Citation Nr: 1101141 Decision Date: 01/11/11 Archive Date: 01/20/11 DOCKET NO. 07-10 979 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for a left foot disability, claimed as flat foot and hallux valgus of the left foot, and if so whether the reopened claim should be granted. 2. Whether new and material evidence has been received to reopen a claim for service connection for migraine headaches, and if so whether the reopened claim should be granted. 3. Whether new and material evidence has been received to reopen a claim for service connection for a cervical spine disorder, claimed as degenerative disc disease (DDD) and degenerative joint disease (DJD), and if so whether the reopened claim should be granted. 4. Entitlement to service connection for psychiatric disability, to include posttraumatic stress disorder (PTSD). 5. Entitlement to a rating in excess of 10 percent for right ulnar neuropathy with postoperative epicondylectomy. 6. Entitlement to a rating in excess of 10 percent for postoperative right hallux valgus with bunionectomy and osteotomy of the right great toe. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from October 1979 to July 1987. This case comes before the Board of Veterans' Appeals (Board) on appeal of a March 2006 and December 2007rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). FINDINGS OF FACT 1. Service connection for a left foot disability and for migraine headaches was denied on the merits in a January 1988 rating decision; the Veteran did not appeal. 2. Evidence received since the January 1988 decision is cumulative or redundant of the evidence previously of record or does not relate to an unestablished fact necessary to substantiate the claims for service connection for a left foot disorder or for migraine headaches. 3. Service connection for a cervical spine disorder was denied on the merits in a March 2005 rating decision; the Veteran did not appeal. 4. Evidence received since the March 2005 decision is cumulative or redundant of the evidence previously of record or does not relate to an unestablished fact necessary to substantiate the claim for service connection for a cervical spine disorder. 5. An acquired psychiatric disorder was not present until more than one year following the Veteran's discharge from service, and no current acquired psychiatric disorder is etiologically related to active service. 6. The Veteran is right-handed. 7. The Veteran's right elbow disability is manifested by mild incomplete paralysis of the ulnar nerve. 8. The Veteran's right foot disability approximates amputation of the great toe, but not amputation with removal of the metatarsal head. CONCLUSIONS OF LAW 1. New and material evidence has not been received to reopen the claim for service connection for a left foot disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2010). 2. New and material evidence has not been received to reopen the claim for service connection for migraine headaches. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2010). 3. New and material evidence has not been received to reopen the claim for service connection for a cervical spine disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2010). 4. Psychiatric disability, to include PTSD, was not incurred in or aggravated by active service, and the incurrence or aggravation of a psychosis during such service may not be presumed. 38 U.S.C.A. §§ 1101, 1112, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2010). 5. The criteria for a rating in excess of 10 percent for right ulnar neuropathy with postoperative epicondylectomy are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.124a, Diagnostic Code 8616 (2010). 6. The criteria for a rating in excess of 10 percent for postoperative right hallux valgus with bunionectomy and osteotomy of the right great toe are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5280 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks service connection for a psychiatric disorder, a cervical spine disorder, a left foot disorder and migraine headaches; she also seeks higher ratings for her service- connected right elbow and right foot disabilities. The Board will initially discuss certain preliminary matters and will then address the pertinent law and regulations and their application to the facts and evidence. Duties to Notify and Assist The Veterans Claims Assistance Act (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 is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to 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 is to 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. Although the regulation previously required VA to request that the claimant provide any evidence in the claimant's possession that pertains to the claim, the regulation has been amended to eliminate that requirement for claims pending before VA on or after May 30, 2008. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held the plain language of 38 U.S.C.A. § 5103(a) requires notice to a claimant pursuant to the VCAA be provided "at the time" or "immediately after" VA receives a complete or substantially complete application for VA- administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement articulated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was not provided adequate VCAA notice prior to the March 2006 rating decision that denied service connection for PTSD. However, following provision of the required notice and completion of all indicated development of the record, the originating agency readjudicated the claim in March 2007. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by readjudication of the claim). There is no indication or reason to believe the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. Additionally, in March 2006, the Court held that because the terms "new" and "material" in a new and material evidence claim have specific, technical meanings that are not commonly known to VA claimants, when providing the notice required by the VCAA, it is necessary, in most cases, for VA to inform claimants seeking to reopen a previously and finally disallowed claim of the unique character of the evidence that must be presented. Kent v. Nicholson, 20 Vet. App. 1, 9-10 (2006). The Veteran was provided Kent-compliant notice by a letter in November 2006, prior to the December 2007 rating decision that denied the Veteran's petition to reopen the previously-denied claims. Special development is required when PTSD claim is based on stressor of alleged physical or sexual assault. See YR v. West, 11 Vet. App. 393, 399 (1998); Patton v. West, 12 Vet. App. 272 (1999); M21-1, Part III, para. 5.14d; 38 C.F.R. § 3.304(f)(3). In this case, the RO sent the Veteran a letter in July 2005 advising her of the elements required to establish service connection for PTSD and the types of evidence that are acceptable toward showing physical or sexual assault in service. In August 2008 the RO issued a memorandum formally finding the Veteran had not presented verifiable in-service stressors that could be submitted to the Joint Services Records Research Center (JSRRC) for verification. The Board also finds the Veteran has been afforded adequate assistance in regard to the claims. The Veteran's service treatment records (STRs), service personnel records (SPRs) and Social Security Administration (SSA) disability records are of record, as are treatment records from those VA and non-VA medical providers identified by the Veteran as having relevant records. The Veteran has been afforded VA medical examinations in response to the claims herein decided. In sum, any procedural errors in the originating agency's development and consideration of the claims were insignificant and non prejudicial to the Veteran. Accordingly, the Board will address the merits of the claims. New and Material Evidence Legal Principles Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2010). Generally, a claim that has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. § 7105(c). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court recently interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, No. 08-3548 (U.S. Vet. App. Nov. 2, 2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992); Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). If the prior final denial and the currently claimed disability involve different diagnostic codes, they are different claims for the purpose of VA adjudication. A claim for one diagnosed disease or injury cannot be prejudiced by a claim for another diagnosed disease or injury; rather, the two claims must be considered independently. Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008), citing Ephraim v. Brown, 82 F.3d 399 (Fed. Cir. 1996). Analysis: New and Material Evidence for Left Foot Disorder The RO denied service connection for flat feet and for headaches by a rating decision in January 1988. The Veteran was notified of the decision by a letter in February 1988 but did not appeal. The evidence of record at the time of the January 1988 rating decision was as follows: service treatment records (STRs) showing bilateral hallux valgus, right worse than left; and the report of a VA examination in September 1987 showing the Veteran complained of bilateral foot pain and bilateral flat feet but was found to have normal feet. The specific reason the RO denied service connection on the merits in January 1988 was that flat feet and hallux valgus preexisted service and were not aggravated by service. Evidence received since January 1988 pertaining to the left foot is as follows: the report of a postal service examination in February 1988 in which the Veteran endorsed history of foot trouble/flat feet but current normal examination of the feet; VA examination report date in February 1989 that is silent in regard to any current left foot disorder; a report of a VA examination of the feet in August 2001 noting diagnosis of hallux valgus of the left foot with small bunion on the left great toe; a report of a VA X-ray study of the left foot in August 2001 showing an impression of mild degenerative change of the first metatarsal phalangeal (MTP) joint; a July 2006 letter from Technical Sergeant Retired (TSGT, Ret.) SP stating that during active duty at Norton Air Force Base (AFB) the Veteran had to perform physically strenuous loading and unloading of aircraft, and that the Veteran's [unspecified] injuries can be related to her military occupation; and VA outpatient treatment records in February 2009 showing left foot bunionectomy consequent to hallux valgus disorder. On review of the evidence above, the Board finds no new evidence that pertains to any previously unestablished element needed to show entitlement to service connection for a left foot disorder. There is nothing in the evidence added to the record suggesting that the current left foot was incurred in or aggravated by active service, rather than a disorder that preexisted service and was not aggravated by service as had been found in the previous denial of the claim. The Board notes the July 2006 letter from TSGT (Ret) SP stating the Veteran performed physically strenuous activities in service and that her [unspecified] injuries can be related to her occupational specialty. "A layperson can certainly provide an eyewitness account of a veteran's visible symptoms;" see Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, SP's statement is not material to this claim because nothing therein asserts that SP observed the Veteran to have any problems with her left foot during service or to have suffered any left foot injuries not documented in STRs. The Board accordingly finds that new and material evidence has not been received to reopen the claim for service connection and that the benefit sought on appeal must therefore be denied. Analysis: New and Material Evidence for Migraine Headaches The RO denied service connection for headaches by a rating decision in January 1988. The Veteran was notified of the decision by a letter in February 1988 but did not appeal. The evidence of record at the time of the January 1988 rating decision was as follows: STRs showing treatment for contraction headaches; and a report of VA examination in September 1987 showing complaint of recurrent headaches but no underlying disorder noted on examination (X-ray of the skull and sinuses normal). The specific reason the RO denied service connection on the merits in January 1988 was that the Veteran had no organic findings related to a headache disorder, and headache alone is not a ratable disability. Evidence received since January 1988 pertaining to a headache disorder is as follows: a report of a postal service examination in February 1988 in which the Veteran endorsed history of frequent or severe headaches, and in which the clinical impression was headaches related to visual impairment but no problem if glasses worn; a report of a VA examination in February 1989 in which she reported migraine headaches since a spinal tap in service in 1986 (no diagnosis of headache disorder in the examination report); a report of a VA examination in November 1992 in which it was noted she reported severe migraine headaches associated with tenseness of the neck muscles (no diagnosis pertaining to headaches in the examination report); a report of a VA neurological consult in June 2004 in which the neurologist's impression was no objective evidence of any neurological abnormality; a July 2006 letter from TSGT, Ret. SP stating that during active duty at Norton AFB the Veteran had to perform physically strenuous loading and unloading of aircraft, and that the Veteran's [unspecified ] injuries can be related to her military occupation; and a report of a VA X-ray study of the sinuses in September 2007 due to complaint of recurrent sinusitis with headaches but showing normal paranasal sinuses. On review of the evidence above, the Board finds no new evidence that pertains to any previously unestablished element needed to show entitlement to service connection for a headache disorder. There continues to be no diagnosis for a chronic headache disorder that was not previously considered. There is no new evidence, to include in the statement by TSGT (Ret) SP, which shows the Veteran had a chronic headache disorder during active service or that she had headache symptoms that were not documented in STRs. The Board accordingly finds that new and material evidence has not been received to reopen the claim for service connection for migraine headaches and that the benefit sought on appeal must therefore be denied. Analysis: New and Material Evidence for Cervical Spine Disorder The RO denied service connection for a cervical spine disorder, on the merits, by a rating decision in March 2005. The Veteran was notified of the decision by a letter in April 2005 but she did not appeal. The evidence of record at the time of the March 2005 rating decision was as follows: STRs; report of VA examination in September 1987 showing complaint of cervical radiculopathy but normal EMG and no evidence of cervical spine disorder on examination; a report of a postal service examination in February 1988 in which the Veteran denied history of back surgery or back injury; reports of VA examinations in February 1989 and November 1992 that are silent in regard to any current cervical spine disorder; VA EMG report in August 1997 showing no cervical radiculopathy; VA physical therapy treatment records in 2004 showing cervical traction and therapeutic stretching exercises for spasms of the cervical paraspinal muscles; a report of a VA X-ray study of the cervical spine in June 2004 showing an impression of mild spondylosis involving C4, C5 and C6; a report of a VA MRI of the cervical spine in August 2004 showing an impression of extruded disc at C4 with stenosis and disc bulge at C6 without stenosis; and a report of a VA examination of the spine in February 2005 showing the examiner diagnosed degenerative disc disease (DDD) and degenerative joint disease (DJD) of the cervical spine with residuals. The specific reason the RO denied service connection on the merits in March 2005 was that the VA examiner in February 2005 had stated as a medical opinion that the Veteran's claimed cervical spine disorder was not related to a cervical spine strain in service. Evidence received since March 2005 pertaining to a cervical spine disorder is as follows: a report of an MRI by Atlantic Radiology Associates in July 2006 showing disc herniation at C4-5, DDD at C5-6 and disc protrusion at C6-7; a July 2006 letter from TSGT, Ret. SP stating that during active service at Norton AFB the Veteran had to perform physically strenuous loading and unloading of aircraft, and that the Veteran's [unspecified ] injuries can be related to her military occupation; a report of a VA neurological consultation in August 2006 showing an assessment of current chronic neck pain due to DDD and C5 radiculopathy; and SSA disability records showing the Veteran had received worker compensation payment for injuries of her neck, left shoulder and left upper extremity incurred at her workplace in October 1991. On review of the evidence above, the Board finds no new evidence that pertains to any previously unestablished element needed to show entitlement to service connection for a cervical spine disorder. There is no new evidence, to include in the statement by TSGT (Ret) SP, which shows the Veteran had a cervical spine injury or disorder during active service or that she had a neck injury that was not documented in STRs. To the degree that SSA records address a post-service cervical spine disorder, they show workplace injury or aggravation after discharge from service and thus do not provide any additional evidence of a disorder originating in or due to active service. Finally, there is nothing in the new evidence to challenge the competent medical opinion of the VA examiner that the Veteran's cervical spine disability is not related to active service. The Board accordingly finds that new and material evidence has not been received to reopen the claim and that the benefit sought on appeal must therefore be denied. Entitlement to Service Connection Legal Principles Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for PTSD "requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms an in-service stressor; and credible supporting evidence that the in-service stressor occurred." 38 C.F.R. § 3.304(f). Generally, when the claimed stressor is not related to combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must contain service records or other corroborative evidence that substantiates the veteran's testimony or statements as to the occurrence of the claimed stressors. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). However, when the claimed PTSD stressor is physical or sexual assault in service, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and, statements from family members, roommates, fellow service members or clergy. Evidence of behavior changes following the claimed assault is one type of evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. 38 C.F.R. § 3.304(f)(4). Further, when the claimed PTSD stressor is physical or sexual assault in service, credible supporting evidence may also consist of a medical opinion, based on review of the evidence, that the personal assault occurred. 38 C.F.R. § 3.304(f)(4) (emphasis added). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests a psychosis to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2009); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis: Service Connection for Psychiatric Disability As noted below, the Veteran has been diagnosed with PTSD, depressive disorder, unspecified anxiety disorder and unspecified mood disorder. The first element of service connection, medical evidence of a disability, is accordingly satisfied. However, evidence of a present condition is generally not relevant to a claim for service connection, absent some competent linkage to military service. Mingo v. Derwinski, 2 Vet. App. 51, 53 (1992). In regard to psychiatric disorders other than PTSD, a decision by the SSA granted the Veteran disability benefits for anxiety- related disorder (primary diagnosis) and mood disorder (secondary diagnosis) effective from July 2005. She was also diagnosed with "depression" or "depressive disorder" by various providers as concomitant with PTSD, but there is no indication that any such disorders are related to service. Careful review of the Veteran's STRs, which are extensive, shows that in July 1982 she presented to the Yongsan Army Hospital (Korea) requesting a profile for a "nervous condition" due to reported family history of problems adjusting to new surroundings, but the physician made no comment as to any current observed psychiatric symptoms. STRs are otherwise silent in regard to any psychiatric complaints or abnormal findings. In February 1987, shortly prior to discharge from service, the Veteran denied a history of nervous trouble, depression or excessive worry. In February 1988, seven months after discharge from service, the Veteran had an employment physical examination for the U.S. Postal Service in which she denied having been treated for a psychiatric disorder but endorsed having used the antidepressant drug Elavil in the past; the examiner noted current mental status as "normal." There is no competent medical opinion of record relating a depressive disorder, unspecified anxiety disorder or unspecified mood disorder to active service. In specific regard to the claimed PTSD, the Veteran asserts she has PTSD due to sexual trauma during service. As noted below, several competent psychologists have diagnosed her with PTSD associated with military sexual trauma (MST). However, just because a physician or other health care professional accepted the appellant's description of his active service experiences as credible and diagnosed the appellant as suffering from PTSD does not mean the Board is required to grant service connection for PTSD. Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). The existence of an event alleged as a "stressor" that caused PTSD, although not the adequacy of the event to cause PTSD, is an adjudicative, not a medical, determination. Zarycki, 6 Vet. App. 91, 97-8. The Veteran has asserted a number of incidents of MST as PTSD stressors. She asserts that during basic training at Fort Jackson, South Carolina the drill sergeants would select recruits with whom they would have forcible sex in return for drugs, alcohol and outside food. When assigned to an Army Aviation unit in Fort Rucker, Alabama the Veteran was raped in barracks by Staff Sergeant DN and subsequently had to have an abortion; she did not report the attack because it would have been her word against that of an NCO, but she was allowed to live outside barracks to remove her from the proximity of the NCO in question. While assigned to duty at Fort Meade, Maryland she was forcibly groped by Captain MC, but she fought him off; he threatened to end her career if she reported the attack. Many years after discharge from service she had a chance encounter with ex-Captain MC at a VA facility, which aggravated her PTSD symptoms. A VA psychiatrist in July 2003 diagnosed MST, depression and chronic pain. The record also contains letters and treatment records from private psychiatrist Dr. EWH, summarized as follows. In letters dated in April 2005, November 2005, April 2008 and October 2008, Dr. EWH diagnosed the Veteran with chronic PTSD and chronic major depression related to sexual harassment in the military. Dr. EWH stated the Veteran reported to him that she began having symptoms in service (nightmares, anxiety, sleep disruption) and currently had similar symptoms of nightmares, panic attacks and flashbacks. The Veteran underwent a 12-session series of VA treatments for MST-related PTSD from August to October 2006; the treatment notes from those sessions are of record. Her diagnoses throughout those sessions were PTSD, MST, history of sexual abuse and depressive disorder. The Veteran is competent to report events during active service. However, once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence if contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board may not ignore a veteran's testimony simply because he or she is an interested party and stands to gain monetary benefits; personal interest may, however, affect the credibility of the evidence. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). In this case the Board finds the Veteran's account of MST during active service, as presented to VA adjudicators and to various treatment providers, is not credible because it is inconsistent with objective evidence of record. Review of STRs confirms that in January 1981 (Fort Rucker) the Veteran was pregnant and requested information on therapeutic abortion (TAB), and she underwent a voluntary interruption of pregnancy (VIP) the same month. In September 1982 (Yongsan, Korea), and September 1983 (Fort Meade) she either requested pregnancy tests or was clinically suspected of being pregnant, and on three occasions while assigned to Norton Air Force Base (California) she also requested pregnancy tests or was clinically suspected of being pregnant (June 1985, November 1985 and February 1986). Thus, while the STRs confirm the Veteran had a terminated pregnancy at Fort Rucker, they also indicate the Veteran was sexually active throughout her entire period of service and that the pregnancy at Fort Rucker may not have been due to rape as she now contends. The Veteran's service personnel records (SPRs) are associated with the claims file. Review of the SPRs shows no indication of disciplinary actions, adverse personnel actions, drop in performance or requests for reassignment; in fact, the Veteran reenlisted in 1983 for four additional years of active duty and was eventually promoted to the rank of Sergeant. During service she was awarded the Army Achievement Medal, the Army Commendation Medal and the Joint Service Medal; according to her own account she was approved for promotion to the next higher rank at the time of her discharge from service. Also, although the Veteran reports she was allowed to live outside barracks at Fort Rucker to separate her from her reported abuser, there is no indication in SPRs that the Veteran was granted Basic Allowance for Quarters (BAQ) to live off base (while at Fort Rucker the Veteran was granted Basic Allowance for Subsistence, otherwise known as "separate rations," because she reported mess hall food made her sick, but there is no indication she was granted BAQ). In a self-reported Report of Medical History in February 1987, shortly prior to discharge from service, the Veteran denied history of nervous trouble of any sort; she also denied depression or excessive worry and denied frequent trouble sleeping. Thus, her reports to Dr. EWW of onset of nightmares and trouble sleeping in service are inconsistent with her own statements at the time of her discharge from service. Given that the Veteran demanded in writing at the time of her discharge to know what disability benefits she would receive, it does not appear that she would have been hesitant to report all her current symptoms. Significantly, a VA outpatient interdisciplinary assessment in December 2001 states the Veteran denied history of MST; depression screen was also negative. Similarly, in February 2003 she denied stressful experience such as being sexually assaulted or raped, and PTSD screen at the time was negative. It was not until July 2003 that the Veteran began to allege MST. The Veteran was referred to the VA mental health clinic in July 2003 for a positive response during depression screen in which she had stated she took little interest or pleasure in things; the Veteran reported that during service she had been sexually harassed in the form of being offensively touched, although she did not provide a direct "yes" or "no" answer when she was asked if she had been raped. It was at this point that a VA psychiatrist first diagnosed MST. The Board notes that the Veteran's reports of MST, which have become increasingly lurid as the claim has progressed, are inconsistent with her previous repeated denials of MST prior to July 2003. Also probative regarding the Veteran's credibility is an examination report by a VA neuropsychologist in August 2006, performed due to the Veteran's concerns about increased severity of memory deficits over the past six months. The psychologist continued the current diagnosis of PTSD, but stated the Veteran appeared to be purposefully feigning problems for secondary gain or unconsciously converting stress and exaggerating symptoms to obtain security and support from others. The various psychiatrists and psychologists who have noted PTSD as due to MST appear to have done so based only on the Veteran's self-reported history, rather than review of the complete record. A medical professional's opinion based on a post-service examination of a veteran is not competent evidence that an in- service stressor occurred. Cohen v. Brown, 10 Vet. App. 128, 145 (1997); Moreau, 9 Vet. App. 389, 395-96. To the degree that the medical providers have based their opinions on the Veteran's self-reported accounts of MST, the Board has found such reports to be not credible, and it follows that medical opinions based on such reports are not probative. Further, because such medical opinions are not based on review of the evidence they do not constitute verification of MST under 38 C.F.R. § 3.304(f)(4). The Veteran's mother submitted letters in August 2005 and December 2007 stating the Veteran's personality changed after she joined the service. While the Veteran was in basic training she called her mother and reported sexual harassment and abuse, but the Veteran did not report the abuse at the time because she did not know anyone she could trust. One night the Veteran called her mother and reported she had an abortion due to rape; the Veteran's mother wanted to pursue legal action against the responsible NCO but feared the consequences to the Veteran had she done so. When the Veteran's mother was seriously ill, the Veteran requested a hardship transfer, which was refused. When the Veteran's mother was able to visit the Veteran, she found the Veteran to be heavily medicated, socially isolated and with a completely changed personality. As a layperson, the Veteran's mother can certainly provide an eyewitness account of the Veteran's visible symptoms at any given time. Espiritu , 2 Vet. App. 492, 494. However, STRs disprove that the Veteran was heavily medicated during service (the Veteran similarly reported to the VA neuropsychologist in August 2006 that she had been very heavily medicated for pain and anxiety at the time of her discharge from service, but the neuropsychologist was able to verify only that the Veteran had been prescribed at the time for a pain reliever, a muscle relaxant and an anti-inflammatory). There is no indication in SPRs that the Veteran requested a hardship transfer as her mother now asserts. While the Veteran's contemporaneous account to her mother of MST must be considered probative, they are insufficient by themselves to verify the stressors since the Veteran's herself denied MST on several occasions after discharge from service. In support of her stressors the Veteran also submitted an August 2005 statement from her friend VRR stating the Veteran's personality had changed dramatically since their school days together. VRR stated the Veteran had informed her of the MST incidents in basic training, Fort Rucker and Fort Meade as described above. Similarly, the file contains a November 2006 letter from retired Master Sergeant (MSG) WAM asserting the Veteran became a "complete and total vegetable" due to abuses by senior officers during active service. There is no indication that either VRR or WAM have any knowledge of the purported stressors other than reliance on the Veteran's own account, which has been deemed to be insufficiently credible. In sum, the Board finds that service connection for PTSD may not be granted because the Veteran has not presented verified or verifiable stressors, and service connection for a psychiatric disorder other than PTSD may not be granted because there is no evidence that such disorder began during service or is etiologically related to service or that the Veteran manifested a psychosis within one year after her discharge from service. Because the evidence preponderates against the claim the benefit- of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. Evaluation of Service-Connected Disabilities General Rating Principles Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2010). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2010). 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. In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare- ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the veteran's ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In both initial rating claims and normal increased rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2 (2010) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service- connected disabilities. The Board has found nothing in the historical record that would lead to the conclusion the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion this case presents no evidentiary considerations that would warrant an exposition of remote clinical histories and findings pertaining to the disabilities on appeal. A. Right Elbow Disability The Veteran is right-handed. Accordingly, the rating criteria cited below refer to the dominant (major) extremity. Disabilities of the ulnar nerve are rated under the criteria of 38 C.F.R. § 4.124a (Diseases of the Peripheral Nerves), Diagnostic Code (DC) 8516 (complete or incomplete paralysis), DC 8616 (neuritis) and DC 8717 (neuralgia). The rating criteria for all these DCs are as follows. A rating of 10 percent is awarded for mild incomplete paralysis of the major extremity. A rating of 30 percent is awarded for moderate incomplete paralysis of the major extremity. A rating of 40 percent is awarded for severe incomplete paralysis of the major extremity. A rating of 60 percent is awarded for complete paralysis of the ulnar nerve in the major extremity (with "griffin claw" deformity due to flexor contraction of the ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers; cannot spread the fingers or reverse; cannot adduct the thumb; flexion of wrist weakened). A note to the rating schedule states the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the "mild" or at most the "moderate" degree. For reference, normal range of motion of the elbow is flexion 0 degrees to 145 degrees. Normal forearm supination is 0 degrees to 85 degrees, and normal forearm pronation is 0 degrees to 80 degrees. 38 C.F.R. § 4.71a, Plate I. Historically, an unappealed rating decision in May 2004 continued the current 10 percent rating. The instant request for a higher rating was received in October 2006. The report of a VA neurology consult dated in June 2004 notes there was no evidence of any neurological abnormality. Significantly, the examiner noted the Veteran appeared to be exaggerating her symptoms in that she complained vociferously of pain when touched on the right upper extremity (RUE) by the examiner, or with any motion of the RUE, but she carried a heavy bag with her right hand and shoulder with no apparent discomfort. A July 2007 letter from chiropractor Dr. RWW states he had been treating the Veteran since March for pain in the right arm and wrist associated with ulnar entrapment and cubital tunnel syndrome that had required a medial epicondylectomy. The pain in the right wrist and fingers could be due to adhesions since surgery. Chiropractic treatment had caused improvement in range of motion and decrease in pain and spasm. The Veteran had a VA examination in July 2007 in which she complained of stinging pain radiating up from the elbow and down into the hand; she also reported she had weakness of the right hand and would sometimes drop objects. She stated the pain was constant and severe every day, not occurring in flares. She reported taking pain medication without significant side effects. Motor examination showed mild weakness of the right finger flexors and mild weakness in elbow flexion and extension (4/5). Sensory examination showed decreased pain sensation and decreased vibratory sensation in the thumb, fourth and fifth fingers of the right hand. The ulnar aspect of the elbow was tender but the elbow had no deformity or crepitation. Range of motion testing of the right elbow disclosed extension to 0 degrees without pain and flexion to 140 degrees, with pain at 140 degrees. Supination and pronation were both 0 degrees to 90 degrees, without pain. Repetition of motion caused no loss of motion secondary to pain, weakness, fatigue or lack of endurance. Reflexes were 2+. The muscles were normal in tone and bulk, without atrophy. There were no tremors, tics or other abnormal movements. X-ray examination of the right elbow showed post surgical changes of the medial epicondyle but was otherwise unremarkable. The examiner diagnosed ulnar neuropathy of the right arm and postoperative medial epicondylectomy. The Veteran stated during examination that she had not been employed for the past four years, having lost her job as a teacher due to stress and depression, but she stated she had missed workdays due to taking for her various musculoskeletal disorders. She also stated that right arm pain interfered with occupational motions such as writing on a chalkboard, repeated writing and use of a computer. The examiner stated the Veteran's disability would cause moderate impact on activities of daily living (ADLs) such as chores, shopping and exercise, and would cause mild impact on ADLs including feeding, bathing, dressing, toileting and grooming. A decision by the SSA granted the Veteran disability benefits for anxiety-related disorder (primary diagnosis) and mood disorder (secondary diagnosis) effective from July 2005. SSA records are silent as to the severity of the right arm disability. The record contains an undated letter from Ms. VR, received in October 2008, and an October 2008 letter from Ms. RMJ. Both letters recount the Veteran's current difficulty caring for herself due to multiple medical and psychiatric problems, but neither letter addresses the right elbow/right arm disability specifically. On review of the evidence above the Board finds the Veteran's disability picture most closely approximates mild incomplete paralysis of the ulnar nerve. The most recent VA examiner characterized the impact of the disabilities on ADLs as ranging between "mild" to "moderate." However, the definition of "complete" paralysis is based primarily on flexion and contraction of the fingers, and the same examiner characterized the weakness of the right finger flexors and the weakness of elbow flexion and extension as "mild." It is accordingly clear that the degree of paralysis as defined by the rating schedule more closely approximates "mild" than "moderate." Although the Veteran complains of significant loss of function of the right arm, to include weakness of grip, she has been clinically noted to exaggerate the severity of her symptoms and her motor strength is objectively measured as 2+. On examination she has near-normal range of motion of the elbow that would not be compensable under any applicable diagnostic code in 38 C.F.R. § 4.71a. There is no indication of muscle atrophy or spasm. The Veteran complains of subjective pain, but the current 10 percent rating is an appropriate compensation for pain. The Board has considered whether a "staged rating" may be assigned, but the criteria for higher evaluation are not shown during any definable period during the course of the appeal. Hart, 21 Vet. App. 505. The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(a). In determining whether a case should be referred for extra- schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case the manifestations of the service-connected disability are contemplated by the schedular criteria. The Board has therefore determined that referral of this case for extra- schedular consideration under 38 C.F.R. § 3.321 is not in order. B. Right Foot Disability Hallux valgus is rated under the criteria of 38 C.F.R. § 4.71a, DC 5280 (hallux valgus, unilateral). A rating of 10 percent is awarded for hallux valgus operated with resection of the metatarsal head, as well as for severe hallux valgus equivalent to amputation of the great toe. There is no provision for a rating higher than 10 percent. Under the "amputation rule" the combined rating for disabilities of an extremity may not exceed the rating for the amputation at the elective level, were the amputation to be performed. 38 C.F.R. § 4.68. Amputation of the great toe is rated under the criteria of DC 5171, under which a rating of 10 percent is awarded for amputation without metatarsal removal. A rating of 30 percent is awarded for amputation with removal of the metatarsal head. Historically, a rating decision in February 2002 continued the current 10 percent rating for postoperative right hallux valgus with bunionectomy and osteotomy of the right great toe. The instant request for a higher rating was received in October 2006. The Veteran had a VA examination of the feet in July 2007 in which she complained of severe pain in the right great toe, constant and not associated with flare-ups. She treated the pain with ointment and used an orthotic shoe, with only partial relief. The Veteran reported she had not worked for the past four years, having lost her job as a teacher due to stress and depression, but stated her foot pain made her unable to be on her feet all day as would be expected of a teacher. She stated she could perform all ADLs but could only walk about a block and could only stand for a few minutes. On examination the Veteran had a slow and unsteady gait, although without evidence of abnormal weight bearing. There was objective evidence of pain with assisted and passive ranges of motion. Repetitive motion caused no additional limitation of function. There was tenderness over the first MTP area but no swelling, instability or weakness. The hallux valgus had been corrected by surgery and the angle was now 12 degrees. There was no skin or vascular foot abnormality. There were no flat foot and no malalignment of the Achilles tendon or of the forefoot or midfoot. There was no muscle atrophy of the foot or other foot deformity. X-rays of the right foot showed bunionectomy of the right great toe and mild degenerative changes of the first MTP joint but were otherwise unremarkable. The examiner's diagnosis was right great toe hallux valgus, postoperative bunionectomy and osteotomy with DJD. A decision by the SSA granted the Veteran disability benefits for anxiety-related disorder (primary diagnosis) and mood disorder (secondary diagnosis) effective from July 2005. SSA records are silent as to the severity of the right foot disability. The record contains an undated letter from Ms. VR, received in October 2008, and an October 2008 letter from Ms. RMJ. Both letters recount the Veteran's current difficulty caring for herself due to multiple medical and psychiatric problems, but neither letter addresses the right foot disability specifically. On review of the evidence above, the Board notes the Veteran's current 10 percent rating is the highest evaluation available under the applicable rating criteria; it is also the highest evaluation available under the "amputation rule." The Veteran was shown on examination to have DJD of the MTP joint. Where medical evidence shows claimant has arthritis, and where the diagnostic code applicable to the disability is not based on limitation of motion, as in this case, a separate rating may be assigned if there is additional disability due to limitation of motion. VAOPGCPREC 23-97 (July 1, 1997); see also Hicks v. West, 8 Vet. App. 417 (1995). However, there is no indication in this case that there is additional disability due to limitation of motion of the great toe. Painful motion of a major joint or groups caused by degenerative arthritis, where the arthritis is established by X-ray, is deemed to be limited motion and entitled to a minimum 10 percent rating, per joint, combined under DC 5003, even though there is no actual limitation of motion. VAOPGCPREC 09-98 (August 14, 1998), citing Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). The Veteran's current 10 percent rating satisfies Lichtenfels. The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(a). In this case the manifestations of the service-connected disability are contemplated by the schedular criteria, and the Board has therefore determined that referral of this case for extra- schedular consideration under 38 C.F.R. § 3.321 is not in order. Thun, 22 Vet. App. 111, 115. ORDER As new and material evidence has not been received, reopening of the claim for service connection for a left foot disability is denied. As new and material evidence has not been received, reopening of the claim for service connection for migraine headaches is denied. As new and material evidence has not been received, reopening of the claim for service connection for a cervical spine disability is denied. Service connection for a psychiatric disability, to include PTSD, is denied. A rating higher than 10 percent for right ulnar neuropathy with postoperative epicondylectomy is denied. A rating higher than 10 percent for postoperative right hallux valgus with bunionectomy and osteotomy of the right great toe is denied. ______________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs