Citation Nr: 1329965 Decision Date: 09/18/13 Archive Date: 09/25/13 DOCKET NO. 05-25 394 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a right wrist sprain disability. 2. Entitlement to service connection for bilateral ankle disability. 3. Entitlement to service connection for bilateral knee sprain disability. 4. Entitlement to an initial compensable disability rating for service-connected right great toe sprain disability. 5. Entitlement to an initial disability rating in excess of 10 percent prior to May 7, 2013 and in excess of 20 percent from May 7, 2013 for service-connected right shoulder sprain disability. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from September 2000 to August 2004. These matters come before the Board of Veterans' Appeals (Board) from a March 2005 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Waco, Texas. These matters were most recently before the Board in February 2013, when they were remanded for further development. They have now returned to the Board for appellate consideration. As is discussed in greater detail below, the Board finds that there has been substantial compliance with its remand, and a further remand is not warranted. The Board will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACT 1. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has a right wrist sprain disability causally related to, or aggravated by, active service. 2. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has a bilateral ankle disability causally related to, or aggravated by, active service. 3. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has a bilateral knee sprain disability causally related to, or aggravated by, active service. 4. During the rating period on appeal, the Veteran's right great toe disability has been manifested by complaints of swelling and pain; objectively, he does not have gout, more than one joint affected by degenerative changes, Morton's disease, hallux valgus, hallux rigidus, hammer toe, moderate malunion or nonunion of the tarsal or metatarsal bones, or moderate foot injury. 5. During the rating period on appeal, the Veteran's right shoulder disability has been manifested by complaints of intermittent pain; objectively he has forward flexion to at least 170 degrees, abduction to at least 175 degrees, external rotation to at least 90 degrees, and internal rotation to at least 85 degrees, with no additional loss due to weakness, fatigue, or incoordination after repetitive use. 6. From May 7, 2013, the Veteran's right shoulder has been manifested by dislocation of the acrominoclavicular joint on the right. CONCLUSIONS OF LAW 1. The criteria for service connection for a right wrist disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, (2013). 2. The criteria for service connection for bilateral ankle disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, (2013). 3. The criteria for service connection for bilateral knee disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, (2013). 4. The criteria for an initial compensable disability rating for service-connected right great toe sprain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R.§§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5276-5284 (2013). 5. The criteria for an initial disability rating in excess of 10 percent prior to May 7, 2013, and in excess of 20 percent from May 7, 2013 for service-connected right shoulder sprain disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R.§§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5200-5203 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The appeal of the right great toe and right shoulder arises from the Veteran's disagreement with the initial evaluations following the grants of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. Notice for the service connection claims was provided in December 2004 and December 2009 and the claims were readjudicated, most recently in a June 2013 supplemental statement of the case. VA also has a duty to assist the Veteran in the development of the claim, which is not abrogated by the granting of service connection. The claims file includes service treatment records (STRs), post service medical records, and the statements of the Veteran in support of the claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that adequate VA examinations/opinions are of record for the issues decided herein; they are predicated on consideration of the Veteran's disabilities, his symptoms, and his medical history. Adequate rationale was provided for the opinions offered. In a July 2013 informal hearing presentation, the appellant's representative contended that the Veteran has not been provided with an adequate examination with regard to his right great toe. The Board finds that the examination, and the record as a whole, provide sufficient evidence upon which to rate the Veteran's right great toe. While the representative contends that the examination report lacks information as to functionality upon repetition of movement and flare-ups, the Board notes that the diagnostic criteria for rating the toe does not include limitation of motion. Moreover, there is ample evidence of record upon which to rate the toe; thus, another examination is not warranted. The representative also contends that the examinations for the right wrist, bilateral knees, and bilateral ankles are inadequate because they fail to address the specific items of evidence noted by the Board in its remand and are conclusory in nature. Upon review, and as discussed in further detail below, the Board finds that a February 2005 VA examination is not probative as to diagnoses of the Veteran's wrist, knee, and ankle; thus, the Board's prior remand directive with regard to the February 2005 diagnoses is no longer relevant, and the February 2005 diagnosis need not be addressed by an examiner. Adequate examinations have been provided and the reports are associated with the claims file. The opinions are based on a review of the claims file, interviews with the Veteran regarding his history and symptoms, and examinations of the Veteran. The reports provided sufficient rationale for the opinions. The Board's most recent remand noted that specific findings with regard to the Veteran's right shoulder, from an October 2011 VA examination, were not associated with the claims file, and that if a complete copy of the October 2011 VA examination report was not available, a negative reply was required. The Board also stated that if the complete copy of the October 2011 VA examination report was not available, the Veteran should be scheduled for another examination of the right shoulder. The claims file does not include a specific negative finding as to the availability of the report; however, as the Veteran was scheduled for another examination, in May 2013, the Board find that more detailed 2011 VA findings were not available, and there has been substantial compliance with its remand. The 2013 examination report contains necessary findings upon which to evaluate the Veteran's shoulder disability. In addition, as the 2011 examiner found that the Veteran had a normal shoulder, the Veteran has not been prejudiced by a lack of more specific findings as to normal. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Organic diseases of the nervous system are included in 38 C.F.R. § 3.309(a). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Rating Disabilities in general 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 applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating musculoskeletal disabilities Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40 and 4.45 (2012), see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. Id. § 4.45. Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to the claims on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Right wrist sprain. In 2004, the Veteran filed claims for entitlement to service connection for numerous disabilities, but did not request entitlement to service connection for a right wrist disability. Nevertheless, the VA examiner, in February 2005, examined the wrist, and made clinical findings with regard to it. Subsequently, the RO denied a claim for a right wrist disability. The Board has considered the Veteran's in-service and post-service clinical records, as stated below. December 2000 service records reflect that the Veteran was seen with tenderness to palpation over the dorsal side of the metacarpal and metacarpophalangeal joint. He complained of right hand 5th digit pain. There was no heat or swelling of the joint. The Veteran had full range of motion. The radiologist's report reflects that there was no fracture or dislocation identified, alignment was anatomic, and joint spaces were well maintained. No osseous erosion was identified. A probable bone island was present at the base of the proximal phalanx of the fifth digit. A March 2001 record reflects a wart on the 3rd digit of the right hand. It is negative for wrist complaints or abnormal findings. An April 2001 record reflects dermatitis of the right thumb and resolved warts. It is negative for wrist complaints or abnormal findings. The Veteran underwent a VA examination in February 2005. The February 2005 examination report reflects that the Veteran reported that he did not know how he injured his right wrist. He reported no past history of trauma. He reported that he occasionally has wrist pain, which was described as a stabbing type of pain. He denied any swelling and reported no use of assistive devices or medications. He reported that it does not bother his occupation and does not interfere with his daily activities. He had no additional limitations with repetitive use and no additional limitation during flare-ups. Upon clinical examination, the right wrist was without palpable tenderness. There were no deformities and no swelling. Right wrist dorsiflexion was to 70 degrees without pain, palmar flexion was to 80 degrees without pain, wrist ulnar deviation was to 45 degrees without pain, and wrist radial deviation was to 20 degrees without pain. Active range of motion did not produce any weakness, fatigue, or incoordination. X-ray of the right wrist revealed "no evidence of fracture or dislocation. An abnormality is not apparent." The examiner diagnosed a right wrist sprain. The probative value of medical opinions is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guarneri v. Brown, 4 Vet. App. 467, 470-71 (1993). There is no requirement that additional evidentiary weight be given to the opinion of a medical provider who treats a veteran; courts have repeatedly declined to adopt the "treating physician rule." See White v. Principe, 243 F.3d 1378, 1381 (Fed. Cir. 2001); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993). The Board finds that the February 2005 opinion with regard to a diagnosis of a wrist sprain lacks probative value. Although the examiner diagnosed the Veteran with a sprain, the examiner did not identify any clinical findings to support such a diagnosis. The clinical findings were that there was no palpable tenderness, no deformities and no swelling, no pain with dorsiflexion to 70 degrees, no pain with palmar flexion 80 degrees, no pain with ulnar deviation to 45 degrees, and no pain with radial deviation to 20 degrees. Active range of motion did not produce any weakness, fatigue, or incoordination. As the clinical diagnosis is not supported by the clinical findings, it is not probative. In a VA Form dated in February 2006, the Veteran stated that he has chronic pain and swelling of the right wrist. In his VA Form 9 dated in July 2005, he stated that his right wrist disability is not caused by a sprain. The Veteran underwent a VA examination in May 2010. The Veteran described no injury, no treatment, and no evaluation of his wrist. He reported that it started bothering him in 2000 or 2001. He described some pain in his mid wrist. He described it as sharp and "kind of" radiated into his hand and up his arm. He reported that he takes over the counter Motrin for it, and that the symptoms last only momentarily. He stated that occasional push-ups bother him. He reported no flare-ups or incapacitating events. He reported that he has an over-the-counter brace that he uses off-and-on a few days at time with some minimal benefit. Upon clinical examination, there was no palpable tenderness. There was no obvious deformity. He had a negative Tinel and negative Phalen test. There was no masses. Motor function was 5/5. His neurovascularly sensory was intact. He had a full active range of motion, with no pain, fatigue, weakness, or incoordination with repetitive motion in any plane. The examiner noted that x-rays in 2000 and 2005 were both negative. The examiner stated that the examination of the Veteran was "a normal examination, normal x-rays, and no pathology of the wrist. There is no obvious explanation for this veteran's complaints. No pathology." The May 2010 VA examiner also stated that it "should be noted that this veteran is very focused on every little tweak and twinge in his body and suspects a serious problem with all of his complaints." The Veteran underwent a VA examination in October 2011 at which time he reported that he gets a burning sensation if he does pushups. Upon examination, he had full flexion and extension with no objective evidence of painful motion. He was able to perform repetitive-use testing with no additional limitation in range of motion or functional loss. He had normal wrist strength of 5/5. No degenerative or traumatic arthritis was documented on x-rays. The report was "normal right wrist." The report reflects that is less likely than not that the Veteran has a right wrist disability causally related to service. The examiner also stated that a bone island is not a symptomatic problem and is not caused by injury. The examiner found no pathology concerning his wrist and no disability upon examination. The Veteran underwent a VA examination in 2013. The Veteran described dorsal mid-carpal wrist pain with dorsiflexion of wrist against resistance, pain with doing push-ups, and a sense of pain/pressure burning sensation for a couple of days which then goes away. The Veteran reported that he was seen several times in service. He described popping with range of motion. Upon clinical examination, he had full palmar flexion with no objective evidence of pain. He had 65 degrees of dorsiflexion with painful motion beginning at 65 degrees. After repetitive motion testing, he had full palmar flexion, and 65 degrees of dorsiflexion. He did not have additional limitation in range of motion after repetitive testing. The examiner found that he had pain on movement as the only functional loss. He had full wrist flexion and extension strength, or a 5/5. The Veteran did not have degenerative or traumatic arthritis. A report of general information, dated May 30, 2013, reflects that the examiner opined that the Veteran had normal range of motion and did not have a right wrist disability. The Board notes that the Veteran contended that he had been several times for his wrist in service; however, the clinical records do not support this contention. The Board notes that it has now been nine years since the Veteran separated from service, and he has been examined on at least four occasions. The probative evidence reflects that he does not have a right wrist disability. Pain alone, without a diagnosed or identifiable underlying malady or condition does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). As a service connection claim requires, at a minimum, medical evidence of a current disability, the Veteran's claim for service connection for a right wrist disability is not warranted in this case. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Even assuming that the Veteran did have a right wrist disability, the competent credible evidence does not reflect that he had a right wrist injury in service. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Bilateral Ankle Disability The Veteran avers that he has a bilateral ankle disability causally related to active service. The Board finds, based on the evidence discussed below, that service connection for bilateral ankle disability, to include bilateral ankle sprain and/or a skin disability, is not warranted. The Board will first consider the Veteran's records during service. A June 4, 2002 family practice record reflects that the Veteran reported dry scaly areas which itch on the bilateral outer ankles for 1 1/2 to 2 months. The assessment was bilateral tinea pedis. The Veteran was prescribed cream and to change his socks. Three days later, a June 7, 2002 record reflects that the Veteran continued to have dry scaly areas of the ankles. Tinea pedis is popularly known as "ringworm of the feet. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (31st Ed. 2007). A January 2003 flight medical clinic record reflects that the Veteran complained of chronic dry skin on the soles of his feet. He was to change his socks twice a day. No symptoms were reported with regard to the ankles. (The Veteran is service-connected for dermatitis of the bilateral feet.) The Veteran separated from service in August 2004. In November 2004, he submitted a claim for "bilateral ankle condition," but he did not specify the condition. A February 2005 VA examination report reflects that the Veteran reported that with regard to his ankles, he noticed sudden onset of itching, redness and a burning sensation. He reported that it had last happened on October 4, 2004. The Veteran denied any pains in the ankles and denied swelling. He reported that he gets an itch with redness mostly on the top of the foot and on the ankles and top of each toe which lasts one to two weeks and usually goes away by itself. He used no assistive devices and it did not interfere with his occupation or daily activities. Upon clinical examination, his gait was noted to be normal. He did not have any edema of the extremities. The ankles revealed no deformities or abnormities; there was no swelling and no visible rash. He had dorsiflexion to 20 degrees without pain, and plantar flexion to 45 degrees without pain. Active range of motion did not produce any weakness, fatigue, or incoordination. The examiner diagnosed the Veteran with "bilateral ankle sprains." A sprain is a joint injury in which some of the fibers of a supporting ligament are ruptured but the continuity of the ligament remains intact. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (31st Ed. 2007). The Board finds that this diagnosis of bilateral ankle sprain lacks probative value as there is no evidence of record to support such a diagnosis. To the contrary, the examiner noted that the Veteran had no deformities or abnormalities, and had full range of motion. In addition, and importantly, the Veteran did not complain of pain or swelling in the ankles (i.e. symptoms of a sprain), but noted that several months earlier, on one date, he had redness, itching, and a burning sensation. The examiner also diagnosed the Veteran with "dermatitis, but not on this examination." Thus, the examiner's opinion was based on the Veteran's self-reported history that he had dermatitis after service. In his VA Form 9, dated in July 2005, the Veteran stated that he was appealing the denial of entitlement to service connection for bilateral ankle sprain; however, he stated that "these evaluations are incorrect because the issue is not or was not caused by a sprain." It appears that the Veteran is contending that his claimed disability is for a rash or skin disability. The Veteran underwent a VA examination in May 2010. The report reflects that there was no history of "sprains or strains." The Veteran reported no problems with his ankles, and no swelling, catching, locking, or giving way. No subluxation or dislocation. He described pain, itching, burning over a skin rash of the lateral ankles. Upon clinical examination, the ankles were stable, the Veteran had motor function 5/5, he was neurovascular sensory intact, he had dorsiflexion to 30 degrees, and he had plantar flexion to 40 degrees. There was no pain, fatigue, weakness, or incoordination with repetitive motion in either ankle. The Veteran had a normal examination and normal x-rays of both ankles. No pathology was found. The report is negative for any findings of a rash or skin disability of the ankles. The Veteran underwent another VA examination October 2011. The Veteran had no current problems with his ankles. Upon clinical examination, there was no objective evidence of painful motion or limitation of motion. There was no functional loss of the ankles. There was no instability of the ankles. The diagnosis was normal bilateral ankles. The report is negative for any findings of a rash or skin disability of the ankles. The Veteran underwent another VA examination in May 2013. The report reflects that the Veteran had no complaints with regard to the ankle joints. He described a rash that comes up on the lateral sides of his ankles in hot weather. There was no rash upon examination in May 2013. There was no history of injury or treatment of for an ankle condition. The VA opinion reflects that the examiner considered the claims file, to include the February 2005 diagnosis. The examiner noted that there was no ankle disability. The examiner stated that the Veteran underwent a normal examination with normal x-rays of both ankles. There was no pathology and no evidence of any skin lesions on the ankles. In sum, the Veteran's ankles have been examined in February 2005, May 2010, October 2011, and May 2013. None of the examination reports reflect a rash. (The May 2010 report notes areas of skin rash on both feet; as stated above, the Veteran is service-connected for dermatitis of the feet.) In addition, no scars or lesions have been noted. The Board acknowledges that the Veteran is competent to report a rash on his ankles; however, he has not been found to have the training, experience, or education necessary to provide an etiology for any such rash. The Board also notes that the skin disability in service was described as dry scaly areas which itch, and was diagnosed as tinea pedis. He was noted to have chronic dry skin on the ankles which lasted for 1 1/2 to two months. The Veteran now contends that he has a rash that appears suddenly on the lateral sides of his ankles in hot weather, is red and itchy, lasts one to two weeks, and usually goes away by itself (February 2005). Thus, the symptoms are not the same. Although the Veteran contends that he has had this rash intermittently since separation from service, there are no clinical records which support such a contention. The Veteran's claim has been pending for almost nine years, and he has provided no clinical evidence to support a rash of the ankles. The Board acknowledges that the absence of any corroborating medical evidence supporting assertions, in and of itself, does not render lay statements incredible, such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of appellant's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). See also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent to establish a diagnosis when . . . a layperson is competent to identify the medical condition.) However, in the present case, not only is there a lack of clinical records, but upon numerous clinical examination, no rash was found, nor were any symptoms of a rash found. There is no competent clinical evidence that the Veteran has a skin disability of the ankles (other than dermatitis of the feet) causally related to, or aggravated by service. In addition, the competent credible evidence of record is against a finding that the Veteran has bilateral ankle sprain, or any other disability, causally related to, or aggravated by, active service. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Bilateral knee sprain In 2004, the Veteran filed claims for entitlement to service connection for numerous disabilities, but did not request entitlement to service connection for a knee disability. Nevertheless, the VA examiner, in February 2005, examined the knees, and made clinical findings with regard to the knees. At the February 2005 VA examination, the Veteran reported numbness just below the knees and pain when he kneels. The medial side of the left knee was noted to be numb. The Veteran reported that he injured both knees in the military. Upon clinical examination, there were no deformities seen. There was slight tenderness at both tibial areas proximately. The Veteran had flexion to 140 degrees without pain, bilaterally. He had full extension bilaterally without pain. There were stable medial and lateral collateral ligaments bilaterally. There were stable anterior and posterior cruciate ligaments bilaterally. There was no weakness, fatigue, or incoordination with active range of motion. The examiner diagnosed the Veteran with bilateral knee sprains. The Board finds that the diagnosis lacks probative value as there is no evidence of record to support such a diagnosis. The STRs are negative for any complaints of, or treatment for, the Veteran's knees. Moreover the Veteran did not file a claim for a knee disability when he filed his other claims. The Board finds that if the Veteran had a knee disability upon separation from service, it would have been reasonable for him to have claimed it when he claimed his other disabilities in 2004, especially as he filed claims for entitlement to service connection for his feet and ankles. The Board also notes, as noted below, that the Veteran has subsequently stated that he did not have knee sprains and that he did not have an injury to the knees. In his VA Form 9, dated in July 2005, the Veteran stated that he was appealing the denial of entitlement to service connection for bilateral knee sprain; however, he stated that "these evaluations are incorrect because the issue is not or was not caused by a sprain." The Veteran underwent a VA examination in May 2010. The report reflects that the Veteran described no injuries for his knees and no treatment. He stated that if he sits on his feet with his knees bent, it causes a sense of dislocation of his knees. He described no swelling. He also reported that "running is okay." He described no limitations in activities of daily living, no flare-ups, and no incapacitating events. He described some numbness over the medial side of the left knee and below the patellar tendon insertion on the tibia on the right. He described some increased pain with kneeling. Upon examination, there was an area over the medial left knee that is very hypersensitive to touch. The examiner noted that the Veteran "tends to jump off the table when you touch his skin. The same with the area over distal to the tibial tubercle. It is very hypersensitive to touch. There are no obvious skin changes. There is no swelling. There is no deformity, heat, erythema, or lesions, or effusion." Both knees were stable to testing. Range of motion was from 0 to 135 degrees with no pain, fatigue, weakness, or incoordination with repetitive knee. X-rays of both knees showed no fracture or dislocation. Joint spaces were adequately preserved. There were no gross soft tissue abnormalities. The examiner stated as follows: This is a normal examination and normal x-rays of both knees. I could find no obvious reason for the hypersensitivity over the skin in these areas. It is not consistent with dermatomes or known sensory nerve innervations in and about the knees. This is a normal examination and normal x-rays of the bilateral knees. NO PATHOLOGY. As noted above, the May 2010 VA examiner stated that it "should be noted that this veteran is very focused on every little tweak and twinge in his body and suspects a serious problem with all of his complaints." The Veteran underwent another VA examination in October 2011. The report reflects that the Veteran indicated that his skin feels numb on the lateral aspect of the knees (not a joint problem). The Veteran also indicated that if he sits too long, he gets pain on the posterior lateral knees. There was no instability, locking, or swelling. The Veteran had full range of motion with no pain. There was no functional loss, even after repetitive use testing. There was no instability upon testing. There was no degenerative or traumatic arthritis documented upon x-ray. The examiner opined that the Veteran had "normal bilateral knees." The examiner also stated that the Veteran is morbidly obese and this might be the cause of his current complaints. In this regard, the Board notes that the Veteran weighed between 195 and 225 pounds while in service, but he weighed in excess of 290 pounds post service in May 2010. The Veteran underwent another VA examination in May 2013. The examiner stated that there is no evidence in the service treatment records of any complaint, treatment, or evaluation in service. The examiner also noted that there is no evidence of a chronic ongoing condition associated with his military service, and there is no evidence of aggravation by the service. The examiner noted that the Veteran does have mild patellar tendonitis and possibly some mild patellofemoral syndrome with normal x-rays of both knees. The examiner stated that the claimed disability of the knees was less likely than not incurred in, or caused by, service. In sum, there is no objective clinical evidence of complaints of, or treatment for, knees in service. Pain alone, without a diagnosed or identifiable underlying malady or condition does not in and of itself constitute a disability for which service connection may be granted. The Veteran had normal knees upon clinical and x-ray examination in May 2010 and October 2011, six years after separation from service. It was not until 2013, more than eight years after separation from service, that the Veteran had a diagnosed disability. There is no clinical opinion which causally relates a current bilateral knee disability to service. Moreover, the theory of continuity of symptomatology is not applicable because tendonitis and patellofemoral syndrome are not chronic disabilities under 38 C.F.R. § 3.309(a). Based on the record as a whole, the Board finds that service connection for bilateral knee disability is not warranted. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Initial compensable disability rating for right great toe sprain. The February 2005 VA examination report reflects that the Veteran reported that his right great toe hurts, but "not on an everyday basis. It is only with bending primary or doing pushups." The Veteran reported that if it does hurt, it can hurt for days. He reported that it occasionally swells and he tries to stay off of it until he gets relief. He further reported that it does not interfere with his daily activities or his occupation. Upon clinical examination, the right great toe showed no deformities or defects and was nontender on palpation with a normal range of motion. In a February 2006 statement (VA Form 9), the Veteran stated that his right great toe disability is not a sprain because a sprain will heal given adequate time and rest. He asserted that he had been seen by a doctor and given medication and a diagnosis of gout. He further stated that the disability has been constant and there is obvious swelling of the joint. A May 2010 VA examination report reflects that the Veteran denied any injury of the toes. He reported that it "just started hurting mainly with prolonged walking or running. He reported occasional swelling, no heat or redness, no drainage, and no limitations in activities of daily living. He describes minor flare-ups with prolonged walking or running." It was further noted that the Veteran "specifically denies any diagnosis of gout." As noted above, the examiner stated that it "should be noted that this veteran is very focused on every little tweak and twinge in his body and suspects a serious problem with all of his complaints." Upon clinical examination in May 2010, the Veteran had a small dorsal osteophyte that was palpable at the metatarsophalangeal joint. There was no crepitus. He had full active and passive range of motion. He was neurovascularly sensory intact, had normal gait, and could walk heel-toe without any difficulty. The Veteran had some point tenderness to palpation over the an area of transversing the lateral sesamoid bone of the 1st metatarsal which "may" represent a bipartite sesamoid versus sesamoid fracture. The examiner opined that there was no evidence on x-ray of erosive lesions consistent with gouty arthritis. He also noted that the Veteran had early minimal degenerative change in the 1st metatarsophalangeal joint, which was not consistent with gout. A February 2011 VA opinion reflects that the Veteran has no evidence or complaints consistent with gouty arthritis of the toe. The examiner opined that the Veteran's early degenerative change in the first metatarsal phalangeal joint is not consistent with gouty arthritis but is consistent with right great toe sprain in service. The Veteran underwent a VA examination in October 2011. The VA examination report reflects that the Veteran had a totally normal examination and no mechanical reason for toe pain. The examiner noted that the Veteran has "no pathology and no toe disability." The Veteran underwent a VA examination in May 2013. The May 2013 VA examination report reflects that the Veteran has minimal arthritis changes in the toe. The examiner stated that the Veteran has never been tested for gout. The Veteran did not report for laboratory work to test for high uric acid on the examination. (The duty to assist is not a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Importantly, the examiner noted that the Veteran's signs and symptoms are not consistent with gout. Moreover his x-ray findings are not consistent with gout. The examiner stated that the Veteran has "very minimal degenerative changes noted in the big toe." It was noted to be "early mild spurring on the lateral and dorsal distal metatarsal of the great toe." The examination report also reflects that the Veteran had no limitations of activities of daily living or working. He did not have hammer toe, Morton's disease, hallux valgus, hallux rigidus, claw foot, malunion or nonunion of tarsal or metatarsal bone, bilateral weak foot, or scars. He did not use assistive devices, and his foot disability did not impact his ability to work. Disabilities of the foot are rated under diagnostic codes 5276 to 5284. The Board has considered all of those codes to determine whether there is an applicable code which would provide the Veteran with a compensable rating based on his symptoms, but finds that there is not. The Veteran does not have acquired flatfoot due to his great toe disability, thus DC 5276 is not applicable. Moreover, mild symptoms would still be rated as noncompensable. The Veteran does not have bilateral weak foot; thus DC 5277 is not applicable. The Veteran does not have claw foot; thus, DC 5278 is not applicable. Moreover, slight symptoms would still be rated as noncompensable. The Veteran does not have Morton's disease; thus, DC 5279 is not applicable. The Veteran does not have hallux valgus or hallux rigidus, or anything approximating to severe hallux valgus equivalent to amputation of the great toe or operated with resection of the metatarsal head; thus, DCs 5280 and 5281 are not applicable. The Veteran does not have hammer toe. Moreover, a single hammer toe would still be rated as noncompensable. The Veteran does not have moderate malunion or nonunion of the tarsal or metatarsal bones; thus, a compensable rating under DC 5283 is not warranted. A compensable evaluation under DC 5284 is not warranted because the Veteran does not have moderate foot injuries. The Board notes that terms such as "severe" and "moderately severe" and "moderate" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C.A. § 7104; 38 C.F.R. §§ 4.2, 4.6. In the present, the Board finds that the Veteran's disability does not manifest to a level which is greater than slight. In sum, his great toe disability has been manifested by reports of intermittent pain and swelling which did not interfere with activities of daily living or work (See February 2005, May 2010, and May 2013 VA examination reports). He had normal range of motion upon testing in February 2005 and May 2010. He has a normal gait and normal neurosensory (May 2010), and a totally normal findings on examination in October 2011. A compensable rating under DC 5003 (arthritis) is not warranted because two or more major joints or two or more minor joint groups are not involved. In addition, a 10 percent rating is not applicable because the great toe is not rated based on limitation of motion. In addition, DC 5171 is not applicable because the Veteran's great toe disability has not been shown to be as severe as, or analogous to, amputation of the great toe, which would warrant a 10 percent evaluation. In sum, his great toe disability does not warrant a compensable evaluation. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Initial disability rating in excess of 10 percent for right shoulder sprain The Veteran's right shoulder sprain disability is evaluated as 10 percent disabling prior to May 7, 2013 and as 20 percent disabling from May 7, 2013. The Veteran is right hand dominant. (See May 2010 VA examination report.) Under DC 5203, a 10 percent rating is warranted for malunion of the clavicle or scapula, or for nonunion of the clavicle or scapula without loose movement. The Veteran would be entitled to an assignment of a maximum 20 percent rating, if he had dislocation of the clavicle or scapula, or nonunion of the clavicle or scapula with loose movement. Under this diagnostic code, impairment of the clavicle or scapula may also be rated on impairment of function of the contiguous joint. Normal ranges of upper extremity motion are defined by VA regulation as follows: forward elevation (flexion) from zero to 180 degrees; abduction from zero to 180 degrees; and internal and external rotation to 90 degrees. Lifting the arm to shoulder level is lifting it to 90 degrees. See 38 C.F.R. §4.71, Plate I (2012). A February 2005 VA examination report reflects that the Veteran reported that his shoulder does well until he puts too much pressure on it, like doing pushups. He does not have pain on an everyday basis and it does not radiate anywhere. He uses no assistance devices. It does not interfere with his occupation or with his daily activities. There is no additional limitation with repetitive use or flare-ups. The right shoulder was tender on palpation at the right AC joint with no deformities present. He had 0 to 170 degrees of forward flexion with pains in the right AC joint at 170 degrees, minus 10 degrees secondary to pain. He had shoulder abduction from 0 to 175 degrees with pains at 175, minus 5 degrees secondary to pain. Shoulder external rotation was to 90 degrees with pain. He had internal rotation to 85 degrees, minus 5 degrees secondary to pain. Active range of motion did not produce any weakness, fatigue, or incoordination. A May 2010 VA examination report reflects that the Veteran reported that he gets an occasional pinching sensation in his shoulder, which will cause some discomfort for days. He reported that he works out in a gym. He also reported that when he throws a ball, he does not throw it overhead. He reported no limitations of activities of daily living. He did not use a brace or other aid. He described no flare-ups or incapacitating events. Upon clinical examination, there was tenderness to palpation of the bicipital groove and a mildly positive impingement sign. The shoulder was stable. Motor function was 5/5 in all muscle groups. He was neurovascularly sensory intact. Forward extension was to 170 degrees, abduction was to 175 degrees, internal and external rotation was to 90 degrees. There was no pain, fatigue, weakness, or incoordination with repetitive motion in any plane. X-rays of the shoulder showed that the bones were well aligned. The was no fracture present. Soft tissues were unremarkable. There was no radiographic abnormality. The examiner noted that the Veteran had "mild intermittent impingement syndrome in the right shoulder." An October 2011 VA examination report reflects that the Veteran had a normal examination without any indication of abnormality or disability. A May 2013 VA examination report reflects that the Veteran had right shoulder flexion to 180 degrees with no objective evidence of painful motion. He had right shoulder abduction to 180 degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with no additional limitation in motion. He had no functional loss and/or functional impairment of the shoulder and arm. He had localized tenderness or pain on palpation of the joints/soft tissues. He had normal muscle strength (5/5) on forward all areas tested. He did not have ankylosis. Upon Hawkin's Impingement testing, he had pain on internal rotation which, according to the examiner, "may signify" rotator cuff tendonopathy or tear." The cross-body adduction test was positive on the right. The examiner noted that the Veteran had dislocation of the acrominoclavicular joint on the right. He had degenerative or traumatic arthritis documented. There was no guarding of the shoulder. The Veteran's right shoulder disability is rated under DC 5203, which provides for a 10 percent rating for nonunion without loose movement, 20 percent rating for nonunion with loose movement, and 20 percent rating for dislocation of the clavicle or scapula. The earliest evidence of dislocation is in May 2013, thus, a rating in excess of 10 percent is not warranted prior to May 2013. There is no evidence of nonunion with loose movement prior to May 2013. DC 5200 is not applicable as the evidence of record is against a finding of ankylosis. DC 5201 provides that limitation of motion of the major arm at shoulder level warrants a 20 percent disability rating. Limitation of motion of the major arm midway between the side and shoulder level warrants a 30 percent disability rating. Limitation of motion of the major arm to 25 degrees from the side warrants a maximum 40 percent rating. As the Veteran has consistently had motion of at least 170 degrees, an increased rating under DC 5201 is not warranted. DC 5202 is not applicable as there is no evidence of loss of head of the humerus, nonunion of humerus, fibrous union of humerus, recurrent dislocation of scapulohumeral joint with frequent episodes of guarding of all arm movements, or malunion of humerus with marked deformity. In sum, the most probative and objective evidence of record is against a finding that the Veteran's service-connected disability warrants a rating in excess of 10 percent prior to May 7, 2013, and in excess of 20 percent from May 7, 2013. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extra-schedular The discussion above reflects that the rating criteria reasonably describe and contemplate the severity and symptomatology of the Veteran's service-connected shoulder disability. The criteria consider that there are varying levels of disability, that there may be limitation of motion, and that there may be loose bodies or dislocation. The Board has considered the Veteran's statements; however, the objective clinical evidence does not reflect that the Veteran has any symptoms, due to his service-connected disability, which have not been considered in the rating criteria. With regard to the toe, the Board finds that the rating criteria, which allows for disabilities of the foot and/or tarsal and metatarsal bones, to be rated as moderate, moderately severe, or severe, considers varying levels of disability sufficient to rate the Veteran if his toe caused moderate or greater impairment. Regardless, even if the Veteran had symptoms not contemplated in the rating criteria, the evidence does not reflect that the Veteran's service-connected disabilities has caused frequent hospitalization or marked interference with work. Therefore, referral for consideration of an extra-schedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). Total rating for compensation purposes based on individual unemployability (TDIU) TDIU is an element of all appeals of an initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to TDIU is raised where a Veteran : (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). However, TDIU is not raised in an increased rating claim unless the Roberson requirements are met. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). The evidence reflects that in February 2005, the Veteran reported that his disabilities did not interfere with his occupation. The May 2010 VA examination report reflects that the Veteran was a full time student. The May 2013 VA examination report reflects that the Veteran's right shoulder disability and right great toe disability did not impact his ability to work. The Board finds there is no evidence of unemployability. Hence further consideration of TDIU is not warranted. ORDER Entitlement to service connection for a right wrist sprain disability is denied. Entitlement to service connection for bilateral ankle disability is denied. Entitlement to service connection for bilateral knee sprain disability is denied. Entitlement to an initial compensable disability rating for service-connected right great toe sprain disability is denied. Entitlement to an initial disability rating in excess of 10 percent prior to May 7, 2013, and in excess of 20 percent from May 7, 2013, for service-connected right shoulder sprain disability, is denied. ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs