Citation Nr: 1433764 Decision Date: 07/29/14 Archive Date: 08/04/14 DOCKET NO. 11-21 348 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for a right shoulder disability. 2. Entitlement to an initial compensable evaluation for a hiatal hernia. 3. Entitlement to an initial compensable rating for degenerative arthritis of the cervical spine. 4. Entitlement to an initial compensable rating for residuals of a right elbow fracture. 5. Entitlement to an initial compensable rating for a right shoulder scar. 6. Entitlement to an initial compensable rating for a right thumb scar. 7. Entitlement to an initial compensable rating for tension headaches. 8. Entitlement to an initial compensable rating for a right thumb fracture. 9. Entitlement to an initial compensable rating for a right ring finger fracture. 10. Entitlement to an initial compensable rating for plantar fasciitis. 11. Entitlement to service connection for a back disability. 12. Entitlement to service connection for a groin condition. ATTORNEY FOR THE BOARD Nadia Kamal, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1986 to February 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Board has reviewed the Veteran's claims file and the record maintained in the Virtual VA paperless claims processing system. FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's service-connected right shoulder disability was manifested by pain upon motion or evidence of malunion of the clavicle or scapula, or for nonunion of the clavicle or scapula without evidence of loose movement. 2. Throughout the period on appeal, the Veteran's hiatal hernia was manifested by at least two or more of the following symptoms: persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation, accompanied by substernal or arm and shoulder pain, productive of considerable impairment of health. 3. Even in consideration of his complaints of pain and functional loss, the Veteran's cervical spine disability does not result in forward flexion of 40 degrees or less, a combined range of motion of 335 degrees or less, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or contour. 4. Throughout the period on appeal, the Veteran's right elbow disability, at its worst, is manifested by pain, flexion limited to no more than 145 degrees, and limitation of extension to no more than 0 degrees. Ankylosis, nonunion of the radius and ulna, impairment of the ulna or radius and significant impairment of the supination or pronation have not been shown. 5. The Veteran's right shoulder surgical scars are manifested by three scars of linear, superficial nature, measuring approximately 1cm by 0.2cm each resulting in no pain or tenderness and no adherence to underlying tissue. There is no inflammation, edema or keloid formation. 6. The Veteran's right thumb scars are manifested by two scars, linear and superficial in nature. The first scar measures 0.5 cm by 0.5 cm, and the second scar measures 0.7 cm by 0.5 cm. There was no evidence of pain, skin breakdown, underlying tissue damage, inflammation, edema, keloid formation, disfigurement or functional limitations as a result of the scars. 7. The Veteran's headaches are manifested by a dull and throbbing aching, occurring 3-4 times a week for approximately 20 minutes per episode. They are not manifested by prostrating attacks. 8. The Veteran's right thumb fracture residual is not manifested by a gap of one to two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Additionally, upon examination, there was no ankylosis of the right thumb, with no evidence of any functional limitations. 9. The Veteran has complete range of motion in his right ring finger, and his right index finger is not ankylosed. 10. The Veteran's bilateral plantar fasciitis manifest as having mild symptoms. It did not manifest as occurring with moderate symptoms. 11. The evidence of record fails to establish that the Veteran currently has a recognized low back disability. 12. The evidence of record fails to establish that the Veteran currently has a recognized groin disability. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for right shoulder torn rotator cuff have not been met. 38 U.S.C.A. §§ 1110, 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.21, 4.71a, Diagnostic Code (DC) 5203 (2013). 2. For the entire rating period, the criteria for a 10 percent evaluation, and no higher, for hiatal hernia has been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.114, DC 7346 (2013). 3. For the entire rating period, the criteria for a 10 percent evaluation, and no higher, for a cervical spine disability are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.59, 4.7, 4.71a, DCs 5235-5243 (2013). 4. For the entire rating period, the criteria for a 10 percent evaluation, and no higher, for residuals of a right elbow fracture have are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, DC 5209 (2013). 5. The criteria for a compensable disability rating for surgical scars of right shoulder as a result of a surgical procedure have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.118, DC 7802 (2013). 6. The criteria for a compensable disability rating for scars of the right thumb, post right thumb fracture repair, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.118, DC 7802 (2013). 7. The criteria for a compensable rating for tension headaches have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.124a, DC 8100 (2013). 8. The criteria to establish a compensable rating for residuals of a right thumb fracture have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DCs 5299-5224, 5228 (2013). 9. The criteria for a compensable rating for the Veteran's residuals of a right ring finger fracture have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.40, 4.71, 4.71a, DCs 5227, 5229 (2013). 10. The criteria for an initial compensable rating for plantar fasciitis were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, DCs 5276, 5284 (2013). 11. The criteria for service connection for a low back disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103(A), 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 12. The criteria for service connection for a groin disability have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103(A), 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, and a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The claims for an increased rating for the Veteran's service-connected right shoulder, hiatal hernia, cervical spine, elbow fracture, scar, headaches, thumb fracture, index finger fracture and bilateral plantar fasciitis disabilities are downstream issues from a July 2010 rating decision, which established service connection for these disabilities. The issues on appeal are the assigned initial ratings. The Court of Appeals for Veterans Claims (Court) held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006), that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008). Thus, to the extent that there is any noncompliance with the statutorily prescribed VCAA notice requirements with respect to the claims for increased initial ratings for the above mentioned disabilities, such noncompliance is deemed to be non-prejudicial to these specific claims. With regard to the Veteran's claim for entitlement to service connection for his lumbar spine and groin disabilities, the Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Here, the record reflects that the originating agency provided the Veteran with the required notice by a letter mailed in January 2010 and notice with respect to the effective-date and rating elements of the claims was included in the January 2010 letter. VA also has a duty to assist the Veteran by making all reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c). VA treatment records have been associated with the record. The Veteran has also provided statements and argument in support of his claims. He has not identified any evidence that has not otherwise been obtained. VA examinations for his disabilities were conducted in February 2010. This examination described the disability in sufficient detail for the Board to make an informed decision. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, after a careful review of the file, 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 concludes that all the available records and medical evidence have been obtained in order to make adequate determinations as to these claims. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. 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). Increased Ratings Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2013). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule but findings sufficient to identify the disease and the resulting disability, and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2013); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). 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. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. § 4.45 contemplate inquiry into whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as at least minimally compensable. See also DeLuca v. Brown, 8 Vet. App. 202 (1995) (indicates that pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain may be the basis for a rating for a disability rated based on limitation of motion, regardless of whether or not the limitation of motion specified in the Diagnostic Code criteria is shown). With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention 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 primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Right Shoulder Rotator Cuff Tear The Veteran is currently assigned a 10 percent disability rating by analogy under 38 C.F.R. § 4.71a, DC 5203 (2013) (addressing instability of the shoulder joint). In order to warrant the next higher rating for the Veteran's bilateral shoulder disability, the evidence must show: * Ankylosis of the scapulohumeral articulation, manifested by favorable abduction to 60 degrees, allowing the mouth and head to be reached (30 percent for the dominant side and 20 percent for the non-dominant side under DC 5200); * Limitation of motion of the arm at shoulder level (20 percent under DC 5201); * Recurrent dislocation of the scapulohumeral joint with infrequent episodes and guarding of movement only at the shoulder level (20 percent under DC 5202); * Malunion of the scapulohumeral joint with moderate deformity (20 percent under DC 5202); * Dislocation or nonunion with loose movement of the clavicle or scapula (20 percent under DC 5203). See 38 C.F.R. § 4.71a (2012). The Veteran has asserted that his right shoulder rotator tear warrants a higher disability rating. He claims that his disability is characterized by pain and limitation of motion. The Board finds that the requirement for a 20 percent rating under DC 5203 has not been met. Specifically, the Veteran does not have loose movement of his clavicle or scapula with nonunion. In a February 2010 VA examination, the Veteran reported symptoms of weakness, stiffness, swelling, lack of endurance, tenderness and pain. He indicated that he did not experience heat, redness, locking, fatigability, deformity or dislocation, but he did experience flare ups as often as 4 times per day, where the severity level of the pain was at a level of 10, and that his flare ups were precipitated by physical activity and were alleviated with rest and Tylenol. He reported that he was not receiving any treatment for his shoulder at the time, but that he had received treatment in the past, specifically in November 2009. Upon examination the examiner noted that the Veteran's range of motion for his right shoulder was as follows: his flexion was 0 to 175 degrees, his abduction ended at 175 degrees, and his external and internal rotations ended at 80 and 85 degrees, respectively. There was no sign of radiating pain upon movement. Upon examination, there was abnormal movement and guarding of movement, but no signs of edema, instability, effusion, weakness, tenderness, deformity, malalignment or drainage. The examiner noted there was no sign of ankylosis. Therefore, as ankylosis or limitation of motion of his arm to shoulder level has not been shown, a rating in excess of 10 percent is not warranted based on limitation of motion. Moreover, a rating in excess of 10 percent is not warranted based on instability. Specifically, at the VA examination in February 2010, the examiner noted that the presence of abnormal movement. However, there were no signs of instability or subluxation. There was no indication of humerus impairment with recurrent dislocation, fibrous union, nonunion, malunion with moderate or marked deformity, or loss of head. Therefore, a rating in excess of 10 percent is also not warranted based on malunion or dislocation in the shoulders. In evaluating the Veteran's increased rating claim, the Board must also address the provisions of 38 C.F.R. § 4.40 and 4.45 (2013). See DeLuca, supra. The Board recognizes the Veteran's complaints of functional loss as a result of his right shoulder disability, notably his pain. However, the Board places greater probative value on the objective clinical findings which do not support the Veteran's contentions regarding the severity of his disability. The Veteran's shoulder flexion and abduction at his February 2010 examination were within normal ranges, without evidence of pain or marked limitation of motion. Hiatal Hernia The Veteran is in receipt of a noncompensable initial evaluation for a hiatal hernia under 38 C.F.R. § 4.114, DC 7346. Under this diagnostic code, a 10 percent evaluation where there are two or more of the symptoms of the 30 percent evaluation, which include persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 38 C.F.R. § 4.114 (2013). In February 2010 the Veteran was afforded a VA examination for his stomach condition and heartburn. At that examination, he reported that over the 4 months prior to the examination, he gained 15 pounds, and had episgastric pain, scapular pain, arm pain, reflux and regurgitation of stomach contents and nausea and vomiting. He had no heartburn, hematemesis or passing of dark tarry stools. He indicted that the symptoms occurred approximately twice a week, with episodes lasting 30-40 seconds each. However, he was not receiving any treatment for his condition, nor did it result in any functional impairment. After a review of all the evidence, lay and medical, the Board finds that, for the entire rating period, the Veteran's hiatal hernia has been manifested by two or more of the symptoms for the 30 percent evaluation, including regurgitation, arm or shoulder pain. Specifically, the Veteran's VA examination reflected that he had symptoms of nausea, regurgitation, epigastric pain and reflux. While these symptoms were noted to be fairly controlled, the severity of these symptoms was such that a 10 percent rating is warranted for a hiatal hernia with GERD under DC 7346. See 38 C.F.R. §§ 4.3, 4.7, 4.114. However, the Board finds that the criteria for next higher 30 percent rating under DC 7346 have not been met, as persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health has not been shown. The Veteran specifically denied having symptoms of dysphagia or difficulty swallowing during a February 2010 VA examination, and there exists no evidence that otherwise identifies the presence of dysphagia or regurgitation. The evidence also does not show that a hiatal hernia with GERD is productive of considerable impairment of health, nor does the Veteran contend such. Instead, the Veteran's disability is shown to be fairly controlled. For these reasons, the Board finds that, for the entire rating period, a higher 30 percent rating is not warranted for a hiatal hernia with GERD under DC 7346. See 38 C.F.R. § 4.114. Therefore, the Board finds that for the period on appeal, the Veteran is entitled to a 10 percent rating, but no more, for his hiatal hernia. Cervical Spine Degenerative Arthritis The Veteran currently has a noncompensable rating for his cervical spine disorder under the general rating formula specified in 38 C.F.R. § 4.71a. Disabilities of the spine are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine. 38 C.F.R. § 4.71, DCs 5235-5242 (2013). For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. See Plate V, 38 C.F.R. § 4.71a. As an initial matter, the Board determines at the outset that a 10 percent rating is warranted for the Veteran's cervical spine disability. Specifically, in cases where a veteran has a noncompensable rating for a musculoskeletal disability, a compensable rating under 38 C.F.R. § 4.59 is for consideration when there is evidence of painful motion even without actual limitation of motion or loss of motion that is non-compensable. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In other words, a diagnosis of arthritis is not necessary in order for a compensable rating to be warranted based simply on pain. Here, a February 2010 X-ray confirmed degenerative arthritis and joint narrowing. Given the Veteran's complaints and the X-ray results, a 10 percent rating is warranted. Next, the Board considers whether a rating in excess of 10 percent is warranted. Under General Rating Formula, in order to warrant an increased rating, the evidence must show: * Forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees (20 percent disabling); * Combined range of motion of the cervical spine not greater than 170 degrees (20 percent disabling); * Muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent disabling); * Incapacitating episodes having a total duration of at least two weeks, but less than four weeks, during the past 12 months (20 percent). For rating purposes, an "incapacitating episode" as "a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." 38 C.F.R. § 4.71a (2013). Based on the evidence, a rating in excess of 10 percent is not warranted. At a VA examination for his cervical spine in February 2010, the Veteran reported stiffness and spasms associated with his condition, but stated that he did not experience fatigue, decreased motion, paresthesia and numbness. The Veteran further reported that in the past he did not suffer periods of overall functional impairment. Upon examination, the examiner noted that there was no sign of radiating pain on movement, muscle spasm, tenderness, guarding, weakness, loss of tone or atrophy of the limbs. There was no ankylosis of the cervical spine. The Veteran exhibited a range of motion that was substantially normal (45 degrees of forward flexion, 45 degrees of extension, 45 degrees of right and left lateral flexion and 80 degrees of right and left rotation), and was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use testing. The Board has considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, an increased evaluation for the Veteran's service-connected cervical spine disability is not warranted on the basis of functional loss due to pain or weakness in this case. The Veteran's symptoms are contemplated by the noncompensable rating already assigned. Indeed, the report of the 2010 VA examination, explicitly noted the absence of pain on forward flexion. The evidence also does not indicate that there is a history of incapacitating episodes. Indeed, at his February 2010 VA examination, he specifically denied such events. The Board has also considered whether a separate evaluation is warranted for any associated neurological abnormality. Under 38 C.F.R. § 4.71(a), any associated objective neurologic abnormalities, including but not limited to, bowel or bladder impairment, separately, is also to be evaluated under the appropriate diagnostic code. See 38 C.F.R. § 4.71(a) (2013). However, a separate rating is not warranted in this case. Specifically, at his VA examination in February 2010, he denied symptoms of numbness or paresthesia. Moreover, a neurological examination of the Veteran's upper extremities was substantially normal in terms of motor functioning, sensory functioning and reflexes. In light of the above, the Board determines that a 10 percent rating, but no more, is warranted for the Veteran's cervical spine disability. In reaching this decision, the Board finds that the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Residuals of a Right Elbow Fracture The Veteran is currently assigned a noncompensable rating for residuals of a fracture to the radial head or the right elbow (his dominant side) under 38 C.F.R. § 4.71a, DC 5213 (addressing limitation of motion of the forearm). In order to warrant a compensable rating for his right a disability, the evidence must show: * Favorable ankylosis of the elbow at an angle between 90 and 70 degrees (30 percent under DC 5205); * Flexion limited to 100 degrees (10 percent under DC 5206); * Extension limited to 45 degrees (20 percent under DC 5207); * Joint fracture, with marked cubitus varus or cubitus valgus deformity, or with ununited fracture of the head of the radius (20 percent under DC 5209); * Nonunion of the radius and ulna with flail false joint (40 percent under DC 5210); * Malunion of the ulna with bad alignment (10 percent under DC 5211); * Malunion of the radius with bad alignment (10 percent under DC 5212); * Impairment of supination and pronation to 30 degrees or less (10 percent under DC 5213). Also, if limitation of both flexion (100 degrees) and extension (45 degrees) are shown to a compensable level, a 20 percent rating is for application under DC 5208. 38 C.F.R. § 4.71a. Based on the evidence of record, a compensable rating is not warranted. Specifically, at his VA examination in February 2010, he stated that his right arm symptoms were characterized by at the bend inferior to the elbow in the front. He reported that the pain occurred 4 times a day and lasted about 10-20 minutes per episode. He claimed that the pain was localized and aching, his worst pain level being at 7. His pain was exacerbated by physical activity and relieved by rest and by Tylenol. The Veteran reported he was never hospitalized for his condition, and that he was not receiving any treatment for his condition. He reported that he did not experience any overall functional impairment from his condition. Upon examination, the examiner noted that the Veteran's right elbow showed no sign of edema, instability, abnormal movement, effusion, weakness, tenderness, deformity, malalignment, or guarding of movement. Moreover, upon examination there was no sign of ankylosis. The recorded range of motion measurements were: 0 degrees of extension, 145 degrees of flexion, 85 degrees of supination and 80 degrees of pronation. There is also no indication that the Veteran experiences any additional functional loss due to pain, weakness, fatigability, incoordination or pain on movement of a joint to warrant a higher rating. See 38 C.F.R. §§ 4.40 , 4.45 (2013); see also DeLuca, supra. Significantly, the Veteran did not complain of increased pain or other limitations while performing repetitive range of motion testing at his VA examinations. Although the examiner noted some mild functional effects in the area of physical activity, there is no indication that these mostly mild effects rise to a level of severity to exceed that already being compensated by the Veteran's painful motion rating under 38 C.F.R. § 4.59. In short, there is no evidence of compensable limitation of extension, flexion, pronation, or supination to warrant an increased rating under the rating criteria for limitation of motion. See 38 C.F.R. § 4.71a, DCs 5206-5208, 5213 (2013). As such, a compensable rating is not warranted. Right Shoulder and Thumb Scars The Veteran currently receives noncompensable ratings for the scars on his shoulder and right thumb. The Board notes at the outset that this section was amended effective October 23, 2008. However, since the Veteran submitted his initial claim after that date, the pre-amended criteria are not for consideration. See 73 Fed. Reg. 54,710 (Sept. 23, 2008). In order to warrant a compensable rating for a scar to the finger or hand, the evidence must show that the scar is: * Deep and nonlinear and an area or areas of at least 6 sq. in. (39 sq. cm) but less than 12 sq. in. (77 sq. cm) (10 percent under Diagnostic Code 7801); * Superficial and nonlinear, and of an area of 144 sq. in. (929 sq. cm) or greater (10 percent under Diagnostic Code 7802); * One or two in number that are unstable or painful (10 percent under Diagnostic Code 7804). See 38 C.F.R. § 4.118. A scar is "superficial" when it is not associated with underlying soft tissue damage. Under Note (1) of Diagnostic Code 7804, a scar is considered "unstable" if there is frequent loss of covering of skin over the scar. If a scar is both unstable and painful, an additional 10 percent will be added to the assigned rating. Moreover, a scar with a compensable rating based on pain and instability may also warrant a separate rating based on size. See 38 C.F.R. § 4.118, DC 7804, Note (3). Based on the evidence of record, a compensable rating is not warranted for either scar. Specifically, at his VA examination in February 2010, the examiner reported that there were three scars on the right shoulder and two on the right thumb. The right shoulder scars were noted to be linear scars, measuring 1 cm by 0.2 cm. The scars were not painful upon examination, with no skin breakdown. The examiner noted that they were superficial scars, with no underlying tissue damage. Inflammation, edema and keloid formation were absent. The scars were not disfiguring, and did not limit the Veteran's motion. The Veteran's right thumb scars were noted to be 0.7 cm by 0.5 cm. The scars were not painful upon examination, and there was no skin breakdown. They were superficial scars with no underlying tissue damage. Inflammation, edema and keloid formations were absent, and the scars were not disfiguring. An increased disability rating under DC 7801 or 7802 is not warranted as the Veteran's right shoulder and right thumb scars did not exceed 77 square centimeters. An increased evaluation is also not warranted under DC 7803 as the Veteran's right shoulder and right thumb scars were not shown to be unstable. Similarly, an increased evaluation is not warranted under DC 7804 as there was no evidence that the Veteran's right shoulder and right thumb scars were unstable or painful. Finally, as to DC 7805, the Board notes that there was no evidence of limitation of function of the right shoulder or right thumb due to the scars. Thus, the Veteran is not entitled to a compensable disability rating for his right shoulder or right thumb scars. Headaches The Veteran currently receives a noncompensable rating for headaches by analogy to migraine headaches under 38 C.F.R. § 4.124a, DC 8100. In order to warrant a 10 percent rating for headaches, the evidence must show characteristic prostrating attacks averaging one in 2 months over the last several months. 38 C.F.R. § 4.124a, DC 8100. Based on the evidence of record, a compensable rating is not warranted. Specifically, at his VA examination in February 2010, the Veteran reported that his headaches were dull and throbbing, and were relieved with rest and with medication. He stated that he was able to work when his headaches occurred, but that he needed to take medication for them. The headaches occurred approximately 3-4 times a week and lasted for approximately 20 minutes each. The ability to perform daily functions during flare ups was not a problem for the Veteran when he was on medication, and he did not have any overall functional impairment from this condition. In this case, the Veteran did not experience prostrating headaches, and therefore is not entitled to a compensable rating for his headaches. Further, the headaches have not affected the Veteran's daily functional activities, or his ability to work. Therefore, a compensable rating is not warranted. Thumb Fracture The Veteran currently has noncompensable ratings for residuals of fractures to the right thumb and ring finger. While, the rating schedule does not have a specific diagnostic code to account for residuals of a thumb fracture, his disability has been evaluated by analogy to limitation of motion of the thumb under DC 5228. Under this diagnostic code, a compensable rating is warranted when there is evidence of a gap of 1 to 2 inches (2.5 to 5.1 centimeters) between the thumb pad and the fingers with the thumb attempting to oppose the fingers. Based on the evidence of record, a compensable rating is not warranted for the Veteran's right thumb fracture. Specifically, at his VA examination in February 2010, he reported that the condition had existed since 1998. He stated that the pain was localized, and occurred 2 times a day, each time lasting 4-5 minutes. The Veteran described the pain level as being at 5. The pain was exacerbated by physical activity, and relieved with Tylenol. The Veteran reported that when he was in pain he could still function even without medication, and that he was not receiving any treatment for his condition at that time. He also reported thumb locking and swelling of the thumb, but stated that he did not suffer any functional impairment of the thumb at the time. Upon examination, the examiner noted that there was no ankylosis of the thumb. The range of motion of the Veteran's right thumb was as follows: the radial abduction was 70 degrees, the palmar abduction 70 degrees, the MP flexion was at 60 degrees and the IP flexion was at 60 degrees. The examiner added that the joint function was not limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. In short, the range of motion of testing in February 2010 has repeatedly shown no limitation of motion of the left thumb or any digits of the left hand, including no gaps, and no objective pain, painful motion, or swelling. Therefore, the Veteran is not entitled to a compensable rating for his right thumb fracture. Right Finger Fracture The residuals of the Veteran's right ring finger fracture have been evaluated as noncompensably disabling under 38 C.F.R. § 4.71a, DC 5230. This is the highest rating allowable under this diagnostic code. However, a compensable rating may be for application if the evidence shows ankylosis of both the thumb and ring finger. See 38 C.F.R. § 4.71a, DC 5223 (30 percent). Based on the evidence of record, a compensable is not warranted. Specifically, at his VA examination in February 2010, ankylosis is neither shown, nor alleged. To the contrary, the range of motion, while slightly limited, was substantial. The examiner also noted that the Veteran's joint function was not limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Moreover, at that VA examination, there was no X-ray evidence of arthritis of the right ring finger. Consequently, there is no basis for applying the criteria in 38 C.F.R. § 4.71a, Codes 5010-5003. A compensable rating for ring finger disability requires amputation (see 38 C.F.R. § 4.71a, Code 5155); the Veteran's left ring finger is intact. Under Codes 5230, 5227, any limitation of motion of a ring finger, to include ankylosis, warrants a 0 percent rating. In summary, the factual evidence of record does not show findings that meet or approximate any schedular criteria for a compensable rating for ring finger disability. Consequently, a compensable rating for residuals of a right ring finger fracture is not warranted. Plantar Fasciitis The Veteran currently receives a noncompensable rating for plantar fasciitis under 38 C.F.R. § 4.71a, DC 5276. In order to warrant a compensable rating for this disorder, the evidence must show moderate impairment, either unilateral or bilateral, involving weight-bearing line over or medial to great toe, inward bowing of the tendon Achilles, pain on manipulation and use of the feet. The Board finds that the evidence of record does not support a compensable rating for the Veteran's bilateral plantar fasciitis under DC 5276. In February 2010 the Veteran was afforded a VA examination for his bilateral plantar fasciitis. At that examination, the Veteran reported that his disability caused pain in the ball and soles of his feet. He reported that the pain was localized, and of an aching and cramping nature, was relieved by rest and was exacerbated by physical activity. While standing or walking the Veteran had pain, weakness and swelling, but no stiffness or fatigue. The Veteran reported that he did not experience any overall functional impairment from his condition. Upon examination, the examiner noted that the Veteran's right foot was tender, but there were no indications of painful motion, edema, disturbed circulation, weakness, atrophy of the musculature, heat, redness or instability. There was active motion in the metatarsophalangeal joint of the right and left great toes. Palpation on the plantar surface of the right foot revealed slight tenderness, as did the left foot. The examiner noted that pes planus was not present, and that the Veteran did not have any limitation with standing or walking upon examination. He further did not require any kind of support with his shoes. X-rays of the right and left feet confirmed findings of pes planus. Based on this VA examination, the Board finds that there was no clinical evidence of a weight-bearing line over or medial to the great toe, any gross deformity, or inward bowing of the Achilles tendon. Additionally, there were no clinical findings of pain on manipulation and use of the feet. To the contrary, on physical examination there was no evidence of painful motion, swelling, tenderness, instability, weakness, or abnormal weight-bearing. Nor was there any evidence of skin or vascular changes in the feet, or any shoe-wear pattern that would indicate abnormal weight-bearing. It is noteworthy that the VA examiner noted that the Veteran was able to walk around fairly normally. In sum, this evidence indicates either asymptomatic plantar fasciitis or mild symptoms at most, and finds that the Veteran is not entitled to a compensable rating for any time during the appeal period. Extraschedular Considerations In evaluating the severity of his service-connected disabilities, the Board also has considered whether the Veteran is entitled to a greater level of compensation for the disabilities at issue on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). The first of the three elements of an extraschedular rating under § 3.321(b)(1) is a finding of either the RO or the Board that the evidence "presents such an exceptional or unusual disability picture that the available schedular evaluations for that service-connected disability are inadequate." See Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (Fed. Cir. 2009). In order to determine whether a disability is "exceptional or unusual," there "must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability." Thun, 22 Vet. App. at 115. "[I]f the [rating] criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, [and] the assigned schedular evaluation is, therefore adequate, and no referral is required." Id. The first Thun element is not satisfied here. The Veteran's service-connected right shoulder disability, hiatal hernia, cervical spine disability, residuals of an elbow fracture, right shoulder and right thumb scars, tension headaches, right thumb fracture, right hand ring finger fracture, and plantar fasciitis are manifested by signs and symptoms which impair his daily activities such as standing and walking. These signs and symptoms discussed above, and their resulting impairment, are contemplated by the applicable rating schedules. For all musculoskeletal disabilities in particular, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. Given the variety of ways in which the rating schedules contemplate functional loss for the disabilities at issue, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture. In short, there is nothing exceptional or unusual about the shoulder disability, hiatal hernia, cervical spine disability, residuals of an elbow fracture, right shoulder and right thumb scars, tension headaches, right thumb fracture, right hand ring finger fracture, and plantar fasciitis because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet. App. at 115. Finally, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (Court) held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the evidence of record does not show, and the Veteran has not asserted, that his shoulder disability, hiatal hernia, cervical spine disability, residuals of an elbow fracture, right shoulder and right thumb scars, tension headaches, right thumb fracture, right hand ring finger fracture, and plantar fasciitis render him unable to obtain substantial and gainful employment. Accordingly, the Board concludes that the issue of TDIU has not been raised in this case. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110; 1131, 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004) (citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002)); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). This principle has been repeatedly reaffirmed by the Federal Circuit, which has stated that "a veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Id. Competent medical evidence means evidence provided by a person who is qualified through special education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). 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(a)(2). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 1507 (West 2002); 38 C.F.R. § 3.102 (2013); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). In this case, the Veteran is seeking entitlement to service connection low back and groin disorders, which he contends are related to his service. However, service connection is not warranted for either disorder, as neither is currently shown. Specifically, at a VA examination in February 2010, the Veteran reported that his low back condition had existed since 2000, which was the result of an injury during unit physical training exercises. Since then, he has experienced limitation in walking, and that he experiences stiffness, spasms and decreased motion as a result of his disability. He reported that he could no longer achieve and maintain an erection. However, after a February 2010 X-ray revealed no abnormalities of the Veteran's low back, the examiner declined to diagnose the Veteran with a low back disability. Regarding the Veteran's groin complaints, the service treatment records do reflect that he was diagnosed with epididymitis of the left testicle while in-service. However, it does not appear that this disorder was chronic in nature, or that there were any residuals. To the contrary, at the February 2010 VA examination, the Veteran complained of pain in the groin area occurring 4 times a month and lasting approximately 5-10 minutes during each episode. Even so, an examination of the genitals reflected normal, well developed and well descended testis with no mass, atrophy or tenderness. As a result, the examiner declined to diagnose the Veteran with any groin disability. When considering these claims, the Board has also considered the statements made by the Veteran regarding his groin and back symptoms. The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)). In this case, however, the Veteran is not competent to provide testimony regarding the etiology of a back or groin disorder. See Jandreau, 492 F.3d at 1377, n.4. Because these disorders are not diagnosed by unique and readily identifiable features, they do not involve a simple identification that a layperson is competent to make. As such, while the Board notes that the Veteran is competent to report such observable symptomatology such as back and groin pain, it must rely on the observations of the VA examiner, who failed to identify a disorder to which these symptoms may be attributed. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Notably, without a diagnosis of an underlying disorder, cannot be service-connected. Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. ORDER An initial disability rating in excess of 10 percent for a right shoulder disability is denied. An initial 10 percent rating, but no more, for a hiatal hernia is granted, subject to controlling regulations applicable to the payment of monetary benefits. An initial 10 percent evaluation, but no more, for a cervical spine disability is granted, subject to controlling regulations applicable to the payment of monetary benefits. An initial compensable rating for residuals of a right elbow fracture is denied. An initial compensable rating for a right shoulder scar is denied. An initial compensable rating for a right thumb scar is denied. An initial compensable rating for tension headaches is denied. An initial compensable rating for a right thumb fracture is denied. An initial compensable rating for a right ring finger fracture is denied. An initial compensable rating for plantar fasciitis is denied. Service connection for a low back disability is denied. Service connection for a groin condition is denied. ____________________________________________ B.T. KNOPE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs