Citation Nr: 1300552 Decision Date: 01/08/13 Archive Date: 01/16/13 DOCKET NO. 07-17 388A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to ratings in excess of 10 percent for patellofemoral syndrome of the right knee. 2. Entitlement to a rating in excess of 10 percent for patellofemoral syndrome of the left knee. 3. Entitlement to a rating in excess of 10 percent for arthritis of the right knee. 4. Entitlement to a compensable rating for arthritis of the left knee. 5. Entitlement to a rating in excess of 10 percent for pseudofolliculitis barbae (PFB). 6. Entitlement to an initial compensable rating for a burn scar on the right ankle. 7. Entitlement to a compensable rating in for chronic bronchitis prior to April 21, 2009. 8. Entitlement to a rating in excess of 10 percent for chronic bronchitis since April 21, 2009. 9. Whether new and material evidence has been submitted in order reopen a claim of entitlement to service connection for a gastroesophageal disorder, diagnosed as gastroesophageal reflux disorder (GERD) and hiatal hernia. 10. Whether new and material evidence has been submitted in order to reopen a claim of entitlement to service connection for otitis media. 11. Whether new and material evidence has been submitted in order to reopen a claim of entitlement to service connection for temporomandibular joint (TMJ) syndrome. 12. Whether new and material evidence has been submitted in order to reopen a claim of entitlement to service connection for a low back disorder. 13. Entitlement to service connection for a low back disorder. 14. Entitlement to service connection for "side effects of medication." 15. Entitlement to service connection for bilateral hearing loss. 16. Entitlement to service connection for sleep apnea. 17. Entitlement to service connection for diabetes mellitus. 18. Entitlement to service connection for a cardiovascular disorder. 19. Entitlement to service connection for a bilateral foot disorder. 20. Entitlement to service connection for fibromyalgia. 21. Entitlement to service connection for a muscle disorder. 22. Entitlement to service connection for a bilateral elbow disorder. 23. Entitlement to service connection for an eye disorder, characterized as blepharitis and presbyopia. REPRESENTATION Appellant represented by: Fleet Reserve Association WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD B. Thomas Knope, Counsel INTRODUCTION The Veteran served on active duty from September 1986 to January 1998. This matter is on appeal from decisions in June 2005, August 2007 and May 2009 by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The Veteran testified before the undersigned hearing officer in August 2012. A transcript of the hearing is of record. An appeal for the issue of entitlement to service connection for tinnitus was also perfected in the Veteran's February 2009 VA Form-9. However, in an August 2011 decision, he was granted service connection for this disorder. This represents a full grant of the benefit sought on appeal, and it is no longer before the Board. See Shoen v. Brown, 6 Vet. App. 456, 457 (1994). The Veteran has recently provided evidence relating to his eye disorder claim which was submitted since the most recent statement of the case. However, in a July 2012 statement, he clearly anticipated that he would be submitting additional evidence in the future, and waived his right to initial consideration by the RO. Therefore, there is no prejudice in adjudicating the claim. The issues of entitlement to service connection for a low back disorder and fibromyalgia 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 patellofemoral syndrome in each of the Veteran's knees has been characterized by degenerative arthritis with some pain in movement and limitation to a noncompensable level; limitation of flexion to 30 degrees, limitation of extension to 15 degrees, a combination or the two, favorable ankylosis of the knee at full extension or in slight flexion between 0 and 10 degrees, a tear to the meniscus or instability in any form has not been shown. 2. The Veteran's PFB has been characterized by ingrown hairs, itchiness, inflammation and some pustules on the face and neck; visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired sent of features (such as nose, chin, forehead, eyes, etc.) or two or three characteristics of disfigurement have not been shown. 3. The scar on the Veteran's right ankle has been characterized by slight irritation; a deep scar an area or areas exceeding 6 sq. in., a superficial scar of an area of 144 sq. in., or a scar that is superficial and either unstable or painful upon examination is not shown. 4. Prior to April 21, 2009, the Veteran's bronchitis has been characterized by chest pain and coughing; a Forced Expiratory Volume in one second (FEV-1) of 71-80 percent of predicted value; a ratio of FEV-1 to Forced Vital Capacity (FEV-1/FVC) of 71-80 percent, or a Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO) of 66-80 percent predicted has not been shown. 5. Since April 21, 2009, the Veteran's bronchitis has been characterized by the use of medications for bronchitis and a DCLO of 71 percent; a FEV-1 of 56-70 percent of predicted value, a FEV-1/FVC of 56-70 percent, or a DLCO of 56-65 percent predicted have not been shown. 6. In February 1998, the RO issued a decision denying service connection for GERD, a TMJ disorder, otitis media and a low back disorder; the Veteran did not appeal this decision, nor did he submit additional relevant evidence within a year of that decision, and it is the last final denial of these claims. 7. The evidence added to the record since February 1998 is not new and material to an unestablished fact necessary to support entitlement to service connection a TMJ disorder, GERD or otitis media, but is new and material to an unestablished fact necessary to support entitlement to service connection for a low back disorder. 8. Bilateral hearing loss, a cardiovascular disorder, bilateral foot disorder, muscle disorder, bilateral elbow disorder, and "side effects of medication" are not currently shown. 9. Diabetes mellitus, sleep apnea and a chronic eye disorder were not shown in service or for many years thereafter, and are unrelated to active duty service. CONCLUSIONS OF LAW 1. The criteria rating in excess of 10 percent for patellofemoral syndrome in the right knee have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DCs 5257-5259 (2012). 2. The criteria rating in excess of 10 percent for patellofemoral syndrome in the left knee have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DCs 5257-5259 (2012). 3. The criteria rating in excess of 10 percent for arthritis in the right knee have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DCs 5003, 5010, 5256, 5260-5261 (2012). 4. The criteria for a 10 percent rating, but no more, for arthritis in the left knee have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DCs 5003, 5010, 5256, 5260-5261 (2012). 5. The criteria for a rating in excess of 10 percent for PFB have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.118, DCs 7800 (2008 & 2012). 6. The criteria for an initial compensable rating a burn scar on the right ankle have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.118, DCs 7801-7804 (2008 & 2012). 7. The criteria for a compensable rating in for chronic bronchitis prior to April 21, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.97, DC 6600 (2012). 8. The criteria for a rating in excess of 10 percent for chronic bronchitis since April 21, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.97, DC 6600 (2012). 9. The February 1998 rating decision that denied the Veteran's claims for entitlement to service connection for GERD, otitis media, TMJ disorder and a low back disorder is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 3.104 (2012). 10. The evidence received subsequent to the February 1998 rating decision is not new and material and the requirements to reopen the claim for entitlement to service connection for a gastroesophageal disorder, diagnosed as GERD and hiatal hernia, have not been met. 38 U.S.C.A. §§ 5103, 5103A, 5108, 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156, 3.159 (2012). 11. The evidence received subsequent to the February 1998 rating decision is not new and material and the requirements to reopen the claim for entitlement to service connection for otitis media have not been met. 38 U.S.C.A. §§ 5103, 5103A, 5108, 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156, 3.159 (2012). 12. The evidence received subsequent to the February 1998 rating decision is not new and material and the requirements to reopen the claim for entitlement to service connection for TMJ disorder have not been met. 38 U.S.C.A. §§ 5103, 5103A, 5108, 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156, 3.159 (2012). 13. The evidence received subsequent to the February 1998 rating decision is new and material and the requirements to reopen the claim for entitlement to service connection for a low back disorder have been met. 38 U.S.C.A. §§ 5103, 5103A, 5108, 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156, 3.159 (2012). 14. "Side effects of medication" was not incurred in or aggravated by service, are not related to service and are not currently shown. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2012). 15. Bilateral hearing loss was not incurred in or aggravated by service, is not related to service and is not currently shown. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.385 (2012). 16. Sleep apnea was not incurred in or aggravated by service, and is not related to service. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2012). 17. Diabetes mellitus was not incurred in or aggravated by service, and is not related to service. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2012). 18. A cardiovascular disorder was not incurred in or aggravated by service, is not related to service and is not currently shown. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2012). 19. A bilateral foot disorder was not incurred in or aggravated by service, is not related to service and is not currently shown. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2012). 20. A muscle disorder was not incurred in or aggravated by service, is not related to service and is not currently shown. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2012). 21. A bilateral elbow disorder was not incurred in or aggravated by service, is not related to service and is not currently shown. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2012). 24. An eye disorder, characterized as blepharitis and presbyopia, was not incurred in or aggravated by service and is not related to service. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Here, neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 556 U.S. 396 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, the VCAA duty to notify was satisfied by way of a letters sent to the Veteran in March 2009 and February 2011 that fully addressed all notice elements. The letters informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. For the claims that have been previously denied, the letters provide the claimant with notice of the basis of the last final denial, as well as what evidence would be necessary in order to reopen the claim. Kent v. Nicholson, 20 Vet. App. 1 (2006). These letters also provided the Veteran with notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. While the Board acknowledges that the February 2011 letter was not sent to the Veteran prior to the initial rating decision, the issues were subsequently adjudicated by the RO in August 2011. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the RO's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the RO); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). Therefore, adequate notice was provided to the Veteran and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). First, the RO has obtained the Veteran's service treatment records and VA outpatient treatment records. Further, the Veteran submitted treatment records from a private facility. Additionally, VA examinations with respect to the issues on appeal were obtained in March 2002, May 2005, February 2007, April 2009 and February 2011. 38 C.F.R. § 3.159(c) (4). To that end, when VA undertakes to provide a VA examination or, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this case, the Board finds that the VA examinations obtained are more than adequate, as they are predicated on a full understanding of the Veteran's medical history and provide a sufficient evidentiary basis for the claim to be adjudicated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4). With regard to the Veteran's service connection claims, the Board acknowledges that a VA medical opinion was not obtained to determine the nature and etiology of these disorders. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Board notes that the Federal Circuit, in a recent decision, upheld the determination that a VA medical examination is not required as a matter of course in virtually every veteran's disability case involving a nexus issue. Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (distinguishing cases where only a conclusory generalized statement is provided by the veteran, in which case an examination may not be required). In this case, the disorders on appeal were either not shown in service or not shown currently. Therefore, the Board finds that a remand for a VA opinion would not be beneficial in the adjudication of these issues to the extent that they were denied, and are thus not required in this case. As for the previously denied claims, VA need not conduct an examination with respect to the claim of whether new and material evidence has been received to reopen previously denied claim of entitlement to service connection because the duty under 38 C.F.R. § 3.159(c)(4) applies to a claim to reopen only if new and material evidence is presented or secured. Paralyzed Veterans of America v. Secretary of Veterans Affairs, 345 F.3d 1334 (Fed. Cir. 2003) (holding that VA need not provide a medical examination or medical opinion until a claim is reopened). See also Woehlaert v. Nicholson, 21 Vet. App. 456 (holding that adequacy of VA medical examination mooted upon Board's determination that claimant not entitled to reopening of claim, and conduct of VA medical examination, when claimant had not presented new and material evidence.) Finally, the Veteran was afforded a hearing before the Board in August 2012. The individual presiding over such a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2), which consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties were met in this case, as the issues on appeal were identified at the hearing, relevant testimony was elicited regarding all issues on appeal, and sources of evidence relevant in this regard were identified during this process. Therefore, the Board does not find that either hearing was deficient, and the Veteran has not asserted otherwise. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45 (2012). The Court of Appeals for Veterans Claims has held that the RO must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The Board notes that the guidance provided by the CAVC in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are as entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See 38 C.F.R. § 4.59 (2012). In cases where the Veteran's claim arises from a disagreement with the initial evaluation following the grant of service connection, the Board shall consider the entire period of claim to see if the evidence warrants the assignment of different ratings for different periods of time during these claims a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). On the other hand, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Knees Regarding knee claims, a claimant who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257 or 5258/5259. See VAOPGCPREC 23-97. For example, when a knee disorder was already rated under DC 5257 (addressing lateral instability), the a separate rating may be warranted if the Veteran's knee also shows limitation of motion which at least meets the criteria for a zero-percent rating under DC 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more). Moreover, a separate rating could also be warranted under 38 C.F.R. § 4.59, based on X-ray findings of arthritis with painful motion. See VAOPGCPREC 9-98; see also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). In addition, the General Counsel has also held that separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint. VAOPGCPREC 09-04. In this case, the Veteran is rated at 10 percent for patellofemoral syndrome in each knee under 38 C.F.R. § 4.71a, DC 5257 (addressing recurrent subluxation and lateral instability). He also has a separate 10 percent rating for the right knee under DC 5010 (addressing traumatic arthritis). Statements of the case beginning in August 2011 state that the Veteran also has a 10 percent rating for arthritis in his left knee. This was erroneous, as his rating decisions routinely reflect that he does not have a compensable rating for arthritis in his left knee. Nevertheless, since the Board must always consider whether separate ratings are warranted when evaluating knee claims, there is no prejudice to the Veteran by continuing to adjudicate the claim. The Board first addresses what the appropriate ratings are for his knees based on limitation of motion. As an initial matter, a 10 percent rating is warranted for arthritis in the left knee. Specifically, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined but not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003, Note (1) (2012). Here, a MRI of the knees in September 2001 reflects early osteoarthritis in both knees. Moreover, VA examinations in April 2009 and February 2011 indicate less than normal range of motion in both knees. Therefore, in addition to the 10 percent rating the Veteran already has for his right knee based on arthritis, a 10 percent rating is also warranted for his left knee under DC 5003. Next, the Board considers whether a rating in excess of 10 percent for either of the Veteran's knees based on traumatic arthritis under DC 5010. Disabilities under this diagnostic code are rated based on limitation of the affected part in the same manner as arthritis. In order to warrant an increased rating for his left knee based solely on limitation of motion, the evidence must show: * Limitation of flexion to 30 degrees (20 percent under DC 5260); * Limitation of extension to 15 degrees (20 percent under DC 5261); * Limitation of flexion to 45 degrees and limitation of extension to 15 degrees (two separate 10 percent ratings under DCs 5260 and 5261, respectively); or * Favorable ankylosis of the knee at full extension or in slight flexion between 0 and 10 degrees (30 percent under DC 5256). See 38 C.F.R. § 4.71a (2012). After a review of the pertinent evidence, the Board determines that a rating in excess of 10 percent is not warranted for either knee based on limitation of motion. Specifically, at a VA examination in May 2005, he complained of pain in the knees that stiffens when he sits for a prolonged period of time. Upon examination, he moved his knees slowly and walked with guarding. Active range of motion was from 0 degrees of extension and 115 degrees of flexion bilaterally. There was slowing of movement, but no further loss in range of motion after repetitive movement. At another VA examination in February 2007, he claimed that he has difficulty driving, and that symptoms were aggravated by prolonged sitting, standing and walking. He claimed of "extreme pain" to the point that a physical examination of his knees was not conducted. At a VA examination in April 2009, the Veteran complained of a "popping sound" in his knees, especially when he gets up from a chair. Upon examination, he was observed to walk without a limp, and alignment of the knees was essentially normal. Range of motion was 0 degrees of extension and 135 degrees of flexion in the right knee, and 0 degrees of extension and 110 degrees of flexion in the left knee. No increase in symptoms was observed upon repetitive motion. At his most recent VA examination in February 2011, the Veteran stated that he had undergone a number of cortisone injections, but they did not produce any relief. He had been experiencing increasing pain when doing things like bending, kneeling, and climbing stairs. Upon examination, no warmth or swelling was observed and there was tenderness upon palpation around the patella. However, the range of motion in both knees included 0 degrees of extension and 130 degrees of flexion. Mild crepitance was observed at 125 degrees. Of the outpatient treatment notes that address the Veteran's knee complaints, most address the presence of pain in the knees. Of note, one treatment in October 2004 he was observed to walk without any limp and, although there was patellar inhibition observed in both knees, he exhibited a full range of motion in both knees. When evaluating the extent of the Veteran's disability in terms of range of motion, the Board also considered the functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-07 (1995). In this case, however, it appears that he experiences pain at all points in motion. The mere presence of pain does not, by itself, constitute functional loss. Rather, the pain must affect some aspect of the normal working movements of the body such as strength, speed, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 37-43 (2011). Put another way, while the Veteran has complained of pain, these complaints are adequately contemplated in the ratings he currently receives. Next, the Board considers whether a rating in excess of 10 percent is warranted for either knee based on instability or cartilage symptoms. In order to warrant a separate rating for this type of disorder, the evidence must show one of the following: * Dislocation of the semilunar cartilage with frequent episodes of "locking," pain and effusion in the joint (20 percent under DC 5258); or * Recurrent subluxation or lateral instability (under DC 5257; 20 percent for moderate symptoms, and 30 percent for severe symptoms). See 38 C.F.R. § 4.71a. Here, the Board determines that a rating in excess of 10 percent is not warranted for either knee based on instability or symptoms related to the semilunar cartilage. Specifically at his VA examination in May 2005, he stated that he wears knee braces. However, no pathology to the semilunar cartilage was observed, there were no complaints of locking, and there was no instability to either knee on valgus or varus stress. At his VA examination in February 2007, the ligaments in both knees were observed to be intact, and the medial and lateral menisci of both knees were intact without any evidence of tear. Moreover, at his most recent VA examination in February 2011, no gross valgus or varus instability was observed, the X-rays taken of the knees was substantially normal. Significantly, there is no observation or complaint of instability of either knee in any of the outpatient treatment notes. Therefore, the Board concludes that a 10 percent rating is warranted for arthritis in the left knee under 38 C.F.R. § 4.71a, DC 5003. However, a rating in excess of 10 percent based on arthritis is not warranted for either knee, nor is a separate rating in excess of 10 percent warranted based on instability or symptoms related to the semilunar cartilage. The appeals are denied to this extent. PFB The Veteran is currently rated at 10 percent for his PFB by analogy under 38 C.F.R. § 4.118, DC 7806 (addressing dermatitis or eczema). Dermatophytosis type disorders, to include PFB, are rated as disfigurement to the head, face or neck (DC7800), scars (DCs 7801-7805) or dermatitis (DC 7806), whichever is the predominant. Here, the disorder involves the face and neck, and the Veteran has been rated based on disfigurement. As an initial matter, the Board notes that the rating criteria for evaluating skin disfigurement and scars under 38 C.F.R. § 4.118, DCs 7800-7805 were amended during the pendency of this appeal (effective October 23, 2008). However, the revised criteria apply only to applications for benefits received by VA on or after the effective date of October 23, 2008. See 73 Fed. Reg. 54,710 (Sept. 23, 2008). It should be noted that a veteran who is rated under DCs 7800 to 7805 before October 23, 2008 may request review under the amended diagnostic codes, irrespective of whether the Veteran's disability has increased since the last review. In such cases, VA will review that veteran's disability rating to determine whether the Veteran may be entitled to a higher disability rating under diagnostic codes 7800, 7801, 7802, 7804, and 7805, but in no case will the revised award be effective before October 23, 2008 In this case, the Veteran's claim for an increased rating was received by the RO in March 2005, which precedes the effective date of the revised criteria. As this claim was received by VA prior to October 23, 2008, the amended criteria are not applicable and are not considered. Under the pre-amended criteria, a rating in excess of 10 percent for disfigurement to the head face or neck is warranted when the disorder causes * visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired sent of features (such as nose, chin, forehead, eyes, etc.); or * two or three of the following characteristics of disfigurement: - a scar 5 or more inches (13 or more cm.) in length; - a scar at least one-quarter inch (0.6 cm.) wide at widest part; - surface contour of scar elevated or depressed on palpation; - a scar adherent to underlying tissue; - skin hypo-or hyper-pigmentation in an area exceeding six square inches (39 sq. cm.); - skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); - underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and - skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). See 38 C.F.R. § 4.118, DC 7800 (30 percent). Based on a review of the pertinent evidence, an increased rating is not warranted, as there is neither gross distortion of a feature to the head, face or neck. Moreover, while his 10 percent rating has been based on the presence of elevated and depressed surface contour, no additional characteristic of disfigurement has been shown. At a VA examination in May 2005, the Veteran stated that he develops ingrown hair which could become inflamed, painful and puss-filled. While he has used a number of topical creams to treat it, none of them helped. He stated that the rash is "very sensitive and itchy." Upon examination, "significant scarring" was observed with inflamed follicles, but the skin was not scaly, and only covered 6 percent of his total body area. No alopecia or hypohydrosis was observed. Next, at a VA examination in February 2007, he stated that his symptoms had worsened. The VA examiner noted a pus-filled rash, infected follicles and "severe scarring" on the Veteran's face that was "disfiguring" in nature. However, a more recent VA examination in April 2009 appears to contradict the previous examinations. On this occasion, the VA examiner noted that it was "difficult to discern that [the Veteran] had any problems with pseudofolliculitis barbae." Upon examination, sparse razor bumps were observed encompassing less than two centimeters on either side of the neck. The skin was not atrophic, irregular, shiny or scaly, nor were there indications of instability or frequent loss of covering of skin, although the Veteran stated that this occurred during flare-ups. The surface contour was elevated upon palpation, however, there was no underlying tissue dancing. Keloids, inflammation and edema were absent, and there was no gross distortion or asymmetry of any feature. At his most recent VA examination in February 2011, the Veteran reported a flare-up of PFB only a week before. However, upon examination, the examiner generally agreed with the April 2009 findings, in that it was difficult to discern that the Veteran had any problems with PFB. To this examiner, the Veteran appeared "remarkably well clean shaven," and only upon close examination were "sparse razor bumps" evident. The area affected encompassed less than a few centimeters on either side of the neck, and the Veteran denied pain in the affected areas. The skin texture was not irregular, atrophic, shiny or scaly. There was no frequent loss of skin or ulceration. Inflammation, keloid formation or edema was absent, and there was only slight hyperpigmentation. Based on these VA examinations, the Board is willing to concede that the surface contours of the Veteran's scars is elevated or depressed upon palpation, and his disorder includes this characteristic of disfigurement. However, as a scar of any size, hypo or hyperpigmentation, abnormal skin texture, underlying soft tissue missing or inflexible skin has not been shown, there is no indication of a second characteristic of disfigurement. Moreover, there is no evidence that the Veteran has "gross distortion or asymmetry of one feature or paired sent of features," nor has he asserted that such distortion or asymmetry exists. Therefore, a rating in excess of 10 percent is not warranted on this basis. Right Ankle Scar In a May 2009 rating decision, the Veteran was granted service connection for a burn scar on his right ankle with a noncompensable rating under 38 C.F.R. § 4.118, DC 7804 (addressing pain of the scar). As was discussed above, this section was amended during the course of the appeal, effective October 23, 2008. As the Veteran's claim (submitted in September 2007) precedes this amendment, the pre-amended criteria are for application. See 73 Fed. Reg. 54,710 (Sept. 23, 2008). In order to warrant a compensable rating for a scar other than to the head, face or neck, the evidence must show that the scar is: * deep or causing limitation of motion, and of an area or areas exceeding 6 sq. in. (39 sq. cm) (10 percent under DC 7801); * superficial and does not cause limited motion, and of an area of 144 sq. in. (929 sq. cm) or greater (10 percent under DC 7802); * superficial and unstable (10 percent under DC 7803); * superficial and painful upon examination (10 percent under DC 7804). See 38 C.F.R. § 4.118. Under DC 7803, Note 1, a scar is considered "unstable" where, for any reason, there is frequent loss of covering of the skin. It is considered "superficial" when it is not associated with underlying tissue damage. In this case, the evidence does not indicate that a compensable rating is warranted for the scar on his ankle. Specifically, at a VA examination in April 2009, the Veteran stated that he experiences "itchiness" on the scar. However, there is no indication that the scar is painful upon examination. Upon examination, the scar was observed to have underlying tissue damage. However, the scar was only 4.1 cm in length and 2.7 cm in width (approximately 11 square cm). Moreover, there was no skin ulceration or breakdown over the scar, no tenderness to palpation or adherence to underlying tissue. At his most recent VA examination in February 2011, the VA examiner observed a hyperpigmented, nontender scar that was superficial in nature and stable. It was measured as 3 cm in length and 1.5 cm in width (4.5 sq. cm). The scar was not painful upon examination, and was no cosmetic defect was evident. Therefore, an increased rating is not warranted on these bases. In addition to the above criteria, a separate rating is also potentially for application if the scar results in limitation of motion of the affected part. See38 C.F.R. § 4.118, DC 7805. However, a compensable rating is not warranted on this basis, as there was no observed limitation of motion resulting from this scar at either VA examination. Thus, the evidence does not indicate that the Veteran's scar is deep or causing limitation of motion, and of an area or areas exceeding 6 sq. in., superficial and does not cause limited motion, superficial and unstable or superficial and painful upon examination. Moreover, there is no clinical evidence indicating that it causes limitation in range of motion. Therefore, a compensable rating is not for application. Chronic Bronchitis prior to April 21, 2009 Prior to April 21, 2009, the Veteran is had a noncompensable rating for his chronic bronchitis under 38 C.F.R. § 4.97, DC 6600. During the pendency of this appeal, VA amended the ratings schedule concerning respiratory conditions effective October 6, 2006, which clarified the use of pulmonary function tests (PFTs) in evaluating respiratory conditions under DCs 6600, 6603, 6604, 6825-6833, and 6840-6845. See 71 Fed. Reg. 52457 (Sept. 6, 2006). However, the changes which are pertinent to this claim are non-substantive in nature. Thus, in order to warrant a compensable rating under this diagnostic code, the evidence must show the following results from a Pulmonary Function Test (PFT): * a Forced Expiratory Volume in one second (FEV-1) of 71-80 percent of predicted value; or * the ratio of FEV-1 to Forced Vital Capacity (FEV-1/FVC) of 71-80 percent; or * a Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO) of 66-80 percent predicted. 38 C.F.R. § 4.97, DC 6600 (10 percent). Based on the evidence of record, a compensable rating is not warranted for the Veteran's bronchitis prior to April 21, 2009. Specifically, at a VA examination in May 2005, he complained of chest pain and coughing, but denied shortness of breath or dyspnea on exertion. He also denied any episodes of bronchitis since his initial diagnosis. Upon examination, his lungs were clear, and he did not exhibit wheezing, rales or rhonchi. A PFT indicated a FEV-1 of 85 percent predicted and FEV-1/FVC of 83 percent. His diffusion capacity was 64 percent predicted but, when adjusted for alveolar volume, it was 93 percent. Next, at a VA examination in February 2007, the Veteran stated that he had been treated for three to four attacks of bronchitis where he had been treated with antibiotics. He also used over-the-counter medication. However, he was not asthmatic. Upon examination, the lungs were clear to auscultation, inspection and palpation. No PFT was performed. Nevertheless, the evidence of record does not indicate that that the Veteran ever exhibited the necessary PFT results to warrant a 10 percent rating. Therefore, a compensable rating is not warranted prior to April 21, 2009. Chronic Bronchitis since April 21, 2009 In an August 2011 decision, the RO increased the Veteran's rating for bronchitis to 10 percent 38 C.F.R. § 4.97, DC 6600, effective April 21, 2009. However, since the RO granted only a portion of the Veteran's increased rating claim, his appeal properly remains before the Board for review. See AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Corchado v. Derwinski, 1 Vet. App. 160 (1991). In order to warrant a rating in excess of 10 percent for bronchitis under this diagnostic code, the evidence must show the following results from a Pulmonary Function Test (PFT): * a FEV-1 of 56-70 percent of predicted value; or * a FEV-1/FVC of 56-70 percent; or * a DLCO of 56-65 percent predicted. 38 C.F.R. § 4.97, DC 6600 (30 percent). Based on the evidence of record, a rating in excess of 10 percent is not warranted since April 21, 2009. Specifically at a VA examination the Veteran underwent in April 2009, he reported "ongoing care" for his bronchitis, although his treating physician had discouraged the use of antibiotics to control it. A PFT performed at that time indicated a post-bronchodilator FEV-1 of 86 percent of predicted value. His FEV-1/FVC was 102 percent, and his DCLO was 71 percent. Next, at his most recent VA examination in February 2011, the Veteran denied receiving any antibiotic treatment in the past 12 months, and also denied any history of asthma or use of inhalers. A PFT taken at that time indicated a post-bronchodilator FEV-1 of 76 percent of predicted. His FEV-1/FVC was 105 percent of predicted, and his DCLO was 79 percent of predicted. Significantly, there were no other PFTs performed on an outpatient basis. Therefore, a rating in excess of 10 percent is not warranted on this basis. In considering these claims, the Board has also considered the Veteran's statements that his disability ratings are worse than the ratings he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability of his service-connected disabilities according to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's service-connected disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. Extraschedular Considerations Next, the Board will consider whether referral for an extraschedular evaluation is warranted. The question of an extraschedular rating is a component of a claim for an increased rating. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Court of Appeals for Veteran's Claims has clarified the analytical steps necessary to determine whether referral for such consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. In this case, the evidence does not indicate that Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. Specifically, his service-connected disabilities have been applied to the applicable rating criteria, general counsel opinions, and case law. Although the diagnostic codes in this case allow for higher ratings, the Board fully explained why the higher ratings were not warranted. Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran's disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, although the Veteran has submitted evidence of a medical disability, and made a claim for the highest rating possible, he has not submitted evidence that he is unemployable due to his service-connected disabilities. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In sum, after a careful review of the evidence of record, the Board finds that a 10 percent rating, but no more, for the Veteran's left knee based on arthritis is warranted. However, as for the remainder of his service-connected disabilities, the evidence does not warrant an increased rating, and these appeals are denied. New and Material Evidence In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. Manio v. Derwinski, 1 Vet. App. 140 (1991). Under the relevant regulation, "new" evidence is defined as evidence not previously submitted to agency decision-makers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. However, new and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). If it finds that the submitted evidence is new and material, VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the veteran in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999); but see 38 U.S.C.A. § 5103A (eliminates the concept of a well-grounded claim). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). Because the Board has the jurisdictional responsibility to consider whether it was proper to reopen the claim, regardless of the RO's determination on the question of reopening, the Board will determine whether new and material evidence has been received and, if so, consider entitlement to service connection on the merits. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). In this case, the Veteran is seeking entitlement to service connection for GERD, otitis media, TMJ syndrome and a low back disorder, all of which were originally denied in February 1998. Specifically, his low back claim was denied on the basis that it was not shown during active duty or currently. His claims related to a TMJ disorder, otitis media and GERD were denied on the basis that none of these disorders shown while on active duty. He did not appeal this decision, nor did he submit any additional relevant evidence within one year of this decision, and it became final one year later. Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). The evidence at the time of February 1998 decision was limited to the Veteran's service treatment records, as he had left active duty only one month before. Since this decision became final, the evidence of record now includes VA treatment records from 1998 through 2011, private treatment records from April to December 1998, as well as a statement from December 2002. He has also undergone a number of VA examinations in March and April 1999, March 2002, May 2005, February 2007 and April 2009. Based on a review of the evidence submitted since the last final denial of the claim, the Board determines that none of it is both new and material to the claims related to his TMJ disorder, GERD or otitis media, and there is no basis to reopen these claims. First, with respect to his TMJ disorder, there is no record that he has received any clinical treatment for these symptoms since the last final denial of the claim. In fact, the only mention of a continued TMJ disorder (other than his statements at his hearing before the Board) is a statement he submitted in May 2006, where he stated that he experiences problems in his jaw, especially when chewing. However, this evidence is not "new," in that his assertions of continued TMJ symptoms were addressed in the last final denial of this claim. With respect to his GERD claim, the evidence includes a treatment note from February 2004, where the Veteran stated that it hurt when he swallowed, but there was no actual difficulty in swallowing. Moreover, in both January and July 2011, he was diagnosed with GERD and nighttime reflux that was resolved through the use of medication such as proton pump inhibitors (PPIs). These treatment notes are all "new" in that they were not considered prior to the last final denial of this claim. However, none of it is "material," as it does not establish the presence of a chronic disorder in service, which was the basis of the February 1998 denial of the claim. As for the Veteran's otitis media claim, the only evidence since the last final denial of this claim was in December 2004, where he complained of ear aches. However, there was no notation by the treating physician as to whether it was related to otitis media, nor was there any evidence indicating that the Veteran had otitis media in service. Of note, even though he underwent a VA audiological examination in February 2011, he did not mention ear aches, nor with the audiologist note it. Thus, even though this evidence is "new" in that it was not considered prior to the last final denial of this claim, it is not "material," as it is not probative to the basis of the last final denial of this claim. With respect to the Veteran's statements, the Board finds that the assertions that he was diagnosed with otitis media, TMJ syndrome and GERD in service and has continued to have problems with these disorders since that time are duplicative of the statements already included in the claims file and considered in the prior final decision. Such information is not new, but instead is merely a recitation of the statements the Veteran previously made. See Reid v. Derwinski, 2 Vet. App. 312, 315 (1992). As such, these statements are not new and material evidence. As for the Veteran's low back claim, the Board determines that this claim should be reopened. Unlike the claims related to TMJ disorder, GERD or otitis media, this claim was denied in February 1998 on the basis that it was not shown during active duty or currently. Since the time that time, evidence has been associated in the claims file that indicates the existence of a current disorder. Notably, in January 2005, an MRI of the low back led to a diagnosed with degenerative disc disease of the lumbar spine without evidence herniation. Not only is this evidence "new" in that it was not considered prior to the last final denial of the claim, it is also "material," as it is probative to an unestablished fact necessary to support the claim. Consequently, the Board finds that none of the current evidence submitted by the Veteran since the February 1998 rating decision is new and material to the claims of entitlement to service connection for a TMJ disorder, GERD or otitis media, and the application to reopen these claims is denied. However, as new and material evidence has been presented relating to his low back disorder, this claim is reopened. 38 C.F.R. § 3.156(a). Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Moreover, under 38 C.F.R. § 3.303(b), the second and third elements of Shedden and Caluza may be established through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. § 1110 (West 2002); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Finally, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). In this case, the Veteran is claiming entitlement to service connection for bilateral hearing loss, sleep apnea, diabetes mellitus, a cardiovascular disorder, bilateral foot disorder, fibromyalgia, a muscle disorder, bilateral elbow disorder and eye disorder. Notably, at his hearing before the Board in August 2012, he provided the following details: * Low back disorder: He claims that, when his ship was stationed of the coast of Liberia in 1991, he fell down a ship's ladder and hurt his low back. He was placed on light duty and given non-prescription medication. He still takes non-prescription medication and wears a brace occasionally. See Hearing Transcript (T.) at 6-9. * Diabetes mellitus: He claims that he was informed that he has diabetes mellitus when he left active duty, although he acknowledged that his blood was never tested. He has since been diagnosed with this disorder and takes Metformin in order to control it. (T. at 13). * Cardiovascular disorder: He recalled complaints of chest pains to treating medics while on active duty. He was given a stress test with the VA, but did not indicate that he was diagnosed with any specific disorder, and acknowledged that he has not been diagnosed with a current disorder (T- at 17-18). * Bilateral foot disorder: He recalled having to walk around with a shower shoe while on active duty, which prevented him from going certain places on the ship, which required boots. However, he acknowledged that he does not have a current condition (T. at 23). * Fibromyalgia: After a discussion of what fibromyalgia is, the Veteran acknowledged that he does not have a current diagnosis of this disorder (T. at 24-25). * Bilateral elbow disorder: He claims that he hurt his elbows after falling off the ship's ladder, but also hurt his elbows often after hauling heavy equipment through the ship's passageways (T at 28). * Eye disorder: He recalled an incident where he got a particle in his eye, and now he sees spots on occasion. He has also complained of worsening vision. * Sleep apnea: He recalled that he would wake up gasping for air (T at 37). It is his assertion that the typical sleep schedule on board ship prevented him from sleeping normally. Bilateral Foot Disorder, Bilateral Elbow Disorder, Cardiovascular Disorder, Muscle Disorder or "Side Effects" The Board addresses the issues of entitlement to service connection for bilateral foot disorder, cardiovascular disorder, elbow disorder, muscle disorder and "side effects" of medication first. Of these disorders, only two were noted in service. Specifically, the Veteran sought treatment for bicep and elbow pain in October 1991 after lifting weights. However, these complaints were diagnosed as a muscle strain and, beyond the prescription of pain relief medication, no further treatment was required. Additionally, while the Veteran complained of chest pain in January 1990 and December 1992, he was diagnosed on both occasions with costochondritis, or chest pain. An underlying heart disorder was not noted on either occasion. As for the other disorders, the service treatment records reflect no complaints of, treatment for, or a diagnosis related to any a bilateral foot disorder, elbow disorder, muscle disorder, side effects of medication, or cardiovascular disorder. Significantly, none of these disorders were noted at his separation physical examination in June 1997. Therefore, while a bilateral elbow disorder and chest pain were observed during his active duty service, a bilateral foot disorder, elbow disorder, muscle disorder or "side effects" of medication were not observed in active duty service. Next, the post-service treatment records do not reflect a current diagnosis of a bilateral foot disorder, elbow disorder, cardiovascular disorder, muscle disorder or any side effects from medication. First, while the evidence indicates that the Veteran complained of pain in his feet in April 1998, there was no chronic foot disorder diagnosed. He again complained of foot pain again in February 2011, and was offered a referral to a podiatrist. However, no chronic foot disorder was diagnosed and the Veteran declined to see a podiatrist. He has never been diagnosed with an actual foot disorder. Additionally, even though the Veteran complained of elbow pain in active duty, an evaluation of the extremities in May 2010 was normal. Next, despite the Veteran's complaints of chest pain in service, evaluations in both April and July 1998, reflected no evidence of active cardiovascular disease. While the Board recognizes that the Veteran was hospitalized in May 2005 with symptoms related to atrial fibrillation, there was no evidence of a myocardial infarction, EKG and echocardiogram were all normal. Therefore, even though he was hospitalized for cardiovascular symptoms in 2005, it does not appear that there was ever an identified underlying disorder. Finally, as for his bilateral foot disorder, muscle disorder and side effects from medication, these disorders were not mentioned in the service treatment records at all. Thus, there is no clinical evidence in the Veteran's post-service treatment records indicating a current bilateral foot disorder, cardiovascular disorder, elbow disorder, muscle disorder or "side effects" of medication. In fact, at his hearing before the Board, the Veteran acknowledged that some of these disorders have not been diagnosed. Therefore, the Board is left to conclude that these disorders do not exist. Moreover, the mere assertion of symptoms alone cannot be compensable without an in-service disease or injury to which any asserted symptoms can be connected by competent evidence. See Sanchez-Benitez v. West, 25 F.3d 1356 (Fed. Cir. 2001). Bilateral Hearing Loss In addition to the regulations listed above, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater, when the auditory thresholds for at least three of the above frequencies are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Moreover, service connection will also be presumed for sensorineural hearing loss, if manifest to a compensable degree within one year after discharge from service. See 38 C.F.R. §§ 3.307, 3.309 (2012). In this case, the service treatment records indicate that the Veteran underwent hearing evaluations on a relatively routine basis, and on no occasion did he exhibit a tonal threshold in excess of 10 dB at any frequency. As such, impaired hearing under 38 C.F.R. § 3.385 was not shown during active duty. However, the Board notes that hearing loss to this degree is not required. Rather, service connection is for application where the evidence indicates a measurable worsening in the Veteran's hearing. See Hensley v. Brown, 5 Vet. App. 155, 160 (1993). In this regard, the changes in tonal thresholds between various evaluations are somewhat inconsistent, as some tonal thresholds worsened and others improved over the course of the Veteran's active duty service. Nevertheless, the Board places significant probative value on notices provided to the Veteran in October 1989 and June 1994, informing him that his hearing test reflected a "significant threshold shift." Based on these notices, the Board will concede that there was some hearing loss incurred in service. However, the post-service evidence of record does not indicate that he currently has hearing loss for purposes of 38 C.F.R. § 3.385. Specifically, the Board places significant probative value on a VA audiological examination that the Veteran underwent in February 2011. At that time, he complained that his hearing "comes and goes," and that sometimes he needs to be closer to hear a person or a telephone ringing. However, upon examination, he did not exhibit a tonal threshold in excess of 10 dB at any frequency from 500 to 4000 Hz in either ear. As such, the requirements of 38 C.F.R. § 3.385 have not been met. Therefore, even though the Veteran has complained of hearing loss symptoms, there is no basis for an actual diagnosis of this disorder for VA purposes, and mere symptoms are insufficient to warrant service connection. See Sanchez-Benitez, 25 F.3d at 1356. Sleep Apnea, Diabetes Mellitus, or Eye Disorder With regard to the Veteran's sleep apnea, diabetes mellitus, and eye disorder, the service treatment records reflect no complaints of, treatment for, or a diagnosis related to either of these disorders. While the Veteran underwent ophthalmological evaluations in January 1994, March 1996 and November 1996, none of these evaluations revealed any eye disorder. Even though these evaluations did note certain degrees of refractive error, refractive error is not a disability for which service connection may be granted. 38 C.F.R. § 3.303(c). Significantly, his separation physical examination in June 1997 did not list either of these disorders, nor did he mention them at that time. In fact, neither disorder was shown until many years after active duty service. Specifically, sleep apnea was not contemplated as a possible disorder until a treating physician noted in May 2005 that the Veteran could have upper airway resistance syndrome, and possibly sleep apnea. Moreover, a service treatment records from July 2010 indicates that the Veteran was not diagnosed with diabetes mellitus until December 2007. Finally, the first indication of an eye disorder for which service connection may be granted was not until 2012, where an ophthalmological evaluation diagnosed blepharitis. Thus, the first diagnoses related sleep apnea, diabetes mellitus and blepharitis was not until 8, 10 and 15 years after he left active duty, respectively. The Board has also considered the Veteran's statements asserting continuity of symptoms. The Board is required to assess the credibility and probative weight of all relevant evidence, including the credibility of the Veteran's statements. McClain v. Nicholson, 21 Vet. App. 319, 325 (2007). In doing so, the Board may consider factors such as facial plausibility, bias, self-interest, and consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. at 511; see also Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007); cf. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Veteran is competent in some cases to self-diagnose some disorders despite his status as a lay person. However, he is not competent diagnose disorders such as diabetes mellitus, sleep apnea or blepharitis, Specifically, "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Nevertheless, the Veteran's lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection, if credible, regardless of the lack of contemporaneous medical evidence. Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Here, however, the Board finds that the Veteran's reported history of continued symptomatology since active service, while competent, is nonetheless not credible. In making this determination, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). Specifically, the Board places significance in the fact that he submitted numerous claims seeking service connection for various disorders since shortly after he left active duty in 1997. However, he did not file claims related to sleep apnea, diabetes mellitus or blepharitis until 2007. By that point, he had already received rating decisions for various claims on five occasions. Moreover, the Board cannot ignore the significance of the fact that the Veteran did not file his claims for service connection for this issue for at least eight years after he left active duty. Shaw v. Principi, 3 Vet. App. 365 (1992) (a veteran's delay in asserting a claim can constitute negative evidence that weighs against the claim). Finally, the Veteran did not appear credible to the undersigned when presenting testimony as to these issues. Therefore, continuity is not established based on the clinical evidence of record or the Veteran's statements. Next, service connection may also be granted when the evidence establishes a medical nexus between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence is against a finding that the Veteran's claimed disorders are related to active duty, despite his contentions to the contrary. Significantly, other than the Veteran's lay opinion, none of the competent evidence of record indicates a relationship between these disorders and active duty, nor has any treating professional indicated such a relationship. In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claims for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. ORDER A rating in excess of 10 percent for patellofemoral syndrome of the right knee is denied. A rating in excess of 10 percent for patellofemoral syndrome of the left knee is denied. A rating in excess of 10 percent for arthritis of the right knee is denied. A 10 percent rating, but no more, for arthritis of the left knee is granted, subject to the laws and regulations governing the payment of monetary benefits. A rating in excess of 10 percent for PFB is denied. An initial compensable rating for a burn scar on the right ankle is denied. A compensable rating in for chronic bronchitis prior to April 21, 2009 is denied. A rating in excess of 10 percent for chronic bronchitis since April 21, 2009, is denied. New and material evidence having not been submitted, the application to reopen a claim of entitlement to service connection for a gastroesophageal disorder, diagnosed as GERD and hiatal hernia, is denied. New and material evidence having not been submitted, the application to reopen a claim of entitlement to service connection for otitis media is denied. New and material evidence having not been submitted, the application to reopen a claim of entitlement to service connection for TMJ disorder is denied. New and material evidence having been submitted, the application to reopen a claim of entitlement to service connection for a low back disorder is granted, and the claim is reopened. Service connection for "side effects of medication" is denied. Service connection for bilateral hearing loss is denied. Service connection for sleep apnea is denied. Service connection for diabetes mellitus is denied. Service connection for a cardiovascular disorder is denied. Service connection for a bilateral foot disorder is denied. Service connection for a muscle disorder is denied. Service connection for a bilateral elbow disorder is denied. Service connection for an eye disorder, characterized as blepharitis and presbyopia, is denied. REMAND With regard to the Veteran's claims related to fibromyalgia and a low back disorder, additional development is required before these claims may be adjudicated. First, with regard to the Veteran's fibromyalgia claim, compensation may be paid to a "Persian Gulf veteran" when the evidence establishes: (1) that he or she is a "Persian Gulf veteran;" (2) who exhibits objective indications of qualifying chronic disability; (3) which became manifest either during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117 (West 2002 & Supp. 2012); 38 C.F.R. § 3.317 (2012). For purposes of 38 U.S.C.A. § 1117, a "qualifying chronic disability" includes medically unexplained chronic multisymptom illness such as fibromyalgia. 38 U.S.C.A. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B); see also 75 Fed. Reg. 61,997 (Oct. 7, 2010). The post-service treatment records indicate that the Veteran was diagnosed with fibromyalgia in July 1998. Moreover, at his hearing before the Board in August 2012, he stated that he had three tours in Southwest Asia, has transited through the Suez Canal and the Strait of Hormuz. However, there is no evidence to corroborate this contention. Notably, his DD-214 does not indicate whether he has ever served in the Southwest Asia theater of operations (such as receipt of the Southwest Asia Service Medal), and the record does not include his personnel records. Therefore, the RO should determine whether he has such service. The Board also concludes that VA examinations are necessary to ascertain the nature and etiology of the Veteran's low back disorder and fibromyalgia. Specifically, it should be noted that the Veteran was diagnosed with fibromyalgia on only one occasion, and this diagnosis (in July 1998) is now many years old. Therefore a VA opinion is necessary to determine whether he indeed has fibromyalgia, and whether it may be attributable to active duty service. Additionally, the evidence of record indicates that the Veteran hurt his back in March 1993 after standing on a wooden chair which fell out from under him. At that time, he complained of persistent pain that was sharp and stabbing in nature. An examination indicated pin-point tenderness in the rib area, but a diagnosis was limited to a contusion, rather than any chronic spine disorder. Nevertheless, the March 1993 treatment does represent an "incident" in service. Since radiographic imaging in January 2005 indicates that he now has degenerative disc disease, a VA examination is appropriate for this issue as well. See 38 C.F.R. § 3.159(c)(4) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006) (evidence required for a VA examination is a "low threshold"). Accordingly, the case is REMANDED for the following action: 1. Acquire any treatment records that may be available from the VA Medical Center in Lebanon, Pennsylvania, since August 2011. If the Veteran has undergone any private treatment for his fibromyalgia or his low back disorder, and the records of such treatment have not been associated with the claims file, such records should also be acquired after obtaining his authorization. 2. Acquire the Veteran's service personnel records from the National Personnel Records Center (NPRC) in St. Louis, Missouri, or any other relevant documents that may be probative in determining whether the Veteran served in the Southwest Asia theater of operations. In attempting to acquire these records, the Veteran should also be asked to provide any information or evidence that he served in the Southwest Asia theater of operations. 3. Afford the Veteran an appropriate VA examination to determine the nature, extent, onset and etiology of any low back disorder. The claims folder should be made available to and reviewed by the examiner. All indicated studies deemed necessary by the examiner should be performed, and all findings of these tests should be reported in detail. The examiner should express an opinion as to whether it is at least as likely as not (i.e., a 50% possibility or greater) that a low back disorder had its onset in or is otherwise etiologically related to active service. The examiner is also asked to provide a statement as to whether the Veteran has a valid diagnosis of fibromyalgia. A basis for this diagnosis should provided and, if there is no diagnosis if fibromyalgia, it would be helpful if the examiner discussed whether July 1998 diagnosis of this disorder was unwarranted. If fibromyalgia is diagnosed, the examiner should express an opinion as to whether it is at least as likely as not (i.e., a 50% possibility or greater) that fibromyalgia had its onset in or is otherwise etiologically related to active service. All opinions must be accompanied by an adequate reasons and bases. Such reasons and bases may include, but is not limited to, the presence of symptomatology in service, specifically cited medical literature, and past evidence in the record, especially prior VA examination reports. The examiner must consider the Veteran's lay statements regarding the incurrence of these disorders, and the continuity of symptomatology. If the examiner cannot provide the requested opinions without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. After completion of the foregoing, readjudicate the claims on appeal. If the benefit sought remains denied, the Veteran and his representative must be furnished a supplemental statement of the case and be given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MATTHEW D. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs