of the right leg. The VA examiner specifically concluded that pain, particularly in the back, could further limit functional ability during flare-ups or with increased use. In August 1999 a hearing before the undersigned Member of the Board was conducted. The veteran testified to having a major calcium buildup and a loss of sensation due to nerve damage in his left leg. Transcript, p. 2. With respect to his left elbow, he testified to having frequent and numerous occasions of loss of sensation through the entire lower portion of his left arm along with lack of coordination. Tr., p. 3. The veteran testified that he was in constant back pain with an inability to sit for an extended period of time. Id. He indicated that he had been terminated from numerous security- related jobs due to his back, left elbow, and lower leg disabilities. Tr., pp. 5-7. He testified that he had eight jobs over the previous year and that he had been terminated from his most recent job. Tr., pp. 3, 5-7. The veteran also testified that he was unable to perform jobs that required prolonged standing because his knees were "shot," and indicated that his knees were causing him a major portion of his problems with his employers. Tr., p. 4. The Board again notes that the veteran has not been service connected for disabilities concerning his knees. General Increased Rating Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See 38 C.F.R. § 4.2 (1999); Francisco v. Brown, 7 Vet. App. 55 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings, nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20 (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. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. The United States Court of Appeals for Veterans Claims (Court) has held that a veteran may not be compensated twice for the same symptomatology as "such a result would overcompensate the veteran for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding in violation of the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. The Court has held that functional loss, supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion, is recognized as resulting in disability. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45. With any form of arthritis, painful motion is an important factor of disability. The intent of the rating schedular is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt doctrine in resolving each such issue shall be given to the veteran. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Left Elbow: Criteria and Analysis Criteria The average normal range of motion of the forearm (elbow) is zero degrees extension, 145 degrees flexion, 80 degrees of pronation, and 85 degrees of supination. Under Diagnostic Code 5206, for either the major or minor arm, when flexion of the forearm is limited to 110 degrees, a zero percent (noncompensable) rating is assigned. A 10 percent rating is warranted if flexion is limited to 100 degrees. A 20 percent rating requires limitation of forearm flexion to 90 degrees, if either the major or minor extremity is involved. When flexion is limited to 70 degrees, a 30 percent rating is assigned for the major arm, and a 20 percent rating for the minor arm. Flexion limited to 55 degrees warrants a 40 percent rating for the major arm, and a 30 percent rating for the minor arm. When flexion is limited to 45 degrees, a 50 percent rating is warranted for the major arm, and a 40 percent rating for the minor arm. 38 C.F.R. § 4.71a, Diagnostic Code 5206 (1999). Under Diagnostic Code 5207, for either the major or minor arm, limitation of extension of the forearm from 45 to 60 degrees warrants a 10 percent rating. If extension is limited to 75 degrees, a 20 percent rating is appropriate if either upper extremity is involved. When extension is limited to 90 degrees, a 30 percent rating is assigned for the major arm, and a 20 percent rating for the minor arm. Extension limited to 100 degrees warrants a 40 percent rating for the major arm, and a 30 percent rating for the minor arm. When extension is limited to 110 degrees, a 50 percent rating is warranted for the major arm, and a 40 percent rating for the minor arm. 38 C.F.R. § 4.71a, Diagnostic Code 5206 (1999). A 20 percent evaluation is warranted where flexion of the forearm is limited to 100 degrees and extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5208 (1999). A 20 percent evaluation is warranted for a joint fracture of either upper extremity when there is marked cubitus varus or cubitus valgus deformity or when there is an ununited fracture of the head of the radius. A flail elbow joint warrants a 50 percent evaluation when the minor upper extremity is involved. 38 C.F.R. 4.71a, Diagnostic Code 5209 (1999). Nonunion of the radius and ulna, with a flail false joint, warrants a 40 percent evaluation when the minor upper extremity is involved. 38 C.F.R. 4.71a, Diagnostic Code 5210 (1999). The Rating Schedule provides compensation for malunion of the minor ulna, with bad alignment (10 percent), nonunion in the lower half of the ulna (20 percent), nonunion in the upper half of the ulna without loss of bone substance or deformity (20 percent), and nonunion in the upper half of the ulna with loss of bone substance (1 inch (2.5 cms.) or more) and marked deformity (30 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5211 (1999). The Rating Schedule provides a 20 percent evaluation for nonunion of the radius of the minor upper extremity in the upper half. A 30 percent evaluation requires nonunion in the lower half with false movement with loss of bone substance or deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5212. (1999). Analysis Initially, the Board notes that the veteran's claim is found to be well-grounded under 38 U.S.C.A. § 5107(a) (West 1991). That is, he has presented a claim which is plausible. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, an allegation of increased disability is sufficient to establish a well-grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is also satisfied that all relevant facts have been properly developed, and that no further assistance is required in order to satisfy the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). In accordance with 38 C.F.R. §§ 4.1 and 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the veteran's left elbow disability. The Board has found nothing in the historical record that would lead to a conclusion that the evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations that would warrant an exposition of the remote clinical histories. The veteran's left elbow disability is currently rated as 10 percent disabling based on traumatic arthritis and limitation of extension of the forearm. He has been found to be right hand dominant. In order to get the next higher rating based on limitation of extension of the minor forearm (20 percent), extension must be limited to 75 degrees. In order to get a higher rating based on limitation of flexion of the forearm, the minor forearm would have to be shown to be limited to at least 90 degrees. A higher rating (20 percent) could also be obtained by establishing that forearm flexion is limited to 100 degrees and extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207, and 5208. On VA examination in May 1998, range of motion in the left elbow was noted as being limited from 15 degrees extension to 140 degrees flexion. This constitutes persuasive evidence that an increased rating based on limitation of flexion or extension of the forearm is not warranted, as the evidence indicates that extension is not limited to 75 degrees and flexion is not limited to 90 degrees, nor to 100 degrees flexion and 45 degrees extension. See 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207, and 5208 (1999). The Board finds that 38 C.F.R. §§ 4.40, 4.45 or 4.59 do not provide a basis for a higher rating. While an x-ray at the May 1998 VA examination was interpreted as showing a deformity of the olecranon, it was found that this was compatible with a healed trauma. The veteran denied having pain in his left elbow and the examiner noted no pain on motion. The May 1998 VA examiner also noted that there was no swelling or tenderness of the elbow. It was noted that the left forearm was 23 cm on the left versus 24 cm on the right, only a difference of 1 cm. In addition, the examiner found the veteran to have 5/5 strength in both upper extremities. The veteran testified in August 1999 to having numerous occasions of loss of sensation through the entire lower portion of the arm and lack of coordination with that arm. He testified to having difficulty with picking up a comb. Tr., p. 3. On VA examination in May 1998 he stated that twisting the arm in a sudden way would result in him losing all feeling and strength below the elbow and that heavy lifting was bothersome. However, on VA examination in May 1998 reflexes and sensation were described as being intact in the left extremity. The veteran reported similar symptoms on VA examination in April 1993; however, it was also noted during this examination that sensation and reflexes in the left arm were intact. Thus, the Board finds that the evidentiary basis does not demonstrate additional disability of the left elbow in excess of the current 10 percent evaluation upon which to predicate a grant of a higher rating under the criteria of 38 C.F.R. §§ 4.40, 4.45 or 4.59. The veteran's left elbow disability does not warrant a higher rating based on a joint fracture with marked cubitus varus or cubitus valgus deformity or with an ununited fracture of the head of the radius. While x-rays taken on VA examination in May 1998 revealed a deformity of the olecranon, it was found that this was compatible with an old healed trauma. It was not interpreted as showing a current fracture, marked deformity of the elbow, or an ununited fracture of the radius. 38 C.F.R. § 4.71, Diagnostic Code 5210 (1999). There is no medical evidence of ankylosis of the elbow, impairment of supination or pronation, or other impairment of the elbow, ulna, or radius, such that another diagnostic code would be more appropriate. There is no documentation in the record of the May 1998 VA examination left elbow x-rays being interpreted as showing ankylosis, nonunion of the ulna or radius, or malunion of the ulna or radius. Thus, these diagnostic codes are not for application in this case. See 38 C.F.R. § 4.71a, Diagnostic Codes 5205, 5209, 5210, 5211, and 5212; Butts v. Brown, 5 Vet. App. 532 (1993). The Court has held that a separate, additional rating may be assigned if the veteran's disability is manifested by a scar that is poorly nourished with repeated ulceration, a scar that is tender and painful on objective demonstration, or a scar that is otherwise causative of limitation of function. 38 C.F.R. § 4.118, Diagnostic Codes 7803, 7804, 7805 (1998); Esteban v. Brown, 6 Vet. App. 259 (1998). On VA examination in May 1998 it was noted that there was a well-healed surgical scar on the posterior lateral aspect of the left elbow. No complaints or objective observation of pain or other limitation secondary to the scar were documented. Therefore, the Board is of the opinion that a separate rating for a scar is not warranted in this instance. Id. There is no evidence from the record that the veteran's service-connected disability has resulted in damage to the nerves that would warrant a separate rating. 38 C.F.R. § 4.124a (1998). While the veteran has alleged loss of sensation and weakness in the left upper extremity, VA examinations in May 1998 and April 1993 have found reflexes and sensation to be normal in the left extremity. As shown above, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign a higher rating. When all the evidence is assembled, the Secretary, is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board finds that a preponderance of the evidence is against the veteran's claim for a rating in excess of 10 percent for his left elbow disability. Spine Disability at T12-L1: Criteria and Analysis Criteria Under Diagnostic Code 5285, residuals of a fractured vertebra with cord involvement, bedridden, or requiring long leg braces warrants a 100 percent rating. A 60 percent rating is warranted for residuals of a fractured vertebra without cord involvement; abnormal mobility requiring a neck brace (jury mast). In other cases, the residuals of a fractured vertebra are to be rated in accordance with definite limited motion or muscle spasm, adding 10 percent for demonstrable deformity of a vertebral body. A note to this diagnostic code provides that, under both ankylosis and limited motion, ratings should not be assigned for more than one segment by reason of involvement of only the first or last vertebrae of an adjacent segment. 38 C.F.R. § 4.71a, Diagnostic Code 5285 (1999). The Rating Schedule provides a compensable rating for limitation of motion of the lumbar spine with the assignment of a 10 percent disability when slight, 20 percent when moderate, or 40 percent when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (1999). The Schedule provides a non compensable evaluation for intervertebral disc syndrome when post-operative, cured, 10 percent when mild, 20 percent when moderate and characterized by recurring attacks; 40 percent when severe and characterized by recurring attacks with intermittent relief, and 60 percent when pronounced with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief. 38 C.F.R. § 4.71a Diagnostic Code 5293 (1999). The rating for intervertebral disc syndrome involves loss of range of motion because the nerve defects and resulting pain associated with injury to the sciatic nerve may cause limitation of motion of the lumbar vertebrae. Therefore, 38 C.F.R. §§ 4.40 and 4.45 should be applied to a veteran's disability under Diagnostic Code 5293. VAOPGCPREC 36-97. The Schedule provides a non-compensable rating for lumbosacral strain when based on slight subjective symptoms only, 10 percent with characteristic pain on motion, 20 percent with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position, and 40 percent with severe lumbosacral strain manifested by listing of whole spine to opposite side, positive Goldthwait's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo- arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (1999). Analysis Initially, the Board notes that the veteran's claim is found to be well-grounded under 38 U.S.C.A. § 5107(a) (West 1991). That is, he has presented a claim which is plausible. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, an allegation of increased disability is sufficient to establish a well-grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is also satisfied that all relevant facts have been properly developed, and that no further assistance is required in order to satisfy the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). In accordance with 38 C.F.R. §§ 4.1 and 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the veteran's back disability. The Board has found nothing in the historical record that would lead to a conclusion that the evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations that would warrant an exposition of the remote clinical histories. The veteran's partially collapsed L1 with narrowing of the intervertebral space at T12-L1 is currently evaluated as 10 percent disabling under Diagnostic Code (DC) 5285 based on a demonstrable deformity of the vertebral body. The veteran is not entitled to 60 or 100 percent ratings under DC 5285 because the medical evidence has not established that the veteran is suffering from residuals of a fractured vertebra that results in his being bedridden or requires a neck brace or long leg brace. Therefore, his disability shall be rated in accordance with definite limited motion and muscle spasm. See 38 C.F.R. § 4.71a, Diagnostic Code 5285 (1999). Under DC 5285, residuals of a fractured vertebra are rated in accordance with definite limitation of motion or muscle spasm, adding 10 percent for a demonstrable deformity of a vertebral body. The RO has already assigned a 10 percent rating for the spinal disability, finding that there was a demonstrable deformity of a vertebral body. The Board concludes that the veteran's spinal disability also warrants a 10 percent rating for slight limitation of motion of the lumbar spine, as flexion of the back was found to be limited to 70 degrees on VA examination in May 1998. 38 C.F.R. § 4.71a, Diagnostic Code 5292. Therefore, the Board concludes that the veteran is entitled to a 10 percent rating for slight limitation of motion of the lumbar spine, with the additional 10 percent for a demonstrable deformity of the lumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5285-5292 (1999). In order for the veteran's spinal disability to warrant a higher rating for limitation of motion there would have to be moderate limitation of motion of the lumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5292. A 20 percent rating for moderate limitation of motion is not warranted in this instance. On VA examination in May 1998, flexion of the back was 70 degrees, extension was 30 degrees, and right and left lateral bending were both 30 degrees. This constitutes persuasive evidence that a higher rating based on moderate limitation of motion of the lumbar spine is not warranted. A higher rating based on intervertebral disc syndrome under DC 5293 is also not warranted. In order to get a higher rating under DC 5293, there would have to be moderate intervertebral disc syndrome with recurring attacks. 38 C.F.R. § 4.71a, Diagnostic Code 5293. The medical evidence does not indicate that the veteran has had recurrent attacks of moderate intervertebral disc syndrome. In fact, the veteran denied having any symptoms of radiation into his lower extremities on VA examination in May 1998. Therefore, a higher rating based on DC 5293 for moderate intervertebral disc syndrome with recurring attacks is not warranted. The probative medical evidence indicates that a higher rating based on lumbosacral strain under DC 5295 is not warranted. A higher rating under DC 5295 requires lumbosacral strain with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in the standing position. 38 C.F.R. § 4.71a, Diagnostic Code 5295. On VA examination, muscle spasm was not documented as being present on extreme forward bending. Rather, the VA examiner only noted that there was pain with extremes of extension and lateral bending. Furthermore, lateral bending was found to be 30 degrees on both the left and right. This constitutes persuasive evidence that a higher rating based on lumbosacral strain is not warranted. The Board additionally notes that the veteran can not be rated separately under Diagnostic Codes 5293 and 5295 because these codes contemplate limitation of motion. See 38 C.F.R. § 4.71, Diagnostic Codes 5293 and 5295 (1999); VAOPGCPREC 36- 97. Diagnostic Code 5292 also contemplates limitation of motion. The veteran is currently evaluated as 10 percent disabled in accordance with limitation of motion of the lumbar spine pursuant to DC's 5285 and 5292. Therefore, to rate the veteran's impairment separately under either Diagnostic Codes 5293 and 5295 would constitute evaluation of an identical manifestation of the same disability under two different diagnoses and would violate the prohibition against pyramiding. 38 C.F.R. § 4.14 (1999); see VAOPGCPREC 36-97. However, the Board concludes that an additional 10 percent rating is warranted pursuant to the provisions under 38 C.F.R. §§ 4.40, 4.45 or 4.59. On VA examination in May 1998 pain was noted as being present on extremes of extension and lateral bending. The veteran reported having to change positions frequently due to his back. The VA examiner concluded that pain, particularly in the back, could further limit functional ability during flare-ups or with increased use. This constitutes persuasive evidence that an additional 10 percent rating based on additional functional loss due to pain is warranted. A rating higher than 10 percent based on 38 C.F.R. §§ 4.40, 4.45 or 4.59 is not warranted. On VA examination in May 1998, extension was 30 degrees and lateral bending was 30 degrees on the right and left. Pain was noted only at the extremes of these motions. The VA examiner noted that there was no spasm or tenderness present during the examination of the back. In addition, the VA examiner noted that the veteran moved about the room without difficulty and was able to squat and rise. For these reasons, the Board concludes that a rating greater than 10 percent based on additional functional loss due to pain or other pathology is not warranted. Finally, the Board notes that there is no evidence in the record of the veteran having ankylosis of the spine as part and parcel of his service-connected disability. X-ray and other laboratory studies have not been documented as revealing such impairments, and service connection has not otherwise been granted in this regard. Therefore, DC's 5286 through 5289 are not for application in this decision. See 38 C.F.R. § 4.71a, Diagnostic Codes, 5286, 5288, 5289. As shown above, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign a higher rating other than which he has already been granted. When all the evidence is assembled, the Secretary, is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board finds that the medical evidence establishes that the veteran's spinal disability warrants an additional 10 percent rating for limitation of motion and an additional 10 percent rating based on additional functional loss due to pain. His back disability therefore warrants a combined 30 percent disability rating. 38 C.F.R. § 4.25 (1999). Healed Fracture of the Left Tibia and Fibula with Shortening of the Left Leg: Criteria and Analysis Criteria Full range of motion in the knee is from 0 degrees extension to 140 degrees flexion. Full ankle dorsiflexion is from 0 degrees to 20 degrees, and full plantar flexion of the ankle is from 0 degrees to 45 degrees. See 38 C.F.R. § 4.71, Plate II (1999). The Rating Schedule provides a compensable rating for limitation of extension of the leg when extension is limited to 10 degrees (10 percent), 15 degrees (20 percent), 20 degrees (30 percent), 30 degrees (40 percent) or 45 degrees (50 percent). A noncompensable evaluation is assigned for extension limited to 5 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261 (1999). The Rating Schedule provides a compensable rating for limitation of flexion of the leg when flexion is limited to 45 degrees (10 percent), 30 degrees (20 percent), or 15 degrees (30 percent). See 38 C.F.R. § 4.71a, Diagnostic Code 5260 (1999). The Rating Schedule provides compensation for a nonunion of the tibia or fibula, with loose motion, requiring brace (40 percent), malunion of the tibia or fibula with marked knee or ankle disability (30 percent), malunion of the tibia or fibula with moderate knee or ankle disability (20 percent), or malunion of the tibia or fibula with slight knee or ankle disability (10 percent). Compensation under the Rating Schedule is provided where there is shortening of the bones of the lower extremity by 1.25 to 2 inches (3.2 cms. to 5.1 cms.) (10 percent), 2 to 2.5 inches (5.1 cms to 6.4 cms.) (20 percent), 2.5 to 3 inches (6.4 cms. to 7.6 cms.) (30 percent), 3 to 3.5 inches (7.6 to 8.9 cms.) (40 percent), 3.5 to 4 inches (8.9 cms. to 10.2 cms) (50 percent), and over 4 inches (10.2 cms.) (60 percent). A note following the criteria stresses that the ratings for shortening of the bones of the lower extremity are not to be combined with other ratings for fracture or faulty union in the same extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5275 (1999). Analysis Initially, the Board notes that the veteran's claim is found to be well-grounded under 38 U.S.C.A. § 5107(a) (West 1991). That is, he has presented a claim which is plausible. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, an allegation of increased disability is sufficient to establish a well-grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is also satisfied that all relevant facts have been properly developed, and that no further assistance is required in order to satisfy the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). In accordance with 38 C.F.R. §§ 4.1 and 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the veteran's healed fracture of the left tibia and fibula with shortening of the left leg. The Board has found nothing in the historical record that would lead to a conclusion that the evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations that would warrant an exposition of the remote clinical histories. The veteran is currently assigned a noncompensable rating based on impairment of the tibia and fibula. The next higher rating for malunion of the tibia or fibula requires malunion of the tibia or fibula with a slight knee or ankle disability. 38 C.F.R. § 4.71a, Diagnostic Code 5262. The Board concludes that a higher rating for impairment of the tibia or fibula is warranted because the evidence indicates that the veteran's left leg disability is manifested by a slight ankle disability. On VA examination in May 1998, the left ankle showed 40 degrees plantar flexion and 5 degrees ankle dorsiflexion. Thus, range of motion in the ankle was less than normal for plantar flexion and for dorsiflexion. The diagnosis indicated that the limited motion of the left ankle was a residual of the healed fracture of the left tibia and fibula. The Board concludes that this constitutes persuasive evidence that the veteran's residuals of a healed fracture of the left tibia and fibula is manifested by malunion with a slight disability of the left ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5262; see also 38 C.F.R. §§ 4.3 and 4.7. The Board further finds that a rating in excess of 10 per cent under DC 5262 is not warranted. The next higher rating under DC 5262 requires malunion of the tibia or fibula with a moderate knee or ankle disability. On VA examination in May 1998, an x-ray of the left tibia and fibula revealed healed fracture deformities of the mid-shafts of the tibia and fibula; however, it was also noted that there were no apparent complications. The VA examiner noted a bony prominence at the junction of the mid and distal one third of the tibia representing the fracture site; however, the examiner also concluded that the left leg was in otherwise good alignment. While the May 1998 VA examination revealed limitation of motion in the left ankle, it was also noted that there was 5/5 strength in the lower extremities. The veteran was noted as being able to move about the room without difficulty and without a definite limp. He was also able to heel and toe walk, squat, and rise. Reflexes and sensation of the lower extremities were found to be intact, and range of motion in both knees was from 0 to 145 degrees. This constitutes persuasive evidence that a rating in excess of 10 percent for malunion of the tibia or fibula is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5262 (1999). The medical evidence establishes that a rating in excess of 10 percent is not warranted under DC's 5260 or 5261 for limitation of motion of the leg. A higher rating under either of these diagnostic codes would require that flexion be limited to 30 degrees or that extension be limited to 15 degrees. As was stated above, the May 1998 VA examination noted that range of motion in the knees was from 0 to 145 degrees, which is beyond the normal range of motion for the knee. See 38 C.F.R. § 4.71, Plate II (1999). This constitutes persuasive evidence that a higher rating based on limitation of motion of the leg is not warranted. The Board also notes that a separate rating for limitation of motion of the ankle is not warranted. See 38 C.F.R. 4.71a, Diagnostic Code 5271. The evaluation of the left ankle disability under DC 5262 as described above was based upon limitation of motion of the ankle. Therefore, to evaluate the veteran's left ankle disability under the criteria for limited motion of the ankle would violate the rule against pyramiding because the same symptoms (limitation of motion) would be used to evaluate the disability under two separate diagnostic codes. A veteran may not be compensated twice for the same symptomatology. See 38 C.F.R. § 4.14; Brady, supra. The Board has considered the provisions regarding functional loss due to pain and concludes that an increased evaluation is not warranted pursuant to 38 C.F.R. §§ 4.40, 4.45, and the holding in DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The probative medical evidence does not show additional functional loss due to pain or other pathology which would warrant a higher rating for the left tibia and fibula disability. In the case at hand, the veteran did not exhibit limitation of motion in his knee, nor was pain documented as being present during range of motion of the knee or ankle on VA examination in May 1998 to a degree that would warrant a conclusion that there is further functional loss due to pain. The May 1998 VA examination did not document swelling or weakness of the left leg. To the contrary, it was noted that veteran was able to walk about the room without difficulty, squat and rise, heel and toe walk, and that there was 5/5 strength in both lower extremities. In addition, reflexes and sensation were both found to be intact on examination. Thus, the probative medical evidence does not show evidence of additional functional loss due to pain or other pathology which would warrant a higher rating for the left tibia and fibula disability. As was stated previously, the veteran's left tibia and fibula disability has been found to result in a shortening of the left leg. VA examination in May 1998 revealed that the left leg had been shortened by a half-inch. Therefore, a higher rating based on shortening of the bones of the lower extremity is not warranted as a 20 percent rating requires that the lower extremity be shortened by at least 2 inches. Even the lower 10 percent rating requires that the bone be shortened by at least 1.25 inches. 38 C.F.R. § 4.71a, Diagnostic Code 5275. As shown above, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign a higher rating, as a preponderance of the evidence is against the claim. Gilbert, supra. Shell Fragment Wound, Right Leg Criteria The Board notes that the regulations concerning muscle disabilities changed effective July 3, 1997. See 62 Fed. Reg. 30,235 (1997). Where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version more favorable to the appellant will apply unless Congress provided otherwise. See Karnas v. Derwinski, 1 Vet. App. 308 (1991). In this case, the revised schedule was not promulgated to substantively change the criteria, but rather "to update this portion of the rating schedule to ensure that it uses current medical terminology and unambiguous criteria." 62 Fed. Reg. 30235. A review of the pertinent regulations, specifically 38 C.F.R. 4.73, Diagnostic Code 5311, reveals no changes in the ratings granted for the classifications of disability from muscle injuries (slight, moderate, moderately severe, and severe). The skeletal muscles of the body are divided for rating purposes into 23 groups, in five anatomical regions. 38 C.F.R. § 4.55. The schedule of ratings provides a 10 percent evaluation for moderate, a 20 percent evaluation for moderately severe, and a 30 percent evaluation for severe disability affecting Muscle Group XI. 38 C.F.R. § 4.73, Diagnostic Code 5311. Muscle Group XI encompasses the posterior and lateral crural muscles including the triceps surae, tibialis posterior, peroneus longus, peroneus brevis, flexor hallucis longus, flexor digitorum brevis, popliteus, and plantaris. Id. For compensable muscle group injuries which are in the same anatomical region but do not act on the same joint, the evaluation for the most severely injured muscle group will be increased by one level and used as the combined evaluation for the affected muscle groups. 38 C.F.R. § 4.55(e). The schedule also provides that a through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 38 C.F.R. § 4.56(b). For VA purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). Slight disability of a muscle anticipates a simple muscle wound without debridement or infection and with a history of a superficial wound with brief treatment and no cardinal signs or symptoms of muscle disability, such as loss of power, weakness, fatigue-pain, or impairment of coordination and uncertainty of movement. Objective findings of a slight disability include a minimal scar, no evidence of fascial defect, atrophy, or impaired tonus, and no impairment of function or retained metallic fragments. 38 C.F.R. § 4.56(d)(1). Moderate disability of muscles is manifested by objective findings of entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Clinical findings include 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)(iii). Moderately severe muscle injury is manifested by objective findings of entrance and (if present) exit scars indicating track of missile through one or more muscle groups. 38 C.F.R. § 4.56(d)(3)(iii). 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. Id. Severe disability of muscles is manifested by objective evidence of ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. 38 C.F.R. § 4.56(d)(4)(iii). In cases of severe disability, palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area and 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. Id. The regulations further provide the following signs of severe muscle disability: x-ray evidence of minute multiple scattered foreign bodies; diminished muscle excitability by electrical tests; visible or measured atrophy; adaptive contraction of an opposing group of muscles. Id. Analysis Initially, the Board notes that the veteran's claim is found to be well-grounded under 38 U.S.C.A. § 5107(a) (West 1991). That is, he has presented a claim which is plausible. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, an allegation of increased disability is sufficient to establish a well-grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is also satisfied that all relevant facts have been properly developed, and that no further assistance is required in order to satisfy the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). In accordance with 38 C.F.R. §§ 4.1 and 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the veteran's shell fragment wound to the right leg. The Board has found nothing in the historical record that would lead to a conclusion that the evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations that would warrant an exposition of the remote clinical histories. The veteran's shell fragment wound to the right leg is currently evaluated as noncompensably disabling under DC 5311. A noncompensable rating contemplates a slight Group XI muscle disability. The next higher rating (10 percent) under DC 5311 contemplates a moderate Group XI muscle disability. 38 C.F.R. § 4.73, Diagnostic Code 5311 (1999). The probative medical evidence indicates that the shell fragment wound to the right leg does not warrant a higher rating under DC 5311. The only positive findings on VA examination in May 1998 was limited dorsiflexion of the right ankle (10 degrees) and several small scars on the lateral aspect of the lower right leg. There was no documentation of some loss of deep fascia, muscle substance, or impairment of muscle tonus and loss of power or lowered threshold of fatigue on VA examination in May 1998. On examination, the quadriceps at three finger breadths above the superior patella were 33 cms. bilaterally, and the calves were found to be 32 cms. bilaterally. The veteran had 5/5 strength in his lower extremities. He was able to move about the room without difficulty and without a definite limp. Both knees were found to have 0 to 145 degrees range of motion. Plantar flexion was 45 degrees. He was able to heel and toe walk, and could squat and rise. Reflexes and sensation were intact in both lower extremities. This constitutes persuasive evidence that the shell fragment wound to the right leg does not warrant a compensable rating because a moderate disability has not been shown. 38 C.F.R. §§ 4.56(d)(2), 4.73, Diagnostic Code 5311. The Court has held that a separate, additional rating may be assigned if the veteran's disability is manifested by a scar that is poorly nourished with repeated ulceration, a scar that is tender and painful on objective demonstration, or a scar that is otherwise causative of limitation of function. 38 C.F.R. § 4.118, Diagnostic Codes 7803, 7804, 7805 (1999); Esteban v. Brown, 6 Vet. App. 259 (1998). In this case, there is no documentation from the May 1998 examination indicating that the veteran's shell fragment wound scars on the right leg were painful, ulcerative, or resulted in limitation of function. The veteran did not allege any problems specifically relating from his right leg scars during the August 1999 hearing and none were documented on VA examination in May 1998. Therefore, separate ratings for poorly nourished, tender, or otherwise limiting scars are not warranted. 38 C.F.R. § 4.118, Diagnostic Codes 7803, 7804, 7805 (1999); Esteban v. Brown, 6 Vet. App. 259 (1998). There is no evidence from the record that the veteran's right lower leg disability has resulted in damage to the applicable nerves that would warrant a separate rating. 38 C.F.R. § 4.124a (1999). Reflexes and sensation were described as intact in the lower extremities on VA examination in May 1998. Therefore, a separate rating based on damage to the applicable nerves is not warranted. As shown above, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign a higher rating. When all the evidence is assembled, the Secretary is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board finds that the evidence demonstrates that the veteran's shell fragment wound to the right leg does not warrant a compensable evaluation. ORDER The veteran, not having submitted a well grounded claim of entitlement to service connection for a shrapnel wound to the jaw and gum, the appeal is denied. Entitlement to a rating in excess of 10 percent for a healed fracture of the left elbow with a residual operative scar, a history of paresthesias of the left arm, and x-ray evidence of degenerative disc disease (minor) is denied. Entitlement to an increased rating of 30 percent for a partial collapse of L1 and narrowing of the intervertebral base at T12-L1 is granted, subject to the governing criteria applicable to the payment of monetary benefits. Entitlement to an increased (compensable rating of 10 percent for a healed fracture of the left tibia and fibula with shortening of the left leg is granted, subject to the governing criteria applicable to the payment of monetary benefits. Entitlement to a compensable evaluation for a shell fragment wound to the right leg is denied. REMAND The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the RO. 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 or by the Court 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. The Board notes that VA regulations provide that to accord justice to the exceptional case where the schedular evaluations are found to be inadequate, an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service connected disabilities may be assigned. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b) (1999). The record does not show that the RO expressly considered referral of this case to the Chief Benefits Director or the Director, Compensation and Pension Service, for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. See Floyd v. Brown, 9 Vet. App. 88 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). During the August 1999 hearing, the veteran indicated that he had been involuntarily terminated from numerous jobs as a result of his back, left elbow, and lower leg disabilities, testifying that he had had anywhere from three jobs to 10 or 11 jobs in a one year period. Transcript, pp. 7-8. The Board is of the opinion that the evidence indicates that the veteran's back, left elbow, and lower leg disabilities may have resulted in marked interference with employment. Therefore, in accordance with the statutory duty to assist the veteran in the development of evidence pertinent to his claim, the case is REMANDED for the following actions: 1. The RO should request the veteran to provide an employment history including attendance records from his employers, medical disability slips, tax records and any other evidence which would reflect the periods he was unable to, or was terminated from work due to his service- connected left elbow disability, back disability, left leg disability, and right leg disability. 2. Thereafter, the RO should adjudicate whether the issue of entitlement to extraschedular benefits for a healed fracture of the left elbow with a residual operative scar, a history of paresthesias of the left arm, and x-ray evidence of degenerative disc disease (minor); a partial collapse of L1 and narrowing of the intervertebral base at T12-L1; a healed fracture of the left tibia and fibula with shortening of the left leg; and/or a shell fragment wound to the right leg, under 38 C.F.R. § 3.321(b)(1), should be referred to the Chief Benefits Director or the Director, Compensation and Pension Services (now the Under Secretary for Benefits) for consideration of assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 3. The RO should review the claims file to ensure that all of the foregoing requested development and adjudicative actions have been completed, and if it has not, the RO should implement corrective procedures. Stegall v. West, 11 Vet. App. 268 (1998). Thereafter, if the RO determines that referral for an extraschedular rating is not appropriate, the veteran and his representative should be furnished a Supplemental Statement of the Case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for appellate consideration, if in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. RONALD R. BOSCH Member, Board of Veterans' Appeals