Citation Nr: 0939367 Decision Date: 10/16/09 Archive Date: 10/28/09 DOCKET NO. 05-11 448 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial compensable rating for residuals of a fractured right wrist prior to September 11, 2008. 3. Entitlement to a rating in excess of 10 percent for residuals of a fractured right wrist from September 11, 2008. 4. Entitlement to an initial compensable rating for history of tinea cruris/pedis, onychomychosis (claimed as jungle rot) prior to September 9, 2008. 5. Entitlement to a rating in excess of 10 percent for history of tinea cruris/pedis, onychomychosis (claimed as jungle rot) from September 9, 2008. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. M. Donahue, Associate Counsel INTRODUCTION The Veteran had active military service in the United States Air Force from March 1965 to May 1966, and in the United States Army from March 1968 to January 1970. The appeal comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts, which denied entitlement to service connection for PTSD, and granted service connection for residuals of a fractured right wrist and history of tinea cruris/pedis, onychomychosis. The Veteran testified during a hearing before a Decision Review Officer in August 2004; a transcript of that hearing is of record. In September 2007, the Board remanded this matter to the RO to afford due process and for other development. Following its completion of the Board's requested actions, the RO continued the denial of the Veteran's PTSD claim (as reflected in an August 2009 supplemental SOC (SSOC)) and returned this matter to the Board for further appellate consideration. The August 2009 SSOC also allowed an increased rating of 10 percent for residuals of a fractured right wrist, effective September 11, 2008, and an increased rating of 10 percent for history of tinea cruris/pedis, onychomychosis (claimed as jungle rot) effective September 9, 2008. As higher schedular evaluation for these disabilities is possible, the issue of entitlement to increased ratings remains before the Board on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claims on appeal has been accomplished. 2. The record does not demonstrate that the Veteran engaged in combat with the enemy. 3. The Veteran's claimed in-service stressful experiences have not been corroborated by service records, and any diagnosis of PTSD was made based on an unverified account of in-service events given by the Veteran. 4. The Veteran is not shown to have PTSD as a result of events during military service. 5. For the time period prior to September 11, 2008, the evidence does not show any complaints of pain or limitation of motion for the Veteran's residuals of the right wrist fracture. 6. For the time period from September 11, 2008, the Veteran's residuals of the right wrist fracture were manifested by pain and limitation of motion. 7. For the time period prior to September 9, 2008, the Veteran's history of tinea cruris/pedis, onychomychosis (claimed as jungle rot), was manifested by an occasional itching of the feet and groin. 8. For the time period from September 9, 2008, the Veteran's history of tinea cruris/pedis, onychomychosis (claimed as jungle rot), was manifested by dermatophytosis constituting about 10 percent of the body surface. CONCLUSIONS OF LAW 1. PTSD was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125 (2009). 2. For the time period prior to September 11, 2008, the schedular criteria for a compensable initial rating for residuals of a right wrist fracture have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R. § 4.71a, Diagnostic Codes 5299-5215 (2009). 3. For the time period from September 11, 2008, the schedular criteria for a disability rating in excess of 10 percent for residuals of a right wrist fracture have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2009). 4. For the time period prior to September 9, 2008, the schedular criteria for a compensable initial rating for history of tinea cruris/pedis, onychomychosis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R. § 4.118, Diagnostic Code 7813 (2009). 5. For the time period from September 11, 2008, the schedular criteria for a disability rating in excess of 10 percent for history of tinea cruris/pedis, onychomychosis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R. § 4.118, Diagnostic Code 7806 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (the Court) have been fulfilled. In this case, the Veteran's claims for service connection for residuals of right wrist fracture, history of tinea cruris/pedis, onychomychosis (skin disorder), and PTSD were received in August 2003. Thereafter, he was notified of the provisions of the VCAA by the RO in correspondence dated in December 2003 and November 2007. These letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claims, identified the Veteran's duties in obtaining information and evidence to substantiate his claims, and provided other pertinent information regarding the VCAA. Thereafter, the claims were reviewed and a supplemental statement of the case (SSOC) was issued in August 2009. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 499 F.3d 1317 (Fed. Cir. 2007). The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008, removing the sentence in subsection (b)(1) stating that VA will request the claimant provide any evidence in the claimant's possession that pertains to the claim. Subsection (b)(3) was also added and notes that no duty to provide § 5103(a) notice arises "[u]pon receipt of a Notice of Disagreement" or when "as a matter of law, entitlement to the benefit claimed cannot be established." During the pendency of this appeal, the United States Court of Appeals for Veterans Claims (hereinafter "the Court") in Dingess v. Nicholson, 19 Vet. App. 473 (2006), found that the VCAA notice requirements applied to all elements of a claim. An additional notice as to this matter was provided in November 2007. The Veteran has been made aware of the information and evidence necessary to substantiate his claims and has been provided opportunities to submit such evidence. A review of the claims file also shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claims during the course of this appeal. His service treatment records, Air Force personnel records, and VA treatment records pertaining to his service-connected disabilities and claimed PTSD have been obtained and associated with his claims file. The Veteran has also been provided with VA medical examinations in December 2003, January 2004, and August and September 2008 to assess the nature and current state of his service-connected disabilities and claimed PTSD. Furthermore, the Veteran has not identified any additional, relevant evidence that has not otherwise been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate his claims, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claims. Service Connection for PTSD Law and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303. Service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. See 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability on the basis of the merits of such claim is focused upon (1) the existence of a current disability, (2) the existence of the disease or injury in service, and (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a) (2009); a link, established by medical evidence, between current symptomatology and an in-service stressor; and credible supporting evidence that the claimed in-service stressor actually occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (2009). If the veteran did not engage in combat with the enemy, his own testimony by itself is not sufficient to establish the incurrence of a stressor; rather, there must be service records or other credible supporting evidence to corroborate his testimony. See Zarycki v. Brown, 6 Vet. App. 91 (1993); Doran v. Brown, 6 Vet. App. 283 (1994). If the claimed stressor is not combat related, it must be corroborated by credible supporting evidence. See Cohen v. Brown, 10 Vet. App. at 142. The Court has held that "[t]here is nothing in the statute or the regulations which provide that corroboration must, and can only, be found in the service records." Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996) (quoting Doran v. Brown, 6 Vet. App. 283, 289 (1994)). However, when a claim for PTSD is based on a noncombat stressor, "the noncombat veteran's testimony alone is insufficient proof of a stressor," Dizoglio, 9 Vet. App. at 166, and "credible supporting evidence of the actual occurrence of an in-service stressor cannot consist solely of after-the-fact medical nexus evidence," Moreau v. Brown, 9 Vet. App. 389, 396 (1996). "Credible supporting evidence" is not limited to service department records, but can be from any source. See Cohen, 10 Vet. App. at 147; Doran, supra. "[T]he absence of corroboration in the service records... does not relieve the BVA of its obligation to assess the credibility and probative value of the other evidence." Doran, 6 Vet. App. at 290-91. However, "[a]n opinion by a mental health professional based on a post service examination of the veteran cannot be used to establish the occurrence of the stressor." Cohen, 10 Vet. App. at 145 (citing Moreau v. Brown, 9 Vet. App. 389, 394-95 (1996)); see also Wood v. Derwinski, 190, 193 (1991). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (2009). Factual Background Service treatment records for the Veteran's first period of service include a March 1966 psychiatry clinic evaluation. The Veteran was referred for evaluation after he expressed an intense disinterest and avowed hate of air police work. He seemed poorly motivated to finish his Air Force career. Upon evaluation, it was noted that the Veteran has a poor record of accomplishment prior to entering military life. His I.Q. was borderline and his motivation was "nil". It was suggested that the be separated from service, as any attempt at cross-training would "be a waste of time." The diagnosis was immature personality. He was discharged from service shortly thereafter. The Veteran's DD-214 for his second period of service reflects that the Veteran served in the Republic of Vietnam. His military occupational specialty at that time was Heavy Truck Driver. Among the awards he received were the Vietnam Defense Service Medal, and Vietnam Service Medal. His highest documented rank in service was E-4. Associated with the claims folder is the citation awarding the Veteran the Army Commendation Medal for meritorious service for the period from March 1969 to March 1970. Service treatment records, including a February 1968 pre- induction physical, a January 1970 separation physical examination and Report of Medical History, as well as periodic Army National Guard examination reports dated in April 1994 and December 1996, are silent for any acquired psychiatric disorder. VA outpatient treatment records have been associated with the claims folder. In a June 2002 VA urgent care note, the Veteran complained of being extremely weepy for a couple of days and that he stated that he was hearing voices. He stated he could hear the voices and yelling of the wounded men that he used to help hold down as their dressings were changed in the hospital. In a June 2002 psychology note, the Veteran complained of the same incident in the hospital, and denied having distressing memories, flashbacks, or nightmares from his experiences in Vietnam or hospital until recently. The Veteran indicated he started to see severely injured soldiers in body casts crying and yelling for help, and stated that he found the images to be very distressing. He reported difficulty with sleeping and relaxing, and feeling apprehensive and tense. Following an examination, the examiner diagnosed acute onset of symptoms suggestive of PTSD, with no depressive symptoms. In a July 2002 VA progress note, the Veteran again recalled his experiences at the hospital during Vietnam and reported that over the past few weeks he had experienced intrusive thoughts of Vietnam and of the military hospital that were very bothersome and distracting. The examiner determined that it was not recommended that the Veteran seek an evaluation for PTSD because of his substance abuse problems. In July 2003, the Veteran appeared in VA urgent care complaining of terrible flashbacks after watching a war movie. In a July 2003 VA psychiatry note the Veteran complained of worsening alcohol problem and PTSD symptoms. He stated he watched a violent war movie which resulted in him experiencing increased nightmares and flashbacks, as well as hypervigilance and anxiety. He described the flashbacks as relating to severely injured people during his hospitalization during Vietnam and seeing people get run over by trucks. VA progress notes dated from July 2003 thru December 2003 showed occasional psychological treatment for episodes and substance abuse. In a January 2004 VA examination report, the Veteran stated he was raised by both of his parents, but that they had problems with alcohol and were, at times, physically violent with each other. The Veteran denied experiencing any traumatic events prior to going to Vietnam. The Veteran indicated that while in Vietnam, his duty was mostly support rather than combat, and that he drove a flat bed delivery truck in Saigon. He reported that he felt that he was always in danger, and he witnessed some horrifying events, including a dead young girl and the scene of a helicopter crash. He reported that there were terrorist acts in the city that he felt continuously anxious and under threat, and that he also had to make deliveries to a leper colony where he saw people with sores and missing fingers. The Veteran stated that when he broke his wrist he was taken to the 106th Hospital in Tansanknut for one week and was then transferred to Yokohama Hospital in Japan for another week. He recalled that while in these hospitals, he was asked to assist in caring for those who were more severely injured including soldiers in terrible pain, missing arms or legs, and one soldier in a full body cast. The Veteran reported that after service he held a number of odd jobs until getting employed by the City of Newton as a truck driver and laborer for 20 years. He related he and his wife separated and for the previous 10 years he had raised his son as a single parent. The Veteran stated he abused alcohol for most of his adult life and also abused marijuana. The Veteran complained of hypervigilance about danger, intrusive thoughts, nightmares of his Vietnam experiences one or twice a week, and difficulty with reminders of those events such as going to a hospital. Following the mental status examination, the examiner diagnosed alcohol abuse and dependence and PTSD-related symptoms. The examiner opined that the Veteran had made a relatively satisfactory adjustment prior to going into the military despite witnessing domestic violence, and that after Vietnam, he had struggled with some symptoms of PTSD, but that they did not appear to be gross indications of severe behavioral control or of great distress. The examiner noted that he did appear to have relatively chronic anxiety that may have been exacerbated by his military experiences but could also be related to his disruptive childhood experiences. In a March 2004 PTSD stressor statement, the Veteran noted that he witnessed many civilians getting killed, and not by combat but by getting run over by vehicles on a daily basis in Saigon. He stated that in late December 1969 he was medically evacuated to a hospital where he was asked to help change bandages of severely injured soldiers. In his August 2004 RO hearing, the Veteran stated that his PTSD was related to seeing people get killed or run over, and the time he spent hospitalized in Japan with wounded soldiers. He stated that while he was not on the front lines, Saigon was a dangerous city, and that he lived under terrorism. He reported that when he hurt his hand he was sent to the 106th General Hospital then Yokohama, Japan. In an August 2008 VA examination report, the Veteran stated that while in Vietnam he functioned as a truck driver, primarily delivering humanitarian supplies for the Red Cross and other organizations. He stated that while he was never in direct combat, he stated that the converted hotel where he stayed was subject to occasional mortar attacks and that on a monthly basis he had to do guard duty at a local headquarters in Camen. He indicated that while on duty he was never directly fired on, but that he was frightened on each occasion. He reported seeing stressful events such as an accident where a young girl was under a bus, the site where a Vietnamese had been blown up by a bomb, a child dead beneath an oil truck. He also indicated that his experience at Yokohama, Japan was the most severe and distressing stressor as he and a few other military people who were ambulatory were called upon to help the orderlies while changing the bandages on some of the severely injured soldiers. He stated that he would have to hold them down while they screamed and cried out in pain, that he found this extremely traumatic, and that he felt profound guilt for having such a minimal injury compared to how severely they had been injured. On mental status examination, the Veteran was found to be well-developed and healthy with rate and flow of speech in normal limits, and no evidence of a thought disorder. He denied delusions or ideas of reference. He complained of episodes of severe anxiety and crying, episodes of severe auditory and visual flashbacks. The examiner noted that the Veteran was not in combat but that he was in an urban area in Vietnam for nearly a year and during that time he witnessed a number of traumatic incidents primarily related to motor vehicle accidents. He also stated that while he was on guard duty he feared for his life, and that while in the hospital in Japan he witnessed and participated in the management of many severely injured soldiers. He noted that the intrusive flashback consisting of visual and auditory imagery from his time at the military hospital continued to the present. He also noted hypervigilance and hyperreactivity to loud noises, and military dreams which were usually precipitated by watching a violent war movie. The examiner diagnosed PTSD, delayed type, mild to moderate degree, and alcohol abuse and dependence. Analysis The evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether the Veteran "engaged in combat with the enemy". See 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(f) (2007); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Participation in combat, a determination that is to be made on a case-by-case basis, requires the veteran to have personally participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. See VAOPGCPREC 12-99 (October 18, 1999). If VA determines the veteran engaged in combat with the enemy and his alleged stressor is combat-related, then his lay testimony or statement is accepted as conclusive evidence of the stressor's occurrence and no further development or corroborative evidence is required - provided that such testimony is found to be "satisfactory", i.e., credible and "consistent with circumstances, conditions or hardships of service". See 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(f); Zarycki, 6 Vet. App. at 98. If, however, VA determines either that the veteran did not engage in combat with the enemy or that he did engage in combat, but that the alleged stressor is not combat related, then his lay testimony, in and of itself, is not sufficient to establish the occurrence of his alleged stressor. Instead, the record must contain evidence that corroborates his testimony or statements. See Zarycki, 6 Vet. App. at 98. Notwithstanding the Veteran's current diagnoses of PTSD, in this case, the claim must be denied because objective evidence does not show that the Veteran engaged in combat with the enemy, and there is otherwise no credible evidence that any of the Veteran's claimed in-service stressors occurred. The Veteran's service personnel records do not reflect any awards or decorations typically associated with combat. The Board points out that the Veteran reported in an August 2008 VA examination report that he did not serve in a combat zone. In other words, combat has not been established by objective, competent, and factual evidence of record. See VAOPGCPREC 12-99 at p. 4. Consequently, the occurrence of the Veteran's claimed stressors of combat cannot be established on the basis of his assertions, alone. The record must contain evidence that corroborates the occurrence of his alleged stressors. While the record contains evidence of treatment with the 106th General Hospital, there are no records which support that the Veteran was asked to help with the care of other wounded soldiers. Furthermore, there simply is no evidence to corroborate the occurrence of the Veteran's alleged in-service stressors including the civilian casualties in motor vehicle accidents or helicopter accident. The Board further notes that the Veteran also has not provided sufficient details to warrant any additional attempts to independently verify the occurrence of the claimed stressful events, and has not provided any other objective evidence-to include statements from other witnesses, or numbers and full names of causalities witnessed-to establish the occurrence of the claimed in- service stressful event, helping at the hospitals. The Veteran was informed of the insufficiencies of his submitted information in the August 2009 SSOC. In light of the foregoing evidence, the Board must conclude that there is no verified or verifiable stressor to support the claim. Simply stated, combat has not been established, the occurrence of none of the Veteran's specific in-service stressful experiences has been corroborated by credible evidence, and the evidence provided by the Veteran does not present any basis for further developing the record in this regard. Furthermore, although the Veteran was diagnosed with PTSD by a VA examiner in August 2008, there is no indication that at the time of diagnosis the examiners conducted a comprehensive review of the entire claims file. As these examinations are based on the Veteran's reported history, they have little probative value. See Black v. Brown, 5 Vet. App. 177 (1993) (an opinion that is based on history furnished by the veteran that is unsupported by clinical evidence is not probative); LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (holding that a bare transcription of a lay history is not transformed into "competent medical evidence" merely because the transcriber happens to be a medical professional); Wood v. Derwinski, 1 Vet. App. 190, 191-192 (1991) (an opinion may be discounted if it materially relies on a layperson's unsupported history as the premise for the opinion). In addition to the medical evidence, the Board has considered the assertions advanced by the Veteran in connection with the appeal. The Board does not doubt the sincerity of the Veteran's belief that he has PTSD as a result of events during military service. However, questions of medical diagnosis and causation are within the province of medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As the Veteran is a layperson without the appropriate medical training or expertise, he is not competent to render a probative (i.e., persuasive) opinion on such a medical matter. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Consequently, the lay assertions as to the nature, onset, or etiology of his claimed PTSD disability have no probative value. In the absence of credible evidence that a claimed stressor (sufficient to support a diagnosis of PTSD) actually occurred, the essential criteria of 38 C.F.R. § 3.304(f) have not been met, and the Board must therefore deny the Veteran's claim of entitlement to service connection for PTSD. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Increased Rating Claims Laws and Regulations The severity of a service-connected disability is ascertained, for VA rating purposes, by the application of rating criteria set forth in VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4 (2009) (Schedule). To evaluate the severity of a particular disability, it is essential to consider its history. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1 and 4.2 (2009). Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. See 38 C.F.R. §§ 3.102, 4.3 (2009). In addition, where there is a question as to which of two disability evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2009). The Board further acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The United States Court of Appeals for Veterans Claims (the Court) held that in evaluating a service-connected disability, functional loss due to pain under 38 C.F.R. § 4.40 (1997) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (1997) must be considered. The Court also held that, when a Diagnostic Code does not subsume 38 C.F.R. §§ 4.40 and 4.45, those provisions are for consideration, and that the rule against pyramiding set forth in 38 C.F.R. § 4.14 does not forbid consideration of a higher rating based on a greater limitation of motion due to pain on use, including use during flare-ups. See DeLuca v. Brown, 8 Vet.App. 202, 206 (1995). When a veteran is diagnosed with an unlisted condition, it must be rated under an analogous diagnostic code. See 38 C.F.R. §§ 4.20, 4.27 (2009). The diagnostic code is "built- up" by assigning the first two digits from that part of the schedule most closely identifying the part of the body involved and then assigning "99" for the last two digits for all unlisted conditions. See 38 C.F.R. § 4.27 (2009). Then, the disability is rated by analogy under a diagnostic code for a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. See 38 C.F.R. §§ 4.20, 4.27 (2009). Therefore, the Veteran's service-connected residuals of a right wrist fracture are rated according to the analogous condition of limitation of motion of the wrist under Diagnostic Codes 5299-5215. 1. Residuals of a Right Wrist Fracture In this case, the Veteran was assigned an initial non- compensable rating for residuals of a right wrist fracture for the time period prior to September 11, 2008, under Diagnostic Codes 5299-5215. The Veteran was assigned a 10 percent disability rating for the time from September 11, 2008, under Diagnostic Code 5003. 5003 Arthritis, degenerative (hypertrophic or osteoarthritis): Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, rate as below: With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations 20 With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups 10 Note (1): The 20 pct and 10 pct ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): The 20 pct and 10 pct ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic code 5013 to 5024, inclusive. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2009). 5214 Wrist, ankylosis of: Major Minor Unfavorable, in any degree of palmar flexion, or with ulnar or radial deviation 50 40 Any other position, except favorable 40 30 Favorable in 20º to 30º dorsiflexion 30 20 Note: Extremely unfavorable ankylosis will be rated as loss of use of hands under diagnostic code 5125. 38 C.F.R. § 4.71a, Diagnostic Code 5214 (2009) 5215 Wrist, limitation of motion of: Majo r Minor Dorsiflexion less than 15º 10 10 Palmar flexion limited in line with forearm 10 10 38 C.F.R. § 4.71a, Diagnostic Code 5215 (2009) Factual Background and Analysis Effective August 12, 2003, the Veteran was granted service connection for residuals of a right wrist fracture based on service treatment records which reveal treatment and casting of the right wrist in January 1970 while in Vietnam. A noncompensable (zero percent) rating was assigned. The assignment was based on service treatment records describing the injury. VA outpatient treatment records dated through 2003 reflect no treatment for the right wrist. In a September 2008 VA joints examination, the Veteran complained of stiffness and pain in the right wrist, which had become progressively worse and was treated with ibuprofen when necessary. The examiner noted that the Veteran's right hand is his dominant hand, and that he had a lump on the dorsum lateral side with restricted range of motion, pain, stiffness, weakness, and no giving way, instability, episodes of dislocation or subluxation, locking episodes, effusion, or flare-ups. Upon examination, active range of motion measured as follows: palmar flexion was from 0 to 75 degrees (with pain at 75 degrees), ulnar deviation was from 0 to 30 degrees, and radial deviation was from 0 to 10 degrees (with pain at 15 degrees). Passive range of motion measured as follows: palmar flexion was from 0 to 75 degrees (with pain at 75 degrees), ulnar deviation was from 0 to 30 degrees, and radial deviation was from 0 to 10 degrees (with pain at 10 degrees). Range of motion against strong resistance measured as follows: dorsiflexion was from 0 to 30 degrees (with pain at 0 degrees), palmar flexion was from 0 to 75 degrees (with pain at 75 degrees), ulnar deviation was from 0 to 25 degrees (with pain at 10 degrees), and radial deviation was from 0 to 10 degrees (with pain at 0 degrees). The examiner found additional limitation on repetitive use of 0 to 10 degrees on radial deviation, and of 0 to 20 degrees on ulnar deviation. The examiner diagnosed traumatic arthritis of the right wrist and noted significant effects on on the Veteran's general occupation. The examiner noted that the Veteran noticed wrist pain when he was driving and the wheel of the truck would jerk causing him right wrist pain, and that if he bumped the right wrist by accident he would receive a painful jolt. Prior to September 11, 2008 Based on the evidence of record, the Board finds that for the time period prior to September 11, 2008, the criteria for a compensable rating for residuals of a right wrist fracture, to include arthritis, have not been met. Aside from service treatment records, there is absolutely no evidence relating to the right wrist prior to September 11, 2009; there is no competent medical evidence of the range of motion of the right wrist dorsiflexion being less than 15 degrees or palmar flexion limited in line with forearm as required for a compensable rating. Consequently, for the time prior to September 11, 2008, a compensable rating for residuals of a right wrist fracture is not warranted. See 38 C.F.R. § 4.71a, DC 5215. The Board has considered whether an increased rating would be warranted under an alternative diagnostic code. As there is no evidence of limitation of motion, and the right wrist is considered one major joint, see 38 C.F.R. § 4.45, the provisions of DC 5003 do not allow for a higher, or 10 percent rating in this case. In addition, there is no evidence of ankylosis (DC 5214). Consequently, a compensable rating for residuals of a right wrist fracture, to include arthritis, is not warranted. See 38 C.F.R. § 4.71a, DCs 5003, 5010, 5214. See also Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of a diagnostic code should be upheld so long as it is supported by explanation and evidence). From September 11, 2008 For the time period from September 11, 2008, the September 2008 VA examination report reveals decreased range of motion of the right wrist; however, there has been no competent medical evidence of the range of motion of the right wrist dorsiflexion being less than 15 degrees or palmar flexion limited in line with forearm as required for a compensable rating under DC 5215. As the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic code, a rating of 10 pct was applied for each such major joint affected by limitation of motion. See 38 C.F.R. § 4.71a, DC 5003 (2009). Hence, the Board will not disturb the RO's 10 percent rating effective September 11, 2008. The Board has considered whether an increased rating would be warranted under an alternative diagnostic code. As the Veteran is already assigned a 10 percent disability rating, which is also the maximum under DC 5215, a rating under that criterion would not serve to increase the Veteran's current rating. In addition, there is no evidence of ankylosis (DC 5214) and no X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations to warrant a 20 percent rating under DC 5003. Therefore, for the time period from September 11, 2008, a disability rating in excess of 10 percent for residuals of a right wrist fracture, to include arthritis, is not warranted. 2. History of Tinea Cruris/Pedis, Onychomychosis The Veteran was assigned an initial noncompensable rating for his service-connected history of tinea cruris/pedis, onychomychosis, pursuant to 38 C.F.R. § 4.114, DC 7813 (2009), effective August 12, 2003. In an August 2009 decision, the RO reclassified the Veteran's service-connected skin disorder and assigned an increased rating of 10 percent, pursuant to 38 C.F.R. § 4.114, DC 7806 (2009), effective September 9, 2008. 780 4 Scar(s), unstable or painful: Ratin g Five or more scars that are unstable or painful 30 Three or four scars that are unstable or painful 20 One or two scars that are unstable or painful 10 Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3): Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. See 38 C.F.R. § 4.118, Diagnostic Code 7804 (2009). 780 6 Dermatitis or eczema. Ratin g More than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period 60 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period 30 At least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period 10 Less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period 0 Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. See 38 C.F.R. § 4.118, Diagnostic Code 7806 (2009). 781 3 Dermatophytosis (ringworm: of body, tinea corporis; of head, tinea capitis; of feet, tinea pedis; of beard area, tinea barbae; of nails, tinea unguium; of inguinal area (jock itch), tinea cruris): Rate as disfigurement of the head, face, or neck (DC 7800), scars (DC's 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), See 38 C.F.R. § 4.118, Diagnostic Code 7813 (2009). Effective October 23, 2008, the Schedule for rating criteria that addresses the evaluation of scars was revised. See VA Schedule for Rating Disabilities; Evaluation of Scars, 73 Fed. Reg. 54,708, 54,708 (Oct. 23, 2008) (to be codified at 38 C.F.R. pt. 4). These new criteria apply to applications for benefits received on or after October 23, 2008, or upon request from a veteran who was rated under the applicable criteria before this date. Id. The Board has not received a request from the Veteran to be rated under the revised criteria, and as such, that rating criteria will not be addressed at this time. Factual Background and Analysis In a December 2003 VA podiatry examination report, the Veteran complained of bilateral "jungle rot" and that his right big toenail which was removed in Saigon. He stated it did not hurt him but that the nail is thick and difficult to cut. Upon examination, the examiner noted that there was no sign of interdigital fungal infection, the skin was supple and well hydrated, the right hallux nail was thick with two small .5 cm scars extending proximally from eponychial fold consistent with prior nail surgery, and the nail was not tender. The podiatrist diagnosed dystrophic nail, possibly caused by old avulsion/removal, which was relatively asymptomatic but difficult to cut. In a December 2003 skin examination, the Veteran complained that during the summer he experienced occasional itching and an occasional small fissure on the groin, but that he used no treatment. Upon examination, the examiner noted that the skin was normal, with a slight thickening of the skin on the left side of the penis. The examiner diagnosed history of tinea cruris, history of tinea pedis, history of onychomycosis with removal of the right great toenail and resultant deformity, and lichen simplex chronicus of the penis. In a September 2008 VA skin examination, the Veteran stated that for the past five to six years he has not been using any treatment neither for his groin nor for his feet and has not been seen by any physician for this problem. Upon examination, the examiner found no active rash, mild hyperpigmentation macule on the left groin and on the left side of the scrotum, about 1 cm in size on the left side, and a 1 cm rounded patch on the scrotum also. The examiner further noted that examination of the feet showed that the left foot was completely normal, and the right foot showed dystrophic dark hypertrophic toenails including the right big toenail and the found toenails on the right side. The examiner indicated that dermatophytosis of the toenails was evidenced on the right foot more than left. The examiner reported there were no diagnostic skin tests and no color photos taken for this problem, and that the Veteran had not been using any treatment for the last five years for either the groin or the feet. The examiner opined that this constituted 10 percent of the boy surface area, and 0 percent of the exposed body surface area. She noted no crustation, no disfigurement, and some thickening o the toenails with discoloration of the nails on the right foot, with no functional impairment secondary to the problem. Prior to September 9, 2008 Considering the pertinent evidence of record in light of the above-noted criteria, the Board finds that the criteria for the assignment of a compensable rating for the Veteran's service-connected history of tinea cruris/pedis, onychomychosis, have not been met during this time period. The Board has considered rating criteria related to scars, but finds that they are not applicable to the Veteran's service-connected history of tinea cruris/pedis, onychomychosis. In the December 2003 VA examination report, the Veteran's scars from tinea cruris/pedis, onychomychosis, was noted as small and nontender. The diagnostic criteria that applies to scars of the head, face, or neck, or that cover an area far greater than the area of the Veteran's scar, are factually inapplicable to this case, and a compensable rating under these Diagnostic Codes is not warranted. See 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, 7803, 7804, 7805 (effective August 30, 2002). See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board's choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). Furthermore, because the Veteran's service-connected skin disorder has not required more than a topical medication, a compensable rating under Diagnostic Code 7806 is likewise not warranted. Consequently, the assignment of a compensable rating for history of tinea cruris/pedis, onychomychosis, is not warranted under the applicable rating criteria for the time period prior to September 9, 2008. From September 9, 2008 Considering the pertinent evidence of record in light of the above-noted criteria, the Board finds that the criteria for the assignment of a rating in excess of 10 percent for the Veteran's service-connected history of tinea cruris/pedis, onychomychosis, have not been met during this time period. In the September 2008 VA examination report, the examiner noted that the Veteran's skin disorder constituted 10 percent of the body surface area, and 0 percent of the exposed body surface area. At no time did the Veteran's skin disorder constitute 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or require systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period warranting a 20 percent evaluation. Consequently, the assignment of a rating in excess of 10 percent for history of tinea cruris/pedis, onychomychosis, is not warranted under the applicable rating criteria for the time period from September 9, 2008. The Board has considered rating criteria related to scars, but finds that they are not applicable to the Veteran's service-connected history of tinea cruris/pedis, onychomychosis. Because the criteria apply to scars that involve disfigurement of the head, face, or neck; or that cover an area far greater than the area of the Veteran's scar, which was shown at most to be less than one centimeter, a compensable rating under these Diagnostic Codes is not warranted. See 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, 7803, 7804, 7805 (effective August 30, 2002). Therefore, the assignment of a rating in excess of 10 percent for history of tinea cruris/pedis, onychomychosis, is not warranted under the applicable rating criteria for the time period from September 9, 2008. All Increased Rating Claims For all the foregoing reasons, the Veteran's claims for entitlement to an initial compensable evaluation for residuals of a right wrist fracture prior to September 11, 2008, for a rating excess of 10 percent from September 11, 2008, for entitlement to an initial compensable evaluation for a skin disorder prior to September 9, 2008, and in excess of 10 percent from September 9, 2008, must be denied. The Board has considered additional staged ratings, under Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), but concludes that they are not warranted. Since the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Finally, the Board has considered whether the Veteran's residuals of a right wrist fracture and skin disorder presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extraschedular rating is warranted. Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology and provide for higher ratings for additional or more severe symptoms than currently shown by the evidence. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER 1. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. 2. Entitlement to an initial compensable rating for residuals of a fractured right wrist prior to September 11, 2008 is denied. 3. Entitlement to a rating in excess of 10 percent for residuals of a fractured right wrist from September 11, 2008 is denied. 4. Entitlement to an initial compensable rating for history of tinea cruris/pedis, onychomychosis (claimed as jungle rot) prior to September 9, 2008 is denied. 5. Entitlement to a rating in excess of 10 percent for history of tinea cruris/pedis, onychomychosis (claimed as jungle rot) from September 9, 2008 is denied. ____________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs