Citation Nr: 1009747 Decision Date: 03/15/10 Archive Date: 03/24/10 DOCKET NO. 07-08 738 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for major depressive episode. 2. Entitlement to an initial evaluation in excess of 10 percent for nasal septal deviation. 3. Entitlement to an initial compensable evaluation for right wrist instability prior to July 18, 2008, and in excess of 10 percent from July 18, 2008. 4. Entitlement to an initial compensable evaluation for left wrist instability prior to July 18, 2008, and in excess of 10 percent from July 18, 2008. 5. Entitlement to an initial compensable evaluation for right foot stress fracture. 6. Entitlement to an initial compensable evaluation for left foot stress fracture. 7. Entitlement to service connection for a left hip disability, claimed as secondary to service-connected back disability. 8. Entitlement to service connection for hearing loss. 9. Entitlement to service connection for tinnitus. 10. Entitlement to service connection for an unspecified disability, claimed as due to exposure to asbestos. REPRESENTATION Appellant represented by: Kentucky Department of Veterans Affairs ATTORNEY FOR THE BOARD A. Shawkey, Counsel INTRODUCTION The Veteran served on active duty from October 1999 to September 2003. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. This matter was previously before the Board in April 2009 at which time the case was remanded for additional development. The matter is once again before the Board. FINDINGS OF FACT 1. From the effective date of the grant of service connection, on September 5, 2003, the Veteran's service- connected major depressive episode has been productive, overall, of no more than occupational and social impairment with reduced reliability and productivity. 2. Effective from September 5, 2003, the Veteran's deviated nasal septum has not been manifested by obstruction of the nasal passages and both nasal passages are not exposed. 3. For the period from September 5, 2003, to July 17, 2008, the Veteran's right wrist disability has been manifested by occasional instability and full painless range of motion; from July 18, 2008, the Veteran's right wrist disability has been productive of occasional instability and limitation of motion with pain. 4. Effective from September 5, 2003, to July 17, 2008, the Veteran's left wrist disability has been manifested by occasional instability and full painless range of motion; from July 18, 2008, the Veteran's left wrist disability has been productive of occasional instability and limitation of motion with pain. 5. Effective from September 5, 2003, the Veteran's stress fracture, right foot, has been manifested by complaints of periodic pain and no objective findings. 6. Effective from September 5, 2003, the Veteran's stress fracture, left foot, has been manifested by complaints of periodic pain and no objective findings. 7. A left hip disability is not currently shown. 8. Bilateral hearing loss for the purpose of VA disability compensation is not currently shown. 9. Tinnitus is not currently shown. 10. A respiratory disorder is not currently shown. CONCLUSIONS OF LAW 1. From September 5, 2003, the criteria for entitlement to an initial evaluation in excess of 50 percent for the Veteran's major depressive episode have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9434 (2009). 2. From September 5, 2003, the criteria for assignment of an initial evaluation greater than 10 percent for septal nasal deviation have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97, Diagnostic Codes 6502, 6504 (2009). 3. The criteria for assignment of an initial compensable evaluation for a right wrist disability from September 5, 2003, to July 17, 2008, and in excess of 10 percent from July 18, 2008, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71, Diagnostic Code 5215. 4. The criteria for assignment of an initial compensable evaluation for a left wrist disability from September 5, 2003, to July 17, 2008, and in excess of 10 percent from July 18, 2008, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71, Diagnostic Code 5215. 5. For the period from September 5, 2003, the criteria for assignment of an initial compensable evaluation for stress fracture, right foot, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71, Diagnostic Codes 5283, 5284 (2009). 6. For the period from September 5, 2003, the criteria for assignment of an initial compensable evaluation for stress fracture, left foot, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71, Diagnostic Codes 5283, 5284 (2009). 7. The Veteran is not shown to have a left hip disability due to disease or injury that was incurred in or aggravated by active service; nor is left hip arthritis proximately due to, the result of or aggravated by his service-connected back disability. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306, 3.307, 3.309, 3.310 (2009). 8. Bilateral hearing loss was not incurred in or aggravated by service nor may sensorineural hearing loss be presumed to be. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2009). 9. Tinnitus was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2009). 10. A respiratory disease, claimed as due to exposure to asbestos, was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 Initially, the Board notes that, in November 2000, the Veterans Claims Assistance Act of 2000 (VCAA) was signed into law. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2009). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The United States Court of Appeals for Veterans Claims' (Court's) decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice, as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits. In this case, the RO furnished VCAA notice to the appellant regarding the issues on appeal in August 2004 which was prior to the November 2004 rating decision on appeal. Therefore, the timing of the notice complies with the express requirements of the law as found by the Court in Pelegrini. In specific regard to the claims for higher initial ratings, as these claims are downstream issues from that of service connection (for which the November 2004 VCAA letter was duly sent), another VCAA notice is not required. VAOPGCPREC 8- 2003. That notwithstanding, another VCAA letter was issued to the appellant in January 2008 pertaining to his claims for higher initial disability ratings. VA has fulfilled its duty to notify the appellant in this case. In the August 2004 and January 2008 letters, the RO informed the appellant of the evidence needed to substantiate his claims, and which party was responsible for obtaining the evidence. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353-56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the appellant to provide any evidence in the appellant's possession that pertains to the claim. 38 C.F.R. § 3.159(b)(1). Thus, the Board finds that the notice required by the VCAA and implementing regulations was furnished to the claimant and that no useful purpose would be served by delaying appellate review to send out additional VCAA notice letters. During the pendency of this appeal, on March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which 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. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Dingess/Hartman, supra. In this case, the Board finds that the appellant is not prejudiced by a decision at this time since he was notified of the disability rating and effective date elements in various letters including in September 2006. The Board also finds that all necessary assistance has been provided to the appellant including requesting pertinent medical records. In regard to VA medical records, the claims file contains a notation dated in June 2009 that there has been no additional VA medical center treatment since October 28, 2008. Thus, all pertinent VA medical records are on file. In addition, the appellant was afforded VA examinations in September 2004, July 2008 and December 2008. The Board finds that the examination findings were based on a thorough examination of the Veteran as well as a review of his medical history and complaints. The examiner noted the appellant's subjective complaints and objective findings were provided with sufficient detail in which to properly evaluate the Veteran's disabilities under the pertinent diagnostic codes with respect to his claims for higher initial ratings. Moreover, regarding the service connection claims, the examiners provided opinions that were based on a thorough examination of the appellant, the appellant's medical history and complaints, and objective findings. His claims file was reviewed in conjunction with the examinations. Therefore, the Board finds that these VA examination reports are adequate for rating purposes and new examinations are not required. See Barr v. Nicholson, 21 Vet. App. 303, 311 (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Also, the appellant was provided with the opportunity to testify at a Board hearing pursuant to his March 2007 request for a hearing, but he later cancelled his hearing request in June 2009. Under these circumstances, the Board finds that VA has fulfilled its duty to notify and assist the appellant in the claims under consideration and that adjudication of the claims at this juncture, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the appellant. See, e.g., Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The appeal is now ready to be considered on the merits. II. Analysis A. Increased Rating Claims 1. General Rating Provisions Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case as is this case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating by analogy is appropriate for an unlisted condition where a closely related condition, which approximates the anatomical localization, symptomatology, and functional impairment, is available. 38 C.F.R. § 4.20. In every instance where the Rating Schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. In evaluating the evidence and rendering a decision on the merits, the Board is required to assess the probative value of proffered evidence in the context of the record as a whole. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The probative value of medical evidence is based on numerous factors and determining the weight to be attached to such evidence is within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). 2. Entitlement to an Initial Evaluation in Excess of 50 Percent for Major Depressive Episode Facts During a VA examination in September 2004, that Veteran reported having significant depression since about 2002. He said he believed that it began after his medical conditions worsened and had been compounded by the murder of his girlfriend by her husband. He related his extreme depression and anxiety to his fears about his inability to work due to his medical problems. He worried that if he was having such problems at such a young age of 25, what was it going to be like when he got older. On examination the Veteran was casually dressed and appeared to have good grooming. He was alert and oriented times three with direct eye contact, but was noted to need several redirections in order to stay task oriented. His speech was unpressured, but talkative, and he had a tendency to derail into his current medical conditions and associated limitations. His affect was depressed and he was tearful on several occasions during the interview. His memory was grossly intact overall and he had fair to good judgment and insight. He did not have impairment in thought process/communication. He denied auditory hallucinations, but described vague, very unusual, visual hallucinations. Inappropriate behavior was not observed. The Veteran denied suicidal or homicidal ideation. He denied memory loss or impairment. He also denied panic attacks, but admitted to frequent daily depression which he assessed as a "4" on a scale from 1 to 10 (10 representing severe depression). Obsessive compulsive disorder symptoms were not elicited, although the Veteran was noted to have a tendency to become overly focused on a particular thing and had trouble derailing himself from the topic or behavior. He described his sleep as poor, but stated he was able to sleep between six and eight hours a night, and it took him one and a half hours to fall asleep. The examiner stated that the Veteran met the diagnostic criteria for major depressive episode, single episode, moderate, with the following symptoms: a depressed mood most of the day since 2002, significant difficulty falling asleep, frequent fatigue and difficulty concentrating, obvious feelings of worthlessness regarding his physical limitations and decrease in his ability to engage in unrestricted work and leisure activities. He was assigned a global assessment of functioning score (GAF) of 60. A VA mental health intake consult in June 2005 shows the Veteran's concern that he was not getting the proper care by VA and that he could not get a job because of orthopedic problems with his hip, back and leg. The Veteran reported that his only treatment for depression had been with VA. He noted that he had been "living in absolute misery". He admitted to irritability, sleep disturbances, a change in eating habits, weight change, deterioration in hygiene or grooming, loss of energy or interest in activities, social withdrawal, paranoid ideation and depression. He denied panic attacks, hallucinations, and psychosis. On examination the Veteran had "fair" dress, was fully alert, cooperative and angry. He had coherent thought content and his speech was rapid, pressured and loud at times. His thoughts were goal directed and he had a depressed and irritable mood. He was tearful at times. He was oriented times four with fair concentration and memory. He expressed hopelessness, worthlessness and helplessness. He was given an impression of depressive disorder most likely secondary to his chronic pain and medical problems, and history of MDD (major depressive disorder). He was assigned a current GAF of 50 and was noted to have a GAF of 55 the past year. VA outpatient records show that the Veteran was admitted as an inpatient in February 2006 after presenting with manic behavior. His behavior was described as labile, ranting, stuttering, crying, restless, short-of-breath and psychotic. He reportedly believed that a metal tube had been put into his skull during a recent laminectomy (performed on February 3, 2006). He was assessed by an attending physician as having bipolar type II (hypomaniac) versus substance-induced mood disorder (amphetamine-laced marijuana). He was given a GAF score of 60 and was discharged in March 2006 with a diagnosis of substance induced mood disorder, rule out. In an addendum discharge note, the Veteran was noted to be anxious about his discharge. The physician found that he was dischargeable though perhaps moving to the depressed phase of a bipolar disorder. A VA Medication Management record dated in September 2006 from the Mental Health Clinic reflects the Veteran's report that his mood was more stable. He described his appetite as "fine" and his sleep as "good". Findings revealed that the Veteran's affect was brighter and his thoughts were organized and goal directed. There was no evidence of psychosis and the Veteran denied suicidal or homicidal ideation. He as diagnosed as having dysthymia. An October 2006 VA Mental Health Clinic Psychotherapy record shows the Veteran's reports of ongoing problems with depression and motivation. He was noted to be euthymic and blunted with no suicidal or homicidal ideation. A VA Medication Management record dated in January 2007 from the Mental Health Clinic notes that the Veteran was continuing to do well with his current dose of medication and was able to socialize with friends. Findings showed that he was calm and appropriate with no suicidal or homicidal ideation. A VA mental health note shows that the Veteran was being seen in a follow up appointment in February 2008 and had last been seen in January 2007. He reported that his mood was much better and he had tapered off of his medication. He said he was doing well in school, but was still withdrawn and didn't socialize. He was noted to be doing well overall. On examination the Veteran was calm and appropriate with no suicidal or homicidal ideation. He had no auditory or visual hallucinations and his insight and judgment appeared intact. He was diagnosed as having depression, not otherwise specified. The Veteran reported during a VA psychiatric examination in December 2008 that he was no longer taking any psychotropic medication. He said that he had met with a VA psychiatrist in October 2008 and the last time he had an individual counseling session was in October 2006. He described his mood as "bland" and said he felt more depressed since the examiner had asked him about his murdered girlfriend. He said he experiences sadness, guilt feelings, feelings of being a failure, and has lost interest in other people and things. On examination he was oriented times three and his thought process and content were unremarkable. He had no delusions or hallucinations. Regarding judgment and insight respectively, the Veteran understood the outcome of behavior and understood that he had a problem. He did not have sleep impairment and did not exhibit inappropriate behavior. He did not have panic attacks or homicidal thoughts. Presently the Veteran had no suicidal thoughts and had good impulse control with no episodes of violence. He was able to maintain minimal hygiene and did not have a problem with activities of daily living. Regarding employment, the Veteran had not worked in five years and was under a VA contract to attend school and obtain an Associate's Degree beginning in the summer of 2008. The diagnosis was major depressive disorder; cannabis abuse; and alcohol abuse in sustained full remission. He was assigned a GAF of 65. During psychological testing the Veteran reported that he got along with his teachers and classmates, but had not made any new friends with his classmates. He reported having two close friends from service whom he had seen in the past two days and had not had a girlfriend since service. He said he played the guitar and had attended a family reunion three months earlier. He denied ever attempting suicide, but said he had contemplated it in early 2006 following back surgery. The examiner stated that the Veteran met the full diagnostic criteria for major depressive disorder, and his depression was of moderate severity. He said that it was the result of the Veteran's multiple medical problems, chronic pain and limitations on daily functioning. He went on to opine that it was the Veteran's medical conditions that prevented him from working, not his depression. The examiner denied that the Veteran's depression caused total occupational and social impairment or that it resulted in deficiencies in areas including judgment, thinking, family relations, work, mood or school. The examiner further remarked that the Veteran's mental disorder symptoms were not severe enough to interfere with occupational and social functioning. Pertinent Criteria and Discussion Under the pertinent criteria (set forth at 38 C.F.R. § 4.130, Diagnostic Codes 9411, 9434 (2009)) for rating mental disorders, a 50 percent rating is assigned for 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 complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned when 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 and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent schedular rating is warranted when 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. The GAF is a scale reflecting the psychological, social and occupational functioning under a hypothetical continuum of mental health-illness. See American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). According to the DSM-IV, a GAF score between 41 and 50 is reflective of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment of social, occupational, or school functioning (no friends, unable to keep a job); a GAF between 51 and 60 is indicative of 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 coworkers). A GAF between 61 and 70 is indicative of some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. The Board finds that the Veteran's major depressive episode symptoms do not more closely approximate the listed deficiencies and symptoms for a rating in excess of 50 percent under the pertinent rating criteria at any time during the duration of this appeal period. In this regard, the Veteran's predominant symptoms during the appeal period have included a depressed and irritable mood, tearfulness, difficulty falling asleep, concentration problems and rapid and pressured speech. As far at the specific criteria under Codes 9411, 9434, for a higher rating, to 70 percent, the Veteran has not been shown to have speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; or an inability to establish and maintain effective relationships. However, the Veteran was noted at the December 2008 VA examination to rinse out glasses for five minutes to get rid of the smell of detergent and to boil water in a pot for five minutes to get rid of the smell of soap in the pot. He also sometimes obsesses about mechanical engineering jobs, but this did not interfere with other areas of functioning. Thus, obsessional rituals are present. In addition, he has repeatedly denied panic attacks and psychosis and has been found to have an unimpaired thought process that was goal directed. Additional findings during the VA examinations in September 2004 and December 2008, as well as VA outpatient records from 2005 to 2007, show that the Veteran had good eye contact, good grooming, was oriented times three, and had fair insight and judgment. While findings repeatedly show that the Veteran had a depressed mood and was tearful at times, his depression has not affected his ability to function independently. Rather the VA examiner in December 2008 opined that the Veteran's mental disorder symptoms were not severe enough to interfere with occupational and social functioning. In addressing the specific criteria for rating mental disorders under VA's Rating Schedule, the VA examiner in December 2008 opined that the Veteran's mental disorder signs and symptoms did not result in deficiencies in areas to include judgment, thinking, family relations, work, mood or school. Both the December 2008 VA examiner and the September 2004 VA examiner assessed the Veteran's mental disorder symptoms as being moderate in severity. The presence of obsessive/ritualistic behavior is the only symptom present which is contemplated in a higher evaluation. The Veteran's GAF scores were recorded as 60 at the VA examination in September 2004, 50 during a VA mental health intake consult in June 2005, 60 at his hospital discharge in March 2006, and 65 at a VA examiner in December 2008. As is noted above, a GAF score between 61 and 70 is indicative of some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score between 51 and 60 is indicative of 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 coworkers), and a GAF between 41 and 50 is reflective of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (no friends, unable to keep a job). The Board finds that the Veteran's actual symptoms are most reflective of moderate symptoms and that his VA examination GAF scores of 60 and 65 are indeed consistent with a 50 percent rating. In further regard to social and occupational impairment, the Veteran was noted to get along with his professors and classmates in school although he said he had not made any new friends. He also reported during psychological testing in December 2008 that he had two close friends from service whom he had seen in the last two days and had attended a family reunion approximately three months earlier. Thus, he has clearly demonstrated some ability to establish and maintain effective relationships with people and does not meet the criteria for a 70 percent rating requiring an inability to establish and maintain effective relationships with people. In short, the Board finds that the Veteran's overall disability picture is most consistent with the criteria for a 50 percent evaluation rather than a 70 percent evaluation. In denying an initial evaluation greater than 50 percent for the Veteran's major depressive disorder, the Board has considered the concept of "staged" ratings pursuant to Fenderson, supra, but a review of the record shows no distinctive periods for which the required schedular criteria were met for a higher rating for this disability. Accordingly, the Board concludes that the preponderance of the evidence is against this claim, and it must be denied. As the preponderance of the evidence is against this claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b). 3. Initial Rating in Excess of 10 Percent for Nasal Septal Deviation Facts Service treatment records note that the Veteran had a history of trauma of a nasal fracture at age 8. These records also reflect the Veteran's complaints of difficulty moving the air through his left nostril. He underwent a septoplasty and rhinoplasty in October 2002. During a VA general examination in September 2004, the Veteran relayed to the examiner that he broke his nose at age 8 during an altercation with his brother. He said that in service he had trouble breathing though his right side, had septoplasty and rhinoplasty, but apparently did not have a good cosmetic outcome. He remarked that he breathed a little better though the right side of the nose, but that it was still crooked. He also reported off and on again sinus congestion and sinus pain in the ethmoid frontal sinus areas. On examination a nasal septal deviation was noted with slight frontal sinus tenderness. Oral mucosa was clear. The Veteran was diagnosed as having nasal septal deviation, x-ray normal; however, clinically the cartilage septum was fairly deviated. In May 2009, the Veteran was again evaluated by VA. The examiner noted that he had reviewed the Veteran's claims file and VA record prior to the examination. The examiner relayed that the Veteran had a septoplasty in 2001 and since that time had had a visual and functional continued deviation of the septum, and no recurring sinus infections. He did note that the Veteran had a leftward deviation of the ala, and when taking a deep breath, he closed off the left side ala. The Veteran expressed his interest at that time to have ear, nose and throat (ENT)-oriented treatment, or a plastic surgery consult to determine if he could have a revision of the previous surgery. Examination findings included closure of the "right" ala with deep breathing and occasional breathing difficulty. There was no nasal obstruction and no polyps, but there was septal deviation due to trauma. Facial examination revealed nasal asymmetry with tip twisting to the left. On further nasal examination the septal cartilage had a sigmoidal curvature at the caudal tip with deviation to the left causing the cosmetic deformity described above. The Veteran's previous septal incision from his 2001 surgery was well-healed, but evident on examination. The Veteran was noted to experience internal nasal valve collapse on deep inhalation. The Veteran was diagnosed as having nasal septal deviation post operative. This disability was noted to have no effects on the Veteran's usual daily activities. He was noted to be unemployed. The examiner explained that the Veteran did not have obstruction as much as he had a significant post-operative shaped deviation of the nasal septum, and left-sided shift of the middle nose. He remarked that since the 2001 surgery the Veteran had never sought reconstructive repair of his nose, but the deviation was currently bothersome and he was interested in follow up treatment evaluation to determine if a second surgery could be completed that might bring his septum more into alignment. Pertinent Criteria and Discussion The Veteran is presently evaluated as 10 percent disabled under Code 6504 which assigns a 10 percent rating for loss of part of one ala, or other obvious deformity. A 30 percent rating is assigned when both nasal passages are exposed. 38 C.F.R. § 4.97. As the findings from the May 2009 VA examination show, the Veteran has an obvious deformity described as a significant post-operative S-shaped deviation of the nasal septum and left sided shift of the middle nose. This deviation was described as "bothersome". These findings clearly approximate the Veteran's current 10 percent rating under Code 6504 for other obvious deformity. However, as both nasal passages are not exposed nor are the findings described above analogous to such a deformity, the Veteran does not meet the criteria for a 30 percent rating under Code 6504. Consideration has also been given to a rating under Code 6502 for deviation of the nasal septum, traumatic only, with a maximum 10 percent rating for 50-percent obstruction of the nasal passage on both sides or complete obstruction on one side. In regard to obstruction, the May 2009 examiner clarified that the Veteran did not have obstruction as much as he had a significant post-operative S-shaped deviation of the nasal septum and left-sided shift of the middle nose. As stated above, he is currently in receipt of a 10 percent rating under Code 5204 for the nasal deviation and left-sided shift. While the examiner did note that the Veteran closes off the left side ala when taking a deep breath, the Board does not find this manifestation to be of the duration or severity as to warrant a separate, compensable, 10 percent, rating under Code 6502. The May 2009 examiner further noted that the Veteran did not have recurring sinus infections. Therefore, consideration of his deviated nasal septum disability under the General Rating for Sinusitis under Codes 6510 through 6514 is not warranted. Based on the foregoing, the Board finds that the preponderance of the evidence is against a higher than 10 percent rating for the Veteran's deviated nasal septum at any stage of the rating period. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for an initial or staged rating in excess of 10 percent must be denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App 49 (1990). 4. Entitlement to an Initial Compensable Evaluation for Right and Left Wrist Instability Prior to July 18, 2008, and in Excess of 10 Percent From July 18, 2008. Facts Service treatment records show that the Veteran was treated for pain on his right hand after playing football. The examiner reported that he had full range of motion of the hand and x-rays were negative. These records also show that the Veteran was treated with an ace wrap on his left wrist status post left wrist pain from arm wrestling. He reported that his left wrist clicked when he grabbed things. The Veteran reported during a September 2004 VA general examination that he had chronic dislocations of both wrists against resistance which he thought was related to arm wrestling in service. He demonstrated to the examiner that he was able to forcefully dislocate both wrists and relocate them. He said the only problem with that was that when lifting heavy objects or lifting certain ways he had to be careful how he held his hands or they would dislocate at the wrists. He said he had no problem with them otherwise. On examination the Veteran had full range of motion of the upper extremities without pain. He was able to manually dislocate both wrists with ulnar deviation and relocate them immediately. He had full range of motion of both hands and wrists without any pain, deformity, laxity, instability, and no fixed deformities other than what he showed the examiner. He was diagnosed as having bilateral wrist instability, normal x-ray. A September 2006 VA outpatient record notes that the Veteran had a history of right wrist recurrent dislocation, but did not want surgery since it only happened occasionally. Findings revealed that the radius and ulna were mobile with respect to the joint. The Veteran was assessed as having wrist instability, recurrent. The Veteran reported during a July 2008 VA orthopedic examination that his wrist disability had stayed about the same since its onset, meaning that it had not gotten better or worse. Range of motion findings included dorsiflexion (extension) of 0 to 70 degrees on the left with pain at 70 degrees and 0 to 65 degrees on the right with pain at 65 degrees. Palmar flexion was 0 to 75 degrees on the left and right with pain at 75 degrees. Following repetitive use, there was no additional limitation of motion, weakness, fatigue, or incoordination noted. There was no joint ankylosis. X-rays of the right wrist revealed a normal wrist. The Veteran was diagnosed as having bilateral limited range of motion of the wrists, bilateral wrist strain. This disability was noted to significantly affect occupational activities due to pain and problems lifting and carrying things. It was noted to have mild to moderate effects on the Veteran's activities of daily living. Pertinent Criteria and Discussion The Veteran's service-connected right and left wrist disabilities have been rated by the RO under the provisions of Diagnostic Code 5215. Under this regulatory provision, a 10 percent rating is warranted for dorsiflexion that is limited to less than 15 degrees; or palmar flexion limited in line with the forearm. Normal range of wrist motion is from zero to 70 degrees in dorsiflexion (extension) and zero to 80 degrees in palmar flexion. 38 C.F.R. § 4.71, Plate I. The pertinent evidence on file for the period prior to July 18, 2008, consists of the September 2004 VA general examination showing that the Veteran had full and painless ranges of motion in both wrists. The predominant manifestation of his wrist disabilities was wrist instability. This required that the Veteran be careful when lifting objects so as to avoid dislocating his wrists. He denied any other wrist problems other than those times. There is also the September 2006 VA outpatient record noting that the Veteran had a history of right wrist recurrent dislocation, but did not want surgery since it only happened occasionally. Findings revealed that the radius and ulna were mobile with respect to the joint. In view of the periodic nature of the Veteran's right and left wrist instability and the full, painless, range of motion he demonstrated in each wrist at the September 2004 VA examination, the Board finds that the Veteran's right and left wrist disabilities are appropriately rated as noncompensably disabled for the period from September 5, 2003, to July 17, 2008. That is, though the Veteran's right and left wrist instability is duly noted, such findings do not rise to the severity as to be analogous to a compensable, 10 percent, rating under Code 5215 for dorsiflexion that is limited to less than 15 degrees; or palmar flexion limited in line with the forearm. As noted above, findings at the July 18, 2008, VA examination show normal to slight limitation of motion of the right and left wrists with pain. Other than pain, the examiner noted that there were no functional limitations due to repetitive motion, weakness, fatigue or incoordination. However, the examiner did note that the Veteran's wrist limitations would significantly affect occupational activities due to pain and problems lifting and carrying things. Thus, although the Veteran's demonstrated dorsiflexion (extension) from 0 to 70 degrees on the left and 0 to 65 degrees on the right, and palmar flexion from 0 to 75 degrees on the left and 0 to 70 degrees on the right, do not approximate the criteria under Code 5215 for a compensable, 10 percent, rating based on a strict adherence to the rating criteria, the Board agrees that his pain and functional limitations warrant a compensable, 10 percent, rating for each wrist. 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra. As 10 percent is the maximum allocable rating under Code 5215, a higher rating is not warranted. See Johnston v. Brown, 10 Vet. App. 80 (1997). Consideration of a higher than 10 percent rating has been considered under Code 5214. Under this code a rating of 30 percent is warranted for favorable ankylosis of the dominant wrist in 20 degrees to 30 degrees of dorsiflexion ; a 20 percent rating is warranted for the minor side. A rating of 40 percent for the dominant wrist or 30 percent for the minor side is warranted for ankylosis in any other position, except favorable. A rating of 50 percent for the dominant wrist or 40 percent for the minor side is warranted for unfavorable ankylosis in any degree of palmar flexion, or with ulnar or radial deviation. As there is no evidence in this case that Veteran's right and left wrist disabilities have been manifested by wrist ankylosis, a higher rating under Code 5214 is not warranted. In this regard, the VA examiner in July 2008 specifically noted that there was no joint ankylosis. Based on the foregoing, the Board finds that the preponderance of the evidence is against compensable ratings for the Veteran's right and left wrist disabilities at any stage of the rating period from September 5, 2003, to July 17, 2008. The Board also finds that the preponderance of the evidence is against higher than 10 percent ratings for the Veteran's right and left wrist disabilities at any stage of the rating period from July 18, 2008. As the preponderance of the evidence is against these claims, the benefit-of-the- doubt doctrine does not apply, and the claims must be denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App 49 (1990). 5. Entitlement to an Initial Compensable Evaluation for Right and Left Foot Stress Fractures Facts Service treatment records show the Veteran had a nondisplaced fracture mid portion of the right second metatarsal bone of his right foot that required casting and a fracture of the 4th metatarsal fracture on the right requiring a cast and cam walker. During a VA general medical examination in September 2004, the Veteran reported that he fractured his left foot in Boot Camp and was told he had stress fractures. He was noted to have no residual problems. With respect to his right foot, he reported that he had several stress fractures of the right foot in service and said he was also told he had metatarsal stress fractures. He was noted to have no residuals from that either. On examination the Veteran had full range of motion of the joints of the lower extremities with no palpable deformities on either foot. His gait was intact. He was given an impression of stress fractures, right and left feet, resolved without residuals. X-rays normal. In September 2007, the Veteran was seen in a VA emergency department complaining of a pain across the mid arch of his right foot with no trauma to the foot. His skin was intact. Findings revealed tenderness in the arch of the right foot and a stable ankle, foot joint. The Veteran was diagnosed as having foot pain and advised to use medication, rest, heat and an ace bandage. An x-ray report of the right foot in September 2007 notes a one week history of right foot pain. The impression given was mild bunion deformity without acute change. The Veteran reported during a VA orthopedic examination in July 2008 that he experienced foot pain flare-ups that were most precipitated by moist weather and cold weather. He said he alleviated the pain by massage and sitting "Indian Style". The report also notes that this had no impact in general on the Veteran's daily activities or occupation. He was not given a foot examination at that time. Regarding a diagnosis, the report notes a prior fracture of the metatarsals bilaterally per the Veteran. Current x-rays were noted as showing no evidence of fracture or degenerative joint disease. The Veteran reported during a May 2009 VA examination that he was currently attending school and did not have to be on his feet as much he used to and, therefore, he did not have the level of pain he had had several years earlier when he was more active. He said that in the event he had to be on his feet for 2 to 3 hours a day for work, the pain would return. The examiner summarized by stating that currently the Veteran was not experiencing foot or toe pain and was sedentary due to school. He further noted that the Veteran's feet had been in "good condition". It is noted on examination that there was no abnormal weight bearing and no restriction in the movement of the Veteran's toes. X-rays of the Veteran's feet revealed no osseous or articular abnormalities of the left foot, i.e., a normal left foot, and stable mild bunion formation of the right foot. The Veteran was diagnosed as having periodic metatarsalgia. This problem was not found to affect the Veteran's usual daily activities. Pertinent Criteria and Discussion The veteran's service-connected right and left foot disabilities have been rated by the RO under the provisions of 38 C.F.R. § 4.71, Diagnostic Code 5284 (governing foot injuries). Under this regulatory provision, a 10 percent rating is warranted for moderate foot injuries; a 20 percent rating is warranted for moderately severe foot injuries; and a 30 percent rating is warranted for severe foot injuries. Actual loss of use of the foot warrants a 40 percent rating. The Board also notes that Diagnostic Code 5283 governs malunion or nonunion of the tarsal or metatarsal bones. The rating criteria are identical to Diagnostic Code 5284. The sole manifestation of the Veteran's right and left foot disabilities as reported by the Veteran is periodic pain. VA treatment records show that the Veteran was treated for complaints of foot pain on one occasion, in September 2007. In this regard, the Veteran was seen in a VA emergency department at that time complaining of a pain across the mid arch of his right foot with no trauma to the foot. Findings revealed tenderness in the arch of the right foot and a stable ankle, foot joint. The Veteran was diagnosed as having foot pain and advised to use medication, rest, heat and an ace bandage. An x-ray report of the right foot in September 2007 noted a one week history of right foot pain. The impression given was mild bunion deformity without acute change. As far as objective findings regarding the Veteran's foot disabilities, there are none on file other than the sole finding of tenderness in September 2007. At a VA general medical examination in September 2004, the Veteran was noted to have no foot residuals. He had full range of motion of the joints of the lower extremities on examination with no palpable deformities on either foot. His gait was intact. He was given an impression of stress fractures, right and left feet, resolved without residuals. X-rays normal. At a VA examination in July 2008, the Veteran said he experienced foot pain flare-ups that were most precipitated by moist weather and cold weather and he alleviated the pain by massage and sitting "Indian Style". Though the Veteran was not given a foot examination at this time, the examination report notes that the Veteran's foot complaints had no impact in general on his daily activities or occupation. Current x- rays were noted as showing no evidence of fracture or degenerative joint disease. At the most recent VA examination in May 2009, the Veteran reported that the pain was not as bad as it had been in the past several years since the Veteran was in school and not as active as he had been. The examiner summarized by stating that currently the Veteran was not experiencing foot or toe pain and was sedentary due to school. He further noted that the Veteran's feet had been in "good condition". It is noted on examination that there was no abnormal weight bearing and no restriction in the movement of the Veteran's toes. X-rays of the Veteran's feet revealed no osseous or articular abnormalities of the left foot, i.e., a normal left foot, and stable mild bunion formation of the right foot. The Veteran was diagnosed as having periodic metatarsalgia. This problem was not found to affect the Veteran's usual daily activities. In short, there is no persuasive medical evidence to suggest that the Veteran's right and/or left foot disabilities are manifested by moderate symptoms. The Board also points out that there is no x-ray evidence of arthritis. Accordingly, there is no basis for assigning a minimum 10 percent rating based on such pain and noncompensable limitation of motion under Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991); see also Hicks v. Brown, 8 Vet. App. 417 (1995). As the preponderance of the evidence is against the claims for initial compensable ratings for stress fractures of the right and left feet, the benefit-of-the-doubt doctrine does not apply, and the claims must be denied. 38 U.S.C.A. § 5107; See Gilbert v. Derwinski, 1 Vet. App 49 (1990). 6. Extraschedular Consideration Finally, the Board would point out that the rating schedule represents as far as practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b) (2009). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). The Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. In regard to the increased initial rating claims discussed above, the Board finds that the rating criteria for each disability reasonably describe the Veteran's level of disability and symptomatology and his evaluations are adequate. Thus, referral for consideration of extraschedular ratings is not warranted. B. Service Connection Claims 1. Law and Regulations Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in active service. 38 U.S.C.A. § 1110 (West 2002). That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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, including arthritis and sensorineural hearing loss, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2009). Further, when aggravation of a nonservice-connected condition is proximately due to or the result of a service- connected condition, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). There must be competent evidence showing the following: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and a disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247 (1999). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107 (West 2002). 2. Entitlement to Service Connection for a Left Hip Disability, Claimed as Secondary to Service-Connected Back Disability. Facts The Veteran's service treatment records show complaints in August 2001 of low back pain on the left side for two days after picking up trash with pain down the left lower extremity. The Veteran was assessed as having possible sciatica. A November 2001 record contains a provisional diagnosis of possible sacroiliac joint dysfunction. The Veteran reported at that time that the pain began with a broken foot on the left and walking in a CAM walker. The Veteran was given home exercises to perform, including hip exercises. He was also seen in March 2002 and August 2002 for low back pain with pain radiating down the posterior left leg into the calf. The Veteran was assessed as having low back pain with radiculopathy. These records are devoid of a hip diagnosis. In May 2004, the Veteran filed a claim of entitlement to service connection for "left hip pain and misaligned bone" asserting that the condition began in 2002. He explained that he hurt his hip walking and working with a CAM walker. During a VA general medical examination in September 2004, the Veteran reported that his left hip pain was his biggest problem and he wanted to find out what was wrong with it and get it fixed. He said that his hip first started bothering him after his series of stress fractures on the right foot in which he had to wear a cast and then a cast boot. He said he thought that the cast-walking boot made him walk funny causing him some kind of back or hip problem. He described a pinching type of sensation and said it radiated from his back through the left hip and into the buttocks area. He said his diagnosis at one time had been mechanical low back pain with left sacroiliac joint dysfunction. He denied any specific injury. On examination the Veteran had a fair amount of discomfort with range of motion and pain in the left lower back, sacroiliac, and hip area. No palpable deformity was noted. The Veteran reported a burning stabbing sensation through the hip and buttocks. He was given an impression of chronic left hip pain. X-rays showed a normal left hip, pelvis and lumbar spine. The examiner stated that there was insufficient clinical evidence at present to warrant a diagnosis of any acute or chronic disorder or residual thereof. He further stated that there was insufficient clinical evidence or documentation to provide an acute or chronic diagnosis. VA outpatient records show that the Veteran reported to a VA emergency room in December 2004 complaining of left hip pain. It was noted that he had been seen previously for this. His history included a service injury to the left hip diagnosed as sciatic nerve pain left hip, with no surgery or fracture to the hip, and no falls, heat or swelling to the hip. On examination there was tenderness of the left hip, normal muscle bulk/tone and a stable left hip joint. A January 2005 VA PCC Consult note shows that the Veteran had had right hip pain since 2001 and localized pain in the left hip area with no radiation. Findings included tenderness in the left hip area, pain on internal rotation of the hip, negative leg raising and strength of 5/5. There were normal sensory findings. An assessment was given of "chronic hip pain no signs of radiculopathy? Origin hip joint? Occult fx?" A VA physical therapy outpatient record in March 2005 reflects the Veteran's chief complaint of left hip pain and back problems. Impressions on bone imaging revealed no evidence of occult fracture involving left hip and normal lumbar spine. On file is an April 2005 VA physical therapy discharge summary showing that the Veteran was being discharged from therapy after two sessions for the reason that there was "no indication for therapy intervention". In May 2005, the Veteran was seen in a VA emergency room complaining of low back pain with sciatic nerve problems for the past several months. He reported that he had been unable to work for two years due to these problems. He was diagnosed as having mechanical low back pain with sciatica. The Veteran attended a VA neurological consult in May 2005 for left hip and gluteal pain. The Veteran reported that the pain began in 2002 when he was in a cast and cane walker and started working in his yard picking up leaves. A bone scan was noted as showing no evidence of occult fracture involving the left hip. The Veteran was assessed as having low back pain and left hip pain. An MRI was ordered of the lumbosacral spine and if negative, EMGS (electromyelograms) were recommended as well as a possible pain management referral. A magnetic imaging resonance (MRI) of the lumbar spine performed in May 2005 revealed a large posterior disc extrusion at L4-L5 with inferior migration extending into the left lateral recess touching the L4 nerve root. It also appeared by physical examination that there were some sensory changes in the left lower extremity in the L5 distribution as well as L4. A June 2005 VA neurosurgery consult record reflects the Veteran's report of worsening left hip pain since April 2005. The examiner reported that the Veteran had a somewhat exaggerated examination, but that this may be from his chronic pain in length of time til diagnosis as reported by the Veteran. He noted that MRI showed a disc herniation to the 4-5 level and indicated that he had discussed with the Veteran the possible need for surgical intervention including bilateral microsurgical discectomy. A follow-up neurology clinic record in June 2005 reflects the Veterans complaint that his back was not hurting him, but that he was experiencing pain down his left leg to his left calf. He was diagnosed as having L4/5 radiculopathy. A VA outpatient record in July 2005 shows that the Veteran was examined for continuing complaints of chronic low back and left hip pain with bilateral lower extremity radiculopathy. He was assessed as having chronic low back pain and bilateral L4 radiculopathy left much worse than right due to large posterior disc extrusion at L4-5 with inferior migration extending into the left lateral recess touching L4 nerve root. The examiner noted that by physical exam it appeared that the Veteran had some sensory changes in the left lower extremity in the L5 distribution as well as L4. In a statement dated in October 2006, the Veteran said that his herniated disc in his spine was the direct cause of his hip pain and not a hip deformity and that it took three years after his separation from service to get a proper diagnosis. He went on to state that he hoped the information would help get his claim granted. In July 2008, the Veteran underwent a VA orthopedic examination. He reported at that time that his hips hurt when his back was hurting. After noting that he had reviewed the Veteran's claims file and examining him, the examiner opined that there was insufficient clinical evidence at that time to warrant a diagnosis of any acute or chronic disorder of the hips or residuals thereof. He went on to opine that most likely the pain in the hip area was a result of radiating pain secondary to the degenerative disease of the lumbosacral spine. He concluded by stating that there was no evidence of a specific degenerative disorder of the hips. Discussion The Veteran's complaints of left hip pain are well documented in the claims file, beginning in service. However, upon review of the evidence of record, the Board finds that there is no current diagnosis of a bilateral hip disability. In this regard, in addressing the question of whether the Veteran had a hip diagnosis during a September 2004 VA examination, the examiner stated that there was insufficient clinical evidence at present to warrant a diagnosis of any acute or chronic disorder or residual thereof, and insufficient clinical evidence or documentation to provide an acute or chronic diagnosis. X-rays showed a normal left hip, pelvis and lumbar spine. The examiner gave an impression of chronic left hip pain. The VA examiner in July 2008 gave a similar opinion. After noting that he had reviewed the Veteran's claims file and had examined the Veteran, the examiner opined that there was insufficient clinical evidence at that time to warrant a diagnosis of any acute or chronic disorder of the hips or residuals thereof. He went on to opine that most likely the pain in the hip area was a result of radiating pain secondary to the degenerative disease of the lumbosacral spine. He concluded by stating that there was no evidence of a specific degenerative disorder of the hips. The VA outpatient records on file are likewise devoid of any specific hip diagnosis. In fact, a January 2005 VA PCC consult note contains more questions than answers given the assessment of "chronic hip pain no signs of radiculopathy? Origin hip joint? Occult fx?" Records in July 2005 reflect diagnoses of chronic low back pain and bilateral L4 radiculopathy left much worse than right due to large posterior disc extrusion at L4-5 with inferior migration extending into the left lateral recess touching L4 nerve root. Regarding this diagnosis, it is pertinent to note that the Veteran is presently service-connected for L4-5 herniated disc, status post L4 laminectomy; lumbar spine. In the absence of proof of a present disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board recognizes that the Veteran has repeatedly complained of left hip pain, but notes that symptoms, such as pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), vacated in part and remanded on other grounds sub nom. Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001)). Based on the foregoing, the Board must conclude that the requirements for establishing service connection on a direct, presumptive or secondary basis have not been met for the simple reason that the Veteran does not have the disability that he claims. That is, he has not been shown by the evidence to have a separate and distinct left hip disability. See 38 C.F.R. § 3.303; Hickson, supra; Brammer, supra. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107, Gilbert v. Derwinski, 1 Vet. App 49 (1990). 3. Entitlement to Service Connection for Hearing Loss and Tinnitus Facts The Veteran's June 1999 pre-enlistment examination report shows hearing acuity in puretone threshold levels of 5, 0, 10, 5, 5 and 10 decibels in the right ear and 20, 10, 20, 15, 10 and 25 decibel levels in the left ear at 500, 1000, 2000, 3000, 4000 and 6000 hertz, respectively. The Veteran denied a history of hearing loss on a June 1999 Report of Medical History. A service medical treatment record dated in June 2000 shows that the Veteran had been issued hearing protection bilaterally. Inservice audiograms dated in October 1999, October 2001 and November 2002 show that the Veteran's puretone hearing threshold levels were 20 decibels or less from 500 to 6000 Hertz. These records also note that the Veteran had routinely been exposed to noise. A September 2002 audiogram report shows puretone threshold levels of 20, 20, 20, 20, 25 and 20 decibels in the left ear and 25, 25, 30, 25, 25 and 35 decibels in the right ear at 500, 1000, 2000, 3000, 4000 and 6000 hertz respectively. This report likewise notes that the Veteran had routine noise exposure. In addition, this report notes "positive STS" and includes the Veteran's signed notation that he was aware of a change in his hearing and the need to return for further follow-up. The Veteran underwent a VA audiological examination in September 2004 where he reported that he did not seem to hear as well as he once did and that during conversational situations he sometimes needed repetitions. He reported inservice exposure to high-intensity noise from working in the engine rooms aboard military ships. He said he always wore ear protection, but the protection did not fit as well in one ear. He went on to report that he experienced occasional tinnitus, but denied that it was bothersome. He reported postservice occupational noise exposure on occasion during his three year employment as a floor stripper. On the authorized audiological evaluation in September 2004, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 20 15 15 LEFT 15 15 20 15 15 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 100 percent in the left ear. The audiologist stated that audiologic test results indicated that hearing thresholds were within normal limits for both ears for test frequencies from 500 to 4000 Hz and that therefore there was no hearing disability present at that time. The examiner did not diagnose the Veteran as having tinnitus. During a VA examination in July 2008, the Veteran reported that in addition to noise exposure to turbine engines aboard ship, there was an incident aboard ship when he went on deck without ear protection while a large gun fire exercise was going on. He denied a history of tinnitus. On the authorized audiological examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 10 10 LEFT 15 10 15 15 15 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 100 percent in the left ear. The examiner stated that audiological results revealed hearing thresholds within normal limits at 250 to 8000 Hz and the Veteran had clinically normal hearing. In regard to tinnitus, the examiner stated that the Veteran denied the existence of tinnitus. Discussion Under 38 C.F.R. § 3.385, for the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. In this case, there is no evidence showing that the Veteran has met VA's definition of hearing impairment as defined in 38 C.F.R. § 3.385 above, either in service or after service. Although "STS" was noted during service in September 2002 requiring audiological follow up, there was no evidence of hearing impairment as defined by VA at that time or any other time thereafter, either in service or after service. Rather, postservice VA audiological examinations performed in September 2004 and July 2008 show normal hearing bilaterally, with puretone threshold levels at 20 decibels or less from 500 to 4000 hertz. These findings simply do not meet VA's regulatory provisions for hearing impairment under 38 C.F.R. § 3.385. Moreover, these VA examiners interpreted the results as revealing hearing thresholds within normal limits at 250 Hz to 8000 Hz, bilaterally. With respect to tinnitus, the evidence does not show that the Veteran has been diagnosed as having this disability either in service or after service. Although the Veteran reported during the September 2004 VA examination that he had tinnitus on occasion that was not bothersome, he was neither diagnosed as having tinnitus by that examiner nor by the July 2008 VA examiner. In fact, the Veteran denied having a history of tinnitus at the July 2008 VA audiological examination. Thus, the only evidence of the Veteran presently having a hearing loss disability related to service is the Veteran's assertions to this affect. While the Veteran may make assertions regarding symptoms he perceives to be manifestations of disabilities, the question of whether he has a present hearing loss impairment (as defined by VA regulation) and tinnitus related to service is one that requires skill in diagnosis, and questions involving diagnostic skills must be made by medical experts. See 38 C.F.R. § 3.159; Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As the Board may consider only independent medical evidence to support its findings as to a current medical diagnosis, which is not capable of lay observation, and as there is no favorable medical evidence of a current hearing loss under 38 C.F.R. § 3.385 or of tinnitus, the preponderance of the evidence is against the claims, and the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. at 55. 4. Entitlement to Service Connection for an Unspecified Disability, Claimed as Due to Exposure to Asbestos. As to asbestos-related diseases, the Board notes there are no laws or regulations specifically dealing with asbestos and service connection. However, the VA Adjudication Procedure Manual, M21-1 (M21-1), and opinions of the United States Court of Appeals for Veterans Claims (Court) and General Counsel provide guidance in adjudicating these claims. In McGinty v. Brown, the Court observed that there has been no specific statutory guidance with regard to claims for service connection for asbestosis and other asbestos-related diseases, nor has the Secretary promulgated any regulations. McGinty v. Brown, 4 Vet. App. 428, 432 (1993). However, VA has issued a circular on asbestos-related diseases, entitled Department of Veterans Benefits, Veteran's Administration, DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988) (DVB Circular), that provides some guidelines for considering compensation claims based on exposure to asbestos. Id. The DVB circular was subsumed verbatim as § 7.21 of Adjudication Procedure Manual, M21-1, Part VI. (This has now been reclassified in a revision to the Manual at M21- 1MR, Part IV, Subpart ii, Chapter 2, Section C.) See also VAOPGCPREC 4-00 (Apr. 13, 2000). The applicable section of Adjudication Procedure Manual M21-1 notes that inhalation of asbestos fibers can produce fibrosis and tumors. The most common disease is interstitial pulmonary fibrosis (asbestosis). Asbestos fibers may also produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, lung cancer, and cancers of the gastrointestinal tract. Cancers of the larynx and pharynx as well as the urogenital system (except the prostate) are also associated with asbestos exposure. See Adjudication Procedure Manual, M21-1, Part VI, 7.21(a)(1). Some of the major occupations involving exposure to asbestos include mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, manufacture and installation of roofing and flooring materials, asbestos cement sheet and pipe products, military equipment, etc. Exposure to any simple type of asbestos is unusual except in mines and mills where the raw materials are produced. See id. at 7.21(b)(1). The latent period for asbestos-related diseases varies from 10 to 45 or more years between first exposure and development of disease. Also of significance is that the exposure to asbestos may be brief (as little as a month or two) or indirect (bystander disease). See id. at 7.21(b)(2). "Asbestosis is pneumoconiosis due to asbestos particles; pneumoconiosis is a disease of the lungs caused by the habitual inhalation of irritant mineral or metallic particles." McGinty, 4 Vet. App. at 429. The clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. Symptoms and signs may include dyspnea on exertion and end-respiratory rales over the lower lobes. Clubbing of the fingers occurs at late stages of the disease. Pulmonary function impairment and cor pulmonale can be demonstrated by instrumental methods. Compensatory emphysema may also be evident. See Adjudication Procedure Manual, M21-1, Part VI, 7.21(c). Neither the Manual M21-1 nor the DVB Circular creates a presumption of exposure to asbestos solely from a particular occupation. Rather, they are guidelines which serve to inform and educate adjudicators as to the high exposure of asbestos and the prevalence of disease found in particular occupations, and they direct that the raters develop the record; ascertain whether there is evidence of exposure before, during, or after service; and determine whether the disease is related to the putative exposure. See Dyment v. West, 13 Vet. App. 141, 146 (1999); see also Nolen v. West, 12 Vet. App. 347 (1999); VAOPGCPREC 4-2000. In this case, there is no evidence to indicate that the Veteran has been diagnosed as having asbestosis or any other asbestos-related disease. Moreover, the Veteran has failed to identify or submit any medical evidence showing that he currently has a respiratory disease. See Brammer, supra. This is despite VA letters to him dated in January 2008 and April 2009 asking that he inform VA of the specific disease he believes is a result of asbestos exposure and provide supportive medical evidence. Thus, as the evidence of record fails to show a current asbestos-related and/or respiratory disease, the Board concludes that service connection is not warranted. See Hickson v. West, 12 Vet. App. at 247. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. at 55. (CONTINUED ON NEXT PAGE) ORDER Entitlement to an initial evaluation in excess of 50 percent for major depressive episode is denied. Entitlement to an initial evaluation in excess of 10 percent for nasal septal deviation is denied. Entitlement to an initial compensable evaluation for right wrist instability prior to July 18, 2008, and in excess of 10 percent from July 18, 2008, is denied. Entitlement to an initial compensable evaluation for left wrist instability prior to July 18, 2008, and in excess of 10 percent from July 18, 2008, is denied. Entitlement to an initial compensable evaluation for right foot stress fracture is denied. Entitlement to an initial compensable evaluation for left foot stress fracture is denied. Entitlement to service connection for a left hip disability, claimed as secondary to service-connected back disability, is denied. Entitlement to service connection for hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for an unspecified disability, claimed as due to exposure to asbestos, is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs