Citation Nr: 1134945 Decision Date: 09/19/11 Archive Date: 09/23/11 DOCKET NO. 09-01 209 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for the residuals of removal of bilateral great toes. 2. Entitlement to service connection for bilateral femur stress fractures. 3. Entitlement to service connection for residual of lymph node removal, right groin. 4. Entitlement to service connection for acne. 5. Entitlement to service connection for fatigue. 6. Entitlement to service connection for a disability involving blood in the urine. 7. Entitlement to service connection for a bilateral eye disability. 8. Entitlement to service connection for a right ear condition. 9. Entitlement to service connection for a right shoulder disability. 10. Entitlement to service connection for a cervical spine disability. 11. Entitlement to service connection for a bilateral wrist disability. 12. Entitlement to service connection for a bilateral knee disability. 13. Entitlement to service connection for a left ankle disability. 14. Entitlement to service connection for bilateral pes planus. 15. Entitlement to an initial evaluation greater than 10 percent for residuals of left index finger laceration. 16. Entitlement to an initial compensable evaluation for hammertoe of the 2nd right foot. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L.J. Bakke, Counsel INTRODUCTION The veteran served on active duty from July 1986 to April 1992. This appeal arises before the Board of Veterans' Appeals (Board) from a rating decision rendered in October 2007 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The veteran testified at the RO before the undersigned in April 2011. A transcript of the hearing is associated with the claims file. During the pendency of this appeal, service connection for wart, left thumb status post removal and plantar fasciitis, right foot was granted. Each disability was evaluated as noncompensable, effective in April 2007. The claims file does not reflect that the Veteran has appealed either the effective date or the evaluation assigned to these disabilities. These issues are therefore not for consideration herein. The issues of service connection for a disability involving blood in the urine, bilateral eye disability, right ear condition, and for right shoulder, cervical spine, bilateral wrist, bilateral knee and left ankle disabilities and for bilateral pes planus are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The medical evidence shows the Veteran manifests residuals of bilateral great toe removal that have been found to be the result of active service. 2. The medical evidence does not establish that the Veteran is diagnosed with a disability of the left or right femur. 3. The medical evidence does not establish that the Veteran manifests residuals of lymph node removal, right groin. 4. The medical evidence does not establish that the Veteran is diagnosed with acne. 5. The medical evidence does not establish that the Veteran is diagnosed with a condition manifested by fatigue. 6. The medical evidence reflects that the service connected residuals of left index finger laceration are manifested by a hypopigmented, painful scar measuring .3 by 1.8 centimeters. 7. The medical evidence reflects that the service connected residuals of left index finger laceration approximate limitation of a gap of one inches or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible; range of motion measurement at zero to 60 degrees at the most restricted with consideration for pain and pain on motion; and clinical findings of no bone pathology. 8. The medical evidence reflects that the service-connected hammertoe of the 2nd right foot is manifested by hammertoe deformity in only one toe. CONCLUSIONS OF LAW 1. The criteria for service connection for the residuals of bilateral great toe removal have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 2. The criteria for service connection for bilateral femur stress fractures have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 3. The criteria for service connection for residual of lymph node removal, right groin have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 4. The criteria for service connection for acne have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 5. The criteria for service connection for fatigue have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). 6. The criteria for an initial evaluation greater than 10 percent for a painful scar of the left index finger laceration have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5229-7804 (2010). 7. The criteria for an initial evaluation of 10 percent and no greater for residuals of left index finger laceration manifested by limitation of motion beginning March 25, 2010, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5229-7804 (2010). 8. The criteria for an initial compensable evaluation for hammertoe of the 2nd right foot have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5282 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2010), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2010), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but do not require that VA provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. VA must also notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA must specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. In the present case, correspondence dated July 2007 satisfied the duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2010). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate his service connection claims, information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. In that same correspondence, the RO additionally notified the Veteran of the process by which initial disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Concerning the issues of higher disability evaluations for the left index finger and right hammertoe disabilities, these issues are "downstream" issues. Once a decision awarding service connection, a disability rating, and an effective date has been made, section 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated. Sutton v. Nicholson, 20 Vet. App. 419 (2006) (citing Dingess). The Board therefore concludes that VCAA notice requirements have been satisfied with respect to the issue on appeal. With respect to the duty to assist, VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2010). Service treatment records have been associated with the claims file. Identified VA treatment records for treatment received from 1992 to 1994 from VA Medical Center (MC) Shreveport, Louisiana, and from 2003-2005 from VAMC Gainesville, Florida have not been obtained. In addition, records from a motor vehicle accident (MVA) in 2007 have not been obtained. However, concerning the issues of service connection herein adjudicated, these records would not be relevant, as medical evidence does not show that the Veteran has been diagnosed with or treated for the conditions claimed contemporaneously with or subsequent to the date of claim in 2007. All other identified and available post-service treatment records have been secured, including other identified VA and private outpatient treatment records. The Veteran was provided with VA examinations in December 2007 and March 2010. The December 2007 VA and March 2010 examinations indicate that the examiners reviewed the Veteran's claim file and past medical history, recorded current complaints, conducted an appropriate evaluation, and rendered appropriate diagnoses and opinion consistent with the remainder of the evidence of record. Thus, the Board concludes that these examination reports are adequate for the purposes of rendering a decision as to the Veteran's claims. See 38 C.F.R. § 4.2 (2010); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and his representative have not contended otherwise. Thus, the duties to notify and assist have been met. I. Service Connection In general, service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2010). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2010). The Veteran testified in April 2011 that he received treatment for his claimed conditions during active service. Specifically, he testified that he underwent removal of his great toenails and a lymph node in his right groin, and was treated for bilateral femur stress fractures, acne, and fatigue during active service, and that he has been treated for these conditions from his discharge to the present. a) Residuals of Bilateral Great Toenail Removal The Veteran's reports of medical history and examination at entrance to active service in November 1985 reflect no findings of any toenail defect, diagnosis or other abnormalities. Service treatment records, however, reveal that during active service the Veteran was treated for a partially detached right toenail due to trauma and an ingrown left toenail in 1988. Records indicate that his right toenail was surgically removed. There is no report of medical history or examination at discharge. Post-service VA treatment records show the Veteran was treated for tinea pedis and was found to have dystrophic toenails as early as 2006. In 2007, the toenails were electrically debrided. The physician, a Doctor of Podiatric Medicine, or D.P.M., opined that the Veteran had deformed dystrophic toenails related to the trauma of combat boots received in the military. A subsequent entry in 2008, indicates that the deformed toenails are the result of poorly fitting combat boots. This note was proffered by a nurse in the podiatry department, but the entry indicates that treatment was provided per orders and under the supervision of the surgical specialty clinic podiatrist. A March 2010 VA examination for skin disease shows that the Veteran at that time manifested no objective findings of ingrown toenails or residuals of great toenail removal. Because no objective pathology was found on examination, the examiner, an M.D., could not make a diagnosis and declined to offer an opinion as to the etiology of any such condition. Service treatment records show the Veteran was treated for ingrown toenails and had at least one toenail removed during active service. As noted above, the Veteran testified that he has received treatment for this condition from his discharge from active duty to the present. Post-service VA treatment records are consistent with his testimony, showing continued treatment for a condition of the toenails, including the bilateral great toenails, as described above. Finally, his VA treating health care provider, a D.P.M., has opined that the cause of the toenail condition, including his bilateral great toenail condition, is trauma from wearing combat boots. The March 2010 VA examination findings that the Veteran exhibited no great toenail removal residuals are noted, but are not as probative as the records of VA treatment and the opinion therein. These records show the Veteran's toenail condition required intermittent debriding, so it is possible that the March 2010 VA examination was conducted at a time when the nails had been treated and therefore did not clearly reflect the severity of the toenail condition. Moreover, the Veteran's health care provider is a D.P.M. and arguably possesses equal or greater medical credentials and expertise in the area of podiatry as the examiner who conducted the March 2010 examination. To the extent that such conflicting findings create any reasonable doubt in the present case, such doubt will be resolved in the Veteran's favor. See 38 C.F.R. § 3.102. Accordingly, the evidence supports a finding that the Veteran manifests residuals of bilateral great toenail removal that are the result of active service. Service connection for the residuals of bilateral great toenail removal is warranted. b) Bilateral Femur Disability, Residuals Right Groin Lymph Node Removal, Acne, and Disability Characterized by Complaints of Fatigue The Veteran's reports of medical history and examination at entrance to active service reflect no findings of any leg or groin defect, diagnosis or other abnormalities; a skin disorder; or complaints or findings of a disorder characterized by fatigue. Service treatment records, however, reveal that during active service, the Veteran was treated for a medial leg pain and right distal femur pain in 1986. Results of X-rays reflected no evidence of stress fracture and, on bone scan, no evidence of right femur stress fracture. These records also show he was in a MVA in 1987 where he was the driver of a vehicle that swerved to miss a deer and rolled after he ran off the road. Treatment records are scant, but those that exist document complaints of pain in the right shoulder and neck, and that he was observed to exhibit full range of motion in his extremities. Service treatment records further reveal that the Veteran underwent surgical removal of a lymph node in the right groin area in 1989, after complaints of pain and lumps on the right side of his pelvic region. A provisional diagnosis of inguinal adenopathy was made, but ultimately the condition was assessed as lymph adenopathy. These records further show he was treated for acne in 1987 and 1989, and that he complained of fatigue associated with administration of Isoniazid from November 1990 through December 1991. As reported above, there is no report of medical history or examination at discharge. Post-service VA treatment records show no diagnoses for a bilateral femur condition or acne, no findings of residuals of lymph removal in the right groin, or of a disability manifested by fatigue. Private medical treatment records dated in August through October 2009 reflect the Veteran was in a MVA. He was riding a motorcycle and struck a deer, hit the ground and rolled several times. He sustained road rash to most of his upper and lower extremities as well as bruising and contusions. He complained of leg pain. However, while these records document treatment for bilateral knee problems, there are no findings-clinical or otherwise-of impairment of bilateral femurs, other than friction burns to his bilateral legs. A September 2009 entry reflects normal lower extremities absent swelling, masses, redness or tenderness; normal strength and tone with full range of motion. He was observed to have a normal, symmetric gait and station with smooth movement and no tilt. Neurological and sensation findings were found to be normal. A December 2007 VA examination for scars reflects that no scar could be visualized in the right groin area. There was no tenderness to palpation, adherence to underlying tissue, limitation of motion or loss of function, underlying soft tissue damage or skin ulceration or breakdown. The examiner was unable to diagnose a condition as no scar was visualized. A March 2010 VA examination for fractures and bone disease shows complaints of pain in both thighs and functional limitation on standing and walking, but no current or objective finding of any right or left femur condition. A March 2010 VA examination for skin diseases found no objective findings of acne. The examiner, an M.D. declined to offer opinions as to the etiology of any such conditions based on no objective findings of any femur or acne conditions. Service connection presupposes a current diagnosis of the claimed disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The U.S. Court of Appeals for Veterans Claims (Court) has held that the "current disability" requirement is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary's adjudication of the claim." See McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, there is no evidence that the Veteran currently has a bilateral femur disability, residuals of lymph removal from the right groin, acne or a disability manifested by fatigue-currently or at any time during the pendency of this claim. While complaints of leg pain have been noted, such complaints have been attributed to other conditions, including burns associate with a MVA in 2009. Moreover, pain is not analogous to disability. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) (holding that pain alone without a diagnosed or identifiable underlying malady or condition did not constitute a disability for which service connection may be granted). To the extent that claims for leg pain and fatigue may represent claims for undiagnosed disabilities characterized by leg pain or fatigue under 38 C.F.R. § 3.317, the Board observes that the Veteran has not claimed these symptoms as undiagnosed illnesses. Furthermore, as above noted, the medical evidence does not reflect that he has been found to manifest symptoms of leg pains or fatigue that are attributed to an undiagnosed condition during the pendency of this appeal. Therefore without a current diagnosis of a bilateral femur disability, residuals of lymph node removal of the right groin, acne, or a disability manifested by fatigue, service connection cannot be warranted. The Veteran has been accorded ample opportunity to present competent medical evidence which includes a diagnosis of a bilateral hip disability. He has not done so. See 38 U.S.C.A. § 5107(a) (West 2002) (it is a claimant's responsibility to support a claim of entitlement to VA benefits). The Veteran testified that the leg pain and acne he experienced during active service persist to the present, and that he also continues to feel fatigued and worn out. He also testified that he feels pain in his groin when he walks, that the excision site swells and is painful to the touch. He is entirely competent to report that he has discomfort and pain in his bilateral legs and groin, that he observes his skin to feel abnormal, and that he feels fatigue. His assertions are therefore credible. However, it is well established that laypersons without medical training, such as the Veteran, are not competent to comment on medical matters such as diagnosis of a disability like a bilateral femur or groin disability, acne, or a disability manifested by fatigue. Cf. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). That is, the Veteran is competent to report that he has leg and groin pain, bumps on his facial skin, and that he feels tired. However, he is not competent to state that such pain, observation of skin abnormality, or fatigue is a manifestation of an underlying bilateral femur disability, residuals of the removal of lymph nodes from the groin, acne, or a disability manifested by fatigue. Accordingly, the Board has placed greater probative weight on the conclusions of VA examiners in 2007 and 2010, medical findings in VA treatment records dated from 2006 through 2010, and medical findings in private treatment records dated in 2009, because such conclusions and findings were made by medical professionals, who are competent to render opinions regarding medical matters. Because the Veteran has not been shown to have the claimed disabilities, his claims fail on Hickson element (1). Therefore, a preponderance of the evidence is against the Veteran's claims for service connection for a bilateral femur disability, residuals of lymph removal in the right groin, acne, and fatigue. The benefit-of-the-doubt rule does not apply, and the service connection is not warranted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Higher Initial Evaluations Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2010). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (2010). When 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 (2010). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2010). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. See 38 C.F.R. § 4.40 (2010). When making a rating determination, VA must consider whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. See 38 C.F.R. § 4.45 (2010); Johnson v. Brown, 9 Vet. App. 7, 10 (1996); DeLuca v. Brown, 8 Vet. App. 202 (1995). In an appeal of an initial rating, consideration must be given to "staged" ratings, that is, disability ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board will thus consider entitlement to "staged ratings" in this case. a) Left Index Finger Service connection for the residuals of laceration to the left index finger was granted in an October 2007 rating decision. The disability was evaluated as zero percent disabling, effective in April 2007. In a July 2010 rating decision, a 10 percent evaluation was granted, effective in April 2007, under Diagnostic Code 5229-7804. As this increased rating does not constitute a full grant of all benefits possible, and as the veteran has not withdrawn his claim, the issue concerning entitlement to an increased rating remains pending. See AB v. Brown, 6 Vet. App. 35 (1993). The diagnostic code assigned the left index finger disability contemplates limitation of motion of the finger (Diagnostic Code 5229) evaluated as an unstable or painful scar (Diagnostic Code 7804). See 38 C.F.R. § 4.27 (2010). The regulations contemplating evaluation of scars were revised October 23, 2008, during the pendency of this appeal. However, these changes apply only to those claims filed on or after October 23, 2008. Since the Veteran's claim in this case was filed prior to this date, the 2008 changes to the rating schedule are not for application; rather, the rating schedule in effect prior to October 23, 2008 are for application. Under the former criteria, Diagnostic Code 7804 provided a maximum 10 percent evaluation for a superficial scar that is painful on examination. Diagnostic Code 7802 was for rating scars other than the head, face, or neck that are superficial, that cover an area(s) of 144 square inches or greater; and provided for only a maximum 10 percent evaluation. A superficial scar is one not associated with underlying soft tissue damage. Diagnostic Code 7803 afforded a maximum 10 percent evaluation for rating unstable superficial scars, or scars where there was frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, Diagnostic Codes 7802, 7803, 7804 (effective prior to October 23, 2008). Under Diagnostic Code 7805 scars may be rated based on any limitation of function of the part affected. 38 C.F.R. § 4.118, Diagnostic Code 7805 (effective prior to October 23, 2008). Diagnostic Code 5229 contemplates limitation of motion of the left index finger and provides a noncompensable evaluation for a gap of less than one inches (2.5 centimeters) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. A 10 percent evaluation if afforded for a gap of one inch (2.5 centimeters) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5229. Ankylosis of the index finger is evaluated under Diagnostic Code 5225, which provides a 10 percent evaluation for ankylosis for favorable or unfavorable ankylosis of the index finger. When evaluating an ankylosis disability of the finger, VA should also consider whether evaluation as an amputation is warranted and whether an additional evaluation is warranted for a resulting limitation of motion of other digits or interference with the overall function of the hand. 38 C.F.R. § 4.71a, Diagnostic Code 5225 (2010). Functional loss due to pain and weakness that cause additional disability beyond that which is reflected on range of motion measurements must also be considered. See 38 C.F.R. § 4.40 (2010); DeLuca v. Brown, 8 Vet. App. 202 (1995). Additionally, the Board must consider the effects of weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45 (2010). A December 2007 VA examination for hand reflects findings of a normal left index finger with no ankylosis. There was deformity at the proximal interphalangeal joint in that the joint appeared to be slightly more prominent as compared to the right. There was no gap between the thumb pad and tips of the fingers or between the finger and proximal transverse crease of the hand. There were no findings of decreased strength or dexterity, and the examiner noted good symmetric grip strength bilaterally. Range of left distal interphalangeal joint was zero to 80 degrees without pain, and proximal interphalangeal joint was zero to 100 degrees with pain. Range of motion at the metacarpophalangeal joint was zero to 90 without pain. Repetitive motion caused pain on the proximal interphalangeal joint but not on the distal interphalangeal or metacarpophalangeal joints. Pain was not productive of additional limitation of motion. Results of X-rays showed no fracture, dislocation or other bony abnormality. Joints and soft tissues were unremarkable. No examination for scars concerning the left finger or hand was accomplished at this time. A March 2010 VA examination for scars reflects findings of a linear scar on the left index extensor surface of the proximal interphalangeal joint measuring .3 centimeters in width and 1.8 centimeters in length. It was observed to be painful on palpation but stable and hypopigmented. There were no findings of ulcerations, limitation of motion or loss of function, inflammation, edema or keloid formation, adherence to underlying tissue, underlying soft tissue damage, underlying tissue loss, elevation, depression or induration or inflexibility. The texture of the scar was found to be normal. A March 2010 VA examination of the hand shows findings of limitation of motion in the left index finger. Specifically, the Veteran was found to exhibit range of left index finger motion at the interphalangeal joint at zero to 100 degrees with pain, pain on motion, and pain after repetitive motion. However, pain was not shown to be productive of additional loss of motion. Range of motion at the distal interphalangeal joint was measured at zero to 60 degrees with pain, pain on motion, and pain after repetitive motion. However, pain was not shown to be productive of additional loss of motion. The left index finger was not characterized by ankylosis or deformity. There were no findings of decreased strength or dexterity. There was a gap of less than one inch between the left index finger and proximal transverse crease of the hand on maximal flexion of the fingers. There was no gap between the thumb pad and tip of the finger on attempted opposition of the thumb to fingers. As the scar on the left index finger measures .3 centimeters in width and 1.8 centimeters in length, is painful on palpation and hypopigmented but stable without ulceration or other symptomatology, no more than 10 percent is warranted for the scar under Diagnostic Codes 7802, 7803, 7804, or 7805. The Veteran has testified and expressed that his left index finger causes him pain and pain on motion, and that he can bend his finger only about halfway to his palm, representing a worsening of the disability since his last, March 2010, VA examination. VA treatment records do reflect treatment for complaints of hand pain. The March 2010 VA examination report shows a gap between the left index finger and proximal transverse crease of the hand on maximal flexion of the fingers, albeit less than one inch. This finding of a limitation of motion is separate and apart from the finding of a painful scar in the March 2010 VA examination for scars. The examiner in this report specifically observed that the scar on the left index finger was painful on palpation but did not limit range of joint motion or function. Accordingly, the evidence creates reasonable doubt as to the degree of the gap created by the Veteran's limitation of motion. All reasonable doubt shall be resolved in the Veteran's favor. Given the findings of painful motion in left index finger joints as noted by the VA examiner in March 2010, along with the finding of a gap less than an inch between the left index finger and proximal transverse crease of the hand on maximal flexion, the Board finds that a separate, 10 percent, evaluation for limitation of motion of the left index finger is warranted under Diagnostic Code 5229 from March 2010, the earliest medical evidence that such a gap exists. An evaluation earlier than this is not warranted. Although the VA examiners in 2007 also noted objective observations of pain and pain on motion in the left index finger, there were no findings of a any limitation of motion in left index finger motion. Rather, the examiner noted that range of left hand motion was within normal limits and zero to 90 degrees of the left index metacarpal phalangeal joint, zero to 100 at the proximal interphalangeal joint, and zero to 60 degrees at the distal interphalangeal joint, albeit with pain and pain on repetitive motion. Moreover, no gap between the thumb pad and tips of the fingers or between the finger and proximal transverse crease of the hand was reported in 2007. An evaluation greater than 10 percent is not provided by the rating criteria under Diagnostic Code 5229. Diagnostic Code 5225, which contemplates ankylosis, also offers 10 percent as the highest evaluation. Consideration has been given to whether other manifestations may warrant a higher evaluation, including for amputation or resulting limitation of other digits or interference with overall function of the hand, as would be indicated if the left index finger were ankylosed, but the evidence does not reflect that the Veteran's left index finger is ankylosed-either favorably or unfavorably, that it is amputated, or that other digits have experienced limitation of motion or interference with overall function due to the left index finger impairment. In contrast, March 2010 VA examination findings show range of motion measurements from zero to 80 degrees in the thumb, zero to 90 degrees in the long, ring, and little fingers at the metacarpophalangeal joint, zero to 100 degrees at the proximal interphalangeal joint and zero to 70 degrees at the distal interphalangeal joint. Finally, the Veteran has not reported, and no findings have been observed, of other residuals of the left index finger laceration that could warrant separate compensable evaluations under diagnostic codes other than have been considered herein. The Board has considered whether an increased disability rating is warranted for the Veteran's left index finger disability based on functional loss due to pain, weakness, excess fatigability, incoordination, and flare-ups. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995) but, as indicated in the discussion above, these manifestations have either not been found or have been considered in the evaluations already awarded. The Board has considered whether staged ratings are applicable in this case and has awarded a separate 10 percent evaluation based on limitation of left index finger movement-as distinct from the painful scar-from the date of the VA examination documenting painful motion, March 25, 2010. No other distinct periods of time where the Veteran's disability was more or less disabling are identified. See Fenderson, supra. A preponderance of the evidence is against an evaluation greater than 10 percent for a painful left index finger scar under Diagnostic Code 7804. A 10 percent evaluation, and no greater, for limitation of motion of the left index finger is warranted from March 25, 2010 under Diagnostic Code 5229. A preponderance of the evidence is against the assignment of a separate, 10 percent evaluation for limited motion of the left index finger prior to March 25, 2010. The benefit-of-the-doubt rule does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). b) Hammertoe of the 2nd Right Foot Service connection for hammertoe, 2nd toe of the right foot was granted in an October 2007 rating decision. The disability was evaluated as zero percent disabling, effective in April 2007, under Diagnostic Code 5282. The diagnostic code assigned the 2nd right hammertoe contemplates hammer toe of the foot and affords a noncompensable evaluation for a single toe hammertoe, and a 10 percent evaluation for unilateral hammer toe in all toes without claw foot. See 38 C.F.R. § 4.71a, Diagnostic Code 5282 (2010). VA examination in March 2010 reflects findings of 2nd right toe hammertoe. VA treatment records reflect complaints of and treatment for painful feet. There is no medical evidence that the Veteran has all toes of the right foot, unilaterally and without claw foot, hammertoes. As the Veteran manifests only the 2nd right toe hammertoe, a compensable evaluation cannot be warranted. The Veteran has reported and testified that he experiences pain in his feet, and he is competent to say that his feet hurt. However, it remains that the diagnostic code contemplates a compensable evaluation only where all toes of the foot are hammertoes. The Board has considered whether an increased disability rating is warranted for the Veteran's 2nd right hammertoe disability based on functional loss due to pain, weakness, excess fatigability, incoordination, and flare-ups. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra. There are no other findings which can be compensated under the diagnostic code. A preponderance of the evidence is against a compensable evaluation for 2nd right hammertoe. The benefit-of-the-doubt rule does not apply, and a compensable evaluation for 2nd right hammertoe is not warranted. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extra-Schedular Considerations The VA schedule of ratings will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In exceptional circumstances when the schedular evaluations are inadequate, the veteran may be awarded a rating higher than that dictated by the schedular criteria. 38 C.F.R. § 3.321(b)(1) (2010). According to the regulation, an extra- schedular disability rating is warranted upon a finding that "the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards." Id. In Thun v. Peake, the Court set forth a three-step inquiry to determine a veteran's entitlement to an extra-schedular rating. 22 Vet. App. 111 (2008). First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the veteran's level of disability and symptomatology and is found to be inadequate, the Board must determine whether the Veteran's 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 extra-schedular rating. In this case, it is not necessary to go any further than the first step of the Thun analysis. The rating criteria are not inadequate. While higher ratings are not available for the single scar or limitation of left index finger motion, separate compensable evaluations are available for other manifestations, and higher evaluations are available for ankylosis should the motion of other digits be affected. Higher ratings are available for hammertoes when all toes of the foot are affected, but the Veteran does not have such symptoms. It does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected left finger and right toe disabilities that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extra-schedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extra-schedular consideration is moot. See Thun, supra. The Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Therefore, the Veteran's disability picture is contemplated by the rating schedule and no extra-schedular referral is required. See 38 C.F.R. § 3.321(b)(1) (2010); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Finally, the Board also notes that the Court has held that the issue of a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when a request for TDIU is reasonably raised by the record. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). However, in the present case, the Veteran has not explicitly raised the issue of TDIU with regard to these disabilities. Likewise, the record does not reasonably raise the issue of TDIU. March 2010 and December 2007 VA examination reports reflect that the left index finger disability was productive of no significant effects on the Veteran's occupation. The March 2010 VA examination report noted that the 2nd right hammertoe was similarly productive of no significant effects on the Veteran's occupation. In light of the foregoing, the Board finds that a claim for TDIU has not been raised. ORDER Service connection for the residuals of bilateral great toe removal is granted. Service connection for bilateral femur stress fractures is denied. Service connection for residual of lymph node removal, right groin is denied. Service connection for acne is denied. Service connection for fatigue is denied. An initial evaluation greater than 10 percent for residuals of left index finger laceration represented by a painful scar is denied. A separate, 10 percent, evaluation for limitation of left index finger motion is granted from March 25, 2010. An initial compensable evaluation for hammertoe of the 2nd right foot is denied. REMAND The Veteran also seeks service connection for a disability involving blood in the urine, for a bilateral eye disability, for a right ear condition, for right shoulder, cervical spine, bilateral wrist, bilateral knee, and left ankle disabilities, and for bilateral pes planus. Service treatment records document treatment for these conditions during active service. Specifically, he received treatment for an eye condition during active service, including a reported trauma. He also received treatment for repeated ear problems and burning on urination. In addition, the Board notes that the Veteran earned the air assault badge during active service, which would require rigorous physical training, including repeated parachute jumps; and that he was involved in a MVA in 1987 during which he was noted to have blunt trauma to the head, with complaints of right shoulder and neck pain. Service treatment records further reflect that he was admitted with a diagnosis of bilateral pes planus, characterized as moderate but asymptomatic. During active service, these records show he was treated for multiple episodes of foot, knee and leg pain, left ankle pain, left elbow and right wrist pain. Finally, the records show he was treated for tuberculosis with isoniazid. Post service VA and private treatment records show treatment for the above claimed conditions, including urological issues, eye problems, ear infections and multiple joint problems. In particular, a 2008 VA treatment entry shows findings of a faint scar in the left eye and faint central striae in the right eye. A 2006 entry notes clinical findings of irregularity in the left navicular bone of the left foot, which the staff physician at the time indicated could be due to prior trauma. First, the record before the Board is incomplete. The Veteran appears to have sustained two post-service MVAs, in 2007 and 2009, complicating matters in this case. While private treatment records concerning the 2009 MVA have been obtained, those concerning the 2007 MVA have not. Second, the Veteran reported in 2007 that he had been treated at the Shreveport VAMC from approximately 1992 to 1994, and that he had been treated at the Gainesville, Florida VAMC from 2003. VA treatment records have been obtained only from 2006 to 2010. These missing records are crucial in this case, particularly as the earlier records could give information of the Veteran's disability picture prior to his first post-service MVA. Third, the Board notes that the VA examiner who conducted the March 2010 examinations for joints and cervical spine appeared to indicate that new and material evidence had not been submitted since the October 2007 rating decision. The presence of new and material evidence is not relevant in the present case, as there has been no prior final denial. In any event, this is a legal distinction inappropriate for a medical evaluation. The March 2010 audiological evaluation does appear to be only for audiology, rather than to include conditions of the ear and ear disease, which are the conditions the Veteran has claimed and for which he has been treated during and after active service. In any event, all VA examinations have been based on review of an incomplete record. Fourth, it does not appear that the claim concerning service connection for bilateral pes planus has properly been identified and adjudicated as one involving a pre-existing condition. See Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). Given the foregoing, the Board finds it is imperative to obtain outstanding private and VA treatment records and, following review of all of the evidence, to provide the Veteran additional VA examinations to clarify the nature, extent, and etiology of his claimed conditions. See, generally, 38 C.F.R. § 3.159; see also Green v. Derwinski, 1 Vet. App. 121 (1991); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the case is REMANDED for the following action: 1. Issue a VCAA notice letter which satisfies all VCAA notice obligations with regard to the issue of service connection based on the aggravation of pre-existing disabilities in accordance with all regulatory and legal precedent. 2. Ask the Veteran to identify any and all health care providers who have treated him for his disability involving blood in the urine, bilateral eye disability, right ear condition, and for right shoulder, cervical spine, bilateral wrist, bilateral knee and left ankle disabilities and for bilateral pes planus since his discharge from active service. Obtain copies of all identified treatment records that are not already of record. Obtain any and all treatment records from the VAMCs in Shreveport, Louisiana and Gainesville, Florida, and from any other VA facility that the Veteran identifies from 1992 to the present that are not already of record. Ask the Veteran specifically to identify any and all records of treatment he received following both MVAs in 2007 and 2009. Obtain those records also. 3. Make another attempt to obtain the Veteran's complete service medical records, to include all clinical and hospital records. All indicated actions and follow-up should be completed. Ask the service department for assistance if necessary. 4. For #1-3, all requests and responses, positive and negative, should be associated with the claims file. Take all follow-up actions indicated. If the records cannot be obtained, inform the Veteran so that he may attempt to obtain them himself. 5. Accord the Veteran VA examinations with the appropriate specialists to determine the nature, extent, and etiology of any pathology involving blood in the urine, and any pathology of the eyes, right ear, right shoulder, cervical spine, wrists, knees, left ankle, and feet. The Veteran's claims folder must be made available to the examiners in conjunction with the examinations and the examiners should note such review in the examination reports. Based on a review of the claims folder and the clinical findings of the examinations, the examiners must offer the following opinions: a) Is it at least as likely as not that any pathology involving blood in the urine, and any pathology of the eyes, right ear, right shoulder, cervical spine, bilateral wrist, bilateral knee and left ankle pathology had its onset during the Veteran's active duty or is otherwise the result of his active duty service or any service-connected disability? b) Is it at least as likely as not that any pathology involving blood in the urine, and any pathology of the eyes, right ear, right shoulder, cervical spine, bilateral wrist, bilateral knee and left ankle pathology is the result of aggravation of a nonservice-connected disability by a service-connected disability. c) Concerning the claimed pes planus, is it at least as likely as not that any bilateral foot pathology (other than the service connected right foot plantar fasciitis) is the result of aggravation of the pre-existing pes planus that was characterized as moderate but asymptomatic on the Veteran's entrance examination. d) In the alternative, is it at least as likely as not that any bilateral foot pathology (other than the service connected right foot plantar fasciitis) is the result of aggravation of a nonservice-connected disability by a service-connected disability. The examiners must provide a clear rationale for all opinions proffered. 6. Advise the Veteran in writing that it is his responsibility to report for VA examinations, to cooperate with the development of his claims, and that the consequences for failure to report for a VA examination without good cause include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2010). In the event that the Veteran does not report for any ordered examination, obtain documentation that shows that notice scheduling the examination was sent to his last known address prior to the date of the examination, to include whether any notice that was sent was returned as undeliverable. 7. To help avoid future remand, ensure the required actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, undertake corrective action before the claims file is returned to the Board. See Stegall v. West, 11 Vet. App. 268 (1998). 8. After completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the claims on appeal. If any benefit sought remains denied, furnish the Veteran and his representative a supplemental statement of the case (SSOC) and afford them an opportunity to respond before the record is returned to the Board for future review. The appellant has the right to submit additional evidence and argument on the 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. 2010). ______________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs