Citation Nr: 1322183 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 10-48 761 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for mouth ulcers, diagnosed as recurrent aphthous ulcerations. 2. Entitlement to service connection for a lower gastrointestinal disability, to include irritable bowel syndrome, to include being due to undiagnosed illness. 3. Entitlement to service connection for a disability manifested by pain following bowel movements. 4. Entitlement to an initial evaluation in excess of 20 percent for status post fusion, C3-C4, spondylotic changes. 5. Entitlement to an initial evaluation in excess of 10 percent for patellofemoral syndrome of the right knee. 6. Entitlement to an initial evaluation in excess of 10 percent for patellofemoral syndrome of the left knee. 7. Entitlement to an initial evaluation in excess of 10 percent for status post fracture of the left shoulder. 8. Entitlement to an initial evaluation in excess of 10 percent for hiatal hernia. 9. Entitlement to an initial compensable evaluation for residuals of multiple rib fractures. 10. Entitlement to an initial compensable evaluation for chronic rhinitis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. P. Simpson, Counsel INTRODUCTION The Veteran served on active duty from August 1986 to September 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2009 and April 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Knoxville, Tennessee. In December 2012, the Veteran had a video conference hearing before the undersigned Acting Veterans Law Judge. At the December 2012 hearing, the undersigned informed the Veteran that it was possible that the claims for service connection had been final and that the Veteran would need to submit new and material evidence to reopen the claims. However, subsequent close review reflects that the service connection issues did not become final, as the Veteran had filed a timely notice of disagreement as to all three issues. These claims are part of the original claims for service connection that were submitted in November 2008. Specifically, these issues were initially considered in a March 2009 rating decision. The notice of disagreement the Veteran submitted was received in April 2010, which is more than one year following the issuance of the March 2009 rating decision. However, the RO reconsidered these claims in an April 2009 rating decision, and thus the April 2010 notice of disagreement was timely filed. The Board has reviewed the Veteran's claims file and the record maintained in the Virtual VA paperless claims processing system. The issues of entitlement to service connection a lower gastrointestinal disability, to include irritable bowel syndrome, and a disability manifested by pain following bowel movements and entitlement to increased ratings for status post fusion, C3-C4, spondylotic changes and patellofemoral syndrome of the right and left knees 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. Mouth ulcers, diagnosed as recurrent aphthous ulcerations, had their onset in service. 2. Status post fracture of the left shoulder has not been manifested by flexion or abduction limited to shoulder level. 3. Hiatal hernia has not been manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 4. Residuals of multiple rib fractures have not been manifested by removal of one rib or the resection of two or more ribs without regeneration. 5. Chronic rhinitis has not been manifested by polyps or greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side. CONCLUSIONS OF LAWS 1. Recurrent aphthous ulcerations were incurred in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for an initial evaluation in excess of 10 percent for status post fracture of the left shoulder have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (Code) 5201 (2012). 3. The criteria for an initial evaluation in excess of 10 percent for hiatal hernia have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.114, Code 7346 (2012). 4. The criteria for an initial compensable evaluation for residuals of multiple rib fractures have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.20, 4.53, 4.71a, 4.71a, Code 5297 (2012). 5. The criteria for an initial compensable evaluation for chronic rhinitis have not been met. 38 U.S.C.A. §§ 1155 , 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.97, Code 6522 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify & Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). As to the claim for service connection for mouth ulcers, the Board is granting this benefit. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and need not be further considered as to that matter. As to the Veteran's claims for increased initial ratings for the shoulder, left knee, hiatal hernia, rhinitis and residual rib fractures, these claims stem from his disagreement with the initial ratings assigned following the grant of service connection. Once service connection is granted, the claim is substantiated. Additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Accordingly, the Board finds that VA satisfied its duties to notify the Veteran in this case. VA's duty to assist the Veteran has also been satisfied. 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records, VA medical records, and identified private medical records have been obtained. VA provided the Veteran a hearing before the Board. The undersigned agreed to leave the claims file open for 60 days to allow the Veteran to submit additional evidence. At the hearing, the Veteran testified that he would waive initial consideration of that evidence by the agency of original jurisdiction. See transcript on pages 2, 18-19 and 38. The Veteran did, in fact, submit additional evidence in February 2013, and the Board may consider this evidence in the first instance. 38 C.F.R. § 20.1304(c) (2012). VA provided the Veteran medical examinations in January 2009. At the hearing, the Veteran testified that he felt his disabilities were worse than the current evaluations assigned. As to his cervical spine disability, the Veteran made a definitive allegation that his cervical spine disability had worsened since the last examination. See transcript on page 3. However, the Veteran did not testify that the disabilities being decided herein had worsened since the 2009 VA examination. Rather, his assertions were that the initial disability evaluations assigned did not sufficiently represent the severity of the service-connected disabilities, which is not indicative of an allegation that the disability has worsened since it was last examined. Therefore the Board finds it does not need to remand these claims for a new examination. The purpose of the remand of the knee disabilities is because the January 2009 VA examination report did not address whether or not the Veteran's right knee had instability, which is a clinical finding that the Board finds is necessary to decide whether an increased rating is warranted. Additionally, the Veteran's December 2012 testimony at the hearing indicated he had instability in the left knee, and the Board finds that a medical professional should examine the left knee as well. Thus, while the January 2009 VA examination was inadequate with respect to the right knee, the Board does not find that it is inadequate with respect to the disabilities being decided herein. The Board concludes that deciding these issues on the merits at this time is appropriate. II. Analysis A. Service Connection Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In order to prevail on the issue of service connection, there must be competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disease or injury. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). After having carefully reviewed the evidence of record, the Board finds that the evidence supports the award of service connection for mouth ulcers. The Veteran stated that these began in service, and the service treatment records support this fact. For example, in June 1992, the Veteran reported having sores in his mouth for 10 days. In September 1993, the Veteran was seen for evaluation of sores in his mouth. At that time, he reported a history of sores in his mouth (tongue, floor of mouth, lips), which would occur in approximately one to one and one-half months cycles and last for five to seven days. In June 2002, the Veteran reported having occasional canker sores. On the March 2006 Report of Medical History completed by the Veteran at that time, he reported a history of infrequent mouth ulcers. Thus, there is documented evidence that the Veteran had mouth ulcers in service. At the December 2012 hearing, the Veteran testified that the mouth ulcers had become more frequent. He submitted a December 2012 letter from a private dentist, Dr. Turner, who stated that he had been treating the Veteran since March 2011 and had witnessed multiple occasions where the Veteran had "at least one, sometimes several recurrent aphthous ulcerations" that were resulting in painful effects in his daily life. Dr. Turner concluded, "[b]ased on the symptoms presented and length of [time] that it has affected [the Veteran], I deem [it] to be a chronic condition." Accordingly, there is competent evidence of in-service mouth ulcers, post service mouth ulcers and evidence of a nexus between the two, and service connection for mouth ulcers is warranted. B. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earnings capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher rating 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. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. As this appeal is from initial ratings assigned with awards of service connection, "staged" ratings are for consideration. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's statements describing his symptoms and condition are competent evidence to the extent that he can describe what he experiences. However, these statements must be viewed in conjunction with the objective medical evidence and the pertinent rating criteria. An evaluation of the level of disability present also includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of disability from arthritis and actually painful joints are entitled to at least the minimum compensable rating for the joint. Where functional loss due to pain on motion is alleged, 38 C.F.R. §§ 4.40 and 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). A finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). A zero percent rating is assigned when the requirements for a compensable evaluation are not met and the schedule does not provide a zero percent evaluation. 38 C.F.R. § 4.31 (2012). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. "[I]nitially, 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." Id. The Court provided that "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." Id. When a service-connected disability or disabilities affects employment in ways not contemplated by the rating schedule, § 3.321(b)(1) is applicable. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996). 1. Status post fracture of the left shoulder Status post fracture of the left shoulder has been evaluated under Diagnostic Code 5203. The shoulder joint is considered a major joint. See 38 C.F.R. § 4.45(f) . Shoulder disabilities are rated under Codes 5200 to 5203. [Because the Veteran is right arm dominant, the left shoulder disability is evaluated as the minor joint.] As the Veteran is not shown to have ankylosis of the shoulder, Code 5200 does not apply. Under Code 5201 (for limitation of shoulder motion), the minimum schedular rating of 20 percent is warranted where there is limitation of motion of an arm at the shoulder level. Limitation of minor arm motion to midway between the side and shoulder level warrants a 20 percent rating. 38 C.F.R. § 4.71a. The Federal Circuit recently held that the plain language of 38 C.F.R. § 4.71a confirms that a veteran is only entitled to a single disability rating under diagnostic code 5201 for each arm that suffers from limited motion at the shoulder joint. The diagnostic code does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to "limitation of motion of" the arm. Yonek v. Shinseki, __ F.3d __, No. 2012-7120, 2013 WL 3368972, slip op. at 4. (Fed. Cit. July 8, 2013). In cases of clavicular or scapular impairment, with dislocation, a 20 percent rating is warranted where the minor arm is involved. Nonunion of the clavicle or scapula with loose movement shall be assigned a 20 percent rating, while nonunion without loose movement warrants a 10 percent evaluation. Malunion of the clavicle or scapula may be assigned a 10 percent rating, or may be rated based on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a, Code 5203. Normal forward flexion of a shoulder is from 0 to 180 degrees, normal abduction of a shoulder is from 0 to 180 degrees, normal external rotation is from 0 to 90 degrees, and normal internal rotation is from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I. At the December 2012 hearing before the undersigned, the Veteran testified that the left shoulder disability involved chronic pain and soreness. He described having atrophy in the because of disuse. The Veteran stated that if he did not move his left arm for a period of time, he would have to move it around to prevent it from hurting. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an initial evaluation in excess of 10 percent for the Veteran's left shoulder disability for any period of time during the appeal period. Initially, the Board notes that the disability is more appropriately rated under Code 5201, as the left shoulder disability does not have the symptoms that are described under Code 5203. For example, he does not have malunion or nonunion of the clavicle or the scapula-neither a medical professional nor the Veteran have made that allegation. Additionally, at the January 2009 VA examination, the Veteran denied any dislocation of the left shoulder, to include recurrent dislocations, and the examiner found there was no evidence of dislocation of the left shoulder joint. Rather, the Veteran's symptoms involve limitation of motion of the left shoulder joint, which is appropriately rated under Code 5201. However, to warrant the 20 percent rating for the shoulder under Code 5201, there must be limitation of arm motion at the shoulder level. Throughout during the appeal, the Veteran has had left arm motion above the shoulder level (shoulder level is at 90 degrees). For example, in the January 2009 VA examination report, the examiner reported that flexion and abduction were to 150 degrees. There was no objective evidence of pain following repetitive motion, to include no additional loss of range of motion following three repetitions. Such is evidence against a finding that a 20 percent rating is warranted. While the Veteran has some additional limitations due to pain and on use of his shoulder as described by him, these do not rise to the level of equivalency to limitation at the shoulder level. In the January 2009 VA examination report, the examiner wrote in describing what the Veteran reported that there was no giving way, no instability, no stiffness, no weakness, no incoordination, no decreased speed of motion, no dislocation or subluxation, no locking, no effusion, no inflammation, and no flare-ups. Consequently, DeLuca factors do not present a basis for an increase in the rating. The 10 percent rating assigned recognizes that the Veteran has painful motion of the shoulder with limitation less than compensable under Code 5201. The 10 percent rating contemplates periarticular pathology productive of painful motion, see 38 C.F.R. § 4.59, and thus there are no left shoulder symptoms/impairment of function shown or alleged that are not fully encompassed by the criteria for the 10 percent rating assigned. Therefore, the schedular criteria are not inadequate, and referral for extraschedular consideration is not indicated. See Thun, 22 Vet App. 111. 2. Hiatal hernia The service-connected hiatal hernia has been rated as 10 percent disabling under Code 7346. Under this Code, a (maximum) 60 percent rating is warranted for 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; with two or more of the symptoms for the 30 percent evaluation of lesser severity, a 10 percent rating is warranted. 38 C.F.R. § 4.114. At the December 2012 hearing before the undersigned, the Veteran testified that he would elevate his head at night so that the acid would not go back into his mouth and cause him to regurgitate. He stated he took medication for acid reflux and described having episodes of symptoms two to four times per month. The Veteran noted that he would wake up in the middle of the night during these episodes and regurgitate. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an initial evaluation in excess of 10 percent for hiatal hernia. To warrant the next higher rating of 30 percent, there must be persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. In reading through the description of the Veteran's symptoms, he does not have that level of severity. For example, at the time of the January 2009 VA examination, the Veteran denied nausea and vomiting, regurgitation, dysphagia, hematemesis, melena, pancreatitis, gallbladder attacks, and abdominal pain. He reported having indigestion and heartburn. In February 2010, an examiner noted the Veteran had acid reflux. In October 2010, the examiner noted the Veteran was "doing well." The Veteran reported some symptoms associated with his service-connected disabilities, but then the examiner noted there were "no other complaints." The Board finds that such is indicative of the Veteran reporting no digestive symptoms. See Kahana v. Shinseki, 24 Vet. App. 428, 439 (2011) (Lance, J., concurring) (the Board may infer from silence in a record that a particular symptom was not observed if it is reasonable to assume that such a symptom would have been recorded had it been present). This is supported by a May 2011 VA treatment record, where the examiner wrote that the Veteran was not having abdominal pain, nausea, vomiting, or diarrhea. When the Veteran was seen in February 2012, the examiner addressed the Veteran's reflux symptoms and wrote that the Veteran was "doing well" and that he had "infrequent symptoms." At the December 2012 hearing, the Veteran testified he had symptoms two to four times per month. Notably, the criteria for a 30 percent rating under Code 7346 are stated in the conjunctive and must all be met to warrant such rating. As the listed criteria are not met, a 30 percent rating is not warranted. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Comparing the manifestations of the Veteran's hiatal hernia and associated impairment shown to the rating schedule, the Board finds that the degree of disability shown throughout the entire period under consideration is wholly encompassed by the schedular criteria for the ratings assigned. The 10 percent rating contemplates two or more of the symptoms for the 30 percent evaluation of lesser severity. The Veteran has heartburn and indigestion, and thus the 10 percent rating is not inadequate. The Veteran has not alleged any symptoms or impairment that exist but are not encompassed by schedular criteria. Therefore, referral for consideration of an extraschedular rating is not necessary. 3. Residuals of multiple rib fractures The RO has evaluated the Veteran's residuals of multiple rib fractures under Code 5297, which provides that a 10 percent evaluation for the removal of one rib or the resection of two or more ribs without regeneration. A 20 percent evaluation is warranted where two ribs have been removed. A 30 percent evaluation is warranted where three or four ribs have been removed. A 40 percent evaluation is warranted where five or six ribs have been removed. And a maximum 50 percent evaluation is warranted for the removal of six or more ribs. Notes to this code provide that the rating for rib resection or removal is not to be applied with ratings for purulent pleurisy, lobectomy, pneumonectomy or injuries of pleural cavity. However, rib resection will be considered as rib removal in thoracoplasty performed for collapse therapy or to accomplish obliteration of space and will be combined with the rating for lung collapse or with the rating for lobectomy, pneumonectomy or the graduated ratings for pulmonary tuberculosis. 38 C.F.R. § 4.71a, Code 5297. At the December 2012 hearing before the undersigned, the Veteran testified that the fractures that occurred in his ribs did not heal properly. He noted that if he got into a sneezing fit, he would develop these cramp-like symptoms. The Veteran stated that when he would bend over, he would get a sharp, stabbing pain. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an initial compensable rating for residuals of multiple rib fractures. As noted above, Code 5297 provides that a 10 percent evaluation is warranted for the removal of one rib or the resection of two or more ribs without regeneration. In this case, it is clear that the Veteran has not suffered the loss or resection of any of his ribs. Rather, the Veteran sustained multiple rib fractures in service that have healed. The Veteran claims that the ribs have not healed properly, however, no medical professional has made such a determination. When the Veteran was seen in January 2009, x-rays were taken, which showed old fractures. There was no notation that such fractures had healed improperly or had not healed correctly. In the March 2006 Report of Medical History completed by the Veteran at that time, he noted he had sustained broken ribs, and the examiner wrote that it was not considered disabling. In a March 2006 Report of Medical Assessment, the Veteran wrote he would get infrequent cramping pain. At the December 2012 hearing, the Veteran reported pain when having a sneezing attack or when he would bend over. Of record are VA treatment records from 2010 to 2013-a period of three years. During these treatments, the Veteran did not report symptoms involving his ribs, which the Board finds is indicative of there being a lack of frequent symptoms associated with this disability, since the Veteran consistently reported symptoms involving his service-connected disabilities when being treated. See Kahana, 24 Vet. App. at 439. Moreover, as the Veteran's residuals of multiple rib fractures do not result in limitation of motion, the DeLuca provisions do not apply. The Board has also considered other potentially analogous rating criteria for the evaluation of this service-connected disability, since the currently-assigned Code contemplates removal of ribs, and the Veteran did not have his ribs removed. However, the evidence does not support the evaluation of the Veteran's fractured right ribs under any other diagnostic codes. The Veteran has not complained of a respiratory disorder associated with the fractured ribs and thus an evaluation of this disability under the criteria for respiratory disorders is not warranted. Thus, the Board finds that no higher evaluation can be assigned pursuant to any other potentially applicable diagnostic code. The evidence of record reflects that the Veteran's symptomatology for the residuals of multiple rib fractures warrant no more than the noncompensable rating currently assigned. The Board finds that no higher rating can be assigned pursuant to any other potentially applicable diagnostic code. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. 49. The noncompensable rating assigned recognizes that the Veteran has had rib fractures in the past; however, these fractures have healed, and, again, there is no competent evidence that they have healed improperly. Thus there are no symptoms/impairment of function shown or alleged that are not fully encompassed by the criteria for the noncompensable rating assigned. Therefore, the schedular criteria are not inadequate, and referral for extraschedular consideration is not indicated. See Thun, 22 Vet App. 111. 4. Chronic rhinitis The RO assigned the noncompensable disability evaluation for the Veteran's service-connected chronic rhinitis under Code 6522, which provides ratings for allergic or vasomotor rhinitis. See 38 C.F.R. § 4.97, Code 6522. Under this Code, 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, is rated 10 percent disabling. Allergic or vasomotor rhinitis with polyps is rated 30 percent disabling. At the December 2012 hearing before the undersigned, the Veteran testified he would have restricted breathing regularly, but he noted he did not have 100 percent obstruction in either nostril. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against an initial compensable rating for chronic rhinitis. The evidence shows that the Veteran has complained regularly of having restricted breathing; however, at the December 2012 hearing, he stated he never had 100 percent obstruction in either nostril, and there is no evidence, including both lay and medical, of polyps. When examined in January 2009, the examiner noted there was mild nasal airway blockage secondary to the edema in the inferior turbinates, but there were no polyps. The Veteran reported that he used both prescription and over-the-counter medications to help with nasal congestion. He stated that his nasal airway is generally fairly good when he is upright, and that it was when he would lie down when he would become more congested. Throughout the appeal, neither the Veteran nor a medical professional has stated that the Veteran has greater than 50 percent obstruction in both nostrils, and the Veteran has stated that he has never had complete obstruction in either nostril. See transcript on pages 24-25. There is no evidence that a compensable rating under any other potentially applicable Codes is warranted, as there is no evidence of sinusitis, nasal disfigurement (including loss of part of the nose or scars), deviated septum, bacterial rhinitis or granulomatous rhinitis. Thus consideration of other Diagnostic Codes 6502, 6504, 6510-6514, 6523 or 6524 is not warranted. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 49. Finally, the Board has considered whether there is evidence showing that the Veteran's service-connected chronic rhinitis should be referred for assignment of an extraschedular rating. The record does not show that this disability has markedly interfered with his employment status beyond that interference contemplated by the assigned rating, and there evidence that this disability has not necessitated any period of hospitalization during the pendency of this appeal. Therefore, the schedular criteria are not inadequate, and referral for extraschedular consideration is not indicated. See Thun, 22 Vet App. 111. ORDER Entitlement to service connection for mouth ulcers, diagnosed as recurrent aphthous ulcerations, is granted. Entitlement to an initial evaluation in excess of 10 percent for status post fracture of the left shoulder is denied. Entitlement to an initial evaluation in excess of 10 percent for hiatal hernia is denied. Entitlement to an initial compensable evaluation for residuals of multiple rib fractures is denied. Entitlement to an initial compensable evaluation for chronic rhinitis is denied. REMAND The Board finds that the claims for service connection for a lower gastrointestinal disability, to include irritable bowel syndrome, and a disability manifested by pain following bowel movements and the claims for increased ratings for the cervical spine and the right and left knees require additional development before the Board can decide the issues. The Board finds that VA examinations are warranted for each of the claims. The Veteran alleges that he has had irritable bowel syndrome or symptoms similar to this disability since serving in the Gulf in 1990. In reading through the service treatment records, there was a lack of documented evidence of chronic symptoms throughout the Veteran's service. For example, in an October 1998 Report of Medical History completed by the Veteran at that time, he denied a history of frequent indigestion and stomach, liver or intestinal problems. While he reported a history of hemorrhoids or rectal disease, he clarified that this involved hemorrhoids. In a February 2001 Report of Medical History completed by the Veteran at that time, he denied a history of frequent indigestion; stomach, liver or intestinal problems; and hemorrhoids or rectal disease. In a March 2006 Report of Medical History completed by the Veteran at that time, he denied a history of frequent indigestion and stomach, liver or intestinal problems. While he reported a history of hemorrhoids or rectal disease, he clarified that this involved hemorrhoids. Thus, while the Veteran claims he has had chronic symptoms similar to irritable bowel syndrome since the 1990s, the service treatment records fail to substantiate that allegation. Regardless, the Veteran is competent to allege chronic symptoms involving his gastrointestinal system and the Board finds a VA examination is warranted to determine if he has irritable bowel syndrome or something similar to this that had its onset in service. On this note, the Veteran alleges pain following bowel movements, which he reported began in 1980. See VA Form 21-526, Veteran's Application for Compensation or Pension, received in November 2008. This would be prior to the Veteran's entrance into service. This is consistent with an April 1998 service treatment record, which shows the Veteran complained of pain in the genitals, which he reported occurred infrequently but had been occurring every three to six months since he was a child and following a bowel movement. At that time, the examiner found an external hemorrhoid, and he was diagnosed with hemorrhoids. The Board finds that a VA examination is warranted to determine the potential cause of this pain and whether this disability was aggravated during service. As to the cervical spine disability, at the December 2012 hearing, the Veteran testified that this disability had worsened since the January 2009 VA examination. Thus, a new examination is necessary. As to the bilateral knee disability, at the December 2012 hearing, the Veteran described having instability of both knees. When the Veteran's knees were examined in January 2009, the examiner addressed whether or not there was instability in the left knee only (the examiner found no instability). For whatever reason, that clinical finding was not reported for the right knee. This makes the January 2009 VA examination inadequate for rating purposes with respect to the right knee and a new examination will be scheduled so that this clinical finding can be addressed. While the examiner reported there was no instability in the left knee, the Board finds that the Veteran is competent to describe having instability in the knee, and that a more recent VA examination is warranted to determine if there is instability now. VA treatment records were obtained by VA from 2010 to July 2012 and thus any VA treatment records since July 2012, if they exist, should be secured. Accordingly, the case is REMANDED for the following action: 1. The Veteran should inform VA of any outstanding relevant medical records pertaining to the claims for service connection for a lower gastrointestinal disorder and rectal pain following bowel movements and the claims for increase involving the bilateral knees and the cervical spine. The Veteran should provide VA with permission to obtain the records or submit them himself. 2. Schedule the Veteran a VA examination for gastrointestinal symptoms and pain following bowel movements. The entire claims file (both the paper file and any electronic portion of the file) must be made available to and be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted and the results reported. The examiner is informed that the Veteran has stated that the symptoms of irritable bowel syndrome and the pain he experiences following bowel movements are two different disabilities. In other words, they do not occur at the same time. As to the pain following a bowel movement, the Veteran has stated that this had its onset in 1980, which is prior to service (the Veteran served from 1986 to 2006). The question with this disability will involve whether it was aggravated during service. Thus, the examiner should specifically ask the Veteran whether the pain he had following bowel movements increased in some way (intensity, more frequently) while in service. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to the following: (i) Are the Veteran's complaints of bowel and stomach problems and pain after bowel movements due to known clinical diagnoses? If so, what are the diagnoses? (ii) If the answer to (i) is no, does the Veteran have a functional gastrointestinal disorder (a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs or disease and may be related to any part of the gastrointestinal tract) excluding structural gastrointestinal diseases? (iii) Are the Veteran's current bowel and stomach complaints (not the pain he experiences following bowel movements) at least as likely as not (50 percent probability or greater) to have had their onset in service? (iv) Is there clear and unmistakable (obvious or manifest) evidence that the Veteran had a disability manifested by pain following bowel movements prior to the veteran's entry into service in 1986? (v) If the answer to (v) is yes, is there clear and unmistakable (obvious or manifest) evidence that the disability manifested by pain following bowel movements was not aggravated during the veteran's active military service? For purposes of this question, the examiner should understand the term "aggravated" to mean that there was a permanent worsening or increase in severity of the disease. (vi) If the examiner concludes that there is clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service, was there an increase in such disability during the veteran's active military service? If there was such an increase in disability, the examiner should indicate whether there is clear and unmistakable evidence (obvious or manifest) that such increase in disability was due to the natural progress of the disease. A rationale for all opinions expressed should be provided. 3. Schedule the Veteran for a VA examination to determine the current severity of the cervical spine and bilateral knee disabilities. The claims folder must be made available to the examiner in conjunction with the examination. All indicated tests should be conducted for both the cervical spine and the bilateral knees. All pertinent symptomatology should be annotated in the evaluation report. As to the cervical spine, the examiner should discuss the extent of any limitation of forward flexion of the Veteran's cervical spine and should address the presence (including degree) or absence of any ankylosis (favorable or unfavorable) of the Veteran's cervical spine or of the Veteran's entire spine. The examiner should address whether there is instability in both knees and, if so, the level of severity of the instability. 4. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, in whole or in part, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. 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). ______________________________________________ M. C. GRAHAM Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs