Citation Nr: 1337650 Decision Date: 11/18/13 Archive Date: 11/26/13 DOCKET NO. 11-12 811 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to a disability rating greater than10 percent for residuals, fracture navicular with arthritis, left wrist. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran served on active duty from September 1966 to September 1970. This case is before the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas which, in part, denied service connection for bilateral hearing loss; and, continued a 10 percent rating for the Veteran's service-connected left wrist disability. This case was previously before the Board in April 2013 at which time it was remanded for additional development. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Bilateral hearing loss did not manifest within one year of the Veteran's discharge from service and it is not shown to be causally or etiologically related to any disease, injury, or incident during service. 2. The Veteran is left-hand dominant; therefore, his left wrist is part of his major upper extremity. 3. The Veteran's current residuals, fracture navicular with arthritis, left wrist is manifested by moderate limitation of motion and complaints of pain. CONCLUSIONS OF LAW 1. Bilateral hearing loss was not incurred in or aggravated by the Veteran's active duty military service and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2013). 2. The criteria for a disability rating greater than 10 percent for residuals, fracture navicular with arthritis, left wrist are not met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.69, 4.71a, Diagnostic Codes (DCs) 5010-5215 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. Regarding claims for an increased rating such as the left wrist disability in the instant case, the VCAA requirement with such claims is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. In May 2010 (left wrist) and June 2010 (bilateral hearing loss) letters, sent prior to the August 2010 rating decision on appeal, the AOJ notified the Veteran of the evidence and information necessary to substantiate his service connection and increased rating claims as well as his and VA's respective responsibilities in obtaining such evidence and information. The May 2010 and June 2010 letters also advised the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman. Relevant to the duty to assist, all of the Veteran's service treatment records, VA treatment records, and private treatment records have been obtained and considered. The Veteran has not identified any additional outstanding records that have not been requested or obtained. The Veteran was afforded VA examinations in June 2010, July 2010, and June 2013 with respect to the issues decided herein. The Board finds that the most recent VA examinations and accompanying opinions are adequate to decide the issues as they are predicated on an interview with the Veteran; a review of the record, to include his service treatment records; and examination. The opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issues decided herein has been met. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); 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 appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis 1. Bilateral Hearing Loss Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including organic diseases of the nervous system, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In an October 4, 1995, opinion, VA's Under Secretary for Health determined that it was appropriate to consider high frequency sensorineural hearing loss an organic disease of the nervous system and therefore a presumptive disability. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). The use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran contends that he currently has bilateral hearing loss as a result of his in-service exposure to excessive noise while serving in Vietnam as a security policeman. Specifically, the Veteran explained in his May 2010 claim that he was exposed to noises of rockets, mortar, and small arms fire. He indicated that he was not provided with hearing protection in the military. In his September 2010 notice of disagreement the Veteran reported that he was exposed to excessive noise while working on the flight line at Ton Son Nhut Air Base. He also indicated that he served during the Tet Offensive where he was exposed to noises of incoming 122mm rockets. In his May 2011 substantive appeal he indicated that his duties during service included patrols, repeated weapons qualifications, and guard duty. He also indicated that he was exposed to small arms fire, M60 machine guns, M50 machine guns, and grenade launchers. Therefore, he alleges that service connection for bilateral hearing loss is warranted. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). 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 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Court has held that service connection can be granted for a hearing loss where the Veteran can establish a nexus between his current hearing loss and a disability or injury he suffered while he was in military service. Godfrey v. Derwinski, 2 Vet. App. 352, 356 (1992). The Court has also held that VA regulations do not preclude service connection for a hearing loss which first met VA's definition of disability after service. Hensley, supra, at 159. The Veteran's service treatment records do show some complaints of hearing loss associated with complaints of nasal stuffiness. Significantly, an audiological examination report conducted during his enlistment in May 1966 reveals the following: Puretone Threshold 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 5 0 0 10 Left Ear 5 -5 5 0 Service department audiometric readings prior to October 31, 1967, must be converted from American Standards Association (ASA) units to International Standard Organization (ISO) units. Based on such conversion, the Veteran's audiological examination at the time of his service entrance in May 1966 reveals the following: Puretone Threshold 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 20 10 10 15 Left Ear 20 5 15 10 The Veteran's May 1966 Report of Medical History is illegible with regard to any complaints of hearing loss. An audiological examination report at separation dated in July 1970 revealed the following: Puretone Threshold 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 5 5 5 15 10 Left Ear 10 5 10 20 20 Significantly, the July 1970 separation examination included an impression of "hearing loss, very mild, see ENT consult and narrative summary." While an "ENT consult and narrative summary" is not included in the Veteran's available service treatment records a subsequent August 1970 service treatment record shows complaints of "alleged hearing loss." In this report it was noted that the Veteran had a long history of nasal stuffiness, mostly late July and August, associated with excess lachrymation, rhinorrhea, and sneezing/pruritus. The Veteran also reported a history of 4+ noise exposure (light infantry security police) in Vietnam for 18 months as well as tinnitus after noise exposure. There was no vertigo, otorrhea, or otalgia. Examination of the ears was negative except for some sclerosis of the left ear. The impression was hypertrophic rhinitis. The Veteran filed a claim for service connection for bilateral hearing loss and tinnitus in May 2010. In connection with this claim the RO obtained VA treatment records showing complaints of hearing loss and tinnitus as early as March 2006. The Veteran was afforded a VA audiological examination in July 2010. Audiological testing revealed the following: Puretone Threshold 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 15 15 35 40 55 Left Ear 15 20 35 40 60 Puretone Threshold Average Right Ear 36.25 Left Ear 38.75 Speech discrimination Right Ear 88% Left Ear 92% Notably, this report shows bilateral hearing loss pursuant to 38 C.F.R. § 3.385. Therefore, as the Veteran has a current diagnosis of bilateral hearing loss, the remaining inquiry is whether it is related to his in-service noise exposure. The July 2010 VA examiner noted the Veteran's military and post-military noise exposure. Specifically, it was noted that the Veteran worked as a military policeman during active duty and was exposed to rocket attacks and weaponry. Post-service the Veteran reported that he worked at a grain elevator, oil refinery, car manufacturing company, warehouse, automotive sales company, and as an unarmed security officer. He denied recreational noise exposure. The Veteran also reported a history of tinnitus that first began during his military service. Based on a review of the claims file the examiner opined that the Veteran's bilateral hearing loss was less likely as not (less than 50/50 probability) caused by or a result of acoustic trauma during military service. This was based on the entrance and separation examinations which were normal, bilaterally. The examiner wrote that although the Veteran was exposed to acoustic trauma during military service, the hearing thresholds bilaterally did not meet the criteria for service connection for hearing loss upon separation. The examiner provided a positive nexus opinion with regard to the Veteran's claimed tinnitus, noting that the Veteran's service treatment records show a complaint of tinnitus in August 1970. As above, in April 2013, the Board remanded this issue for additional development. At that time the Board found that the July 2010 VA audiological opinion did not address whether any hearing loss was incurred in service, regardless of whether it was shown in service or on service separation. See Hensley, 5 Vet. App. at 159-60 (holding that if hearing loss as defined by 38 C.F.R. § 3.385 is not shown in service or at separation from service, service connection may still be established if medical evidence shows that it is actually due to incidents during service). Indeed, while in-service hearing loss as per VA standards was not shown, there appeared to have been a threshold shift shown on service separation examination. Furthermore, mild hearing loss was documented on separation examination. Moreover, the Veteran's exposure to acoustic noise trauma had been conceded. As such, a new examination was requested to ascertain the etiological relationship of the Veteran's bilateral hearing loss. Pursuant to the April 2013 Board remand, the Veteran was afforded an additional VA audiological examination in June 2013. Audiological testing revealed the following: Puretone Threshold 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 20 20 35 40 60 Left Ear 10 5 35 60 60 Puretone Threshold Average Right Ear 39 Left Ear 40 Speech discrimination Right Ear 94% Left Ear 96% Notably, this report also shows bilateral hearing loss pursuant to 38 C.F.R. § 3.385. Based on a review of the claims file the June 2013 examiner opined that the Veteran's bilateral hearing loss was less likely as not (less than 50/50 probability) caused by or a result of an event in military service. The examiner noted the audiological findings in the Veteran's service treatment records as well as the Veteran's MOS of security and law enforcement and reported exposure to aircraft noise, rockets, and weaponry during military service. The examiner referenced the Handbook of Standard Procedures and Best Practices for Audiology: Compensation and Pension Examinations, indicating that impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater. Threshold examination upon separation did not meet the VA criteria for service connection, even after the Veteran was exposed to acoustic trauma. The examiner wrote that she was not refuting the Veteran's claimed exposure to noise, rather she was stating that the exposure did not result in hearing loss that met the criteria for service connection. Furthermore, the June 2013 VA examiner wrote that a standard threshold shift did NOT occur for either ear when comparing entrance and separation evaluations. Institute of Medicine (2005) concluded that based on current knowledge of cochlear physiology, there was insufficient scientific evidence for delayed-onset hearing loss secondary to military noise exposure. Hearing loss should occur at the time of the exposure. There is not sufficient evidence from longitudinal studies to determine whether permanent noise induced hearing loss can develop long after cessation of noise exposure. The available anatomical and physiologic evidence suggests that delayed post exposure noise induced hearing loss is not likely. If hearing is normal on discharge AND there is no permanent significant threshold shift greater than normal progression and test re-test variability during military service, then there is no basis on which to conclude that a current hearing loss is causally related to military service, including noise exposure. There was no nexus between any current hearing loss and military service, regardless of the cause of the hearing loss. The examiner noted the Veteran's post-service occupational noise exposure, including grain elevator, oil refinery, GM (General Motors), and security work. The examiner also noted that the Veteran denied a history of ear infections, ear surgery, vertigo, ototoxic medications, or a family history of hearing loss. The Board has first considered whether service connection is warranted for bilateral sensorineural hearing loss on a presumptive basis. However, the record fails to show that the Veteran manifested such to a degree of 10 percent within the one year following his active duty service discharge in September 1970. As such, presumptive service connection is not warranted for bilateral sensorineural hearing loss. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Additionally, the probative evidence of record fails to show a link between the Veteran's in-service noise exposure and his current bilateral hearing loss. As above, the audiological findings on the Veteran's May 1966 enlistment examination report and July 1970 separation examination report do not show bilateral hearing loss pursuant to 38 C.F.R. § 3.385. Also, while the Veteran's July 1970 separation examination shows "hearing loss, very mild" and an August 1970 service treatment record shows complaints of decreased hearing, both the July 2010 and the April 2013 VA examiners reviewed the claims file, interviewed the Veteran, and performed audiological examinations. They specifically noted the Veteran's normal audiological evaluations during enlistment and separation, his history of noise exposure both during and after service, and opined that it was less likely than not that hearing loss is related to military service. The Board accords great probative weight to the April 2013 VA examiner's opinion as such is predicated on an interview with the Veteran; a detailed review of his records, including his service enlistment and separation examinations; and an audiometric examination. Moreover, the April 2013 VA examiner's opinion contained clear conclusions with supporting data as well as a reasoned medical explanation connecting the two. See Nieves- Rodriguez, 22 Vet. App. 295, 304 (2008); Stefl, 21 Vet. App. at 124 ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). There is no contrary medical opinion of record. Furthermore, the Board notes that there is no evidence of audiometric test results reflecting an upward shift in tested thresholds in service, as was the case in Hensley, 5 Vet. App. at 159, with regard to the majority of the Hz findings. Rather, in comparing seven of the eight audiological findings at the various Hz upon enlistment and separation shows that the Veteran's hearing actually improved over the course of his four years of active military service. The only Hz that showed an upward shift is the left ear at 4000 Hz. The Board notes that the Veteran has contended on his own behalf that his bilateral hearing loss is related to his military service. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno, 6 Vet. App. at 469-70. Lay evidence may also be competent to establish medical etiology or nexus. Davidson, 581 F.3d at 1316. However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to." Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's bilateral hearing loss and any instance of his military service, to include his exposure to noise, to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, while the Veteran is competent to describe his in-service noise exposure and his current problems regarding difficulty hearing, he cannot, as a layperson, provide competent medical evidence establishing a connection between his current hearing loss and his in-service noise exposure. In this regard, assessing the impact noise has on an individual's ability to hear involves consideration of the way humans process noise and the type, frequency, and volume of noise exposure. There is no indication that the Veteran possesses an expertise in such area. Moreover, he has offered only conclusory statements regarding the relationship between his in-service exposure to noise and his current bilateral hearing loss. Therefore, as the April 2013 VA examiner possesses the expertise necessary to identify the relevant factors to consider in assessing causality and provided an opinion in consideration of all of the relevant evidence, the Board accords great probative weight to this opinion. As such, it is not outweighed by the lay opinion asserted by the Veteran. Based on the foregoing, the Board finds that service connection is not warranted for bilateral hearing loss. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. 2. Residuals, fracture navicular with arthritis, left wrist Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that 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. 38 C.F.R. § 4.3. Service treatment records show that the Veteran fractured his left wrist in December 1968. Upon separation from military service the Veteran submitted a claim for service connection for residuals of a left wrist fracture and, by rating decision dated in May 1971, the RO granted service connection for residuals, fracture navicular with arthritis, left wrist, assigning a 10 percent disability rating effective October 1, 1970, the day after the Veteran's discharge from military service. The Veteran submitted the current claim for an increased rating for his left wrist disorder in April 2010. The Veteran's residuals, fracture navicular with arthritis, left wrist has been assigned a 10 percent rating under the provisions of 38 C.F.R. § 4.71a, DC 5010-5215 (traumatic arthritis/limitation of motion of the wrist). Pursuant to 38 C.F.R. § 4.27, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Traumatic arthritis is rated under DC 5003, for degenerative arthritis. Under DC 5003, degenerative arthritis established by X-ray findings is evaluated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under DC 5003. A rating of 20 percent is for application when there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. Under DC 5215, a 10 percent rating is warranted when palmar flexion is limited to a position in line with the forearm, or when dorsiflexion is less than 15 degrees. This 10 percent rating is applicable for either the major or minor limb. A 10 percent rating is the only, and therefore the maximum, rating available under this code. As the Veteran is already receiving the maximum evaluation allowable under DC 5215, the Board must also consider DC 5214, which provides for higher evaluations for ankylosis of the wrist. Under this code, a 40 percent rating is warranted when there is unfavorable ankylosis, in any degree of palmar flexion, or with ulnar or radial deviation of the minor wrist. A 30 percent rating is warranted when there is ankylosis of the minor wrist in any other position, except favorable. Finally, a 20 percent rating is warranted when there is favorable ankylosis in 20 degrees to 30 degrees dorsiflexion in the minor wrist. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury or surgical procedure." See Colayong v. West, 12 Vet. App. 524, 528 (1999); Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Normal range of motion is: dorsiflexion (extension) to 70 degrees, palmar flexion to 80 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. 38 C.F.R. § 4.71, Plate I. Furthermore, when an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. For rating purposes, a distinction is made between major (dominant) and minor musculoskeletal groups. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69. Here, as the medical evidence shows that the Veteran is left-hand dominant, for rating purposes, his left wrist is part of his major upper extremity. Evidence relevant to the current level of severity of the Veteran's left wrist disorder includes VA examination reports dated in June 2010 and June 2013. During the June 2010 VA examination the Veteran reported that while he was stationed in Vietnam he fractured his left navicular bone and he had surgery to correct this in 1970. At the time of the examination the Veteran complained of decreased range of motion and pain. The Veteran reported that his left wrist disorder had been getting progressively worse and that he treated it with pain medication. The Veteran reported that he was left hand dominant. With regard to the left wrist there was no deformity, giving way, or incoordination. However, there was instability, pain, stiffness, and weakness. There was also decreased speed of joint motion. There were no episodes of dislocation of subluxation, locking episodes, effusions, or symptoms of inflammation. The condition did not affect the motion of the joint and there were no flare-ups of joint disease. There were no constitutional symptoms or incapacitating episodes of arthritis. Range of motion testing revealed the dorsiflexion from 0 to 45 degrees, palmar flexion from 0 to 70 degrees, radial deviation of 15 degrees, and ulnar deviation from 0 to 45 degrees of the left wrist. There was no objective evidence of pain following repetitive motion and no additional limitations after three repetitions of range of motion. There was no joint ankylosis. X-ray examination revealed mild osteoarthritic changes at the radial carpal joints and at the navicular greater multangular joint. There was no evidence of fracture or dislocation. The impression was mild osteoarthritis. It was noted that the Veteran was employed fulltime as a security guard and had lost one week of work in the past 12 months due to illness. The diagnosis was mild osteoarthritis of the left wrist associated with pain. There were no significant effects on usual occupation. With regard to effects of usual daily activities, it was noted that the Veteran's left wrist disorder had a mild effect with regard to chores, shopping, exercise, sports, and driving. His left wrist disorder had no effect on recreation, traveling, feeding, bathing, dressing, toileting, and/or grooming. During the June 2013 VA examination the examiner continued a diagnosis of status post wrist fracture. The Veteran reported that while he was deployed to Vietnam, he fractured his left wrist. He was casted over a period of months but needed surgery for an open repair in about 1970. Since service he had worked in various jobs (maintenance, assembly line, office, security, etc.). At the time of the examination the Veteran reported experiencing left wrist pain approximately once daily, typically for several minutes. He also complained of reduced range of motion and weakness. It was noted that the Veteran's left hand was his dominant hand. On range of motion testing the Veteran had palmar flexion to 65 degrees and dorsiflexion to 45 degrees. There was no objective evidence of painful motion with regard to either movement. The Veteran was able to perform repetitive-use testing with three repetitions and this testing also showed palmar flexion to 65 degrees and dorsiflexion to 45 degrees of the left wrist. There was no additional limitation in range of motion following repetitive-use testing. The examiner wrote that the Veteran had functional loss and/or functional impairment of the left wrist consisting of less movement than normal. There was no localized tenderness or pain on palpation of joints/soft tissue of the wrist. Muscle strength testing was normal. There was no ankylosis of the wrist. It was noted that the Veteran had undergone total wrist joint replacement in 1970 with residuals consisting of intermediate degrees of residual weakness, pain, and/or limitation of motion. It was also noted that the Veteran had not had arthroscopic or other wrist surgery and did not have any residual signs and/or symptoms due to arthroscopic or other wrist surgery. It was noted that the Veteran had scars related to his left wrist disorder but that the scars were not painful and/or unstable, and were less than 39 square centimeters. With regard to other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the left wrist disorder it was noted that crepitence was clearly audible with left wrist flexion. The examiner noted that there was no functional impairment of the left wrist such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies revealed degenerative or traumatic arthritis of the left wrist. There were no other significant diagnostic test findings and/or results. The examiner wrote that the Veteran's left wrist disorder did impact his ability to work in that he must avoid lifting or using tools with his left hand. While the June 2013 VA joints examiner did not review the claims file at the time of the examination, an August 2013 addendum shows that the claims file was reviewed and did not change anything with regard to the June 2013 report. Given the evidence of record, the Board finds that a disability rating greater than 10 percent is not warranted. As above, the Veteran is already in receipt of the maximum schedular rating under DC 5215 for a wrist disability. While DC 5214 affords a 20 percent rating when there is favorable ankylosis in 20 degrees to 30 degrees dorsiflexion in the minor wrist, the Board observes that there have been no clinical findings at any time of left wrist ankylosis for which a higher rating might be warranted. As above, during the June 2010 VA examination, the Veteran had dorsiflexion from 0 to 45 degrees, palmar flexion from 0 to 70 degrees, radial deviation of 15 degrees, and ulnar deviation from 0 to 45 degrees. During the June 2013 VA examination, the Veteran had dorsiflexion from 0 to 45 degrees and palmar flexion from 0 to 65 degrees. Also, since the Veteran already receives the maximum rating possible under DC 5215, the analysis required by DeLuca would not result in a higher schedular rating. Moreover, both the June 2010 and June 2013 examiners indicated that there was no additional limitation of motion, after at least three repetitions. Notably, in his September 2010 notice of disagreement, the Veteran argued that a 20 percent disability rating for his left wrist disability was warranted under DC 5003. As above, under DC 5003 a rating of 20 percent is for application when there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. In an October 2013 Informal Hearing Presentation the Veteran's representative wrote that the Veteran had arthritis in two joints, the radial carpal joint and at the navicular greater multangular joint. However, the Board notes that the Veteran is currently in receipt of a compensable rating for limitation of motion of the left wrist. Thus, a separate or increased rating is not warranted under DC 5003 at any time during the claims period for the left wrist disability based on noncompensable limited motion. Furthermore, under 38 C.F.R. § 4.45(f), for the purpose of rating disability from arthritis, the only major joints are the shoulder, elbow, wrist, hip, knee and ankle. Additionally groups of multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities; the interphalangeal, metatarsal and tarsal joints of the lower extremities; the cervical vertebrae; the dorsal vertebrae; and the lumbar vertebrae, are considered groups of minor joints, ratable on parity with major joints. 38 C.F.R. § 4.45(f). This implies that the Veteran's left wrist is considered to be one joint. The Board also finds that no higher evaluations can be assigned pursuant to any other potentially applicable diagnostic codes. Because there are specific diagnostic codes to evaluate the wrist, consideration of other diagnostic codes for evaluating the disability is not appropriate. See 38 C.F.R. § 4.20 (permitting evaluation, by analogy, where the rating schedule does not provide a specific diagnostic code to rate the disability); Butts v. Brown, 5 Vet. App. 532 (1993). The Board has also considered his statements that his disability is worse. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of this disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's left wrist disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective evidence of complaints of increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect the credibility of testimony). In conclusion, the Board finds that the preponderance of the evidence is against a disability rating greater than 10 percent for residuals, fractured navicular with arthritis, left wrist. Next, the Board has considered whether referral for extra-schedular consideration is warranted. In exceptional cases where schedular evaluations are found to be inadequate, consideration of an extra-schedular evaluation is made. 38 C.F.R. § 3.321(b)(1). As above, the record shows that the Veteran currently employed as a contractor/manager. There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability and the established criteria found in the rating schedule to determine whether the veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id. at 115-16; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. at 116. Here, the record does not establish that the rating criteria are inadequate for rating the Veteran's left wrist disability. The competent evidence of record shows that his left wrist disorder is primarily manifested by pain, tenderness and limitation of motion. The applicable diagnostic codes used to rate the right wrist provides for ratings based on limitation of motion. Furthermore, the effects of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The effects of the left wrist disability have been fully considered and are contemplated in the rating schedule; hence, referral for an extraschedular rating is unnecessary at this time. As a final point, the Board notes that, although a claim for a total disability rating based on individual unemployability (TDIU) may be raised in the record as a component of a claim for higher rating (see e.g., Rice v. Shinseki, 22 Vet. App. 447 (2009)), here, the evidence reflects the Veteran has been fully employed at all times pertinent to this appeal, and there is no evidence or argument even suggesting that his left wrist disability effectively renders him unemployable. As such, a claim for a TDIU due to a left wrist disorder has not reasonably been raised, and need not be addressed. (CONTINUED ON THE NEXT PAGE) ORDER Service connection for bilateral hearing loss is denied. A disability rating greater than10 percent for residuals, fracture navicular with arthritis, left wrist is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs