Citation Nr: 1306343 Decision Date: 02/25/13 Archive Date: 03/01/13 DOCKET NO. 10-36 097A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial compensable disability rating for acne vulgaris prior to February 3, 2010, and in excess of 60 percent thereafter. 2. Entitlement to an initial disability rating in excess of 10 percent for left shoulder bursitis. 3. Entitlement to an initial compensable disability rating for right foot strain. 4. Entitlement to service connection for a back disability. 5. Entitlement to service connection for a right knee disability. 6. Entitlement to service connection for functional diarrhea, claimed as a stomach disability. 7. Entitlement to service connection for hearing loss disability of the right ear. 8. Entitlement to service connection for hearing loss disability of the left ear. ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran served on active duty from December 2001 to December 2006. This matter comes to the Board of Veterans' Appeals (Board) from a November 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. During the course of the appeal, in July 2010, the RO granted an increased rating of 60 percent for the Veteran's acne vulgaris, effective February 3, 2010, and of 10 percent for the Veteran's left shoulder bursitis, effective February 19, 2008. However, inasmuch as higher ratings are available for these disabilities and the Veteran is presumed to seek the maximum available benefit for a disability, the claims for higher rating remains viable on appeal. Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35, 38 (1993). In reviewing the Veteran's appeal for increased ratings, the Board has not overlooked the recent holding of the States Court of Appeals for Veterans Claims (Court) in Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that claims for higher evaluations also include a claim for a total rating based on individual unemployability (TDIU) when the appellant claims he is unable to work due to a service connected disability). However, the Board notes that the Veteran has not specifically indicated that he is unemployed or unemployable as result of his service-connected disabilities on appeal. Additionally, the evidence does not suggest that the Veteran is unemployable because of his service-connected skin, left shoulder, or right foot disability (either individual, or in combination). As such, the Board finds that Rice is not applicable to the current appeal. There must be cogent evidence of unemployability in the record. See Rice, 22 Vet. App. 447, citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). Accordingly, the Board finds that issue of entitlement to TDIU has not been raised. FINDINGS OF FACT 1. Prior to February 3, 2010, the Veteran's service-connected acne vulgaris was covered less than five percent of the entire body or exposed areas without intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs. 2. From February 3, 2010, the Veteran's service-connected acne vulgaris covered more than 40 percent of his entire body. 3. Throughout the entire period of appeal, the Veteran's left shoulder bursitis is manifest by limitation of motion of the minor joint to the shoulder level. 4. Throughout the entire period of appeal, the Veteran's right foot strain is manifest by no more than moderate painful motion. 5. The preponderance of the evidence is against finding that the Veteran has a back disorder that was incurred in, aggravated by, or otherwise related to a disease, injury, or event in service. 6. The preponderance of the evidence is against finding that the Veteran has a right knee disorder that was incurred in, aggravated by, or otherwise related to a disease, injury, or event in service. 7. The preponderance of the evidence is against finding that the Veteran has a disability manifest by diarrhea that was incurred in, aggravated by, or otherwise related to a disease, injury, or event in service. 8. The preponderance of the evidence is against finding that the Veteran has a hearing loss disability of the right ear that was incurred in, aggravated by, or otherwise related to a disease, injury, or event in service. 9. The preponderance of the evidence supports a finding that the Veteran has a hearing loss disability of the left ear that was incurred in, aggravated by, or otherwise related to a disease, injury, or event in service. CONCLUSIONS OF LAW 1. The criteria for an initial compensable disability rating prior to February 3, 2010, and in excess of 60 percent thereafter, for service-connected acne vulgaris have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.118, Diagnostic Code 7806 (2012). 2. Throughout the period of appeal, the criteria for an initial evaluation of 20 percent, but no higher, for left shoulder bursitis have been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.71a, Diagnostic Code 5201 (2012). 3. The criteria for an initial compensable disability rating for service-connected right foot strain have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.40, 4.71a, Diagnostic Code 5284 (2012). 4. A back disorder was not incurred in or aggravated by active military service, and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 5. A right knee disorder was not incurred in or aggravated by active military service, and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 6. A disability manifest by diarrhea was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307 (2012). 7. A right ear hearing loss disability was not incurred in or aggravated by active military service, and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.385 (2012). 8. Resolving all reasonable doubt in favor of the Veteran, a left ear hearing loss disability was incurred in active military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.385 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the Veterans Claims Assistance Act of 2000 (VCAA), when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that VA must inform the claimant of any information and 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. Concerning the claims for service connection, VCAA letters dated in March and October 2008 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2011); Quartuccio, at 187. The Veteran was aware that it was ultimately his responsibility to give VA any evidence pertaining to the claims. These letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. Furthermore, these letters described how appropriate disability ratings and effective dates were assigned. Furthermore, the Board notes that, for claims for higher ratings, where, as here, service connection has been granted and the initial rating and effective date have been assigned, the claim of service connection has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement (NOD) with the rating or the effective date of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board also concludes VA's duty to assist has been satisfied. The Veteran's available service treatment records and relevant VA medical records are in the file. The Board finds that all relevant records identified by the Veteran as relating to this claim have been obtained, to the extent possible. The record contains sufficient evidence to make a decision on the claims. VA has fulfilled its duty to assist. With respect to claims for higher initial ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). With regard to the Veteran's claims for higher initial ratings for his service-connected acne vulgaris, left shoulder bursitis, and right foot, the Veteran was provided VA examinations which addressed these claims, the most recent of which was conducted in February 2010. There is no objective evidence indicating that there has been a material change in the severity of these service-connected disabilities since he was last examined. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. The Board finds these examination reports to be thorough and consistent with contemporaneous medical records. The examinations in this case are adequate upon which to base a decision with regards to this claim. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). With regard to claims for service connection, the duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). The Veteran was provided a VA examination in September 2008 which addressed his claims for service connection for a back disorder, right knee disorder, and diarrhea. Additionally, he was provided with VA audiological examinations in August 2008 and February 2010. Each examiner reviewed the claims file, conducted the appropriate diagnostic tests, and considered the Veteran's reported history. The Board finds these examination reports and opinions to be thorough and complete. Therefore, the Board finds these examination reports and opinions are sufficient upon which to base a decision with regard to these service connection claims. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Claims for Higher Initial Ratings The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). An appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates "staged ratings" where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). However, "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). In general, evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. See 38 C.F.R. § 4.45. (1) Acne Vulgaris In a November 2008 rating decision, the RO granted service connection for acne vulgaris and assigned a noncompensable evaluation, effective February 19, 2008. Subsequently, in a July 2010 rating decision, the RO assigned a 60 percent evaluation for acne vulgaris, effective February 3, 2010, under Diagnostic Code 7806. The Board acknowledges that 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 were amended, effective from October 23, 2008. However, as the Veteran is not rated under these diagnostic codes, the Board finds that this amendment will essentially have no impact on his disability rating for acne vulgaris, as will be discussed in further detail below. Under Diagnostic Code 7806, a 0 percent rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation will be assigned where 20 to 40 percent of the entire body or 20 to 40 percent of exposed area is affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation will be assigned for dermatitis that covers more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or with constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118 (2012). Diagnostic Code 7806 remained under the same under the criteria effective October 23, 2008. Prior to February 3, 2010, a compensable disability rating is not warranted for the service-connected acne vulgaris. Post service VA outpatient records are silent for any treatment for a skin disorder. The Veteran underwent VA fee-basis compensation and pension examination in September 2008. The Veteran reported that he experienced skin crusting. The Veteran reported that he had not undergone any treatment for his skin disorder over the previous 12 months. The examiner observed papules on the Veteran's arms, back, and chest. Exfoliation, crusting, and abnormal textures were observed. The examiner said there was no ulceration, disfigurement, tissue loss, induration, inflexibility, hypopigmentation, hyperpigmentation, or limitation of motion. The report specified that 0 percent of the Veteran's exposed area and less than 1 percent of the Veteran's whole body area was affected. As just noted, the medical evidence of record does not reflect that the Veteran's acne vulgaris affected at least five percent of the Veteran's entire body or exposed area prior to February 3, 2010. Moreover, the medical evidence of record does not reflect that intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required during this time period. Additionally, the Veteran has not claimed that prior to February 3, 2010, his skin disability covered at least 5 percent of his entire body, or of his exposed area, or has required systemic therapy. As such, a compensable evaluation is not warranted for this disability prior to February 3, 2010 under Diagnostic Code 7806. On VA skin examination in February 2010, the examiner observed a diffuse maculopapular eruption which involved the Veteran's back, trunk, buttocks, thighs, and arms. There was no scarring or disfigurement. The examiner specified that the skin disorder involved 0 percent of the Veteran's exposed skin area but 47 percent of his entire body. As the evidence shows that over 40 percent of the Veteran's body was affected by the service connected acne vulgaris, the requirements for a 60 percent disability rating under Diagnostic Code 7806 were met as of February 3, 2010. The Board notes that a 60 percent disability rating is the maximum schedular rating available under Diagnostic Code 7806. The Board has reviewed the remaining diagnostic codes relating to skin disabilities but finds that they are inapplicable in this case. See 38 C.F.R. § 4.118 (2008, 2012). Specifically, the Board notes that the Veteran has not been noted as having scars due to his acne vulgaris. Furthermore, the record does not show symptoms consistent with exfoliative dermatitis (erythrodema) with generalized involvement of the skin plus systemic manifestations and constant or near constant systemic therapy or electron beam therapy during any 12 month period as contemplated by a 100 percent disability evaluation under Diagnostic Code 7817. Therefore, the Board finds the Veteran is most appropriately evaluated under Diagnostic Code 7806, as opposed to any of the criteria or revised criteria for evaluating scars or exfoliative dermatitis. In summary, the Board finds that the preponderance of the evidence is against granting an initial compensable disability rating for acne vulgaris prior to February 3, 2010, and in excess of 60 percent thereafter; the assignment of further staged ratings is not for application. (2) Left Shoulder Bursitis In a November 2008 rating decision, the RO granted service connection for left shoulder strain and assigned a noncompensable evaluation, effective February 19, 2008. Subsequently, in a July 2010 rating decision, the RO assigned a 10 percent evaluation for left shoulder strain, effective February 19, 2008. The normal range of shoulder motion is forward elevation (flexion) to 180 degrees; abduction to 180 degrees, external rotation to 90 degrees and internal rotation to 90 degrees. 38 C.F.R. § 4.71, Plate I. A distinction is made between major (dominant) and minor upper extremities for rating purposes. The evidence shows that the Veteran's right arm is his major upper extremity. Under 38 C.F.R. § 4.71a, Diagnostic Code 5201, a 20 percent evaluation is warranted for limitation of motion of the arm at the shoulder level. A 20 percent evaluation is also warranted for limitation of motion for the minor extremity midway between the side and shoulder level. A 30 percent evaluation is warranted for limitation of motion of the minor extremity to 25 degrees from the side. On VA fee-basis examination in September 2008, the Veteran complained of constant pain in his left shoulder. He rated his pain as a 10 on a 1 (low) to 10 (high) pain scale. He stated that the pain was elicited by physical activity and relieved by rest. The examiner noted that the Veteran was right hand dominant. The examiner found no signs of edema, effusion, weakness, redness, heat, or guarding of movement. There was no subluxation. Flexion of the left shoulder was to 96 degrees with pain. Abduction was to 95 degrees with pain. External and internal rotation were to 85 degrees with pain. After repetitive motion, the joint function was limited by an additional 12 degrees. Pain, fatigue, weakness, and lack of endurance were objectively observed after repetitive motion. On VA joint examination in February 2010, the Veteran mentioned that he could dress and undress. He could lift up to 40 pounds. The Veteran treated his left shoulder pain with Motrin and Tylenol. The examiner found no evidence of flare-ups. The Veteran complained of pain in front of and on top of the shoulder. He also described pain inside of the joint. The examiner observed that the Veteran had difficulty taking the shoulder above a right angle. The examiner further observed that the Veteran's left shoulder drooped. There was no evidence of wasting of the deltoid, swelling, redness, or heat. The examiner remarked that left shoulder abduction was to 150 degrees; however, in order to get to that position, the Veteran underwent a few contortions and was unable to lower his arm in a straightforward manner. Flexion was to 120 degrees with pain at 115 degrees. Internal rotation was to 60 degrees without pain. External rotation was to 45 degrees without pain. Extension was to 40 degrees with no pain. On repetitive motion, there was evidence of pain but no fatigue or weakness. X-rays yielded normal results; however, the acromioclavicular joint showed evidence of subluxation. The Veteran opined that the Veteran had a moderate disability. Extending every reasonable doubt to the Veteran, the Board finds that a 20 percent disability rating, but no higher, is warranted for the Veteran's left shoulder disorder throughout the period of appeal. The results of the September 2008 VA examination clearly show that the Veteran's left shoulder motion was limited to shoulder level, which warrants a 20 percent rating under Diagnostic Code 5201. The Board has considered that the February 2010 VA examiner recorded findings for the left shoulder that a greater range of motion than that contemplated by a 20 percent rating. However, the examiner also stated that in order for the Veteran to achieve those motions, he had to contort himself. The examiner specified that by objective examination, the Veteran had difficulty taking the shoulder above a right angle. With consideration of 38 C.F.R. §§ 4.40, 4.45, 4.59, and DeLuca, supra, the Board finds that the requirements for a 20 percent rating have been met throughout the period of appeal. A rating in excess of 20 percent is not warranted under Diagnostic Code 5201, as even with consideration of pain, at no time does the evidence of record reflect that the range of motion of the Veteran's left arm was limited to midway between his side and shoulder level. Additionally, a 30 percent rating is not warranted under 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202, or 5203. Diagnostic Code 5200 addresses ankylosis of scapulohumeral articulation, which is not present. Similarly, as there is no evidence of dislocation of the scapulohumeral join, malunion of the humerus, or dislocation or nonunion of the clavicle or scapula, a higher rating of 30 percent is not warranted under Diagnostic Codes 5202 or 5203. In summary, the Board finds that the preponderance of the evidence warrants granting a disability rating of 20 percent, but no higher, for the Veteran's left shoulder bursitis throughout the period of appeal; the assignment of staged ratings is not for application. (3) Right Foot Strain In a November 2008 rating decision, the RO granted service connection for right foot strain and assigned a noncompensable evaluation, effective February 19, 2008. Disabilities of the foot are generally evaluated under Diagnostic Codes 5276 through 5284. See 38 C.F.R. § 4.71a (2012). Diagnostic Code 5284, Foot Injuries, other, provides a 10 percent rating for moderate symptoms, a 20 percent rating for moderately severe, a 30 percent rating for severe, and a 40 percent rating for loss of use of the foot. In a November 2008 rating decision, the RO granted service connection for right foot strain and assigned a noncompensable evaluation, effective February 19, 2008. On VA fee-basis examination in September 2008, the Veteran complained of constant pain in his right foot. He rated his pain as a 7 on a 1 (low) to 10 (high) pain scale. He related that his pain was elicited by physical activity and weather changes. The Veteran reported that he was not receiving any treatment for his right foot strain. The examiner found no signs of abnormal weight bearing or breakdown, callosities, or any unusual shoe wear pattern. The examiner found no objective evidence of painful motion, edema, disturbed circulation, weakness, or atrophy. There was active motion in the metatarsophalangeal joint of the right great toe. An X-ray of the right foot was within normal limits. The examiner gave a diagnosis of right foot strain. On VA compensation and pension examination in February 2010, the Veteran stated that he could not stand for long periods of time. He said that he treated his foot with Motrin, Tylenol, and ice. He remarked that his pain was on the top and on the inside at the base of the great toe; he did not hurt distally or around the ankle. The examiner noted that the Veteran walked slowly but without a limp. No functional limitations were found on standing and walking. The examiner found no swelling, redness, tenderness, or heat in the foot, including the navicular bone. There was no evidence of abnormal weight bearing. The examiner noted that the Veteran had normal subtalar and mid-tarsal motion to inversion and eversion. Dorsiflexion was to 30 degrees. Plantar flexion was to 40 degrees. Inversion was to 30 degrees. Eversion was to 20 degrees. The examiner found no evidence of pain, fatigue, weakness, lack of endurance, instability, or incoordination with repeated testing. An X-ray was normal. An MRI revealed reactive changes in the tendons and ligaments that the examiner specified were not diagnostic and were not of special concern. The diagnosis given was right foot strain. In light of the above, the Board finds that the Veteran's right foot strain does not meet the criteria for a compensable rating under Diagnostic Code 5284 because, clearly, the Veteran's symptoms are not shown to be "moderate" so as to warrant the next higher, 10 percent rating criteria. As shown above, the February 2010 VA examiner noted there was normal range of motion of the ankles, the Veteran was able to walk without a limp, plantar flexion and dorsiflexion were normal, and his stance and walking weight bearing appeared to be normal. Also, it was noted that his foot conditions were presently treated with over-the-counter pain relievers. Likewise, it was noted that his x-rays were essentially normal, and an MRI did not reveal a diagnosable disability. All of these factors indicate that the right foot strain is not "moderate" in severity, much less "moderately severe" or "severe." With regard to Deluca considerations, while the Board acknowledges the Veteran's complaints of pain and loss of motion and function, the Board ultimately places more weight on the objective findings of the VA examiner that the Veteran experienced no functional limitations, his range of motion was normal, x-rays were normal, etc., based on his medical expertise. The Board has considered whether the Veteran may be entitled to a higher rating under any other diagnostic code. Diagnostic Codes 5276, 5277, 5278, 5279, 5280, 5281, 5282 and 5283 are not for application because the medical evidence does not indicate flat foot deformity, atrophy of the musculature, disturbed circulation and weakness of the feet, claw foot, hallux rigidus, hammer toe, or malunion or nonunion of tarsal or metatarsal bones. Additionally, a higher rating is not warranted under Diagnostic Code 5003, as arthritis has not been established by X-ray findings. The Board adds that no limitation of motion is shown. In summary, the Board finds that the preponderance of the evidence is against granting a compensable disability rating for the Veteran's right foot strain; the assignment of staged ratings is not for application. (4) Extraschedular Consideration In reaching these conclusions, the Board also has considered whether the Veteran is entitled to a greater level of compensation for the disabilities at issue on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's service-connected acne vulgaris, left shoulder bursitis, and right foot strain are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology. Claims for Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic disorders, including arthritis, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2012). (1) Back Disability (2) Right Knee Disability and (3) Functional Diarrhea A January 2002 service treatment record contains the Veteran's complaints of right knee pain. The examiner found patella tenderness. In April 2002, the Veteran told a service examiner that he experienced diarrhea. Service treatment records from March 2003 show that the Veteran experienced back pain after falling down a flight of stairs. An X-ray revealed well-aligned vertebral bodies; the interpreter noted a mild scoliosis of the thoracolumbar spine and said that the X-ray was otherwise negative. A lumbar sprain and spasm was noted. Over the following few months, the Veteran received follow-up chiropractic care. A December 2003 service treatment record reflects that the Veteran had fallen on his right knee during exercise. Swelling was noted. The diagnosis given was right knee pain. A March 2006 service treatment record contains the Veteran's complaints of right knee and back pain. In April 2006, the Veteran complained of back pain to a service treatment provider. An MRI was within normal limits. The examiner indicated that the Veteran had lumbago. A May 2006 service record indicates that the Veteran had viral gastroenteritis. In July 2006, a service treatment provider noted that the Veteran had functional diarrhea. A treatment record from August 2006 reflects that the Veteran had pain in his right knee. It was noted that the Veteran had a PCL tear in 2004. It was also noted that the Veteran had a back injury in 2002 or 2003. The Veteran indicated on a November 2006 Report of Medical History that had recurrent back pain, knee trouble, foot trouble, and intestinal trouble. On VA fee-basis examination in September 2008, the Veteran reported experiencing constant back pain. He said that the pain was elicited by physical activity and was relieved by rest. The examiner indicated that the Veteran's posture and gait were within normal limits. The examiner found no evidence of radiating pain or ankylosis of either the cervical or the thoracolumbar spine. No sensory or motor dysfunction was present. X-rays of the cervical and thoracic spine were within normal limits. The examiner remarked that an X-ray of the lumbar spine was also within normal limits, although the Veteran had six lumbar vertebrae, which the examiner explained was a normal variant. The examiner opined that there was no diagnosis of a back condition because there was no pathology to render a diagnosis. The Veteran also told the VA examiner that he experienced right knee pain. The examiner found no weakness, swelling, heat, redness, giving way, lack of endurance, locking, fatigability, or dislocation. The examiner observed that there was no locking pain, genu recurvatum, or crepitus. The medial and lateral collateral ligaments stability test of the right knee was within normal limits. An X-ray of the right knee was noted to be within normal limits. The examiner explained that there was no diagnosis of a right knee condition. The Veteran also told the VA examiner that he experienced diarrhea. No nausea, vomiting, or constipation was reported. The Veteran reported abdominal pain. He stated that he was not receiving any treatment for the condition. The examiner found no signs of liver enlargement, distension of the superficial veins, striae on the abdominal wall, or tenderness to palpation of the abdomen. No intestinal fistulas were found on examination. A rectal examination yielded normal findings. No hemorrhoids, fissures or masses were found. The examiner opined that there was no diagnosis because there was no pathology to render a diagnosis. While the evidence shows that the Veteran currently experiences bouts of diarrhea and has pain in his back and right knee as shown above, clinical evaluation has not revealed any underlying disability. The Board observes that pain alone, without a diagnosed or identifiable underlying malady or condition, does not itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). The Board acknowledges the Veteran's belief that he has back and right knee disabilities, as well as a disability manifest by diarrhea, and he is competent to testify as to symptomatology such as experiencing pain. See Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, as noted above, the objective evidence fails to show any currently-manifested diagnosable disorder of the back, right knee, or bowels. In this matter, the Board finds that the opinion of the September 2008 VA examiner outweighs the opinion of the Veteran, as the VA examiner was a medical professional who had the training and education necessary to make medical diagnoses. In the absence of any diagnosed back or right knee disability, or diagnosable disability manifest by diarrhea, at any time since the filing of the claim, service connection may not be granted. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (holding that service connection cannot be granted if the claimed disability does not exist.) Accordingly, the first Hickson element, evidence of a current disability, has not been met, and the claim fails on this basis alone. In reaching this conclusion, the Board also considered the doctrine of reasonable doubt. See 38 U.S.C.A. § 5107(b) (West 2002). However, as the preponderance of the evidence is against the claim, the doctrine is not for application. See Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (4) Right Ear and (5) Left Ear Hearing Loss Disability For VA purposes, hearing impairment is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz 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 (2012). In this case, the Veteran's service personnel records show that his military occupational specialty was 2846 (ground radio intermediate repairer). Service audiology testing conducted in March 2006 included the following audiometric findings, in decibels: HERTZ 500 1000 2000 4000 RIGHT 75 85 90 90 LEFT 75 85 90 90 The examiner recorded the Veteran's report of sleeping through his alarm clock. The examiner remarked that the Veteran's tympanic membranes were difficult to access due to the amount of cerumen in his ears. The Veteran noted on a November 2006 Report of Medical History that he experienced hearing loss. Post-service, the Veteran was administered a VA audiology examination in August 2008. The Veteran reported that he had hearing loss that began from working around machine guns, jet engines, and radio equipment. The Veteran reported that he was not receiving any treatment for his ears. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 45 45 55 50 55 LEFT 40 45 55 55 60 Speech audiometry testing revealed speech recognition ability of 56 percent in the right ear and 56 percent in the left ear. The examiner specified that the Veteran's test results were inconsistent, and as such, a determination regarding hearing impairment could not be rendered. The examiner recommended that the Veteran be administered a repeat audiogram to rule out malingering. Another VA audiology examination was administered in February 2010. The examiner reviewed the results of the 2008 examination and commented that valid results could not be obtained in 2008. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 25 20 25 LEFT 20 25 25 25 20 Speech audiometry testing revealed speech recognition ability of 94 percent in the right ear and 92 percent in the left ear. The examiner opined that the results obtained may be slightly elevated, and the word recognition score in the left ear was slightly poorer than expected given the Veteran's otherwise normal hearing. In reviewing the record, the examiner opined that the in-service hearing test from 2005 may not be reliable due to the severity of the hearing loss which was obtained. The examiner felt that the Veteran did not have a hearing loss disability in either ear. As an initial matter, concerning the Veteran's right ear, the Board notes that the pure tone thresholds as recorded by the February 2010 VA audiologist do not meet the numerical standards enumerated by 38 C.F.R. § 3.385 (2012). As such, the Veteran does not have a hearing loss disability in the right ear for VA benefit purposes. The Board recognizes that earlier audiological test results from the August 2008 VA fee-basis examination met the required numerical standards; however, those results were not considered reliable by either the August 2008 VA examiner or the February 2010 VA examiner. Thus, these recording findings are of no probative value. Without a diagnosis of a current hearing loss disability in the right ear that meets the standards of 38 C.F.R. § 3.385, service connection cannot be granted for hearing loss, right ear. In reaching this conclusion, the Board acknowledges that the Veteran is competent to report difficulty hearing in his right ear. However, he is not competent to state that his right ear puretone thresholds or speech recognition scores arise to levels sufficient to warrant a disability for VA purposes. Accordingly, the Board has placed greater probative value on the contemporaneous medical evidence that does not support a finding of a right ear hearing loss disability for VA purposes. However, concerning the Veteran's left ear, the February 2010 audiological findings support the conclusion that the Veteran has a hearing loss disability in the left ear for VA compensation purposes, as he demonstrated speech recognition ability of 92 percent in the left ear. 38 C.F.R. § 3.385 (2012). Therefore, the question to be decided in the present appeal is whether such hearing loss of the left ear is associated with the Veteran's active duty. In this regard, the Board notes that the Veteran is competent to describe the circumstances surrounding his in-service noise exposure and to report difficulties hearing in his left ear as such comes to him through his senses and, as such, requires only personal knowledge rather than medical expertise. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). See also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lay evidence-as, for example, the Veteran's contentions in the present case-does not lack credibility simply because it is unaccompanied by contemporaneous medical evidence). Moreover, the Veteran has consistently complained of difficulty hearing in his left ear since he left service. The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). However, the threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, at 83. Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno, 6 Vet. App. at 469. As the Veteran is competent to describe his in-service noise exposure and current difficulty hearing in his left ear, and his assertions regarding a continuity of symptomatology since service are credible. Thus, the medical and lay evidence for the claim and the evidence against the claim are at least in equipoise. Accordingly, the benefit-of-the-doubt rule applies and service connection for hearing loss disability of the left ear is warranted. See 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial compensable disability rating for acne vulgaris prior to February 3, 2010, and in excess of 60 percent thereafter, is denied. Entitlement to an initial disability rating of 20 percent, but no higher, for left shoulder bursitis, is granted, subject to the law and regulations governing the payment of VA compensation benefits. Entitlement to an initial compensable disability rating for right foot strain is denied. Entitlement to service connection for a back disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for functional diarrhea, claimed as a stomach disability is denied. Entitlement to service connection for hearing loss disability of the right ear is denied. Entitlement to service connection for hearing loss disability of the left ear is granted. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs