Citation Nr: 1321830 Decision Date: 07/09/13 Archive Date: 07/18/13 DOCKET NO. 09-45 047 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an increased evaluation for residuals of a left wrist injury, initially evaluated as 0 percent disabling and evaluated as 10 percent disabling from January 3, 2011. 2. Entitlement to service connection for a low back disability. 3. Entitlement to service connection for a right foot or ankle disability. 4. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Elizabeth Jalley, Counsel INTRODUCTION The Veteran served on active duty with the United States Army from May 21, 1989, through June 3, 1989, with prior and subsequent periods of active duty for training and inactive duty training with the United States Army Reserve terminating in June 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The May 2008 rating decision granted service connection for residuals of a left wrist injury and assigned a 0 percent rating, effective October 9, 2007. This decision also denied service connection for a low back disability, a disability of the right Achilles heel, and tinnitus. In a January 2012 rating decision, the rating for the Veteran's left wrist disability was increased from 0 percent to 10 percent, effective January 3, 2011. The Board has broadened the Veteran's original claim of entitlement to service connection for a right Achilles heel condition to more broadly contemplate service connection for a right foot or ankle disability pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, he or she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). As will be discussed in more detail below, the Board believes that this recharacterization more accurately encompasses the Veteran's actual disability contentions in this case. In February 2010, the Veteran testified at a personal hearing before a Decision Review Officer (DRO) at the Indianapolis RO. A transcript of this hearing was prepared and associated with the claims file. In his November 2009 substantive appeal, the appellant requested a hearing at a local VA office before a Member of the Board. He was scheduled for a hearing for February 2011, and he was sent a notice letter in January 2011. The appellant did not report for this hearing. He has neither requested a new hearing nor shown good cause for his failure to report to the prior hearing. Therefore, his Board hearing request is deemed withdrawn. The Board also notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim. This evidence has been considered in the following decision, and any future adjudication of this appellant's case should take into consideration the existence of this electronic record. The issues of entitlement to service connection for a right foot or ankle disability and tinnitus 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. From October 9, 2007, through April 28, 2010, the residuals of the Veteran's left wrist injury are manifested by objectively-confirmed limitation of motion to a noncompensable degree, but not by x-ray evidence of arthritis. 2. On and after April 29, 2010, the residuals of the Veteran's left wrist injury are manifested by objectively-confirmed limitation of motion to a noncompensable degree and magnetic resonance imaging (MRI) evidence of arthritis. 3. The preponderance of the evidence is against finding that the Veteran has a current low back disability that had its onset in service or that is otherwise associated with service. CONCLUSIONS OF LAW 1. From October 9, 2007, through April 28, 2010, the criteria for a compensable disability rating for residuals of a left wrist disability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5215 (2012). 2. On and after April 29, 2010, the criteria for a rating of 10 percent, but no higher, for residuals of a left wrist disability are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5215 (2012). 3. Service connection for a low back disability is not warranted. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Public Law No. 106-475, 114 Stat. 2096 (2000), substantially amended the provisions of chapter 51 of title 38 of the United States Code, concerning the notice and assistance to be afforded to claimants in substantiating their claims. VCAA § 3(a), 114 Stat. 2096, 2096-97 (2000) (now codified as amended at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012)). In addition, VA published regulations, which were created for the purpose of implementing many of the provisions of VCAA. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (now codified, in pertinent part, at 38 C.F.R. § 3.159 (2012)). The notice requirements of the VCAA require VA to notify the veteran of any evidence that is necessary to substantiate a claim, as well as the evidence VA will attempt to obtain and which evidence the veteran is responsible for providing. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements, however, may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Dingess, supra; Pelegrini, supra. However, for initial rating claims, where, as here, entitlement to disability benefits has been granted and an initial rating has been assigned, the original claim has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for entitlement to benefits has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dingess, 19 Vet. App. at 490-491; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In any event, the Board finds that the notification requirements of VCAA have been satisfied in this case. In this regard, the Board notes an evidentiary development letter dated in January 2008, prior to the initial adjudication of the Veteran's claims in May 2008, in which the RO advised the appellant of the evidence needed to substantiate his service connection claims. This letter advised the Veteran of his and VA's responsibilities under VCAA, to include what evidence should be provided by him and what evidence should be provided by VA. This letter also advised the Veteran as to the type of evidence needed to substantiate both the disability rating and effective date elements of his claims, pursuant to the Court's holding in Dingess, supra. The Board further finds that the duty to assist requirements of VCAA have also been satisfied in this case. 38 U.S.C.A. §§ 5103 and 5103A. Specifically, the Board finds that all obtainable evidence identified by the Veteran relative to the issues on appeal has been obtained and associated with the claims folder. In particular, the Board notes that the RO obtained the Veteran's service treatment records, service personnel records, and VA medical records. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in initial service connection claims, the VA must provide a VA medical examination where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service; and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. The Board notes that the Veteran has not been scheduled for, or provided with, a VA examination for the claim of entitlement to service connection for a low back disability. However, as will be discussed in more detail below, the Board finds that an examination is not necessary to decide this claim due to an absence of competent and credible evidence of an in-service injury or a low back disability for at least five years following his separation from service. Therefore, a VA examination is not warranted for this claim. The RO arranged for the Veteran to undergo VA examinations in connection with his left wrist claim in June 2009, April 2010, and December 2011. The Board finds that the resulting examination reports are adequate for the purpose of determining entitlement to an increased rating. The examiners elicited from the Veteran his history of complaints and symptoms, and the examination reports provide pertinent clinical findings detailing the results of the examinations to allow for effective evaluation of the Veteran's disability. For these reasons, the Board concludes that the examination reports in this case provide an adequate basis for a decision. The evidence of record provides sufficient information to adequately evaluate the claims. Therefore, no further assistance to the Veteran with the development of evidence is required, nor is there notice delay or deficiency resulting in any prejudice to the Veteran. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). II. Increased Rating The Veteran has claimed entitlement to an increased rating for residuals of a left wrist injury. This disability has been evaluated as 0 percent disabling from October 9, 2007, through January 2, 2011, and as 10 percent disabling on and after January 3, 2011. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. Cf. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Fenderson, the Court also discussed the concept of the 'staging' of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126-127. The Court has held that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (2012) and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45 (2012). See, in general, DeLuca v. Brown, 8 Vet. App. 202 (1995). Another intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). Under 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012), arthritis due to trauma that is substantiated by x-ray findings is rated under the rating criteria for degenerative arthritis. Under Diagnostic Code 5003, degenerative arthritis, when substantiated by x-rays, will be 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 of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under 38 C.F.R. § 4.45(f), the wrist is considered a major joint. The Veteran's left wrist disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5215. That diagnostic code assigns a 10 percent rating for dorsiflexion less than 15 degrees or for palmar flexion limited in line with the forearm on either the dominant or non-dominant wrist. The Veteran's initial 0 percent rating appears to have been assigned based on limitation of motion of the wrist that did not satisfy the compensable rating criteria of Diagnostic Code 5215. The Board notes, however, that the 10 percent rating that was assigned in the January 2012 rating decision was based on functional impairment due to pain, fatigue, weakness, or lack of endurance pursuant to DeLuca, supra, and 38 C.F.R. §§ 4.40, 4.45, and 4.59. Based on a review of the evidence of record, the Board finds that a compensable rating is not warranted prior to April 29, 2010. A 10 percent rating, but no higher, is warranted effective April 29, 2010. A May 12, 2010, MRI notes mild degenerative changes in the first carpometacarpal joint. The April 29, 2010, VA examination report notes left palmar flexion from 0 degrees to 60 degrees with objective evidence of pain with active motion. The Board notes that 38 C.F.R. § 4.71, Plate I, lists normal range of palmar flexion as being from 0 degrees to 80 degrees. Given that the record contains evidence of objectively-confirmed noncompensable limitation of motion with arthritis on diagnostic testing, the Board finds that a 10 percent rating is warranted under 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board will assign the 10 percent rating effective from the date of the April 29, 2010, VA examination report. Prior to the April 29, 2010, VA examination, the Board observes that the record does not contain x-ray evidence of arthritis. The Board notes that the June 2009 VA examination report reflects limitation of dorsiflexion (to 50 degrees, with normal dorsiflexion being to 70 degrees) and palmar flexion (to 70 degrees, with normal palmar flexion being to 80 degrees), and it notes objective evidence of swelling and tenderness on motion. However, the June 2009 radiology report notes that there are no signs of arthritis. Thus, a 10 percent rating is not available under Diagnostic Code 5003 prior to April 29, 2010. The Board has considered whether a rating in excess of 10 percent may be assigned under a different diagnostic code. The Board notes, however, that, in the absence of ankylosis, the higher ratings that are assigned for ankylosis of the wrist under 38 C.F.R. § 4.71a, Diagnostic Code 5214 are not warranted. The Board further finds that, in the absence of evidence of neurological deficits that are related to the left wrist injury, a separate compensable rating for neurological disability of the left wrist is not warranted. In sum, with consideration of all of the evidence, the Board finds that the record contains MRI evidence of left wrist arthritis and objectively-confirmed noncompensable limitation of motion from April 29, 2010. Thus, the criteria for a 10 percent rating, but no more, are satisfied from April 29, 2010. Prior to that date, however, in the absence of x-ray evidence of left wrist arthritis, a compensable disability rating for residuals of a left wrist injury is not warranted. In reaching this conclusion, the Board also has considered whether the Veteran is entitled to an even greater level of compensation for the disability at issue on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected left wrist disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the Board finds that the rating criteria of Diagnostic Code 5003 for the Veteran's service-connected left wrist injury adequately contemplate the level of impairment that is demonstrated in the evidence of record. As noted above, musculoskeletal disability ratings contemplate factors such as functional loss due to pain, weakness, fatigability, incoordination, or pain on movement of a joint, as well as actually painful, unstable, or malaligned joints due to healed injury. The left wrist injury in the case at hand is not characterized by any additional complaints or symptoms that are not contemplated by the applicable rating criteria. The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. III. Service Connection The Veteran has claimed entitlement to service connection for a low back disability. He essentially contends that he currently suffers from a low back disability that originated during service. In general, applicable laws and regulations state that service connection may be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That a condition or injury occurred in service alone is not enough; there must be disability resulting from that condition or injury. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Service connection may also be granted for a disease first 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). 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Additionally, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. As an alternative to the nexus requirement, service connection for these chronic disabilities may be established through a showing of continuity of symptomatology since service. 38 C.F.R. § 3.303(b)(2012). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). However, presumptive periods do not apply if a veteran has served fewer than 90 days of continuous, active duty, nor are they applicable to periods of active duty for training or inactive duty training. 38 C.F.R. 3.303(a)(1); Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Therefore, because the appellant's personnel records do not reflect service of 90 consecutive days of active duty, he is not eligible for service connection on a presumptive basis, regardless of whether his claimed back condition can be categorized as a chronic disability. Active military, naval, or air service includes any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of inactive duty training during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C.A. § 101(21-24) (West 2002); 38 C.F.R. § 3.6 (2012). The term "active duty" includes full-time duty in the Armed Forces, other than active duty for training, and authorized travel to or from such duty or service. 38 U.S.C.A. § 101(21)(A),(E) (West 2002). Active duty for training includes full-time duty in the Armed Forces performed by Reserves for training purposes or full-time duty performed by members of the National Guard of any State. 38 U.S.C.A. § 101(22)(C); 38 C.F.R. § 3.6(c)(1),(3) (2012). Inactive duty training includes duty (other than full-time duty) prescribed for Reserves. 38 U.S.C.A. § 101(23)(A). It also includes special additional duties authorized for Reserves by an authority designated by the Secretary concerned and performed by them on a voluntary basis in connection with the prescribed training or maintenance activities of the units to which they are assigned. 38 U.S.C.A. § 101(23)(B). It follows from this that service connection may be granted for disability resulting from disease or injury incurred or aggravated while performing active duty for training, or from injury incurred or aggravated while performing inactive duty training. 38 U.S.C.A. §§ 101, 106, 1110, 1131. Thus, with respect to his periods of active duty for training and inactive duty training, the evidentiary burden is on the appellant to show that he became disabled from an injury (or a disease in the case of active duty for training service) that was incurred in the line of duty. The Veteran described his claimed in-service back injury at his February 2010 DRO hearing. When asked to describe how he believed his back disability occurred, he stated the following: Well, I believe it occurred, me being in 13B Heavy Artillery, when I was ... I was in the back of the 155's or the 107's in the ... in the powder range ... you had to put the powder in, like, I had to load on special ... I had to ... actually hit me ... and another guy we had to load the round back in the Howitzer, and that's probably caused my back injury along with ... uh ... road marches with 75 pound rucks on my back. He reported that he went on these marches at least four to five times per month. He reported that he did not receive treatment for his low back while in service. He also reported that he had abused drugs in the past, in part to mask physical pain, and that he started seeking treatment for his low back when he stopped using drugs. The Veteran's service treatment records do not reflect that he ever sought treatment for a low back injury in service, which is consistent with his hearing testimony. These records reflect that his spine was clinically normal upon examination in March 1979, September 1979, November 1979, September 1980, September 1981, March 1985, and February 1993. He expressly denied any history of, or current, recurrent back pain on medical history reports dated in September 1979, September 1980, September 1981, January 1990, March 1985, and February 1993. Otherwise, the service treatment records do not reflect that the Veteran ever complained of, or sought treatment for, low back complaints. The Veteran's VA medical records reflect that he has sought treatment for back pain following service. These records reflect that the Veteran has had physical therapy for low back pain and has been prescribed Vicodin, Flexeril, and Methocarbamol for his low back pain at various times. An October 2007 emergency room record notes that the Veteran reported that his back pain had its onset three or four years earlier. The Veteran denied back pain during appointments in December 2007 and June 2009. A July 2011 record notes no point tenderness, no neurological deficits, and normal gait on examination. No low back diagnosis was listed at that time. The Veteran was fitted for a back brace in September 2011. A January 2013 VA medical record notes that the Veteran had tenderness in the L5 and sacroiliac joint area bilaterally. A March 2013 emergency room record notes that the Veteran sought treatment for back pain "which started after he bent down to pick up a wet floor sign at work. He has been cleaning the floor prior to this but states this is his usual job." Mild tenderness in the L4 to L5 region was found on examination, with more tenderness over the right paraspinous muscles in that region. The Veteran was assessed as having low back pain due to myofascial sprain. He was given a Toradol injection. He was discharged to home on Vicodin and was told to continue his current muscle relaxer. Based on the above, the Board finds that entitlement to service connection for a low back disability is not warranted. In doing so, the Board notes that the Veteran's service treatment records do not support the Veteran's contention that he injured his low back in service. The vast majority of the Veteran's military service has been classified as active duty for training or inactive duty training, meaning that the injury in question had to have occurred in the line of duty. While the Veteran's reported circumstances of injury do qualify for "line of duty" classification, the Veteran's service treatment records refute any allegation of in-service back pain. Specifically, these records reflect that he never complained of or sought treatment for back pain at any time during service, that his low back was found to be clinically normal on every in-service examination, and that he expressly denied any past or current recurrent back pain on every medical history report that he filled out. In light of the above, the Board finds that the Veteran's reports of an in-service back injury are directly contradicted by his service treatment records and are, therefore, not credible. Furthermore, the Board notes that none of the Veteran's post-service treatment records reflect that he ever reported having suffered a back injury in service. The most specific of these records states that the Veteran had injured his back at work in March 2013, while an October 2007 emergency room record reflects that the Veteran estimated that his back pain had its onset three or four years earlier. If the Board were to accept the Veteran's estimate of back pain of four years' duration, it would have had its onset in late 2003, which is more than five years following his last period of service. Evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). These reports of medical history, in particular the reported onset of late 2003, expressly contradict any current assertion from the Veteran that he has had problems with his low back since service. In short, the Board finds that the Veteran's service treatment records do not reflect that he suffered a back injury in service, and there is no competent, credible evidence of any such injury. The Board further finds the post-service medical evidence reflects that the Veteran did not have low back symptoms until at least five years after his separation from service. The Board further notes that no competent, credible medical evidence has been received demonstrating a nexus between the Veteran's service and any current low back disability. The Board thus finds that a preponderance of the evidence is against finding a link between a current low back disability and the Veteran's military service. The Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, entitlement to service connection for a low back disability is not warranted. ORDER Entitlement to a compensable rating for residuals of a left wrist injury from October 9, 2007, through April 28, 2010, is denied. Entitlement to a 10 percent rating, but no higher, for residuals of a left wrist injury from April 29, 2010, through January 2, 2011, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 10 percent for residuals of a left wrist injury on and after January 3, 2010, is denied. REMAND The Veteran has also claimed entitlement to service connection for a right foot or ankle disability and tinnitus. The Board finds it necessary to remand these claims for further development before it may determine whether service connection for either disability is warranted. As noted above, in initial service connection claims, the VA must provide a VA medical examination where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service; and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. See McLendon, supra. The Court in McLendon observed that the third prong, which requires an indication that the claimant's disability or symptoms 'may be' associated with the established event, is a low threshold. Id. at 83. With respect to the right foot or ankle disability claim, the Board finds that the first McLendon requirement is satisfied in that the record contains a May 2009 VA x-ray report noting an impression of mild degenerative disease of the bilateral calcanei. The Veteran's VA medical records also reflect that the Veteran uses orthotics. Specifically, an April 2009 VA medical record notes that the Veteran was fit with "size large wonderzorb heel wedges," while a May 2009 record notes that the insoles of the Veteran's shoes were replaced with "Dr. Comfort plastazote insoles." With respect to the second McLendon requirement, as noted above, the Board has broadened the claim of entitlement to service connection for a right Achilles heel condition to more broadly encompass entitlement to service connection for a right foot or ankle disability. The Board has found that this recharacterization was necessary given the Veteran's contentions concerning this issue, in particular as they were articulated by the Veteran during his February 2010 DRO hearing. Specifically, the Veteran testified that he injured his right heel while racing a private during a training at Fort Benning, Georgia. The Veteran's service treatment records reflect that he sought treatment in July 1992 while stationed at Fort Benning because "3 days ago [he] noted foot pain after running" and that this injury was determined to be a broken bone in the right foot. This injury was expressly determined to have been incurred in the line of duty during a period of active duty for training. Service treatment records reflect that the Veteran was placed on physical profile for two weeks and that he was given a cane and allowed to wear a soft shoe. The Board finds that this evidence satisfies the second McLendon requirement, as it establishes the incurrence of a right foot injury in service. The low threshold of the third McLendon element is also satisfied, as the Veteran reported during an October 2007 emergency room visit that he had experienced right ankle pain since 1994. There is, however, insufficient evidence of record to decide this case. Therefore, a remand for a VA examination and etiology opinion is necessary. The Board also finds that the McLendon requirements are satisfied with respect to the Veteran's tinnitus claim. The record contains a December 2012 VA hearing loss and tinnitus examination report that notes the Veteran has reported recurrent tinnitus since service. It also describes the Veteran's reported in-service acoustic trauma, noting that the Veteran's duties as a drill sergeant/trainer exposed him to hazardous levels of noise, including from grenades, howitzers, mortars, and heavy artillery. It noted that this type and degree of noise exposure is known to cause sensorineural hearing loss and that the Veteran's service treatment records showed a shift in his hearing in the high frequencies over the course of his service time. Based on this information, the VA examiner found it was at least as likely as not that the Veteran's bilateral hearing loss was caused by in-service noise exposure. The examiner did not furnish an opinion with respect to the tinnitus claim because this claim was already in the appeals process. In short, the record contains evidence of a current tinnitus, in-service acoustic trauma, and a link between the Veteran's tinnitus and his military service. Therefore, the Board finds it necessary to remand this claim for a VA examination and etiology opinion. Accordingly, the case is REMANDED for the following action: 1. Arrange for the Veteran to undergo an appropriate VA examination to determine the nature and etiology of any current right foot or ankle disability. The claims folders must be thoroughly reviewed by the examiner in connection with the examination, and a complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. The examiner should identify any pertinent pathology found and should diagnose any current relevant disabilities. As to any pertinent disability identified on examination, the VA examiner should express an opinion as to whether it is at least as likely as not (a 50 percent probability or more) that any such disability had its onset in service, was aggravated by service, or is otherwise related to any incident of service. The examiner should expressly discuss any service treatment records that document a relevant in-service injury or medical treatment. Any opinion expressed must be accompanied by a complete rationale. 2. Arrange for the Veteran to undergo a VA examination to determine the nature and etiology of any current tinnitus. The claims folders must be thoroughly reviewed by the examiner in connection with the examination, and a complete history should be elicited directly from the Veteran, to include any reports of in-service and post-service noise exposure. Any tests and studies deemed necessary should be conducted. All findings should be reported in detail. The examiner should determine whether a diagnosis of tinnitus is warranted and should express an opinion as to whether it is at least as likely as not (a 50 percent probability or more) that any tinnitus was incurred in service or is related to service, including to any in-service acoustic trauma. Any opinion expressed must be accompanied by a complete rationale. 3. After the development requested above has been completed, again review the record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs