Citation Nr: 1325015 Decision Date: 08/07/13 Archive Date: 08/13/13 DOCKET NO. 10-02 563 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for lumbar scoliosis. 2. Entitlement to an initial rating in excess of 10 percent for irritable bowel syndrome (IBS). 3. Entitlement to an initial rating in excess of 30 percent for bilateral flatfoot. 4. Entitlement to service connection for bilateral hearing loss. 5. Entitlement to service connection for allergic rhinitis, claimed as allergies. 6. Entitlement to service connection for chronic sinusitis. 7. Entitlement to service connection for a right wrist disorder, to include right wrist overuse syndrome. REPRESENTATION Veteran represented by: Maryland Department of Veterans Affairs ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from August 1979 to August 2007. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland, which, in pertinent part, granted the Veteran's claims for service connection for IBS, a chronic lumbar strain and bilateral plantar fasciitis and assigned an initial noncompensable rating for each disability. In addition, his claims for service connection for allergies, chronic sinusitis, hearing loss and right wrist overuse syndrome were denied. A May 2012 Decision Review Officer (DRO) decision recharacterized the Veteran's service-connected bilateral plantar fasciitis as bilateral flatfoot and assigned a 30 percent rating. In addition, recharacterized the Veteran's service-connected chronic lumbar strain as lumbar scoliosis and recharacterized his service-connected spastic colon as IBS; a 10 percent rating was also assigned for each disability. As the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation, it follows that such a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Therefore, the issues have been characterized as shown on the first page of this decision. In February 2013, the Veteran withdrew his request for a hearing. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeals. The issue of entitlement to service connection for a prostate disorder was raised by the Veteran in a December 2009 substantive appeal, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. For the period prior to December 16, 2011, the Veteran's service-connected lumbar scoliosis manifested as lumbar flexion that was limited to 45 degrees, at worst, with subjective complaints of pain; the record was negative for ankylosis, doctor prescribed bedrest, bowel or bladder impairments attributable to this disability, or neurological impairments. 2. For the period beginning on December 16, 2011, the Veteran's service-connected lumbar scoliosis manifested as lumbar flexion that was limited to 75 degrees, with subjective complaints of episodic pain; the record was negative for ankylosis, doctor prescribed bedrest, bowel or bladder impairments attributable to this disability, or neurological impairments. 3. For the entire appeal period, the Veteran's service-connected IBS manifested as loose stool; the record was negative for nausea, vomiting or intestinal pain, and there were no findings related to abdominal tenderness. 4. For the period prior to December 16, 2011, the Veteran's service-connected bilateral flatfoot manifested as heel pain, tenderness under the arches with the use of inserts and arch supports; the record was negative for pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation. 5. For the period beginning on December 16, 2011, the Veteran's service-connected bilateral flatfoot manifested as marked pronation, extreme tenderness of the plantar surfaces of the feet, and marked inward displacement with the use of orthopedic appliances that did not improve his symptoms; the record was negative for claw foot, malunion or nonunion of the tarsal or metatarsal bone, hammer toes, hallux valgus, hallux rigidus, swelling on use or characteristic calluses. 6. The Veteran has not been shown to have a current bilateral hearing loss for VA purposes. 7. Resolving all doubt in favor of the Veteran, allergic rhinitis is etiologically related to active military service. 8. Resolving all doubt in favor of the Veteran, chronic sinusitis is etiologically related to active military service. 9. Resolving all doubt in favor of the Veteran, right wrist overuse disorder is etiologically related to active military service. CONCLUSIONS OF LAW 1. The criteria for an initial 20 percent rating for lumbar scoliosis for the period prior to December 16, 2011 have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.40, 4.45, 4.55, 4.56, 4.71a, 4.73, 5235-5243 (2012). 2. The criteria for an initial rating in excess of 10 percent for lumbar scoliosis for the period beginning on December 16, 2011 have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.40, 4.45, 4.55, 4.56, 4.71a, 4.73, 5235-5243 (2012). 3. The criteria for an initial rating in excess of 10 percent for IBS are not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.114, 7319 (2012). 4. The criteria for an initial rating in excess of 30 percent for bilateral flatfoot for the period prior to December 16, 2011 have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.71a, 5276, 5284 (2012). 5. The criteria for an initial 50 percent rating for bilateral flatfoot for the period beginning on December 16, 2011 have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321, 4.1-4.10, 4.71a, 5276, 5284 (2012). 6. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2012). 7. Allergic rhinitis was incurred during active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 8. Chronic sinusitis was incurred during active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 9. Right wrist overuse syndrome was incurred during active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between a Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. As the Board's decision to award service connection for allergic rhinitis, chronic sinusitis and right wrist overuse syndrome herein constitute a complete grant of the benefits sought on appeal, no further action is required to comply with the VCAA and the implementing regulations. With regards to the claim for service connection for hearing loss, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a pre-rating September 2007 advised the Veteran of the evidence and information necessary to substantiate his service connection claim as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, the September 2007 letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. With respect to the propriety of the initially assigned ratings for the service-connected lumbar scoliosis, IBS and bilateral flatfeet, the Veteran has appealed from the original grant of benefits. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess/Hartman, supra. In this case, the Veteran's claims for service connection for lumbar scoliosis, IBS and bilateral flatfeet were granted and initial ratings were assigned in the December 2007 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned ratings, no additional 38 U.S.C.A. § 5103(a) notice is required as the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment records, private treatment records, and VA examination reports have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. Additionally, the Veteran was afforded a VA examination in order to adjudicate his claim for service connection for bilateral hearing loss. In this regard, the Board notes that the July 2007 VA audiological examiner based her findings on interviews with the Veteran, a review of the record, and a full examination. Therefore, the Board finds the examination to be adequate for adjudication purposes. With regards to the claims for an increased rating, the Veteran was afforded VA examinations, to include those conducted in August 2007 and December 2011, to determine the severity of his disabilities. Neither the Veteran nor his representative have alleged that these VA orthopedic and podiatry examinations are inadequate for rating purposes. Although the Veteran's representative has argued that a VA gastrointestinal examination was inadequate as there were no findings made with regards to abdominal distress, and as discussed below, the Veteran denied such symptoms on examination. Thus, the Board determines that a new VA gastrointestinal examination is not required. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected lumbar scoliosis, IBS, and plantar fasciitis as they include interviews with the Veteran, a review of the record, and full examinations, addressing the relevant rating criteria. Moreover, neither the Veteran nor his representative has alleged that his disabilities have worsened in severity since the December 2011 VA examination. Rather, they argue that the evidence reveals that the Veteran's disabilities have been more severe than the currently assigned ratings for the duration of the appeal period. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). Therefore, the Board finds that the examinations of record are adequate to adjudicate the Veteran's claims for an increased rating and no further examinations are necessary. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. 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); 38 C.F.R. § 3.102. A. Lumbar Scoliosis The Veteran contends that he is entitled to a 20 percent rating for lumbar scoliosis due to his limited flexion and that a staged rating may be warranted due to the VA examination findings. His lumbar scoliosis, which was previously characterized as a chronic lumbar strain, is rated under the diagnostic code for a lumbosacral strain. Under the General Rating Formula for Rating Diseases and Injuries of the Spine, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: a 10 percent rating is warranted if forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, the combined range of motion of the thoracolumbar spine was greater than 235 degrees or that muscle spasms or guarding not resulting in an abnormal gait or abnormal spinal contour. A 20 percent rating is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, the combined range of motion of the thoracolumbar spine was not greater than 120 degrees or that muscle spasms or guarding were severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. A 40 percent rating is warranted if forward flexion of the thoracolumbar spine is to 30 degrees or less or if there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is warranted for ankylosis of the entire spine. 38 C.F.R. § 4.71a, 5235-5243. Under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes, effective beginning on September 26, 2003, a 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months and a 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, 5243. An "incapacitating episode" is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bedrest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, 5235-5243, Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. Normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees and the normal combined range of motion of the cervical spine was 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Each range of motion measurement is to be rounded to the nearest five degrees. 38 C.F.R. § 4.71a, 5235-5243, Note (2). VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45 pertaining to functional impairment for disabilities evaluated on the basis of limitation of motion. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. An August 2007 VA examination report reflected the Veteran's complaints of low back pain that occurred during certain activities such as doing the dishes and which lasted until he took a rest. Incapacitating episodes of low back pain which caused him to be bedridden had occurred on two occasions, one such occasion lasting four days and one lasting three days. Radiation of low back pain was denied. Physical examination revealed mild scoliosis with no postural abnormalities and a mild spasm of the paravertebral muscles in the lumbar region as well as tenderness to palpation. Lumbosacral forward flexion was to 45 degrees, extension was to 20 degrees, bilateral lateral flexion was to 20 degrees and bilateral rotation was to 30 degrees. The examiner noted that movements of the thoracolumbar spine were performed slowly with pain on all movements and that there was no evidence of weakened movement against resistance. An accompanying X-ray revealed minimal S-shaped scoliosis. A second August 2007 VA examination report indicated that there were no lumbar muscle spasms and that straight leg raising was negative. Lateral flexion was to 35 degrees, lateral rotation was to 35 degrees, extension was to 25 degrees and forward flexion was to 90 degrees, all "on three trials without event." A December 16, 2011 VA orthopedic examination report reflected the Veteran's reports that his back pain was not present "every day" but that it troubled him on eight to 10 occasions each month and can incapacitate him on three to four occasions per month. He further reported that there had been no change in how the problem was "behaving" since he was awarded service connection, that there had been no treatment prescribed for his back disability, that he was not followed by a physician and that he did not experience any signs or symptoms of radiculopathy. Physical examination was negative for localized tenderness, pain to palpation, guarding or muscle spasms. Lumbosacral forward flexion was to 75 degrees, extension was to 30 degrees, bilateral lateral flexion was to 25 degrees and bilateral rotation was to 30 degrees, all without objective evidence of painful motion. Repetitive motion testing revealed no additional limitations of motion and found lumbosacral forward flexion to be 80 degrees and bilateral lateral flexion to be 30 degrees. The examiner determined that the Veteran did not suffer from IVDS or documented arthritis. For the period prior to December 16, 2011, and considering the General Rating Formula for Rating Diseases and Injuries of the Spine as well as the Veteran's subjective complaints of back pain, the evidence of record shows that lumbar flexion was to 45 degrees, at worst, and that his spinal alignment showed S-shaped scoliosis. Although the Veteran has subjectively complained of back pain and objective evidence of pain was noted on range of motion testing, no additional functional impairments were found. 38 C.F.R. §§ 4.40, 4.45, 4.59; Deluca, supra; Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (pain, without additional functional impairment, is insufficient to warrant a higher rating). In addition, the examinations have been negative for ankylosis and the Veteran has retained range of motion in the lumbar spine. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992) (indicating that ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable). Therefore, a rating of 20 percent, but no higher, on the basis of limitation of motion for the period prior to December 16, 2011 is warranted. For the period beginning on December 16, 2011, and considering the General Rating Formula for Rating Diseases and Injuries of the Spine as well as the Veteran's subjective complaints of episodic back pain, the evidence of record shows that lumbar flexion was to 75 degrees. Although the Veteran has subjectively complained of back pain, no such pain or additional functional impairment was found on range of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; Deluca, supra.; Mitchell, supra. In addition, the examinations have been negative for ankylosis and the Veteran has retained range of motion in the lumbar spine. See Dinsay, supra; Lewis, supra. A rating in excess of 10 percent on the basis of limitation of motion for the period beginning on December 16, 2011 is therefore not warranted. Although the Veteran has subjectively reported incapacitating episodes that occurred on multiple occasions each month, and he has stated that these episodes have been incapacitating and left him bedridden, the clinical evidence of record is negative for doctor-prescribed bedrest and the December 2011 VA examiner determined that the Veteran did not suffer from IVDS. A higher rating is therefore not warranted under the criteria for IVDS. The Veteran has not reported urinary or fecal incontinence; a separate rating for bowel or bladder impairments is not warranted. In addition, the Veteran denied radiculopathy and objective examinations found normal sensation in the lower extremities; consideration of a separate rating for neurological impairments is also not warranted. The Board has considered whether additional staged ratings beyond those already assigned herein under Hart, supra, are appropriate for the Veteran's service-connected lumbar scoliosis; however, the Board finds that his symptomatology has been stable throughout each stage of the appeal. Therefore, assigning additional staged ratings for such disability is not warranted. B. IBS The Veteran's IBS is rated under the diagnostic code for IBS. He contends that he is entitled to a higher rating due to his diarrhea symptoms. Irritable colon syndrome (spastic colitis, mucous colitis, etc.) that was moderate with frequent episodes of bowel disturbances with abdominal distress warrants a 10 percent rating. Severe IBS with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, warrants a 30 percent rating. 38 C.F.R. § 4.114, 7319. An August 2007 VA examination report reflected the Veteran's reports of bowel movements that usually occurred once per day and two to three times per day during periods of mental stress. Physical examination found the abdomen to be soft, nontender and not distended with no palpable masses and bowel sounds that were normoactive. A December 2011 VA examination report reflected the Veteran's complaints of loose stools that occurred about 10 to 15 days per month and constipation that occurred less than monthly. Nausea, vomiting, intestinal pain, ulcerative colitis or other symptoms were denied. Physical examination found his overall general health to be good and that there was no significant weight loss or malnutrition, signs of anemia, fistula, abdominal mass or abdominal tenderness. The Board finds that the Veteran is not entitled to an initial rating in excess of 10 percent as his IBS does not more nearly approximate the criteria necessary for a 30 percent rating. In this regard, despite the representative's allegation that abdominal disress was not addressed and while he has symptoms of loose stool, he denied other symptoms of abdominal distress such as nausea, vomiting or intestinal pain, and there were no findings related to abdominal tenderness on objective examination. Therefore, absent more severe symptoms, the next higher 20 percent criteria have not been approximated, and the Board finds that the Veteran is not entitled to an initial rating in excess of 10 percent. The Board has considered whether the Veteran is entitled to a separate or higher rating under other potentially applicable diagnostic codes; however, 38 C.F.R. § 4.113 provides that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. Additionally, 38 C.F.R. § 4.114 indicates that ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive, will not be combined with each other. Rather, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such evaluation. Therefore, as the Veteran's IBS is evaluated under Diagnostic Code 7319, he is not entitled to a higher or separate rating under any other potentially applicable diagnostic code. The Board has considered whether staged ratings are warranted herein under Hart, are appropriate for the Veteran's service-connected IBS; however, the Board finds that his symptomatology has been stable throughout the appeal. Therefore, assigning staged ratings for such disability is not warranted. C. Bilateral Flatfoot The Veteran contends that he his symptoms warrant a rating for pronounced flatfoot. The Veteran's bilateral flatfoot is rated under the diagnostic code for acquired flatfoot. Bilateral acquired flatfoot that is severe with objective evidence of a marked deformity (pronation, abduction, etc), pain on manipulation and use accentuated, indication of swelling on use and characteristic callosities warrants a 30 percent rating. Pronounced acquired flatfoot consisting of marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, was not improved by orthopedic shoes or appliances, warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5276. Also potentially applicable is Diagnostic Code 5284, which is used to rate other foot injuries. Moderate residuals of foot injuries are rated 10 percent disabling; moderately severe residuals of foot injuries are rated 20 percent disabling; and severe residuals of foot injuries are rated 30 percent disabling. A Note to Diagnostic Code 5284 provides that foot injuries with actual loss of use of the foot are to be rated 40 percent disabling. 38 C.F.R. § 4.71a. An August 2007 VA examination report reflects the Veteran's complaints of heel pain on waking that was eased with ambulation and that he used inserts and arch supports in his shoes. Physical examination revealed bilateral pes planus and tenderness under the arches without pronation, bony deformities or calluses. A December 16, 2011 VA examination report noted that there was tenderness involving the Veteran's medial band of the plantar fascia, the medial longitudinal arch and the medial process of the calcaneal tuberosity secondary to heel spur syndrome and plantar fasciitis. Physical examination revealed marked pronation, accentuated pain on use, pain on manipulation, extreme tenderness of the plantar surface and decreased longitudinal arch height on weight-bearing bilaterally. The examiner noted that the Veteran's symptoms were not relieved by arch supports or orthotics. Examination was negative for Morton's neuroma, hammer toes, hallux valgus, hallux rigidus, pes cavus, malunion or nonunion of the tarsal or metatarsal bones, a weakened foot, swelling on use or characteristic calluses. For the period prior to December 16, 2011, the Veteran's bilateral flatfoot manifested as complaints of heel pain, tenderness under the arches with the use of inserts and arch supports without pronation or calluses. The clinical evidence does not suggest, and the Veteran did not report, extreme tenderness of the plantar surfaces of the feet, marked inward deplacement or severe spasms of the tendo achillis on manipulation. Therefore, absent more severe symptoms, the Board finds that the Veteran is not entitled to an initial rating in excess of 30 percent prior to December 16, 2011. For the period beginning on December 16, 2011, the Veteran's bilateral flatfoot manifested as marked pronation, extreme tenderness of the plantar surfaces of the feet, and marked inward displacement. In addition, the Veteran used orthopedic appliances that did not improve his symptoms. As the Veteran's symptoms most nearly approximates pronounced acquired flatfoot, a rating of 50 percent, the highest schedular rating available under this Diagnostic Code 5276, is warranted beginning on December 16, 2011. The Board has also considered whether a higher rating is warranted under any other potentially applicable diagnostic code but has determined that the most appropriate diagnostic code for rating the disability is the diagnostic code for flatfeet and that no reasonable basis exists for assigning a higher rating under another diagnostic code. The Veteran does not have hammer toes, hallux valgus, hallux rigidus, pes cavus, malunion or nonunion of the tarsal or metatarsal bones, a weakened foot, swelling on use or characteristic calluses as documented in the VA examination reports; therefore, consideration of Diagnostic Codes 5277 through 5283 are not warranted. Throughout the appeal period, Board also finds that a higher overall rating is not warranted for the assignment of separate ratings under Diagnostic Code 5284 for other foot injuries. Prior to December 16, 2011, it cannot be said that the Veteran's right and left foot were each at least moderately severe so as to warrant separate 20 percent ratings. In this regard, the Board finds it significant that the August 2007 examination noted that the Veteran's heel pain eased with ambulation and that there was no weakened movement against resistance. Acknowledging that "moderately severe" is not defined by the regulation, the Board finds that this symptomatology does not rise to the level of being moderately severe given the capabilities demonstrated by the Veteran (no weakened movement and improvement upon ambulation). Similarly, after December 16, 2011, it likewise cannot be said that the right and left foot each more nearly approximated a severe foot injury so as to warrant separate 30 percent ratings. Rather, the December 2011 VA examination indicated that his pain and discomfort was worse in the early mornings (with the first few steps) and after exercise. Although the term "severe" is not defined, given the noted worsening only in the morning and after exercise, the Board finds that this description does not reflect an overall severe foot disability, especially in light of the fact that the Veteran described a worsening of pain only periodically, i.e. for a few steps in the morning and following exercise. The Board has considered whether staged ratings beyond those already assigned herein under Hart, are appropriate for the Veteran's service-connected bilateral flatfoot; however, the Board finds that his symptomatology has been stable at each stage of the appeal. Therefore, assigning staged ratings for such disability is not warranted. D. Other Considerations Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected lumbar scoliosis, IBS and bilateral flatfeet with the established criteria found in the rating schedule. The Board finds that the Veteran's symptomatology is fully addressed by the rating criteria under which each disability is rated and that there are no additional symptoms of his disabilities that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disabilities. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Therefore, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). The Court held that when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a total disability rating based on individual unemployability (TDIU) will be considered "part and parcel" of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) (when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered "part and parcel" of the claim for benefits for the underlying disability). However, the Veteran reported that he had worked full-time in logistics for the past two to five years in the December 2011 VA examination. He does not allege, and the record does not show, that his service-connected disabilities have rendered him unemployable at any time during the course of the appeal. Therefore, further consideration of a TDIU is not necessary. III. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. In some cases, service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). To the extent that the Veteran does not have a disease recognized as chronic under 38 C.F.R. § 3.309(a), the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology are inapplicable. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including organic diseases of the nervous system (which has been interpreted to include hearing loss), to a degree of 10 percent within one year and three years, respectively, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. A. Bilateral Hearing Loss The Veteran contends that he suffers from bilateral hearing loss as a result of his exposure to noise during service. Service connection for impaired hearing is subject to 38 C.F.R. § 3.385, which provides that impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. Service treatment records are negative for complaints, treatments or diagnoses related to hearing loss. A March 2007 audiological examination, conducted in conjunction with the Veteran's separation examination, revealed the following pure tone thresholds, measured in decibels: Hertz 500 1,000 2,000 3,000 4,000 Right 10 0 0 5 10 Left 25 10 10 25 15 The Veteran was afforded a VA audiological examination in August 2007, while he was on active duty and in conjunction with the Benefits Delivery at Discharge (BDD) program. Pure tone thresholds, measured in decibels, were as follows: Hertz 500 1,000 2,000 3,000 4,000 Right 15 10 0 5 15 Left 15 10 10 10 20 Speech discrimination was found to be 94 percent in the right ear and 100 percent in the left ear. The remaining post-service clinical evidence is negative for findings related to hearing loss or for further audiological testing. The Board concedes that the Veteran was likely exposed to acoustic trauma in service as his DD-214 listed aviation maintenance as a ratings. Nevertheless, in comparing the results of the August 2007 VA examination to the regulatory criteria set forth in 38 C.F.R. § 3.385, the Board must conclude that the preponderance of the evidence is against a finding that the Veteran currently suffers from a bilateral hearing loss disability as defined for VA compensation purposes. Importantly, no other competent medical evidence in the record indicates a hearing loss disability in accordance with 38 C.F.R. § 3.385. The Court has held that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, and that a claimant may be granted service connection even though the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In the instant case, the Veteran filed a claim for service connection in July 2007 in conjunction with the BDD program. However, in contrast to McClain, in the instant case, there is no competent evidence showing a bilateral hearing loss disability from July 2007 through the course of the appeal. Again, the VA examiner clearly found that the Veteran did not meet the criteria for bilateral hearing loss. Regardless, the medical evidence simply does not show that the criteria under 38 C.F.R. § 3.385 has been met at any point since the date of claim for service connection. In this regard, the Veteran does not have an auditory threshold of 40 decibels or greater in any of the frequencies or 26 decibels or greater for at least three of the frequencies. Further, his speech recognition scores using the Maryland CNC Test are 94 percent or greater bilaterally. In the absence of proof of a present disability, there can be no valid claim for service connection as Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). In reaching this decision, the Board has considered the Veteran's arguments in support of his assertions that he suffers from bilateral hearing loss as a result of his service. However, the resolution of an issue that involves medical knowledge, such as the diagnosis of a disorder, requires professional evidence. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). It is true that the Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of the disorder or symptoms of the disorder subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disorder even where not corroborated by contemporaneous medical evidence). However, bilateral hearing loss requires specialized training for a determination as to diagnosis, to include the interpretation of audiological results, and is therefore not susceptible of lay opinions as to diagnosis and/or etiology. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for bilateral hearing loss. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. B. Allergic Rhinitis, Chronic Sinusitis and Right Wrist Disorder The Board finds that service connection for allergic rhinitis, chronic sinusitis and a right wrist disorder, namely right wrist overuse syndrome, is warranted as service treatment records reflect the diagnosis of, and treatment for, allergic rhinitis and chronic sinusitis. In addition, service treatment records reflect complaints of right wrist pain due to using a mouse and working on the computer. An August 2007 VA General Medicine examination, conducted while the Veteran was on active duty in conjunction with the BDD program, documented the Veteran's complaints of sinusitis and contained diagnoses of allergic rhinitis and right wrist overuse syndrome; the examiner did not address the Veteran's complaints of sinusitis or determine whether a diagnosis of the same was warranted. The available post-service clinical records document diagnoses of chronic sinusitis and allergic rhinitis. The Veteran maintains that his allergic rhinitis, chronic sinusitis and right wrist overuse syndrome were incurred during service and that there is no evidence of suggesting any post-service injury. Therefore, in light of in-service diagnoses and/or symptoms of allergic rhinitis, chronic sinusitis and right wrist overuse disorder, as well as current symptoms of such disabilities, the Board resolves all doubt in the Veteran's favor and finds that allergic rhinitis, chronic sinusitis and right wrist overuse disorder are related to his service. Therefore, service connection for such disabilities are warranted. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER An initial 20 percent rating for lumbar scoliosis for the period prior to December 16, 2011 is granted, subject to the legal authority governing the payment of VA compensation. An initial rating in excess of 10 percent for lumbar scoliosis for the period beginning on December 16, 2011 is denied. An initial rating in excess of 10 percent for IBS is denied. An initial 30 percent rating for bilateral flatfoot for the period prior to December 16, 2011 is denied. An initial 50 percent rating for bilateral flatfoot for the period beginning on December 16, 2011 is granted, subject to the legal authority governing the payment of VA compensation. Service connection for bilateral hearing loss is denied. Service connection for allergic rhinitis is granted, subject to the legal authority governing the payment of VA compensation. Service connection for chronic sinusitis is granted, subject to the legal authority governing the payment of VA compensation. Service connection for right wrist overuse syndrome is granted, subject to the legal authority governing the payment of VA compensation. ______________________________________________ K. GIELOW Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs