Citation Nr: 1312762 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 08-26 807 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for a left knee disorder. 2. Entitlement to service connection for bronchitis, to include as secondary to service-connected gastroesophageal reflux disease (GERD). 3. Entitlement to service connection for chronic sinusitis, to include as secondary to service-connected GERD. 4. Entitlement to service connection for recurrent pharyngitis, to include as secondary to service-connected GERD. 5. Entitlement to an initial compensable evaluation for chronic rhinitis with inferior turbinate hypertrophy. 6. Entitlement to an initial compensable evaluation for residuals of a fracture of the right ring finger. 7. Entitlement to an initial evaluation in excess of 10 percent for GERD. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran had active military duty from November 1983 to January 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction of the case has subsequently been transferred to the New Orleans, Louisiana, RO. In his August 2008 Substantive Appeal, the Veteran requested a Board hearing in Washington, D.C. Such was scheduled for January 2010. In January 2010 he informed the Board that he was unable to attend the hearing. The Veteran has not requested that such hearing be rescheduled. Therefore, his request for a Board hearing is considered withdrawn. The Board remanded this case in January 2010 for further development. At that time it was noted that in his January 2007 notice of disagreement (NOD) the Veteran raised claims for service connection for a hearing impairment, tinnitus, impaired vision, and headaches. Because these matters had not yet been adjudicated, they were referred to the RO for appropriate action. Subsequently, an October 2011 rating decision granted service connection for a right knee strain, which was assigned an initial 10 percent rating; left shoulder supraspinatus tendinopathy, which was assigned an initial 10 percent rating; and lumbar strain, which was assigned an initial 10 percent rating; all effective February 1, 2005. The Veteran has not disagreed with the initially assigned disability ratings or effective dates. Therefore, such issues are not properly before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). As the claims for service connection for a hearing impairment, tinnitus, impaired vision, and headaches have still not been adjudicated, they are again referred to the RO for appropriate action. The issue of entitlement to service connection for a left knee disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. For the entire appeal period, the Veteran does not have a current diagnosis of bronchitis. 2. For the entire appeal period, the Veteran does not have a current diagnosis of chronic sinusitis. 3. For the entire appeal period, the Veteran does not have a current diagnosis of recurrent pharyngitis. 4. The Veteran has 90 percent obstruction of the right naris and 50 percent obstruction of the left naris, but has not had any nasal polyps at any time during this appeal. 5. The Veteran does not have any limitation of motion of the ring finger of the right hand and does not have any bony abnormality or functional impairment of that finger or any adjacent finger; nor is function of that finger so impaired as to equate with loss of use or amputation of any portion of that finger. 6. The Veteran's GERD is manifested by pyrosis and regurgitation, but there is no material weight loss, hematemesis, anemia, or arm or shoulder pain, and the GERD is not productive of considerable impairment of health. CONCLUSIONS OF LAW 1. The criteria for service connection for bronchitis, to include as secondary to service-connected GERD, are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2006), (2012). 2. The criteria for service connection for chronic sinusitis, to include as secondary to service-connected GERD, are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2006), (2012). 3. The criteria for service connection for recurrent pharyngitis, to include as secondary to service-connected GERD, are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2006), (2012). 4. The criteria for an initial 10 percent evaluation, but no higher, for chronic rhinitis with inferior turbinate hypertrophy are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.2, 4.7, 4.10, 4.21, 4.97, Diagnostic Code 6522 (2012). 5. The criteria for an initial compensable evaluation for residuals of a fracture of the right ring finger are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.2, 4.7, 4.10, 4.21, 4.40, 4.41, 4.45, 4.59, 4.69, 4.71a, Diagnostic Code 5230 (2012). 6. The criteria for an initial evaluation in excess of 10 percent for GERD are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.2, 4.7, 4.10, 4.20, 4.21, 4.27, 4.104, Diagnostic Code 7346 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. Regarding the service connection claims adjudicated herein, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, October 2008 and February 2010 letters, sent after the initial unfavorable decision issued in January 2006, advised the Veteran of the evidence and information necessary to substantiate his service connection claims on a direct and secondary basis as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, March 2007, October 2008, and February 2010 letters advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. While the March 2007, October 2008, and February 2010 letters were issued after the initial January 2006 rating decision, the United States Court of Appeals for the Federal Circuit has held that VA could cure such a timing problem by readjudicating the Veteran's claim following a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case could constitute a readjudication of the Veteran's claim. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the March 2007, October 2008, and February 2010 letters were issued, the Veteran's claims were readjudicated in the August 2008 statement of the case and the June 2009 and October 2011 supplemental statements of the case. Therefore, any defect with respect to the timing of the VCAA notice has been cured. Pertaining to the initial rating claims adjudicated herein, the Board observes that the Veteran has appealed with respect to the propriety of the initially assigned ratings for his chronic rhinitis, residuals of a fracture of the right ring finger, and GERD from the original grant of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claims for service connection for his chronic rhinitis, residuals of a fracture of the right ring finger, and GERD were granted and initial ratings were assigned in the January 2006 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned ratings, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. 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). The Veteran's service treatment records (STRs) as well as post-service VA examination reports have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. In this regard, the Board notes that the case was remanded in January 2010 in order to provide the Veteran an opportunity to identify all current treatment for his disorders, which was accomplished in a February 2010 letter, and to obtain additional STRs which he reported existed. However, he has not identified any additional records of post-service treatment for the disabilities addressed herein. Also, on remand, additional steps were taken to locate the STRs which the Veteran alleged existed. After unsuccessful efforts, a memorandum making formal finding of unavailability was made, stating that medical records from Barksdale, Air Force Base (AFB) dated 1983 to the present were unavailable. The procedures and steps taken were enumerated and it was concluded that all efforts had been exhausted and that further attempts would be futile. The Veteran was advised of such in an April 2011 letter. Moreover, the Board's review of the STRs reveals that records from Barksdale AFB from 1986 to 1993 are on file. Therefore, the Board finds that VA has satisfied its duty to assist in this regard. Relevant to the Veteran's service connection claims, he was afforded VA examinations in November 2005 and December 2010. The Board finds that such VA examinations and accompanying opinions are adequate to decide the issues as they are predicated on an interview with the Veteran; a review of the record, to include his service treatment records; and a physical examination with diagnostic testing. The conclusions reached considered all of the pertinent evidence of record, to include the statements of the Veteran, and was accompanied by a complete rationale, relying on and citing to the records reviewed. Pertinent to the Veteran's initial rating claims, he was likewise afforded VA examinations in November 2005 and December 2010. Neither the Veteran nor his representative has alleged that such are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected disabilities as they include an interview with the Veteran, a review of the record, and a full physical examination, addressing the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's claims and no further examination is necessary. As noted previously, January 2010, the Board remanded the case for additional development, to include affording the Veteran secondary VCAA notice, allowing him an opportunity to identify any post-service treatment records, attempting to obtain records from Barksdale AFB, and affording him VA examinations. As discussed in the preceding paragraphs, a February 2010 letter advised the Veteran of the information and evidence necessary to substantiate his service connection claims on a secondary basis and requested that he identify any post-service treatment records. Furthermore, the AOJ attempted to obtain records from Barksdale AFB, but such were unavailable. Finally, the Veteran was afforded VA examinations in December 2010 that addressed the Board's inquiries. Therefore, the Board finds that the AOJ has substantially complied with the January 2010 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. Background The Veteran's August 1983 examination for military enlistment found no pertinent abnormality but an adjunct medical history questionnaire note that he had had a 1976 right patella fracture and a 1965 left inguinal herniorrhaphy. An undated STR reflects that the Veteran had recurrent pharyngitis. In September 1986 the Veteran had respiratory complaints and a recurrent sore throat. An initial assessment was that an upper respiratory infection (URI) was to be ruled out but about a week later the assessment was sinusitis. In October 1988 his complaints included sinus congestion and on examination percussion of his sinuses was negative. The assessment was a URI with post-nasal drip. A little more than a week later the assessment, after an examination, was that his URI was resolving. However, in November 1988, he again complained of sinus drainage and the assessments were a URI and questionable bronchitis. A November 1988 chest X-ray revealed mild peribronchial thickening consistent with bronchitis but without evidence of pneumonia, and was otherwise within normal limits. In June 1989 the Veteran had stomach cramps and erythema of his throat. The assessments were pharyngitis and acute gastroenteritis. He received an injection of penicillin. In December 1989 there was another assessment of pharyngitis. In January 1990 there were assessments of acute exudative tonsillopharyngitis, which later that month was noted to have resolved. In July 1990 the Veteran was hospitalized for several days for complaints of a headache, chronic cough, and sore throat. The discharge diagnoses were acute tonsillopharyngitis and resolved acute gastritis. In December 1991 the Veteran complained of sinus drainage, a cough, and sore throat and the assessment was a mild URI. Several days later it was noted to have resolved. In February 1993 he had a productive cough which was occasionally blood-tinged. The assessment was that he had a viral URI or bronchitis, and in March 1993 the assessment was that bronchitis was resolving. However, later in March 1993 it was reported that he had had a diagnosis of a viral syndrome, and the assessment was viral bronchitis. In January 1994, with complaints of congestion and coughing, the assessment was again bronchitis. In May, there were assessments of a fever; sinusitis, clinically, and pharyngitis. Clinical sinusitis was again assessed in June 1994, when he complained of sinus headaches and drainage. In November 1994 the Veteran was noted to have a history of recurrent pharyngitis and after an examination the assessment was exudative pharyngitis, for which he was given penicillin. In January 1995 he had symptoms of allergic versus vasomotor rhinitis. After an examination the assessment was sinusitis with pharyngitis. When he complained of nasal congestion and a head cold in March 1995 the assessment was sinusitis. In December 1997 the Veteran complained of sinus problems, vomiting, and a runny nose. The assessment was a URI with a bacterial secondary infection, but early sinusitis was to be ruled out. In March 1998 he complained of recurrent congestion and after an examination the assessment was chronic sinusitis. A history of chronic sinusitis was again noted in January 1999. In June 1999 he again complained of sinus congestion but after an examination the assessment was a URI. Several days later, when he had continued symptoms, the assessments were "sinusitis/bronchitis." In April 2000 it was noted that he had had "chronic sinusitis" every spring since 1994 when living in California and Texas, which had been treated with antibiotics and other medications but he denied any complications. An assessment of a URI was noted in October 2000 but the history reported in April 2000 was again noted in December 2000, at which time it was reported that he had chronic mild sinusitis, for which he had been seen twice in the past 1 1/2 years but recovered quickly and had no symptoms between bouts and it did not interfere with his past flying status. In June 2001 the Veteran's complaints included nasal congestion and the assessment was a URI. In July 2001 there was an assessment of persistent complaints of congestion with post-nasal drip and cough. He underwent pulmonary function testing and the report of a spirometric testing was that it was within normal limits. Later in July 2001 and again in January 2002 the assessments were "SAR" (seasonal allergic rhinitis). The Veteran was treated in August 2003 for a right knee injury and fracture of the right ring finger due to a fall. He was treated for a possible right knee meniscal tear. X-rays in October 2003 revealed a small minimally displaced tuft fracture of the distal phalanx of the right 4th finger. In January 2004 he complained of running sinuses and a sore throat. The assessment was a URI. Also in that month it was reported that his respiratory complaints due to Eustachian tube dysfunction did not interfere with his flying status. In March 2004 there was another assessment of a URI, which in early April 2004 had resolved. On VA examination in November 2005 the Veteran's claim file and his VA medical records, including his electronic medical records were reviewed. It was noted that he was left handed. He had had a bilateral inguinal hernia repair as a child. He had five years of college education. He was a supervisor of a maintenance department. With respect to the Veteran's GERD, he took Zantac, occasionally, as needed which was about 3 to 4 times weekly for heartburn and usually at night. He did not have dysphagia. He had some pyrosis, usually late in the evening. He did not have hematemesis or melena. He had reflux, especially at night but did not have nausea or vomiting. It was noted that the Veteran had had pharyngitis and sinusitis in the past. After coming back to Louisiana, however, he had not recently had any problems with pharyngitis and sinusitis. It was noted that he had had sinus complaints in the past but currently he did not complain of any symptoms of sinusitis. He did have interference with breathing through his nose but the location of the problem was his nose and not his sinuses. He did not have purulent discharge or dyspnea at rest "on" exertion. He was not currently on any treatment program for any respiratory or sinus condition. While he did have headaches, he did not have any speech impairment, or chronic sinusitis. It was noted that he was not currently complaining of any sinus problems. He did not have allergy attacks. He did not have any incapacitating period in the past several years requiring bedrest or treatment by a physician. It was reported that he had had bronchitis in the past but did not currently have, nor had he recently had, a bronchial infection. He did not complain of fever, night sweats, or loss or gain of weight. He did not have hemoptysis and was not on any current treatment program. It was specifically noted that he did not currently have any respiratory complaints. As to the Veteran's right ring finger, it was noted that he had not had surgery following his 2003 injury. He did not have any complaint of pain in the right hand or fingers of that hand. He did not have any flare-ups of joint pain or finger pain. On physical examination the Veteran was 71 inches in height and weighed 188 pounds. His nose, sinuses, mouth, and throat were normal. There was no frontal or maxillary sinus tenderness. There was no postnasal drip. His lungs were clear and without crackles or wheezes. His abdomen was soft and nontender and there was no organ enlargement or masses. On active, passive and repetitive joint motions there was no pain. He was not additionally limited by pain, fatigue, weakness or lack of endurance following repetitive motions. There was no objective evidence of painful motion, edema, effusion, instability, weakness, redness, heat or abnormality or guarded movement. There was no incoordination of movement. There was no ankylosis of any joint and no evidence of inflammatory or constitutional signs of arthritis. The examiner opined that there was no additional functional impairment on the basis of fatigue, incoordination, pain or weakness. Also on examination, there was no ankylosis of any of the fingers. Metacarpophalangeal flexion was from zero to 30 degrees. Proximal interphalangeal flexion was from zero to 30 degrees. The hands were able to function as a unit and the tips of the fingers were able to touch the thumb. The tips of the fingers crossed over the medial transverse fold. The Veteran had good strength for pushing, pulling, and twisting. He had good dexterity for twisting, probing, writing, touching, and expression. There was no functional impairment noted. There were no fibrous or bony residuals of a fracture. There had been no amputation. X-rays of the Veteran's right hand revealed no significant osseous or articular abnormality. A sinus CT scan revealed no acute sinusitis but revealed chronic rhinitis with contributing nasal obstruction. An upper gastrointestinal (GI) X-ray series (UGI) revealed gastric reflux but otherwise the upper GI tract was satisfactory. Pulmonary function testing was normal with no evidence of obstruction or restriction. The pertinent diagnoses were (1) status post fracture of the right hand without loss of function; (2) GERD, under treatment; (3) normal examination of the respiratory system; and (4) chronic rhinitis inferior turbinate hypertrophy. On VA examination in December 2010 the Veteran's claims files and electronic records were reviewed. Since his service discharge he had worked as a supervisor of a maintenance department. As to bronchitis, sinusitis, and pharyngitis, as well as rhinitis on VA examination in December 2010 the Veteran reported that during service he had been treated on multiple occasions, usually with antibiotics, for allergic rhinitis, sinusitis, and pharyngitis. His rhinitis was treated with nasal sprays but he had not been able to use nasal sprays while on flight status. His allergy problems were aggravated by moving to an environment which exposed him to allergens, e.g., ragweed and pollen. However, when he was in a dry environment he did not have a problem. By his history, the humidity when stationed at Barksdale AFB had brought on his problems. He had never had sinus surgery and inservice allergy testing was negative. He reported that he had never been hospitalized for his sinuses and had never had incapacitating episodes. However, he reported that as to his rhinitis and sinusitis he had nasal discharge which would become yellowish or green. The last time he had such an episode was 1 1/2 years ago and he had to have antibiotics. VA clinical records revealed that he had been treated in November 2007 for acute sinusitis. He reported intermittently using over-the-counter cold and cough medicines. He took TheraFlu about 6 times yearly with good results, but he had not sought treatment by a physician. He self-treated episodes of sore throats, which he attributed to reflux because it caused a burning sensation in his throat for which he took over-the-counter medication. The Veteran also reported that he had not sought treatment by a physician for pharyngitis and had not been treated by one, to his recollection, for several years. As to bronchitis, he reported having had recurrent inservice treatment, beginning in about 1984 or 1985. He had been treated conservatively with nose sprays and antibiotics. He had been treated about 6 times for bronchitis between 1983 and 2005, but was never hospitalized or had incapacitating episodes. The examiner noted that the Veteran felt that all of his symptoms, e.g., bronchitis, rhinitis, and sinusitis were related to his GERD. However, the Veteran reported that since his 2005 service discharge he had not been treated for bronchitis. He did not use inhalers and denied exertional dyspnea. He had not been diagnosed as having asthma. He had not required oxygen and was not incapacitated due to bronchitis. He also denied having cor pulmonale, pulmonary hypertension and right ventricular hypertrophy. He had no history of weight gain or loss, although he may have gained 10 pounds since 2005. He had no history of restrictive or obstructive lung disease. Therefore, the examiner stated, the Veteran's bronchitis had not turned into or been treated consistently as a chronic condition since service discharge, although the STRs documented multiple treatments for this problem during service. On physical examination the Veteran's nares were patent but asymmetrical due to mucosal edema secondary to congestion. His nasal septum was in the mid-line. The right naris was 90 percent obstructed but without epistaxis or discharge. There was some dried mucous along the mucosal wall, medially. The left naris was patent but 50 percent obstructed and without epistaxis or significant discharge. There was no maxillary or fontal sinus tenderness. His lungs were clear to auscultation and without rales, rhonchi or wheezes. A sinus CT scan found a trace of fluid in the left maxillary sinus but was otherwise normal. A chest X-ray revealed both lungs were clear of any active process. The diagnoses were (1) chronic rhinitis; (2) no evidence of chronic sinusitis and no evidence of current pharyngitis since military service discharge in 2005 and this condition was inactive; (3) no evidence of bronchitis and no exacerbations since military service discharge in 2005. The examiner noted that the Veteran had been treated during service for bronchitis, along with sinusitis, rhinitis, and pharyngitis but he had not developed any chronic conditions since service discharge which required treatment and, thus, bronchitis was not found on the current examination. The examiner further stated that as to the Veteran's nose, sinus, larynx, and pharynx it was found that the Veteran had a diagnosis of chronic rhinitis. He had sinusitis and recurrent pharyngitis for which he was treated during service but which had not been active since service and, thus, those conditions were considered in remission. As to the Veteran's report of recurrent episodes of a sore throat and cough concomitant with reflux, the cough and recurrent sore throat were considered sequelae of the reflux but not a chronic condition because the Veteran had not required any intervention or treatment other than to treat the reflux. Specifically, the examiner opined that it was at least as likely as not that the chronic rhinitis, chronic sinusitis, and recurrent pharyngitis were conditions related to the Veteran's active duty; however, the chronic rhinitis was the only active condition that had persisted after military discharge. His sinusitis and recurrent pharyngitis were currently inactive. The rationale was that he had been treated multiple times during service for chronic rhinitis, chronic sinusitis, and recurrent pharyngitis but currently there was no evidence of chronic sinusitis or pharyngitis. He did have a sore throat and intermittent cough related to reflux. It was now recognized that a sore throat and recurrent cough could be related to GERD, as symptoms of GERD, but he had not required any intervention for these symptoms of reflux, other than using Zantac and antihistamines. Thus, it was not at least as likely as not that chronic sinusitis or recurrent pharyngitis were caused or aggravated by the service-connected GERD. The rationale was that the association that the Veteran was claiming was not documented in the STRs. During service he was treated with antibiotics, antihistamines, and nose sprays. These were independent conditions during service and were not treated or associated with the diagnosed GERD. As to bronchitis, there was no evidence of bronchitis being clinically found on the current examination, and he had not required treatment for bronchitis since service. While he reported having a recurrent or intermittent cough that could possibly be related to reflux, the cough had not required any intervention or treatment, other than the treatment for GERD. The cough that the Veteran had, from reflux, should not be labeled as bronchitis because he had not exhibited nor been diagnosed with bronchitis as a residual of GERD and he did not any chronic pulmonary conditions as this time. As to the service-connected right ring finger fracture residuals, the December 2010 VA examination revealed the Veteran complained of episodes of stiffness and pain in his right hand. However, he admitted being able to perform his activities of daily living and could drive. He could also perform recreational activities and had no work restrictions due to this condition. He was able to perform manual labor and computer typing and writing. He had not seen a physician for this condition. He reported that cold weather aggravated twisting motions of the right hand, such as using a wrench at work, but was still able to perform his work. When he intermittently got pain in the right 4th finger he used Aleve, to which he had a good response. He reported having intermittent flare-ups of this problem. The severity was 3 to 4 on a scale of 10, with the frequency being once to twice weekly, and the duration being from minutes to hours, but resolving with use of Aleve. On physical examination the Veteran's hands were symmetrical without synovitis, erythema, warmth or effusion of the joints of the fingers of the right hand. There were no bony deformities or ankylosis of any fingers and his dexterity was intact. He could use his fingers and hands to perform activities of buttoning and unbuttoning, and he could dial a phone. Comparative testing of grip strength of his hands revealed no significant decrease right hand grip, compared to the left hand. X-rays of the right hand were normal and the bony structures and joint spaces were essentially intact and well maintained. The examiner, upon rendering a diagnosis, found that the Veteran did not have a bony deformity nor was there any traumatic arthritis, by X-ray. Rather, the Veteran had normal dexterity and function of the right ring finger which he reported was his nondominant hand. With respect to the service-connected GERD, the December 2010 VA examination revealed that the Veteran was taking Zantac, over-the-counter, twice daily for reflux symptoms. He reported that any type of food would cause reflux symptoms, particularly fried, Mexican or greasy food. It was noted that in the past, but not currently, he had been treated conservatively with proton pump inhibitors. He reported that the regurgitant material during reflux made him nauseated. He reported eating antacids like candy. The worst part was reflux in the late evening but that stress and exercise would aggravate his reflux. He denied having any coffee ground emesis or bright red blood with vomitus. He had daily bowel movements but no melena or hematochezia. He felt that he had recurrent sore throats, which he called recurrent pharyngitis, due to reflux symptoms. He admitted having flare-ups of reflux at least 3 to 4 days of the week, and sometimes more, depending upon his intake. He had undergone a life style change, confirmed by some VA clinical records but none from 2008 to 2010. On physical examination his abdomen was flat and scaphoid. Bowel sounds were normal and there was no appreciable hepatosplenomegaly. There was no rebound, guarding or masses. A UGI was normal. The diagnosis was mild GERD, with a currently normal UGI. Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. In some cases, service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Inasmuch as the Veteran does not have a disease recognized as chronic under 38 C.F.R. § 3.309(a), the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology are inapplicable. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that the provisions of 38 C.F.R. § 3.310 were amended during the pendency of the Veteran's appeal, effective October 10, 2006; however, the new provisions state that service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Although the stated intent of the change was merely to implement the requirements of Allen, supra, the Board finds that the new provisions amount to a substantive change to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the Veteran as it does not require the establishment of a baseline level of disability before an award of service connection may granted. See generally, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay 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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The credibility of lay evidence may not be refuted solely by the absence of corroborating medical evidence, but it is a factor. Davidson, 581 F.3d at 1316 (Fed.Cir. 2009). Mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Once lay evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). It is clear that the Veteran was treated during service for episodes of bronchitis, sinusitis, and pharyngitis. He now attributes these to reflux from his service-connected GERD. On the other hand, he has more recently reported that these were related to his having stationed in a humid environment and having been exposed to allergens. However, he has reported that since military service he had not had bronchitis, sinusitis, and pharyngitis (although he still occasionally had a sore throat from reflux). Further, since his military service he has not been treated for bronchitis, sinusitis or pharyngitis. Each of the two postservice VA examinations noted that the Veteran had not had, and had not been treated for, bronchitis, sinusitis or pharyngitis. Further, the 2010 VA examination noted that he had no history of obstructive or restrictive lung disease. A CT scan at the 2005 VA examination found no acute sinusitis and a CT scan at the 2010 VA examination found no more than a trace of maxillary sinus fluid. While the 2010 VA examiner stated that the Veteran's sinusitis and pharyngitis were as likely as not related to military service, that examiner specifically found that the Veteran did not how have chronic sinusitis or chronic pharyngitis; rather, it was now in remission. In other words, current disability from sinusitis and pharyngitis were not found. The 2010 VA examiner also found that there was no evidence of bronchitis being clinically found. The requirement for a claimant to have a 'current disability' is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or has a disability during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In other words, if a disability for which service connection is sought existed prior to filing a VA claim but also resolves prior to filing the claim, the claimant cannot be said to have a "current" disability at the time the claim was filed or during the pendency of the claim. Such is the case here. See McClain, Id. In this case, since the Veteran's discharge from active service, and by the STRs since at least 2004, the Veteran has not had any complaints or been treated for bronchitis, sinusitis or pharyngitis. Further, these have not clinically been shown to be in existence since his discharge from active service and, as observed by the 2010 VA examiner, are currently inactive. Since they are not shown to have existed as chronic disabilities since military service, even though they were acute during active service, service connection is also not warranted on the basis of these disabilities being caused or aggravated, as contended, by the Veteran's service-connected GERD. To the extent that the Veteran has alleged that he has current diagnoses of bronchitis, chronic sinusitis, and recurrent pharyngitis, the question of diagnosis involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. In this regard, the diagnosis of such respiratory disorders involve a physical examination as well as diagnostic testing and there is no indication that the Veteran has the medical training or expertise to conduct or interpret such evaluations. As such, the question of diagnosis in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Jandreau, supra; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). As these claimed disabilities are not shown to have been present any time since VA receives a claim for compensation for that disability, the claims must be denied. See McClain, supra; Gilpin v. West, 155 F.3d 1353 (Fed.Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (19982). For these reasons, there is no reasonable doubt to be resolved as to these issues. See 38 U.S.C.A. § 51407(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Initial Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). Chronic Rhinitis with Inferior Turbinate Hypertrophy Under 38 C.F.R. § 4.97, DC 6522 allergic or vasomotor rhinitis without polyps but with greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side, warrants a 10 percent rating. With polyps a maximum 30 percent rating is assigned. The December 2010 VA examiner observed that of the Veteran's multiple respiratory complaints only his chronic rhinitis has continued since military service as an active disease entity. That examination revealed that the Veteran's right naris was 90 percent obstructed with no epistaxis or discharge, although there was some dried mucous present along the mucosal wall medially. The left naris was patent but it was 50 percent obstructed. There was no epistaxis or significant discharge. Here, the evidence shows that the Veteran has almost complete obstruction of the right naris. That is, he lacks, by 10 percent, the degree of obstruction in one naris which a requirement for a 10 percent rating. Moreover, while he has 50 percent of an obstruction in both nasal passages, and the regulation requires greater than 50 percent of obstruction of each naris, which is an alternative means of warranting a 10 percent disability rating, the Board will resolve all doubt in his favor and find that his chronic rhinitis more nearly approximates functional impairment consistent with greater than 50 percent obstruction of the nasal passage on both sides, thus warranting an initial 10 percent rating. However, because the Veteran has not had polyps in either nares at any time during the appeal, he is not entitled to the next higher, and maximum, schedular rating of 30 percent. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for an initial rating in excess of 10 percent. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107. Right Ring Finger Fracture Residuals The Veteran is left-handed and, so, the right ring finger fracture residuals affect his nondominant upper extremity. See 38 C.F.R. § 4.69. Under 38 C.F.R. § 4.71a, DC 5230 limitation of motion of the ring finger of either the dominant or non-dominant hand does not warrant a compensable disability rating. Under DC 5227 ankylosis, either favorable or unfavorable, of the right ring finger does not warrant a compensable disability rating. A note to DC 5227 provides that consideration is to be given for possible evaluation as amputation and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. Under DC 5155, amputation of the right finger of either the dominant or non-dominant hand with metacarpal resection (more than one-half the bone lost) warrants a 20 percent rating. Without metacarpal resection of the right finger of either the dominant or non-dominant hand, at proximal interphalangeal joint or proximal thereto a 10 percent rating is warranted. Disability of the musculoskeletal system is primarily the inability to perform the normal working movements with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. § 4.40. The factors of joint disability reside in reductions of normal excursion of movements in different planes. Also for consideration are more or less than normal movement, weakened movement, excess fatigability, incoordination, painful motion, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. When evaluating joint disabilities rated on the basis of limited of motion, a higher rating may be warranted when there is functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Moreover, although pain may be a cause or manifestation of functional loss, limited motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. Functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). VA must determine the overall functional impairment of joint disability due to the factors listed above. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Painful motion with joint or periarticular pathology is productive of disability, and actually painful, unstable, or malaligned joints, due to healed injury, warrant at least the minimum compensable rating. 38 C.F.R. § 4.59. At the 2005 VA examination the Veteran had no complaints, including no flare-ups, relative to his right 4th finger, or to the right hand or other fingers of that hand. That examination found no impairment of motion, not even due to pain, fatigue, weakness of lack of endurance after repetitive motion. He had no incoordination, edema, effusion, redness, heat or abnormality or guarded movement. While the Veteran more recently, on VA examination in 2010, reported having flare-ups of pain and stiffness, by his own admission he could perform his activities of daily living and had no restriction in recreational or work activities. While he reported taking over-the-counter medication for episodes of pain, a physical examination was essentially negative and there was no decreased in his grip strength of the right hand, on comparison to the left (his dominant upper extremity). Equally important, X-rays at the time of the 2010 examination found no bony abnormality, including no traumatic arthritis. That examiner concluded that the Veteran had no impairment of dexterity of function due to the past right ring finger fracture residuals. In sum, despite the Veteran's complaint of episodic pain, he has not reported having had nor is he shown to have any actual functional impairment, including none due to pain. Further, there is no evidence of ankylosis and because there is no functional impairment, there can be no disability which equated to loss of use or amputation. See 38 C.F.R. §§ 4.63, 4.68. Accordingly, even with favorable resolution of doubt in favor of the Veteran, the disability from residual impairment as a result of the right ring fracture does not warrant a compensable rating at any time during this appeal. GERD The service-connected GERD is rated analogously as a hiatal hernia under 38 C.F.R. § 4.104, DC 7346. A disorder not listed in the rating schedule may be rated as if it were a closely related disease or injury, when (1) the functions affected, (1) the anatomical localization, and (3) symptoms are closely analogous. 38 C.F.R. §§ 4.20, 4.27; see also Lendenmann v. Principi, 3 Vet. App. 345, 351 (1992) and Archer v. Principi, 3 Vet. App. 433 (1992). The Board finds that the use of DC 7346, for rating a hiatal hernia is appropriate because the functions affected, anatomical localization, and symptomatology are closely analogous. Gastroesophageal reflux is the "reverse flow of material from stomach to esophagus." Cox v. Brown, 5 Vet. App. 95, 97 (1993). Gastroesophageal reflux is the most disabling manifestation of a hiatal hernia. 76 Fed.Reg. 39160, 39174 (July 5, 2011). 38 C.F.R. § 4.104, DC 7346 provides that a 60 percent rating is warranted when there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent rating is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is warranted when there are two or more of the symptoms for the 30 percent evaluation of less severity. "'Pyrosis' is defined as '[s]ubsternal pain or burning sensation, usually associated with regurgitation of acid-peptic gastric juice into the esophagus.' STEDMAN'S MEDICAL DICTIONARY 1494 (27th ed.2000)." Melendez-Pimentel v. Peake, slip op. (U.S. Vet. App. September 2, 2008) (non-precedential Memorandum decision) (Slip Copy, 2008 WL 4118042 (Vet.App.)). In other words, pyrosis is heartburn. The 2010 VA examination reflects the Veteran's complaints of flare-ups of GERD 3 to 4 times weekly, just as he reported at the 2005 VA examination, although at the 2010 examination he indicated it could be more often, depending on his food intake. Each examination noted that he had pyrosis, regurgitation of material into the esophagus, usually in the evening and the 2010 examination noted that this could be aggravated by stress or exercise. However, neither examination found that he had hematemesis. "Hematemesis is vomiting of blood." Vega v. Shinseki, No. 10-3483, slip op. (U.S. Vet. App. March 13, 2012); 2012 WL 803299; (nonprecendential memorandum decision) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 831 (32d ed. 2011)). Also neither examination found that he had melena, or hematochezia. Hematochezia is the passage of blood through the feces. Gregory v. Brown, 8 Vet. App. 563, 566 (1996). The 2010 examination indicated that the Veteran's complaints of an intermittent cough as well as a sore throat were associated with his GERD. However, there is no evidence of dysphagia. "'Dysphagia' is 'difficulty in swallowing'." Silimon v. Shinseki, No. 12-0668, slip op. (U.S. Vet. App. Jan. 17, 2013) 2013 WL 174423 (Vet.App.) (citing DORLAND's at 579). Likewise, there is no evidence of arm or shoulder pain. The 2010 VA examiner observed that the Veteran had undergone a life style change due to GERD. Nevertheless, the 2010 VA examiner stated that the Veteran's GERD, even with a cough and recurrent sore throat, was no more than mild in severity. The results of that examination are essentially the same as at the time of the 2005 VA examination and, as such, the Board concludes, even after considering the doctrine of the favorable resolution of doubt, that the Veteran has not had considerable impairment of health due to GERD at any time during this appeal. Further, the evidence shows that there has been no material weight loss nor is there any evidence of anemia. Accordingly, an initial rating in excess of 10 percent for GERD is not warranted. Other Considerations In making its determinations in this case, the Board has carefully considered the Veteran's contentions with respect to the nature of his service-connected disabilities at issue and notes that his lay testimony is competent to describe certain symptoms associated with these disabilities. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability ratings that have been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. In reaching the aforementioned determinations, the Board has considered the holding in Mittleider v. West, 11 Vet. App. 181, 182 (1998), "when it is not possible to separate the effects of the [service-connected condition and [a] non-service-connected condition], VA regulations at 38 C.F.R. § 3.102, which require that reasonable doubt on any issue be resolved in the appellant's favor, clearly dictate that such signs and symptoms be attributed to the service-connected condition." As applied in this case, the Board has attributed all potentially service-connected symptoms to the chronic rhinitis with inferior turbinate hypertrophy, right ring finger fracture residuals, and GERD. The Board has also considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected disabilities; however, the Board finds that his symptomatology has been stable throughout the appeal. Therefore, assigning staged ratings for such disabilities is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration for any of the disabilities at issue. An extra-schedular disability rating is warranted if 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 application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 claimant's disability picture requires the assignment of an extra-schedular rating. Id. The rating criteria for rhinitis contemplates the primary impairment from that disability, i.e., interference with breathing and this is encompassed in the award of a 10 percent rating. Varied gastrointestinal symptoms are considered under the DC applicable to the service-connected GERD, i.e., pain, vomiting, material weight loss, hematemesis, melena, anemia; epigastric distress, dysphagia, pyrosis, regurgitation, and even substernal or arm or shoulder pain. Here, the Veteran has not alleged and shown that there are any other significantly impairing symptoms attributable to his GERD. As to impairment from the right ring finger fracture residuals, a wide range of signs and symptoms are contemplated in the applicable rating criteria. The service-connected disorder requires application of the holding in Deluca, supra, and Mitchell, supra, which, in turn, requires consideration of 38 C.F.R. §§ 4.40 and 4.45. 38 C.F.R. § 4.40 requires consideration of functional loss, including the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, pain, weakness, and atrophy. Likewise, 38 C.F.R. § 4.45 requires consideration of, in part, incoordination, impaired ability to execute skilled movements, painful motion, swelling, deformity, disuse atrophy, instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing. Also, 38 C.F.R. § 4.59 requires consideration of such matters as unstable or mal-aligned joints, and crepitation as well as any painful arthritic motion. Comparing the Veteran's current disability levels and symptomatology to the Rating Schedule, the degree of disability for each disorder is contemplated by the Rating Schedule and the assigned schedular ratings are adequate. There are no additional symptoms of each disability that are not addressed by the rating schedule or considered in this decision. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability levels and symptomatology of his service-connected disabilities. Thus, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). "Because the VA disability rating schedule is designed to consider the disabling effect of disabilities separately, no single DC provision will adequately assess the variety of symptoms involved with multiple service-connected disabilities." Johnson v. Shinseki, No. 10-1785, slip op. at 10 (Vet. App. Mar. 27, 2013) (en banc). Thus, as to the question of "whether [38 C.F.R.] § 3.321(b)(1) requires VA to consider multiple service-connected disabilities on a collective basis" the Court held that it did not. Johnson v. Shinseki, No. 10-1785, slip op. at 4 (Vet. App. Mar. 27, 2013) (en banc) (noting that a concurring opinion in Brambley v. Principi, 17 Vet. App. 20, 27 (2003) that there should have been a determination of "whether the appellant's service-connected disabilities as a whole [sic] entitled [a Veteran] to [an extraschedular rating] under § 3.321(b)(1)" had never been adopted by the Court and concurring opinions are not binding on the Court" (citing Maryland v. Wilson, 519 U.S. 408, 412-13). Stated in other terms, an extraschedular rating may not be assigned for the cumulative impact of the service-connected disabilities herein at issue. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the VA examinations in 2005 and 2010 noted that the Veteran had remained gainfully employed since his discharge from military service. Therefore, the Board finds that the issue of entitlement to a TDIU is not expressly raised by the Veteran or reasonably raised by the record and, consequently, further consideration of such is not necessary. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims of entitlement to an initial compensable evaluation for residuals of a fracture of the right ring finger, and initial ratings in excess of 10 percent for chronic rhinitis with inferior turbinate hypertrophy and GERD. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C.A. § 5107. ORDER Service connection for bronchitis is denied. Service connection for chronic sinusitis is denied. Service connection for recurrent pharyngitis is denied. An initial 10 percent evaluation, but no higher, for chronic rhinitis with inferior turbinate hypertrophy is granted, subject to applicable law and regulations governing the award of monetary benefits. An initial compensable evaluation for residuals of a fracture of the right ring finger is denied. An initial evaluation in excess of 10 percent for GERD is denied. REMAND With respect to the Veteran's claim of entitlement to service connection for a left knee disorder, the Board finds that a remand is necessary as the opinion proffered by the December 2010 VA examiner is inadequate to decide the claim. In this regard, the presumption of soundness under 38 U.S.C.A. § 1111 mandates that Veterans are presumed to be in sound condition upon entry into service, except as to disabilities noted at that time. Dye v. Mansfield, 504 F.3d 1289, 1293 (Fed. Cir. 2007); see also Holton v. Shinseki, 557 F.3d 1362, 1367 (Fed.Cir. 2009). The presumption may be rebutted where clear and unmistakable evidence demonstrates both that the injury or disease existed before acceptance and enrollment and that it was not aggravated during active service. 38 U.S.C. § 1111; see Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). The presumption of soundness may be rebutted by clear and unmistakable evidence consisting of an appellant's own admissions of a pre-service disability. Doran v. Brown, 6 Vet. App. 283, 286 (1994). Also, a later medical opinion based on statements made by a Veteran about the pre-service history of his condition may be sufficient to rebut the preexistence prong of the presumption of soundness, notwithstanding the lack of contemporaneous clinical evidence or recorded history. See Harris v. West, 203 F.3d 1347, 1349 (Fed. Cir. 2000). Thus, in the absence of any contention that the appellant never made the statements attributed to him, such admissions alone may rebut the preexistence prong of the presumption of soundness. Horn v. Shinseki, 25 Vet. App. 231, 237 - 389 (2012). Aggravation of a pre-existing disorder not found on the service entrance examination can be rebutted by VA only if there is clear and unmistakable evidence of no increase in disability during service, or clear and unmistakable evidence that any increase was due to the natural progress of the disability. Wagner, 370 F.3d at 1096. The Board remanded the Veteran's claim for service connection for a left knee disorder in order to obtain an etiological opinion. In this regard, while the Veteran's pre-service left patella fracture was reported in the medical history questionnaire at service entrance, such is not the same as having been found on the examination for service entrance. Nevertheless, this together with the Veteran's admission that he had a pre-service left patella fracture, and the 2010 VA examiner's unrebutted opinion that a current left knee disability was the result of the pre-service injury serves to unequivocally and undebatably rebut the presumption of soundness at service entrance. The examiner further opined that it was not at least as likely as not that the pre-existing left patella fracture was permanently increased in severity beyond its natural progression during service because the STRs did not document any chronic disability nor was the Veteran's functional capacity of the left knee impaired during service. (Emphasis added). This included his not going before a medical board for this condition and, also, current left knee X-rays were negative even though he reported having intermittent pain with cold weather. Further, there was no evidence of residual traumatic arthritis of the left knee. However, the examiner did not address the proper evidentiary standard. In this regard, the presumption of soundness may be rebutted where clear and unmistakable evidence demonstrates both that the injury or disease existed before acceptance and enrollment and that it was not aggravated during active service. 38 U.S.C. § 1111; see Horn v. Shinseki, 25 Vet. App. 231, 235 (2012) (emphasis added). Therefore, a remand is necessary in order to obtain an addendum opinion regarding this matter. Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the VA examiner that offered an etiological opinion regarding the Veteran's left knee disorder in December 2010 for an addendum opinion. If the December 2010 VA examiner is no longer available or able to provide such addendum opinion, such opinion should be obtained from an equally qualified medical professional. Examination of the Veteran is left to the discretion of the examiner selected to offer the opinion. The claims file, including a complete copy of this remand, must be made available. The examiner is then asked respond to the following questions: Is there clear and unmistakable evidence that the pre-existing disorder left knee disorder (diagnosed as left knee strain in December 2010) did not undergo an increase in the underlying pathology during service? If there was an increase in the severity of the Veteran's left knee disorder during service, was such increase clearly and unmistakably due to the natural progress of the disease? The rationale for any opinion offered should be provided. 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraph, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matter 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 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). ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs