Citation Nr: 1418181 Decision Date: 04/23/14 Archive Date: 05/02/14 DOCKET NO. 11-09 204 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection a right elbow disorder. 2. Entitlement to service connection for a left foot disorder. 3. Entitlement to service connection for chronic pain in both calf muscles, including as a result of undiagnosed illness. 4. Entitlement to service connection for tinnitus. 5. Entitlement to service connection for a gastrointestinal disability, including gastroesophageal reflux disease (GERD), hiatal hernia, parasitic infection, or the result of undiagnosed illness. 6. Entitlement to service connection for cardiovascular disease. 7. Entitlement to an increased compensable rating for degenerative joint disease of the right ankle. 8. Entitlement to an increased compensable rating for status post rectal fissures with residual scarring. REPRESENTATION Appellant represented by: Tommy D. Klepper, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from January 1986 to January 1989 and from December 1989 to August 1998. This case comes to the Board of Veterans' Appeals (Board) on appeal of a September 2010 rating decision of the Muskogee, Oklahoma, Regional Office (RO) of the Department of Veterans Affairs (VA). In November 2011 a travel board hearing was held before the undersigned in Muskogee, Oklahoma. A transcript of the hearing is associated with the Veteran's claims file. At the travel board hearing in November 2011, the issues of service connection for headaches and a disability manifested by dizziness were raised. These matters have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The Veteran has also claimed service connection for hearing loss, post traumatic stress disorder (PTSD), degenerative joint disease of the cervical spine, and bruxism with jaw pain; and an increased rating for lumbosacral strain. Service connection for hearing loss was denied by the RO in the September 2010 rating decision; however, this condition was not included in the Veteran's initial notice of disagreement with that rating action. Service connection for PTSD, arthritis of the cervical spine, bruxism with jaw pain, and an increased rating for lumbosacral strain were denied by the RO in a May 2011 rating decision. In response to the Veteran's notices of disagreement to each rating decision, Statements of the Case (SOC) were issued in July 2011 and February 2013. The Veteran was informed of the time limits for perfection of his appeal. He has not perfected these appeals. Absent a decision, a notice of disagreement, a statement of the case and a substantive appeal, the Board does not have jurisdiction of an issue. Rowell v. Principi, 4 Vet. App. 9 (1993); Roy v. Brown, 5 Vet. App. 554 (1993). Hence these issues are not properly before the Board. The issues of service connection for tinnitus, a gastrointestinal disability, and cardiovascular disease are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. A chronic disability of the right elbow has not been demonstrated at any time during the pendency of the appeal. 2. A chronic disability of the left foot has not been demonstrated at any time during the pendency of the appeal. 3. The Veteran served in Southwest Asia from September 1990 to April 1991. 4. A chronic disability manifested by pain in both calf muscles, the result of undiagnosed illness, is not shown to be manifested to a degree of 10 percent at any time. 5. Prior to August 2, 2010, degenerative joint disease of the right ankle was manifested by pain with normal range of motion; from August 2, 2010, degenerative joint disease of the right ankle has been manifested by dorsiflexion from 0 to 40 degrees and dorsiflexion from 0 to 20 degrees, with pain. 6. Throughout the appeal, status post rectal fissures with residuals scar were asymptomatic. CONCLUSIONS OF LAW 1. A chronic right elbow disorder was neither incurred in nor aggravated by service. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.117 (2013). 2. A chronic left foot disorder was neither incurred in nor aggravated by service. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.117 (2013). 3. A chronic disability manifested by pain in both calf muscles was neither incurred in nor aggravated by service. 38 U.S.C.A. §§ 1110, 1117 (West 2002); 38 C.F.R. §§ 3.303, 3.117 (2013). 4. The criteria for a compensable rating for degenerative joint disease of the right ankle have not been met for the period prior to August 2, 2010. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code (Code) 5271 (2013). 5. The criteria for an increased rating of 10 percent for degenerative joint disease of the right ankle have been met as of August 2, 2010. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code (Code) 5271 (2013). 6. The criteria for an increased compensable rating for status post rectal fissures with residuals scar have not been met for any period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.114, Code 7335 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between a veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increase, the VCAA requirement 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). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to the initial adjudication of the claims. April and July 2010 letters explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. These letters also informed the Veteran of disability rating and effective date criteria. The Veteran has had ample opportunity to respond and supplement the record. With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. The Veteran was afforded a VA medical examination, most recently in August 2010. The Board finds that the opinions obtained are adequate for the issues decided herein. The opinions were provided by a qualified medical professional and were predicated on a full reading of all available records. The examiner also provided a detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the representative has challenged the adequacy of the examination obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2013). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of 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. With chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, as identified in 38 C.F.R. § 3.309(a), noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). 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). It is noted that the Veteran is claiming service connection for various disabilities, which he believes are the result of his service in the Persian Gulf during 1990 and 1991. Service connection may be established for a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than not later than December 31, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1). In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Compensation shall not be paid under this section if: (1) there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. §3.317(c). The term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(d)(1). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. §3.317(d)(2). In order to prevail on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1990). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1990); 38 C.F.R. § 3.303(a). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2013). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). As a fact finder, the Board is obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (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.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr 21 Vet. App. at 303 (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d at 1377. Also, a veteran as a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F.3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; the person is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Right Elbow and Left Foot Disorders The Veteran claims service connection for disorders of the right elbow and left foot that he believes are the result of active duty. In correspondence and testimony at the Board hearing in November 2011, he has contended that these disorders are related to injuries he sustained while on active duty. After review of the entire evidence of record, the Board finds that a disorder of the right elbow or left foot have not been manifested at any time during the appeal. Review of the Veteran's STRs shows that during service he had complaints of pain in various joints on different occasions, but no specific complaint of pain in the right elbow or left foot. On examination for separation from service, he reported having or having had foot pain that was noted to have been from plantar warts. No other complaint of left foot disability is shown in the post-service treatment records that have been received from private or VA sources. An outpatient treatment record shows one complaint of elbow pain in October 2008 that was reportedly the result of weight lifting. On examination by VA in May 2010, there were no specific complaints or manifestations regarding pain of the right elbow or left foot. An examination was conducted by VA in August 2010. At that time, the Veteran reported having had left foot pain that resolved after he started using a sole insert and he denied any current left foot pain. He also reported having had bilateral elbow pain associated with weightlifting while working out in the gym. He reported that he had stopped lifting weights, which resolved the pain. He denied any present elbow pain. Physical examination showed no abnormality of the right elbow or left foot and no diagnosis of right elbow or left foot pain was made. Whether service connection is claimed on direct, presumptive, or any other basis, a necessary element for establishing such a claim is the existence of a current disability. See Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In this case, the record does not show that the Veteran has manifested chronic right elbow or left foot disability manifested by pain since his claims were filed in April 2010. Accordingly, service connection for a right elbow or left foot disability is not warranted. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claims of service connection for right elbow or left foot disorders, and the claims must be denied. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Disability Manifested by Chronic Pain in Both Calves The Veteran is seeking service connection for a disability manifested by chronic pain in both calves. He has contended that the disability is the result of undiagnosed illness from service in the Persian Gulf. The Board notes that the Veteran served in Southwest Asia from September 1990 to April 1991 and is, therefore, considered to be a veteran for which the presumptive provisions are applicable. Review of the record shows no complaints or manifestations of any disability manifested by chronic pain in the calves while the Veteran was on active duty. Post-service treatment records show that he did have complaints of such pain coincident with his claim of service connection. On examination by VA in August 2010, the Veteran reported having pain in both calf muscles that had started with the taking of statin medication in 2002. He stated that his primary care doctor had reduced his dosage, which improved the pain. An recent increase in the dosage of the statin drug had made his calf muscle pain worse. He denied claudication symptoms, redness, swelling, drainage, mass, lesion or history of blood clots in the lower extremities. The examiner rendered an opinion that the Veteran had pain in the calf muscles with normal physical examination and normal CPK level, with insufficient evidence to warrant a diagnosis of chronic pathological disorder. Therefore, the pain in the calf muscle is an undiagnosed illness. Under regulations applicable to veterans of the Persian Gulf, service connection will be established for an undiagnosed illness unless the disability is shown to be the result of another (supervening) cause, or is not manifested to a degree of 10 percent. In this case, the Veteran reported a supervening cause for his calf pain and, moreover, the disability is not shown to be manifested to a degree of 10 percent. In this regard, the report of August 2010 VA examination showed that the Veteran began having calf pain at the time he was prescribed statin medication. The pain improved and increased with decreases and increases of the dosages of his medication. For disability of the muscles of the calves, slight impairment is rated as zero percent disabling and a compensable (10 percent) rating requires disability to moderate degree. 38 C.F.R. § 4.73, Code 5311. Review of the evidence of record, including the VA May and August 2010 examination reports, show no more than slight disability of either calf muscle associated with undiagnosed illness. As such, service connection is not warranted. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a disability manifested by pain in both calves, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2013). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2013). The United States Court of Appeals for Veterans Claims (Court) has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Right Ankle Service connection for degenerative joint disease of the right ankle was awarded in an August 1999 rating decision of the RO. The current noncompensable (zero percent) rating was assigned at that time under the provisions of Code 5010, for traumatic arthritis. Diagnostic Code 5010 provides that arthritis due to trauma that is substantiated by X-ray findings is to be rated as degenerative arthritis. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 pct and 10 pct ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Normal ranges of motion of the ankle are dorsiflexion from 0 degrees to 20 degrees, and plantar flexion from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5270 provides ratings for ankylosis of the ankle. Ankylosis of the ankle in planter flexion less than 30 degrees is to be rated 20 percent disabling; ankylosis of the ankle in planter flexion between 30 degrees and 40 degrees, or in dorsiflexion between 0 degrees and 10 degrees, is to be rated 30 percent disabling; ankylosis of the ankle in planter flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion, or eversion deformity, is to be rated 40 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5271 provides ratings based on limitation of extension of the ankle. Moderate limitation of motion of the ankle is rated as 10 percent disabling; and marked limitation of motion of the ankle is rated as 20 percent disabling. 38 C.F.R. § 4.71a. An examination was conducted by VA in May 2010. At that time, the Veteran reported that he had giving way, lack of endurance, and pain of the right ankle. He denied experiencing weakness, stiffness, swelling, heat, redness, locking, fatigability, deformity, tenderness, drainage, effusion, subluxation and dislocation. He stated that he experienced flare-ups as often as once per day. The flare-ups were precipitated by physical activity and going down a hill or stairs. During a flare-up, he described being unable to walk for long periods of time. He treated with Ibuprofen. He had never been hospitalized, had surgery, or been incapacitated by this disorder. On examination, the right ankle showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation, or guarding of movement. Range of motion was within normal limits, with dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. There was no additional functional impairment due to pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. An examination was conducted by VA on August 2, 2010. At that time, the Veteran reported pain in the right ankle with degenerative joint disease. He took Ibuprofen for the pain, with good result. He reported no stiffness, locking, instability, or giving way. He reported of no signs of inflammation, redness, swelling, heat, tenderness or drainage. On examination, the ankle was normal to appearance, with no tenderness to palpation. There was no laxity noted. Range of motion was from 0 to 20 degrees dorsiflexion and from 0 to 40 degrees plantar flexion. With repetition, there was no change in range of motion secondary to pain, fatigue, weakness, or lack of endurance. There was no varus or valgus angulation noted. The diagnosis was intermittent strain of the right ankle. On initial examination following the Veteran's claim of increased rating, the right ankle showed pain, but normal range of motion of the ankle joint. Range of motion was shown to be diminished in plantar flexion on examination on August 2, 2010. While this is noncompensable limitation of motion under the regulatory criteria for evaluation of ankle disability, such noncompensable limitation of motion resulting from degenerative joint disease warrants a 10 percent evaluation. Limitation of motion or other functional impairment warranting an evaluation in excess of 10 percent is not shown. With the resolution of reasonable doubt in the Veteran's favor, a 10 percent rating is warranted as of August 2, 2010. Status Post Rectal Fissures with Residual Scarring Service connection for status post rectal fissures with residual scarring was awarded by rating decision of the RO in August 1999. A noncompensable rating was assigned under the provisions of Code 7335 for fistula in ano, which is rated on impairment of sphincter control under Code 7332. Diagnostic Code 7332 provides ratings based on impairment of sphincter control. Healed or slight impairment of sphincter control, without leakage, is rated noncompensable (0 percent) disabling. Constant slight impairment of sphincter control, or occasional moderate leakage, is rated 10 percent disabling. Occasional involuntary bowel movements, necessitating wearing of pad, are rated 30 percent disabling. Extensive leakage and fairly frequent involuntary bowel movements are rated 60 percent disabling. Complete loss of sphincter control is rated 100 percent disabling. 38 C.F.R. § 4.114. The Veteran contends that an increased rating is warranted for status post rectal fissures because he occasionally has episodes of bleeding. He has not contended, nor does VA or private outpatient treatment records show, complaints or manifestations of impaired sphincter control. An examination was conducted by VA in May 2010. At that time, the Veteran complained of itching, pain, and a nagging feeling to empty bowel and perianal discharge. There was no swelling. Bleeding in large amounts of bright red blood was reported. He reported no leakage of stool. He did not have hemorrhoids. He had not had surgery for this condition and treatment included topical pads and Preparation H. His only functional impairment was reported to be long periods of time in a restroom due to bleeding. A rectal fissure scar was noted. The Veteran had no complaints relative to the scar, and no symptoms of the scar were noted. The Veteran's status post rectal fissures are not shown to cause slight impairment of sphincter control or occasional moderate leakage. As such, the disability is not shown to be productive of more than healed or slight impairment and a compensable evaluation is not shown to be warranted. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for an increased rating for status post rectal fissures with residual scarring, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Extraschedular Considerations The Board also has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is 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. 38 C.F.R. § 3.321(b)(1) (2013); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. In this case, comparing the Veteran's disability level and symptomatology to the rating schedule, the degree of disability throughout the appeal period under consideration is contemplated by the rating schedule. The Veteran's right ankle limitation of plantar flexion is noncompensable under the schedular criteria for evaluation of ankle impairment, but rated compensable as part of the arthritis. This directly corresponds to the schedular criteria for the 10 percent evaluation for noncompensable limitation of motion due to arthritis, which also incorporates various orthopedic factors that limit motion or function of the knee. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. Status post rectal fissures are essentially asymptomatic, without complaints or manifestations of impaired sphincter control, so a noncompensable evaluation is specifically contemplated in the schedular rating criteria. For these reasons, the Board finds that the assigned schedular ratings are adequate to rate the Veteran's right ankle and anal fissure disabilities, and no referral for an extraschedular rating is required. Finally, the record, including a March 2011 VA psychiatric examination report, shows that the Veteran is employed. Consequently, the matter of entitlement to a total disability rating based on individual unemployability is not raised by the Veteran or the evidence of record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Service connection for a right elbow disorder is denied. Service connection for a left foot disorder is denied. Service connection for a disability manifested by pain in both calf muscles is denied A compensable rating for degenerative joint disease of the right ankle prior to August 2, 2010, is denied. A 10 percent rating, and no higher, is granted for degenerative joint disease of the right ankle from August 2, 2010, subject to controlling regulations governing the payment of monetary benefits. A compensable rating for status post rectal fissures with scarring is denied. REMAND The Veteran is also seeking service connection for tinnitus, a chronic gastrointestinal disorder, and cardiovascular disease. Review of the record regarding the claim of service connection for tinnitus shows that the Veteran was afforded a VA audiologic examination in August 2010 at which time an opinion was rendered that it was less likely as not that the Veteran's tinnitus was related to military acoustic trauma. The rationale given was that there were no complaints of tinnitus shown in the Veteran's records. As noted, lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional and a veteran as a layperson is competent to offer an opinion on a simple medical condition. Jandreau, 492 F.3d at 1377; Davidson, 581 F.3d at 1313. The VA examination in August 2010 did not address the Veteran's assertion of continuity of symptomatology of tinnitus since service. The Court held that, even though disabling hearing loss may not be demonstrated at separation, a veteran may nevertheless establish service connection for a current hearing loss disability by submitting evidence that the current disability is related to service. Hensley v. Brown, 5 Vet. App. 155 (1993). The same is considered by the Board to be true of tinnitus. Taking into account the Veteran's statements in support of his claim, as well as VA treatment reports of record which note that the Veteran has a current diagnosis of tinnitus, the Veteran's claim of service connection should be remanded for additional VA examination so as to determine whether any currently-diagnosed tinnitus is etiologically-related to acoustic trauma during his period of active service. Regarding the claim of service connection for a gastrointestinal disability it is noted that current treatment records show diagnoses of GERD, hiatal hernia, esophageal mucosal, Barrett's esophagitis, congestive gastropathy, and erosive gastritis. While a VA examiner in August 2010 found that GERD with hiatal hernia was a diagnosable chronic multisymptom illness that was not related to the Veteran's specific exposure event experienced in "Southeast Asia," the examiner did not comment on symptoms of gastritis and other gastrointestinal complaints for which the Veteran was treated while he was on active duty. Specifically, it is noted that gastritis was assessed in July 1996. After considering the statements and evidence in the record, the Board finds that an additional medical examination is warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (setting forth the criteria under which VA is required to obtain an examination). Regarding the claim of service connection for cardiovascular disease, it is noted that service connection has been awarded for hypertension and that STRs include an electrocardiogram (EKG) study that was consistent with sinus arrhythmia. VA examination in August 2010 included a diagnosis of mitral and tricuspid regurgitation, which was opined to be a disease of clear and specific etiology so as not to be related to any specific exposure experienced by the Veteran in the Persian Gulf. While this may decide the issue as it relates to the provisions of 38 C.F.R. § 3.317, it does not answer the question regarding whether the Veteran has a current cardiovascular disease that is caused or aggravated by his service-connected hypertension. As such, an additional examination is found to be warranted. McLendon, 20 Vet. App. at 79. Accordingly, these issues are REMANDED for the following actions: 1. The RO should arrange for the Veteran to undergo a medical examination to ascertain the current nature and etiology of his tinnitus. The examiner should be requested to render an opinion regarding whether it is at least as likely as not (a probability of 50 percent or more) that the tinnitus is related to service, including exposure to acoustic trauma during service. Consideration must be given to the Veteran's assertion of continuity of symptomatology. The claims folder should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 2. The RO should arrange for the Veteran to undergo a medical examination to ascertain the current nature and etiology of any gastrointestinal disorder. The examiner should be requested to render an opinion regarding whether it is at least as likely as not (a probability of 50 percent or more) that the current gastrointestinal disorder is related to service, including complaints noted while the Veteran was on active duty. The claims folder should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 3. The RO should arrange for the Veteran to undergo a medical examination to ascertain the current nature and etiology of any cardiovascular disease. The examiner should be requested to render an opinion regarding whether it is at least as likely as not (a probability of 50 percent or more) that any cardiovascular disorder is related to service, including complaints noted while the Veteran was on active duty, or is caused by, or aggravated by service-connected hypertension. The claims folder should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 4. Thereafter, the RO should readjudicate the issues on appeal. If any determination remains unfavorable to the Veteran, he and his representative should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claims. The Veteran should be given an opportunity to respond to the SSOC prior to returning the case to the Board for further review. The appellant 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). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2013). 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). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs