Citation Nr: 1508122 Decision Date: 02/25/15 Archive Date: 03/11/15 DOCKET NO. 10-41 264 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Evaluation of carpal tunnel syndrome of the right upper extremity, rated as 10 percent disabling prior to September 10, 2013. 2. Evaluation of carpal tunnel syndrome of the right upper extremity, rated as 30 percent disabling since September 10, 2013. 3. Evaluation of carpal tunnel syndrome of the left upper extremity, rated as noncompensable prior to September 10, 2013. 4. Evaluation of carpal tunnel syndrome of the left upper extremity, rated as 20 percent disabling since September 10, 2013. 5. Evaluation of thoracolumbar strain, rated as 10 percent disabling prior to September 10, 2013. 6. Evaluation of thoracolumbar strain, rated as 20 percent disabling since September 10, 2013. 7. Entitlement to service connection for peripheral neuropathy of the lower extremities. 8. Entitlement to service connection for residuals of malaria. 9. Entitlement to service connection for bilateral hearing loss. 10. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Paul Bradley, Agent ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION The Veteran served on active duty from May 2004 to August 2008. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which denied the Veteran's claims for service connection of bilateral hearing loss, tinnitus, residuals of malaria, and peripheral nerve damage of the lower extremities. This decision also granted service connection for bilateral carpal tunnel syndrome and lumbar and thoracic strain, status-post fall; noncompensable disability ratings were assigned effective August 27, 2008. In an August 2010 rating decision, the disability rating assigned for the Veteran's lumbar and thoracic strain, status-post fall was increased to 10 percent disabling, effective August 27, 2008. This rating decision also provided for separate ratings for the Veteran's carpal tunnel syndrome; the Veteran was assigned a 10 percent disability rating for his right carpal tunnel syndrome and a noncompensable disability rating for his left carpal tunnel syndrome, effective August 27, 2008. More recently, in an August 2014 rating decision, the Veteran's lumbar and thoracic strain was recharacterized as listed above, and a 20 percent disability rating for thoracolumbar strain effective September 10, 2013. The Veteran was also granted an increased, 20 percent disability rating for his right carpal tunnel syndrome and an increased, 10 percent disability rating for his left carpal tunnel syndrome; an effective date of September 10, 2013 was assigned. The Veteran continued to disagree with the ratings assigned; therefore, the grant of higher ratings is not a full grant of the benefits sought on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims held that a TDIU claim is part of an increased rating claim when such claim is reasonably raised by the record. The Veteran was awarded TDIU in a November 2013 rating decision. As such, a claim for TDIU is not for consideration. The Virtual VA claims file has been reviewed. Other than VA treatment records considered by the RO in the August 2014 supplemental statement of the case, documents contained therein are duplicative of those in the paper claims file. Documents in the Veterans Benefits Management System are duplicative of those in the Virtual VA and paper claims files. FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's right (major) carpal tunnel syndrome has been manifested by no more than moderate incomplete paralysis of the median nerve. 2. Throughout the rating period on appeal, the Veteran's left (minor) carpal tunnel syndrome has been manifested by no more than moderate incomplete paralysis of the median nerve. 3. Throughout the entire rating period on appeal, the Veteran's thoracolumbar strain is manifest by pain and spasm, without abnormal gait or spinal contour. Forward flexion is at times limited to 60 degrees. 4. Peripheral neuropathy of the lower extremities was not manifest during service or within one year of separation. Peripheral neuropathy of the lower extremities is not attributable to service. 5. The Veteran was treated for malaria in service. There are no residuals of malaria. 6. The Veteran does not have bilateral hearing loss disability for VA disability compensation purposes. 7. Tinnitus is attributable to service. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating of 30 percent for carpal tunnel syndrome of the right upper extremity have been met for the period prior to September 10, 2013. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8515 (2014). 2. The criteria for a disability rating in excess of 30 percent for carpal tunnel syndrome of the right upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8515 (2014). 3. The criteria for an initial disability rating of 20 percent for carpal tunnel syndrome of the left upper extremity have been met for the period prior to September 10, 2013. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8515 (2014). 4. The criteria for a disability rating in excess of 20 percent for carpal tunnel syndrome of the left upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8515 (2014). 5. The criteria for a disability rating of 20 percent for thoracolumbar strain have been met for the period prior to September 10, 2013. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.71a, Diagnostic Codes 5235 to 5243 (2014). 6. The criteria for a disability rating in excess of 20 percent for thoracolumbar strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.71a, Diagnostic Codes 5235 to 5243 (2014). 6. Peripheral neuropathy of the lower extremities was not incurred in or aggravated by service, and cannot be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2014). 7. Residuals of malaria were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). 8. Bilateral hearing loss disability was not incurred in or aggravated by service, nor can an organic disease of the nervous system be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2014). 8. Tinnitus was incurred in wartime service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (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. In this case, the agency of original jurisdiction (AOJ) issued notice letters, dated in September 2008 and August 2012, to the Veteran. These letters explained the evidence needed to substantiate the claims for service connection, as well the legal criteria for entitlement to such benefits; the Veteran's claims for increased ratings are downstream from claims for service connection. Nevertheless, the letters explained the evidence necessary to substantiate claims for increased ratings, as well as the legal criteria for such benefits. The letters also informed him of his and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The claims file contains the Veteran's available service treatment records, reports of post-service treatment, and the Veteran's own statements in support of his claims. The Veteran was also afforded VA examinations responsive to the claims for increased ratings. The examination reports contain all the findings needed to rate the Veteran's service-connected disabilities, including history and clinical evaluation. The Board has reviewed the examination reports, and finds that they are adequate for the purpose of deciding the issues on appeal. The Veteran was afforded VA examinations responsive to the claims for service connection. McClendon v. Nicholson, 20 Vet. App. 79 (2006). The opinions were conducted by a medical professional, following thorough examination of the Veteran, solicitation of history, and review of the claims file. The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Disability Evaluations Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the service-connected disabilities have not materially changed and uniform evaluations are warranted. In addition, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Carpal Tunnel Syndrome The Veteran was assigned disability ratings for his carpal tunnel syndrome in accordance with the provisions of 38 C.F.R. § 4.124a, Diagnostic Code 8515. See 38 C.F.R. § 4.20 (when an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology, are closely analogous). The Veteran's carpal tunnel syndrome of the right (major) wrist is rated as 10 percent disabling prior to September 10, 2013 and 30 percent disabling thereafter. His carpal tunnel syndrome of the left (minor) wrist is rated as noncompensable prior to September 10, 2013 and 20 percent disabling thereafter. Under Diagnostic Code 8515, for the major wrist, a 10 percent evaluation is assigned for mild incomplete paralysis; a 30 percent rating requires moderate incomplete paralysis; and a 50 percent rating requires severe incomplete paralysis. A 70 percent disability rating requires complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of thenar eminence, the thumb in the plane of the hand; pronation incomplete and effective, absence of flexion of the index finger and feeble flexion of the middle finger, that cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of the thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. See 38 C.F.R. § 4.124a, Diagnostic Code 8515. Under Diagnostic Code 8515, for the minor wrist, a 10 percent rating requires mild incomplete paralysis. A 20 percent rating requires moderate incomplete paralysis. A 40 percent rating requires severe incomplete paralysis. A 60 percent disability rating requires complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of thenar eminence, the thumb in the plane of the hand; pronation incomplete and effective, absence of flexion of the index finger and feeble flexion of the middle finger, that cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of the thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. See 38 C.F.R. § 4.124a, Diagnostic Code 8515. The Veteran contends that higher disability ratings are warranted for his right and left carpal tunnel syndrome. The Veteran is right-hand dominant. This was confirmed in the March 2009 and September 2013 VA examination reports. After a review of the evidence, the Board finds that for the entire rating period on appeal the Veteran's service-connected right and left carpal tunnel syndrome more nearly approximates the criteria for a 30 percent rating on the right and a 20 percent rating on the left for the entire rating period on appeal, since August 27, 2008. The Veteran's right and left carpal tunnel syndrome have been characterized by no more moderate incomplete paralysis of the median nerve. According to the March 2009 VA examination reports, the Veteran complained of wrist pain. A May 2009 VA treatment record indicates that the Veteran avoided repetitive movements of the wrists, but experienced numbness; in September 2010, he complained of tingling, pain, and paresthesia of the upper extremities. A July 2010 record indicates that the Veteran stated that his symptoms were not relieved with use of splints; deep tendon reflexes were normal. At the more recent VA examination in September 2013, the Veteran complained of severe pain and paresthesia, and moderate numbness of the upper extremities. Upon examination, testing of muscle strength and reflexes was normal bilaterally; sensory examination of the upper extremities was also normal. Phalen's sign testing was negative, but Tinel's sign was positive bilaterally. Nerve testing showed moderate incomplete paralysis of the median nerve bilaterally. The Board acknowledges that the Veteran complained of severe symptoms at this examination, but points out that he had full fist closure without pain and no motor or sensory complaints at an April 2013 VA clinic visit; objective manifestations did not show that the Veteran has severe incomplete paralysis of the median nerve. In conclusion, the evidence of record reveals manifestations consistent with a 30 percent disability rating, but no higher, for carpal tunnel syndrome of the right upper extremity for the entire rating period, and that a 20 percent rating, but no higher, for carpal tunnel syndrome of the left upper extremity for the entire rating period. 38 C.F.R. §§ 4.3, 4.7. Thoracolumbar Strain The Veteran was initially assigned a 10 percent disability rating for his thoracolumbar strain pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237. As previously discussed, a 20 percent evaluation was assigned, effective September 10, 2013. Lumbosacral and cervical spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine ("general rating formula"). 38 C.F.R. § 4.71a, DCs 5237-5242. Intervertebral disc syndrome (IVDS) is rated under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. See 38 C.F.R. § 4.71a, DC 5243. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, entire thoracolumbar spine, or entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 68 Fed. Reg. 51,443, Note (5) (Aug. 27, 2003). The Formula for Rating IVDS Based on Incapacitating Episodes provides for ratings from 10 to 60 percent based on the frequency and duration of incapacitating episodes, defined in Note 1 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. The maximum 60 percent schedular rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the previous 12 months. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note 1 provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note 2 provides that, for VA compensation purposes, the combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. Note 4 provides that range of motion measurements are to be rounded to the nearest five degrees. Note 5 defines unfavorable ankylosis as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note 6 provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. According to the general rating formula, a 10 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is to be assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is to be assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is to be assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5237 for lumbosacral strain; Diagnostic Code 5242 for degenerative arthritis of the spine; and Diagnostic Code 5243 for intervertebral disc syndrome. After a review of all the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran's thoracolumbar strain most closely approximates a 20 percent disability evaluation for the entire rating period on appeal, since August 27, 2008. At the March 2009 VA examination, the Veteran had flexion to 90 degrees, extension to 30 degrees, and lateral flexion to 30 degrees bilaterally. VA treatment records dated 2009 through 2013 show consistent complaints of low back pain; in September 2010, there was pain and muscle spasm of the back. At the September 2013 VA examination, the Veteran had flexion to 60 degrees, extension to 20 degrees, lateral flexion to 20 degrees bilaterally, and lateral rotation to 20 degrees bilaterally. The Veteran's VA examination reports show pain, tenderness, and spasm, without guarding or abnormal gait. The VA examination reports and treatment records indicate that there was pain on motion, without weakness or atrophy; strength and reflex testing was normal. There was no evidence of postural abnormalities or abnormalities of the musculature of the spine. Thus, applying the facts to the criteria set forth above, the Veteran is entitled to a 20 percent evaluation, but no higher, for his service-connected thoracolumbar strain for the entire rating period on appeal (since August 27, 2008) under the General Rating Formula for Diseases and Injuries of the Spine. The Board finds that the criteria for a disability rating of 40 percent have not been met or more nearly approximated for any part of the rating period on appeal. The evidence shows that the Veteran experiences forward flexion of the thoracolumbar spine which is better than 30 degrees. Here, the lay evidence has been considered; however, that evidence when accepted as correct does not establish that he is functionally limited to 30 degrees or less. He does not experience incontinence or bowel complaints as a result of his thoracolumbar strain. Further, the evidence does not show favorable or unfavorable ankylosis of the entire thoracolumbar spine during the rating period on appeal. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. To the extent that the Veteran claims that his pain upon motion is the equivalent of limited motion, the Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current rating is based on the objectively demonstrated reduced motion; the VA examination reports indicate that the Veteran complained of pain, but physical examination did not demonstrate any additional limitations in response to pain, including incoordination, weakness, or fatigability, beyond which was reflected in the examination reports. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) ("pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system"). Therefore, the lay and medical evidence demonstrates that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a rating in excess of the current 20 percent disability rating. The evidence also shows that the Veteran's thoracolumbar strain has not been productive of incapacitating episodes for the rating period on appeal. The Veteran has not reported, and the evidence does not demonstrate, that he experiences incapacitating episodes requiring bed rest; the Veteran's treatment records do not confirm that his treating physicians noted any incapacitating episodes or prescribed bed rest. With consideration of the provisions of Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, the Board notes that there is no objective evidence of record for the entire rating period on appeal which demonstrates that the Veteran experiences any neurologic symptomatology of the lower extremities. As the Veteran is separately evaluated for his neurological deficits of his right and left upper extremities, it is not for consideration here. Extraschedular Considerations As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's carpal tunnel syndrome and thoracolumbar strain are fully contemplated by the applicable rating criteria. As shown above, the rating criteria include symptoms, which were addressed in the VA examination reports and which provided the basis for the disability ratings assigned for the period on appeal. In any event, the evidence does not reflect that there has been marked interference with employment, frequent hospitalization, or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. Therefore, referral for consideration of extraschedular ratings for the Veteran's carpal tunnel syndrome and thoracolumbar strain is not warranted. 38 C.F.R. § 3.321(b)(1). Finally, the Board notes that under Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. In the absence of exceptional factors associated with carpal tunnel syndrome and thoracolumbar strain, the Board finds that the criteria for submission for assignment of extraschedular ratings pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2014). To establish a right to compensation for a present disability, a Veteran must show: (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-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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. As peripheral neuropathy, tinnitus, and bilateral hearing loss are chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310. The Veteran's DD Form 214 reflects that his military occupational specialty was interior electrician and that he had service in Afghanistan from January 2005 to January 2006; the Board notes that the Veteran does not have any military awards which are indicative of combat per se, but points out that the Veteran's DD 214 reflects service in an imminent danger pay area and training as a marksman, sharpshooter, and expert with a machine gun. As will be discussed below, the Board therefore finds that he had in-service noise exposure. See 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a) (each disabling condition for which a veteran seeks service connection must be considered based on factors including the basis of places, types, and circumstances of service as shown by service record). Peripheral Neuropathy and Residuals of Malaria The Veteran claims that he has residuals of malaria related to his active service. He also claims that he has peripheral nerve damage related to his service, including as secondary to his service-connected thoracolumbar strain. The Board acknowledges that the Veteran's service treatment records reflect a diagnosis of malaria. A July 2006 treatment record indicates that the Veteran was given a malaria smear test, which was normal; the assessment was viral syndrome. A November 2006 post-deployment examination report was normal; an associated notation indicates that the Veteran reported a history of malaria, which was resolved with treatment and without any symptoms. Service treatment records dated November 2007 show that malaria was listed as "problem" and that the Veteran complained of a "malaria outbreak"; the assessment was genital rash and headaches. Another November 2007 record indicated that the Veteran reported a history of malaria 14 months earlier. The Board acknowledges that the Veteran's service treatment records reflect a malaria diagnosis and that the Veteran complains of peripheral neuropathy, sciatica, and radiculopathy due to his service-connected thoracolumbar strain. However, the March 2009 VA examination was normal; there was no evidence of any residuals of malaria and the VA examiner noted that there were no objective findings of malaria in the Veteran's service treatment records. In addition, both the March 2009 VA examination and the September 2013 VA examination were negative for any neurological symptoms or diagnoses related to the lower extremities. Physical examination and EMG testing did not show any evidence of peripheral neuropathy (or sciatica or radiculopathy); sensory examination was negative. In the absence of disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There is also no probative evidence of treatment for residuals of malaria or peripheral neuropathy of the lower extremities in any of the Veteran's post-service treatment records. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000) (a Veteran seeking disability benefits must establish the existence of a disability and a connection between such Veteran's service and the disability). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Veteran is competent to report that he has been diagnosed with malaria and that he has neurological symptoms in his lower extremities. However, his statements must be balanced against the other evidence of record, which does not show current residuals of malaria or peripheral neuropathy of the lower extremities. To the extent that there are lay statements asserting that the Veteran has a residuals of malaria or peripheral neuropathy of the lower extremities related to an in-service injury or illness, including his service-connected thoracolumbar strain, the Board finds that the probative value of the general lay assertions are outweighed by the medical evidence of record which does not show any pathology, disease or residuals of injury. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011) (noting impropriety of the Board categorically discounting lay testimony and requiring the Board to determine, on a case by case basis, whether a veteran's particular disability is the type of disability for which lay evidence is competent); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). The Board has also considered the case under the law governing Gulf War veterans. Howevever, neither claimed condition qualifies as an undiagnosed illness for compensation purposes. Malaria is a known clinical diagnosis and is therefore excluded. In regard to the neurologic complains, the objective testing disclosed that he was normal. Thererfore, he does not have a disability (impairment), and in the absence of disability, there can be no valid claim, 38 U.S.C.A. § 1117. For purposes of section 1117, VA defines disability as an inability to pursue an occupation due to physical or mental impairment. However, unlike 38 U.S.C.A. § 1110, the disability need not be due to an identified disease or injury. See, Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); 38 C.F.R. § 4.1. However, regardless of addressing an issue under section 1110, 1131 or 1117, there must be disability (impairment) and here, there is none. For the foregoing reasons, the preponderance of the evidence is against the claims for service connection of residuals of malaria and peripheral neuropathy of the lower extremities. The benefit-of-the-doubt doctrine is therefore not for application, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Bilateral Hearing Loss Disablity The threshold for normal hearing is from 0 to 20 decibels. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Despite the Veteran's complaints of bilateral hearing loss, the post-service medical evidence reflects that the Veteran does not have hearing loss disability of either ear for VA disability benefits purposes at any time. He had a Maryland CNC speech recognition score of 100 percent bilaterally at the March 2009 VA examination. Pure tone thresholds at the relevant frequencies were all 25 decibels or less. Similarly, his military and VA audiological evaluations show that the Veteran does not have sufficient hearing loss in either ear to meet the threshold minimum requirements of 38 C.F.R. § 3.385 to be considered a disability by VA. See Brammer, supra (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). The Board acknowledges the Veteran's noise exposure during service and his assertions that this noise exposure caused his bilateral hearing loss. Nonetheless, the Board notes that, despite the Veteran's complaints, the Veteran did not have auditory thresholds of 26 decibels or greater in at least three frequencies for either ear, or auditory threshold in excess of 40 decibels in either ear at any time. Clearly the Veteran is competent to report a decrease in hearing acuity. However, the results of the audiometric examination are controlling. Furthermore, in the absence of disability, the issue cannot be considered under 38 U.S.C.A. § 1117. For the foregoing reasons, the preponderance of the evidence is against the claim of service connection for bilateral hearing loss disability. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Tinnitus The March 2009 VA audiological examination established that the Veteran suffers from tinnitus. Likewise, the Veteran reported experiencing tinnitus since service at a September 2009 VA PTSD examination. The Veteran reported exposure to gunfire, artillery, explosions, aircraft, and power tools. As previously indicated, the Board finds that the Veteran had in-service noise exposure. Regarding tinnitus, the Board observes that the March 2009 VA examiner stated that, since the Veteran did not have bilateral hearing loss, the etiology was unknown; an addendum stated that no etiology could be determined for the tinnitus without resorting to speculation. Nonetheless, the Veteran's competent and credible statements thus provide a nexus linking his current tinnitus and to his in-service noise exposure. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2008) (lay evidence may suffice to prove service connection on its own merits). The March 2009 VA examiner's inconclusive nexus opinion failed to address the Veteran's credible lay statements attesting the onset of tinnitus during service or his documented history of noise exposure in service. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative); 38 C.F.R. § 3.303(d) (service connection warranted in some circumstances where disease is first diagnosed after service). Hence, on this record, the evidence is found to be at least evenly balanced in showing that the Veteran's tinnitus at least as likely as not had clinical onset following his exposure to harmful noise levels in connection with his service in Afghanistan. In resolving all reasonable doubt in the Veteran's favor, service connection is warranted. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Entitlement to a 30 percent disability evaluation for carpal tunnel syndrome of the right upper extremity is granted for the period prior to September 10, 2013, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a disability evaluation in excess of 30 percent for carpal tunnel syndrome of the right upper extremity is denied. Entitlement to a 20 percent disability evaluation for carpal tunnel syndrome of the left upper extremity is granted for the period prior to September 10, 2013, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a disability evaluation in excess of 20 percent for carpal tunnel syndrome of the left upper extremity is denied. Entitlement to a 20 percent disability evaluation for thoracolumbar strain is granted for the period prior to September 10, 2013, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to a disability evaluation in excess of 20 percent for thoracolumbar strain is denied. Entitlement to service connection for peripheral neuropathy of the lower extremities is denied. Entitlement to service connection for residuals of malaria is denied. Entitlement to service connection for bilateral hearing loss disability is denied. Entitlement to service connection for tinnitus is granted. ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs