Citation Nr: 0812598 Decision Date: 04/16/08 Archive Date: 05/01/08 DOCKET NO. 05-15 958 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Evaluation of gastroesophageal reflux disorder (GERD), currently rated as 10 percent disabling. 2. Evaluation of bilateral shin splints, currently rated as 0 percent disabling. 3. Entitlement to an evaluation in excess of 0 percent disabling for cognitive disorder, claimed as psychomotor retardation, prior to January 11, 2006. 4. Evaluation of cognitive disorder, claimed as psychomotor retardation, currently rated as 30 percent disabling. 5. Evaluation of bilateral bunions with hallux valgus deformity, currently rated as 0 percent disabling. 6. Entitlement to service connection for a right wrist sprain. 7. Entitlement to service connection for lipoma. 8. Entitlement to service connection for pes planus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD E. I. Velez, Associate Counsel INTRODUCTION The veteran had active service from June 1984 to June 2004. This matter came before the Board of Veterans' Appeals (Board) on appeal from decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The issue of service connection for pes planus 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. The Board notes that service connection for headaches and condyloma accumulate was granted via a rating decision of November 2004. Therefore, these issues are no longer on appeal. FINDINGS OF FACT 1. GERD is manifested by episodes of dysphagea and heartburn which are not productive of a considerable or severe impairment of health. 2. The veteran's bilateral bunions with hallux valgus deformity is not manifested by resection of the metatarsal head of either foot, nor is it equivalent of having the great toe amputated. 3. A right wrist sprain was first manifested in service. 4. A chronic lipoma was manifested in service. 5 Cognitive disorder is productive of slowness in movement and thought with thought processes reduced to one fourth of its normal rate. 6. The veteran's bilateral shin splints are manifested by no more than subjective complaints of pain with weight bearing with objective evidence of some tenderness and no current evidence of shin splints. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for GERD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.114, Diagnostic Code 7346 (2007). 2. The criteria for an evaluation in excess of 0 percent disabling for bilateral bunions with hallux valgus deformity have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.71a, Diagnostic Code 5280 (2007). 3. A right wrist sprain was incurred in service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2007). 4. A lipoma was incurred in service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2007). 5. Cognitive disorder is 70 percent disabling, prior to and after January 11, 2006. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.130, Diagnostic Code 99327 (2007). 7. The criteria for an evaluation in excess of 0 percent for bilateral shin splints have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.20, 4.27, Diagnostic Code 5299-5020 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2007), provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. To be consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) a VCAA notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant's possession that supports the claim, or something to the effect that the claimant should "submit any additional evidence that supports your claim." This "fourth element" of the notice requirement comes from the language of 38 C.F.R. § 3.159(b)(1). The Board notes that in Mayfield v. Nicholson, 444 F. 3d. 1329 (2006), the Federal Circuit Court held that the VCAA notice must be provided prior to the initial decision or prior to readjudication, and such duty to notify cannot be satisfied by post-decisional communications. In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006) the Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. The timing requirement enunciated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), applies equally to all five elements of a service connection claim. Id. The Board finds that the VA's duties under the VCAA and the implementing regulations have been fulfilled with respect to the issues of the evaluation of GERD, shin splints, cognitive disorder and bilateral bunions, and service connection for right wrist sprain, and lipoma excision. In a VCAA letter of April 2004 the appellant was provided adequate notice as to the evidence needed to substantiate his claims. He was informed of the evidence necessary to establish entitlement, what evidence was to be provided by the appellant and what evidence the VA would attempt to obtain on his behalf; it also in essence told him to provide relevant information which would include that in his possession. See generally Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice predated the rating decision. With regard to notice as to disability ratings and effective date assignment, notice was not provided until March 2006. However, the lack of timeliness is not prejudicial to the appellant because his claim is denied, and, therefore, the issues of rating and effective date do not arise. The Board finds that the VA has no outstanding duty to inform the appellant that any additional information or evidence is needed. The Board notes that in an increased-compensation claim, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez- Flores v. Peake, No. 05-0355, (U.S. Vet. App. January 30, 2008). Further, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Vazquez-Flores, slip op. at 5-6. In regards to the issues of the evaluation of GERD, cognitive disorder and bilateral bunions, the Board finds that the requirements enunciated in Vazquez-Flores have been met. In a Statement of the Case (SOC) of November 2004, the appellant was provided with all of the relevant Diagnostic Codes in his case. Furthermore, in a letter of March 2006 he was provided with examples of the medical and lay evidence he may submit to substantiate his case. Subsequent to the SOC and the March 2006 letter the appellant's claim was readjudicated in Supplemental Statements of the Case of December 2006 and March 2007. Therefore, the appellant was afforded the required due process. While there was error in initially not providing the veteran with the required notice was error, such error was not prejudicial. The veteran was provided with the notice and was given the opportunity to submit additional evidence, he was provided time to submit the same and he was afforded subsequent due process. Therefore, to decide the appeal would not be prejudicial. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2007). In connection with the current appeal service medical records and VA outpatient treatment records have been obtained. The veteran was afforded VA examinations. Therefore, the Board finds that the VA has satisfied its duties to notify and to assist the claimant in this case. No further assistance to the veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). Legal Criteria and Analysis Evaluations Disability evaluations are determined by the application of a schedule of ratings, which is based on average industrial impairment. 38 U.S.C.A. § 1155. A proper rating of the veteran's disability contemplates its history, 38 C.F.R. § 4.1, and must be considered from the point of view of a veteran working or seeking work. 38 C.F.R. § 4.2. The evaluation of the level of disability is to be based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.5. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion. 38 C.F.R. § 4.40 (2007). The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45 (2007). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2007). The Court has held that functional loss, supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion, is recognized as resulting in disability. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45 (2007). At the outset the Board notes that the veteran is appealing the original assignments of disability evaluations following the award of service connection. In such cases, the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). However, there is nothing in the record to reflect that there has been any significant change in the disabilities and uniform ratings are warranted. Gastroesophageal reflux disease The veteran's service-connected GERD is currently evaluated as 10 percent disabling under the provisions of Diagnostic Code 7346, 38 C.F.R. § 4.114, for hiatal hernia. Diagnostic Code 7346 provides a 10 percent evaluation when the evidence shows two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation contemplates a level of impairment, which includes symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. In the instant case, the Board finds that the veteran does not meet or nearly approximate the criteria for a rating in excess of 10 percent under Diagnostic Code 7346. A VA examination report of March 2004 notes that the veteran reported he suffered form dyspnea and reflux which he treated with antiacids which eventually became ineffective. He reported no regurgitation of food chunks to the oral orifice. He reported treating the symptoms with Aciphex and Maalox. He was diagnosed with gastroesophageal reflux disease (GERD). The examiner noted that the veteran had a normal nutritional status. The veteran weighed 180 pounds. A VA examination report of March 2006 notes the veteran reported he experiences occasional dysphagia and has to drink some fluid to push the food. He also reported experiencing pyrosis if he eats spicy foods. He reported heartburn and sometimes spitting mucus. He denied any hematemesis or melena, and denied any nausea or vomiting. The examiner noted that the veteran had good nutrition and that his weight had been stable since last March. He was diagnosed with GERD improved with medication. The Board notes that while the overall evidence of record reflects that the veteran's GERD is manifested primarily by dysphagea, pyrosis and heartburn, the evidence does not show that the veteran's symptoms result in considerable impairment of the veteran's health as required for a 30 percent rating. Nutrition has been reported as good with no anemia. Furthermore, it has been consistently reported that the veteran's symptoms are to some extent controlled by medication. In light of the foregoing, the Board finds that the evidence establishes that the veteran's service-connected GERD is not manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by sternal or arm pain, productive of considerable impairment of health. Nothing in the treatment records or the pertinent VA examinations indicates the disability has resulted in considerable impairment of health. While the veteran has GERD, the reflux symptoms are not shown to warrant a rating in excess of 10 percent. Without evidence of more severe symptomatology, disability due to the veteran's GERD does not warrant an increased rating. Moreover, the evidence is not so evenly balanced as to allow for the application of reasonable doubt. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.102, 4.7, 4.114, Code 7346. Bilateral bunions The veteran's service-connected bilateral bunions with hallux valgus deformity is currently evaluated as 0 percent disabling under the provisions of Diagnostic Code 5280, 38 C.F.R. § 4.71a. Under Code 5280, a 10 percent rating is warranted if there has been an operation and resection of the metatarsal head. A 10 percent rating is also warranted for a severe case, if equivalent to amputation of great toe. A VA examination report of March 2006 noted the veteran's posture as normal. The alignment of the Achilles tendon was also normal. There were 5 degrees of valgus which was noted to be mild and correctable. He had 20 degrees of hallux valgus bilaterally. There was no forefoot or midfoot malalignment. X-rays of the feet showed mild hallux valgus on the left and moderate hallux valgus deformity in the right. The medical evidence relating to the veteran's hallux valgus shows that he has not had a resection of the metatarsal head of either foot. There is also no medical evidence indicating that the condition of the veteran's bilateral hallux valgus is the equivalent of having the great toe amputated. Therefore, a 10 percent evaluation under Diagnostic Code 5280 is not warranted. The Board will consider, along with the schedular criteria, any functional loss due to flare-ups of pain, fatigability, pain on movement, and weakness. Under 38 C.F.R. § 4.59 (2007), it is the intention to recognize actually painful or unstable joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. The Board notes that while the veteran reported pain on walking and standing, he has attributed the pain to his shin splints and ankles and not his hallux valgus. The Board has also considered whether a higher than 0 percent rating is warranted under other Codes applicable to foot disabilities and finds that the veteran is not entitled to a rating in excess of 0 percent under any other Diagnostic Code. Cognitive Disorder Under the rating criteria of 38 C.F.R. § 4.130, Diagnostic Code 9327 (Other Organic Mental Disorder) (2007), a 100 percent evaluation is provided where there is 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. A 70 percent evaluation is provided where there is 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 or hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 50 percent evaluation requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereo- type speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 30 percent evaluation is provided for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130 (2007). In evaluating psychiatric disorders, it must be shown that industrial impairment is the result of actual manifestations of the service-connected psychiatric disorder. The severity of a psychiatric disability is based upon actual symptomatology, as it affects social and industrial adaptability. Two of the most important determinants of disability are time lost from gainful employment and decrease in work efficiency. 38 C.F.R. § 4.130 (2007). Although the GAF score does not fit neatly into the rating criteria, the GAF score is evidence. Carpenter v. Brown, 8 Vet. App. 240 (1995). The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect 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). GAF scores ranging from 41 to 50 reflect 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). GAF scores ranging from 31-40 reflect some impairment in reality testing or communication (e.g., speech is at time illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). See Id. at 242. In reaching a determination in this case, the Board has considered the whole of the evidence, to include the appellant's statements, the assigned GAF scores, and the medical opinions. A VA examination report of March 2004 notes the veteran's mood as generally calm with affect appropriate to the mood. He was alert and oriented to all spheres and cooperative. He reported difficulty sleeping at night. He denied any significant disturbance to his appetite. He denied any suicidal or homicidal ideations or intent. Thought process was goal-directed and his thought content was logical. He denied any perceptual disturbances. The examiner noted a prior medical report which noted moderate memory loss. The report further noted that the veteran suffered from a cognitive disorder characterized primarily by mild to moderate deficits in attention and concentration, and a moderate memory deficit. The general and intellectual functioning and reasoning skills appeared to be well intact. IQ score was 103. He was assessed with cognitive disorder seen primarily as moderate memory deficit. His GAF score was noted as 55. VA outpatient treatment records of January 2006 note that the veteran experienced a marked change from his function prior to service. The veteran noted he rarely socializes after work, he feels he is a burden and stress to his wife and he was quite irritable. He also reported difficulties with sleep. The veteran also reported continued problems with his memory. A mental examination of April 2006 notes that the veteran moved slowly. It was noted he sat immobile with sad facies, eyes downcast. He maintained a slight frown and the voice was sad. The examiner noted he had severe psychomotor retardation sometimes waiting 30 seconds before replying to a question and then limiting his reply to a few words. No delusions or hallucinations were reported and he denied suicidal ideations. Mood was depressed, though the veteran denied being depressed. Affect was sustained depressed. He was oriented to time and place. The examiner noted that the veteran's most obvious characteristic was his slowness of movement and thought. Thought was slow to at least one fourth the normal rate. His appearance, facies, posture, and voice quality denote depression. It was noted he tries to reply to questions and does not give up, but it takes him a long time to consider the question and respond. There was no defect in his reasoning only in the speed of process. He showed some deficit in memory. GAF score was 45 and was 50 percent due to dysthymia and 50 percent due to cognitive disorder. VA outpatient treatment records of October 2006 note that the veteran continued to experience a decrease in depressive and anxious symptomatology. There was notable improvement in his overall level of functioning. However, he continued to experience memory problems. In November and December 2006 the veteran was noted to experience a decline in his overall level of functioning. In December 2006 he was diagnosed with depression. In January 2007 he was noted to have returned to a level of functioning at or above the most recent decline. In March 2007 it was noted that he was less irritable, was sleeping 7 hours, was able to concentrate better and had no crying spells. There was no evidence of thought or major mood or memory disorder. GAF score was 60. He was diagnosed with depression. A. Staged rating The Board has been presented with differing medical reports and the veteran's own statements. Throughout the appeal period, the veteran has asserted that his service-connected cognitive disorder was worse. This is evidence that must be considered. The RO has assigned a staged rating. Service connection was granted in a rating decision of August 2004. The RO assigned a 0 percent evaluation. In a rating decision of December 2006 the RO increased the evaluation to 30 percent disabling effective January 2006. The RO has assigned a staged rating. However, in this case, the Board concludes that during the course of the appeal, the veteran's disability has not significantly changed. Therefore, the Board disagrees with the staged rating and concludes that a uniform rating is warranted. B. Evaluation of PTSD rated as 0 percent disabling prior to January 11, 2006 and currently 30 percent disabling. As noted above, the RO assigned a staged rating. We conclude that the disability has not significantly changed and that a uniform increased evaluation is warranted for the entire appeal period. The Board has been presented with a remarkable conflict in the evidence. However, in view of the veteran's particular disability, the examination that best describes the veteran's disability is the April 2006 evaluation conducted by a staff psychiatrist. That examination confirmed the presence of a cognitive disorder. There was slowness of movement and thought. It took him a very long time to consider a question and respond. The fact that he had good responses pales into insignificance when it took him 30 seconds to respond. His thought processes were slowed to one fourth of the normal rate. Based upon the criteria that would be applicable to this veteran, the disability is 70 percent disabling. However, an evaluation in excess of 70 percent is not warranted. While the evidence shows that the veteran's symptoms are significant, the veteran's overall disability picture is best represented by a 70 percent evaluation. The evidence does not show 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. At the March 2004 VA examination the veteran reported having memory problems which had affected his ability to concentrate and which had caused increased conflicts with his wife. However, he reported that he had not lost time from work. He was described as having moderate memory loss. However, his mood was generally calm and his affect was appropriate to the mood; he was oriented to all spheres; he denied any suicidal or homicidal ideations or thoughts. Thought process was goal-oriented and content was logical. His GAF score was 55. In January 2006 the veteran reported rarely socializing at work and being irritable, and having difficulties with sleep. It was noted the veteran continued to remain consistent with difficulties and challenges to daily functioning as a result of his cognitive disorder. However, he exhibited no significant psychopathology and he remained employed. While in April 2006 it was reported that he was exhibiting severe psychomotor retardation, he continued to work. Furthermore, while it was reported that he had no friends and did not socialize after work, he still did the chores around the house, maintained the yard, surfed the internet a couple of hours a day, took care of a new puppy, and accompanied his wife to the mall and other errands. By August 2006 the veteran's motivation was improved and his functioning level continued to improve through the latest treatment records of March 2007 which noted no problems with memory, thought or mood. As such, the veteran's symptoms do not meet the requirements for an evaluation in excess of 70 percent. Shin Splints The veteran is seeking a higher evaluation for his service connected shin splints. A VA examination report of March 2004 notes that the veteran reported he thought his shin splints improved with rest but they never fully resolved. He reported prior fractures occurring secondary to the chronic shin splints; however, no casting was required. This was an isolated occurrence which was treated conservatively with crutches. There has been no surgical intervention and treatment has been conservative. The veteran wears inserts in his boots and shoes, and has been issued compression sleeves to be worn on his shins during activity. Both feet and legs are most painful when standing for extended lengths of time, navigating stairs, walking or running for long distances. The veteran reported pain on a daily basis waxing and waning throughout the day dependent upon level of physical activity. There was no overt deformity noted on the legs and no erythema or ecchymosis. There was tenderness to palpation over the distal anterior medial tibia bilaterally. X-rays showed no fracture lucencies, focal sclerotic or lytic lesions or obvious radioopaque foreign body. The alignment was unremarkable. The soft tissues were unremarkable. A VA examination report of March 2006 notes that the veteran complained of pain on his knees and shins and calves with tightening when running. He stated he felt tightening of the shins and calves upon standing for more than an hour or ambulating for 2 blocks. He stated he rests for a few minutes, stretches and re starts again. The veteran had normal ambulation, he had braces on both knees and left ankle. He had tender shins without swelling, calves were normal and asymptomatic. There was no joint involvement. Peripheral pulsations were present, good quality. There was no malunion, nonunion, loose movement or false joint. He was diagnosed with shin splints. The diagnosis was changed to no shin splints found after a bone scan which revealed no evidence of shin splints or stress fractures. The veteran's service-connected shin splints have been rated 0 percent disabling by the RO under the provisions of Diagnostic Code 5299-5020. 38 C.F.R. §§ 4.20, 4.27, 4.71a. The veteran's shin splints are evaluated under Diagnostic Code 5020, which provides the criteria for evaluating disability due to synovitis. Diagnostic Code 5020 provides that synovitis is rated on limitation of motion of affected parts as degenerative arthritis. Arthritis established by x- ray findings is rated on the basis of limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, and 5020 (2007). Under Diagnostic Code 5010, arthritis due to trauma, substantiated by X-ray findings, shall be rated as degenerative arthritis under Diagnostic Code 5003. Diagnostic Code 5003 specifies that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. In the absence of limitation of motion, a 10 percent rating may be assigned for arthritis with X-ray evidence of involvement of a major joint or two or more minor joint groups. A 20 percent evaluation will be assigned with X-ray evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. The veteran's symptomatology does not entail arthritis of a major joint or two or more minor joints. Indeed, there have been no x-ray findings of arthritis involving the veteran's lower extremities. Moreover, the medical evidence of record shows no evidence of shin splints or stress factures. As such, a 10 percent evaluation is not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5020. Diagnostic Code 5262 pertains to impairment of the tibia and fibula. It provides that when there is nonunion of the tibia and fibula with loose motion requiring a brace, or malunion of the tibia and fibula, a 10 percent evaluation is assignable for impairment of the tibia and fibula with slight knee or ankle disability. A 20 percent evaluation is assignable for impairment of the tibia and fibula with moderate knee or ankle disability. When impairment of the tibia and fibula is manifested by malunion with marked knee or ankle disability, a 30 percent evaluation is assigned. Nonunion, with loose motion requiring a brace, is assigned a 40 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5262. In order to warrant a compensable evaluation, the evidence must show malunion or nonunion of the tibia and fibula. The veteran does not warrant a compensable evaluation under Diagnostic Code 5262 because the evidence does not show that he has malunion or nonunion of the tibia and fibula. Furthermore, his disability does not result in impairment of function of either the ankle or the knee. Rather, examination disclosed no joint involvement. As such, evaluations based upon joint involvement, limitation of motion or functional impairment of a joint are not warranted since there is no functional impairment of a joint. See DeLuca, supra. Therefore, an evaluation in excess of 0 percent disabling for bilateral shin splints is not warranted. Service Connection Compensation may be awarded for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Service connection basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303 (2007). Service connection for a chronic disease such as atherosclerotic coronary heart disease or cardiovascular disease, including hypertension, may be granted if manifest to a compensable degree within one year of separation form service. See 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted for any disease 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). The chronicity provision of 38 C.F.R. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. Savage v. Gober, 10 Vet. App. 488, 498 (1997). In addition, if a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b) (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Initially, the Board notes the appellant does not assert that his claimed disabilities are a result of combat. Therefore, the provisions of 38 U.S.C.A. § 1154(b) (West 2002) are not for application in this matter. Right Wrist Service medical records show that in September 1990 the veteran was treated for a possible sprained wrist due to lifting a tow bar. It was not specified which wrist was possibly strained. In March 1993 the veteran was treated for a right wrist sprain. A separation physical of March 2004 noted abnormal upper extremities. In the report of medical history the veteran noted he had sprained his right hand while in service. A VA examination report of March 2004 noted the right wrist range of motion to be extension to 70 degrees, flexion to 90 degrees, radial deviation to 20 degrees, and, ulnar deviation to 55 degrees. Painful motion was noted on radial deviation between 15 to 20 degrees and in ulnar deviation from 45 to 55 degrees. The veteran was diagnosed with right wrist sprain, diagnosed as chronic right wrist sprain. The examiner noted that the right wrist sprain was noted early in the veteran's military tenure and became gradually and progressively worse with time. After a careful review of the evidence of record the Board finds that the evidence is in favor of a grant for service connection for a right wrist disability. There is evidence that the veteran was treated for a right wrist sprain while in service. Furthermore, the veteran noted in his separation examination that he had sprained his right wrist. In the VA examination done in association with his separation from service, the veteran was diagnosed with chronic right wrist sprain and the VA examiner noted that the condition had been noted early in the veteran's military tenure and had become gradually worse with time. The medical opinion is competent and provides a nexus to service. The Board finds that there is competent evidence of a current disability and a link to service. Therefore, service connection for a right wrist disability is granted. Lipoma The veteran is claiming service connection for lipoma. After a careful review of the evidence of record the Board finds that the evidence is in favor of a finding of service connection for lipoma. Service medical records show that in January 1998 the veteran was found to have a chest lipoma. A separation physical of March 2004 noted a lipoma in the chest area. A VA examination report of March 2004 notes a 3 centimeter superficial mobile mass consistent with lipoma on the sternum. The evidence is clear, the veteran was diagnosed with a lipoma while in service, which was also noted at the separation physical, and which was diagnosed at the March 2004 VA examination. The evidence shows that a lipoma was incurred in service. Accordingly, service connection is granted. ORDER An evaluation in excess of 10 percent disabling for GERD is denied. An evaluation in excess of 0 percent disabling for bilateral bunions with hallux valgus deformity, is denied. Prior to and after January 11, 2006, a 70 percent evaluation for PTSD is granted, subject to the controlling regulations applicable to the payment of monetary benefits. An evaluation in excess of 0 percent disabling for bilateral shin splints is denied. Service connection for a right wrist sprain is granted. Service connection for a lipoma is granted. REMAND The VCAA requires that VA afford a veteran a medical examination or obtain a medical opinion when necessary to make a decision on the claim. Duenas v. Principi, 18 Vet. App. 512 (2004); see 38 U.S.C.A. § 5103A(d). When medical evidence is not adequate, the VA must supplement the record by seeking an advisory opinion or ordering another examination. 38 C.F.R. § 3.159(c)(4)(i). See Littke v. Derwinski, 1 Vet. App. 90 (1991). The veteran is seeking service connection for pes planus. An enlistment physical examination of August 1983 noted pes planus. A separation physical of March 2004 also noted pes planus. A VA examination report of March 2004 notes pes planus as one of the veteran's musculoskeletal conditions. The examiner goes on to state that the multiple above conditions were noted early in the veteran's military tenure becoming progressively worse with time. They are the culmination of multiple strains and sprains incurred during field maneuvers and physical training. The examiner goes on to discuss each of the musculoskeletal conditions separately, however, he did not discuss the veteran's pes planus. It is unclear from the examination report whether the veteran's pes planus worsened during service due to its natural progression or whether service aggravated it beyond its natural progression. A clarification of the opinion is needed. Accordingly, the case is REMANDED for the following action: The veteran should be afforded an orthopedic VA examination to determine the nature and etiology of any pes planus the veteran may currently have. The claims folder should be made available to the examiner for review before the examination. The examiner should specifically comment as to whether it is as likely as not (i.e., to at least a 50-50 degree of probability) that any currently found pes planus was aggravated by the veteran's service or whether such an etiology or relationship is unlikely (i.e., less than a 50-50 probability). The examiner should specifically determine whether the veteran's service aggravated the veteran's pes planus beyond its natural progression. It is requested that reasoning be afforded in support of any opinion provided. 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). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs