Citation Nr: 0810560 Decision Date: 03/31/08 Archive Date: 04/09/08 DOCKET NO. 06-11 479 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Togus, Maine THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for post-traumatic stress disorder (PTSD). 2. Entitlement to an initial rating in excess of 10 percent for residuals of a shell fragment wound to the right flank. 3. Entitlement to an initial rating for residuals of a shell fragment wound to the right calf, rated as 10 percent disabling for muscle injury and noncompensably disabling for residual scar. 4. Entitlement to an initial compensable rating for residuals of a shell fragment wound to the left hand. 5. Entitlement to service connection for heart disease. 6. Entitlement to service connection for bladder cancer, to include as due to herbicide exposure. REPRESENTATION Appellant represented by: Maine Veterans' Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Riley, Associate Counsel INTRODUCTION The veteran served on active duty from June 1965 to June 1967. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Augusta, Maine (known as the Togus, Maine RO). That decision granted service connection for PTSD, evaluated as 30 percent disabling, effective June 30, 2004; residuals of shell fragment wounds of the right calf, right ankle, right flank, left middle finger, evaluated as non compensable, effective May 7, 2004; and denied entitlement to service connection for ischemic heart disease and coronary artery disease, and for bladder cancer. In March 2006, the veteran provided testimony at a hearing before a hearing officer at the RO. A transcript of this hearing is of record. In an April 2006 rating decision, the veteran was awarded a rating of 50 percent for his PTSD, effective June 30, 2004, and increased evaluations of 10 percent for residuals of a shell fragment wounds to the right flank and right calf, effective May 7, 2004. A separate noncompensable rating was also assigned for a residual scar of the right calf, effective May 7, 2004. A veteran is generally presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). Therefore, despite the RO's May 2006 letter informing the veteran that its April 2006 decision fully resolved his appeal, the appeals of the initial evaluations for PTSD and shell fragment wounds to the right flank and calf remain before the Board. Service connection for low back degenerative joint disease and residuals of a shell fragment wound to the left ankle was also granted in an April 2006 VA rating decision. The veteran has not disagreed with the initial evaluations assigned these disabilities, and as the grant of service connection constitutes a complete grant of the benefits on appeal, the issues of entitlement to service connection for low back and left ankle disabilities are not before the Board. In October 2006, the RO granted entitlement to a total rating for compensation purposes based on individual unemployability. The issue of entitlement to service connection for heart disease is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the appeals period, the veteran's PTSD has been manifested by deficiencies in most areas of work, school, family relationships, thinking, judgment and mood without total occupational and social impairment. 2. Injury to the right flank muscle most nearly approximates moderate muscle injury. 3. The veteran's scar of the right calf is manifested by objective pain and no limitation of motion; injury to the right calf muscle most nearly approximates moderate muscle injury. 4. The veteran's scar of the left hand is asymptomatic and does not approximate an area of 12 square inches. 5. Bladder cancer was not present in service or within one year of service and is not the result of a disease, injury, or exposure to herbicides in service. CONCLUSIONS OF LAW 1. The criteria for a 70 percent disability rating, but not higher, for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2007). 2. The schedular criteria for a rating in excess of 10 percent for residuals of a shell fragment wound to the right flank have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.7, 4.14, 4.56, 4.73, 4.118, Diagnostic Code 5321 (2007). 3. The schedular criteria for a rating in excess of 10 percent for shell fragment wound residual right calf muscle injury have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.7, 4.14, 4.56, 4.73, 4.118, Diagnostic Codes 5310-5312 (2007). 4. The schedular criteria for a 10 percent rating for shell fragment wound scar of the right calf scar have been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.7, 4.14, 4.56, 4.73, 4.118, Diagnostic Codes 7802-7805 (2007). 5. The schedular criteria for an initial compensable rating for shell fragment wound residual left hand scar have not been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.7, 4.14, 4.56, 4.73, 4.118, Diagnostic Codes 7802-7805 (2007). 6. The veteran's bladder cancer was not incurred or aggravated during service and is not proximately due to or the result of exposure to herbicides. 38 U.S.C.A. §§ 1110, 1112, 1116 (West 2002 & Supp 2007); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2007) redefined VA's duty to assist the veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007). Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In letters issued in June 2004 and September 2004, prior to the initial adjudication of the claims, the RO notified the veteran of the evidence needed to substantiate his claims for entitlement to service connection. The letters also satisfied the second and third elements of the duty to notify by informing the veteran that VA would try to obtain medical records, employment records, or records held by other Federal agencies, but that he was nevertheless responsible for providing any necessary releases and enough information about the records to enable VA to request them from the person or agency that had them. With respect to the fourth element of VCAA notice, the June and September 2004 letters contained a notation that the veteran should submit any evidence in his possession pertinent to the claims on appeal. In addition, he received information regarding the effective date or disability rating elements of his claims in March 2006. With respect to the veteran's claims for increased ratings, the appeals arise from disagreement with the initial evaluations following the grant of service connection. The courts have held that once service connection is granted and the claim is substantiated, additional VCAA notice is not required; and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VCAA notice must be provided prior to the initial adjudication of a claim; however, if the notice is provided after the initial adjudication, the timing defect will be cured by re-adjudication of the claim after the notice has been provided. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). While the VCAA notice was provided after the initial adjudication of the claims, the timing defect was cured by readjudication of the claims in April 2006. The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained records of treatment reported by the veteran, including service medical records, records from various federal agencies, and private medical records. The Board also acknowledges that the veteran has not been afforded a VA examination in response to his claim for entitlement to service connection for bladder cancer, but has determined that no such examinations are required in this case because the medical evidence of record is sufficient to decide the claims and there is no reasonable possibility that such examinations would result in evidence to substantiate the claims. In this regard, the Board notes that the veteran's service treatment records are negative for evidence of cardiac or bladder disabilities. In addition, there is no post-service medical evidence of the claimed disabilities until more than 25 years after the veteran's separation from active duty service. The Board therefore finds that any medical nexus opinion provided by a examiner would be based solely on history provided by the veteran. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. Initial Ratings I. General Legal Criteria Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2007). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7 (2007). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2007). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. In Fenderson, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the initial evaluation period. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). II. PTSD A. Legal Criteria When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2007). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2007). The schedular criteria, effective as of November 7, 1996, incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. §§ 4.125, 4.130. A 50 percent rating is warranted for PTSD if it is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Codes 9411. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Codes 9411. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF score of 31 to 40 signifies some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., where a depressed man avoids friends, neglects family, and is not able to work). Id. A GAF score of 41-50 is assigned where there are, "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A GAF score of 51-60 means there are, "Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." Id. B. Factual Background Records from the Social Security Administration dated in September 1999; show that the veteran was found to be disabled due to ischemic heart disease with angina. In October 2004, the veteran underwent a psychiatric examination with his private social worker, D.M. He reported having a history of depression, as well as feelings of social isolation, and chronic sleep problems, including nightmares and night sweats. He complained of flashbacks triggered by sounds, smells, and war movies. He avoided crowds and had become more angry and frustrated since September 11, 2001, especially with his son being stationed in Iraq. He had been married 32 years, and reported having a good marriage. He had three adult children and reported that the family was close. D.M. noted that the veteran presented with classic PTSD and had used alcohol to self-medicate following his period of active duty. The diagnosis was PTSD and a GAF score of 40 was assigned. The veteran was provided a VA psychiatric examination in January 2005. He stated that he had nightmares, flashbacks, and was quite a loner. During the examination, he had some difficulty with concentration, and complained of anxiety. His affect was blunted and his mood was depressed. The veteran had rambling speech, and expressed a feeling of emotional numbness. He did not report panic attacks or current substance abuse, but stated that he had a phobia of violence on television. There were no obsessions or compulsions and although his recent memory was diminished, he was oriented to time, place, and person. His personal hygiene was adequate and he denied suicidal or homicidal ideation. The veteran reported that he had been married many years to the same spouse and had grown children, two of whom were in the military service. He had worked until two year earlier, when he retired due to a heart disability. A diagnosis of PTSD was rendered and a GAF score of 60 was assigned. The examiner found that the veteran had moderate impairment of his industrial and social functioning. In July 2005, D.M. sent a letter to VA with further information on the severity of the veteran's PTSD. Specifically referencing the January 2005 VA examination report, D.M. noted that while the veteran denied having certain symptoms during his VA examination, he experienced panic attacks several times a month as well as other significant problems, particularly regarding short-term memories. D.M. also noted that he encouraged the veteran to keep a daily journal for the months of May and June 2005 that portrayed his complaints of sleep disturbance, social isolation, and panic and anxiety attacks. D.M. found that the veteran's GAF scores throughout the past year had ranged from 40 to 42 and were reflective of his panic attacks, memory problems, and lack of a social system other than his family. On VA examination for a condition not currently at issue in March 2006, the veteran was described as a retired supervisor. His retirement had been due to heart problems. In a statement received in March 2006, the veteran asserted that memory and concentration problems would preclude him from working. The veteran's most recent VA psychiatric examination was conducted in April 2006. He stated that during his first VA examination he did not confide completely in the examiner and reported being depressed, experiencing crying spells, and having trouble around other people. The veteran had trouble with concentration and made several mistakes on simple calculations. He had a blunted affect with adequate hygiene. He had no psychotic delusions, but did report flashbacks. He stated that nightmares occurred four to five times a week. The veteran had a decrease in recent memory and rambling speech. He reported having panic attacks in crowds and that he was avoidant of other people and had almost no social contract other than his wife. The examiner also noted that the veteran had been retired for several years due to his cardiac condition. The diagnosis was PTSD and a GAF score of 50 was assigned. The examiner concluded that the veteran had moderate to severe impairment of industrial capacity and severe social impairment. At his hearing the veteran testified that memory and concentration problems would prevent him from working. C. Analysis The criteria for a 70 percent rating for a psychiatric disability are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). On VA psychiatric examination in April 2006, the examiner concluded that the veteran had moderate to severe industrial impairment resulting from his PTSD and severe social impairment. A GAF score of 50, consistent with serious symptoms was assigned. Furthermore, throughout the claims period, the veteran's therapist has assigned GAF scores ranging from 42 to 40, also consistent with serious impairment, and he noted that the veteran had significant problems from his PTSD. The medical record also establishes that the veteran's PTSD has manifested symptoms such as sleep disturbance, flashbacks, panic attacks, depression, and isolation. He was found to have no social structure other than his wife, and has been consistently observed to have memory and concentration deficiencies. The VA examiners noted that the veteran had rambling speech, presented with a blunted affect and appeared emotionally numb. While the veteran's PTSD has not manifested all the symptoms associated with a 70 percent rating, the Board notes that his GAF scores throughout the claims period have been consistent with serious symptoms and his PTSD has been characterized as severe. Resolving reasonable doubt in the veteran's favor, the Board finds that the veteran's disability most closely approximates the criteria for a 70 percent rating since the effective date of service connection. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). On the other hand, if the evidence shows that the veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Ultimately in Mauerhan the Court upheld the Board's decision noting that the Board had considered all of the veteran's psychiatric symptoms, whether listed in the rating criteria or not, and had assigned a rating based on the level of occupational and social impairment. Mauerhan v. Principi, at 444. Applying this analysis to the criteria for the 100 percent rating, if follows that the veteran would be entitled to that rating if PTSD caused total occupational and social impairment, regardless of whether he had some, all, or none of the symptoms listed in the rating formula, and regardless of whether his symptoms were listed or not. While the veteran has not been employed throughout the appeals period, the undisputed evidence is to the effect that he stopped working due to his cardiac disability. Examiners have found that he has less than total occupational impairment attributable to PTSD alone. The RO granted a total rating on the basis of the combined effects of PTSD and a back disability. The veteran has been married for many years to his wife and the veteran has maintained good relationships with his grown children. It is therefore clear that PTSD does not result in disability approximating total social and occupational impairment. III. Residual Shell Fragment Wounds to Right Flank, Right Calf, Left Hand A. Legal Criteria The rating criteria for scars provide that superficial scars which are painful on examination or are unstable (frequent loss of skin over the scar) warrant a 10 percent evaluation. 38 C.F.R. § 4.118, Diagnostic Codes 7803 and 7804 (2007). Superficial scars that do not cause limited motion warrant a 10 percent evaluation if they involve an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2007). Scars may also be rated based upon the limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2007). Evaluation of injury includes consideration of resulting impairment to the muscles, bones, joints and/or nerves, as well as the deeper structures and residual symptomatic scarring. See 38 C.F.R. §§ 4.44, 4.45 (2007). Muscle Group (MG) damage is categorized as mild, moderate, moderately severe, and/or severe, and evaluated accordingly. 38 C.F.R. § 4.56 (2007). The provisions of 38 C.F.R. § 4.56, as applicable to the pending claim, are as follows: (b) A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. (c) For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. (d) Under Diagnostic Code 5301 through Diagnostic Code 5323, disabilities resulting from muscle injuries shall be classified as follows: (1) Slight disability of muscles--(i) Type of injury. Simple wound muscle without debridement or infection. (ii) History of complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments remained in muscle tissue. (2) Moderate disability of muscles--(i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in- service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. (3) Moderately severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low- velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. B. Factual Background Service treatment records show that the veteran sustained shell fragment wounds from the explosion of a grenade. He was noted to have wounds in the right calf, flank, and middle finger. He was hospitalized for nine days, and his wounds were debrided. He was noted to develop chest pain after the debridement. A chest X-ray was interpreted as normal. He was returned to duty. Later in July 1966, wire sutures were removed. Service treatment records show no further complaints or treatment referable to the fragment wounds. On examination for separation from service in May 1967, scars were noted on the right chest, leg, and ankle. In a report of medical history completed at the same time, the veteran reported that he was in good health, and indicated no pertinent complaints. Service connection for shell fragment wounds to the right flank, right calf, and left hand was granted in the March 2005 rating decision on appeal. Noncompensable disability ratings were assigned, effective May 7, 2004. As noted above, increased ratings of 10 percent were granted for the residual muscle injuries on the veteran's right flank and right calf in an April 2006 rating decision, also effective May 7, 2004. In addition, service connection and a noncompensable rating were assigned for a right calf scar, effective May 7, 2004. The record reflects that the veteran sustained multiple shrapnel wounds to his right flank, right leg, and left hand from grenade fragments while serving in Vietnam in July 1966. There was no artery or nerve involvement, and the wounds were initially debrided. While the veteran complained of developing chest pain, contemporaneous X-rays of the chest were negative. The veteran's claims for entitlement to service connection were received by VA in May 2004. In response to his claims, he was provided a VA examination in January 2005. He claimed to have retained foreign bodies in his right posterior ribcage and right proximal calf. Upon physical examination, the examiner noted scars over the right distal leg above the ankle and below the knee, and over the left ring finger. There was no loss of motion of the left hand, the veteran was able to make a fist, and there was no weakness. X-rays of the right tibia revealed a metallic foreign body below the right knee and between the tibia and fibula. X-rays of the right posterior chest showed a metallic foreign body above the diaphragm at the outer margin of the chest. The diagnosis was status post shell fragment wound right calf, right ankle, right chest area (flank), and left middle finger without objective pathology. The veteran was afforded another VA examination in March 2006. He complained of tenderness on his right calf. Physical examination revealed a well-healed 3 centimeter (cm) by 1.5 cm scar that was somewhat sensitive to palpation. It was nonadherent, smooth, shiny, and stable. It was slightly depressed. The scar was somewhat deep but without any significant loss of muscle tissue. There was no inflammation, edema, or keloid formation. The color of the scar was similar to the adjacent skin and there was no area of induration, inflexibility, or limitation of motion caused by the scar. The examiner also noted a scar in the interosseus space between the left ring and left middle fingers with essentially no limitation of motion. The diagnoses were residual scars of the right lateral calf and no evidence of a shell fragment wound to the left middle finger. C. Analysis The veteran is currently assigned 10 percent evaluations for residuals of right flank and right calf muscle injuries and noncompensable evaluations for his left hand and right calf scars. With respect to the veteran's scar residuals, the March 2006 VA examiner noted that the veteran's right calf scar was sensitive to palpation. The Board finds that a rating of 10 percent is therefore warranted for the period since the effective date of service connection under Diagnostic Code 7804 for superficial scars painful upon examination. As there is no evidence that the right calf scar causes limitation of motion or that it involves an area greater than 929 sq cm, a rating in excess of 10 percent is not warranted at any time. Fenderson. Regarding the veteran's left hand scar, while he has stated that his ring finger is often painful, there is no objective medical evidence that the veteran's scar is sensitive or otherwise painful. The January 2005 VA examiner noted that there was no loss of motion of the left hand, the veteran was able to make a fist, and there was no weakness. Furthermore, it is clear that the veteran's scar does not involve an area of 12 square inches (929 sq cm) or more. Therefore, a compensable rating is not warranted for the veteran's residual left hand scar. Turning to the veteran's muscle injuries, the Board finds that ratings in excess of 10 percent for residuals of shell fragment wounds to the right calf and right flank are not warranted, as any current muscle damage most nearly approximates moderate rather than moderately-severe. The Diagnostic Codes pertaining to the veteran's service- connected muscle groups, 5310-5312 and 5321, rate moderate muscle injuries as 10 percent disabling. While the service treatment records following the veteran's injuries document that there was debridement of the wounds, there was no artery or nerve involvement. Furthermore, while his right flank scar was noted to be somewhat deep by the March 2006 VA examiner, there was no significant loss of muscle tissue. Moreover, the March 2005 VA examiner found no evidence of objective pathology associated with the veteran's service- connected injuries. There are also no records of consistent complaints of the cardinal symptoms of muscle disability, no loss of deep fascia, muscle substance, or firm resistance of muscles from the veteran's service-connected disabilities. While X-rays show retained metal fragments in the veteran's flank and calf, absent associated disability, the Board finds that the veteran's impairment from his muscle injuries has not most nearly approximated moderately-severe and higher initial ratings are not warranted at any time since the effective date of service connection. The Board has considered whether there is any other schedular basis for granting higher ratings, but has found none. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this period because the preponderance of the evidence is against higher ratings at any time during the appeal period. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Extraschedular Ratings In exceptional cases where the schedular evaluation is found to be inadequate, pursuant to 38 C.F.R. § 3.321(b)(1) (2007), the Under Secretary for Benefits or the Director of VA's Compensation and Pension Service may approve an extra- schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. In the instant case the disabilities at issue have not required any periods of hospitalization. The shell fragment wounds have had no reported impact on the veteran's work or ability to work. Hence, referral of that issue for extraschedular consideration is not warranted. The 70 percent evaluation for PTSD is intended to compensate for severe impact on employment. See 38 C.F.R. § 4.1 (2007) (providing that the schedular rating is meant to compensate for considerable time lost from employment commensurate with that evaluation). The veteran has also been awarded a total rating for compensation based on individual unemployability in recognition of the extraschedular impacts of his disabilities on employment. As discussed above, PTSD alone is not shown to cause total occupational impairment. The record does not show marked interference with employment beyond that contemplated by a 70 percent rating. Referral for consideration of an extraschedular rating is therefore, not warranted. Service Connection Claims I. General Legal Criteria Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). Lay persons are not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson; see Grover v. West, 12 Vet. App. 109, 112 (1999); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (lay person competent to testify to pain and visible flatness of his feet); Espiritu, 2 Vet. App. at 494- 95 (lay person may provide eyewitness account of medical symptoms). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2007). Additionally, for veteran's who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as cardiovascular- renal disease, are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). II. Bladder Cancer The veteran contends that he incurred bladder cancer as a result of herbicide exposure during his active duty service in Vietnam. For purposes of establishing service connection for a disability resulting from exposure to a herbicide agent, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam between January 1962 and May 1975, shall be presumed to have been exposed during such service to a herbicide agent, absent affirmative evidence to the contrary demonstrating that the veteran was not exposed to any such agent during service. 38 U.S.C.A. § 1116(f) (West 2002). Moreover, the diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne and porphyria cutanea tarda shall have become manifest to a degree of 10 percent or more within one year, after the last date on which the veteran was exposed to an herbicide agent during active service. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(ii) (2007). In addition, the United States Court of Appeals for the Federal Circuit has determined that a veteran is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Service treatment records are negative for any complaints, treatment, or diagnoses pertaining to bladder cancer. Moreover, the examination for separation from service in May 1967 shows that the veteran's genitourinary system was found to be normal. The post-service medical evidence of record establishes that the veteran was diagnosed with low grade urothelial carcinoma in August 2003 following a cystoscopy of the bladder. With respect to the veteran's contention that his bladder cancer was incurred as a result of exposure to Agent Orange during active duty service, although the veteran's exposure to herbicides is presumed based upon his service in Vietnam, cancer of the bladder is not subject to presumptive service connection on the basis of herbicide exposure. 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. § 3.309(e). Turning to the issue of direct service connection, while the post-service medical evidence of record shows that the veteran has been diagnosed and treated for cancer of the bladder, there is no evidence of this disorder until more than 35 years after the veteran's discharge from service. There is also no other evidence of a continuity of symptomatology since service. The Board notes that the veteran testified at his March 2006 hearing that he was told by his private physician that his cancer was caused by toxins introduced in the workplace. The veteran further stated that since his only exposure to toxins was during his active duty service in Vietnam, this was the cause of his cancer. The Board has considered the statements of the veteran, but notes that the record does not contain any medical evidence linking his bladder cancer to his active duty service or his exposure to herbicides. Moreover, the veteran has no medical or scientific expertise that would qualify him to provide a competent opinion in this regard. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Accordingly, the Board must conclude that the preponderance of the evidence is against the claim for service connection for bladder cancer. ORDER Entitlement to an initial 70 percent rating for PTSD is granted, effective June 30, 2004. Entitlement to an initial rating in excess of 10 percent for residuals of a shell fragment wound to the right flank is denied. Entitlement to an initial rating in excess of 10 percent for residuals of a shell fragment wound injury to the right calf consisting of muscle injury is denied. Entitlement to an initial 10 percent rating for shell fragment wound residual scar of the right calf is granted, effective May 7, 2004. Entitlement to an initial compensable rating for residuals of a shell fragment wound to the left hand is denied. Entitlement to service connection for bladder cancer, to include as due to herbicide exposure, is denied. REMAND Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). The veteran's reports of a constinuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, at 83. The service medical record document an episode of chest pain after debridement of a shell fragment wound, and the veteran has testified that he experienced several episodes of arrhythmia beginning during combat in Vietnam. The veteran would be competent to report symptoms of arrhythmia. As a combat veteran, his reports of arrhythmias in are presumed to have occurred. The veteran also reported a history of arrhythmias when he was initially treated for heart disease in 1993. He has current diagnoses of ischemic heart disease with a history of myocardial infarction. An examination is needed so that a competent medical professional can opine as to the relationship between the current heart disease and the symptoms reported in service. Accordingly, this case is REMANDED for the following: 1. The veteran should be afforded a VA heart or cardiovascular examination to determine the relationship between current heart disease and in-service chest pain and arrhythmias. The examiner should review the claims folder and note such review in examination report or in an addendum. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any current heart disease is related to the chest pain or arrhythmias that reportedly began in service. The examiner should provide a rationale for this opinion. The examiner is also advised that under 38 U.S.C.A. § 1154(b), the veteran's reports of injuries or symptoms during combat are presumed creates a presumption that the injuries or symptoms occurred during such combat. 2. If the benefit sought is not granted, the agency of original jurisdiction should issue a supplemental statement of the case before returning the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs