Citation Nr: 9904431 Decision Date: 02/18/99 Archive Date: 02/24/99 DOCKET NO. 96-46 032 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder, depression, and alcoholism. 2. Entitlement to service connection for hearing loss. 3. Entitlement to service connection for a stomach disorder. 4. Entitlement to an increased rating for lumbar arthritis, currently rated as 20 percent disabling. 5. Entitlement to an increased rating for bilateral inguinal hernias, currently rated as 20 percent disabling. 6. Entitlement to an increased rating for a right (major) clavicle fracture with malunion, currently rated as 10 percent disabling. 7. Entitlement to an increased (compensable) rating for residuals of a left shoulder injury. 8. Entitlement to an increased rating for residuals of a right knee injury, currently rated as 10 percent disabling. 9. Entitlement to an increased (compensable) rating for left knee crepitus. 10. Entitlement to an increased rating for fractures of the left (minor) little and ring fingers with carpal arthritis and carpal tunnel syndrome, currently rated as 10 percent disabling. 11. Entitlement to an increased rating for a nose fracture with sinusitis, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Michael Martin, Counsel INTRODUCTION The veteran had active service from August 1974 to July 1980, and from July 1982 to August 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from decisions of June, November and December 1995 by the Department of Veterans Affairs (VA) Anchorage, Alaska, Regional Office (RO) and from a decision of August 1996 by the Cleveland, Ohio, RO. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that the RO made a mistake by denying his claim for service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder, depression, and alcoholism. He asserts that he has depression as a result of his service-connected physical disabilities. He also states that he has post-traumatic stress disorder as a result of witnessing an incident in which people were killed when an ejector seat discharged while a plane was still on the ground. The veteran also contends that he is entitled to service connection for hearing loss. He asserts that he developed hearing loss as a result of exposure to loud noises in service such as the sound from aircraft engines. The veteran contends that service connection should be granted for a stomach disorder because he was treated for complaints of stomach pain during service. The veteran also contends that the RO should have assigned higher disability ratings for his service-connected disabilities. He asserts that a rating higher than 20 percent is warranted for his lumbar arthritis because the disorder causes symptoms of pain and chronic aching in the lumbar area. He also reports that the disorder causes significant limitation of motion of the spine. The veteran contends that a rating higher than 20 percent is warranted for his bilateral inguinal hernias. He reports that examination has revealed the presence of recurrent hernias with obvious bulges on each side. He states that he had pain in the inguinal areas and that he uses a truss on occasion. He also states that his ability to lift is limited. The veteran contends that a rating higher than 10 percent is warranted for his right (major) clavicle fracture with malunion. He states that he experiences symptoms of pain and a feeling of looseness in the joint. He also states that there is a deformity of the clavicle which causes limitation of motion. The veteran contends that a compensable rating should be granted for his residuals of a left shoulder injury. He states that he has tenderness and limitation of motion in the shoulder. He also says that making a motion such as opening a door causes pain and discomfort. The veteran contends that a rating higher than 10 percent is warranted for his residuals of a right knee injury because the disorder causes pain and decreased strength. He states that he notices the knee making popping and cracking sounds on movement. He also states that the knee disorder is occasionally productive of edema, and that extension of the knee is limited by 10 degrees. The veteran further contends that he is entitled to an increased (compensable) rating for left knee crepitus. He states that he must take medications to relieve symptoms of pain and edema. The veteran contends that a rating higher than 10 percent is warranted for his fractures of the left (minor) little and ring fingers with carpal arthritis and carpal tunnel syndrome. He states that he has received treatment for the disorder at a VA medical center. He reports having pain and degenerative changes in the hand. Finally, the veteran contends that a rating higher than 10 percent is warranted for his nose fracture with sinusitis because the disorder causes obstruction of the nasal passages. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1998), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim for service connection for a psychiatric disorder, to include post-traumatic stress disorder, depression, and alcoholism. It is also the decision of the Board that the claims for service connection for hearing loss and a stomach disorder are not well- grounded. Finally, it is the decision of the Board that the preponderance of the evidence is against the claims for increased ratings, except for the claim for an increased (compensable) rating for a left shoulder injury. FINDINGS OF FACT 1. An acquired psychiatric disorder, to include post- traumatic stress disorder, depression, and alcoholism was not present until many years after service and has not been shown to be related to any incident in service. 2. The veteran has not presented any competent evidence demonstrating a link between his current hearing loss and his period of service. 3. The veteran has not presented any competent evidence demonstrating that he currently has a stomach disorder. 4. The lumbar arthritis is not productive of more than moderate limitation of motion, and has not caused severe manifestations of a lumbosacral strain such as listing of the whole spine to the opposite side, a positive Goldthwait's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of the joint space, or some of the above with abnormal mobility on forced motion. 5. The bilateral inguinal hernias are postoperative, recurrent hernias which are readily reducible and well supported by a truss or belt. 6. The right (major) clavicle fracture with malunion is not productive of nonunion with loose movement, dislocation of the clavicle or scapula, or impairment of function of a contiguous joint resulting in limitation of motion of the right arm to shoulder level. 7. The residuals of a left shoulder injury include painful arthralgia which slightly limits motion of the joint, but does not limit motion of the joint to shoulder level. 8. The residuals of a right knee injury are productive of no more than slight impairment of the joint. 9. The left knee crepitus is not productive of impairment of the joint. 10. The fractures of the left (minor) little and ring fingers with carpal arthritis and carpal tunnel syndrome have not resulted in more than mild incomplete paralysis of the median nerve. 11. The nose fracture with sinusitis is no more than moderate in degree, and is not productive of more than one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder, to include post- traumatic stress disorder, depression, and alcoholism, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.304 (1998). 2. The claim for service connection for hearing loss is not well-grounded. 38 U.S.C.A. § 5107 (West 1991). 3. The claim for service connection for a stomach disorder is not well-grounded. 38 U.S.C.A. § 5107 (West 1991). 4. The criteria for a disability rating higher than 20 percent for lumbar arthritis are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5292, 5293, 5295 (1998). 5. The criteria for a disability rating higher than 20 percent for bilateral inguinal hernias are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.114, Diagnostic Code 7338 (1998). 6. The criteria for a disability rating higher than 10 percent for a right (major) clavicle fracture with malunion are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5201, 5203 (1998). 7. The criteria for a 10 percent disability rating for residuals of a left shoulder injury are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5201 (1998). 8. The criteria for a disability rating higher than 10 percent for residuals of a right knee injury are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5257, 5260, 5261 (1998); VAOPGCPREC 23-97. 9. The criteria for an increased (compensable) rating for left knee crepitus are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5257, 5260, 5261 (1998); VAOPGCPREC 23-97. 10. The criteria for a disability rating higher than 10 percent for fractures of the left (minor) little and ring fingers with carpal arthritis and carpal tunnel syndrome are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (1998). 11. The criteria for a disability rating higher than 10 percent for a nose fracture with sinusitis are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.96, Diagnostic Codes 6510-6514 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In reviewing any claim for VA benefits, the initial question is whether the claim is well-grounded. The veteran has "the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well- grounded." See 38 U.S.C.A. § 5107(a); Robinette v. Brown, 8 Vet. App. 69, 73 (1995). A well-grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of § [5107]." See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1991). If not, the claim must be denied and there is no further duty to assist the veteran with the development of evidence pertaining to that claim. See 38 U.S.C.A. § 5107(a) (West 1991). I. Entitlement To Service Connection For An Acquired Psychiatric Disorder, To Include Post-Traumatic Stress Disorder, Depression, And Alcoholism. Service connection may be granted for disability due to disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131 (West 1991). If a chronic disorder such as a psychosis was manifest to a compensable degree within one year after separation from service, the disorder may be presumed to have been incurred in service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1998). Service connection may not be granted for disability which results from the abuse of alcohol or drugs. See 38 C.F.R. § 3.301 (1998). Service connection may also be granted for disability shown to be proximately due to or the result of a service-connected disorder. See 38 C.F.R. § 3.310(a) (1998). This regulation has been interpreted by the United States Court of Veterans Appeals (Court) to allow service connection for a disorder which is caused by a service-connected disorder, or for the degree of additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder. See Allen v. Brown, 7 Vet. App. 439 (1995). In order for a claim for service connection to be well- grounded, there must be competent evidence of current disability, of incurrence or aggravation of a disease or injury in service, and a nexus between the in-service injury or disease and the current disability. Medical evidence is required to prove the existence of a current disability and to fulfill the nexus requirement. Lay or medical evidence, as appropriate, may be used to substantiate service incurrence. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995). The Board has found that the veteran's claim for service connection for a psychiatric disorder is "well-grounded" within the meaning of 38 U.S.C.A. § 5107 (West 1991). That is, the claim is not inherently implausible. The Board also finds that all relevant facts have been properly developed. All evidence necessary for an equitable resolution of this issue has been obtained. The Board does not know of any additional relevant evidence which is available. Therefore, no further assistance to the veteran with the development of evidence is required. The veteran's service medical records do not reflect the presence of an acquired psychiatric disorder other than a disorder associated with alcohol dependence. A service mental health clinic record dated in July 1993 shows that the veteran had made progress in Substance Abuse Recover Center (SARC) program. The only Axis I diagnoses were alcohol dependence in remission, and nicotine dependence. Similarly, although a mental health clinic record dated in April 1994 shows that the veteran's complaints included having a depressed mood, an acquired psychiatric disorder other than alcohol and nicotine dependence was not diagnosed. The report of a medical history given by the veteran in April 1994 for the purpose of his separation from service shows that the veteran reported a history of having depression or excessive worry. In a typed note associated with the medical history report, it was indicted that the history of depression or excessive worry referred to the SARC program in 1993. The report of a medical evaluation conducted in April 1994 shows that psychiatric evaluation was normal. The report of a psychiatric examination conducted by the VA in November 1994 shows that the examiner interviewed the veteran and reviewed his claims file. The veteran reported that he was taking an antidepressant. He gave a history of losing his sense of reality during service in April 1993. He said that he had not been able to deal with the pressures of being a quality assurance inspector for aircraft engines. He also reported drinking alcohol daily since age 16. In 1983, he had been run off the road by a car while he was riding a motorcycle. He reportedly was intoxicated at that time. In December 1992, he received a DUI followed by an Article 15. In early 1993, he had to be picked up at a servicemen's club by his wife because he was intoxicated. He also reportedly fell down a flight of stairs once. He was admitted to a service medical center from May through June 1993 for a required alcohol detoxification prior to entering the Substance Recovery Center on base. At that time, he was feeling drained, depleted of energy, sad, hopeless, overwhelmed, empty and useless. He was relieved of his duties as an aircraft quality assurance inspector and was assigned to maintenance and repair duties on base. He said that he liked that work assignment. After the substance abuse program, he received follow up treatment by visits to the mental health center until separation from service. He was given desipramine at bedtime for depressive symptoms starting in April 1994 and continuing until his separation from service. When leaving service in September 1994, he had several refills left on his prescription, and had continued taking the medication. It was also noted that the veteran had gone to a service mental health center from April to December 1986 in regard to marital problems. He attended an anger management group during that period. On mental status examination by the VA in November 1994, the veteran's mood was mildly dysphoric and depressed. His affect was mildly constrictive. His thought content had no psychotic symptoms and no plan to hurt himself or others. There was no formal thought disorder. The veteran was alert and had clear consciousness during the interview. The diagnoses were alcohol dependence, in remission, and organic mood syndrome with depressed features, secondary to alcohol. The Board notes that compensation may not be paid for disability which is secondary to alcohol abuse. At the hearing held in April 1997, the veteran testified that he had bouts of depression that began in service and which continued to occur on a daily basis. He stated that he believed that his symptoms were not related to abuse of alcohol. He stated that his psychiatric symptoms were related to physical disabilities that began in service, and due to a traumatic incident in which he witnessed two men killed when the ejection seat went off on an aircraft on the ground. He said that this occurred at the Shaw Air Force Base in South Carolina during the summertime, but he did not remember what year. He said that the men killed were not members of his unit, and he did not know their names. The veteran also recounted an incident in which he tried to extract a 4 year old girl out of an auto accident. Regarding the veteran's contention that his depression is secondary to his service-connected disabilities, the Board notes that the Court has held that lay persons, such as the veteran, are not qualified to offer an opinion that requires medical knowledge, such as a diagnosis or an opinion as to the cause of a disability. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). See also Grottveit v. Brown, 5 Vet. App. 91, 93 (1993), in which the Court held that a veteran does not meet his burden of presenting evidence of a well- grounded claim where the determinative issue involves medical causation and the veteran presents only lay testimony by persons not competent to offer medical opinions. Regarding the veteran's contention that he developed post- traumatic stress disorder as a result of incidents which occurred in service, the Board notes that service connection for post-traumatic stress disorder requires medical evidence establishing a clear diagnosis of the condition, credible evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. See 38 C.F.R. § 3.304(f) (1998). As to the requirement under 38 C.F.R. § 3.304(f) (1998) that there be medical evidence establishing a clear diagnosis of post-traumatic stress disorder, the Board finds that the evidence which is of record includes diagnoses of that disorder. For example, VA medical treatment records dated in 1996 and 1997 include a VA outpatient mental health clinic record dated in November 1996 which shows that the veteran had obsessive preoccupation with loss and trauma eliciting intrusive memories of an auto accident. He also report nightmares. The diagnosis was PTSD. The Board finds, however, that the veteran does not have post-traumatic stress disorder. The detailed report by the VA psychiatric examiner in November 1994 which did not result in a diagnosis of post-traumatic stress disorder was based not only on an interview with the veteran but also on review of his claims file. The Board finds that the records has higher probative value that the treatment records dated in November 1996. The Board also notes that the veteran failed to appear for a mental status examination which was scheduled for July 1996. Furthermore, even if the veteran had a clear diagnosis of post-traumatic stress disorder, the stressors claimed by the veteran have not been corroborated. Regarding the issue of whether there is credible evidence that the veteran's claimed stressors actually occurred, the Board notes that if a claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed inservice stressor. See 38 C.F.R. § 3.304(f) (1998). Where the claimed stressor is not related to combat, "credible supporting evidence" means that "the appellant's testimony, by itself, cannot as a matter of law, establish the occurrence of a noncombat stressor." See Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In Cohen v. Brown, 10 Vet. App. 128 (1997), the Court clarified the analysis to be followed in adjudicating a claim for service connection for PTSD. The Court pointed out that the VA has adopted the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) in amending 38 C.F.R. §§ 4.125 and 4.126. See 61 Fed. Reg. 52695-52702 (1996). Therefore, the Court took judicial notice of the effect of the shift in diagnostic criteria. The major effect is that the criteria have changed from an objective ("would evoke ... in almost anyone") standard in assessing whether a stressor is sufficient to trigger PTSD, to a subjective standard. The criteria now require exposure to a traumatic event and response involving intense fear, helplessness, or horror. The question of whether a claimed stressor was severe enough to cause post-traumatic stress disorder in a particular individual is now a clinical determination for the examining mental health professional. See Cohen, supra. Nothing in Cohen, however, negates the need for a noncombat veteran to produce credible corroborating and supporting evidence of any claimed stressor used in supporting a diagnosis of PTSD. Id. at 20; Moreau v. Brown, 9 Vet. App. 389, 395 (1996). The corroboration may be by service records or other satisfactory evidence. See Doran v. Brown, 6 Vet. App. 283, 289 (1994). In Doran, a veteran's service records had been lost due to fire; however, his account of inservice stressors was corroborated by statements from fellow servicemen. The Board notes that the RO made efforts to verify the stressors claimed by the veteran. Significantly, however, the veteran has not provided enough specific information to allow the VA to attempt to confirm the occurrence of any stressors. A letter from the U. S. Armed Services Center for Research of Unit Records dated in October 1997 shows that they coordinated their research with the U. S. Air Force Safety Agency, but were unable to locate any documentation concerning the aircraft accident described by the veteran. They indicated that in order to provide additional research concerning the accident, the veteran would have to provide the date within seven days, the unit designation of the aircraft, and the full names of the casualties. The veteran however, has previously indicated that he is not able to provide this information. The Board also notes that there is no corroborating evidence with respect to the veteran's contention that he witnessed the aftermath of an auto accident. Furthermore, the evidence in this case, unlike the evidence in Doran, does not include any lay statements from other servicemen corroborating the veteran's account of his claimed stressors. For the foregoing reasons, the Board finds that there is no credible corroborating evidence that the claimed inservice stressors actually occurred. For the foregoing reasons, the Board finds that post- traumatic stress disorder has not been shown to be related to any incident in service. Accordingly, the Board concludes that an acquired psychiatric disorder, to include post- traumatic stress disorder, depression, and alcoholism., was not incurred in or aggravated by service. II. Entitlement To Service Connection For Hearing Loss. At the hearing held in April 1997, the veteran testified, in essence, that he was exposed to loud noise in service and that this exposure caused him to sustain hearing loss. Before service connection may be granted for hearing loss, the hearing loss must be of sufficient severity to be considered to be a disability under VA regulations. For the purpose of applying the laws administered by the VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385 (1998). On the authorized audiological evaluation in November 1994, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 5 10 10 LEFT 10 10 0 20 30 The average loss in the right ear was 9 decibels. The average loss in the left ear was 15 decibels. Speech audiometry revealed speech recognition ability of 98 percent in the right ear and of 96 in the left ear. The examiner stated that the hearing loss was within normal limits for the right ear and within normal limits for adjudication purposes in the left ear, though a mild sensory neural decrease was noted at 4KHz. The examiner also noted that the veteran's hearing was sufficient for good speech understanding. The Board notes that these results are not severe enough to be considered to be a hearing loss disability for which service connection may be granted. The Board notes that a more recent hearing test was conducted for treatment purposes. The report of an audiology report dated in February 1997 shows that the veteran had a 40 decibel loss in the left ear at 4000 Hz. This indicates that the veteran has a hearing loss disability in the left ear under the standards set forth above. Nevertheless, this evidence still is not adequate to support the claim as there is no medical opinion linking any current hearing loss to service. Accordingly, the Board concludes that the claim for service connection for hearing loss is not well-grounded. III. Entitlement To Service Connection For A Stomach Disorder. The veteran's service medical records show that the veteran was seen for complaints pertaining to his stomach. For example, a service medical record dated in December 1976 shows that the veteran complained of having stomach pains and headaches. On examination, the left upper quadrant was tender. The assessment was probable gastritis. Medication was prescribed. A service medical record dated in July 1985 shows that he complained of having a 6 month history of stomach pain which was made worse by overeating. On objective examination, bowel sounds were present, and the abdomen was soft, nontender, and there were no masses pr organomegaly. The assessment was rule out peptic ulcer disease. Upper GI x- rays were ordered. A service radiology report dated in September 1985 shows that the upper GI series demonstrated no significant abnormality. A service medical record dated in November 1987 shows that the veteran was hospitalized for two days with diarrhea, vomiting, and weakness. The assessment was acute gastroenteritis with dehydration. The report of a medical examination conducted in April 1980 for the purpose of the veteran's separation from his first period of service shows that clinical evaluation of the veteran's abdomen and viscera was normal. A service hospital summary dated in June 1993 shows that while being treated for alcohol dependence, it was noted that the veteran had a history of episodic left upper quadrant abdominal pain. The report of a medical history given by the veteran in April 1994 shows that he gave a history of having frequent indigestion. However, the report of a medical examination of the veteran conducted in April 1994 for the purpose of the veteran's separation from his second period of service shows that no abnormality pertaining to the stomach was noted. The report of a disability compensation examination conducted by the VA in November 1994 does not contain any mention of a stomach disorder. The veteran reportedly could eat any food without trouble, though he avoided hot spicy foods. Examination of the abdomen was unremarkable. There was no pain, tenderness, masses or spasm. Similarly, the report of a disability evaluation examination conducted for the VA by a fee basis examiner in October 1995 does not contain any references to any problems with the veteran's stomach. A VA radiology consultation report dated in March 1997 shows that an upper GI series showed that the stomach displayed normal shape, size, contour, and peristalsis with no evidence of mucosal abnormalities, filling defects or rigidity. The duodenal bulb and sweep were unremarkable. The impression was normal upper GI. A VA gastric clinic record dated in April 1997 shows that the veteran complained of left upper quadrant discomfort. The assessment was intermittent left upper quadrant pain. The physician stated that it was possibly due to an irritable bowel, but more likely musculoskeletal in nature. Thus, a stomach disorder was not diagnosed. The veteran testified during a hearing held in April 1997 that he thought that he had developed stomach pain in service due to the use of medications such as Motrin. As noted above, however, the veteran is not qualified to offer medical opinion. Thus, the veteran has not presented any competent evidence of a current stomach disorder. A service-connection claim must be accompanied by evidence which establishes that the claimant currently has the claimed disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Accordingly, the Board concludes that the claim for service connection for a stomach disorder is not well-grounded. In reaching the foregoing disposition of the veteran's claims for service connection for hearing loss and a stomach disorder, the Board recognizes that these issues are being disposed of in a manner slightly different from that employed by the RO. The RO denied the veteran's claims on the merits, while the Board has concluded that the claims are not well grounded. However, the Court has held that "when an RO does not specifically address the question [of] whether a claim is well grounded but rather, as here, proceeds to adjudication on the merits, there is no prejudice to the veteran solely from the omission of the well-grounded-claim analysis." See Meyer v. Brown, 9 Vet. App. 425, 432 (1996). Further, the Board views its discussion as sufficient to inform the veteran of the evidence which he must present in order to make his claims well grounded, and the reasons why his current claims are inadequate. See Robinette v. Brown, 8 Vet. App. 69, 77-78 (1995). IV. Entitlement To An Increased Rating For Lumbar Arthritis, Currently Rated As 20 Percent Disabling. The Court has held that a mere allegation that a service- connected disability has become more severe is sufficient to establish a well-grounded claim for an increased rating. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App 629, 632 (1992). Accordingly, the Board finds that the veteran's claim for an increased rating is "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). Once a claimant has presented a well-grounded claim, the VA has a duty to assist the claimant in developing facts which are pertinent to the claim. See 38 U.S.C.A. § 5107(a) (West 1991). The Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue on appeal has been obtained. The evidence includes the veteran's service medical records, and post-service medical treatment records. The veteran has been afforded disability evaluation examinations and a personal hearing. The Board does not know of any additional relevant evidence which is available. Therefore, no further assistance to the veteran with the development of evidence is required. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. See 38 U.S.C.A. § 1155 (West 1991). Separate diagnostic codes identify the various disabilities. The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for an increased rating, the Board must consider which diagnostic code or codes are most appropriate for application in the veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Under 38 C.F.R. § 4.71a, Diagnostic Code 5295 (1998), a noncompensable rating is warranted where a lumbosacral strain is productive of slight subjective symptoms only. A 10 percent disability rating may be assigned where there is characteristic pain on motion. A 20 percent rating is warranted where there is muscle spasm on extreme forward bending, or unilateral loss of lateral spine motion in a standing position. A 40 percent rating is warranted if the lumbosacral strain is severe with listing of the whole spine to the opposite side, a positive Goldthwait's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritis changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. Alternatively, under Diagnostic Code 5293, a noncompensable rating is warranted for intervertebral disc syndrome which is postoperative and cured. A 10 percent rating is warranted for intervertebral disc syndrome which is mild in degree. A 20 percent rating is warranted for intervertebral disc syndrome which is moderate in degree with recurring attacks. A 40 percent rating is warranted for severe intervertebral disc syndrome with recurring attacks and little intermittent relief. A 60 percent rating is warranted for intervertebral disc syndrome which is pronounced, with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief. Diagnostic Code 5292 provides that a 10 percent rating is warranted for limitation of motion of the lumbar spine which is slight in degree. A 20 percent rating is warranted for moderate limitation of motion. A 40 percent rating is warranted if the limitation of motion is severe. The Court has emphasized that when assigning a disability rating, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on movements. See DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). The rating for an orthopedic disorder should reflect functional limitation which is due to pain which is supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is also as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. See 38 C.F.R. § 4.40 (1998). The factors of disability reside in reductions of their normal excursion of movements in different planes. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight bearing are related considerations. See 38 C.F.R. § 4.45 (1998). It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimal compensable rating for the joint. See 38 C.F.R. § 4.59 (1998). The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. See 38 C.F.R. § 4.14 (1998). At the hearing held in April 1997, the veteran testified that he had chronic pain in his upper and lower back. He said that in the last few months it felt like a knife was stabbing him. He said that pain severely limited his ability to bend backwards. He also said that he had been seen for back problems at the VA medical center, but that he had not been issued a back brace. He reported that he had been taking Naprosyn as needed. The medical evidence pertaining to the severity of the back disorder includes the report of a disability compensation examination conducted by the VA in November 1994 which shows that the veteran said that in 1977 a weight fell on his back and since then he had pain for which he took Motrin three times a day. On physical examination, his build, state of nutrition, carriage, posture and gait were all good. He could flex his back forward 95 degrees without difficulty. He could retroflex 35 degrees, rotate 35 degrees, and bend sideways 35 to 45 degrees without difficulty. There was no tenderness over the spinous processes, and there was no evidence of paraspinous muscle pain or spasm. On neurological examination, sensation was normal throughout the body. The reflexes were active and equal. The impression was that the veteran was a normal, healthy adult male with the above indicated history but without a great deal of objective data to substantiate disability at the time of the examination. An x-ray of the veteran's lumbosacral spine taken by the VA in November 1994 was interpreted as showing that the vertebral alignment was maintained. There was no loss of vertebral height. There was minor endplate irregularity of the thoracic spine, but it was stated that this could be seen as a normal variant. There was minor facet sclerosis at L4-5 and L5-S1. There was no evidence of pars defect. Soft tissues were unremarkable. The impression was minor degenerative changes of the lumbar spine. VA medical treatment records include the report of a history and physical examination performed August 1995 which shows that the veteran reported multiple complaints, including low back pain. On examination, straight leg raising was to 70 degrees in both legs. He lacked about two inches of touching his toes. The motion of the lumbar spine was slightly decreased. X-rays of the spine showed a few minor osteoarthritic changes, but the disk spaces appeared normal. He could walk on his heels and toes without difficulty. Deep tendon reflexes were symmetrical and active. The pertinent diagnosis was multiple pains in the back, low back, right scapular area, both hands, and right clavicular area. The report of an orthopedic examination conducted by a VA fee basis examiner in October 1995 shows that the veteran said that in the left side of his low back he felt a pinching, crushing pain, and that after strenuous work he had a severe pulling pain. He said that his back cramped up. He also said that the right lower side of the back felt strained when he was carrying a load. He gave a history of having an injury to the back when he was hit by the generator from a C-130. He said that he had continual problems since then. He said that he had been treated conservatively. He did not have radiation of pain into the buttocks or legs. He also did not have any bowel or bladder problems. On examination, the lumbar range of motion was to 80 degrees of flexion with his fingers within six inches from the floor. Extension was to 25 degrees, right and left side bending were to 20 degrees, and rotation to the right and left were both to 30 degrees. His pelvis was level. The right shoulder was 3 cm lower than the left. Light and deep palpation throughout the paraspinal muscles in the thoracic and lumbar spine was negative. Light percussion over the spine revealed tenderness from T4 thought T6. Axial loading on the head and shoulders was negative. There were normal back curves. Deep tendon reflexes of the ankles and knees were 2+ and symmetrical. Babinski's were down-going bilaterally. Indirect sciatic stretch test was negative at 90 degrees bilaterally. Sensory examination was normal. Group testing of the lower extremities was 5/5 in all groups tested. The diagnoses did not include a disorder of the spine. The report of a spinal cord examination conducted by the VA in October 1997 shows that the veteran reported having low back pain and cervical pain. He said that these were in two separate locations, and that he had no radiation of the pain from either of the sites to anywhere else. He said that he was weak at times, but that this was truly pain limitation now. He said that his pain ran from a two to an eight on a scale of one to ten. He denied having any sensory changes or bowel or bladder problems. On neurological testing, he had 5/5 strength throughout with the exception of his ilio-psoas muscle which was 4+/5. Both tone and rapid alternating movements were within normal limits. Pronator drift was negative. There was no evidence of atrophy or fasciculations. Deep tendon reflexes were 2/4 throughout, and were bilaterally symmetrical. On sensory testing, he had normal sensation to light touch, pinprick, vibration, and double simultaneous extinction. He did have decreased pinprick in the left inguinal region which he related to surgical problems. His gait was unremarkable. He could walk on heels and toes without difficulty. Romberg test was negative, and tandem gait was unremarkable. The examiner noted that no test results were available for his review, so he requested either an MRI scan or a CAT scan of the lumbar spine. The pertinent impression was chronic lumbosacral strain. A VA radiology report dated in October 1997 shows that an x- ray of the veteran's lumbar spine was interpreted as showing (1) mild congenital stenosis at L5; and (2) minimal disc bulge at L3-4 and 5-1. The report of a disability evaluation examination conducted in November 1997 (labeled as an examination of the hand, thumb and fingers) shows that the veteran said that he had pain in his lumbosacral region on a daily basis with no reducing factors. He said that he could not tolerate taking ibuprofen. He reported that the pain did not radiate to his lower extremities, and was not accompanied by incontinence. He recounted that the discomfort started in December 1977 when a 95 pound generator fell and struck his back. He reported that he did not use a cane, walker, or crutches. He said that he had been seeing a chiropractor, and had been told not to lift any heavy weights. He also said that he formerly ran, but did not currently do so. Upon examination, he had mild right scoliosis. Flexion was to 80 degrees, left and right abduction was to 20 degrees, and extension was to 10 degrees. These were active ranges of motion. There was not any appreciable difference on passive range of motion. Upon palpation there was left pelvic brim tenderness. A CT scan revealed mild congenital stenosis at L5 with minimal disc bulge at L3-4 and S-1. The pertinent diagnosis was chronic lumbosacral syndrome. After considering all of the evidence, the Board finds that the manifestations of the service-connected low back disorder most closely approximate the criteria for the currently assigned 20 percent disability rating under Diagnostic Code 5295. With respect to the evidence of recurrent muscle spasm, the Board notes that muscle spasm is the type of symptom contemplated under the currently assigned rating. The evidence generally shows that the lumbosacral strain is not productive of severe manifestations such as listing of the whole spine to the opposite side, a positive Goldthwait's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of the joint space, or some of the above with abnormal mobility on forced motion. He has had some limitation of range of motion of the low back, but not to a marked degree and not with objectively supported pathology. Although there have been some radiological findings of degenerative disease and disk space changes, these were characterized by the VA radiologist as being minor in degree. Thus, they do not demonstrate the presence of a severe lumbosacral strain. Accordingly, the Board concludes that the criteria for a disability rating higher than 20 percent for a low back disorder under Diagnostic Code 5295 are not met. The Board also finds that the disorder is not productive of more than moderate limitation of motion of the spine. The examination reports have repeatedly shown only slight limitation of motion. Therefore, a higher rating based on limitation of motion under Diagnostic Code 5292 is not warranted. Similarly, the Board finds that the disorder is not productive of more than moderate intervertebral disc syndrome. Although the veteran has complained of pain in the area of his spine, there is no evidence of chronic neurological involvement of such severity that a higher evaluation would be warranted under the provisions of Diagnostic Code 5293 which rate intervertebral disc syndrome. The VA examinations have consistently demonstrated that the veteran has few, if any, significant neurological findings. The Board also notes that the evidence does not reflect the existence of lower extremity neurological deficits such as drop foot which might warrant a separate compensable rating. See Bierman v. Brown, 6 Vet. App. 125, 131 (1994). The Board further finds that the 20 percent rating adequately reflects that impairment attributable to functional impairment from pain, weakness, and fatigability, as there currently is no objective evidence (i.e., "adequate pathology") supporting the veteran's subjective complaints so as to provide a basis for assigning an increased rating pursuant to 38 C.F.R. § 4.40. Accordingly, the Board concludes that the criteria for a disability rating higher than 20 percent for a lumbar arthritis are not met. V. Entitlement To An Increased Rating For Bilateral Inguinal Hernias, Currently Rated As 20 Percent Disabling. Under 38 C.F.R. § 4.114, Diagnostic Code 7338 (1998), a noncompensable rating is warranted when an inguinal hernia is small, reducible, or without true hernia protrusion. A noncompensable rating is also warranted where the hernia has not been operated upon but is remediable. A 10 percent rating is warranted for a postoperative recurrent hernia which is readily reducible and well supported by a truss or belt. A 30 percent rating is warranted if there is a small postoperative recurrent or unoperated irremediable hernia which is not well supported or is not readily reducible. A 60 percent rating is warranted if there is a large postoperative recurrent hernia which is not well supported under ordinary conditions and not readily reducible, when considered inoperable. An additional 10 percent is to be added for bilateral involvement, provided that the second hernia is compensable. This means that the more severely disabling hernia is to be evaluated, and 10 percent, only, added for the second hernia, if the latter is of compensable degree. The report of a disability compensation examination conducted by the VA in November 1994 shows that the veteran said that he had a pulling feeling where his left inguinal hernia had been repaired. On examination, the surgically repaired inguinal rings were tight. There was no indication of recurrence of the inguinal hernias. A medical report dated in February 1996 from the Providence Anchorage Anesthesia Medical Group shows that the veteran reported complaints of pain which was greater in the left groin than in the right groin. He described the pain as being crampy, with numbness, and pins and needles. He said that the pain was presently a four on a scale of ten, and that at its worst it was a ten out of ten. He said that the tingling component radiated from the left inguinal area down to the left inner thigh. He said that factors that increased the pain included sexual orgasm and any type of repetitive activity. Factors that decreased the pain included staying still, soaking in a hot tub, and Motrin and alcohol. He reported that his level of activity was severely limited secondary to the pain, and that he could not work. On examination, the right groin had no motor or sensory deficits. There was no allodynia, no trigger points, and no scar neuromas. The left groin had no allodynia. There was decreased sensation to pinprick, light touch, and temperature in the distribution of the left ilioinguinal and iliopogastric nerves. The cremaster reflex was positive on the right and the left. There were no masses palpated in the testicular region. The genitalia were normal. The initial diagnosis was bilateral groin pain, left greater than right, musculoskeletal and neuropathic components. The plan was to try neuropathic medications, to change Naprosyn to Trilisate, to try ilioinguinal and iliopogastric nerve blocks with local anesthetic only, and to undergo a behavioral medicine evaluation for cognitive behavioral therapy, relaxation training, and stress management. The report of a disability evaluation examination of the veteran conducted by the VA in June 1996 (labeled as an examination of the hand, thumb, and fingers) shows that the veteran gave a history of having bilateral herniorrhaphies, with a recurrence on the left side that was repaired at a later date. He said that he continued to have discomfort at the site of the surgery, mostly on the left side. He also said that he had been told that a nerve was trapped in the mesh which had been placed there during the last surgery. He reported that the problems occurred on a daily basis. Examination of the inguinal areas revealed a scar on the right side which was well healed. Examination through the scrotum for a recurrent hernia on the right side was negative. The examiner stated that the repair was holding fast. On the left side, there was tenderness over the transverse scar which was also well healed. On examination for hernia through the scrotum, the ring of the mesh could be palpated. The external ring was enlarged. On straining, there was a slight bulge in the medial and upper portion of the external ring. The diagnosis was status postoperative surgery for bilateral inguinal hernia. The examiner noted that there had been a second operation on the left for recurrence. He also stated that on examination there was a very tiny recurrence on that side. At the hearing held in April 1997, the veteran testified that he had undergone a hernia repair operation in 1989. At that time a sheet or prolene was sewed in on the left side. He also had a previous operation in 1987 on the right side. He said that he currently had pain on both sides. He said that the pain was a stringy, pulling, sharp stabbing pain any time he did any type of tugging, pulling or lifting. The veteran reported that VA physicians had suggested using injections to kill the nerve that was causing the pain. He also said that his hernia had not come back yet because he had been very cautious in dealing with it, but that his doctors had told him that it might come back within three to five years. The report of a disability evaluation examination conducted in November 1997 (labeled as an examination of the hand, thumb and fingers) shows that the veteran reported having g left inguinal surgery in 1980 and 1981. He said that it had been redone since then. He reported that any strenuous activity made the area hurt, and that he had a bulge present. He said that the right side had been repaired on only one occasion at the internal ring. He said that he had numbness on both sides when he strained. He also reported having frequent testicular aching. He said that he wore a truss after strenuous activity. Upon examination, there was a left surgical scar of 9 centimeters, and a right surgical scar of 7 centimeters. There was a visible bulge on both the right and left sides. Gross sensory examination revealed that there was numbness in the left inguinal area. On the right side, the internal ring was loose, and on the left there was a palpable left hernia. The Board finds that the veteran's bilateral inguinal hernias are postoperative, recurrent hernias which are readily reducible and well supported by a truss or belt. Accordingly, the Board concludes that the criteria for a disability rating higher than 20 percent for bilateral inguinal hernias are not met. VI. Entitlement To An Increased Rating For A Right (Major) Clavicle Fracture With Malunion, Currently Rated As 10 Percent Disabling. A fracture of the clavicle may be rated under Diagnostic Code 5203 which provides a 10 percent rating if there is malunion. A 10 percent rating may also be granted if there is nonunion without loose movement. A 20 percent rating is warranted if there is nonunion with loose movement, or if there is dislocation of the clavicle or scapula. Or, alternatively, the disorder may be rated based on impairment of function of a contiguous joint. Under Diagnostic Code 5201, a 20 percent rating may be granted if there is limitation of motion of the arm to shoulder level. At the hearing held in April 1997, the veteran testified that his collar bone had been fractured in four places and approximately 2 inches of it had been removed. He said that as a result he had lost 30 percent of the motion on the arm in all directions. He also said that extensive use or heavy lifting caused severe aching pain, and flash pain in the joint. His reported that it was very discomforting, and that the collar bone rode up on top of the sternum and left a very disfiguring appearance. He also said that the disorder also caused his right shoulder blade to stick out. The report of a disability compensation examination conducted by the VA in November 1994 shows that the veteran gave a history of fracturing his collarbone during a motorcycle accident in 1983. On examination, he had a small lemon sized callus over the right clavicle area. It was not tender to touch. It had been surgically repaired, and the scar was not unduly fixed to the underlying tissue. Otherwise, the collarbones and the scapulae were normal. There was no tenderness over the acromioclavicular or the sternoclavicular joints. An examination report from Robert E. Gieringer, M.D., dated in July 1995 shows that the veteran had a history of a motorcycle accident when he was in the military in 1983. About two years later, he underwent a resection arthroplasty of the right sternoclavicular joint. He said that he had pain and was unable to do work as an aircraft mechanic. On physical examination, he had a very prominent sternoclavicular joint with a surgical scar overlying it. He had no tenderness. Both the Hawkins and Neer impingement signs were positive. There was no instability. Surprisingly, the range of motion was pretty good. There was normal elevation overhead, normal external rotation, and slightly reduced internal rotation. His protraction and retraction were normal. Instability examination was negative. External rotation strength was good. The examiner noted that he tried several times to stress the sternoclavicular joint but could not achieve any instability there. The impression was old anterior sternoclavicular joint fracture dislocation by patient's history. The examiner concluded that nothing could be done or needed to be done at the present time. The report of a physical examination conducted by the VA in August 1995 shows that the veteran reported having three weeks of pain in the right scapular area. He also reported pain in other areas including the right clavicular area where he previously had an open reduction and internal fixation of a fracture of the medial right clavicle. On examination, there was a gibbus over the medial right clavicle and a surgical scar in that area with some tenderness on palpation. Abduction of the right shoulder was to 120 degrees, while the left shoulder was to 180 degrees. Extension of the right shoulder was to 160 degrees. The pertinent impression was multiple pains in the back, low back, right scapular area, both hands and right clavicular region. The report of an orthopedic examination conducted by a VA fee basis examiner in October 1995 shows that the veteran reported a history of a broken clavicle due to a motorcycle accident in January 1983. He recounted that in November 1984 the proximal end of the right clavicle was excised. He said that the right shoulder around the proximal end of the clavicle clicked and popped and this caused an aching feeling. He also said that he had overuse of the left shoulder due to his right clavicle disorder. On examination, the right shoulder was 3 centimeters lower than the left. The range of motion of the shoulders was full, except for abduction of the right shoulder which was limited to 140 degrees. There was a large deformity of the proximal right clavicle with a well healed scar measuring 5.5 centimeters. The proximal right clavicle reportedly sticks [out] anteriorly, approximately 4 centimeters, and felt fixed in its position. The diagnosis was fracture, right clavicle. The report of a disability evaluation examination conducted in November 1997 (labeled as an examination of the hand, thumb and fingers) shows that the veteran reported having bilateral shoulder problems. He said that the pain began in January 1983 when he had a motorcycle accident. After 16 months of various treatments, he ended up having surgery in November 1984 for what was described as a clavicle fracture. He said that currently his shoulder hurt with use and weather changes. He was right hand dominant. He said that he had noticed reduced range of motion in the right shoulder which limited his sports activities. Upon examination, there was a 4 centimeter clavicular scar with a visible deformity of the bony structures. There was no tenderness to palpation. Reduced range of motion was noted for active abduction which was only 140 degrees, and external and internal rotation which were each reduced to 75 degrees. The left shoulder reportedly had developed problems due to compensatory use, and also had reduced motion. The diagnosis was bilateral shoulder arthralgia, right shoulder is status post surgery. After reviewing the relevant evidence, the Board finds that the disorder has not resulted in nonunion with loose movement or dislocation of the clavicle. The Board further finds that the right (major) clavicle fracture with malunion is not productive of impairment of function of a contiguous joint of sufficient severity to warrant a higher rating. Limitation of motion of the right arm to shoulder level has not been shown. Accordingly, the Board concludes that the criteria for a disability rating higher than 10 percent for a right (major) clavicle fracture with malunion are not met. VII. Entitlement To An Increased (Compensable) Rating For Residuals Of A Left Shoulder Injury. As was noted above, under Diagnostic Code 5201, a 20 percent rating may be granted if there is limitation of motion of the arm to shoulder level. The Board further notes that, where there is limitation of motion which is noncompensable under the diagnostic code for a particular joint, a 10 percent rating may be assigned under Diagnostic Code 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or other satisfactory evidence of painful motion. At the hearing held in April 1997, the veteran testified that he experienced a sharp stabbing pain in the left shoulder. He said that after using it and trying to lift it to a 45 degree position, it felt like a hatpin was being shoved through the joint. He said that it did not feel loose. He said that the disorder had been treated through the use of anti-inflammatory drugs. The report of a disability compensation examination conducted by the VA in November 1994 shows that the veteran could move his shoulders through a full range of motion without difficulty. A shoulder questionnaire filled out by the veteran in July 1995 shows that while seeking treatment from a private physician for his right shoulder joint he also indicated that he had pain and limitation of use in the left shoulder. A treatment record of the same date from Robert Gieringer, M.D., does not contain any significant references to the left shoulder. A history and physical examination report dated in August 1995 shows that the veteran was seen for multiple complaints, including pain in the right scapular area, low back pain, and hernia pain. No complaints pertaining to the left shoulder were noted. On examination, abduction of the left shoulder was to 180 degrees. The diagnostic impression did not include any disorder of the left shoulder. The report of an orthopedic examination conducted by a VA fee basis examiner in October 1995 shows that the veteran reported that his left shoulder had a continuous ache, and felt gritty. He also said that his left collarbone felt weak and strained when he carried a load from the right side. He said that he originally injured his right shoulder and then developed clicking and pain in the left shoulder due to overuse. On examination, there was a full range of motion in the left shoulder. Muscle testing revealed that strength in the upper extremities was 5/5 in all groups tested. The diagnoses did not include a disorder of the left shoulder. A VA outpatient medical treatment record dated in December 1996 shows that the veteran reported that he had experienced left should pain for ten days. He said that he had pain only when using the left arm to open doors. On physical examination, the upper extremities had good ranges of motion, and good strength. The reflexes were intact. There was point tenderness at the AC joint. The assessment was tendinitis. The veteran was advised to take nonsteroidal anti-inflammatories as needed, to ice the joint as needed, and to avoid overuse activities that caused pain. A VA medical treatment record dated in January 1997 shows that the veteran reported a complaint of having persistent left shoulder pain. He said that taking Naproxen helped. On examination, no findings pertaining to the left shoulder were noted. The assessment was left shoulder pain, chronic. The report of a disability evaluation examination conducted in November 1997 (labeled as an examination of the hand, thumb and fingers) shows that the veteran reported having pain in both shoulders. He said that he had developed problems in the left shoulder due to compensating for impairment in the right shoulder. On examination, the left shoulder had a reduced range of motion, with abduction to 140 degrees, and internal and external rotation of 75 degrees. There was pain to palpation at the acromioclavicular joint on the left. The pertinent diagnosis was bilateral shoulder arthralgia. The Board finds that the residuals of a left shoulder injury do not limit motion of the joint to the degree necessary to warrant a 20 percent rating under Diagnostic Code 5201. In this regard, the Board notes that none of the evidence demonstrates that motion of the arm is limited to shoulder level. Nevertheless, the Board notes that point tenderness was noted in December 1996, and slight limitation of motion was noted in November 1997. Accordingly, the Board concludes that the criteria for a 10 percent rating for residuals of a left shoulder injury under Diagnostic Code 5003 are met. VIII. Entitlement To An Increased Rating For Residuals Of A Right Knee Injury, Currently Rated As 10 Percent Disabling. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1998), a 10 percent rating is warranted for recurrent subluxation or lateral instability which is productive of slight impairment of the knee. A 20 percent rating is warranted for moderate impairment. A 30 rating is warranted for severe impairment. Under 38 C.F.R. § 4.31 (1998), however, a zero percent rating shall be assigned when the requirements for a compensable evaluation are not met. The Board must also consider whether the evidence warrants a separate compensable rating for arthritis of the right knee. When a knee disorder is already rated under Diagnostic Code 5257, a separate rating for arthritis may be assigned if the veteran has limitation of motion which is at least noncompensable under Diagnostic Codes 5260 or 5261. See VAOPGCPREC 23-97. Under Diagnostic Code 5260, a noncompensable rating is warranted where flexion of the knee is limited to 60 degrees. A 10 percent rating is warranted where flexion is limited to 45 degrees. A 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating is warranted where flexion is limited to 15 degrees. Under Diagnostic Code 5261, a noncompensable rating is warranted where extension of the knee is limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating is warranted where extension is limited to 20 degrees. At the hearing held in April 1997, the veteran testified that when walking down the street he could get a stabbing pain going through the knee joint. He said that once it started he also got flash aches around the knee cap, and a feeling of fatigue in the back of the knee. He said that he would then have to stop and massage it and let it rest. He also said that it felt like it was going to give away or lock up. He indicated that he could flex to at least 45 degrees, but that he had popping or cracking sounds in the knee. He reported that this happened twice a day such as after squatting. The report of a disability compensation examination conducted by the VA in November 1994 shows that no complaints pertaining to the knees were noted in the report. The knees could move through a full range of motion without difficulty or pain. The examiner stated that the veteran was a normal healthy adult male without a great deal of objective data to substantiate disability. The report of an orthopedic examination conducted by a VA fee basis examiner in October 1995 shows that the veteran said that both of his knees ached and had stabbing pains. He said that the knees felt strained and drained. He also reported that both knees clicked and popped. He said that he did not recall any specific injury to either knee. He said that he had developed bilateral knee pain over the years without locking but with popping and giving away. He was not aware of any swelling. On examination, he could do a full squat and recovery without difficulty, although he had significant popping in both knees. The right knee range of motion was from full extension to 140 degrees of flexion. The patella was freely mobile, but there was a mildly positive patellar apprehension test. There was no evidence of an effusion or medial joint line tenderness. Drawer sign was negative, as was McMurray's and Lachman's. The right knee was stable to varus and valgus stress. There was no palpable or audible crepitus under either patella. The pertinent diagnosis was rule out degenerative joint disease of the right knee. An x- ray of the veteran's right knee taken by the VA in November 1995 was interpreted as being normal. VA medical treatment records dated in 1996 and 1997 do not contain any significant references to the veteran's knee disorders. The report of a disability evaluation examination conducted in November 1997 (labeled as an examination of the hand, thumb and fingers) shows that the veteran gave a history of both knees hurting for at least ten years. He said that the pain began in the military with frequent walking on concrete. He reported that Naprosyn helped the pain. He said that he had occasional edema and occasional erythema in the patellar area. He also described having shooting pains in both knees. He said that only rarely did the knees give away. On examination, there was no laxity of the joints and there was no visible edema. The only reduced range of motion was in the right knee with passive extension reduced by 10 degrees. Flexion of the right knee was full. There was a full range of motion of the left knee. The pertinent diagnosis was bilateral knee arthralgia. The Board finds that the residuals of a right knee injury are productive of no more than slight impairment of the joint. Therefore, the Board concludes that the criteria for a disability rating higher than 10 percent for residuals of a right knee injury are not met. The Board further finds that a separate compensable rating is not warranted for arthritis of the knee as there is no x-ray evidence of the presence of arthritis. An x-ray of the veteran's right knee taken by the VA in November 1995 was interpreted as being normal. Accordingly, the Board finds no basis for assigning a disability rating higher than 10 percent for the residuals of a right knee injury. IX. Entitlement To An Increased (Compensable) Rating For Left Knee Crepitus. At the hearing held in April 1997, the veteran testified that the symptoms in his left knee were similar to the symptoms in the right knee. He said that he had a stabbing pain that shot through the knee after walking. The medical evidence pertaining to the left knee is summarized above along with the evidence pertaining to the right knee. The Board notes that the medical evidence consistently shows normal function of the left knee. Limitation of motion has not been demonstrated, and there is no instability or subluxation of the knee. Therefore, the Board finds that the left knee crepitus is not productive of impairment of the joint. Accordingly, the Board concludes that the criteria for an increased (compensable) rating for left knee crepitus are not met. X. Entitlement To An Increased Rating For Fractures Of The Left (Minor) Little And Ring Fingers With Carpal Arthritis And Carpal Tunnel Syndrome, Currently Rated As 10 Percent Disabling. Carpal tunnel syndrome may be rated by analogy to paralysis of the median nerve under 38 C.F.R. § 4.124a, Diagnostic Code 8515. A 10 percent rating is warranted if there is mild incomplete paralysis of the median nerve of the major extremity. A 30 percent rating is warranted if there is moderate incomplete paralysis. A 50 percent rating is warranted if there is severe incomplete paralysis. A 70 percent rating is warranted for complete paralysis of the median nerve of the major extremity. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, moderate degree. At the hearing held in April 1997, the veteran testified that his left hand could only endure two to three minutes of activity until the back of it locked up from cramping. He also said that when the hand was used abundantly, it would start aching with short sharp pains in the back of the base of the hand next to the wrist. During the hearing, the veteran went through a motion of the wrist and it made a distinct popping noise. The report of a disability compensation examination conducted by the VA in November 1994 shows that the veteran gave a history of injuring his left hand is service around the fifth carpal area. He said that he wore a cast for a while. He reported having tenderness in the left fifth tarsal area. On examination of the veteran's upper extremities, he could move the wrists, hands and fingers through a full range of motion without difficulty. He could dorsiflex and palmar flex both wrists easily, and could do radial and ulnar deviation of the wrists normally. He could oppose the thumbs to each finger bilaterally, and could abduct and adduct the fingers. The examiner also stated that there was possibly a bulbous swelling which was nontender at the right fifth metacarpal which may have been a callus from an old fracture. An x-ray of the veteran's left hand taken by the VA in August 1995 was interpreted as showing an old healed right fifth metacarpal fracture with slight angulation, but otherwise unremarkable hands. A medical record dated in September 1995 from Robert W. Lipke, M.D., a hand specialist, shows that the veteran's first problem was an unstable CMC joint. He had a history of jamming the finger while attempting to control a hanger door. Following that he had pain, swelling and stiffness intermittently since that time. He also reportedly had crepitus with longitudinal traction flexion and extension of the joint. There was localized tenderness at the CMC joint. X-rays were interpreted as showing osteophytic spurs of the joint. The impression was fifth MC CMC arthritis. The physician recommended consideration of a fusion using an ASIF plate. The physician stated that the veteran's second problem was ulnar neuropathy at the left wrist. The veteran reportedly had numbness and tingling into the little finger with electrical shocks into the wrist with localized tenderness at the hook of the hamate. There was a positive Tinel's sign. The first dorsal interosseous and abductor digiti minimi were strong. No fracture was visualized or suspected on X-rays. The impression was ulnar neuropathy at the wrist level. The report of an orthopedic examination conducted by a VA fee basis examiner in October 1995 shows that the veteran reported having a sharp pinching pain in his left ring finger which went all the way back to the wrist. He also said that he had tingling and numbness over the fifth metacarpal which had been broken. He reported losing strength in both hands. On examination, there was significant callusing over both hands with a full range of motion of all joints in the fingers except for the small right finger which lacked 20 degrees of full extension at the PIP joint. Group muscle testing of the upper extremities was 5/5 in all groups tested. Sensory examination was normal. The pertinent diagnosis was fracture, fifth metacarpal bilaterally. The report of an examination of the veteran's hand conducted by the VA in June 1996 shows that the veteran reported that his left wrist was hit by a heavy piece of wood in service. He said that it was in a cast for a while, but was not operated on. He also said that he continued to have discomfort in the wrist. On examination, the left hand had some apparent loss of bony substance or contraction of bone substance. There was slight ulnar deviation of the hand on the wrist. Dorsiflexion was to 30 degrees, and palmar flexion was to 80 degrees. The wrist was tender to palpation. The pertinent diagnosis was residuals of trauma to the left wrist. The examiner stated that he felt that there was some problem with the carpal bones such as possibly an old fracture or some type of traumatic arthritis. A VA radiology report dated in June 1996 shows that an x-ray of the veteran's left wrist was interpreted as being normal. VA medical treatment records show that the veteran was examined in March 1997 in the orthopedic clinic. He said that ten years earlier he sustained a left fifth CMC dislocation while in service. He said that it had gotten worse with prolonged use of tools. On examination, there was crepitus and grinding. There was tenderness over the 5th CMC. Range of motion was intact. X-rays revealed degenerative joint disease. The impression was post- traumatic DJD left fifth CMC. An orthopedic note dated in August 1997 contains similar information, but also shows that a VA physician concluded that the veteran did not need a fusion at that time. The report of an examination conducted by the VA in October 1997 shows that the examiner examined the veteran for neurological impairment of the left hand. The veteran gave a history of having been hit in the left MCP joint with resultant broken bones. He also said that at another time he snapped the ring finger tendons trying to open a frozen hammer door. He said that he sometimes could not release his grip. He also said that he got flash pain in his hand and paresthesias when the weather turned freezing. Following examination, the pertinent diagnosis was left hand injury leading to no neurological residual effects at this time. The report of an examination of the veteran's hand, thumb and fingers conducted in November 1997 shows that the veteran said that he had problems with his left hand locking up. He said that he had been told that a plate needed to be put in the wrist to relieve nerve impingement caused by bony abnormalities. His left ring finger reportedly was status post muscle injury with reduced strength. Upon examination, the left ring finger did have reduced flexion and extension of grade 4/5. However, there was a negative Tinel's sign, negative Phalen's sign, and no suggestion of median nerve injury. The diagnosis was left hand arthralgia, etiology to be determined. The Board finds that the fractures of the left (minor) little and ring fingers with carpal arthritis and carpal tunnel syndrome have not resulted in more than mild incomplete paralysis of the median nerve. Accordingly, the Board concludes that the criteria for a disability rating higher than 10 percent for fractures of the left (minor) little and ring fingers with carpal arthritis and carpal tunnel syndrome are not met. XI. Entitlement To An Increased Rating For A Nose Fracture With Sinusitis, Currently Rated As 10 Percent Disabling. Sinusitis may be rated under Diagnostic Codes 6510 through 6514. The Board notes that by regulatory amendment effective October 7, 1996, substantive changes were made to the schedular criteria for evaluating diseases of the respiratory system, as set forth in 38 C.F.R. § 4.97. See 61 Fed. Reg. 46720-46731 (1996). Where law or regulations change while a case is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. See Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). Accordingly, the Board will consider the veteran's claim under both the old and the new criteria. Under the old rating criteria, a noncompensable rating is warranted where there are only x-ray manifestations, or where there are only mild or occasional symptoms. A 10 percent rating is warranted where the sinusitis is moderate in degree, with symptoms such as discharge or crusting or scabbing, and infrequent headaches. A 30 percent rating is warranted if the sinusitis is severe, with frequently incapacitating recurrences, severe and frequent headaches, purulent discharge or crusting reflecting purulence. A 50 percent rating is warranted where the sinusitis is postoperative following a radical operation, with chronic osteomyelitis requiring repeated curettage, or severe symptoms after repeated operations. The new rating criteria provide that where the disorder is detected by X-ray only, a noncompensable rating is warranted. Where there are one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting, a 10 percent rating is warranted. An incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. Where there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non- incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting, a 30 percent rating is warranted. Following radical surgery with chronic osteomyelitis, or when there is near constant sinusitis characterized by headaches, pain and tenderness of the affected sinus, and purulent discharge or crusting after repeated surgeries, a 50 percent rating is warranted. The report of a disability compensation examination conducted by the VA in November 1994 shows that the veteran reported having a history of right side sinusitis. On examination, the veteran could take a full breath of air through each nostril separately without difficulty. The choanae and meati were free of infection, inflammation or allergic reaction. The nasal mucosa was normal. At the hearing held in April 1997, the veteran testified that his right nasal area had collapsed by 70 percent and this caused restriction of air motion. He said that at least once a month he felt his sinuses get packed, and that it took him two or three days to relieve it. He said that he used saline solution. He also said that he did not use any type of antibiotics. The report of an examination of the veteran's nose and sinuses which was performed by the VA in October 1997 shows that the veteran complained of having right nasal obstruction. His complaints of obstruction were characterized as appearing moderate to severe in nature. The veteran was not undergoing therapy for it. On examination, the veteran had a traumatic nasal deformity with a right nasal dorsum that was somewhat medialized. The internal nasal cavity was erythematous with crusting on the left and a mild degree of septal deviation with mild to moderate nasal obstruction. The rest of the examination was essentially normal. The assessment was that the veteran had mild to moderate right nasal obstruction with a traumatic nasal deformity, and that he might possibly benefit from a septorhinoplasty. After considering all of the evidence, the Board finds that the sinusitis is no more than moderate in degree. The Board also finds that the disorder is not productive of more than one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Accordingly, the Board concludes that the criteria for a disability rating higher than 10 percent for sinusitis are not met. X. Extra-schedular Rating The veteran's representative has urged the Board to conduct an extra-schedular evaluation of the veteran's disabilities. Therefore, the potential application of various provisions of Title 38 of the Code of Federal Regulations (1998) have been considered, but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1)(1998). In this regard, the Board finds that there has been no showing by the veteran that his service-connected disabilities have resulted in marked interference with employment or necessitated frequent periods of hospitalization. He has not been hospitalized recently for the disorders. There has also been no evidence submitted that the veteran is unemployable due to his service-connected disabilities. Neither the VA examiner nor the veteran's private physicians have given an opinion as to the employability of the veteran. Under these circumstances, the Board finds that the veteran has not demonstrated marked interference with employment so as to render impractical the application of the regular rating schedule standards. In the absence of such factors, the Board finds that criteria for submission for assignment of an extra-schedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER 1. Service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder, depression, and alcoholism is denied. 2. Service connection for hearing loss is denied. 3. Service connection for a stomach disorder is denied. 4. An increased rating for lumbar arthritis, currently rated as 20 percent disabling, is denied. 5. An increased rating for bilateral inguinal hernias, currently rated as 20 percent disabling, is denied. 6. An increased rating for a right (major) clavicle fracture with malunion, currently rated as 10 percent disabling, is denied. 7. A 10 percent rating for residuals of a left shoulder injury is granted, subject to the laws and regulations applicable to the payment of monetary benefits. 8. An increased rating for residuals of a right knee injury, currently rated as 10 percent disabling, is denied. 9. An increased (compensable) rating for left knee crepitus is denied. 10. An increased rating for fractures of the left (minor) little and ring fingers with carpal arthritis and carpal tunnel syndrome, currently rated as 10 percent disabling, is denied. 11. An increased rating for a nose fracture with sinusitis, currently rated as 10 percent disabling, is denied. WARREN W. RICE, JR. Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1998), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 42 -