Citation Nr: 1338699 Decision Date: 11/25/13 Archive Date: 12/06/13 DOCKET NO. 12-17 615 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for bilateral hearing loss disability. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for fungal infection in the groin. 4. Entitlement to an initial compensable disability rating for a right fourth finger disability. 5. Entitlement to an initial compensable disability rating for a left fifth finger disability. 6. Entitlement to a 10 percent disability rating based on multiple noncompensable service-connected disabilities under 38 C.F.R. § 3.324. 7. Entitlement to service connection for a chronic sinus disability, to include sinusitis and rhinitis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Cheryl E. Handy, Counsel INTRODUCTION 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). The Veteran, who is the appellant, served on active duty from April 1943 to February 1946, including service during World War II. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions in May 2010 and March 2012 of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which respectively denied service connection for all the disabilities on appeal and granted service connection for the left fifth and right fourth finger disabilities and assigned noncompensable (0 percent) disability ratings for each. The issue of entitlement to service connection for a chronic sinus disability is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Bilateral hearing loss disability is not shown to have had its onset in service or the first post-service year, or to be the result of service. 2. Tinnitus is not shown to have had its onset in service or the first post-service year, or to be the result of service. 3. Fungal infection of the groin is not shown to have had its onset in service or to be the result thereof. 4. Throughout the rating period on appeal, the Veteran's right fourth finger disability has been characterized by an unstable proximal interphalangeal joint with frequent hyperextension and posterior dislocation without traumatic arthritis of that joint and otherwise normal functioning of the right hand. 5. Throughout the rating period on appeal, the Veteran's left fifth finger disability has been characterized by ankylosis of the distal interphalangeal joint at 30 degrees without traumatic arthritis at that joint and otherwise normal functioning of the left hand. 6. The Veteran's right fourth finger and left fifth finger disabilities are not of such character as clearly to interfere with normal employability. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2013). 2. The criteria for service connection for tinnitus have not been met. 38 U.S.C.A. §§ 1110, 5103, 5107 (West 2002 & Supp. 2013); §§ 3.102, 3.159, 3.303 (2013). 3. The criteria for service connection for fungal infection of the groin have not been met. 38 U.S.C.A. §§ 1110, 5103, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 4. The criteria for an initial compensable disability rating for right fourth finger disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5230 (2013). 5. The criteria for an initial compensability disability rating for left fifth finger disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5227 (2013). 6. The criteria for a 10 percent disability rating for multiple noncompensable disabilities have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.324, 4.3 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Duty to Notify Proper notice from VA must inform the claimant of any information and medical or lay 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's claims for compensable ratings for his right fourth and left fifth fingers, as well as for a 10 percent disability rating based on multiple noncompensable disabilities, arise from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice with respect to these claims is needed under VCAA. Here, the Veteran was sent letters in March 2010 and June 2010 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran was afforded VA examinations with opinions in April 2010 and December 2011, as well as an addendum opinion in May 2012, with respect to the disabilities on appeal. The Board notes that the VA examination reports contain sufficiently specific clinical findings and informed discussion of the pertinent history and features of the disability on appeal to provide probative medical evidence adequate for rating purposes. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board has reviewed the electronic evidence contained in the Veteran's Virtual VA folder, as well as the paper file. These files together comprise the claims file. The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also 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 the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Principles of Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131. Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All three elements must be established by competent and credible evidence in order that service connection may be granted. In this case, several legal theories operate in conjunction with 38 U.S.C.A. §§ 1110 and 1131 as implemented in 38 C.F.R. § 3.303. For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for organic diseases of the nervous system, which includes hearing loss and tinnitus, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. § 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Evidentiary Standards VA must give due consideration to all pertinent medical and lay evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility 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"). A Veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). The Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed. Cir. 2000) ("Fact-finding in veterans cases is to be done by the Board")). When there is an approximate balance of positive and negative admissible evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Facts and Analysis Hearing Loss and Tinnitus The Veteran's service records indicate that his duties in service were those of a surgical technician. He has stated that he was stationed in Guam and worked in the hospital as a medic. As such, it appears that he was not subject to hazardous noise exposure in service. His service separation examination in February 1946 showed a normal whispered voice test, with no reports of hearing loss or tinnitus noted. The remainder of his service treatment records do not reflect any complaints, treatment, or diagnosis of hearing loss or tinnitus in service. The Veteran has provided statements asserting that he had subjective diminished hearing and tinnitus in service and that when he complained of these symptoms he was told they would resolve with time. A written statement in March 2010 stated that his hearing difficulties started in service and that one of his otolaryngologists had told him his hearing problems were a direct result from his sinus infections backing up into his ears. On audiometric evaluations he has also reported that after service he worked for 27 years in an automotive plant, with hearing protection worn daily only during the last 10 of those years. A private audiometric evaluation in October 2009 showed that the Veteran had mild sloping to profound mixed hearing loss in both ears, right worse than left. Pure tone thresholds, in decibels, ranged from 40 to 75, well within the VA definition of hearing loss disability. The Veteran was afforded a VA audiometric examination in December 2011, with a follow-up opinion in May 2012. The examination showed bilateral hearing loss, right worse than left. The Veteran reported that he was first tested for hearing loss in 1999 and showed some evidence of hearing loss at that time. He also reported constant bilateral tinnitus for 15-20 years. Audiometric testing showed pure tone thresholds of 35 decibels to 80 decibels, with speech recognition scores of 76 percent in the right ear and 66 percent in the left ear. In the May 2012 opinion, the VA examiner stated that the Veteran's duties in service as a medic in a hospital were associated with a low probability of noise exposure, in contrast with his post-service work at the auto plant. It was the examiner's opinion that the Veteran's hearing loss and tinnitus were less likely than not caused by his military noise exposure. The examiner noted that the Veteran has sensorineural hearing loss, as opposed to conductive or mixed hearing loss, which would be expected if the problem were related to chronic sinusitis. In addition, the examiner noted that permanent hearing loss from sinusitis is rare; therefore the examiner determined the Veteran's hearing loss was not caused or aggravated by chronic sinusitis. Hearing loss disability is defined by regulation, based on audiometric testing showing auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz as 40 decibels or greater; or when the auditory thresholds for at least three of those 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. In this instance, it is clear from the audiometric testing that the Veteran has a current hearing loss disability for VA purposes and that he has a current diagnosis of tinnitus. However, the record does not show any indication of diagnosed hearing loss or tinnitus in service, nor does it show any hazardous noise exposure. Rather, the Veteran was assigned as a medic in a hospital on Guam during service and had a normal whispered voice hearing test at service separation in 1946. The first medical evidence of a hearing loss disability appears to have been at the testing in 1999, more than 50 years after service separation. In the interim, in addition to the passage of time, the Veteran was also subjected to 27 years of civilian noise exposure in his work at an auto plant, the first 17 of those without hearing protection. These facts weigh against any finding of service connection for the Veteran's hearing loss and tinnitus. The Board acknowledges that the Veteran is considered competent to offer evidence as to facts and symptoms of which he has first-hand experience, such as diminished hearing acuity and tinnitus. Moreover, given that hearing loss and tinnitus are deemed chronic diseases under 38 C.F.R. § 3.309(a), an award of service connection is potentially available on the basis of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, in this case, no complaints or findings of hearing loss or tinnitus were noted on separation, which weighs against a finding of continuous symptomatology. Moreover, the Veteran reported an onset of tinnitus only 15-20 years prior to his 2011 VA examination, which would not establish continuous symptoms- rather, such would suggest that the claimed tinnitus arose, at the earliest, around 1980, well over four decades after discharge from service. Regarding the hearing loss, he did not expressly indicate to the examiner that his hearing loss dated continuous back to service. Therefore, to the extent that he elsewhere claims continuity of symptomatology, such statements are not found credible. Moreover, the Veteran does not have the requisite medical training or expertise to offer an opinion as to the cause of any hearing loss disability or tinnitus. The only competent medical opinion causation is that of the VA examiner, who stated that it was less likely than not that either condition was due to the Veteran's military service. There is no medical opinion to the contrary. Further, the Veteran's hearing loss is not shown to be caused or aggravated by his chronic sinusitis. The VA examiner stated that the nature of hearing loss shown is inconsistent with such an etiology and that hearing loss due to chronic sinusitis is rarely permanent. Despite the Veteran's statements regarding what he was told by a physician, there is no specific medical evidence to link the hearing loss to sinusitis. As such, the question of secondary service connection for hearing loss may be definitively denied despite the fact that the question of service connection for sinus disability remains open. Based on the evidence of record, the preponderance of the evidence is against the Veteran's claims of service connection for hearing loss disability and tinnitus and the benefit of the doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Fungal Infection The Veteran's service treatment records show that he was treated in service in June 1944 for rhus dermatitis of the penis and face. He was treated with Calamine lotion. On service separation examination in February 1946, the Veteran's skin and genito-urinary areas were described as normal and he had no venereal disease. The Veteran was provided a VA dermatology examination in April 2010, where the examiner noted the treatment of rhus dermatitis in service, as well as a facial furuncle and a sebaceous cyst. The Veteran provided a history of a groin rash for years, with intermittent symptoms of burning and itching that had been treated on multiple occasions with topical steroids and antihistamines. Physical examination was normal, with the exception of two verrucous brown papules in the left inguinal fold, affecting less than 1 percent of the total body surface and of the exposed areas. The examiner diagnosed scrotodynia and stated that it was not related to the Veteran's service and was not related to the rhus dermatitis in service. As noted, the Veteran was treated in service for a condition diagnosed as rhus dermatitis, which is a rash caused by reaction to urushiol in plants such as poison ivy, poison oak, and poison sumac. (See page 502, Dorland's Illustrated Medical Dictionary (31st ed., 2007). The April 2010 VA examination yielded a diagnosis of scrotodynia, or painful scrotum. The examination also noted two verrucous papules, or warts, in the left inguinal fold. The VA examiner stated that the current diagnosis was not related to the diagnosis in service or to the Veteran's service in general. There is no competent medical evidence to the contrary. While the Veteran is considered competent to report on the symptoms he has experienced, there is no evidence that he has the necessary medical training and expertise to offer a diagnosis of a specific dermatologic condition or an opinion as to the cause of such a condition. The Board acknowledges the Veteran's statements to the examiner that he has experienced and been treated for a groin rash for years. However, there is no evidence regarding the source of the rash or the specific diagnosis for the rash. Indeed, there is no medical evidence regarding the rash during the nearly 65 years between the Veteran's separation from service and his claim of service connection. In any event, as the disorder in question is not a chronic disease under 3.309(a), an award of service connection based on continuity of symptomatology is not for application here. Based on the evidence set forth above, the Board finds that the VA examiner's opinion that the Veteran's current diagnosed groin condition is not related to his military service or his diagnosis of rhus dermatitis therein is both probative and persuasive. As the preponderance of the evidence is against the claim, the benefit of the doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Disability Ratings A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Facts and Analysis Finger Disabilities The Veteran's service-connected right fourth finger and left fifth finger disabilities have been evaluated as noncompensable under 38 C.F.R. § 4.71a ever since service connection was established, from May 28, 2010. The Veteran's right fourth finger is rated under Diagnostic Code 5230, for which a noncompensable (0 percent) rating is the maximum permitted for any limitation of motion of the major or minor ring (4th) or little (5th) finger. The Veteran's left fifth finger is rated under Diagnostic Code 5227, for which a maximum noncompensable rating is also assigned for ankylosis of the major or minor ring or little finger. A note to Code 5227 indicates that it should also be considered whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. Under 38 C.F.R. § 4.71a, Diagnostic Code 5223, for two digits of the same hand, favorable ankylosis of the ring and long (or little) fingers warrants a 10 percent rating, and favorable ankylosis of the ring and index fingers warrants a 20 percent rating. Another potentially provision to consider is Diagnostic Code 5010, which provides that arthritis due to trauma substantiated by X-ray findings is rated under Diagnostic Code 5003 as degenerative arthritis. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When there is some limitation of motion of the specific joint that is noncompensable under the appropriate diagnostic codes, a rating of 10 percent for each such major joint affected by limitation of motion is assigned. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 should be considered. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Veteran was afforded a VA examination of both finger disabilities in December 2011. The examiner found ankylosis in the distal interphalangeal joint of the left fifth finger and an unstable proximal interphalangeal joint of the right fourth finger. The Veteran's hands were otherwise normal, with a firm grip and normal function. The right fourth finger was painful when hyperextended and dislocated posteriorly, which happened several times each day. The left fifth finger was ankylosed at 30 degrees of flexion at the distal interphalangeal joint and a one centimeter gap between the crease of the palm and the tip of the finger. There was no loss of motion in the fingers and nor functional impact of the injuries, including with repetitive motion. X-rays showed age-related arthritis throughout both hands, but no specific effects localized to either of the affected joints. The examiner noted that the specific disabilities at issue are soft tissue problems not visible on X-ray. In this instance, the question of assigning the appropriate disability rating for the Veteran's right fourth and left fifth finger disabilities is rather straight-forward. The specific rating codes applicable to the fourth and fifth fingers do not allow for a compensable disability rating for any type of disability, including loss of range of motion or ankylosis. See Diagnostic Codes 5227, 5230, 38 C.F.R. § 4.71a. While a 10 percent disability rating is possible for amputation of the fifth finger and 20 percent for amputation of the fourth finger, or for loss of function equivalent to amputation, such functional loss has not been demonstrated here with respect to either finger. See Diagnostic Codes 5155, 5156, 38 C.F.R. § 4.71a. Also, the Veteran is not shown to have traumatic arthritis in either finger as a result of either disability. The arthritis shown on X-ray is age-related and affects the entirety of both hands. Therefore, a compensable rating under Diagnostic Codes 5003 and 5010 is also not warranted. 38 C.F.R. § 4.71a. Finally, a 10 percent disability rating would be appropriate if both the fourth and fifth finger on the same hand were to be ankylosed. See Diagnostic Code 5223, 38 C.F.R. § 4.71a. However, the Veteran's two disabilities affect two different hands, and this rating criterion is likewise not applicable. In short, the current rating code does not allow for a compensable disability rating for either finger disability unless it results in significant functional limitations. Such limitations were not shown on VA examination and there is no evidence of record to suggest that any such limitations exist. The claims must be denied. Multiple Noncompensable Service-Connected Disabilities Whenever a Veteran is suffering from two or more separate permanent service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree under the rating schedule, the rating agency is authorized to apply a 10 percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324 (2013). As discussed above, the December 2011 VA examination found that the Veteran had no functional limitation in either hand as a result of either disability. The ankylosis of the left fifth finger did not prevent use of the hand, nor did the recurrent hyperextension and dislocation of the right fourth finger, however momentarily painful. The Veteran retained a good firm grip and normal function in both hands. As such, there would be no interference with normal employability and no basis for awarding a 10 percent disability rating under 38 C.F.R. § 3.324. Extraschedular Rating Although the Board is precluded by regulation from assigning extraschedular ratings under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for a service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology related to his finger disabilities, and provide for higher ratings for more severe symptoms. As noted above, the record reflects that the Veteran has no functional impairments as a result of either finger disability, although he does experience discomfort with recurrent dislocations of the right fourth finger. Nevertheless, the Veteran's grip is not affected and he retains full use of both hands. Thus the disability pictures are contemplated by the Rating Schedule and the assigned schedular ratings are adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). ORDER Entitlement to service connection for bilateral hearing loss disability is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for fungal infection in the groin is denied. Entitlement to an initial compensable disability rating for a right fourth finger disability is denied. Entitlement to an initial compensable disability rating for a left fifth finger disability is denied. Entitlement to a 10 percent disability rating for multiple noncompensable disabilities is denied. REMAND The Veteran also seeks service connection for a disorder he has described as chronic sinusitis. While the record shows such a diagnosis, including multiple sinus surgeries, there is also evidence of chronic rhinitis diagnosed during visits for sinus complaints. Multiple medical diagnoses that differ from the claimed condition do not necessarily represent wholly separate claims, and what constitutes a claim cannot be limited by a lay Veteran's assertion of his condition in his application, but must be construed based on the reasonable expectations of the non-expert claimant, and the evidence developed in processing the claim. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In this instance, to afford the Veteran the broadest possible consideration, the Board has recharacterized the issue as one of entitlement to service connection for a sinus disability, to include chronic sinusitis and chronic rhinitis. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. Afford the Veteran an appropriate VA examination to determine whether it is at least as likely as not (probability 50 percent or greater) that his current sinus disability, to include sinusitis and rhinitis, was incurred in his military service, to include the episode of nasopharyngitis in 1943. The examiner is specifically asked to consider and address the Veteran's complaints of chronic symptoms for many years. The examiner is advised that the lack of documented medical treatment in service is not considered dispositive with respect to the presence of symptoms in service. The examiner should address the Veteran's history of sinus surgery and indicate whether any of these surgeries was related to any disability incurred in or otherwise related to his military service. The examiner should provide the rationale for any opinions rendered. A copy of the claims file should be provided to the examiner for review. 2. On completion of the foregoing, the claim should be adjudicated. If the decision remains adverse to the Veteran, then provide him and his representative a supplemental statement of the case and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ Eric S. Leboff Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs