Citation Nr: 0003013 Decision Date: 02/07/00 Archive Date: 02/10/00 DOCKET NO. 98-09 941 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, Philippines THE ISSUES 1. Entitlement to an increased evaluation for residuals of a gunshot wound to Muscle Groups III and IV of the left shoulder, currently rated as 20 percent disabling. 2. Entitlement to an increased (compensable) evaluation for residuals of a shell fragment wound to the left temple with retained metallic foreign bodies. 3. Entitlement to an increased (compensable) evaluation for a residuals of a shell fragment wound to the right upper arm with retained metallic foreign bodies. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. M. Cote, Associate Counsel INTRODUCTION The veteran had active duty in the Commonwealth Army of the Philippines in the service of the Armed Forces of the United States as follows: beleaguered status from April 8, 1942 to May 5, 1942, missing from May 6, 1942 to June 25, 1942 and from October 20, 1944 to January 8, 1945, recognized guerilla service from January 9, 1945 to November 4, 1945, and regular Philippine Army (PA) status from November 5, 1945 to December 20, 1945. These matters come to the Board of Veterans' Appeals (Board) from a November 1997 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO). In that rating decision, the RO denied entitlement to increased ratings for the disorders shown above. The veteran has perfected an appeal of that decision. The veteran has submitted two statements and copies of employment and private medical records directly to the Board. Under the provisions of 38 C.F.R. 20.1304(c) (1999), pertinent evidence that has not already been considered must be reviewed by the RO unless a valid waiver of consideration has been received. No such waiver has been received in this case. However, the evidence submitted directly to the Board consists of X-ray films similar to those previously considered by the RO and records regarding his employment history. The veteran also submitted statements in which he summarized these records and reported on his current health status. The Board finds that the evidence submitted directly to it is either duplicative or not pertinent, and does not require referral to the RO. 38 C.F.R. 20.1304(c). In a rating decision dated in December 1998, the RO denied entitlement to a total rating for compensation based on individual unemployability. The veteran has not submitted a notice of disagreement with that decision, and the Board does not have jurisdiction to consider this issue. Shockley v. West, 11 Vet. App. 208 (1998) (the Board does not have jurisdiction over an issue unless there is a jurisdiction conferring notice of disagreement) see also Ledford v. West, 136 F.3d 776 (Fed. Cir 1998); Collaro v. West, 136 F.3d 1304 (Fed. Cir. 1998); Buckley v. West, No. 96-1764 (U.S. Vet. App. Dec. 3, 1998). FINDINGS OF FACT 1. All relevant evidence necessary for an informed decision of the veteran's appeal has been obtained by the RO. 2. The veteran sustained a through and through gunshot wound involving Muscle Groups III and IV, which resulted in moderate disability in each muscle group, and a well-healed scar. 3. The residuals of a shell fragment wound to the left temple are manifested by retained foreign metallic bodies and a well-healed scar. 4. The residuals of a shell fragment wound to the right upper arm are manifested by retained metallic foreign bodies and a well-healed scar. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for the residuals of a gunshot wound to Muscle Groups III and IV of the left shoulder are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.40, 4.73, Diagnostic Codes 5303, 5304 (1999). 2. The criteria for a compensable disability rating for residuals of a shell fragment wound of the left temple are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.40, 4.118, Diagnostic Codes 7800, 7803, 7804, 7805 (1999). 3. The criteria for a compensable disability rating for residuals of a shell fragment wound to the right upper arm are not met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.40, 4.118, Diagnostic Codes 7800, 7803, 7804, 7805 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background The veteran's service medical records show that he was wounded in action by hand grenade fragments in June 1945 in the right temple and lower third of the right arm. No service medical records are available relating to treatment of those injuries. In August 1945, he sustained a gunshot wound (GSW) to the left shoulder in action, with the point of entry at the supraspinatus and exit at the trapezius and top of shoulder. The shoulder wound was treated with debridement and the closure was performed in September 1945. The report of a September 1950 VA medical examination shows that the veteran had a semi-circular keloid scar from the supraclavicular region at the level of the middle third of the clavicle, left to the supradeltoid region on external end of the same clavicle through the supraspinatus portion of the left scapula 7 inches by 3/4 inch in size. The semi-circular scar was reported to be a result of the "coaptation" of the gunshot wound. Small palpable MFBs on the temporo-parietal region with no visible residuals of a scar on the right temple and a small, non-adherent scar at the antero-lateral aspect of the lower third of the right arm were recorded. X- ray studies confirmed multiple MFBs in the soft tissue over the left parietal and frontal skull bone. The largest fragment was .7 by .5 cm in size. No bony abnormalities were noted. There were also multiple metallic foreign bodies in the soft tissue of the right arm, with the largest fragment .2 cm in diameter. In a December 1950 rating decision, the RO granted service connection for the residuals of the GSW to the left shoulder and SFWs of the right arm and scalp. The injury to Muscle Groups III and IV of the left shoulder girdle as residuals of the GSW was assigned a 20 percent rating. Service connection was granted for a scar of the right arm and left temple as a residual of a SFW and retained foreign bodies, with a noncompensable rating. The veteran complained of left chest and back pain with movement of the left upper extremity in an August 1971 VA examination. A scar of the postero-superior aspect of the inner region of the left shoulder which was slightly depressed, slightly adherent with muscle injury involving trapezius and supraspinatus was noted. No limitation of motion of the left shoulder was observed. In a March 1972 VA examination, the veteran complained of pain at the left shoulder and radiating pain to the anterior chest and tingling at the site of the scar on heavy lifting. A scar at the left shoulder, starting at the left acromio- clavicular joint extending to about 7 cm medially in a "U" shape was noted. Each arm of the "U" was about 9 cm long and 1 cm wide. The scar was adherent and depressed at the medial arm of the "U". Extension of the arm at the left shoulder was to 160 degrees. A scar at the left temporal area appeared superficial and non-adherent to the skin. The scar at the right arm was non-adherent. X-ray studies revealed no abnormality of the left shoulder and no MFBs were noted. An adherent scar at the shoulder, causing limitation of motion, and scars to the left temporal area and right arm, which were non-adherent and non- disfiguring, were diagnosed. The veteran again claimed entitlement to an increased rating for the SFW to the head in September 1994. He claimed that he suffered pain as a result of MFBs in his body and severe headaches as a result of MFBs in his head. A September 1994 private X-ray examination revealed MFBs in the soft tissues of the left temporal, parietal, cheek and mandibular regions. Private examination of the left shoulder in October 1994 revealed a scar over the supraclavicular area at the level of the middle third to the proximal third of the clavicle. A scar was also noted over the supradeltoid extending to the outer third of the clavicle extending to the left scapular region measuring about 7 inches by 1/2 inch. On percussion over the left shoulder, tingling was noted and limitation of shoulder movement was observed. It was found that due to residuals of the SFW over the left temporal area, pain was felt on pressure. It was also found that due to scarring from the GSW, the shoulder muscles became fibrotic thus limiting movement. The physician indicated that paresthesia may have been due to an injury to the nerves of the shoulder area, causing radiating pain. In a November 1994 VA orthopedic examination, the veteran complained of occasional pain in the left shoulder. No limitation of motion of the shoulder was noted. Residuals of shrapnel wound to the left shoulder in Muscle Groups III and IV and residuals of MFBs in the left scalp and cheek and right arm were diagnosed. In the November 1994 VA muscular examination muscle loss at the left shoulder in Muscle Groups III and IV was noted. A neurologic examination revealed limitation of movement of the left shoulder but no neurological deficits were noted. X-ray examination of the skull revealed a number of small MFBs in the scalp over the left parietal bone and in the left cheek, antero-inferior to the ear. No bone injury was noted. Residual MFBs in the left scalp and cheek was diagnosed. No cranial fracture was noted. X-ray examination of the right arm revealed a few small MFBs imbedded in the distal anteromedial biceps muscle. No bone injury or sign of soft tissue reaction were seen. Residual MFBs of the right biceps muscle were diagnosed. In a July 1995 statement, the veteran indicated that his service connected shoulder condition was aggravating a hand condition. An August 1995 VA examination of the veteran's left shoulder joint showed flexion and abduction to 160 degrees, and external and internal rotation to 80 degrees. The shoulder joint was found to be normal. A curved and well-healed surgical scar on the left shoulder was also noted. A scar and muscular examination revealed an "evident" scar on the left temple and scar over the right arm. Residuals of a SFW to the left shoulder girdle in Muscle Groups III and IV and residuals of MFBs in the left scalp and cheek and in the right arm were also noted. In an orthopedic examination, the veteran complained of pain in the left shoulder, right arm and temple. No evidence of fracture of the left shoulder joint was noted. No other diagnoses were made. In a neurologic examination, the veteran complained of pain and limitation of movement of the left shoulder. X-ray examinations made at that time revealed essentially no abnormality of the left shoulder. MFBs in the left scalp and cheek and in the right arm were detected. In an August 1995 private examination, the veteran reported that he was right handed and had been suffering pain and numbness in the left upper extremity since 1945. Full range of motion of the shoulder was noted. An electromyographic examination was performed and mild multiple peripheral neuropathy affecting the upper extremity was diagnosed. In an August 1997 VA neurologic examination, the veteran complained of pain at the left shoulder. No weakness, atrophy, reflex or sensory impairment was noted in the upper extremities. No neurologic deficit was detected. During the orthopedic examination, the veteran complained of pain in the left shoulder with heavy lifting or in the cold. Diagnoses of a healed scar at the left shoulder girdle as a residual of a GSW to Muscle Groups III and IV of the left shoulder and a healed scar at the right arm as a residual of MFBs were made. No limitation of movement of the left shoulder was noted. X- ray examination of the left shoulder joint found it to be fairly maintained. Examination of the skull found no evidence of craniofacial fracture. MFBs in the left parietal and preauricular soft tissues were also detected. Examination of the right upper arm revealed MFBs. An August 1997 muscular examination revealed an old injury to Muscle Groups III and IV. No tissue loss was noted. Fair muscle strength of the left upper extremity was noted. Some pain was noted upon elevation of the shoulder. Examination of the joints revealed flexion, abduction, and extension of the left shoulder to 120 degrees, rotation to 40 degrees. Pain at the left shoulder was noted. The diagnosis was a healed scar at the left shoulder girdle as a residual of the GSW. A scar examination at that time noted the 14 cm "U" shaped scar at the left shoulder as a residual of a GSW. The scar was slightly depressed, non-adhesive, and non-tender. Pain on forward flexion and abduction of the shoulder was observed. No limitation of motion of the left shoulder was noted, however. A barely visible healed scar at the right arm in the distal medial third and left temple was noted. The temple scar was non-tender and non-adhesive. X-rays revealed MFBs in the shoulder joint, left scalp, cheek, and right arm. Diagnoses of residual GSW to the left shoulder girdle and injury to Muscle Groups III and IV, and healed scar of the right arm, left temple and retained MFBs to the left scalp, cheek and right arm were made. An August 1998 VA muscular examination noted a 12 cm slightly depressed, non-tender scar over the supra scapularis muscle area. Flexion of the left shoulder was to 130 degrees, abduction was to 120 degrees, adduction was to 30 degrees and external and internal rotation was to 50 degrees. A nerve examination revealed sensory motor loss over the peripheral nerve of the left upper extremity, sensory loss over the median/radial ulnar nerve distribution. There was no evidence of peripheral neuropathy. No tenderness over the shoulder scarring was noted during the VA scar examination. A non-tender 1-cm by 1-cm scar was noted over the anterior aspect, middle third area, of the right arm. A diagnosis of a GSW to the left shoulder over the suprascapularis muscle area was made. The veteran indicated in his February 1998 notice of disagreement that he suffered pain, particularly in the areas where MFBs are located. In a May 1999 statement, the veteran complained of shoulder pain and tingling at the shoulder scar site upon heavy lifting. He provided a private X-ray examination report dated in April 1999 which noted calcific densities in the left temporo-occipital area of the scalp and ventral aspect of the soft tissue shadow of the distal third of the right arm. There were no other significant findings noted. II. Laws and Regulations The Board finds that the veteran's claims for increased ratings are well grounded within the meaning of the statutes and judicial construction and that VA has a duty, therefore, to assist him in the development of the facts pertinent to his claim. 38 U.S.C.A. § 5107(a); see also Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The relevant evidence pertaining to the issue consists of the veteran's available service medical records, VA and private medical examinations and the veteran's statements. The Board concludes that all relevant data has been obtained for determining the merits of the veteran's claims and that VA has fulfilled its obligation to assist him in the development of the facts of his case. Disability ratings are based on the average impairment of earning capacity resulting from disability. The percentage ratings for each diagnostic code, as set forth in the VA's Schedule for Rating Disabilities, codified in 38 C.F.R. Part 4, represent the average impairment of earning capacity resulting from disability. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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. 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 may be due to pain, supported by adequate pathology and evidenced by 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. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, including less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. The laws and regulations governing the evaluation of muscle injuries were amended effective June 3, 1997. Where a claim was pending at the time of the changes, VA is required to consider both the old and new version of the regulations and apply the version most favorable to the veteran. Fischer v. West, 11 Vet. App. 121 (1998); see also Karnas v. Derwinski, 1 Vet. App. 308 (1991). The former provisions of 38 C.F.R. § 4.55 provide in pertinent part as follows: The following principles as to combination of ratings of muscle injuries in the same anatomical segment, or of muscle injuries affecting the movements of single joint, either alone or in combination or limitations of the arc of motion will govern the ratings: (a) Muscle injuries in the same anatomical region, i.e., (1) shoulder girdle and arm, (2) forearm and hand, (3) pelvic girdle and thigh, (4) leg and foot, will not be combined, but instead, the rating for the major group will be elevated from moderate to moderately severe, or from moderately severe to severe according to the severity of the aggregate impairment of function of the extremity. (b) Two or more severe muscle injuries affecting the motion (particularly strength of the motion) about a single joint may be combined but not in combination receive more than the rating for ankylosis of that joint at an "intermediate" angle, except that with severe injuries involving the shoulder girdle and arm, the combination may not exceed the rating for unfavorable ankylosis of the scapulohumeral joint. Claims of an unusually severe degree of disability involving the shoulder girdle and arm or the pelvic girdle and thigh muscles wherein the evaluation in criteria under this section appears inadequate may be submitted to the Director, Compensation and Pension Service, for consideration under § 3.321(b)(1) of this chapter. (c) With definite limitation of the arc of motion, the rating for injuries to muscles affecting motion within the remaining arc may be combined but not to exceed ankylosis at an "intermediate" angle. (d) With ankylosis of the shoulder, the intrinsic muscles of the shoulder girdle (Groups III or IV) are out of commission and carry no rating for injury however severe. The extrinsic muscles (Group I and II) which act on the shoulder as a whole may, if severely injured elevate the rating to ankylosis at an unfavorable angle. (f) With disability such as flail joint, ankylosis, faulty union, limitation of motion, etc., muscle injuries affecting junction at a lower level may be separately rated and combined, always reserving the maximum amputation rating for the most severe injuries. (g) Muscle injury ratings will not be combined with peripheral nerve paralysis ratings for the same part, unless affecting entirely different functions. 38 C.F.R. § 4.55 (1996) The current provisions of 38 C.F.R. § 4.55 read as follows: (a) A muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. (b) For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in 5 anatomical regions: 6 muscle groups for the shoulder girdle and arm (diagnostic codes 5301 through 5306); 3 muscle groups for the forearm and hand (diagnostic codes 5307 through 5309); 3 muscle groups for the foot and leg (diagnostic codes 5310 through 5312); 6 muscle groups for the pelvic girdle and thigh (diagnostic codes 5313 through 5318); and 5 muscle groups for the torso and neck (diagnostic codes 5319 through 5323). (c) There will be no rating assigned for muscle groups which act upon an ankylosed joint, with the following exceptions: (1) In the case of an ankylosed knee, if muscle group XIII is disabled, it will be rated, but at the next lower level than that which would otherwise be assigned. (2) In the case of an ankylosed shoulder, if muscle groups I and II are severely disabled, the evaluation of the shoulder joint under diagnostic code 5200 will be elevated to the level for unfavorable ankylosis, if not already assigned, but the muscle groups themselves will not be rated. (d) The combined evaluation of muscle groups acting upon a single unankylosed joint must be lower than the evaluation for unfavorable ankylosis of that joint, except in the case of muscle groups I and II acting upon the shoulder. (e) 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. (f) For muscle group injuries in different anatomical regions which do not act upon ankylosed joints, each muscle group injury shall be separately rated and the ratings combined under the provisions of Sec. 4.25. 38 C.F.R. § 4.55 (1999). The former provisions of 38 C.F.R. § 4.56 read as follows: Muscle injuries are considered slight if they involve simple muscle wounds without debridement, infection or the effects of lacerations. Treatment records typically show a wound of slight severity or relatively brief treatment and a return to duty, and healing with good functional results, and no consistent complaints of the cardinal symptoms of muscle injuries or painful residuals. The objective findings would include a minimal scar, little if any evidence of a fascial defect, atrophy, or impaired muscle tonus, and no significant impairment of function and no retained metallic fragments. Muscle injuries are considered moderately disabling under the criteria contained in 38 C.F.R. 4.56, if they involve deep penetration by small shell fragments of relatively short track. The medical records would show hospitalization during service and records following service showing consistent complaint from the time of the first examination forward of one or more of the cardinal symptoms of muscle wounds particularly fatigue and fatigue pain after moderate use. Current objective findings would include scars indicative of a relatively short track of the missile through muscle tissue, signs of moderate loss of deep muscle fascia or substance, or impairment of muscle tonus, and of definite weakness or fatigue. A moderately severe shell fragment wound would result from a deep penetrating wound by a high velocity missile of small size or large missile of low velocity, with debridement, prolonged infection or sloughing of soft parts, and intermuscular cicatrization (scars extending into muscle tissue). The medical records would show hospitalization for a prolonged period during service for treatment of a severe wound with record s of consistent complaints of the cardinal symptoms of a muscle injury. The objective findings would include relatively large scars so situated as to indicate a track of the missile through important muscle groups. There would be indications of moderate loss of muscle substance or moderate loss of normal firm resistance compared with the sound side. There would also be evidence of marked or moderately severe muscle loss. 38 C.F.R. § 4.56 (1997). The current provisions of 38 C.F.R. § 4.56, read as follows: (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. (d) Under diagnostic codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows: (1) Slight disability of muscles--(i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles--(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. (3) Moderately severe disability of muscles--(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. (4) Severe disability of muscles--(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 (1999). Diagnostic Code 5303 for injury to Muscle Group III provides rating criteria for the clavicular and deltoid muscles of the shoulder girdle. A 30 percent rating applies if the disability of the non-dominant extremity is severe, a 20 percent rating applies if the disability is moderately severe or moderate, and a noncompensable rating applies if the disability is slight. 38 C.F.R. § 4.73. Diagnostic Code 5304 for injury to Muscle Group IV provides rating criteria for the supraspinatus, infraspinatus, teres minor, subscapularis, and coracobrachialis muscles of the shoulder girdle. A 30 percent rating applies if the disability is severe, a 20 percent rating applies if the disability is moderately severe, a 10 percent rating applies if the disability is moderate, and a noncompensable rating applies if the disability is slight. 38 C.F.R. § 4.73. Diagnostic Code 7800 provides a 10 percent evaluation for scars that are slightly disfiguring of the head, face or neck. Diagnostic Code 7803 provides a 10 percent evaluation if a superficial scar is poorly nourished with repeated ulceration. Diagnostic Code 7804 provides a 10 percent evaluation for superficial scars that are tender and painful on objective demonstration. Diagnostic Code 7805 for other scars indicates that other scars are to be evaluated based on the limitation of function of the part affected. 38 C.F.R. § 4.118. The evaluation of the severity of disability is to be based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). III. Analysis A. Increased Rating for Injury to Muscle Groups III and IV Currently, the veteran's service connected residuals of a GSW injury to Muscle Groups III and IV of the left shoulder are rated as 20 percent disabling under Diagnostic Code 5303. Under the former provisions of 38 C.F.R. § 4.72 (1997), and the current provisions of 38 C.F.R. § 4.56, a through and through GSW with muscle damage will warrant at least a moderate rating. The record shows that the veteran's gunshot wound involved an entrance site and an exit site. Thus, it must be concluded that the injury was through and through. Recent examinations have shown fair muscle strength and depressed scars. All examinations have reported residuals of a wound involving Muscle Groups III and IV. Therefore the Board finds that the through and through wound was accompanied by muscle damage. Under the old and new provisions of 38 C.F.R. § 4.55, muscle injuries in the same anatomical region, i.e., shoulder girdle and arm, will not be combined, but instead the rating for the major group will be elevated from moderate to moderately severe. Regardless of which group is considered to be the major group, both Muscle Groups III and IV provide for a 20 percent evaluation for moderately severe injury. Therefore, elevating the veteran's disability to the moderately severe level results in the current evaluation of 20 percent. If the veteran's injuries met the criteria for a moderately severe injury they could be elevated to the severe level and awarded an increased rating. However, the record does not show that his injury required prolonged hospitalization. He has not been found to have loss of deep fascia. Indeed no loss of muscle has been reported. There was no evidence of injury by a large missile, prolonged infection, sloughing of soft parts or intramuscular cicatrization, however. The objective findings have not included bone fracture, ragged scarring or scarring residuals are indicative of wide damage to muscle groups. There was no evidence of a loss of deep fascia or abnormal muscle swelling or contraction. Nor were minute multiple scattered foreign bodies detected. There was also no evidence of scar adhesion to any bone structures or any muscle atrophy. Thus, the competent medical evidence does not show muscle damage consistent with criteria that is indicative of severe muscle damage. Recent examinations have revealed no evidence of muscle injury. Although the veteran claims pain with use of the left shoulder, no loss of power, weakness, fatigue, impairment of coordination and uncertainty of movement has been shown. No fatigue, weakness, atrophy, reflex or sensory impairment was noted in an August 1997 VA examination. Some sensory motor loss was noted in the area during an August 1995 private examination and an August 1998 VA examination, but no other signs or symptoms of muscle disability were noted. Accordingly, the Board must conclude that the veteran's injury is not manifested by the objective findings necessary for an increased evaluation under either version of 38 C.F.R. § 4.56. The Board notes that separate and distinct manifestations arising from the same disease or injury may be rated separately. Manifestations are considered to be separate and distinct if none of the symptomatology for any of the manifestations is duplicative of or overlapping with the symptomatology of the other manifestation. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994); 38 C.F.R. § 4.25. In addition to the injuries to Muscle Groups III and IV, the medical evidence shows that the residual scars are well healed, only slightly depressed, and not tender deforming or adherent (although they were previously reported to restrict arm motion, this finding has not been duplicated on more recent examinations). The scar is not poorly nourished with repeated ulceration, tender or painful on objective demonstration, nor does it result in any functional limitation to the upper extremity. The Board finds, therefore, that an increased rating for the wound scar is not warranted. B. Increased Rating for Scars The veteran's service medical records show that he incurred a scar as a result of a SFWs of the right arm and left temple, with retained metallic foreign bodies. The medical evidence indicates that the shell fragment injury did not result in any injury to the muscles, bones, or nerves of the arm, skull, or cheek, and the manifestations of the injuries are therefore limited to the scarring. Although the veteran contended in an August 1994 statement that the MFBs in his head cause headaches, his assertions are not supported by medical evidence showing that the MFBs have resulted in any disability, other than scarring. Headaches have not been reported on examinations See Espiritu v. Derwinski, 2 Vet. App. 492 (1992) (holding that a lay person is not competent to offer an opinion as to medical causation). The evidence does not show that the scarring of the head or right arm is poorly nourished with repeated ulceration, tender and painful on objective demonstration, or that it results in any limitation of function. The Board finds that the preponderance of the evidence is against the claim of entitlement to a compensable disability rating for the scarring of the right arm, left temple and cheek. Extraschedular ratings are for consideration when there is an exceptional or unusual disability picture, with such factors as marked interference with employment or frequent periods of hospitalization, so as to render impractical the application of the regular schedular criteria. 38 C.F.R. § 3.321(b)(1). The evidence does not show that the residuals of the veteran's GSW or SFWs have resulted in frequent hospitalizations, or that they have caused marked interference with his employment. Indeed, the veteran has not undergone any recent hospitalization for his service connected disabilities. The veteran has asserted that his disabilities caused him to retire early because of his service connected disabilities. This assertion could be construed as asserting that his disabilities caused marked interference with employability. In an application for increased compensation based on individual unemployability received in August 1998, the veteran indicated variously that he had retired in July 1998, at the age of 76, or that he was currently employed. The veteran's ability to maintain employment on at least a half time basis well into an advanced age, belies a finding that his service-connected disabilities have caused marked interference with employment. It is true that the veteran reported that he had changed jobs in October 1969 and become self employed because of an inability to perform heavy lifting, however, there is no indication that this change was economically detrimental to the veteran, or was not adequately compensated by his schedular evaluation. In short, there has been no showing that the application of the regular schedular criteria is impractical. The Board finds, therefore, that remand of the case to the RO for referral to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of an extra-schedular rating is not appropriate. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). ORDER The claim of entitlement to an increased evaluation for residuals of a gunshot wound to Muscle Groups III and IV of the left shoulder, currently rated as 20 percent disabling is denied. The claim of entitlement to an increased (compensable) evaluation for residuals of a shell fragment wound to the left temple with retained metallic foreign bodies is denied. The claim of entitlement to an increased (compensable) evaluation for residuals of a shell fragment wound to the right upper arm with retained metallic foreign bodies is denied. Mark D. Hindin Member, Board of Veterans' Appeals