Citation Nr: 1536200 Decision Date: 08/25/15 Archive Date: 08/31/15 DOCKET NO. 10-46 010 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for residuals of a fatty tumor of the head. 2. Entitlement to service connection for headaches. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for a left wrist disorder. 5. Entitlement to a disability rating higher than 10 percent for a left ankle disability. REPRESENTATION Appellant (the Veteran) is represented by: The American Legion ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active duty service from June 1996 to November 2000. This appeal comes before the Board of Veterans' Appeals (Board) from June 2008 and September 2009 rating decisions of the RO in Chicago, Illinois. The Veteran also initiated an appeal of the denials of service connection for tinnitus and a right ankle disorder; however, the RO granted the complete benefit sought (service connection) with regard to each issue in a January 2012 rating decision. Although the Veteran also initiated an appeal of the initial disability rating assigned for his right ankle disability, he did not perfect the appeal following issuance of a statement of the case in April 2014. 38 C.F.R. §§ 20.200, 20.302(a),(b) (2015). FINDINGS OF FACT 1. Headaches, a fatty tumor of the head, and a left wrist disorder, are not related to service. 2. At no time pertinent to this appeal has the Veteran had hearing loss to the extent that constitutes a disability for VA purposes. 3. The Veteran's left ankle disorder is manifested by painful motion with normal range of dorsiflexion and plantar flexion. CONCLUSIONS OF LAW 1. A fatty tumor of the head was not incurred in service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). 2. Headaches were not incurred in service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). 3. A left wrist disorder was not incurred in service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). 4. The basic service connection criteria for the claimed hearing loss are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.385 (2015). 5. The criteria for a disability rating higher than 10 percent for the left ankle disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5271 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Claims I. Fatty Tumor of the Head, Headaches, and Left Wrist The Veteran is seeking service connection for claimed residuals of a fatty tumor of the head, to include headaches, on the basis that each had onset as a chronic disorder in service. He is seeking service connection for a left wrist disorder on the basis that a current disorder is related to an injury of the left wrist incurred in service. On a VA Form 21-526 dated January 2008, the Veteran reported that, while on active duty with the US Marine Corps, he incurred injuries that continue to plague him. His left wrist was injured when a steel sheave fell on it. The Veteran reported: "I developed a fatty tumor while I was in the [C]orp[s], and they treated it like a pimple. After I got out I went to a civilian hospital and they removed it." He asserted that the tumor began in 1998 and that he was not treated until 2003. The Veteran also reported: "I still have migraines and eat Tylenol every day." On the notice of disagreement dated May 2009, the Veteran asserted that a benign fatty tumor of the head began "while I was on active duty" and that, after coming off active duty, the condition worsened, and then it was removed at a private facility. He asserted that migraine headaches began on active duty, "about the time I developed the tumor on my head." He also asserted that a left wrist injury began on active duty. The term service connection applies to disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Proving entitlement to service connection requires (1) medical evidence of current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For specific enumerated diseases designated as "chronic" there is a presumption that such chronic disease was incurred in or aggravated by service even though there is no evidence of such chronic disease during the period of service. This presumption applies to veterans who served 90 days or more during a period of war or after December 31, 1946. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Headaches and fatty tumors are not among the chronic diseases listed under 38 C.F.R. § 3.309(a), therefore the presumption of service connection and the theory of continuity of symptomatology do not apply. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). While arthritis is among the enumerated chronic diseases, in this case, the Veteran's left wrist disorder has been diagnosed as a sprain and not arthritis. Accordingly, the presumption of service connection and the theory of continuity of symptomatology do not apply. Service treatment records reveal no complaint of or treatment for headaches or a fatty tumor of the head. While the Veteran was treated for a carbuncle on August 11, 2000, the location was on the right calf. The Veteran was treated for a left wrist sprain on July 23, 1997. At that time, he was unable to do a pull-up due to intense discomfort. He was prescribed analgesics and assigned to limited duty. He was instructed to follow-up only if needed. He was treated again on December 2, 1997 for a recurrence of symptoms. He noted that he only experienced pain when doing chin-ups or heavy lifting. On physical examination of the wrist, there was very mild point tenderness at the distal end of the ulna; there was no edema or effusion; there was full range of motion; and strength and neurovascular inspection were intact. The diagnosis was resolving left wrist injury. The Veteran was returned to full duty and advised to take analgesics or return for a follow-up as needed. When the Veteran was examined for service separation in December 29, 1999, his head, skin, and upper extremities were each found to be clinically normal. At that time, the Veteran reported that he had no history of-or current-frequent or severe headaches, tumor, growth, cyst, or cancer, arthritis, rheumatism, or bursitis, swollen or painful joints, and no bone, joint, or other deformity. After service, the first reference to a tumor of the head comes in a May 13, 2003 operative report from Harrisburg Medical Center. It was noted that the Veteran "has noticed a mass on the top of his head." The date of this discovery was not reported. The mass, described as a lipoma of the scalp, was excised. Pertinent to this first clinical notation, the Veteran made no assertion as to having incurred or noted the lipoma in service. The report of a VA examination in April 2008 reveals the Veteran's account that he injured his left wrist in 1997-1998 and was treated with a brace. Since then, he could not lift or carry more than 5-10 lbs. Moving the wrist would cause pain. Aching and sharp pain would radiate up to below the elbow. Stabbing pain rated at 8 out of 10 would continue for the whole day, every day. Performing a lot of typing and wood work would irritate the left wrist and he would have to stop working. He was taking Tylenol for pain and wearing a brace. X-rays of the left wrist were normal. The diagnosis was a sprain. The opinion of the examiner was that the left wrist sprain was less likely than not related to the treatment for a left wrist pain in service. The rationale was that the x-rays in service were negative and the diagnosis in service was also a sprain. There is no medical opinion that purports to relate any current left wrist disorder, current headaches, or fatty tumor of the head to service. While the Veteran is competent to describe his symptoms, as well as when they began, to the extent he now claims that his headaches and a fatty tumor of the head began in service or were noted in service, this is in direct contradiction of his report of medical history at service separation, at which time he reported not only that he had no current frequent or severe headaches, tumors, growths, cysts, or cancers, but that he had no history of frequent or severe headaches, tumors, growths, cysts, or cancers. Regarding the left wrist, the evidence establishes that the Veteran sprained his left wrist in service, and that he also had a left wrist sprain in April 2008. To the extent the Veteran now contends that his symptoms have been constant since the in-service sprain, and that this demonstrates an ongoing disorder, as opposed to separate and distinct injuries, this is in direct conflict with his statement at service separation that he had no history of or current arthritis, rheumatism, or bursitis, swollen or painful joints, and no bone, joint, or other deformity. Of particular significance is his statement that he had no current painful joints. Bolstering the accuracy of the accounts given at service separation is the fact that these statements were consistent with the normal clinical evaluation at that time, whereas, his current assertions are in conflict with the normal clinical evaluations at service separation. Those accounts are also consistent with the lack of treatment for headaches and a fatty tumor of the head in service. While the Veteran was treated for a skin lesion (carbuncle), this was on his left calf, not on his head. Moreover, because the Veteran was then (at service separation) not yet seeking disability compensation, but was simply reporting for a routine medical evaluation, it seems likely that he would report events carefully and accurately. The "medical diagnosis or treatment" exception to hearsay rule (Fed. R. Evid. 803) provides that "statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care." While Fed. R. Evid. 803 was not directly discussed by the United States Court of Appeals for Veterans' Claims (Veterans Court), in Rucker v. Brown, 10 Vet. App. 67 (1997), the Veterans Court held that recourse to the Federal Rules of Evidence by the Board is appropriate where they will assist in articulation of the Board's reasons. In contrast to the Veteran's account at service separation, when the Veteran thereafter presented his account, he was seeking VA benefits rather than medical treatment. The Board is of course cognizant of possible self interest which any veteran has in promoting a claim for monetary benefits. The Board may properly consider the personal interest a claimant has in his or her own case, but the Board is not free to ignore his assertion as to any matter upon which he is competent to offer an opinion. See Pond v. West, 12 Vet. App. 341, 345 (1999); and see Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). There is no question that the Veteran is competent to relate the onset of symptoms such as pain or the appearance of a mass under the skin as he remembers it. Thus, his competency is not at issue with regard to recounting onset of headaches or a fatty tumor of the head in service, or ongoing left wrist symptoms following the in-service sprain. Rather, it is the accuracy of the Veteran's recent account which the Board finds is lacking. Simply put, the report of medical history at separation from service, as bolstered by the normal clinical examination findings, is more reliable and convincing than the Veteran's later statements made in support of a claim for monetary benefits. The Board also notes that, in the absence of ongoing symptoms, establishing a relationship between a current sprain and a sprain incurred years before requires medical knowledge and is not capable of lay observation. Accordingly, as the Board has found that symptoms were not ongoing, the Veteran's assertion that the April 2008 sprain is related to the remote in-service sprain is not competent evidence. In light of the facts found, i.e., no injury or disease in service or nexus regarding headaches and a fatty tumor of the head, and no nexus between the in-service left wrist sprain and any current left wrist disorder, the Board concludes that service connection for these claimed disorders is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). II. Hearing Loss The Veteran is seeking service connection for bilateral hearing loss on the basis that such hearing loss exists as a current disability and is related to noise exposure in service. Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz). Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a veteran has a disability based on hearing loss is governed by 38 C.F.R. § 3.385. 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, or 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. When the pure tone threshold at each of the four specified frequencies (1,000, 2,000, 3,000 and 4,000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman Numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. When the pure tone threshold is 30 decibels or less at 1,000 Hertz, and 70 decibels or more at 2,000 Hertz, the rating specialist will determine the Roman Numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86. Audiometric testing was conducted on several occasions during service, including at service separation. When tested at service entrance on July 24, 1995 at 06:23, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 0 5 LEFT 30 25 40 20 50 The test was repeated at 06:40 the same day and pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 0 0 LEFT 5 0 0 0 10 The results of the second test were apparently accepted as accurate, as the Veteran was found to have normal auditory acuity on the examination report. Testing on June 25, 1996 reveals pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 -5 0 0 5 LEFT 5 5 -5 -5 10 Testing on February 25, 1997 reveals pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 0 0 5 LEFT 0 0 0 0 20 Testing on July 1, 1998 reveals pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 5 0 LEFT 0 0 0 0 15 Testing for service separation on December 29, 1999 reveals pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 -5 0 5 0 LEFT 5 5 0 0 15 Testing was again conducted on January 12, 2000, at which time pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 0 0 15 LEFT 0 5 -5 0 5 It was noted on the January 2000 report that the Veteran was routinely noise exposed. On the report of examination at service separation, the Veteran's ears and auditory acuity were clinically normal. On the concurrent report of medical history, the Veteran reported that he had no history of-or current-hearing loss or ear trouble. When audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a "disability" at that time, he or she may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley, 5 Vet. App. 155. Audiometric testing conducted in developing the current claim reveals the following pure tone thresholds, in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 10 5 LEFT 10 5 5 10 10 Speech audiometry revealed speech recognition ability of 94 percent in the right ear and 96 percent in the left ear. The examiner diagnosed normal hearing in the right ear and normal hearing in the left ear. The VA examiner opined that any hearing loss present was not at least as likely as not (50% probability or greater) caused by or a result of an event in military service. The rationale was that The initial hearing test at service entrance documented a loss of acuity in the left ear. However, the hearing test was redone and documented hearing within the normal range from 500-6000 Hz. Subsequent hearing tests in 1996, 1997, 1998, and separation in 2000 all document hearing within the normal range bilaterally. There was no hearing loss documented in the file during the Veteran's military career. Based on the audiometric and speech recognition results, the Board finds that there is no current hearing loss disability as that term is defined for VA purposes. There are no auditory thresholds of 40 decibels or greater. There are no auditory thresholds of 26 decibels or greater. Speech recognition scores using the Maryland CNC Test are not less than 94 percent. See 38 C.F.R. § 3.385. While the presence of a disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative, McClain v. Nicholson, 21 Vet. App. 319 (2007), Congress has specifically limited entitlement to service-connection to cases where such in-service disease or injury has resulted in disability. See 38 U.S.C.A. § 1110. Hence, where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As there is no current disability, the Board concludes that service connection for bilateral hearing loss is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Increased Rating Claim The Veteran is seeking an increased disability rating for his service-connected left ankle disability, which is currently assigned a 10 percent rating. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The current appeal arises from a claim of entitlement to service connection for an ankle disorder received at the RO on January 28, 2008. In the July 2008 rating decision, the RO granted service connection and assigned an initial rating of 10 percent for "left ankle sprain" pursuant to Diagnostic Code 5271, effective January 28, 2008. Under Diagnostic Code 5271, a 10 percent rating is assigned for limitation of ankle motion that is moderate. A maximum 20 percent rating is assignable for limitation of ankle motion that is marked. 38 C.F.R. § 4.71a, Diagnostic Code 5271. The Board notes that the term "marked" is not defined under VA regulations. That term also does not appear to have a generally accepted medical definition. Therefore, the Board finds that it is appropriate to turn to a general purpose dictionary definition of these terms. The adjectives "marked" and its related form "markedly" are defined as strikingly noticeable or conspicuous. Synonyms include striking, outstanding, obvious, and prominent. See "marked," The American Heritage Dictionary of Idioms . Under Diagnostic Code 5270, a 20 percent rating is assignable for ankylosis in plantar flexion, less than 30 degrees. A 30 percent rating is assignable for ankylosis in plantar flexion, between 30 degrees and 40 degrees, or in dorsiflexion, between 0 degrees and 10 degrees. A 40 percent rating is assignable for ankylosis in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5270. Normal range of motion of the ankle is considered to be attained if dorsiflexion is possible to 20 degrees and plantar flexion is possible to 45 degrees. See 38 C.F.R. § 4.71, Plate I. A 20 percent rating is also available for malunion of the os calcis or astragalus with marked deformity and for residuals of astragalectomy. 38 C.F.R. § 4.71a, Diagnostic Codes 5273, 5274. The report of a VA examination in April 2008 reveals the Veteran's report that the ankle swells with aching sharp pain rated at 7-8 out of 10. Symptoms were constant and would stay the whole day and would occur depending on walking and standing. The symptoms reported by the Veteran included pain, stiffness, swelling, locking, and fatigue. The Veteran reported that there were no flares, but that symptoms were constant. The Veteran was working as a correctional officer, and the disability was affecting his job. On objective examination, the Veteran's gait was assessed as normal. There were no calluses; and there was no skin breakdown or unusual shoe wear pattern. There was objective evidence of tenderness and edema, but no objective evidence of effusion, instability, weakness, redness, or heat. There was also no abnormal movement/guarding of movement. There was no ankylosis in any degree. Dorsiflexion was measured from 0 to 20 degrees with complaint of pain. Plantar flexion was measured from 0 to 50 degrees with complaint of pain. X-rays revealed no acute fracture, subluxation, or dislocation. The diagnosis was a sprain. The report of VA examination in November 2011 reveals complaint of worsening of the pain in the past year. The Veteran stated that he would roll his left ankle a lot when walking and he attributed this to the worsening of his ankle condition. He stated that he had constant soreness in his left ankle. He had flare-ups anytime he would roll his left ankle and rated the pain at 6-8 out of 10, which would last the entire day. On objective physical examination, there was no ankylosis to any degree. Dorsiflexion was measured from 0 to 20 degrees with no objective indication of pain associated with motion. Plantar flexion was measured from 0 to 45 degrees with no objective indication of pain associated with motion. With three repetitions the results were the same. The examiner noted no limitation in range of motion following repetitive-use testing. There was no localized tenderness or pain on palpation of joints/soft tissue. Testing of muscle strength was normal. Testing for joint laxity was also normal. Significantly, the examiner also found that the Veteran did not have "any functional loss and/or functional impairment of the ankle" and had no other pertinent physical findings, complications, conditions, signs and/or symptoms related to the diagnosis. The examiner found no impact of the Veteran's ankle condition on his ability to work. While it is clear from the record that the Veteran has peri-articular pathology, i.e., a chronic sprain of the left ankle, and that there is painful motion of the left ankle, and the provisions of 38 C.F.R. § 4.59 establish that the Veteran is entitled to the minimum compensable evaluation for painful motion even if motion is not limited to a compensable degree, see also Burton v. Shinseki, 25 Vet. App. 1 (2011), the minimum compensable rating of 10 percent has already been assigned. Evaluations in excess of the minimum compensable rating must be based on demonstrated functional impairment. Here, despite what is reported as constant pain, the Veteran was able to attain entirely normal excursions of motion on both examinations, and to walk with a normal gait. The Board acknowledges the Veteran's complaint that he frequently rolls his ankle. While it is unclear what is intended by this description, the result, as described by the Veteran, appears to be more pain. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 38; see 38 C.F.R. § 4.40. Thus, the symptomatology described by the Veteran does not itself support any higher rating. Regarding the Veteran's report of flare-ups of symptoms to the November 2011 VA examiner, he did not describe any additional limitation of motion associated with those flares, but described his pain at 6-8 out of 10 during flares. Notably, he described pain at 7-8 out of 10 to the April 2008 examiner when he denied flare-ups. The Board has acknowledged that the Veteran's left ankle is constantly painful and that pain is present with all motion. However, such symptomatology does not support a higher rating without resulting limitation of motion that is "marked" or without other appropriate symptoms as described in the rating schedule. In light of the consistently normal measurements of range of motion, and the Veteran's normal gait, the Board finds that, to the extent there is limitation of left ankle motion in this case, it is not strikingly noticeable, conspicuous, or obvious. As such terminology are synonymous with the word "marked," the Board finds that there is not marked limitation of left ankle motion, as is required for a 20 percent rating. Moreover, in light of the findings of the April 2008 and November 2011 examiners that there is no ankylosis, the Board also finds that a rating under Diagnostic Code 5270 is not warranted. And, in light of the finding of the November 2011 VA examiner that there is no malunion of the calcaneous (os calcis) or talus (astragalus), the Board finds that a rating of 20 percent under Diagnostic Codes 5273 or 5274 is not warranted. Finally, the Board has considered whether the question of entitlement to a total disability rating based on unemployability due to service-connected disability (TDIU) is reasonable raised by the record in this case. Where there is evidence of unemployability raised by the record during a rating appeal period, the issue of TDIU entitlement is an element of an appealed rating claim. Rice v. Shinseki, 22 Vet. App. 447 (2009). However, in this case, the evidence establishes that the Veteran's left ankle sprain permits normal range of ankle motion and a normal gait. Particularly significant in regard to TDIU consideration is the finding of the November 2011 VA examiner that the Veteran did not have "any functional loss and/or functional impairment of the ankle" and that there was no impact of the Veteran's ankle condition on his ability to work. In light of this evidence, the Board finds that the matter of TDIU entitlement, or referral for extraschedular consideration, is not reasonably raised in this case. In sum, to the extent any higher level of compensation is sought regarding the left ankle disability, the preponderance of the evidence is against the claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether an extraschedular evaluation is warranted for the rating issue on appeal. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, 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. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found 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." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairments caused by the Veteran's service connected left ankle disability is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran has not expressly raised the matter of entitlement to an extraschedular rating. His contentions have been limited to those discussed above, i.e., that his left ankle disorder is more severe than is reflected by the assigned rating. The symptomatology associated with his service-connected left ankle includes constant pain and pain on motion which does not reduce range of motion markedly. This impairment is contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to disabilities of the ankle provide disability ratings on the basis of limitation of motion. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet.App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement; excess fatigability; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet.App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture. In short, there is nothing exceptional or unusual about the Veteran's left ankle disability because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet.App. at 115. As was explained in the merits decision above in denying higher ratings, the criteria for higher schedular ratings were considered, but the ratings assigned were upheld because the rating criteria are adequate. In view of the circumstances, the Board finds that the rating schedule is adequate, even in regard to the collective and combined effect of all of the Veteran's service connected disabilities, and that referral for extraschedular consideration is not warranted under the circumstances of this case. Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014). Duties to Notify and Assist The Veteran does not assert that there has been any deficiency in the notice provided to him in February 2008 and August 2009 under the Veterans Claims Assistance Act of 2000 (VCAA) and he has not identified any prejudice resulting from any deficiency. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (no presumption of prejudice on a notice deficiency; the burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency's determination). The RO has obtained pertinent medical records including the service treatment records, VA outpatient treatment reports, and private treatment reports identified by the Veteran. The RO has also obtained a thorough medical examination regarding the left wrist and left ankle claims, and the hearing loss claim, as well as medical opinions. The Veteran has made no specific allegations as to the inadequacy of any opinion. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). The Board acknowledges that request for a new VA examination for the Veteran's left ankle disability in the June 2015 informal hearing presentation. The Veteran's representative noted "the VA examination of record is no longer contemporaneous, being from 2011." When a claimant alleges that his or her service-connected disability has worsened since the last examination, a new examination may be required to evaluate the current degree of impairment. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Here, the representative did not describe any worsening of the disability. The mere age of an examination does not suggest inadequacy in the absence of some evidence of material worsening in the disability. The Board also notes that, in November 2011, the Veteran reported that his left ankle disability was prone to flares, but that he was not having a flare at the time of the examination. The Veterans Court has held that "where there is a history of remission and recurrence of a condition, the duty to assist encompasses the obligation to evaluate a condition during an active rather than an inactive phase." Ardison v. Brown, 6 Vet. App. 405, 407-8 (1994). However, the Veteran's description of his flares does not suggest that it would be practical to schedule an examination during those periods. See Voerth v. West, 13 Vet. App. 117, 123 (1999) (indicating that "the practical aspects of scheduling a medical examination within [a] short period" are relevant in determining whether an examination must be conducted during an active phase). Moreover, in Voerth, the Veterans Court found Ardison inapplicable where the Veteran's disability, in its recurrent state, did not affect his earning capacity and the worsened condition did not last more than a few days. Voerth v. West, 13 Vet. App. 117, 122-23 (1999). Here, the Veteran described his flare ups as lasting one day, and the November 2011 examiner found no impact on his ability to work. The Board acknowledges that the Veteran has not been afforded a VA medical examination with respect to the headaches and fatty tumor claims. However, the Board finds that a VA examination is not necessary in order to decide these claims. The VA Secretary must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McClendon v. Nicholson, 20 Vet App. 79, 81 (2006). As discussed above, the Board has found that the Veteran's account of having sustained onset of headaches or a fatty tumor of the head in service is not accurate. Because there is no in-service injury or disease to which competent medical opinion could relate a current disability, there is no reasonable possibility that a VA examination or opinion could aid in substantiating these claims. See 38 U.S.C.A. § 5103A(a)(2) (West 2002) (VA "is not required to provide assistance to a claimant...if no reasonable possibility exists that such assistance would aid in substantiating the claim"); 38 C.F.R. § 3.159(d) (VA to discontinue assistance where there is "no reasonable possibility that further assistance would substantiate the claim"). The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of these claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. CONTINUED ON NEXT PAGE-ORDER ORDER Service connection for residuals of a fatty tumor of the head is denied. Service connection for headaches is denied. Service connection for a left wrist disorder is denied. Service connection for bilateral hearing loss is denied. A disability rating for a left ankle disorder in excess of 10 percent is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs