Citation Nr: 1327910 Decision Date: 08/30/13 Archive Date: 09/05/13 DOCKET NO. 94-04 227 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a skin disability involving the scrotum, groin, anus, and buttocks. 2. Entitlement to a disability rating in excess of 10 percent for patellar bursitis and synovitis of the left knee. 3. Entitlement to a compensable disability rating for hemorrhoids. 4. Entitlement to a compensable disability rating for ingrown toenail of the right great toe, status-post nail plate removal. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from July 1971 to April 1974. These matters initially came to the Board of Veterans' Appeals (Board) on appeal from a June 1992 rating decision that denied service connection for a skin disability involving the scrotum, groin, anus, and buttocks; and denied a disability rating in excess of 10 percent for service-connected patellar bursitis and synovitis of the left knee, and denied compensable disability ratings for service-connected hemorrhoids and service-connected ingrown toenail of the right great toe, status-post nail plate removal. The Veteran timely appealed. In February 1994, the Veteran testified during a hearing before a former Veterans Law Judge at the RO. In February 1995, the Board remanded the matters for additional development. In a November 1999 decision, the Board denied service connection for a skin disability involving the scrotum, groin, anus, and buttocks; and remanded each of the claims for increased disability ratings for further development. The Veteran appealed the November 1999 Board decision to the United States Court of Appeals for Veterans Claims (Court). In February 2001 Motions, the parties moved to vacate the Board decision and remand the case to the Board. The Court granted the motions. Thereafter, the case was returned to the Board. In May 2002, the Board remanded the matters for additional development. In a September 2005 decision, the Board denied each of the Veteran's claims. The Veteran again appealed to the Court. In a December 2007 Joint Motion, the parties moved to vacate the Board decision and remand the case to the Board. The Court granted the motion. Subsequently, the case was returned to the Board; and the Board remanded the matters again in May 2008 for additional development, consistent with the Court's order. In December 2010, the Board duly notified the Veteran that the Board no longer employed the Veterans Law Judge that conducted the February 2004 Board hearing and that he had the right to another Board hearing. In January 2011, the Veteran indicated that he did not want an additional hearing. In a March 2011 decision, the Board denied each of the Veteran's claims. The Veteran again appealed to the Court; the Court vacated the March 2011 Board decision, and returned the case to the Board in February 2012. In April 2013, the Board remanded the matters for additional development, consistent with the Court's order. The Board is satisfied there was substantial compliance with its remand orders for each of the issues decided below. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Court has recently held that a request for a TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board notes that the Veteran continues to work at least part-time, and has not alleged that his service-connected disabilities prevent him from obtaining or maintaining substantially gainful employment. The matter is not raised by the record, and the Board finds it unnecessary to remand the matter for further action. Lastly, in addition to reviewing the Veteran's paper claims file, the Board has surveyed the contents of his Virtual VA file. The issue of service connection for a skin disability involving the scrotum, groin, anus, and buttocks is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. Throughout the rating period, the Veteran's patellar bursitis and synovitis of the left knee has been manifested by complaints of pain, X-ray evidence of degenerative changes, and flexion limited to no less than 105 degrees at worse with functional loss due to painful motion; slight or moderate instability, or limited extension to 5 degrees or worse have not been demonstrated. 2. Throughout the rating period, the Veteran's hemorrhoids have been no more than moderate in degree and have not been productive of large or thrombotic hemorrhoids that are irreducible and have excessive redundant tissue, evidencing frequent occurrences. 3. For the period from November 21, 1991, through May 21, 2013, the Veteran's ingrown toenail of the right great toe, status-post nail plate removal, has been tender and painful; three or more scars that are unstable or painful, or loss of function of the body part affected have not been demonstrated. 4. For the period from May 21, 2013, the Veteran's ingrown toenail of the right great toe, status-post nail plate removal, has not been tender or painful; three or more scars that are unstable or painful, or loss of function of the body part affected have not been demonstrated. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for the Veteran's patellar bursitis and synovitis of the left knee have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.20, 4.40, 4.45, 4.59, 4.71, Table II, 4.71a, Diagnostic Codes 5003, 5019, 5020, 5257, 5260, 5261 (2012). 2. The criteria for a compensable evaluation for hemorrhoids have not been met or approximated. 38 U.S.C.A. §§ 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.114, Diagnostic Code 7336 (2012). 3. The criteria for a 10 percent, but no higher, disability evaluation for the ingrown toenail of the right great toe, status-post nail plate removal, from November 21, 1991, through May 21, 2013, are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.20, 4.118, Diagnostic Code 7804 (2007). 4. The criteria for a compensable disability evaluation for the ingrown toenail of the right great toe, status-post nail plate removal, from May 22, 2013, are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.20, 4.118, Diagnostic Code 7804 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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). VA should notify the Veteran of: (1) the evidence that is needed to substantiate the claim(s); (2) the evidence, if any, to be obtained by VA; and (3) the evidence, if any, to be provided by the claimant. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (codified at 38 C.F.R. Part 3). A decision by the United States Court of Appeals for the Federal Circuit has addressed the amount of notice required for increased rating claims, essentially stating that general notice is adequate and notice need not be tailored to each specific Veteran's case. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Through June 2008 and June 2009 letters, the RO and AMC notified the Veteran of elements of an increased rating claim and the evidence needed to establish each element. These documents served to provide notice of the information and evidence needed to substantiate the claims. In each letter, the RO or AMC specifically notified the Veteran of the process by which initial disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Defects as to the timeliness of the statutory and regulatory notice are rendered moot because each the Veteran's claims decided on appeal has been fully developed and re-adjudicated by an agency of original jurisdiction after notice was provided. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). There is no indication that any additional action is needed to comply with the duty to assist the Veteran. The RO or AMC has obtained copies of the service treatment records and outpatient treatment records, and has arranged for VA examinations in connection with the claims decided on appeal, reports of which are of record and are adequate for rating purposes. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (Court) recently held that the Veterans Law Judge who chairs a Board hearing fulfill two duties to comply with 38 C.F.R. § 3.103(c)(2). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. Here, during the hearing, the former Veterans Law Judge sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked, or was outstanding that might substantiate the claim. It was suggested that any evidence tending to show a worsening in severity of current symptoms would be helpful in substantiating the claims for an increased rating. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2); and no prejudice has been identified in the conduct of the Board hearing. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Analysis Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. 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 (2012). The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That being said, given unintended delays during the appellate process, VA's determination of the "current level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period that the increased rating claim has been pending. In those instances, it is appropriate to apply staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012). For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45 (2012), pertaining to functional impairment. If feasible, these determinations are 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 (2012). Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 10 percent evaluation is assignable each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). He is also competent to report symptoms of knee pain, hemorrhoidal pain, and foot pain. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. A. Patellar Bursitis and Synovitis of the Left Knee Service connection has been established for patellar bursitis and synovitis of the left knee. The RO has evaluated the Veteran's left knee disability as 10 percent disabling under Diagnostic Code 5020-5257, based on evidence showing definite swelling in the prepatella bursa and slight increased crepitus at the extreme of flexion. Bursitis and synovitis are rated on limitation of motion of affected parts, as arthritis, degenerative. 38 C.F.R. § 4.71a, Diagnostic Codes 5019, 5020. The standard ranges of motion of the knee are zero degrees of extension and 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Limitation of motion of the knee is rated under Diagnostic Codes 5260 and 5261: 5260 Leg, limitation of flexion: Flexion limited to 15° 30 percent Flexion limited to 30 20 Flexion limited to 45 10 Flexion limited to 60 0 5261 Leg, limitation of extension: Extension limited to 45° 50 percent Extension limited to 30 40 Extension limited to 20 30 Extension limited to 15 20 Extension limited to 10 10 Extension limited to 5 0 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Moreover, Diagnostic Code 5257 provides a 10 percent evaluation for lateral instability or recurrent subluxation of a knee that is slight, a 20 percent rating when those symptoms are moderate, and a 30 percent rating when severe. The terms "mild," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. VA's General Counsel has also held that separate ratings can be provided for a claimant who has compensable arthritis and instability of the knee. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). A separate rating for arthritis can be awarded on the basis of X-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998). In addition, separate ratings can be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Alternatively, dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain and effusion into the joint warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Historically, the Veteran reportedly hurt his left knee while lifting heavy objects in active service. He also played basketball, and was told by a physician that he had a "high-jumper's knee." VA examination within the first post-service year included complaints of constant left knee pain, and diagnoses of patellar bursitis and synovitis of the left knee. In August 1976, the Veteran reported that the left knee occasionally gave way, but he did not fall. He also reported slight swelling on occasion, but no locking. His left knee pain increased with walking, and ached when sitting. X-rays taken of the left knee in August 1979 revealed no abnormalities. The Veteran again reported his left knee giving way in July 1982. VA examination in December 1982 failed to reveal any limitation of motion of the leg upon the knee joint. Nor was there swelling or effusion. The Veteran was able to squat fully, and to walk on his toes and his heels. X-rays taken of the left knee in July 1987 were normal. X-rays taken of the left knee in July 1990 revealed minimal arthritic spurring of the patella, with no other abnormalities. Records from the Florida Department of Corrections (FDOC) show that the Veteran was treated in March 1991 for complaints of left knee pain, which he injured while playing basketball. In April 1991, the Veteran was seen with complaints that his left knee went out and he had a surge of pain. He reported that now when he moved it, it felt like the left knee "catches." On objective examination, there was no swelling or deformity or discoloration; there was decreased range of motion. The assessment was possible sprain of left knee. Follow-up treatment in June 1991 revealed no deformity of the left knee; range of motion was full, and gait was normal. The Veteran initiated a claim for an increased rating in November 1991. FDOC records reveal that examination in April 1992 revealed full extension and full flexion of the left knee. There was objective evidence of pain around the knee on examination, and medications were continued. In May 1993, the Veteran was treated for recurrent left knee pain. Examination at that time revealed full range of motion; there was no muscle atrophy. Diagnosis was arthritic pain of the left knee. VA treatment records show that range of motion of the Veteran's left knee in August 1993 was to 140 degrees on flexion, and to 0 degrees on extension. There was neither swelling nor erythema at the time. X-rays revealed no significant bone or joint abnormality. Records show an assessment of chondromalacia of the left knee in October 1993. In February 1994, the Veteran testified that he had constant pain daily in his left knee, and very limited motion upon repetition-especially when climbing stairs. He testified that it was difficult to bear weight on his left side, and that there was swelling of the left knee. FDOC records show continuing complaints of chronic left knee pain. FDOC examination in September 1996 revealed no swelling and no loss of motion; there was pain with weight-bearing and without weight-bearing. The assessment was joint pain, and anti-inflammatory medications were provided. In September 2001, the Veteran again complained of left knee pain. Examination of the left knee then revealed slight crepitus; there was no laxity or swelling. X-rays revealed mild degenerative arthritis of the left knee. Records show continuing complaints of left knee pain in February 2004 and in August 2007. Assessments included bilateral knee pain and arthritis. The Veteran was provided with elastic knee braces. Records show that the Veteran was no longer was incarcerated, and that he underwent a VA examination in May 2013 to determine the current severity of his left knee disability. His medical history reflects that the Veteran had fallen on his left knee and developed prepatellar bursitis in 1971, and that he then had a locking episode during a basketball game. He currently had degenerative joint disease in his knees and was told he needed a knee replacement; and recently underwent an injection. The Veteran reported having no flare-ups. Examination in May 2013 revealed that the range of motion of the Veteran's left knee was to 105 degrees on flexion and to 0 degrees on extension. There was no objective evidence of painful motion. The Veteran was able to perform repetitive testing, without additional limitation in ranges of motion. Less movement than normal was noted. Muscle strength testing and joint stability testing were normal. There was no evidence of recurrent patellar subluxation or dislocation. The Veteran reported that he regularly used a left knee brace. X-rays revealed small effusions, and moderate patellofemoral degenerative changes. Effects on occupation or daily activities included limiting lifting to 15 pounds and primarily sitting duties. Here, throughout the rating period, the objective evidence of record does not reflect degrees of limited motion of the left knee to warrant compensable disability ratings either under Diagnostic Code 5260 or 5261. In fact, the Veteran's range of motion on extension was assessed as normal; and flexion was assessed as at worse 105 degrees, which does not warrant a compensable disability rating for limited motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. Regarding any functional loss due to pain, fatigue, incoordination, or the like, the March 2013 examiner confirmed that repetitive testing did not result in additional limitation of motion. Even with consideration of functional loss expressed by the Veteran as pain and noted by examiners in regard to lifting and climbing stairs, the Veteran's left knee disability does not demonstrate a compensable degree of motion loss either in flexion or in extension. Regarding flare-ups, the Veteran has not reported frequent flare-ups; and records show that he took pain medications. Examiners have noted decreased motion, and X-rays document degenerative changes. The currently assigned 10 percent disability rating under Diagnostic Code 5020 already compensates the Veteran for significant functional impairment due to synovitis, based on painful motion. There is no evidence of dislocated cartilage to warrant an increased disability rating under Diagnostic Code 5258. Regarding instability, examiners basically have found the Veteran's left knee to be stable. The April 2013 examiner found no evidence of recurrent patellar subluxation or dislocation. Although the Veteran has reported occasions when his left knee gave way, the objective clinical findings based on diagnostic testing outweigh the Veteran's lay assertions regarding severity. The evidence does not warrant a separate, compensable disability rating under Diagnostic Code 5257. There also is no evidence or allegation that any other diagnostic code pertaining to the Veteran's left knee disability is applicable in the present case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). For the foregoing reasons, an increased disability evaluation for the Veteran's service-connected patellar bursitis and synovitis of the left knee is not warranted. The objective clinical findings consistently fail to show that his left knee disability meets the criteria for an increased rating, and the Board concludes that those findings outweigh the Veteran's lay assertions regarding severity. Clinicians have evaluated his left knee to determine the extent of the disability, and the findings do not show that the Veteran has slight or moderate lateral instability or compensable limitation of motion. B. Hemorrhoids Service connection has been established for hemorrhoids, based on evidence showing a history of recurrent hemorrhoids. The RO has evaluated the Veteran's hemorrhoids as 0 percent disabling (noncompensable) under Diagnostic Code 7336. Diagnostic Code 7336 provides a noncompensable evaluation for mild or moderate external or internal hemorrhoids. A 10 percent evaluation requires large or thrombotic, irreducible hemorrhoids with excessive redundant tissue evidencing frequent recurrences. A 20 percent rating requires hemorrhoids with persistent bleeding and secondary anemia or with fissures. 38 C.F.R. § 4.114, Diagnostic Code 7336. FDOC records, dated in January 1991, show that the Veteran had undergone a hemorrhoidotomy in December 1990 and he was in the process of healing. The Veteran initiated a claim for an increased rating in November 1991. In May 1992, the Veteran had rectal bleeding and underwent a rubber band ligation of an internal hemorrhoid. In February 1994, the Veteran testified that he still had bleeding from hemorrhoids, and that he had experienced two protruding hemorrhoids. He also had itching and swelling, and used stool softeners. The Veteran testified that he took sitz baths at least twice per week. FDOC records show a diagnosis of hemorrhoids in June 1996. Examination in May 2002 revealed no hemorrhoids. External hemorrhoids were noted by examiners in September 2004, in June 2005, in September 2006, in August 2007, and in February 2008. VA treatment records, dated in October 2012, show that the Veteran again reported the presence of hemorrhoids with some bleeding. In January 2013, the Veteran reported constant rectal pain with bowel movements, and frequently seeing some blood in tissue paper and toilet water. He reported that pain affected his sleep, daily activities, physical activity, mood, emotions, and walking. His pain was partially or completely relieved by over-the-counter medication. During a May 2013 VA examination, the Veteran reported having pain, burning, and itching daily; and that he regularly saw blood on tissue. He used stool softener daily, and had several banding and laser procedures in the past. The Veteran's symptoms were attributed to internal and external hemorrhoids, described as mild or moderate, with daily blood on tissue and pain. Examination revealed no external hemorrhoids; only skin tags were noted. The diagnosis was internal or external hemorrhoids. In this case, although the Veteran's hemorrhoids are symptomatic at times, as indicated by his report of bleeding and pain that required medication for relief, the objective evidence throughout the rating period reflects that the Veteran's hemorrhoids are not more than moderate in degree; and thus properly rated as noncompensable under Diagnostic Code 7336. Except for the two occasions that required either a hemorrhoidotomy or internal ligation, there has been no showing of large or thrombotic, irreducible hemorrhoids, with excessive redundant tissue, evidencing frequent occurrences to warrant a compensable evaluation. While the Board recognizes that there might have been exacerbations of pain just prior to his December 1990 surgery and prior to the May 1992 internal ligation, such exacerbations do not justify an increased rating. "Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. The months preceding the surgery and ligation were just such a time period, but the Veteran's general level of disability due solely to his hemorrhoids throughout the rating period has been much less severe. The June 2013 examiner found no external hemorrhoids, only skin tags, and described the internal or external hemorrhoids as mild or moderate, with daily blood on tissue and pain. Following the December 1990 surgery and May 1992 ligation, no examiner has described the Veteran's hemorrhoids as large or thrombotic or with persistent bleeding and secondary anemia or with fissures. The hemorrhoids do not impact the Veteran's ability to work. Here, the objective clinical findings outweigh the Veteran's lay assertions regarding severity. Hence, his symptoms do not meet or approximate the criteria for a compensable disability rating under 38 C.F.R. § 4.114, Diagnostic Code 7336. C. Ingrown Toenail, Status-Post Nail Plate Removal Service connection has been established for ingrown toenail of the right great toe, based on evidence showing slight in growing of the lateral border of the nail and no skin irritation or infection. The RO has evaluated the Veteran's ingrown toenail of the right great toe, status-post nail plate removal, as 0 percent disabling (noncompensable) under Diagnostic Code 7899. Ingrown toenails are not assigned a specific diagnostic code in the rating schedule. When a disability not specifically listed in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Although, no more than one rating may be assigned without violating the rule against the pyramiding of disabilities. 38 C.F.R. § 4.14. The RO has evaluated the Veteran's ingrown toenail of the right foot as analogous to Diagnostic Code 7899, pertaining to scars and skin disorders. A deep scar is one that is associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (2). A scar at a location other than the head, face, or neck that is deep or that causes limitation of motion would have to have an area exceeding 6 square inches (39 square centimeters) to warrant a 10 percent rating, 12 square inches (77 square centimeters) to warrant a 20 percent rating, 72 square inches (465 square centimeters) to warrant a 30 percent rating, or 144 square inches (929 square centimeters) to warrant a 40 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7801. A superficial scar is one that is not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802, Note (2). A scar at a location other than the head, face, or neck that is superficial and that does not cause limitation of motion would have to have an area exceeding 144 square inches (929 square centimeters) to warrant a 10 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7802. A 10 percent evaluation is provided for superficial scars that are poorly nourished with repeated ulcerations under 38 C.F.R. § 4.118, Diagnostic Code 7803; or for superficial scars that are tender or painful on objective demonstration under 38 C.F.R. § 4.118, Diagnostic Code 7804 (2007). Disabling effects are to be rated either as scars or as impairment of function, whichever results in the higher rating. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2007). Although, no more than one of these ratings may be assigned without violating the rule against the pyramiding of disabilities. 38 C.F.R. § 4.14. During the course of this appeal, VA revised the criteria for evaluation of scars, effective on October 23, 2008. 73 Fed. Reg. 54708 (September 23, 2008) (codified at 38 C.F.R. § 4.118 (2009)). Initially, the revised criteria were applicable only to claims received by VA on or after October 23, 2008; and, hence, were inapplicable in this case. Since then, VA published a correcting amendment to allow Veterans whose scars were rated by VA under the former criteria (versions in effect prior to October 23, 2008) to request evaluation review under the revised criteria. See 77 Fed. Reg. 2909 (January 20, 2012). The correction amendment specifically encompasses claims that have received an initial rating, and are still pending in the appeals process. Id. The correction is effective January 20, 2012. The revised criteria for Diagnostic Code 7804 provide that one or two scars that are unstable or painful warrant a 10 percent rating; three or four scars that are unstable or painful warrant a 20 percent rating; and five or more scars that are unstable or painful warrant a 30 percent rating. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1) (October 23, 2008). Alternatively, the revised criteria provide that disabling effects not considered in a rating provided under Diagnostic Codes 7801, 7802, and 7804 are to be rated as impairment of function. 38 C.F.R. § 4.118, Diagnostic Code 7805 (October 23, 2008). Historically, the Veteran's right great toenail showed slight in-growing along the lateral border of the nail, without signs of inflammation or infection in June 1975. In August 1979, the Veteran reported having three episodes of pain, soreness, and drainage involving his ingrown toenail. Examination then revealed that the right great toe was tender and slightly swollen, without drainage. In November 1982, a table dropped on the Veteran's right great toe and the nail became loose and the toe became infected. For the Period from November 21, 1991, to May 21, 2013 In this case, the objective evidence supports a 10 percent disability rating on the basis of scars under the former criteria for the rating period from the date of claim on November 21, 1991, to May 21, 2013. Records reflect that the Veteran's right great nail plate was surgically removed from the nail bed in September 1993. Although follow-up treatment revealed no erythema or purulence, mild tenderness to palpation was noted at the time. The assessment was onychocryptosis, status-post nail surgery. In February 1994, the Veteran testified that he experienced new growth in the area, but that it did not cover the full encompass of the toe. Given these findings, the Veteran's complaints of flare-ups not properly treated while incarcerated, and resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence meets the criteria for a 10 percent disability rating under Diagnostic Code 7804. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The evidence does not reflect any functional impairment from the ingrown toenail of the right great toe, status-post nail plate removal, during the rating period. Solely on the basis of tenderness and pain on objective examination, the evidence does not meet either the former or revised criteria for a disability rating in excess of 10 percent under any diagnostic code. 38 C.F.R. § 4.7. The objective clinical findings outweigh the Veteran's lay assertions regarding severity. For the foregoing reasons, the evidence is in favor of a 10 percent, but no higher, evaluation during the rating period from November 21, 1991, to May 21, 2013, for the ingrown toenail of the right great toe, status-post nail plate removal. For the Period from May 22, 2013 Records show that the Veteran was no longer was incarcerated, and that he underwent a VA examination in May 2013 to determine the current severity of his ingrown toenail of the right great toe, status-post nail plate removal. His medical history reflects that the right great toenail had been excised once. On examination, the Veteran's right great toenail was described as normal. The examiner found no skin disability affecting the Veteran's ability to work. Here, the objective evidence does not support a compensable disability rating on the basis of scars, from May 22, 2013. The Veteran did not claim any impairment resulting from the ingrown toenail of the right great toe, status-post nail plate removal. The objective evidence during the applicable period reflects that the Veteran's service-connected ingrown toenail of the right great toe, status-post nail plate removal, has been manifested primarily by a normal toenail. Solely on the basis of the right great toenail being without pain or tenderness, the evidence does not meet the criteria for a compensable disability rating, from May 22, 2013, either under the former or revised criteria. 38 C.F.R. § 4.118, Diagnostic Code 7804. The Board notes that the May 2013 examiner did not indicate that the right great toenail bed was poorly nourished with repeated ulcerations or unstable. Moreover, loss of function of the body part affected has not been demonstrated; no other diagnostic codes are applicable. Thus, the weight of the evidence is against the grant of a compensable disability rating for the ingrown toenail of the right great toe, status-post nail plate removal, from May 22, 2013. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Again, the objective clinical findings outweigh the Veteran's lay assertions regarding severity. D. Extraschedular Consideration Finally, an extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that the schedular evaluations assigned for the Veteran's service-connected patellar bursitis and synovitis of the left knee; hemorrhoids; and ingrown toenail of the right great toe, status-post nail plate removal, are adequate in this case. Examiners have not noted any occupational impairment, and the Veteran's functional impairment due to left knee pain is already contemplated by the schedular criteria for limitation of motion of the leg. Specifically, the diagnostic criteria adequately describe the severity and symptomatology of each of the Veteran's service-connected disabilities. Therefore, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER A disability rating in excess of 10 percent for patellar bursitis and synovitis of the left knee is denied. A compensable disability rating for hemorrhoids is denied. For the period from November 21, 1991, to May 21, 2013, a 10 percent disability rating for ingrown toenail of the right great toe, status-post nail plate removal, is granted, subject to the regulations governing the award of monetary benefits. For the period from May 22, 2013, a compensable disability rating for residuals of ingrown toenail of the right great toe, status-post nail plate removal, is denied. REMAND The Veteran contends that service connection for a skin disability involving the scrotum, groin, anus, and buttocks is warranted on the basis that his skin disability had its onset in active service and continued to worsen post-service. VA is required to seek a medical opinion if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but contains competent lay or medical evidence of a current disability; establishes that the Veteran suffered an event, injury or disease in service; and indicates that the current disability may be associated with the in-service event, injury or disease. 38 C.F.R. § 3.159(c)(4) (2012). Here, the current medical evidence establishes that the Veteran has a diagnosis of tinea cruris of the groin area. Although the Veteran's available service treatment records are absent complaints or treatment for tinea cruris, he is a credible and reliable historian with regard to the observable symptoms he experienced both in service and after service, to include experiencing recurrent fungal infections in his groin and buttock areas, as well as secondary infections requiring antibiotics. The question therefore remains whether the evidence indicates that there may be an association between his current diagnosis and service. See, e.g., McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a) (West 2002); 38 C.F.R. § 3.303(a) (2012); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Service treatment records document a "scrotal abscess" in October 1972, and complaints of "rectal itching" and "itching all over" in April 1974. The Veteran is competent to describe his symptoms since diagnosis, and has done so, indicating that he uses antifungal cream daily. This is sufficient to trigger the duty to assist in obtaining a medical examination and opinion as to the etiology of his currently diagnosed tinea cruris of the groin area. With regard to a plausible claim for secondary service connection, an opinion is needed as to whether the Veteran's current tinea cruris of the groin area is related to or is a residual associated with the service-connected hemorrhoids. Moreover, VA should seek a medical opinion regarding whether the Veteran's tinea cruris of the groin area is aggravated by the service-connected disability. Hence, the Board cannot resolve this matter without further medical clarification. While further delay of this case is regrettable, due process considerations require such action. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of his diagnosed tinea cruris of the groin area. The claims file, and any pertinent records contained in any electronic claims folder, must be reviewed in conjunction with the examination. All testing deemed necessary must be conducted and results reported in detail. Based on the review and physical examination, the examiner is asked to render an opinion as to: (a) Whether it is at least as likely as not that the Veteran's tinea cruris of the groin area is medically related to his service-specifically, to include the "scrotal abscess" in October 1972, and "rectal itching" and "itching all over" in April 1974, as noted in service treatment records; and the Veteran's credible complaints of itching then, and since then; (b) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected hemorrhoids have caused tinea cruris of the groin area; (c) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected hemorrhoids have aggravated his tinea cruris of the groin area (i.e., whether his tinea cruris of the groin area has permanently worsened beyond the natural progression of the disease due to the service-connected disability). If aggravation is shown, the examiner should specify what permanent, measurable increase in the severity of tinea cruris of the groin area is attributable to the service-connected disability. An explanation of the underlying reasons for any opinions offered must be included. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. The examiner is also advised that the Veteran is a credible and reliable historian with regard to the observable symptoms he experienced in service and after service, regardless of the lack of documented complaints in the service treatment records. 2. Thereafter, readjudicate the claim on appeal. If the benefits sought are not fully granted, furnish the Veteran and his representative a supplemental statement of the case (SSOC), and allow the appropriate response time before the claims file is returned to the Board, if otherwise in order. No action is required of the Veteran and his representative until they are notified by the RO or AMC; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs