SCARS DUE TO OTHER CAUSES NOT OF THE HEAD, FACE, OR NECK

A. JAEGER · 2026 · Case ID: 26005062

MIXED

Summary

The veteran, who served from March 1975 to June 1979, appeals the denial of increased ratings for residuals of a left foot gunshot wound and associated scarring. The Board reviewed the evidence, including multiple VA examinations and private medical opinions, to assess the severity of the veteran's left foot gunshot wound residuals affecting Muscle Group X and various scars on his left foot, left calf, upper lip, and lower gum. The Board found that the evidence supported a 10 percent rating for moderate muscle injury to Muscle Group X for the entire appeal period, citing the lack of objective findings of severe impairment despite the veteran's reported pain and fatigue. For scarring, the Board determined staged ratings were appropriate, granting a 10 percent rating for two painful left foot scars prior to April 24, 2012. From April 24, 2012, to December 10, 2015, a 20 percent rating was granted for three painful scars on the left foot and calf. As of December 10, 2015, a 30 percent rating was granted for five painful scars including the upper lip and lower gum. As of November 5, 2018, a 40 percent rating was granted for five painful scars, with an additional 10 percent added due to two facial scars being both painful and unstable, resulting in a combined 40 percent rating for the scars. The Board denied higher ratings for the facial scars, finding they did not meet the criteria for gross distortion or asymmetry of multiple features or six or more characteristics of disfigurement. The claim for compensation under 38 U.S.C. § 1151 for cerebral infarction, claimed as residual to left foot surgery, was remanded due to inadequacies in a prior VA opinion regarding the Veteran's blood thinner use.

Rationale

Staged ratings applied based on number and nature of scars; 20% for three painful left foot/calf scars (pre-Dec 2015); 30% for five painful scars (post-Dec 2015); 40% for five painful scars with two being unstable (post-Nov 2018)

Special Benefit

§1151

Diagnostic Code

7804

Docket No.

10-31 533

Full Decision Text

Citation Nr: 26005062
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 10-31 533
DATE: April 29, 2026

ORDER

For the entire appeal period, a separate initial rating of 10 percent, but no higher, for left foot gunshot wound residuals affecting Muscle Group X is granted, subject to the laws and regulations governing the payment of monetary awards.

Prior to April 24, 2012, an initial rating in excess of 10 percent for residual painful scars on the left foot is denied.

From April 24, 2012, to December 10, 2015, an initial rating of 20 percent, but no higher, for residual painful scars on the left foot, left calf, and upper lip (as of November 2, 2015), is granted, subject to the laws and regulations governing the payment of monetary benefits.

From December 10, 2015, to November 5, 2018, an initial rating of 30 percent, but no higher, for residual painful scars on the left foot, left calf, upper lip, and lower gum is granted, subject to the laws and regulations governing the payment of monetary benefits.

As of November 5, 2018, an initial rating of 40 percent, but no higher, for residual painful scars on the left foot, left calf, upper lip, and lower gum is granted, subject to the laws and regulations governing the payment of monetary benefits.

A rating in excess of 30 percent for upper lip and lower gum scars is denied.

REMANDED

Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for cerebral infarction, claimed as residual to left foot surgery, is remanded.

FINDINGS OF FACT

1. For the entire appeal period, the Veteran's left foot gunshot wound residuals resulted in, at most, moderate disability of Muscle Group X.

2. Prior to April 24, 2012, the Veteran's left foot gunshot wound residuals resulted in two scars to the left foot that were painful, but not unstable, not of a size to warrant a compensable rating, and did not result in any disabling effects.

3. From April 24, 2012, to November 2, 2015, the Veteran's left foot and left calf resulted in three scars that were painful, but not unstable, not of a size to warrant a compensable rating, and did not result in any disabling effects.

4. From November 2, 2015, to December 10, 2015, the Veteran's left foot, left calf, and upper lip scars resulted in four scars that were painful, but not unstable, those affecting his left foot and calf are not of a size to warrant a compensable rating, and such scars did not result in any disabling effects.

5. From December 10, 2015, to November 5, 2018, the Veteran's left foot, left calf, upper lip, and lower gum scars resulted in five scars that were painful, but not unstable, those affecting his left foot and calf are not of a size to warrant a compensable rating, and such scars did not result in any disabling effects.

6. As of November 5, 2018, the Veteran's left foot and left calf resulted in three scars that were painful, but not unstable, not of a size to warrant a compensable rating, and did not result in any disabling effects, and his upper lip and lower gum scars resulted in two scars that were painful and unstable, but did not result in any disabling effects.

7. For the entire appeal period, the Veteran's upper lip and lower gum scars do not result in visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or four or five characteristics of disfigurement.

CONCLUSIONS OF LAW

1. For the entire appeal period, the criteria for a separate initial rating of 10 percent, but no higher, for left foot gunshot wound residuals affecting Muscle Group X been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.55, 4.56, 4.73, Diagnostic Code (DC) 5310.

2. Prior to April 24, 2012, the criteria for an initial rating in excess of 10 percent for residual painful scars on the left foot have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4
foot gunshot wound residuals affecting Muscle Group X been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.55, 4.56, 4.73, Diagnostic Code (DC) 5310.

3. From April 24, 2012, to December 10, 2015, the criteria for an initial 20 percent rating, but no higher, for residual painful scars on the left foot, left calf, and upper lip (as of November 2, 2015) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, DC 7804.

4. From December 10, 2015, to November 5, 2018, the criteria for an initial rating of 30 percent, but no higher, for residual painful scars on the left foot, left calf, upper lip, and lower gum have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, DC 7804.

5. As of November 5, 2018, the criteria for an initial 40 percent rating, but no higher, for residual painful scars on the left foot, left calf, upper lip, and lower gum have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, DC 7804.

6. The criteria for a rating in excess of 30 percent for upper lip and lower gum scars have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, DC 7800.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from March 1975 to June 1979.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2009, February 2016, and April 2016 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office.

In April 2012, the Veteran testified at a Board hearing before a Veterans Law Judge in regard to his claim for a higher initial rating for left foot gunshot wound residuals. A transcript of the hearing is associated with the record. In June 2012 and July 2015, the Board remanded such matter for additional development. Upon its return, the Veteran, his spouse, and his daughter testified at another Board hearing in April 2023 before the undersigned Veterans Law Judge, as the prior Veterans Law Judge had retired, as to all issues on appeal. A transcript of the hearing is associated with the record.

In September 2023, the Board remanded the claims on appeal for additional development. In July 2024, the Board again remanded the claims for increased ratings for the Veteran's left foot gunshot wound residuals and scarring, and denied compensation under the provisions of 38 U.S.C. § 1151 for cerebral infarction. The Veteran subsequently appealed such denial to the United States Court of Appeals for Veterans Claims (Court). In July 2025, the Court granted the Veteran's and the Secretary of VA's (the parties') Joint Motion for Partial Remand (JMPR), which vacated and remanded the July 2024 decision as to such matter. All issues have now been returned to the Board for further appellate review.

The Board notes that, following the issuance of the December 2024 supplemental statement of the case, additional evidence, to include updated VA treatment records and unrelated VA examination reports, have been received. While the Veteran has not waived Agency of Original Jurisdiction (AOJ) consideration of such newly received
arction. The Veteran subsequently appealed such denial to the United States Court of Appeals for Veterans Claims (Court). In July 2025, the Court granted the Veteran's and the Secretary of VA's (the parties') Joint Motion for Partial Remand (JMPR), which vacated and remanded the July 2024 decision as to such matter. All issues have now been returned to the Board for further appellate review.

The Board notes that, following the issuance of the December 2024 supplemental statement of the case, additional evidence, to include updated VA treatment records and unrelated VA examination reports, have been received. While the Veteran has not waived Agency of Original Jurisdiction (AOJ) consideration of such newly received evidence, such is irrelevant to the issue adjudicated herein or contain findings duplicative to those previously considered by the AOJ. Therefore, no prejudice results to the Veteran in proceeding with a decision at the present time. 38 C.F.R. § 20.1305(c).

1. Entitlement to an initial rating in excess of 10 percent for left foot gunshot wound residuals with scars.

2. Entitlement to an initial rating in excess of 10 percent prior to December 10, 2015, and in excess of 20 percent thereafter for residual painful scars on the upper lip, lower gum, and left foot.

3. Entitlement to a rating in excess of 30 percent for upper lip and lower gum scars.

Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7.

Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id.

For the entire appeal period stemming from February 11, 2009, the date of service connection, to November 2, 2015, the Veteran's left foot gunshot wound residuals with scars is rated as 10 percent disabling pursuant to DC 5310-7804 and, thereafter, such is rated as 10 percent disabling with his upper lip scar, as well as his lower gum scar as of December 10, 2015, pursuant to DC 7804. 38 C.F.R. §§ 4.73, 4.118.

Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. In the instant case, the hyphenated diagnostic code indicates an injury to Muscle Group X, which is rated under DC 5310 pertinent to the intrinsic muscles of the foot, to include those involving the plantar muscles, affecting movements of the forefront and toes, and propulsion thrust in walking, is the service-connected disorder and left foot scarring under DC 7804 is the residual condition (as detailed further below). Thus, for the entire appeal period, the Veteran's left foot gunshot wound residuals has been rated based on residual scarring.

Muscle Injury

VA regulations provide that 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. A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each
to include those involving the plantar muscles, affecting movements of the forefront and toes, and propulsion thrust in walking, is the service-connected disorder and left foot scarring under DC 7804 is the residual condition (as detailed further below). Thus, for the entire appeal period, the Veteran's left foot gunshot wound residuals has been rated based on residual scarring.

Muscle Injury

VA regulations provide that 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. A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. 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. 38 C.F.R. § 4.56(a),(b),(c).

Under DCs 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe. Pursuant to DC 5310, a noncompensable rating is warranted for slight muscle injury. A 10 percent rating is warranted for moderate muscle injury. A 20 percent rating is warranted for moderately severe muscle injury. A 30 percent rating is warranted for severe muscle injury. As relevant to the instant case, the type of injury associated with a moderate disability is a 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. Objective findings should include entrance and (if present) exit scars; small or linear, indicating short track of missile through muscle tissue; some loss of deep fascia or muscle substance or impairment of muscle tonus; and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56 (d)(2).

A moderately severe muscle disability comprises a through-and-through or deep open penetrating wound by a small high-velocity missile or a large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. There should be a history of hospitalization for a prolonged period for treatment of the wound, with a record of consistent complaints of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating track of missile through one or more muscle groups; and 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 should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56 (d)(3).

A severe muscle disability contemplates through-and-through or deep penetrating wounds 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. There should be a history of hospitalization for a prolonged period for treatment of the wound, with consistent complaints of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings should include ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track; palpable loss of deep fascia or muscle substance, or soft flabby muscles in wound area; and abnormal muscle swelling and hardening in contraction; tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. 38 C.F.R. § 4.56 (d)(4).

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
severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d).

As indicated previously, for the entire appeal period, the Veteran's left foot gunshot wound residuals have been rated based on residual scarring; however, for the reasons described herein, the Board finds that the evidence shows that such disability also results in, at most, moderate disability of Muscle Group X, thereby warranting a separate initial 10 percent rating pursuant to DC 5310. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994).

Turning to the evidence of record, the Veteran's service treatment records reflect that he incurred a gunshot wound to the left foot between the second and third digits in October 1975. Such was described as clean through the skin without shattering bone, and X-rays showed no fracture.

At a May 2009 VA examination, it was noted that the Veteran suffered a through-and-through projectile (standard 5.56-mm) injury from a rifle (M-16). He reported that he was hospitalized for ten days; however, such records could not be found. He also complained of pain, weakness, and fatigue, which made his job as a mail carrier more difficult. Here, the Veteran noted that he walked approximately seven miles a day, and used medication, shoe inserts, and massages to relieve his symptoms. Upon examination, it was noted that he had entrance and exit scars; he was able to dorsiflex and plantar flex all of his toes on the left foot with no difficulty; there was no evidence of excess callus formation; his arch was not collapsed; his Achilles tendon was non-tender; compression of the metatarsal heads of the left foot produced minimal discomfort, and compression of the heel, great toe, and Achilles produced no discomfort; and there was no limitation of motion of the ankle or toes.

At a November 2009 VA examination, the Veteran complained of left foot pain, cramping at times, and fatigue. He denied having any weakness in his left foot. It was noted that he was able to perform his usual occupation as a postal worker, but had missed approximately 20 days in the past year due to pain. It was also noted that he used medication and shoe inserts, which provided no relief, and he was soon to be fitted with a custom orthotic. Upon examination, there was no evidence of painful motion, edema, weakness, or instability; there was tenderness on the plantar and dorsal surfaces of the left foot (with pain produced on passive and active manipulation of the foot); there were no hammertoes, bunions, callosities, high arch, or flat foot; weight-bearing and gait were normal; and there was no tenderness of the heels, great toe, or Achilles tendon.

At his April 2012 Board hearing, the Veteran complained of left foot pain, which progressively became worse over the course of his workday as a mail carrier. He further reported that he limped a lot and favored his left foot, and his left foot resulted in painful movement, activity restrictions, and days lost from work.

An April 2012 private Disability Benefits Questionnaire (DBQ) and August 2012 VA examination both reflect, as relevant, a finding of left foot metatarsalgia, which the Veteran is already separately rated for as a residual of his left foot gunshot wound for the entire appeal period. Additionally, while the August 2012 VA examiner noted a left plantar heel spur (which was also shown later in September 2024), she indicated that such was a non-pathologic incidental finding and was unrelated to the Veteran's gunshot wound or metatarsalgia.

Notably, the April 2012 private DBQ also reflects that Dr. E.L. determined the Veteran had a left foot gunshot wound that was moderate in severity, and he was unable to stand or walk for
(DBQ) and August 2012 VA examination both reflect, as relevant, a finding of left foot metatarsalgia, which the Veteran is already separately rated for as a residual of his left foot gunshot wound for the entire appeal period. Additionally, while the August 2012 VA examiner noted a left plantar heel spur (which was also shown later in September 2024), she indicated that such was a non-pathologic incidental finding and was unrelated to the Veteran's gunshot wound or metatarsalgia.

Notably, the April 2012 private DBQ also reflects that Dr. E.L. determined the Veteran had a left foot gunshot wound that was moderate in severity, and he was unable to stand or walk for long hours without having pain. Further, while such DBQ notes findings of bilateral weak foot and left foot arthritis, the Board finds that such is substantially less probative than the remaining evidence of record, to include the August 2012 VA examination (conducted shortly thereafter), and the June 2015, October 2015, November 2023, and September 2024 VA examinations (as detailed further below) which all demonstrate the Veteran had neither bilateral weak foot nor left foot arthritis.

At a June 2015 VA examination, the Veteran complained of left foot daily pain (to include cramping) that worsened with weight-bearing. It was noted that he was unable to weight-bear or walk after he reached his walking limit of approximately one mile. It was also noted that he had left foot metatarsalgia/Morton's neuroma, as well as a left foot gunshot wound that chronically compromised weight-bearing, did not require arch supports, custom orthotic inserts, or shoe modifications, and was described as moderate in severity. At an October 2015 VA examination, the same findings as above were noted with no change.

At his April 2023 Board hearing, the Veteran reported that he experienced pain, numbness, soreness, shaking/twitching, swelling, cramping, flare-ups, and difficulty walking more than one mile; his toes stuck together; he had discoloration/blackness underneath and on the top of his foot; he had an altered gait; and he had callouses on the bottom of his feet.

At an October 2023 VA examination, the examiner determined the Veteran did not have a muscle injury diagnosis. At such time, the Veteran complained of a slow gait and some staggering. Upon examination, it was noted that he had loss of power (could not generate strength for long on the right side), weakness (both sides feel weak, but only the right tests weak), and lowered threshold of fatigue (both sides fatigue easily), and muscle strength testing of his left lower extremity was normal with the exception of 4/5 with ankle plantar flexion. It was also noted that the Veteran used a cane, and had to limit his walking and standing. In this regard, the examiner indicated that, while the Veteran had the above-mentioned abnormalities, a muscle injury was not found on examination. She further indicated that he only had a motor control deficit and weakness due to his cerebrovascular accident, and his impaired gait was outside the scope of any muscle injury diagnosis.

At a November 2023 VA examination, the Veteran complained of constant left foot pain (on active motion and weight-bearing), which worsened after walking for long periods of time. Here, he noted that he was unable to play sports or walk for more than a mile before experiencing pain/fatigue. It was also noted that he had left foot metatarsalgia/Morton's neuroma, as well as a left foot gunshot wound that required the use of a cane.

At a September 2024 VA examination, the examiner diagnosed the Veteran with residuals of a gunshot wound in the left foot affecting Muscle Group X. Upon examination, it was noted that the Veteran had entrance and exit scars indicating a short track of missile through muscle tissue. There was no known fascial defects or evidence of fascial defects associated with any muscle injuries; and the examiner found the Veteran's muscle injury did not affect muscle substance or function. In Muscle Group X, there was consistent fatigue and/or pain. The Veteran's muscle strength was normal. The condition did not impact the Veteran's ability to work.

An additional September 2024 VA examination reflects the Veteran complained of left foot cramps, tremors, and numbness. It was noted that he had a left foot gunshot wound that did not chronically compromised weight-bearing, or require arch supports, custom orthotic inserts, or shoe modifications, and was described as moderate in severity. It was also noted that the Veteran had difficulty walking or standing for several hours daily, which results in discomfort and numbness. The condition
the examiner found the Veteran's muscle injury did not affect muscle substance or function. In Muscle Group X, there was consistent fatigue and/or pain. The Veteran's muscle strength was normal. The condition did not impact the Veteran's ability to work.

Based on the foregoing, the Board finds that, for the entire appeal period, the Veteran's left foot gunshot wound residuals resulted in, at most, moderate injury to Muscle Group X. Thus, a separate initial rating of 10 percent, but no higher, pursuant to DC 5310 is warranted.

In this regard, the Veteran's service treatment records are negative for hospitalization for a prolonged period for treatment of his wound or consistent complaints of cardinal signs and symptoms of muscle disability, to include evidence of an inability to keep up with work requirements. Additionally, the evidence of record reflects entrance and exit scars; however, the September 2024 VA examiner found that such indicated a short track of missile through muscle tissue, there was no known fascial defects or evidence of fascial defects, and the Veteran's muscle injury did not affect muscle substance or function.

Further, while the Veteran has reported pain, cramping, weakness, tremors, fatigue, soreness, swelling, flare-ups, difficulty walking more than one mile, and an altered gait, clinical testing revealed no objectively apparent loss of strength or function. Here, tests of strength and endurance compared with sound side do not show positive evidence of impairment as muscle strength testing conducted during the appeal period is normal (with the exception of 4/5 with ankle plantar flexion in October 2023, which was noted to be due to his cerebrovascular accident rather than his gunshot wound) and no muscle atrophy is present.

Thus, the Board finds that the type of injury, history and complaint, and objective findings associated with the Veteran's Muscle Group X injury approximates no more than a moderate muscle injury. Therefore, a separate initial rating of 10 percent, but no higher, pursuant to DC 5310 is warranted.

The Board further observes that the Veteran is in receipt of separate ratings for metatarsalgia as of February 11, 2009, and radiculopathy of the left lower extremity with posterior tibial nerve involvement as of September 16, 2024, residual to his left foot gunshot wound residuals. However, the propriety of such separate ratings are not currently before the Board. De Hart v. McDonough 37 Vet. App. 371 (2024).

Scarring

As indicated previously, the Veteran is in receipt of an initial 10 percent rating for his painful left foot scars from February 11, 2009, to November 2, 2015, which, as of such date, was rated as 10 percent disabling with his painful upper lip scar, and, as of December 10, 2015, was rated as 20 percent disabling with his painful lower gum scar pursuant to DC 7804. He is also in receipt of a separate 30 percent rating pursuant to DC 7800 for his upper lip and lower gum scars, which stems from his November 2, 2015, increased rating claim for the former disability, plus the one-year look-back period, and December 10, 2015, the date of service connection for the latter disability. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010).

In this regard, scars are rated under 38 C.F.R. § 4.118, DCs 7800 through 7805. During the pendency of the appeal, VA amended the criteria for rating the skin, to include scars. See Schedule for Rating Disabilities: Skin, 83 Fed. Reg. 32,592 (July 13, 2018). As pertinent to the instant appeal, such amendment changed DC 7801 by removing the term "deep and nonlinear" and replacing it with "associated with underlying soft tissue damage," and changed DC 7802 by removing the term "superficial and nonlinear" and replacing it with "not associated with underlying soft tissue damage." Such also amended the accompanying notes to read: Note (1): For the purposes of DCs 7801 and 780
7800 through 7805. During the pendency of the appeal, VA amended the criteria for rating the skin, to include scars. See Schedule for Rating Disabilities: Skin, 83 Fed. Reg. 32,592 (July 13, 2018). As pertinent to the instant appeal, such amendment changed DC 7801 by removing the term "deep and nonlinear" and replacing it with "associated with underlying soft tissue damage," and changed DC 7802 by removing the term "superficial and nonlinear" and replacing it with "not associated with underlying soft tissue damage." Such also amended the accompanying notes to read: Note (1): For the purposes of DCs 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2): A separate evaluation may be assigned for each affected zone of the body under this diagnostic code if there are multiple scars, or a single scar, affecting multiple zones of the body. Combine the separate evaluations under § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this DC.

DC 7800 pertains to burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. Under such DC, a 30 percent rating is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent rating is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent rating, the highest rating available under DC 7800, is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement.

Note (1) following DC 7800 identifies 8 characteristics of disfigurement, for the purposes of evaluation under § 4.118: (1) scar 5 or more inches (13 or more cm.) in length; (2) scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.).

DC 7801 pertains to burn scars or scars due to other causes, not of the head, face, or neck, that are, prior to August 13, 2018, deep and nonlinear and, after such date, associated with underlying soft tissue damage. Under this DC, a 10 percent rating is assigned when the scar(s) cover an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). Higher ratings are available for greater areas affected.

DC 7802 pertains to burn scars or scars due to other causes not of the head, face, or neck that are, prior to August 13, 2018, superficial and nonlinear and, after such date, not associated with underlying soft tissue damage. Under this DC, a single 10 percent rating is assigned when the scar(s) cover an area or areas of 144 square inches (929 sq. cm) or greater.

DC 7804 provides that one or two scars that are unstable or painful warrant a 10 percent evaluation. Three or four scars that are unstable or painful warrant a 20 percent rating, while five or more scars that are unstable or painful warrant a 30 percent evaluation. Note (1) states that an unstable scar
scars or scars due to other causes not of the head, face, or neck that are, prior to August 13, 2018, superficial and nonlinear and, after such date, not associated with underlying soft tissue damage. Under this DC, a single 10 percent rating is assigned when the scar(s) cover an area or areas of 144 square inches (929 sq. cm) or greater.

DC 7804 provides that one or two scars that are unstable or painful warrant a 10 percent evaluation. Three or four scars that are unstable or painful warrant a 20 percent rating, while five or more scars that are unstable or painful warrant a 30 percent evaluation. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) states that if one or more scars are both unstable and painful, the rater is to add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Scars evaluated under DCs 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7804, when applicable. Note (3).

DC 7805 provides that other scars (including linear scars) and other effects of scars evaluated under DCs 7800, 7801, 7802, and 7804 that require the evaluation of any disabling effect(s) not considered in a rating provided under DCs 7800-7804 should be rated under an appropriate DC.

Turning to the evidence of record, at a May 2009 VA examination, two scars of the left foot were noted: one scar that was between the base of the second and third digits on the dorsal surface of the left foot, which was darker than the surrounding tissue, had irregular texture, and measured 1 cm by 1 cm, and one scar on the plantar surface of the left foot with similar dimensions. On examination, it was noted that there was tenderness and pain at such area, which was unaccompanied by redness, increase in local heat, swelling, or drainage. It was also noted that there was no significant adhesion, elevation, or depression, and no limitation of function.

At a November 2009 VA examination, two scars were noted: one scar that was on the dorsum of the left foot at the space between the second and third metatarsal heads and one scar that was on the plantar surface of the left foot. On examination, both scars were noted to be painful, darker than the surrounding tissues (hyperpigmentation), measuring 1 centimeter (cm) by 1 cm each, superficial, and tender. There was no redness, increased local heat, swelling, draining, adhesion, elevation, depression, underlying tissue loss, adherence to underlying tissue, deformity, keloid formation, limitation of function, or ulceration.

At his April 2012 hearing, the Veteran indicated that the two scars on his left foot were painful. He also indicated that he underwent surgery to release some of the tension on his left Achilles tendon as a result of his gunshot wound, which resulted in a tender scar on the back of his calf. Further, his representative noted that the Veteran's lip scar was visible above his mustache and tender, appeared to be slightly darker than the surrounding skin, and measured approximately "sixteenth of an inch wide" and "an inch and a half to an inch and three eighths in length." Shortly thereafter, the Veteran submitted photographs of his lip scar, which showed tissue loss and gross distortion/asymmetry of the lips.

The April 24, 2012, private DBQ reflects, as relevant, four scars: one linear scar on the left calf muscle (as a result of the March 2010 left gastrocnemius trigger-type slide procedure the Veteran underwent due to his left foot metatarsalgia), which measured 7.5 cm; one bullet scar on the left foot, which measured 1 cm by 0.5 cm; one bullet scar on the left foot, which measured 0.2 cm. by 0.2 cm; and one scar on the upper lip, which measured 2 cm by 0.5 cm. On examination, it was noted that the bullet scars were deep and non-linear, and all of the scars were painful. It was also noted that none of the scars were unstable; however, the upper lip scar had a total area of 1 square cm, and resulted in depression on palpation, adherence to underlying tissue, hyperpigmentation, and induration and inflexibility. There was no gross distortion or asymmetry of facial features or palpable tissue loss. None of the scars resulted in
5 cm; one bullet scar on the left foot, which measured 0.2 cm. by 0.2 cm; and one scar on the upper lip, which measured 2 cm by 0.5 cm. On examination, it was noted that the bullet scars were deep and non-linear, and all of the scars were painful. It was also noted that none of the scars were unstable; however, the upper lip scar had a total area of 1 square cm, and resulted in depression on palpation, adherence to underlying tissue, hyperpigmentation, and induration and inflexibility. There was no gross distortion or asymmetry of facial features or palpable tissue loss. None of the scars resulted in limitation of function.

At an August 2012 VA examination, it was noted that the Veteran had two well-healed minor circular scars on his left foot that were 1/2 cm in diameter, non-tender, and almost indiscernible visually. It was also noted that such scars were not painful, unstable, or had a total area equal or greater than 39 square cm.

At a June 2015 VA examination, two scars were noted: one scar on the left medial lower leg (as a result of his Achilles tendon lengthening surgery in March 2010), which measured 5.5 cm by 2 millimeter (mm); and one scar on the left foot between the second and third toes dorsal surface just proximal to the metatarsophalangeal joints (as a result of his neurectomy in January 2014), which measured 2 cm by 2 mm. On examination, both scars were noted to be linear and painful, but were not unstable or resulted in limitation of function. There was no soft tissue damage. It was also noted that the Veteran reported the incision for his neurectomy was made at the same site as his previous gunshot wound scar. At an October 2015 VA examination, the same findings as above were noted with no change.

At a November 2015 VA examination, an upper lip scar was noted, which measured 3 cm by 0.1 cm. On examination, such scar was noted to be painful, but not unstable. There was no elevation, depression, adherence to underlying tissue, missing underlying soft tissue, abnormal pigmentation or texture, gross distortion or asymmetry of facial features, palpable tissue loss, or limitation of function. Similarly, at an August 2017 VA examination, an upper lip scar was noted, which measured 2 cm by 0.2 cm. On examination, such scar was noted to be painful, but not unstable. There was no elevation, depression, adherence to underlying tissue, missing underlying soft tissue, abnormal pigmentation or texture, tenderness to palpation, gross distortion or asymmetry of facial features, palpable tissue loss, or limitation of function.

At a November 5, 2018, VA examination, four scars were noted: one scar on the upper lip, which measured 0.5 cm by 3.5 cm; one scar on the lower gum, which measured 0.5 cm by 0.2 cm; one scar on the top left foot, which measured 2.5 cm by 0.2 cm; and one scar on the left calf, which measured 8.5 cm by 0.4 cm. On examination, the Veteran's left lower extremity scars were described as being well-healed; painful, but not unstable; tender to palpation; and without underlying tissue damage. His upper lip scar was well-healed, but it was noted that his lower gum scar would get swollen and bleed at times. Additionally, both of his facial scars were noted to be painful, unstable, and tender to palpation. It was also noted that the upper lip scar resulted in depression on palpation and abnormal texture (scaly); the lower gum scar resulted in missing underlying soft tissue; and there was gross distortion and asymmetry of the Veteran's lips. None of the scars above resulted in limitation of function. Further, the examiner indicated that the Veteran's left calf scar was a result of his loosening surgery of his Achilles tendon due to gunshot wound pain, and his left foot scar was caused by his neuroma removal as a result of his gunshot wound.

At a May 2019 VA examination, an upper lip scar was noted, which measured 1.1 cm by 1.1 cm. On examination, such scar was noted to not be painful or unstable. There was no elevation, depression, adherence to underlying tissue, missing underlying soft tissue, abnormal pigmentation or texture, tenderness to palpation, gross distortion or asymmetry of facial features, palpable tissue loss, or
scars above resulted in limitation of function. Further, the examiner indicated that the Veteran's left calf scar was a result of his loosening surgery of his Achilles tendon due to gunshot wound pain, and his left foot scar was caused by his neuroma removal as a result of his gunshot wound.

At a June 2019 VA examination, two scars were noted: one scar on the upper lip, which measured 2.4 cm by 1 cm; and one scar on the lower gum, which measured 0.5 cm by 0.2 cm. On examination, the Veteran's upper lip scar was noted to be painful, but neither of his facial scars were unstable or tender to palpation. It was also noted that the upper lip scar resulted in elevation on palpation, hypopigmentation (shiny), and abnormal texture; the lower gum scar resulted in depression on palpation; and there was no gross distortion or asymmetry of the facial features, or visual or palpable tissue loss. Neither of the scars above resulted in limitation of function.

At his April 2023 hearing, the Veteran reported that his upper lip scar was painful, sensitive to different temperatures, and very noticeable without facial hair, and he experienced swelling, twitching, and irritation with eating.

At a November 2023 VA examination, five scars were noted: one scar on the left medial leg, which measured 5.5 cm by 0.2 cm; one scar on the left interspace, second and third toes dorsal, which measured 2 cm by 0.2 cm; one scar on the left interspace, second and third toes plantar, which measured 1.5 cm. by 0.5 cm; one scar on the upper lip, which measured 2.4 cm by 1 cm; and one scar on the lower gum, which measured 0.6 cm by 0.2 cm. On examination, the Veteran's left lower extremity scars were described as being not painful or unstable, or with underlying soft tissue damage; however, his left medial leg scar was noted to be tender to palpation. Additionally, both of his facial scars were noted to be painful and tender to palpation, but not unstable. It was also noted that the upper lip scar resulted in hypopigmentation (shiny) and abnormal texture; the lower gum scar resulted in elevation on palpation and hyperpigmentation; and there was no gross distortion or asymmetry of the facial features, or visual or palpable tissue loss. None of the scars above resulted in limitation of function.

At a September 2024 VA examination, a scar between the left second and third toes was noted, which measured 6 cm by 0.3 cm. On examination, such scar was not painful, unstable, or tender to palpation, and did not have underlying soft tissue damage. It was also noted that such scar did not result in limitation of function.

Based on the foregoing, with respect to the Veteran's painful scarring rated under DC 7804, the Board finds that, prior to April 24, 2012, he had two painful, but not unstable, scars located on his left foot, thus warranting the currently assigned 10 percent rating. Accordingly, a higher for such scarring is not warranted.

However, as of April 24, 2012, but no earlier, the Board finds that a rating of 20 percent, but no higher, is warranted under DC 7804 as the evidence demonstrates the presence of three painful, but not unstable, scars located on the Veteran's left calf and left foot (2). Accordingly, a higher rating, beyond the 20 percent rating assigned herein, for such scarring is not warranted.

Notably, while evidence dated in 2012 also suggests that the Veteran's upper lip scar is painful, but not unstable, such pre-dates the appeal period stemming from his November 2, 2015, claim by more than a year. 38 C.F.R. § 3.400(o)(2); Harper v. Brown, 10 Vet. App. 125 (1997) (if the increase became ascertainable more than one year prior to the date of receipt of the claim, then the proper effective date would be the date of claim). Nonetheless, even if such were considered, a rating in excess of 20 percent would not be warranted as such rating is assigned for three or four painful scars. Thus, as of November 2, 2015, the date of the receipt of the Veteran's claim for an increased rating for his upper lip scar, his left foot, left calf, and upper lip scars resulted in four scars that were painful, but not unstable, which also results in a 20 percent rating.

However, as of December 10, 2015, the date of service connection for the Veteran's lower gum scar, the Board finds that his left foot, left calf, upper lip, and lower gum scars resulted in five scars that were painful, but not unstable, which warrants a 30 percent rating under DC 7804. Here, the Board observes that there is no contemporaneous addressing the severity of the Veteran's lower gum scar for the period from December 10, 2015, to November 5, 2018; however, as the March 2024 rating decision found such to be painful, which resulted in the current assignment of an increased rating as of December 10, 2015, the Board likewise finds that such was painful at time of service connection. Consequently, with five painful, but not unstable, scars, an initial 30 percent rating is warranted as of such date.

Additionally, as of November 5, 2018, the Board finds that a rating of 40 percent, but no higher, is warranted under DC 7804 as the evidence demonstrates the presence of five painful scars located on the Veteran's upper lip, lower gum, left foot (2), and left calf. Here, the Board notes that his left foot dorsum scar associated with his gunshot wound, and left foot scar associated with his neurectomy are the same as he reported the incision for his neurectomy was made at the same site as his previous gunshot wound scar. See June 2015 VA examination report.

Further, while the Veteran's left lower extremity scars were not found to be unstable, it was noted that both of his facial scars were. In this regard, Note (2) of DC 7804 indicates that, if one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is passed on the total number of unstable or painful scars. Thus, as the Veteran would be entitled to a 30 percent rating under DC 7804 for five or more scars that are unstable or painful, an additional 10 percent must be added as two scars are both unstable and painful.

Finally, as the evidence does not show that the Veteran's left lower extremity scars are of a size to warrant separate compensable ratings under DC 7801 or 7802, and none of his scars result in any disabling effects as contemplated by DC 7805, higher or separate ratings are not warranted under such DCs at any point pertinent to the appeal period other than the currently separately assigned noncompensable rating for residual left foot scar pursuant to DC 7805, which is not at issue in the present appeal. De Hart, supra.

The Board further finds that a rating in excess of 30 percent for the Veteran's upper lip and lower gum scars is not warranted under DC 7800 as the record fails to show that such disability results in visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or four or five characteristics of disfigurement.

In this regard, the November 2015, August 2017, and May 2019 VA examiners found that his upper lip scar did not result in elevation, depression, adherence to underlying tissue, missing underlying soft tissue, abnormal pigmentation or texture, gross distortion or asymmetry of facial features, or palpable tissue loss.

Additionally, the November 2018 VA examiner indicated that the Veteran's upper lip and lower gum scars resulted in gross distortion and asymmetry of one paired set of features (lips), but there was no visible or palpable tissue loss. Further, the examiner indicated that such scars resulted in only one characteristic of disfigurement (depression on palpation). Here, while she noted that the Veteran's upper lip scar also resulted in abnormal texture and his lower gum scar resulted in missing underlying soft tissue, the areas affected did not exceed six square inches. Also, the June 2019 VA examiner noted that there was no gross distortion or asymmetry of the facial features, or visual or palpable tissue loss, and the Veteran's upper lip and lower gum scars resulted in only two characteristics of disfigurement (elevation and depression on palpation). Here, while she indicated that his upper lip scar also resulted in hypopigmentation and abnormal texture, the areas affected did not exceed six square inches.

Moreover, the November 2023 VA examiner similarly found that there was no gross distortion or asymmetry of the facial features, or visual or palpable tissue loss, and the Veteran's upper lip and lower gum scars resulted in only one characteristic of disfigurement (elevation on palpation). Here, while she noted that his upper lip scar resulted in hypopigmentation and abnormal texture, and his lower gum scar resulted in hyperpigmentation, the areas affected did not exceed six square inches. Consequently, a rating in excess of 30 percent for the Veteran's facial scars pursuant to DC 7800 is not warranted.

Other Considerations

The Board acknowledges that, in Ingram v. Collins, 38 Vet. App. 130 (2025), the Court held that the beneficial effects of medications must be discounted where the applicable diagnostic code does not reference medication as a factor in evaluation. See also Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). In the instant case, the Veteran's Muscle Group and scar disabilities are rated pursuant to DCs that do not reference the ameliorative effects of medication. While he did not report the use of medication for treatment of the latter disability, he did indicate that he used medication to treat his symptoms related to his Muscle Group injury at the May 2009 and November 2009 VA examinations; however, there is no indication that he had taken such medications prior to the aforementioned examinations. Moreover, he reported that he achieved no relief with the use of such medications. Consequently, the Board finds that the findings from such examinations were rendered without the beneficial effects of such medication, and accurately captures the totality of the nature and severity of the Veteran's Muscle Group disability without consideration thereof.

In reaching its conclusions in the instant case, the Board acknowledges the Veteran's belief that his left foot gunshot wound residuals, to include his associated muscle injury and scarring, and upper lip and lower gum scars are more severe than as reflected by the current assigned disability ratings. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes the Veteran is competent to describe his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Ultimately, the Board finds the medical evidence in which professionals with specialized expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of his disabilities.

The Board has considered whether additional staged ratings under Fenderson, supra, and Hart, supra, are appropriate for the Veteran's service-connected disabilities; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings is not warranted. Furthermore, neither the Veteran nor his representative have raised any other issues, and no other issues have been reasonably raised by the record, in regard to the initial and increased rating claims adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017).

In reaching the foregoing determinations, the Board has resolved all doubt in the Veteran's favor, which has resulted in a partial award
his disabilities.

In reaching the foregoing determinations, the Board has resolved all doubt in the Veteran's favor, which has resulted in a partial award of a separate rating for impairment of Muscle Group X, increased ratings for his painful left foot, left calf, upper lip, and lower gum scars. However, insofar as the Board has denied higher or separate ratings for the disabilities on appeal, the weight of the probative evidence is against such aspects of the Veteran's claims. Therefore, the benefit of the doubt doctrine is not applicable in such regard, and his initial and increased rating claims must otherwise be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

REASONS FOR REMAND

5. Entitlement to compensation under the provisions of 38 U.S.C. § 1151 for cerebral infarction, claimed as residual to left foot surgery.

Upon consideration of the points raised in the July 2025 JMPR, the Board finds that a remand is necessary in order to obtain an addendum opinion addressing the etiology of the Veteran's cerebral infarction, claimed as residual to left foot surgery.

In this regard, in July 2024, the Board denied the claim on appeal based, in part, on a December 2023 VA opinion. Specifically, such examiner opined that it was less likely than not that the Veteran had an additional disability of cerebral infarction that was caused or aggravated by the left foot neurectomy performed by VA in January 2014, to include the non-use of blood thinners prior thereto. However, in the July 2025 JMPR, the parties questioned the adequacy of such unfavorable opinion. Specifically, the parties found that, in support of her opinion, the December 2023 VA examiner only cited a January 9, 2014, Anesthesiology Note in finding that the Veteran was clearly advised to keep taking aspirin, and reiterated such finding in her rationale. However, the parties determined that, even assuming the Veteran continued to take aspirin prior to his surgery, in their testimony, the Veteran and his spouse appeared to have been referring to the blood thinner Warfarin, which he was given following his stroke, not aspirin. Here, the parties noted that the examiner acknowledged the Veteran was not on a more potent blood thinner such as Warfarin at the time of his surgery. The parties further found that as the examiner did not acknowledge the January 9, 2014, Podiatry History and Physical Note instruction to hold aspirin five days prior to surgery, it was unclear (1) whether the examiner relied on an inaccurate factual premise regarding the use of blood thinners prior to surgery and (2) whether her medical opinion would be different if the Veteran had stopped taking aspirin five days before the surgery and then resumed the day of or after surgery.

Thus, based on the inadequacies in the December 2023 VA opinion as identified in the JMPR, the Board finds that a remand is necessary to obtain an addendum opinion that addresses such concerns.

The matters are REMANDED for the following action:

Forward record, to include a copy of this Remand, to an appropriate VA examiner to obtain an addendum opinion addressing the etiology of the Veteran's cerebral infarction, claimed as residual to left foot surgery. After a review of the record, the examiner should address the following inquiries:

(A) Is it at least as likely as not that the Veteran has an additional disability of cerebral infarction that was caused or aggravated by the left foot neurectomy performed by VA in January 2014, to include the non-use of blood thinners other than aspirin prior thereto? If so, please identify the nature of such disability (or disabilities).

(B) If the Veteran has an additional disability of cerebral infarction related to his left foot neurectomy performed by VA January 2014, is it at least as likely as not that such additional disability was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical
least as likely as not that the Veteran has an additional disability of cerebral infarction that was caused or aggravated by the left foot neurectomy performed by VA in January 2014, to include the non-use of blood thinners other than aspirin prior thereto? If so, please identify the nature of such disability (or disabilities).

(B) If the Veteran has an additional disability of cerebral infarction related to his left foot neurectomy performed by VA January 2014, is it at least as likely as not that such additional disability was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination, to include in failing to administer blood thinners other than aspirin prior to such surgery?

(C) If the Veteran has an additional disability of cerebral infarction related to his left foot neurectomy performed by VA in January 2014, is it at least as likely as not that such additional disability was due to an event not reasonably foreseeable? A "not reasonably foreseeable" event is one that would not be reasonably anticipated or expected by a health care provider who utilized the degree of care a prudent or competent person so engaged would exercise.

In offering such opinion, the examiner must consider the following:

(1) the Veteran's and his family member's reports that VA failed in their care by not administering a blood thinner other than aspirin prior to his January 2014 left foot surgery, and subsequent treatment providers had indicated that such should have been provided and the failure to do so resulted in his stroke;

(2) the January 9, 2014, Podiatry History and Physical Note which reflects the Veteran was instructed to hold aspirin five days prior to surgery; and

(3) the January 9, 2014, Anesthesiology Note which reflects the Veteran was advised to keep taking aspirin prior to surgery.

A complete rationale for any opinion offered should be provided.

A. JAEGER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Koria B. Stanton, Associate Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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