Citation Nr: 1333936 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 09-48 574 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for bilateral hearing loss disability. 2. Entitlement to an initial rating in excess of 50 percent for post-traumatic stress disorder (PTSD). 3. Entitlement to an increased rating for a shell fragment wound (SFW) of the right lumbar area, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from January 1967 to December 1968. These matters come before the Board of Veterans' Appeals (Board) from a December rating decision 2008 (shell fragment wound, hearing loss disability) and a March 2010 rating decision (PTSD) of the Department of Veterans Affairs (VA), Regional Office (RO) in Jackson, Mississippi. In an April 2012 rating decision, the RO evaluated the Veteran's PTSD as 50 percent disabling effective from September 2009. The Veteran's claim for entitlement to service connection for bilateral hearing loss disability was denied by the RO in a December 2008 rating decision. The Veteran was notified of the denial in correspondence dated December 13, 2008. The Veteran filed a notice of disagreement and the RO issued a statement of the case in August 2009. On December 1, 2009, the Veteran submitted a VA Form 9. In December 2010 correspondence, the RO informed the Veteran that he had been notified of the denial for service connection for hearing loss disability on December 13, 2008 and that he did not timely appeal that decision; therefore, it was a final denial. However, the Board finds that the December 1, 2009 VA Form 9 was a timely substantive appeal because it was filed within one year of the December 13, 2008 notification of the RO denial. Thus, the issue is not whether new and material evidence has been received to reopen a previously denied claim, but is rather, an issue of entitlement to service connection. In July 2012, the Veteran testified before a Decision Review Officer in Jackson, Mississippi. A transcript of that hearing is of record. In April 2013, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The issue of entitlement to an initial rating in excess of 50 percent for post-traumatic stress disorder (PTSD) 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. The Veteran had abnormal left hearing acuity upon entrance; however, it was within normal limits upon separation. 2. The earliest post service clinical evidence of record of hearing acuity difficulty is in 2007, approximately 30 years after separation from service. 3. The Veteran's testimony with regard to the onset of his hearing loss disability is outweighed by other more contemporaneous evidence. 4. There has been no demonstration by competent medical evidence, or competent and credible lay evidence, that the Veteran has bilateral hearing loss disability causally related to active service. 5. The probative and competent clinical evidence of record is against a finding that the Veteran has a bilateral hearing loss disability that is causally related to active service. 6. The Veteran's shell fragment wound of the right lumbar area has been manifested by complaints of pain and itching; objectively, it is manifested by no more than moderate symptoms. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss disability have not been met. 38 U.S.C.A. §§ 1110, 1111, 1112, 1154, 1137 (West 2002); 38 C.F.R. § 3.303, 3.304, 3.307, 3.309 (2013). 2. The criteria for a rating in excess of 10 percent for a shell fragment wound of the right lumbar area, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.73, Diagnostic Code 5319, § 4.118, DC 7800 - 7805 (as in effect prior to October 23, 2008) and 7800 - 7002, 7804, 7805 (as in effect from October 23, 2008). 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). Notice was provided to the Veteran in November 2008. VA has a duty to assist the Veteran in the development of the claims. The claim file includes service treatment records (STRs), post service medical records, and the statements of the Veteran in support of his 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. With regard to the SFW, the Board acknowledges the Veteran's statement in 2007 that his non-VA primary care physician thinks that the Veteran's pain is from nerve damage from the gunshot wound. It has now been more four years since the Veteran filed his claim and he was notified of the evidence necessary for his claim; the Veteran has failed to provide any records or correspondence from his physician providing any such opinion. He has also not provided authorization for VA to obtain any such clinical opinion or records. The Board also notes that the Veteran has indicated that he had an MRI at a non-VA facility in 2007 which was normal. Again the Veteran has not submitted this report or authorization for VA to obtain it. Moreover, as the Veteran has reported that the MRI was normal, the Board finds that a remand to obtain it is not necessary as it would not benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). Finally, the Board notes that the Veteran testified at the Board hearing that he believes that he was given a hearing test for his employment in 1980 or 1981; however, he has not provided VA with a copy of this test, or authorization for VA to obtain it. In sum, VA does not have a further duty to assist the Veteran in obtaining records. 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). VA examinations were obtained in July 2006, November 2008, September 2009, January 2011, May 2011, and August 2012. 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 the examination/opinions are adequate as they are predicated on consideration of the Veteran's disabilities, his service, and his post service symptoms and history. Adequate rationale has been provided. In addition, the reports of the examination contain findings necessary to evaluate the Veteran's service-connected disability under the applicable diagnostic code rating criteria. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4). 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). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000 and 4,000 Hertz is 40 decibels or greater; or when the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2013). Rating Disabilities 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 (West 2002); 38 C.F.R. Part 4 (2013). 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. This appeal originates from a rating decision that granted service connection and assigned the initial rating. Accordingly, "staged" ratings may be assigned, if warranted by the evidence. Fenderson v. West, 12 Vet. App. 119 (1999). Under 38 C.F.R. § 4.56 muscle disabilities are evaluated as follows: (a) An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. (b) A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. (c) For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. Under Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows: (1) Slight disability of muscles--(i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles--(i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. (3) Moderately severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound due to high- velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56 (d)(2013). 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. Hearing Loss Disability The Veteran avers that he has a bilateral hearing loss disability as a result of active service, to include combat service in Vietnam. An essential element of a claim for service connection is evidence of a current disability. A January 2011 VA audiology examination report revealed that the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 40 45 60 LEFT 20 25 40 60 70 The Veteran's speech recognition score was 94 percent for the right ear and 94 percent for the left ear. Based on the foregoing, the Veteran has a current bilateral hearing loss disability for VA purposes. 38 C.F.R. § 3.385. A second element of a claim for service connection is medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease. The Veteran's DD 214 reflects one year and seven months of foreign service, and service with the USARV (U.S. Army Republic of Vietnam). It also reflects that he was awarded the Combat Infantryman Badge. The Veteran's military occupational specialty (MOS) was as a light weapon infantryman. The Veteran has testified that he was exposed to acoustic trauma from mortars, grenades, and rifles. The Board finds that acoustic trauma in service is consistent with Veteran's service in combat in Vietnam. Thus, a second element for service connection has been met. A third requirement for service connection is competent credible evidence of a nexus between the current disability and the in-service disease or injury. The Board finds, for the reasons noted below, that the third requirement for service connection has not been met. The Board notes that in the 1960's, the military changed its standard of measuring hearing acuity. The American Standards Association (ASA) units were replaced with the current International Standards Organization (ISO) units. The Veteran's report of medical examination for pre-induction purposes is dated in November 1966. The Board follows the policy that STRs dated October 31, 1967 or earlier, are assumed (if not otherwise noted) to use American Standards Association (ASA) units rather than the current International Standards Organization (ISO) units. To convert the units, the Board adds 15 decibels to 250 Hz., 15 decibels to 500Hz, 10 decibels to 1,000 Hz, 10 decibels to 2000 Hz, 10 decibels to 3,000 Hz., and 5 decibels to 4,000 Hz. The Veteran's November 1966 pre-induction medical report reflects that audiometric testing results, prior to conversion were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -10 -5 -10 -- 0 LEFT -10 [unreadable] -10 -- -5 When converted to the current ISO standard, it reflects that the Veteran's hearing acuity was as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 0 -- 5 LEFT 5 unable to convert 0 -- 0 The Veteran underwent another audiogram in January 1967. It reflects that prior to conversion, his acuity was as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 0 -5 5 LEFT -5 -10 0 5 20 When converted to the current ISO standard, it reflects that the Veteran's hearing acuity was as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 10 10 5 10 LEFT 10 0 10 15 25 The Veteran's December 1968 separation examination report reflects that Veteran's hearing acuity was as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 5 -- 10 LEFT 10 5 5 -- 15 In Hensley v. Brown, 5 Vet.App. 155, 157 (1993) the Court held that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Thus, the reports reflect that the Veteran entered service with normal hearing, with the exception of abnormal left ear hearing at the 4,000 HZ level, and the Veteran separated from service with normal hearing. When a disability is noted prior to service, the presumption of soundness on induction does not attach, and service connection may be considered only on the basis of aggravation of the disability in service. 38 C.F.R. § 3.304 (2013). In the present case, the Veteran had abnormal hearing in the left ear prior to service; however, it was not yet at the level which would constitute a disability under 38 C.F.R. § 3.385. In determining whether the Veteran is entitled to service connection, the Board has considered both theories of entitlement in analyzing the Veteran's claim; that he had a preexisting disability and, alternatively, that he did not have a preexisting disability of the left ear. The Veteran separated from service in December 1968. The next month, in January 1969, he had a VA examination for his back. While the VA examination report reflects that the Veteran was seen for back pain, it also reflects notations with regard to the Veteran's ears. The report reflects "external canals clean. Drums intact. No hearing loss noted." In June 2006, the Veteran filed claims for 13 disabilities; he did not file a claim for entitlement to service connection for hearing loss. In July 2006, the Veteran submitted a statement noting numerous disabilities, but again, he did not file a claim for entitlement to service connection for a hearing loss disability. The Board finds that if the Veteran had hearing loss which he reasonably believed was related to service, it would have been reasonable for him to have noted it when he noted his other disabilities. The earliest post service clinical evidence is from 2007, more than 39 years after separation from service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). A November 2007 VA clinical record reflects that the Veteran reported a history of "gradual hearing loss." Again, the Board finds that if the Veteran had experienced noticeable hearing loss since service or shortly thereafter, it would have been reasonable for him to have stated such, rather than stated it was a gradual onset. The Veteran testified that he had a hearing test in 1980 or 1981 but did not have a copy of the results. (See Board hearing transcript page 5.) If the results indicated a hearing loss, his statement to the November 2007 examiner as to a gradual onset would not make sense as it would have been over 20 years. If the results indicated normal hearing, it would reflect that the Veteran had normal hearing for more than 20 years after separating from service. The Board finds that any statement by the Veteran that he has had hearing problems since separation from service, or a few months after separation is outweighed when considered with the record as a whole. The Board finds that the statements contemporaneous to service are more credible than those made decades later for compensation purposes. Not only does the December 1968 audiology report reflect normal hearing upon separation, but the Veteran, in December 1968, denied any hearing loss. The Veteran's December 1968 report of medical history reflects that he reported that he had, or previously had, mumps, severe tooth or gum trouble, skin diseases, shortness of breath, recent gain or lost weight, and recurrent back pain. Notably, he denied hearing loss or ear trouble. The Board finds that if the Veteran had noticeable hearing loss at that time, he would have reported it when he reported his other disabilities, rather than deny it. See Cartright v. Derwinski, 2 Vet. App.24, 25 (1991) (finding that, while the Board may not ignore a Veteran's testimony simply because he or she is an interested party and stands to gain monetary benefits, personal interest may affect the credibility of the evidence); see also Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the testimony). A September 2009 VA examination report is of record. It reflects that the Veteran reported that his occupational noise exposure included driving a forklift for approximately two to three years. He reported minimal shooting, "possibly 10 times" since he was out of the military, or approximately 10 times in the last 30 years. The Veteran also reported intermittent tinnitus which he first noticed while in service following an incident with an artillery shell. The Board notes, however, that other VA records, to include a January 2011 VA mental health examination report, reflect that the Veteran reported that he worked for a manufacturing company for 13 years after service, where he drove a forklift, and that subsequent to that work, he worked in forestry for the next 25 years, to include supervising loggers. In addition, a January 2007 VA clinical record, reflects that the Veteran, although he had not been hunting in the past two years, belonged to a hunting club. Finally, the Board notes that the Veteran's November 1966 pre-induction report of medical history reflects that he reported that he has occasional buzzing in the ears. In sum, the Board finds that the Veteran has been inconsistent with his history as it relates to his claim. The September 2009 VA examiner noted that the Veteran had normal hearing upon examination in December 1968; thus, in the examiner's opinion, the Veteran's hearing loss was not caused by, nor due to, noise exposure in the military. A January 2011 VA audiology examination report reflects that the Veteran reported no occupational noise exposure. The January 2011 audiology report also reflects that the Veteran had recreational noise exposure from hunting, on a "very seldom basis". The January 2011 VA examiner stated that the Veteran's hearing loss is not due to, or the result of, noise exposure in service as evidenced by his hearing which was "well within normal limits in both ears" upon separation. The Veteran testified at the July 2012 DRO hearing that while in service he was exposed to the sounds of grenade explosions, mortars, bombs, and rifles. He reported that during his nine months of service in Vietnam, he never wore ear protections. He testified that he did not remember having a hearing exam when he got out of service. (See DRO hearing transcript page 5.) Despite the Veteran's recollection, the evidence does reflect that he had a hearing test upon separation. In the present claim, there is no clinical opinion, or credible continuity of symptomatology, which supports a causal relationship between a hearing loss disability and active service. The Veteran is competent to attest to factual matters of which he has first-hand knowledge (e.g., hearing difficulty). To this extent, the Board finds that the Veteran is competent to report that he has current hearing difficulty. The Board notes that there is no clinical evidence that he complained of, or sought treatment for, hearing loss for four decades after separation from service, and in 2007, he reported a gradual decrease in hearing acuity. While 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 Veteran'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.) While the Veteran had exposure to acoustic trauma in service, he also had post service exposure to occupational noise, as well as some recreational noise exposure. The Veteran has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation in the present case (i.e. gradual sensorineural hearing loss first diagnosed decades after separation from service with post-service exposure to acoustic trauma working in a manufacturing plant driving a forklift, and working in forestry, to include supervising loggers, and with advanced age.) Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issues in this case in light of the education and training necessary to make a finding with regard to the complexities of hearing loss decades after service. The Board finds that such etiology findings fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). When audiometric test results at separation from service do not meet the regulatory requirements for establishing a "disability" at that time, a Veteran may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). While the regulations do not necessarily preclude service connection when hearing loss first meets the requirements after service, the regulations also do not hold that service connection is warranted, or mandatory, for hearing loss disability in the absence of a competent credible clinical nexus opinion or credible continuity of symptomatology from service. In the present claim, there is no clinical opinion which supports a causal relationship between the Veteran's current hearing loss disability and active service, and no credible evidence of continuity of symptoms. In sum, the Veteran's hearing was normal upon separation in 1968, the Veteran denied hearing loss upon separation in 1968, no hearing loss was noted in 1969, the earliest clinical evidence of hearing loss is more than three decades after separation from service, and the clinical evidence of record is against a finding that the Veteran's hearing loss is casually related to active service. Thus, service connection is not warranted. In addition, the Veteran's hearing in the left ear upon separation was no longer in the abnormal range, as it had been on entrance. Thus, it does not show aggravation or an increase in severity. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), 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). Increased rating for a right lumbar area SFW, currently rated as 10 percent disabling The Veteran is service-connected for residuals of a through and through shell fragment wound (SFW) of the right lumbar area involving Muscle Group XIX with a scar, evaluated as 10 percent disabling from December 1968. In October 2008, the Veteran submitted a claim for an increased rating; thus, the rating period on appeal may be from October 2007, one year prior to the date of receipt of the increased rating claim, provided that the evidence reflects an increase in disability during that one year period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). 38 C.F.R. § 3.400(o)(2) (2011). However, in accordance with 38 C.F.R. §§ 4.1 and 4.2 (2011) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the history of the disability is for consideration in rating a disability. A November 1968 clinical record reflects that the Veteran was "complaining of back pain by 2 [month] old bullet wound. Pain in the right back when he bends over to pick up something or upon carrying a pack. Sight [right] paravertebral hypertonicity." The Veteran's December 1968 report of medical history reflects that he was shot in the back in August 1968 and has recurrent pain. His December 1968 report of medical examination was normal with the exception of a scar on the right paralumbar area. A January 1969 VA examination, taken less than two months after separation from service, reflects that the Veteran reported a through and through wound of the right lumbar region. The Veteran reported that he was treated with debridement and closure and returned to duty. He was treated with Robaxin for pain. The Veteran reported that he continued to have low back pain and spasm in the area of the wound. There was no leg radiation pain or weakness. Examination showed that the Veteran had a moderate increase in lumbar lordosis "which is a developmental condition." There was no scoliosis or malalignment. The cervical and dorsal spines showed no midline or paravertebral muscle tenderness, spasms, or limitation of motion. He had two scars in the right paravertebral region. The "entry" wound was two inches by one-fourth inches and had signs of a surgical closure. The exit wound was one inch by 3/8th inch. Both scars were well healed and soft and pliable. They were not deeply adherent but there was slight subjective tenderness "deep to the scars". There was "possibly a minimal muscle atrophy on the right." The Veteran had full range of motion in all planes without objective pain reaction or muscle spasm. There was no calf atrophy or weakness. The service-connected disability at issue is currently rated under 38 C.F.R. § 4.73, Diagnostic Code (DC) 5319, for Muscle Group XIX. The noted function of Muscle Group XIX is support and compression of the abdominal wall and lower thorax; flexion and lateral motions of the spine; synergists in strong downward movements of the arm. The provisions of DC 5319 establish that muscle injury involving the lumbar region is evaluated as follows: Severe 50 percent disabling Moderately severe 30 percent disabling Moderate 10 percent disabling Slight non compensable After considering the evidence, noted above and below, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent for his SFW residuals. July 2006 VA clinical records reflect that the Veteran reported numbness down the left side and pain down the lower back down from the right side. A July 2006 VA examination report reflects that the Veteran reported that he was injured in Vietnam, and underwent debridement, cleansing and suturing at that time. He reported that he remained at the base hospital for two days and was then returned back to his unit. He denied any pain or discomfort from the scars until the last year (2005). He reported pain radiating from his back to his toes on the right side and from his lower back to the knee on the left side. The Veteran denied being incapacitated at any time from his injury, and reported that his injury does not impact his employment as a forester or restrict him from doing his chores at home. Upon examination, the Veteran had a full range of motion of his lumbar spine. He had no tenderness over the spine processes. Knee and Achilles reflexes were 2+. Sensory examination was normal. The Veteran could squat and arise without assistance. The examiner could not detect any motor weakness or sensory deficit in the Veteran's lower extremities. There was a 2 1/2 inch scar and a 1 inch scar on the lower lumbar area. The scars were well-healed, hyperpigmented, smooth, flat, and stable. There were no chronic skin changes, and no adherence to underlying tissue. The Veteran denied pain or sensitivity of the scars. They did not present any limitation of motion, and there was no muscle loss or disfigurement. An x-ray of the lumbar spine showed normal alignment and no acute fracture or dislocation. All the vertebral bodies and disc spaces were well preserved. The examiner found no objective evidence of weakness, incoordination, fatigue, or lack of endurance. A September 2007 VA clinical record reflects that the Veteran has polyneuropathy with mild sensory loss in the feet, with diabetes as the most likely cause of the polyneuropathy. A December 2007 VA clinical record reflects that the Veteran reported low back pain which radiates to the right leg and sometimes the left leg gets numbness and weakness. The Veteran reported that he had an MRI of the lumbar spine at a non-VA facility a few months earlier which was normal. The Veteran further reported that his non-VA primary care physician thinks his pain is from nerve damage from the gunshot wound. The Veteran reported that he takes over-the-counter Aleve for his pain but would like something stronger. He had no fecal incontinence. He had urinary hesitancy. Upon examination, he had well healed scars in the lower right flank. The spine was nontender, straight leg test was negative, and deep tendon reflexes were normal. Babinski sign was not present and he was able to toe and heel walk. The impression was peripheral neuropathy. A December 2007 VA clinical record reflects that the Veteran reported low back pain radiates to his right leg and that he sometimes gets left leg numbness and weakness. He reported that he has had low back pain since the injury in Vietnam. The Veteran testified at a September 2008 DRO hearing that he had to take time off from work due to back pain. In an October 2008 statement, the Veteran asserted that he has severe pain in his back due to his gunshot wound. November 2008 VA examination reports are of record. They reflect that the Veteran reported that he can only walk a mile before his legs and his back hurt too much, requiring him to rest for 10 to 15 minutes before being able to continue. The Veteran reported that his did not have pain or discomfort for the scars until the prior year. He denied any treatment for the wound. He denied any problems associated with his scars and denied being incapacitated at any time from his injury. He stated that his injury does not impact his employment or restrict him for doing his chores at home. He is independent in activities of daily living, transfers, and ambulation. He had a full range of motion of his lumbar spine with no pain or tenderness over the spinal processes. His reflexes were 2+, and his sensory examination was normal. He can squat and arise without assistance. His muscle strength was 5+ in the lower extremities. There as a 6 x .025 cm scar and a 2.5 x .025 scar on the lower lumbar area. The scars were well healed, hyperpigmented, smooth, flat and stable. There were no chronic skin changes. There was no adherence to underlying tissue. The texture of the scars was normal with that of the surrounding skin. The Veteran denied any pain or sensitivity of the scars. The scars do not prevent any limitation of motion. There was no muscle loss and no disfigurement. The scars were stable. The Veteran did not offer any complaints of fatigue. There was no objective evidence of weakness, incoordination, fatigue, or lack of endurance. The Veteran was provided with the results of the July 2006 examination and denied any change in his condition from the shrapnel injury since the 2006 examination. A December 2008 VA clinical record reflects that the Veteran reported that his left leg will go numb after standing for a while. He also reported right knee pain for 10 years and denied any new or old known injury. The Board finds that this is less than credible given the July 2008 private record from Dr. R. Haimson which reflects that the Veteran reported that he originally hurt his right knee approximately 5 to 6 years earlier while working in forestry when he stepped in a stump hole and twisted his knee. The Board finds that the Veteran is not credible, or competent to make a finding, that his SFW causes him leg numbness or knee pain. In a November 2009 VA Form 9, the Veteran stated that he has steadily continued to be in more pain in the injured part of his back and side. He reported that this pain is more severe than he "can stand." He further stated that "any effort to do anything results in me being unable to do anything for a day or two afterwards." A May 16, 2011 VA examination report reflects that the Veteran reported low back pain, but in the examiner's opinion, the Veteran's current lower back pain appears to be more related to lumbosacral pain than the penetrating injury to the right lumbar area. The Veteran reported no incapacitating episodes of back pain in the past 12 months. The Veteran gave conflicting reports as to whether he had pain in the left side. The examiner noted that in response to his questions, "[a]ll of [the Veteran's] answers are somewhat vague. Direct answers are not provided." The examiner also stated, in pertinent part, as follows: [b]ased on his answers, it appears that he has only pain in the back related to the bullet wound, although there are clear occurrences of pain which are not related to the bullet wound. Differentiating these is somewhat difficult as the patient has purposely blurred the distinction in his mind. As best can be determined, he does have stiffness, fatigue, weakness, and decreased motion of the lower back. There are no back spasms that he is aware of. The only numbness or paresthesias occur on the left leg and radiate from the lower back to the bottom of the foot. These are unrelated to the bullet wound. He states that he has a weakness in the leg and that the left leg is weaker than the right leg. There are bladder complaints of which urgency is the only complaint. There are no bowel complaints. He is able to walk without assistance for short distances. He uses a cane at other times. The examiner also noted that with regard to the scar as follows: [the Veteran] states that he had had pain and discomfort from the scar since the bullet wound. This is indirect contradiction with the information which is recorded in April 2010. At that time, had no problem with pain or discomfort from the scars until 2007 when he developed a burning sensation and numbness of both lower extremities and feet. This was attributed to the diabetes, but he stated that the problem may be associated with the gunshot injury. He denies having any treatment for the residual of the gunshot injury. He uses the cane in ambulation because of the peripheral neuropathy from his diabetes, although he states that it is also related to the gunshot injury. Upon examination, the spine appeared normal. The entry wound of the bullet was 7 cm. x 75 cm. The exit wound was 3 cm. x 1.2 cm. The scars were superficial, well healed, hyperpigmented, smooth, flat and stable. There was no adherence to underlying tissue, the texture of the scars was normal and similar to the surrounding skin. There was a very slight sensation of discomfort which the veteran stated is present overlying the scars, but this was inconsistent with the findings. The scars did not show any loss of limitation of motion. There was no muscle loss or disfigurement. The Veteran had forward flexion to 75 degrees and extension to 20 degrees. There was no additional limitation of motion after repetitive motion, and no objective evidence of pain. Although the Veteran stated that it is tender, there was no clear physical finding to support tenderness. There was no objective evidence for painful motion, spasm, weakness, atrophy, or guarding. There were no postural abnormalities, fixed deformity, ankylosis, or abnormality of the muscles of the back. The examiner stated in pertinent part as follows: the current degenerative changes of the lumbar spine are not caused by the service-connected residual through and through shell fragment wound of the right lumbar area. The shell wound was through the muscle only and did not involve the spinal cord or canal. Further the location of the gunshot wound and the direction of the bullet are away from the spine. Further, the development of the back pain more than 20 years following the gunshot wound suggests very strongly that there is no relationship whatsoever between the gunshot wound and the degenerative change of the lumbar spine. Further, the severity of the lumbar spine degenerative change is relatively minor. The neurological symptoms are entirely contralateral to the gunshot wound. There is no possibility that this gunshot wound caused the patient to have degenerative changes of the lumbar spine. The lumbar spine degenerative changes are not caused by or a result of the service-connected gunshot wound to the right lower back. An August 2012 VA examination report is of record. The Veteran reported that occasionally he may experience itching at the site of the wound, but no actual pain in the area of the scar. He denied numbness. There was no muscle weakness in the extremities. The Veteran reported pain in the area of the bullet entry and that it often feels stiff. He reported that if he bends in a certain fashion, he has pain in the low back area. He denied being incapacitated. The examiner found that the Veteran did not have a history of rupture of the diaphragm with herniation, and did not have a history of extensive muscle hernia of any muscle. The entry and exit scars were small or linear, indicating short track of missile through muscle tissue. The Veteran had no known fascial deferences or evidence of such. His muscle injury did not affect muscle substance or function. The Veteran reported fatigue pain which was constant on the right. He did not have loss of power, weakness, lowered threshold of fatigue, impairment of coordination, or uncertainty of movement. He had 5/5 or normal strength on muscle strength testing in all upper and lower extremity groups. He did not have muscle atrophy. It was noted that the Veteran used a cane regularly for locomotion. The Veteran reported that he used a cane due to peripheral neuropathy and a previous left knee surgery. The Veteran had the following ranges of motion of the lumbar spine: forward flexion -- to 75 degrees extension -- to 20 degrees left lateral flexion - to 25 degrees right lateral flexion - to 25 degrees There was no limitation of motion after three repetitions, muscle strength was normal, there was no sensory loss, muscle tone was normal. Strength was normal. There was no objective evidence of painful motion, weakness, atrophy or guarding. His muscle injury did not impact his ability to work. The Veteran would be entitled to a higher rating if his disability were moderately severe (30 percent rating) or severe (50 percent rating). The evidence, as noted above, is against such a finding. A moderately severe disability of the muscles would be evidenced by indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side, or evidence of impairment when comparing tests of strength and endurance compared of the injured side against the sound side. The most probative clinical evidence is against a finding that the Veteran's back pain and leg symptoms are related to his SFW. His gunshot wound residuals are not more than moderate in degree. The Board finds that the Veteran's statement that his physician thinks his back pain is from nerve damage from the gunshot wound is insufficient evidence upon which to grant a higher rating. The clinical evidence of record is against a finding that the Veteran has back pain with radiating leg pain due to his SFW; such evidence is more probative than the Veteran's statement as to what he believes he was told. As the Court has noted "the connection between what a physician said and the layman's account of what he purportedly said, filtered as it was through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute 'medical' evidence." Robinette v. Brown, 8 Vet. App. 69, 77 (1995). (1995). The Board has also considered whether the Veteran is entitled to a separate rating for his SFW scars, but finds that he is not. While the Veteran's claim was pending, new rating criteria for evaluating skin disabilities became effective on October 23, 2008; these regulations apply only to claims filed on or after October 23, 2008, or when requested by the Veteran. However, the Board has an obligation to consider all potentially applicable provisions of law and regulation and to apply the diagnostic criteria in a manner that maximizes his benefits. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); Bradley v. Peake, 22 Vet. App. 280 (2008). The revised diagnostic criteria are potentially applicable for purposes of establishing an appropriate rating from October 23, 2008, onward. See Fenderson v. West, 12 Vet. App. 119 (1999). The evidence of record is against a finding that the Veteran is entitled to a separate rating for his scars under either the old or the current rating criteria. The Veteran does not have a deep scar, a scar that causes limitation of motion, a scar exceeding 6 square inches in size, a scar that is unstable, a scar that is painful. Although the Veteran is competent to report pain, the Board find that his contentions as to pain are not credible because they are inconsistent with the objective clinical examination, and are internally inconsistent. The Board finds that the objective clinical findings are more probative than his statements which are made for financial purposes. Moreover, an itching of his scar is not severe enough to warrant a separate compensable rating on a schedular basis, and has not been shown to cause marked interference with employment or frequent periods of hospitalization such as to warrant a rating on an extraschedular basis. The Veteran is competent to attest to factual matters of which he has first-hand knowledge (e.g., pain, numbness, discomfort). However, he has not been shown to have the training, education, and experience necessary to provide a competent opinion as to whether his symptoms are related to his SFW or to degenerative arthritis and/or peripheral neuropathy. The Board finds that such etiology findings fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The clinicians who have provided opinions are competent to provide such opinions. In sum, the objective clinical evidence of record is against a finding that the Veteran's SFW symptomatology is more than moderate in severity. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), 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). Extraschedular Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extra-schedular disability rating would be warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). The Board has reviewed the evidence of record and finds that it does not show such an exceptional disability picture. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule; hence, an extraschedular rating is not warranted. The rating criteria allows for symptoms to be classified as "slight, moderate, moderately severe, and severe". Thus, regardless if the actual related symptom (e.g. pain, itching) is listed in any criteria, it is still considered based on its severity. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). Total rating for compensation purposes based on individual unemployability (TDIU) Entitlement to an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) and a TDIU extra-schedular rating under 38 C.F.R. § 4.16(b), although similar, are based on different factors. See Kellar v. Brown, 6 Vet. App. 157 (1994). An extra-schedular rating under 38 C.F.R. § 3.321(b)(1) is based on the fact that the schedular ratings are inadequate to compensate for the average impairment of earning capacity due to the Veteran's disabilities. In addition, exceptional or unusual circumstances, such as frequent hospitalization or marked interference with employment, are required. In contrast, 38 C.F.R. § 4.16(b) merely requires a determination that a particular Veteran is rendered unable to secure or follow a substantially gainful occupation by reason of his or her service-connected disabilities. See VAOPGCPREC 6-96. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. The Veteran was employed as a forest technician until October 2008. A November 2012 VA Form 21-4142 signed by the Veteran's supervisor reflects that the Veteran was terminated in October 2008 because his position was eliminated. The July 2006 and November 2008 VA examination reports reflect that the Veteran stated that his SFW did not impact his employment. Entitlement to TDIU was denied in December 2011. The Veteran has a combined rating of 100 percent disabling from August 2012. The evidence is against a finding that a claim for TDIU based on the Veteran's service-connected SFW has been raised by the record. ORDER Entitlement to service connection for bilateral hearing loss disability is denied. Entitlement to an increased rating for a shell fragment wound of the right lumbar area, currently rated as 10 percent disabling, is denied. REMAND PTSD The Veteran is service connected for PTSD, evaluated as 50 percent disabling from September 2009. The claims file includes February 2010, August 2011, August 2012 and December 2012 VA examination reports. In a January 2010 statement (VA Form 21-41380, the Veteran stated that he gets treatment through the Jackson Vet Center. The Veteran did not return a completed VA Form 21-4142 for VA to obtain Vet Center records. The Veteran's January 2010 statement indicates that he wished VA to consider his Vet Center records. The Veteran also indicated at the 2013 Board hearing that he was attending Vet Center meetings; thus, the Board finds that VA should attempt to obtain them. Accordingly, the case is REMANDED for the following action: 1. The AOJ should attempt to obtain any pertinent records not already associated with the claims file for any treatment facilities, to include Vet Centers, in which he was treated for a mental health disability. 2. Thereafter, readjudicate the PTSD increased rating claim. If the benefit sought is not granted, issue a supplemental statement of the case and afford the appellant and his representative an appropriate opportunity to respond. Thereafter, the case should be returned to the Board, as warranted. The appellant has the right to submit additional evidence and argument on the matter 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 MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs