Citation Nr: 1320879 Decision Date: 06/28/13 Archive Date: 07/05/13 DOCKET NO. 07-29 007 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an increased disability evaluation for osteoarthritis of the right knee, currently evaluated as 10 percent disabling. 2. Entitlement to a compensable disability evaluation for bilateral inguinal hernia repair. 3. Entitlement to a compensable disability evaluation for residual neurological deficit, history of a laceration, right ring finger. 4. Entitlement to a compensable disability evaluation for seasonal allergies. 5. Entitlement to service connection for osteoarthritis of the left knee. 6. Entitlement to service connection for a low back disorder. 7. Entitlement to service connection for varicose veins of the right lower extremity. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran had active service from October 1979 to March 1995. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The Board notes that, pursuant to his request in his September 2007 substantive appeal, the Veteran was scheduled for a videoconference hearing before a Veterans Law Judge of the Board at the RO in February 2013; however, he failed to report for that hearing. As he has not provided cause for his failure to appear or requested another hearing, the Veteran's hearing request is deemed withdrawn and the Board will proceed with its review on the present record. See 38 C.F.R. § 20.704(d), (e) (2012). The claims for service connection for osteoarthritis of the left knee and a low back injury are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the entire rating period on appeal, the right knee osteoarthritis most closely approximates limitation of motion objectively confirmed by painful motion but not ankylosis, dislocated semilunar cartilage, limitation of flexion to no worse than 90 degrees, no limitation of extension, or impairment of the tibia and fibula. 2. Throughout the rating period on appeal, the Veteran's bilateral inguinal hernia repair is not manifested by a recurrent hernia; the Veteran has pain, but no other residuals. 3. Throughout the rating period on appeal, the Veteran's residual neurological deficit, history of a laceration, right ring finger has not been shown to be manifested by even mild incomplete paralysis of the median nerve. 4. Throughout the entire rating period on appeal, the Veteran's service-connected seasonal allergies are productive of nasal passage of less than 50 percent occlusion, or tenderness. 5. Varicose veins of the right lower extremity are not attributable to service. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 10 percent for right knee osteoarthritis have not been met for the entire rating period on appeal. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260 (2012). 2. The criteria are not met for a compensable disability rating for bilateral inguinal hernia repair. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.114, Diagnostic Code 7338 (2012). 3. The criteria for an increased, compensable disability rating for residual neurological deficit, history of a laceration, right ring finger have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.124a, Diagnostic Code 8515 (2012). 4. The criteria are not met for a compensable rating for allergic rhinitis. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.97, Diagnostic Code 6522 (2012). 5. Varicose veins of the right lower extremity were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the agency of original jurisdiction (AOJ) issued notice letters, dated in March 2006, April 2006, and May 2006, to the Veteran. These letters explained the evidence necessary to substantiate the Veteran's claims for service connection and increased ratings, as well as the legal criteria for entitlement to such benefits. The letters also informed him of his and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The claims file contains the Veteran's available service treatment records, reports of private and VA post-service treatment, and the Veteran's own statements in support of his claims. The Veteran was afforded VA examinations responsive to the claims for increased disability ratings. The Board has reviewed the examination reports, and finds that they are adequate for the purpose of deciding the issues on appeal. The examination reports contain all the findings needed to rate the Veteran's service-connected right knee osteoarthritis, bilateral inguinal hernia repair, right ring finger laceration, and seasonal allergies, including his history and clinical evaluation. The Veteran's appeal for higher evaluations for the right knee, bilateral inguinal hernia, repair, right ring finger, and seasonal allergies is distinguished from the facts in Proscelle v. Derwinski, 2 Vet. App. 629, 633 (1992), where no VA examination was provided during the rating claim, and a veteran specifically stated that his disability "has increased in severity [such] that I rate a higher disability," constituting at least both some assertion by the veteran and some evidence of worsening of disability since the last VA examination. Proscelle, 2 Vet. App. at 632. In the Veteran's case currently on appeal to the Board, there is no evidence of worsening of the Veteran's disabilities since the 2008 and 2012 VA examinations, including no assertion by the Veteran of worsening since the last VA examination. The Veteran here does not assert that his right knee disability has worsened since the July 2012 VA examination or that his bilateral inguinal hernia repair, right ring finger laceration, or seasonal allergies have worsened since the August 2008 VA examination; he merely asserts entitlement to a higher disability evaluation. The Veteran has not submitted evidence of worsening, and the evidence of record, including the medical evidence reflecting on the severity of the disabilities on appeal, does not suggest that these disabilities worsened since the most recent VA examinations, or since VA treatment records in 2012. As there is no evidence of worsening since the last VA examination, a remand for a new VA examination is not warranted, and is not required by the VCAA. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination); VAOPGCPREC 11-95 (interpreting that a new examination is appropriate when there is an assertion of an increase in severity since the last examination). The Veteran has been afforded adequate examinations on the issues decided herein. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran has not been examined by VA in connection with his claim for service connection of varicose veins of the right lower extremity; however, no examination or nexus opinion is required regarding this claim as the weight of the evidence demonstrates no related injury, disease, or event during service; therefore, no examination or nexus opinion is required, and any opinion would be speculative, as there is no injury, disease, or event during service to which such a currently diagnosed disorder could be related. For this reason, a remand to provide the Veteran with a medical examination and/or obtain a medical opinion is not required with respect to the claim for service connection of varicose veins of the right lower extremity. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (where the Board makes a finding that lay evidence regarding an in-service event or injury is not credible, a VA examination is not required). Additionally, the Veteran has not alleged that any examination is inadequate to decide the claims being adjudicated herein, so the examinations are presumed to have been adequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of the opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Legal Criteria for an Increased Disability Evaluation Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where the veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). More generally, disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, 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. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In addition, the intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. This regulation also provides that the intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and that crepitation should be noted carefully as points of contact which are diseased. Thus, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The Court has also held that VA's regulations pertaining to whether a compensable rating is warranted for pain (as shown by adequate pathology and evidenced by the visible behavior in undertaking motion), 38 C.F.R. §§ 4.40 and 4.59, apply regardless of whether the painful motion is related to arthritis. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Analysis for an Increased Disability Evaluation Factual Background The Veteran was initially provided with a VA examination in connection with his claims for increased ratings in March 2006. According to that report, the Veteran complained of pain, stiffness, swelling, and instability of the right knee, with occasional locking. He reported that he cannot climb stairs or walk long distances. He also complained of pain and a pulling sensation due to his bilateral inguinal hernia repair, without functional impairment. Examination was negative for evidence of a hernia; there was a scar about 7.5 cm by .2 cm, with hypopigmentation of less than 6 square inches, without tenderness, disfigurement, ulceration, adherence, tissue loss, inflammation, edema, instability, keloid formation, hyperpigmentation, or abnormal texture. Upon examination of the right knee, there was tenderness to palpation, and "locking" pain. Range of motion was to 130 degrees flexion upon repetitive use, with pain at 90 degrees. The right knee was not additionally limited by fatigue, weakness, lack of endurance, or incoordination. Anterior and posterior cruciate ligament stability was normal, as was medial and lateral collateral ligament stability. X-rays of the right knee showed degenerative arthritic changes. A January 2007 VA treatment report indicates that the Veteran complained anterior knee pain, exacerbated by deep flexion and effusion. Upon examination, motor strength was full, sensation was intact, and reflexes were 2+. The Veteran had full range of motion, with pain upon full flexion, tenderness to palpation at the patella, medial joint line, and lateral joint line, but drawer, McMurray's, and Lachman testing was normal. There was crepitus, but there was no atrophy, swelling, or gross deformity noted. An August 2008 VA examination report indicates that the Veteran complained of tingling, numbness, abnormal sensation, and pain due to his neurological deficit of the right ring finger, status-post laceration. The Veteran reported having difficulty typing, but no other functional impairment and he denied receiving treatment. Regarding his right knee, the Veteran complained of pain, weakness, stiffness, instability, swelling, lack of endurance, locking, and fatigability. Regarding his seasonal allergies, the Veteran complained of interference with breathing through his nose, but denied purulent discharge, hoarseness, pain, and crusting. He denied any current symptoms related to his bilateral inguinal hernia repair. Examination showed 20 percent nasal obstruction on the left side, but without a deviated septum, loss of part of the nose, disfigurement, or nasal polyps; there was allergic rhinitis present. There was a scar of the inguinal region, measuring 8.5 cm by .1 cm, with hypopigmentation and abnormal texture of less than 6 square inches, but without keloid, hyperpigmentation, inflammation, edema, adherence, ulceration, tenderness, or disfigurement. There was no hernia present. Examination of the Veteran's abdomen showed no evidence of striae of the abdominal wall, distension of superficial veins, ostomy, splenomegaly, ascites, liver enlargement, or aortic aneurysm. The Veteran is right hand dominant. He had right wrist dorsiflexion to 70 degrees, palmar flexion to 80 degrees, radial deviation to 20 degrees, and ulnar deviation to 45 degrees. Wrist range of motion was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination. The Veteran had right hand and finger dexterity, and could approximate the proximal transverse crease off the palm. With thumb attempting to oppose fingers, the measurement between the pad of the right thumb and the right ring finger is 0 cm. Right hand strength was normal and right ring finger metacarpointerphalangeal (MIP) joint flexion was to 90 degrees, proximal interphalangeal (PIP) joint flexion was to 110 degrees, and distal interphalangeal (DIP) joint flexion was to 70 degrees. Joint function of the right hand and fingers was not additionally limited by pain, fatigue, weakness, or incoordination. Neurological examination of the right upper extremity was normal. There was edema, effusion, tenderness, and guarding of the right knee, but there was no weakness, redness, heat, or subluxation. Range of motion was to 90 degrees. Range of motion was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination. There was moderate instability of the right knee medial and lateral collateral ligaments. Treatment records dated 2010 to 2012 show complaints and treatment for knee pain. Range of motion was full. A February 2010 letter from the Veteran's treating provider at VA indicates that the Veteran experiences knee pain. A multiple impairment questionnaire also indicates that the Veteran experiences chronic knee pain. The Veteran was most recently afforded a VA examination in connection with his right knee in July 2012. According to that report, the Veteran complained of swelling and pain. Upon examination, he had full range of motion, without additional limitation of range of motion due to repetitive use testing, but he had pain on movement and tenderness to palpation. Strength testing was normal, there was no indication of instability or patellar subluxation/dislocation, and the Veteran did not have shin splints. The Veteran had a history of a meniscal tear of the right knee, without meniscectomy. The VA examiner noted that the Veteran had "Waddell signs of overreaction" and that the Veteran used a cane regularly due to his knees. Right Knee Osteoarthritis The Veteran's right knee osteoarthritis is rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5010-5260. The knee is rated as 10 percent disabling. Under DC 5010, degenerative or traumatic arthritis substantiated by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. The appropriate diagnostic codes for the knee joint are DCs 5260 and 5261, applicable to limitation of flexion and extension of the leg, respectively. Under DC 5260, limitation of flexion of a leg warrants a noncompensable rating when flexion is limited to 60 degrees. A 10 percent rating is warranted if flexion is limited to 45 degrees, and a 20 percent rating is warranted if flexion is limited to 30 degrees. Flexion that is limited to 15 degrees warrants a 30 percent rating. Under DC 5261, limitation of extension of a leg is noncompensable when extension is limited to 5 degrees, warrants a 10 percent rating when it is limited to 10 degrees, a 20 percent rating when it is limited to 15 degrees, a 30 percent rating when limited to 20 degrees, a 40 percent rating when limited to 30 degrees, and a 50 percent rating when limited to 45 degrees. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. VA's General Counsel has held that separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. VAOPGCPREC 9-2004 (2004). After a review of the lay and medical evidence, the Board finds that the Veteran's right knee osteoarthritis most nearly approximates the criteria for a 10 percent disability evaluation under Diagnostic Codes 5010-5260. The current evaluation contemplates pathology productive of painful motion. The evaluation would also be consistent with limitation of flexion to 45 degrees. In order to warrant a higher evaluation, there must be the functional equivalent of limitation of flexion to 30 degrees. A separate evaluation may be assigned if there is compensable limitation of extension. The Veteran does not have flexion of the right knee functionally limited to 30 degrees as required for a 20 percent rating (Diagnostic Code 5260), or any limitation of extension (Diagnostic Code 5260). See VAOPGCPREC 9-2004. VA treatment records clearly indicate that the Veteran experienced painful motion of the right knee. At the March 2006 VA examination, the Veteran complained of pain and had flexion to 130 degrees on the right with complaints of pain at 90 degrees. Likewise, at the August 2008 VA examination, flexion was to 90 degrees, with pain. At the July 2012 VA examination, he had full range of motion. VA considers "full" range of motion for the knee to be from 0 to 140 degrees (full extension to full flexion). See 38 C.F.R. § 4.71, Plate II. No lay or medical evidence suggests that flexion is functionally limited to 30 degrees. The Board accepts the lay evidence that he has pain and stiffness. However, such evidence does not establish that flexion is functionally limited to less than 45 degrees or that there is any compensable impairment of extension. There is no objective clinical indication that he has additional functional impairment, above and beyond the 10-percent level. In this regard, the Board points out that the Veteran's VA examination reports were repeatedly negative for objective evidence of incoordination, weakness, abnormal movement, or deformity. See DeLuca, citing 38 C.F.R. §§ 4.40, 4.45, and 4.59. There was also no evidence of fatigability, although the Veteran reports experiencing pain, crepitus, and swelling. Likewise, there was no objective evidence of decreased motor strength and x-rays did not show a fracture or dislocation. His pain did not significantly inhibit his range of motion or otherwise create functional limitations. There also is no objective clinical indication that he has other symptoms (e.g., premature or excess fatigability, weakness, incoordination) which otherwise result in any additional functional limitation in his right knee to a degree or extent that would support a higher rating. In particular, the August 2008 and July 2012 VA examiners noted that there was a mild increase in pain upon repetitive use, but found that there was no additional weakness, fatigability, incoordination, lack of endurance, or additional loss of motion. As a result, his current 10 percent rating for osteoarthritis of the right knee adequately compensates him for the extent of his pain, including insofar as its resulting effect on his range of motion. DCs 5256 and 5262 provide for higher ratings for ankylosis and impairment of the tibia and fibula, respectively. DC 5258 provides for a 20 percent evaluation for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Although the Veteran has pain of the right knee, he does not have overall moderate impairment of his tibia and fibula. Although there was an occasional report of locking and effusion, such reports and findings were infrequent and not indicative of frequent episodes. The Board also observes that the Veteran is in receipt of a separate, 10 percent evaluation for instability of the right knee pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board has fully considered the lay pleadings. However, the repeated objective medical evidence is far more detailed, probative and more credible than the lay evidence. Bilateral Inguinal Hernia Repair The Veteran currently has a noncompensable rating for his bilateral inguinal hernia repair under 38 C.F.R. § 4.114, Diagnostic Code 7338. According to Code 7338, a noncompensable disability rating is for assignment where there is an inoperable but remediable inguinal hernia or a small, reducible inguinal hernia or an inguinal hernia without true hernia protrusion. A 10 percent rating is warranted for a postoperative, recurrent, readily reducible hernia that is well supported by a truss or belt. A 30 percent rating requires a small, postoperative, recurrent, or irremediable hernia that is not well supported by a truss, or not readily reducible. Whereas a 60 percent rating requires a large, postoperative, recurrent hernia that is not well supported under ordinary conditions and is not readily reducible, when considered inoperable. See 38 C.F.R. § 4.114, Code 7338 (2012). After a review of the lay and medical evidence, the Board finds that the Veteran's current noncompensable disability rating is most appropriate for the Veteran's bilateral inguinal hernia repair, for the entire rating period on appeal, and that a higher, compensable rating is not warranted. 38 C.F.R. § 4.7. The objective medical evidence of record indicates that the Veteran's bilateral inguinal hernia repair is productive of subjective complaints of pain. However, at his most recent, August 2008 VA examination, the area of the Veteran's bilateral inguinal hernia repair was non-tender and his scar was well healed, without underlying tissue damage. Moreover, the VA examiner did not state that the Veteran required a truss or belt; the VA examiner found that the examination of the Veteran's abdomen showed no evidence of a hernia. There was also no evidence of striae of the abdominal wall, or tenderness to palpation. As such, the Veteran is not entitled to a compensable disability rating for his residuals of a bilateral inguinal hernia repair. Additionally, the Board has considered whether the Veteran is entitled to a separate rating for the scar under 38 C.F.R. § 4.118, Diagnostic Codes 7801 to 7805. In this case, however, the evidence does not establish that such criteria have been met. On VA examination in March 2006 and August 2008, the Veteran's scar was noted as measuring 8 centimeters, and productive of hypopigmentation. The scar was not tender to palpation and there was no evidence of skin breakdown, disfigurement, keloid formation, adherence, or inflammation. For these reasons, assignment of a separate evaluation for the Veteran's surgical scar is not warranted. Residual Neurological Defect, Right Ring Finger The Veteran's residual neurological deficit, history of a laceration, right ring finger is rated as noncompensable according to the provisions of 38 C.F.R. § 4.124a, Diagnostic Code 8515, for paralysis of the median nerve. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2012). At the Veteran's August 2008 VA examination, he reported that he is right-handed. Under Diagnostic Code 8515, for the major wrist, a 10 percent evaluation is assigned for mild incomplete paralysis; a 30 percent rating requires moderate incomplete paralysis; and a 50 percent rating requires severe incomplete paralysis. A 70 percent disability rating requires complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of thenar eminence, the thumb in the plane of the hand; pronation incomplete and effective, absence of flexion of the index finger and feeble flexion of the middle finger, that cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of the thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. See 38 C.F.R. § 4.124a, Diagnostic Code 8515. After a review of the lay and medical evidence, the Board finds that the Veteran's disability picture is most consistent with his current noncompensable disability rating for his residual neurological deficit, history of a laceration, right ring finger. While the evidence shows that the Veteran is right-handed, the evidence of record does not show that he experiences mild incomplete paralysis of the medial nerve. He complained of numbness and tingling at his August 2008 VA examination; however, he denied experiencing weakness or problems with his dexterity. Upon examination in August 2008, he had right wrist dorsiflexion to 70 degrees and palmar flexion to 80 degrees, and he could approximate the proximal transverse crease off the palm. Sensation, muscle strength, and neurological evaluation were normal. There was no evidence of adverse effects on his activities of daily living; he denied functional impairment beyond difficulty typing. Stated differently, there is minimal, if any, neurologic impairment. Therefore, his symptomatology most closely fits within the criteria for the currently assigned noncompensable disability evaluation. Seasonal Allergies The Veteran is presently assigned a noncompensable disability rating for his seasonal allergies under 38 C.F.R. § 4.97, Diagnostic Code 6522. According to this code, the minimum compensable rating of 10 percent is warranted for allergic rhinitis without polyps but with greater than 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. A 30 percent disability evaluation requires polyps. See 38 C.F.R. § 4.97, Diagnostic Code 6522. After a review of the lay and medical evidence, the Board finds that the Veteran's current noncompensable disability rating is most appropriate for his seasonal allergies, and that his claim for a higher rating must be denied. The objective clinical evidence of record does not show that he experiences at least at least 50 percent obstruction of either nasal passage or nasal polyps. Indeed, the medical evidence of record indicates that the Veteran's allergic rhinitis causes no occlusion of the right nasal passage and 20 percent occlusion of the left nasal passage, and that he does not require any medication for symptoms as of the August 2008 VA examination. The Board acknowledges that the August 2008 VA examiner stated that the Veteran's allergic rhinitis causes symptoms such as congestion, but points out that the Veteran denied crusting, hoarseness, purulent discharge, and dyspnea. In addition, there was no tenderness to palpation of the face or evidence of a deviated septum. Therefore, his symptomatology specifically attributable to his seasonal allergies most closely fits within the criteria for the currently assigned noncompensable disability evaluation. Lay Pleadings One function of the Board is to consider the lay evidence and pleadings. However, other than that recorded during medical evaluations, the record is remarkably lacking in substantive pleadings from the Veteran or the representative. Under the circumstances, the medical evidence is more probative than any implied pleadings or lay evidence. Extraschedular Considerations As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. 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. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's right knee disability, bilateral inguinal hernia repair, seasonal allergies, and neurological residual of the right ring finger laceration are fully contemplated by the applicable rating criteria. As shown above, the criteria include symptoms, each of which were addressed in the VA examinations and treatment records and which provided the basis for the disability ratings that have been assigned. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. In any event, the Veteran did not claim, and the evidence does not reflect, that there has been marked interference with employment, frequent hospitalization, or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. None of the VA examiners indicated that the Veteran lost any time from work due to his right knee disability, bilateral inguinal hernia repair, seasonal allergies, and neurological residual of the right ring finger laceration. Therefore, referral for consideration of an extraschedular rating for the Veteran's right knee disability, bilateral inguinal hernia repair, seasonal allergies, and neurological residual of the right ring finger laceration is not warranted. 38 C.F.R. § 3.321(b)(1). In the absence of exceptional factors associated with right knee disability, bilateral inguinal hernia repair, seasonal allergies, and neurological residual of the right ring finger laceration, the Board finds that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Legal Criteria for Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006). Service connection may be granted for any disease initially diagnosed after service 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). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including cardiovascular-renal disease (including hypertension) and organic diseases of the nervous system (including sensorineural hearing loss) are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of 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 cardiovascular-renal disease (including hypertension) and organic diseases of the nervous system (including bilateral hearing loss) are considered to be chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Here, the Veteran does not have any "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply to the claim for service connection for varicose veins of the right lower extremity. Service connection is also warranted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Analysis for Service Connection The Board notes that, whether service connection is claimed on direct or secondary basis, a necessary element for establishing such a claim is the existence of current disability. See Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). As explained by the Federal Circuit, in order for a veteran to qualify for entitlement to compensation under the pertinent statutes and regulations pertaining to direct service connection, a veteran must prove existence of a disability, and one that has resulted from a disease or injury that occurred in service. See Sanchez-Benitez v. Principi, 259 F.3d 1356, 1361-1362 (2001). In this case, the Veteran must show that he has currently has varicose veins of the right lower extremity due to disease or injury in service or caused or aggravated by service-connected disability. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000) (a Veteran seeking disability benefits must establish the existence of a disability and a connection between such Veteran's service and the disability). See also Sanchez-Benitez, 259 F.3d at 1362 (without factual finding of nexus between current neck pain and in-service neck trauma, Federal Circuit could not reach the question of whether veteran's current pain was statutorily compensable). The Veteran reported that he had varicose vein of the right leg when he filed his claim for service connection in July 2005. However, the weight of the evidence is against the existence of varicose veins of the right lower extremity that is due to a disease or injury in service or caused or aggravated by service connected disability. The evidence shows that service treatment records do not show any complaints, treatment, or diagnoses of varicose veins of the right lower extremity during or after service. See Kahana v. Shinseki, 24 Vet. App. 428, 439 (2011) (citing Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (Lance, J., concurring) (VA may use silence in the service treatment records as evidence contradictory to a veteran's assertions if the service treatment records appear to be complete and the injury, disease, or symptoms involved would ordinarily have been recorded had they occurred). Regardless, the Veteran has not alleged any in-service injury or treatment and his vascular system (to include varicosities) was normal upon separation. Therefore, the Veteran's later allegation of such treatment and diagnosis, first given only when seeking service connection for this disability, is not credible when seen in light of the other evidence of record. In other words, the Board finds the statements made contemporaneous to separation indicating a lack of complaints related to the vascular system of his right leg have more probative weight than the later statements made during the course of a claim for compensation. See Pond v. West, 12 Vet. App. 341, 345 (1999); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest may affect the credibility of testimony). The Veteran is competent to report certain symptoms related his claimed disability; however, the Board finds that his vague assertions of current varicose veins of the right leg are not credible. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007), and n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). We again note that the Veteran is competent to report what he was told by a professional. Here, he has reported that he was told that he had a varicose vein at retirement. However, this remote lay assertion is inconsistent with the clinical evaluation which was normal when examined for varicosities. We find that the in-service normal finding is far more probative than a remote assertion advanced in support of a claim for monetary benefits. For these reasons, the Board finds that the weight of the evidence demonstrates that the Veteran does not have varicose veins of the right lower extremity that started in service. To the extent that he is competent to report that he has varicose veins that started in service and continued, such lay evidence is inconsistent with the separation examination disclosing no (normal) varicosities. The separation examination is more credible and probative than the lay evidence in this case. The benefit-of-the-doubt doctrine is therefore not for application, and the claim for entitlement to service connection for varicose veins of the right lower extremity must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER Entitlement to a disability evaluation in excess of 10 percent for osteoarthritis of the right knee is denied. Entitlement to a compensable disability evaluation for bilateral inguinal hernia repair is denied. Entitlement to a compensable disability evaluation for residual neurological deficit, history of a laceration, right ring finger is denied. Entitlement to a compensable disability evaluation for seasonal allergies is denied. Entitlement to service connection for varicose veins of the right lower extremity is denied. REMAND VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement pertinent records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. The Veteran has not been provided with VA examinations in order to address whether his claimed low back injury and left knee osteoarthritis are related to his active military service. In particular, the Veteran contends that he currently has low back and left knee disabilities related to his military service. The Board observes that the Veteran's service treatment records confirm that the Veteran was treated low back strain and complaints of back pain after a lifting injury in 1981. Likewise, the Veteran's service treatment records indicate that the Veteran underwent arthroscopic surgery of the left knee due to complaints of pain after an injury. However, at separation, the Veteran complained only of right knee pain, not left, although he also complained of chronic low back pain; his separation examination was normal. Moreover, the Board finds that it is unclear from the available medical evidence whether there are any residuals of the Veteran's in-service treatment for his low back and left knee. In this regard, the Board notes that the Veteran was evaluated for his left knee at the March 2006, August 2008, and July 2012 VA examinations, but that the examination reports came to 2 different conclusions; the March 2006 VA examiner found that the Veteran had early osteoarthritis of the left knee, whereas the August 2008 and July 2012 VA examiners essentially found that the Veteran's left knee was normal, other than complaints of pain. Similarly, the Veteran's VA treatment records show repeated complaints of back pain and a March 2008 radiology report shows sclerosis at L5-S1, but an otherwise normal lumbosacral spine. As such, the Board finds that VA examinations are warranted to determine whether the Veteran has current low back and left knee disabilities and, if so, whether such disabilities are related to in-service injuries. VA adjudicators may consider only independent medical evidence to support their findings; they may not rely on their own unsubstantiated medical conclusions. If the medical evidence of record is insufficient, VA is always free to supplement the record by seeking an advisory opinion, or ordering a medical examination to support its ultimate conclusions. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board finds that the Veteran should be afforded a VA examination. See 38 U.S.C.A. § 5103A(d)(1); 38 C.F.R. § 3.159(c)(4) (VA has an affirmative duty to obtain an examination of the claimant at VA health-care facilities if the evidence of record does not contain adequate evidence to decide a claim). See also Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination as to the nature and etiology of any left knee disorder, to include osteoarthritis. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should first clearly identify all left knee disabilities. With respect to each diagnosed disability, the examiner should indicate whether it is as least as likely as not (50 percent probability or more) that such left knee disability is related to service or if any osteoarthritis of the left knee manifested within one year of the March 1995 separation from service. The examiner should specifically address the in-service left knee arthroscopy and symptoms. The provider is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinions. A complete rationale should accompany each opinion provided. 2. Schedule the Veteran for a VA examination as to the nature and etiology of any low back disorder, to include sclerosis at L5-S1. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should first clearly identify all lumbar spine disabilities. With respect to each diagnosed disability, the examiner should indicate whether it is as least as likely as not (50 percent probability or more) that such lumbar spine disability is related to service or if any arthritis of the lumbar spine manifested within one year of the March 1995 separation from service. With regard to manifestation within one year of service, the question refers to whether there were any symptoms indicative of disease that manifested later and does not require a diagnosis during that time period. The examiner should specifically address the in-service complaints of back pain and injury, as well as the in service diagnosis of low back strain The provider is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinions. A complete rationale should accompany each opinion provided. 3. Readjudicate the claims for service connection. If, upon completion of the above action, the benefits sought remain denied, the case should be returned to the Board after compliance with requisite appellate procedures. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs