Citation Nr: 1535962 Decision Date: 08/21/15 Archive Date: 08/31/15 DOCKET NO. 11-27 030 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for paresthesias in the region supplied by the left infraorbital nerve. 2. Entitlement to an evaluation in excess of 10 percent for residuals, status post left shoulder strain. 3. Entitlement to an evaluation in excess of 10 percent for residuals, status post right shoulder strain. 4. Entitlement to an evaluation in excess of 10 percent for carpal tunnel syndrome of the right wrist. 5. Entitlement to an evaluation in excess of 10 percent for service-connected headaches. 6. Entitlement to service connection for a low back disorder. 7. Entitlement to service connection for a left eye disorder only as secondary to service-connected paresthesias in the region supplied by the left infraorbital nerve. 8. Entitlement to service connection for a sleep disorder other than sleep apnea. 9. Entitlement to service connection for anxiety. 10. Entitlement to service connection for a right knee disorder. 11. Entitlement to service connection for a left knee disorder. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Higgs, Counsel INTRODUCTION The Veteran served on active duty from July 2001 to July 2005. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2011 rating decision of the Lincoln, Nebraska, Department of Veterans Affairs (VA) Regional Office (RO). In May 2013, the Veteran testified at a video conference hearing before a Veterans Law Judge (VLJ). The VLJ who conducted the hearing has since left the Board. In July 2014, the Veteran was notified of this fact and given the opportunity to request another Board hearing. However, that same month, the Veteran responded that he did not want another hearing. In a January 2014 decision, the Board denied the issues of whether new and material evidence had been received to reopen a claim for service connection for bilateral hearing loss and entitlement to an increased rating for carpal tunnel syndrome of the right wrist. Thereafter, the Veteran appealed the portion of the decision that denied an increased rating for carpal tunnel syndrome of the right wrist to the United States Court of Appeals for Veterans Claims (Court). In a May 2014 Joint Motion for Remand (JMR), the Secretary of VA and the Veteran (the parties) moved the Court to vacate the January 2014 decision with respect to the denial of entitlement to an increased rating for carpal tunnel syndrome of the right wrist, and the Court granted the motion in a May 2014 Order. The JMR also noted that the Veteran did not challenge the determination in the January 2014 decision with respect to the denial of whether new and material evidence had been received to reopen a claim for bilateral hearing loss. Therefore, that issue is no longer before the Board. The Board remanded the matter of entitlement to a rating in excess of 10 percent for carpal tunnel syndrome of the right wrist in January 2015 for further development and adjudication in compliance with the May 2014 Joint Motion for Remand and Order of the Court. In April 2015, the AOJ granted an increased rating of 10 percent for paresthesias in the region supplied by the left infraorbital nerve, claimed as numbness of the left side of the face. The Veteran has continued his appeal for a higher rating. See AB v. Brown, 6 Vet. App. 35 (1993). The AOJ initially denied the Veteran's claim for service connection for left knee strain and right knee strain in a rating decision dated in August 2005. The claim was denied based in part on a March 2005 pre-discharge VA examination at which a diagnosis of status post bilateral knee strain with no current residuals was rendered. However, in June 2006, within one year after issuance of the August 2005 rating decision, private treatment records from the Nebraska Medical Center were received that indicated the Veteran was shown by X-ray to have effusion in the left knee in December 2005, and was noted to have mild tenderness around the patellar regions of the knees and diagnosed as having possible patellofemoral syndrome of the knees in October 2005 and November 2005. A December 2005 X-ray of the right knee was said to show "just a little dislocation of the right patella in groove otherwise no evidence of arthritis." Further, it was suggested that he seek physical therapy for his bilateral knee disorder, and in December 2005 he was prescribed Celebrex specifically for his knee pain. By history, in October 2005, it was related that the Veteran had experienced his knee pain "for a few years," which would relate the condition back to his period of active service. The Board finds that, as to the matters of current disability and whether the condition began during active service, the above-discussed records of treatment at the Nebraska Medical Center received in June 2006 constituted new and material evidence received within one year after the August 2005 denial of his claims for service connection for left and right knee strain. As a result, the August 2005 decision did not become final and readjudication was to be accomplished without the requirement that new and material evidence be received to reopen the claim. See 38 C.F.R. § 3.156(b) (2015). Consequently, the Board has rephrased the issues on appeal as for service connection for left and right knee disabilities without the requirement that new and material evidence be received to reopen the claim. See 38 C.F.R. § 3.156(b); Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). In April 2015, the Veteran submitted additional evidence along with a waiver of initial consideration by the RO of all newly submitted evidence from that time forward. Thus, the Board will consider the evidence received since the most recent Supplemental Statements of the Case issued in conjunction with this appeal. See 38 C.F.R. § 20.1304(c). This appeal was processed using the paperless, electronic Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. Here, the Veteran attempted to submit a new claim for service connection for sleep apnea by a VA Form 21-526EZ application in August 2014. The Veteran related that a VA examiner had told him that some of his sleeping problems may be related to sleep apnea, although he had never been tested for sleep apnea. The AOJ found this to be a continuation of a claim for service connection for a sleep disorder. However, the Board agrees with the Veteran that this is an etiologically separate claim from his appealed claim for a sleep disorder, which, upon reviewing the claims file, is a claim for service connection for insomnia related to service-connected PTSD, a condition etiologically and physiologically distinct from sleep apnea. The issue of service connection for sleep apnea has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for a low back disorder, and right and left knee disorders, and entitlement to increased evaluations for the right and left shoulder disorders, right carpal tunnel syndrome, and headaches are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1 The preponderance of the evidence shows that the Veteran does not have a current left eye disorder that is caused or aggravated by his service-connected paresthesias in the region supplied by the left infraorbital nerve. His myokymia is a benign idiopathic condition that is not caused or aggravated by service-connected paresthesia in the area of the left infraorbital nerve. 2. The preponderance of the evidence shows that the Veteran does not have severe nerve damage of his fifth (trigeminal) cranial nerve, but rather has moderate, incomplete impairment. 3. The evidence indicates that the Veteran's sleep difficulty and anxiety are part and parcel of his service-connected PTSD and are not separate disabilities. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for paresthesias in the region supplied by the left infraorbital nerve, claimed as numbness of the left side of the face, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.124a, Diagnostic Code 8205 (2015). 2. The criteria for service connection for a left eye disorder have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). 3. The criteria for service connection for a sleep disorder have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). 4. The criteria for service connection for anxiety have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify & Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The notice must be provided to the Veteran prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). For the claims for service connection and a higher initial rating for paresthesia in the area of the left infraorbital nerve, VA has satisfied its duty to notify by issuing notice letters in August 2010 and October 2011. The letters advised the Veteran of what evidence was required to substantiate his claims, and of his and VA's respective duties for obtaining evidence. The letters provided notice regarding the disability evaluation and effective date elements of a service connection claim. Dingess, 19 Vet. App. at 473. Although arguably not all required notice was provided prior to the date of initial adjudication in February 2011, this was no more than harmless, nonprejudicial error, as the claims were readjudicated thereafter, including as recently as in April 2015 supplemental statement of the case. Id. Moreover, the claim for a higher initial rating for the region supplied by the left infraorbital nerve arises from a notice of disagreement with the initial rating awarded with the grant of service connection in February 2011. Thus the claim was not only substantiated, it was proven, and no further duty to notify arose upon receipt of the notice of disagreement with the initial rating assigned. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice arises upon receipt of a notice of disagreement). The duty to assist provisions of the VCAA have been met. The claims file contains service treatment records (STRs), reports of post-service medical treatment, and VA examination reports dated in January 2011, September 2012, March 2014, and October r2014, for the Veteran's claims. There is no requirement that a medical examiner comment on every favorable piece of evidence in a claims file. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012); Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners). Examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion. Monzingo, 26 Vet. App. at 105. These examinations taken together, and particularly as supplemented by the March 2014 VA examination and October r2014 opinion, are adequate, and a new VA examination to rate the severity of his paresthesia in the area of the left infraorbital nerve or to adjudicate the claims for service connection is not warranted. The March 2014 VA examiner explained his findings at length and made all required findings to adjudicate the claims, in a manner which allows his opinions and reports to be afforded a very high probative value, as will be discussed below at length. The October 2014 addendum opinion addressed the etiological issue. The examination reports sufficiently informs the Board of the medical expert's judgment on the medical questions at issue and the essential rationale for those opinions. Monzingo, 26 Vet. App. at 105. The Veteran has submitted personal statements and representative argument. Additionally, the Veteran testified at a May 2013 Board videoconference hearing before a VLJ no longer at the Board. It is the responsibility of the hearing officer to explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position. 38 C.F.R. § 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The hearing officer has two distinct duties under section 3.103(c)(2). First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Bryant, 23 Vet. App. at 496 (finding that a hearing officer's inquiries regarding the existence of a current disability and a nexus to service did not equate to explaining to the claimant that these issues were material to substantiating the claim). Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Bryant, 23 Vet. App. at 496-97. The rule of prejudicial error applies in assessing any deficiency with respect to the hearing officer's duties under section 3.103(c). Bryant, 23 Vet. App. at 498. Although the hearing officer did not explicitly explain the material issues of medical nexus and current disability, the "clarity and completeness of the hearing record was intact" and the purpose of section 3.103(c)(2) fulfilled because the record reflected that these issues were developed by VA, including the provision of a VA examination, and there was no indication that the appellant had any additional information to submit. Bryant, 23 Vet. App. at 498-99. At the hearing, the Veteran testified as to the current severity of his let infraorbital nerve impairment and the nature of the disabilities for which he sought service connection. He demonstrated a clear understanding of what was required to establish service connection. He was asked if any medical professional had provided a medical nexus. He was subsequently afforded VA examinations to determine the nature of the claimed left eye condition and whether it was related to service. He discussed the nature and extent of his facial nerve impairment at length. Moreover, any deficiencies in the May 2013 Board hearing under section 3.103(c)(2) were not prejudicial, because the matter was addressed at length and in depth at the March 2014 VA examination and October 2014 addendum opinion. Through notice letters, the Veteran has been advised of what evidence would substantiate his claims, and accorded opportunities to provide substantiating evidence. VA has otherwise developed this claim, including obtaining records on the Veteran's behalf and providing VA examinations which specifically address the outstanding issues in this case. A great deal of new private and VA medical records have been sought and obtained. There is no indication of any outstanding evidence he might submit with respect to his claimed left eye disability and his service-connected left infraorbital nerve disorder. See id. at 499. Thus, given the development undertaken by VA with respect to this claim, and in light of the Veteran's testimony at the hearing, the clarity and completeness of the hearing record is intact and the purpose of section 3.103(c)(2) to develop the record has been fulfilled. Accordingly, the Veteran's right to a Board hearing has been satisfied and no prejudicial error exists with regard to the hearing officer's duties under section 3.103(c)(2). The Board notes that the VLJ who conducted the hearing has since left the Board. In July 2014, the Veteran was notified of this fact and given the opportunity to request another Board hearing. However, that same month, the Veteran responded that he did not want another hearing. The Veteran has not made the RO or the Board aware of any additional evidence that must be obtained in order to fairly decide the matters adjudicated directly below. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the issues are ready for appellate review. Service Connection--General Law and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prevail on the merits on the issue of service connection, there must be competent evidence of current disability; competent evidence of in-service incurrence or aggravation of a disease or injury; and competent evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Secondary service connection shall be awarded when a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable. 38 C.F.R. § 3.310(a). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) competent evidence of a current disability; (2) a service-connected disability; and (3) competent evidence of a nexus between the service-connected disease or injury and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even in cases where the disability resolves prior to the Secretary's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321-323 (2007). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Service Connection for a Left Eye Disorder The Veteran seeks service connection for a left eye disorder, which he claims is caused or aggravated by his service-connected paresthesias in the distribution of the left cranial nerve. Initially, the Board notes that the Veteran has indicated that he felt he may have blurred vision and pain behind his eye as a result an injury in the area of his left infraorbital nerve during active service. He indicated at his May 2013 Board hearing that he felt that episodes of blurred vision and tearing were related to his eye twitches, which were in turn related to his in-service facial nerve injury. In contrast, three detailed VA eye and neurological examinations, discussed below, collectively constituting competent evidence of a very high probative value and weight, have indicated that Veteran has no visual impairment, and the Veteran has most recently indicated that his eyes work fine, as recorded at the March 2014 VA examination. The Board finds the medical findings of the VA examiners to be of a greater probative value than the lay impression of the Veteran that symptoms he experiences such as eye twitching are related to nerve or other damage affecting the left eye. Thus, the Board finds the preponderance of the evidence to show there is no current eye-related visual impairment. However, there is left the matter of whether service connection is warranted for the Veteran's left myokymia, or left eyelid twitching. At a VA eye examination in January 2011, there were no physical findings of abnormal accommodation, abnormal lacrimal duct function, or abnormal eyelids, chronic conjunctivitis, residuals of eye injury, legaphthalmos, symblepharon, ptosis, nystagmus, eyelash loss, or eyebrow loss. The Veteran did have paresthesia extending from under the medial left lower lid extending downward to the left upper lip. The examiner found the Veteran to have symptoms consistent with lid myokymia on the left, which he noted to be a benign condition of occasional twitching of eyelid muscles. The examiner asserted that this was likely idiopathic and not related to the prior trauma. The examiner found no ophthalmic etiology for the Veteran's left eye pain. The examiner found the Veteran's left facial paresthesias was related to an in-service injury. The examiner opined that no other significant pathology was found. At a VA examination in September 2012, the examiner diagnosed left eyelid myokymia and left infraorbital nerve paresthesia. The examiner noted that, as documented in the STRs, the Veteran was injured when the nose of a football hit him in the left eye during active service, in March 2002. The Veteran was noted to have been stunned at first, but was reportedly fine after he had iced the area. He denied pain, but the area was slightly numb. Eye motility was normal bilaterally, pupils were normal, and visual acuity was 20/15 bilaterally. Some left eye ecchymosis was noted. The examiner commented that it was unclear whether the STR note meant the conjunctiva or the periorbital tissues, but that it was likely the latter. The September 2012 VA examiner noted that the Veteran additionally described an intermittent twitching of the left orbicularis muscle. He described fasciculation that starts without any predictable exacerbating factor and typically resolves within minutes. The Veteran indicated that he noticed this after the in-service football accident but was unsure if it was present prior to the injury. He denied involuntary strong forceful closure characteristic of facial spasm or blepharospasm. On examination correct and uncorrected visions was 20/40 or better. The pupils were round and reactive to light. There was no afferent pupillary defect present. He did not have a corneal irregularity that resulted in severe irregular astigmatism. He did not have diplopia. He did not have a visual field defect. His eyelid condition was indicated not to cause scarring or disfigurement. The examiner commented that the Veteran's symptoms were consistent with lid myokymia on the left, which was a benign condition of occasional twitching of the eyelid muscles. The examiner commented that this was likely idiopathic was not related to the prior trauma. The Veteran reported that the condition was stable. The examiner reported that the myokymia was not witnessed on examination as is typically the case with this sporadic phenomenon. The examiner commented that it can occur more frequently when a patient uses stimulants like caffeine, illicit drugs, etc., but was more commonly idiopathic and benign. At a VA examination in March 2014 the Veteran related that his left and right eyes were working fine. The examiner found that the Veteran's eyelid myokymia was less likely than not cause by or aggravated by the infraorbital nerve paresthesia. He related that eyelid myokymia was a typically benign condition that causes lid twitching when an individual is fatigued or occasionally with stimulant usage. The examiner noted that eyelid twitching can also be caused by facial nerve compression, but that there was no evidence of this. The examiner stated that infraorbital nerve injury is not known to cause myokymia. The examiner noted that the Veteran had abnormal sensation and pain under the left eye, which he found was caused by the left infraorbital nerve injury. The symptoms were noted to be in the distribution of the infraorbital nerve and consistent with the Veteran's injury. The examiner opined that the eyelid myokymia was less likely than not caused by or aggravated by the infraorbital nerve paresthesia. The examiner commented that eyelid myokymia is a typically a benign condition that causes lid twitching when an individual is more fatigued or occasionally with stimulant usage. The examiner discussed the possibility that the nerve injury may have been related to an orbital fracture on the left and that a CT scan could be helpful in this regard. Days after the examination, a VA CT scan of the orbits of the Veteran's eyes was conducted. The examiner reviewed the report and found that CT of the orbits was normal. Further he found that there was no evidence of any prior orbital fracture or damage to the infraorbital canal. The Board finds the opinion of the March 2014 VA examiner that the Veteran's eyelid twitching is a benign myokymia that is not related to his service-connected paresthesias in the area of the left infraorbital nerve to be of significant probative value and weight. The opinion is well-explained, based on expert examination and analysis, and sufficient to inform the Board of the examiner's findings and essential rationale. To the extent the Veteran believes his left myokymia, or left eye lid twitching, to be related to his paresthesias in the area of the left infraorbital nerve, the Veteran is not competent to provide such an opinion. Though it is easy to understand why the Veteran might feel that his eyelid twitching is related to his nerve injury in the same general area, nerve distributions and areas affected by injury of a specific nerve, are highly complex medical matters not susceptible to lay observation and outside of the competence of a layperson. Additionally, however, the Board finds the March 2014 VA examiner's opinion to be very highly probative and to outweigh any nexus opinion provided by the Veteran. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for resolution of this aspect of his appeal. See Gilbert, 1 Vet. App. at 55. Service Connection for Anxiety and Sleep Disorder The Veteran seeks service connection for anxiety and a sleep disorder. He has characterized his sleep disorder as insomnia and trouble falling asleep. At a June 2012 VA PTSD examination, the diagnosis was service-related PTSD. The examiner expressly found that there was no more than diagnosable mental health disorder, which encompasses anxiety. In evaluating the Veteran's symptoms, the examiner did not check the boxes for difficulty falling or staying asleep, chronic sleep impairment, or anxiety as among the Veteran's PTSD symptoms. In a March 2014 addendum opinion, however, the examiner reviewed the claims file, and affirmatively indicated that the Veteran's anxiety problems and sleep impairment are related to the Veteran's service connected PTSD. The examiner noted that there was no other diagnosable sleep disorder from non-mental health causes. The Board finds that service connection for these disorders is not warranted as the medical evidence indicates that they are not separate disorders, but aer symptoms related to the Veteran's service-connected PTSD. To the extent the Veteran claims they are separate disabilities, his opinion is outweighed by the VA examiner, who has explained his findings after a lengthy examination of the Veteran an detailed review of the claims fiel. The Board notes that in assigning a rating for aspects of the Veteran's service-connected PTSD, these symptoms will be included by the RO, to include in the adjudication of the Veteran's referred claim for an increased evaluation for PTSD. As noted in the introduction section of this decision, above, the Veteran's claim for service connection for sleep apnea is a claim for an etiologically and medically separate disorder that has yet to be adjudicated by the AOJ. Increased Rating Paresthesias Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2015). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. The use of manifestations not resulting from service-connected disease or injury in establishing the service-connected rating is to be avoided. 38 C.F.R. § 4.14. Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, evaluations may be "staged." See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). This, in turn, will compensate the veteran for times since the effective date of his award when his disability may have been more severe than at other times during the course of his appeal. The Veteran's paresthesia in the region supplied by the left infraorbital nerve is rated under Diagnostic Code (DC) 8205 for paralysis of the fifth (trigeminal) cranial nerve. Under DC 8205, a 10 percent rating is warranted for moderate incomplete paralysis of the nerve; a 30 percent rating is warranted for severe incomplete paralysis of the nerve; and a 50 percent rating is warranted for complete paralysis of the nerve. The rating is dependent on relative degree of sensory manifestation or motor loss. See 38 C.F.R. § 4.124a, Diagnostic Code 8205. Diagnostic Code 8205 is the appropriate rating code in this matter because it identifies the specific nerve affected and adequately encompasses the Veteran's neurological symptoms. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Lay statements may serve to support a claim by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran's paresthesias in the region supplied by the left infraorbital nerve, claimed as numbness of the left side of the face, are currently rated as 10 percent disabling, for incomplete, moderate impairment, under Diagnostic Code 8205. At a January 2011 VA examination the examiner found the Veteran to have paresthesia extending from under the medial left lower lid extending downward to the left upper lip. The January 2011 examiner found no ophthalmic etiology for the Veteran's left eye pain. The examiner noted that the Veteran did not seem particularly bothered by the left eye complaint. The examiner opined that no other significant pathology was found. In September 2012, the Veteran was afforded a VA examination to determine the current severity of his service-connected paresthesias in the region supplied by the left infraorbital nerve. The Veteran described a stable paresthesia in the left mid-face (infraorbital distribution). The Veteran described being slightly numb in the area. He described paresthesia in the region of the left infraorbital nerve. The examiner indicated that these sensations often resolve a few months after nerve injury. He commented that it was possible that the orbital floor was fractured, a common reason for injury to this nerve; however, a direct injury to the nerve outside of the maxilla was possible as well. The examiner commented that the orbital fracture, if one existed, would be best seen with a CT of the orbits. The VA examiner noted upon review of the claims file that no imaging of the infraorbital nerve had been taken during the in-service accident as well as post-service. Therefore, it could not be determined if there was a fracture to the orbital floor or direct injury to the nerve outside of the maxilla without an orbital computed tomography (CT) scan. At a VA examination in March 2014 the Veteran related that his left and right eyes were working fine. He was noted to have mild paresthesias or dsythesias of the mid-face. He was diagnosed as having impairment of the left cranial nerve that was incomplete and moderate. The examiner opined that the Veteran had abnormal sensation and pain under the left eye caused by the left infraorbital nerve injury. The symptoms were noted to be in the distribution of the infraorbital nerve and consistent with the Veteran's injury. Like the September 2012 examiner, the March 2014 examiner discussed the possibility that the nerve injury may have bene related to an orbital fracture on the left and that a CT scan cold be helpful in this regard. The examiner opined that the impairment of the trigeminal nerve was incomplete and moderate. He noted that paralysis was not present, as paralysis implies loss of the ability of movement. He elaborated that a paresthesia, or alteration of sensation, was present. He noted that the trigeminal nerve supplies sensation to the face. He wrote that on particular branch of the trigeminal nerve was affected in this case, the infraorbital nerve. He described this as a small percentage of the entire sensory innervation of the trigeminal nerve. He noted that the trigeminal nerve also has a motor component, the muscles of the jaw and mastication, and that this was unaffected. Days after the examination, a VA CT scan of the orbits of the Veteran's eyes was conducted. The March 2014 VA examiner reviewed the report and in a VA examination addendum report found that CT of the orbits was normal. He concluded that that there was no evidence of any prior orbital fracture or damage to the infraorbital canal. The March 7, 2014, CT scan report itself states that the orbits appeared normal without deformity; soft tissues of the orbits appeared normal; there was no evidence of a previous blowout fractures; the canal for the infraorbital nerve was normal and the infraorbital foramen was normal bilaterally. The impression was normal CT study of the facial bones. The claims file also includes a report of a July 2014 MRI of the brain which states that visualized orbits, paranasal sinuses, skull base and calvarium were unremarkable. The evidence of record shows moderate and incomplete paralysis and not severe. The Board finds the March 2014 VA examiner's rationale for finding that the Veteran's impairment of the left infraorbital branch of the trigeminal nerve was moderate to be well-explained and analyzed. It is explained that the impairment is sensory and only a small part of the distribution of the trigeminal nerve and that the motor components of the nerve are unaffected. The opinion reflects expertise in the appropriate area of medicine and the opinion is well-reasoned and well-explained. Therefore, the Board finds this opinion to be of significant probative value and weight. To the extent the Veteran may contend that the impairment is severe, he has not alluded to specific symptoms or manifestations, of which he would be competent to report, that would support the use of the descriptive term "severe." The histories and descriptions provided by him consistent indicate abnormal sensation of a portion of the face, which the Board finds is best described by the term "moderate." To the extent the Veteran believes his left eye lid twitching to be part of the disability picture, the Board finds the March 2014 VA examiner's opinion to be very highly probative that the Veteran's service-connected injury to the left infraorbital nerve is not a disorder of a type that would result in or aggravate twitching of the eyelid. Though it is easy to understand why the Veteran might feel intuitively that his eyelid twitching is related to his nerve injury in the same general area, nerve distributions and areas affected by injury of a specific nerve are outside of the competence of a layperson, and therefore the Veteran's opinion as to this matter is of a low probative value as compared to the technical medical neurological analysis of the VA examiner. For the reasons discussed above, the Board finds that the preponderance of the evidence shows that the Veteran's impairment of the infraorbital branch of the left trigeminal nerve is best described as moderate rather than severe. Accordingly, the current rating of 10 percent under Diagnostic Code 8205, best characterizes the level of impairment, and the next higher rating of 30 percent, for incomplete severe impairment, is not warranted. See 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8205. There is no period for which severe findings are present-there is only stable sensory impairment of the infraorbital section of the trigeminal nerve as described by the three VA examiners. Accordingly, a staged rating of 30 percent or higher for incomplete severe or greater impairment is not warranted for any period subject to this appeal. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). The Board has also considered whether referral for an extraschedular rating is appropriate. In this regard, the Board notes that ratings are generally based on average impairment, and that the rating schedule represents, as far as is practicable, the average impairment of earning capacity. See 38 C.F.R. § 3.321(a), (b). However, in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.3211 (b). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. at 115-16. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, and is therefore found to be inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. Id. Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Id. As noted above, the Veteran's paresthesias in the region supplied by the left infraorbital nerve, claimed as numbness of the left side of the face, involves abnormal sensation and pain in the affected area. Such impairment is specifically contemplated by the rating criteria. See 38 C.F.R. § 4.124a, Diagnostic Code 8205. The impairment as ascertained by VA examiners is sensory, as there is no loss of ability of movement, whereas he does have paresthesia. The examiner specifically found that the muscles of the jaw and mastication, as can be affected by the motor component of the trigeminal nerve, were unaffected. The abnormal sensation resulting from the disorder is fully contemplated by the rating code and in the rating assigned. Accordingly, the Board finds that the Veteran does not present such an exceptional or unusual disability picture that the available schedular evaluation for his carpal tunnel syndrome of the right wrist is inadequate. Therefore, the Board concludes that referral for consideration of an extraschedular rating is not warranted in this case. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). As Board finds that the preponderance of the evidence is against the claim for a rating in excess of 10 percent for paresthesias in the region supplied by the left infraorbital nerve, claimed as numbness of the left side of the face, the benefit-of-the-doubt rule is not for application in resolution of this matter. See Gilbert, 1 Vet. App. at 55. ORDER Entitlement to a rating in excess of 10 percent for paresthesias in the region supplied by the left infraorbital nerve is denied. Entitlement to service connection for a left eye disorder is denied. Entitlement to service connection for a sleep disorder secondary to service-connected PTSD is denied. Entitlement to service connection for anxiety secondary to service-connected PTSD is denied. REMAND Increased Evaluation Right Carpal Tunnel Syndrome Remand is required for additional VA records and current examination. The most recent records of VA treatment in the claims file are from January 2015. The most recent VA examination was in February 2015. The most recent Supplemental Statement of the Case is dated in March 2015. In May 2015 correspondence, the Veteran stated that his current treating physician had informed him his carpal tunnel syndrome had worsened. He also indicated that he went to VA primary care in April 2015 for both his right and left carpal tunnel symptoms, and that he received shots and an EMG was to be ordered if the pain and numbness were still affecting him. The AOJ should seek to obtain the updated records of treatment and afford the Veteran a new VA examination in light of his worsening symptoms. See 38 C.F.R. § 3.159(c) (noting that the duty to assist included obtaining relevant VA records); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (stating that when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate). Increased Evaluation for Headaches Remand is required for private treatment records and a current VA examination. At the Veteran's most recent VA examination for his headaches, in March 2014, the examiner indicated that it was less likely than not that the Veteran had characteristic prostrating headaches. It was indicated he had undergone no assessment for headaches since 2013. The examiner noted he was not on any type of abortive medications for migraines. He was noted to have been taken off of abortive medications for headaches. The examiner asserted that he had reviewed the medical records from 2006 forward and that the records were silent for objective evidence of prostrating attacks other than past reports to Compensation and Pension providers. However, in May 2015, the Veteran submitted records of Botox injections in May 2015 as ordered by a private physician. It was indicated that the Veteran had a few break-through migraines over the past couple of weeks and had been treated with 10 Botox injections. He was to return in three months for more injections. The diagnosis was chronic migraine without aura. In a concurrently submitted written statement the Veteran wrote that he received these shots every three months and was experiencing severe migraines that which cause him to miss work during the last 3 weeks before the next round of shots. He wrote that without the Botox shots his headaches are very frequent and completely prostrating with prolonged attacks. The full recent records of Dr. KLB, as to treatment of the Veteran's headaches should be obtained and the Veteran should be afforded a new examination as to what by his account appear to be worsening headaches. See 38 C.F.R. § 3.159(c) (noting that the duty to assist included reasonable attempts to obtain relevant private records); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (stating that when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate). Increased Evaluation for Right and Left Shoulders Remand is required for a clarifying opinion. At a VA examination in September 2014, the Veteran gave a history of left shoulder surgery in 2013, but the examiner reported on the results of examination as though it was the right shoulder. This has apparently resulted in confusion in the assignment of ratings for left and right shoulder disability. For example, the Veteran was assigned a temporary total rating for the right shoulder rather than the left shoulder effective from September 13, 2013, to October 31, 2013. Further, the accuracy of the history as understood by the examiner and the examination results of the left shoulder versus right shoulder are called into question. The actual records of the private left shoulder surgery as well as private records of treatment for both left and right shoulder disability were received in November 2014, so that the VA examiner did not have access to these records for review at the September 2014 VA examination. Consequently, the Board finds that a new VA examination and opinion with respect to the Veteran's shoulders should be provided. Service Connection for Low Back Disorder Remand is required for an examination and clarifying opinion. In a November 2010 private opinion, the physician provided a positive nexus opinion upon a review of the claims file, but without rationale. In a January 2011 VA examination report, the examiner provided a negative nexus opinion. In an April 2012 submission, a private physician, Dr. SLW, indicated that the Veteran had experienced intermittent back pain since 2003 (during service). At a March 2014 VA examination of the back the examiner did not provide an opinion as to whether the Veteran's low back disability began during service or is related to any incident of service. In October 2014 an opinion was obtained from another VA examiner. He opined in part that "there is no preponderance of medical evidence to support the condition had its onset or is anyway due to or the result of military duty." This is an insufficient explanation, particularly in light of the positive opinions of record. Service Connection for the Bilateral Knees Remand is required for an examination. Private treatment records from the Nebraska Medical Center indicate the Veteran was shown by X-ray to have effusion in the left knee in December 2005, and was noted to have mild tenderness around the patellar regions of the knees and diagnosed as having possible patellofemoral syndrome of the knees in October 2005 and November 2005. A December 2005 X-ray of the right knee was said to show "just a little dislocation of the right patella in groove otherwise no evidence of arthritis." Further, it was suggested that he seek physical therapy for his bilateral knee disorder, and in December 2005 he was prescribed Celebrex specifically for his knee pain. By history, in October 2005, it was related that the Veteran had experienced his knee pain "for a few years," which would related the condition back to his period of active service. Thus, a VA examination and opinion as to whether the Veteran's disability began during service or is related to some incident of service is required in adjudicating the claim. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i). The requirement under the VCAA for warranting a VA examination, that the evidence "indicates" that the veteran's disability "may" be associated with the veteran's service, is a low threshold. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Accordingly, the case is REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the paper or virtual claims file all outstanding records of treatment, to include those for carpal tunnel syndrome treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records, to include records from Dr. K.L.B., M.D., for headaches, as discussed above. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. Once all available medical records are received and associated with the claims file, schedule a VA examination to determine the current severity of the Veteran's service-connected headaches. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate Disability Benefits Questionnaire (DBQ). The examiner must determine whether the Veteran suffers from headaches manifested by prostrating attacks. If headaches with prostrating attacks are found, examination findings should be expressed in terms of average of such attacks per week and the resultant impact on economic adaptability. 4. Once all available medical records are received and associated with the claims file, schedule a VA orthopedic examination for the purpose of determining the current severity of his service-connected left and right shoulder disorders. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate DBQ. The examiner must attempt to provide clarity regarding the evaluations of the right and left shoulders, to include clarifying the statements of the most recent VA examination. 5. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his knees and low back. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. Regarding the knees, the examiner must provide an opinion, in light of the examination findings and the service and post-service evidence of record whether it is at least as likely as not (50 percent or greater probability) that any right knee disorder present at any time after July 2005 was caused or aggravated by the Veteran's military service. The examiner must consider the following: (1) December 2005 private treatment records indicating the Veteran was shown by X-ray in December 2005 to have effusion in the left knee, and was noted to have mild tenderness around the patellar regions of the knees and diagnosed as having possible patellofemoral syndrome of the knees in October 2005 and November 2005; (2) a December 2005 X-ray showing "just a little dislocation of the right patella in groove otherwise no evidence of arthritis."; (3) October 2005 private records in which it was related that the Veteran had experienced his knee pain "for a few years"; and (4) the November 2010 private nexus opinion. Regarding the low back, the examiner must provide an opinion, in light of the examination findings and the service and post-service evidence of record whether it is at least as likely as not (50 percent or greater probability) that any diagnosed low back disorder present at any time after July 2005 was caused or aggravated by the Veteran's military service. The examiner must consider the following: (1) a November 2010 private positive nexus opinion; (2) a January 2011 VA negative nexus opinion; and (3) an April 2012 a private DBQ that indicated that the Veteran had experienced intermittent back pain since 2003. 6. Once all available relevant medical records have been received and associated with the claims file, provide the Veteran a VA neurological examination for the purpose of determining the current severity of his service-connected right carpal tunnel syndrome. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate DBQ. The examiner should indicate the nerve affected by the Veteran's carpal tunnel syndrome and whether the Veteran has complete paralysis, incomplete paralysis, neuritis, or neuralgia, and whether the condition is severe, moderate or mild. 7. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2015). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 8. Review each examination report to ensure that it is in complete compliance with the directives of this remand. If a report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 9. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2014). ______________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs