Citation Nr: 1604676 Decision Date: 02/08/16 Archive Date: 02/18/16 DOCKET NO. 12-28 310 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for left wrist disability, claimed as left carpal navicular fracture. 2. Entitlement to an initial rating in excess of 10 percent prior to July 31, 2012, and 20 percent thereafter, for a back disability, claimed as lumbar disease with scoliosis. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for a gastrointestinal disorder. 5. Entitlement to service connection for headaches. ATTORNEY FOR THE BOARD A. Lech, Associate Counsel INTRODUCTION The Veteran had active service from December 1970 to October 1972. Here, the Board is cognizant that the Veteran related in a December 2015 statement that he "served in the U.S. Army from December 7, 1970 through October 13, 1970." These dates, however, constitute an error on the Veteran's part. His DD-214 reflects the dates above. This matter comes before the Board of Veterans' appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. This case was before previously before the Board in January 2015, when it was remanded for additional development. While the Veteran's appeal was pending before the Board, the RO issued a rating decision in November 2015, which granted service connection for sinusitis. Since that grant constitutes a full grant of the benefits sought on appeal, that claim is no longer before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The issue of entitlement to service connection for a gastrointestinal disorder is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran has withdrawn his appeal seeking entitlement to service connection for headaches. 2. For the period prior to July 31, 2012, the Veteran's back disability was not productive of forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 3. Throughout the period on appeal, the Veteran's back disability has not been productive of flexion of 30 degrees or less; unfavorable or favorable ankylosis; or incapacitating episodes having a total duration of at least 4 weeks. 4. Chronic hearing loss was not shown in service or within a year of service discharge; and, the preponderance of the evidence fails to establish that the Veteran's current hearing loss disability is etiologically related to his active service, to include noise exposure with documented hearing loss. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a Substantive Appeal by the Veteran as to the issue of entitlement to service connection for headaches have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. §§ 20.202, 20.204 (2015). 2. The criteria for an initial rating in excess of 10 percent for a left wrist disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215 (2015). 3. For the period prior to July 31, 2012, the criteria for a rating higher than 10 percent for a back disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§4.59, 4.71a, Diagnostic Code 5237 (2015). 4. The criteria for a rating higher than 20 percent for a back disability have not been met at any time during the appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§4.59, 4.71a, Diagnostic Code 5237 (2015). 5. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§1101, 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawal In correspondence received by the Board on December 28, 2015, the Veteran indicated that he wished to withdraw one of the issues currently on appeal - entitlement to service connection for headaches. The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2014). A Substantive Appeal may be withdrawn at any time before the Board promulgates a decision. 38 C.F.R. § 20.202 (2015). Withdrawal may be made by the Veteran or by his authorized representative. 38 C.F.R. § 20.204 (2015); Hanson v. Brown, 9 Vet. App. 29, 31 (1996) (When a claim is withdrawn by a Veteran, it ceases to exist; it is no longer pending and it is not viable). As of December 28, 2015, the Board had not yet issued a final decision on that issue. Because the Veteran has clearly expressed his desire to terminate his appeal for the above-enumerated benefits, and because the Board had not yet promulgated a decision on his appeal at the time of his request for withdrawal, the legal requirements for a proper withdrawal have been satisfied. 38 C.F.R. § 20.204(b) (2015). The withdrawal of an appeal effectively creates a situation where there is no longer an allegation of error of fact or law with respect to the determination that had been previously appealed. Consequently, in such an instance, dismissal of the appeal as to the issue of entitlement to service connection for headaches is appropriate. See 38 U.S.C.A. § 7105(d) (West 2014). Increased Ratings Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2015). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(a), 4.1 (2015). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2015). However, that does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one Diagnostic Code is duplicative of or overlapping with the symptomatology justifying a rating under another Diagnostic Code. Esteban v. Brown, 6 Vet. App. 259 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2015). Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id.; see also 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45 (2015). Consideration of a higher rating for functional loss, to include during flare ups, due to these factors accordingly is warranted for Diagnostic Codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2015); DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain itself does not constitute functional loss, and painful motion does not constitute limited motion for the purposes of rating under Diagnostic Codes pertaining to limitation of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain indeed must affect the ability to perform normal working movements with normal excursion, strength, speed, coordination, or endurance in order to constitute functional loss. Id. A. Left Wrist Disability The Veteran's left wrist disability is currently rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5215. He seeks a higher initial disability rating. Diagnostic Code 5215 provides ratings based on limitation of motion of the wrist. Limitation of palmar flexion in line with the forearm is rated 10 percent disabling for the major wrist and 10 percent for the minor wrist. Limitation of dorsiflexion to less than 15 degrees is rated 10 percent disabling for the major wrist and 10 percent for the minor wrist. A 10 percent rating is the maximum schedular rating available under DC 5215. 38 C.F.R. § 4.71a (2015). Normal ranges of motion of the wrist are dorsiflexion from 0 degrees to 70 degrees, and palmar flexion from 0 degrees to 80 degrees. 38 C.F.R. § 4.71, Plate I (2015). The Veteran underwent a VA examination for his left wrist in January 2010. X-rays showed old left carpal navicular fracture. Upon examination, the left wrist revealed no redness, heat, swelling, or deformity. There was slight subjective tenderness at the palmar base of the hand. The wrist had 0-55 degrees of dorsiflexion, 0-70 degrees of palmar flexion, 0-25 degrees of ulnar deviation, and 0-20 degrees of radial deviation. There was no objective evidence of pain on motion, and no additional loss of range of motion after repetitions. The July 2012 VA examiner related that the Veteran complained of stiffness, pain, and occasional numbness of the left thumb with increased activity. There was normal range of motion in the fingers, no functional loss or impairment of the fingers or thumbs, no pain on examination, and no loss of muscle strength. Left wrist range of motion was noted to be 40 degrees on dorsiflexion, 60 degrees on palmar flexion, and 20-25 degrees on radial and ulnar deviation. The April 2015 VA examination showed diagnosis of a closed fracture of the left navicular, a burn on the left hand (which the Veteran suffered in 1991 and is not service-connected), and an open fracture of the left index finger proximal phalanx with laceration (again, a non-service related fracture that the Veteran experienced in 2000). The Veteran denied any left wrist problems except for left wrist pain and minimal stiffness, "popping," and decreased strength. The examiner noted that the Veteran was right hand dominant. He denied any left wrist swelling, redness, heat, locking, giving way, dislocation, any surgeries, or any other left wrist complaints. Upon physical examination, the left wrist range of motion was 50 degrees for palmar flexion, 45 degrees for dorsiflexion, 30 degrees for ulnar deviation, and 10 degrees for radial deviation. There was no pain upon examination and no changes in range of motion after three repetitions. Muscle strength was normal, there was no ankylosis, no arthritis, and no objective tenderness on either forearms or wrists. The Veteran reported subjective tenderness along the distal left forearm and dorsal surface, as well as minimally subjective tenderness diffusely over the dorsal wrist. Examination showed no findings of decreased sensation or numbness on forearms, wrists, or hands. X-rays were normal. The treatment records of evidence do not provide any evidence contrary to that obtained at the VA examinations. Based upon the medical evidence of record, the Board finds that the Veteran's left wrist disability does not warrant an increase. 10 percent is the maximum disability rating available under Diagnostic Code 5215. In fact, it is important for the Veteran to understand, that in applying the above law to the facts of the case, he would not even be entitled to the 10 percent disability rating for his left wrist disability, let alone a higher rating. This is the case because there is no evidence of limitation of palmar flexion in line with the left forearm or limitation of dorsiflexion to less than 15 degrees. At worst, the Veteran's left wrist palmar flexion was limited to 50 degrees and left wrist dorsiflexion to 40 degrees. 38 C.F.R. § 4.71a, DC 5215 (2015). However, with consideration of the Veteran's statements, the 10 percent rating is possible. To warrant an increase under a different Diagnostic Code, the Veteran would have to exhibit symptoms showing ankylosis of the left wrist or neurological involvement. The Veteran does not exhibit any such symptoms, he has never complained of any such symptoms, and he has not been found by physicians to have ankylosis or neurological issues of the left wrist. Additionally, X-rays of the left wrist taken at the April 2015 VA examination do not document arthritis to warrant a higher rating under 38 C.F.R. § 4.71a, DC 5003 (2015). In forming this decision, the Board has considered the Veteran's complaints of occasional pain in the left wrist. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). However, the lay and objective medical evidence does not persuasively show that his symptoms result in additional functional limitation to the extent that the Veteran's disability warrants a higher disability rating under DC 5215. 38 C.F.R. § 4.71a (2015). Specifically, the examinations determined that the Veteran did not have pain upon examination, no changes in range of motion after three repetitions, no left wrist swelling, redness, heat, locking, giving way, dislocation, any surgeries, or any other left wrist complaints. Muscle strength was normal, there was no ankylosis, no arthritis, and no objective tenderness on either forearms or wrists. The Board recognizes the Veteran's lay statements of pain (it is the basis of the 10%). However, the VA examinations, and the treatment records, do not establish that the Veteran's pain has caused him to be ankylosed. Further limitation of motion does not entitle the Veteran to a higher disability rating. The Veteran is already in receipt of the maximum schedular disability rating available for limitation of motion under DC 5215. Accordingly, the Board finds the current evaluation assigned adequately compensates the Veteran for the pain and functional impairment caused by his service-connected disability. DeLuca, 8 Vet. App. at 202; 38 C.F.R. §§ 4.40, 4.59 (2015). Moreover, where the Veteran is already receiving the maximum disability rating for limitation of motion, 38 C.F.R. §§ 4.40 and 4.45 are not applicable. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Furthermore, the Veteran's symptoms do not appear to have changed significantly during this initial rating period so as to warrant further staged ratings. Fenderson, 12 Vet. App. at 126. In forming these decisions, the Board has considered the lay statements from the Veteran. The Board notes that in adjudicating a claim, the competence and credibility of lay statements must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report that he experiences certain symptoms, such as pain, and he is credible in this regard. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran's competent and credible belief that his disability is worse than the assigned rating, however, is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings. Also, as stated above, the rating criteria are specific in indicating that some of the criteria must be objectively demonstrated. In sum, the preponderance of the evidence is against the assignment of an initial disability rating in excess of 10 percent for the service-connected left wrist disability at any time during the appeal period. Thus, the claim is denied. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015); see Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). B. Back Disability The Veteran contends that his back disability warrants higher ratings than those he was awarded. The Veteran's back disability is currently evaluated as 10 percent disabling prior to July 31, 2012, and 20 percent thereafter. Disabilities of the spine are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine. 38 C.F.R. § 4.71, Diagnostic Codes 5235-5242 (2015). The Veteran has been diagnosed with lumbar disc disease with scoliosis, acute lumbar myofascial strain, degenerative disc disease, and spondylosis without myelopathy. His back disability has been rated under Diagnostic Code 5237. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243 (2015). The rating criteria, in pertinent part, provide a 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for when forward flexion of the thoracolumbar spine is limited to 30 degrees or less; when or favorable ankylosis of the entire thoracolumbar spine is present. A 50 percent rating is assigned where unfavorable ankylosis of the entire thoracolumbar spine is present, and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. These ratings are made with or without symptoms such as pain (whether or not it radiates), stiffens, or aching in the area of the spine affected by residuals of injury or disease). Id. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. 38 C.F.R. § 4.71a, Note (2) (2015). Intervertebral Disc Syndrome (IVDS) is rated under Diagnostic Code 5243 and is evaluated under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25 . 38 C.F.R. § 4.71a, Note (6) (2015). In this case, the Board notes that the Veteran has not been diagnosed with IVDS and, as such, this Diagnostic Code will not be considered. The Veteran underwent a VA examination for his back in January 2010. He reported chronic back pain over the years. He denied radiation of pain, no loss of bowel or bladder control, flare-ups every three months, no prescribed bed rest in the past year, and relief with medication. He reported working full-time. Upon physical examination, the examiner noted that the Veteran had 0-70 degrees of flexion, 0-20 degrees of extension, 0-20 degrees of left and right lateral bending, and 0-30 degrees of right and left lateral rotation. The Veteran reported pain at the endpoint of left lateral rotation. X-rays showed multilevel lumbar disc disease with scoliosis. The Veteran underwent another VA spinal examination in July 2012. The Veteran reported pain with radiation (the Veteran receives a separate rating under DC 8520 for right lower extremity radiculopathy associated with lumbar disease with scoliosis). The Veteran related that he applied whiskey to his back and consumed whiskey to treat back pain, but did not take any prescribed or over the counter medications for his back. Upon physical examination, the Veteran's forward flexion ended at 55 degrees, extension ended at 20 degrees, right lateral flexion ended at 20 degrees, left lateral flexion ended at 15 degrees, right lateral rotation ended at 20 degrees, left lateral rotation ended at 15 degrees, and all ranges of motion had objective evidence of pain. The Veteran did not have any additional loss of range of motion after repetitive testing. Guarding and/or muscle spasms were present, but they did not result in abnormal gait or spinal contour. Muscle strength was normal. There was no IVDS. X-rays showed evidence of scoliosis and degenerative joint disease of the lumbosacral spine. The examiner noted that the back disability did not interfere with the Veteran's employment. The Veteran underwent another VA examination in June 2015. The Veteran reported that he had back spasms, muscle spasms, and back pain with bending, and was able to lift up to 40 pounds. He related that he utilized a heating pad and muscle relaxers for his back. Upon physical examination, his forward flexion was to 55 degrees, extension to 20 degrees, bilateral lateral flexion to 20 degrees, and bilateral lateral rotation to 20 degrees. Pain was noted objectively only at the very distal extreme of forward flexion (55 degrees). There was no additional loss of function or range of motion after three repetitions. Muscle spasms and localized tenderness resulted in abnormal gait or abnormal spinal contour. There was no guarding. Muscle strength was normal, and there was no atrophy. The Veteran was noted not to have IVDS. X-rays confirmed arthritis and scoliosis. The examiner related that the Veteran retired from his job in 2011, and would be able to perform in a sedentary job (or a physical job that did not require heavy lifting, bending at waist, or standing for more than 1.5 hours). In fact, the Board wishes to draw Veteran's attention to the physician's notes at the end of the April 2015 VA examination, where the examiner noted that the Veteran's in-service muscle strain was acute and self-limiting. The examiner added that strain does not involve vertebral bodies or discs, does not cause damage to them, and does not "predispose" one to degenerative disc disease or spondylosis, and that the Veteran's back issues are most likely related to his age. In sum, after review of the totality of the competent medical evidence on file regarding the Veteran's back symptomatology, a rating in excess of 10 percent for the period prior to July 31, 2012, and a rating in excess of 20 percent for the period after July 31, 2012, is not warranted based on range of motion because the evidence on file does not show symptoms productive of forward flexion of the thoracolumbar spine limited to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine, so as to warrant a 40 percent disability rating. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2015); Hart v. Mansfield, 21 Vet. App. 505 (2007). The preponderance of the evidence is also against the finding that, even considering pain, weakness, and functional impairment, the Veteran's disability would warrant a disability rating in excess of 10 percent (for the first period on appeal) and a disability rating in excess of 20 percent (for the second period on appeal) based on range of motion. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243 (2015); DeLuca v. Brown, 8 Vet. App. 202 (1995). Thus, the claim is denied. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015); see Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service Connection The Veteran asserts that he has bilateral hearing loss and a gastrointestinal disability as a result of his active service. As an alternative theory of compensation, the Veteran has asserted that his gastrointestinal disability is related to his service-connected back disability as he believes that it results from the medication he takes for his back. Under the relevant laws 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 (West 2014). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2015). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d) (2015). In a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim: the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2015); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A. Bilateral Hearing Loss The Veteran asserts that his bilateral hearing loss is related to his active service and, specifically, to the hazardous noise exposure he experienced in service, particularly when stationed in Germany. As an initial matter, the Board notes that the post-service August 2012 VA audio examination results did reflect bilateral hearing loss for VA purposes as defined by 38 C.F.R. § 3.385. Shedden element (1) is therefore met. Turning to Shedden element (2), the Veteran's September 1970 entrance examination showed normal hearing bilaterally. The September 1972 separation examination still showed normal hearing bilaterally, with some threshold shifts. As such, while a threshold shift was clearly shown in service, a chronic hearing loss disability was not demonstrated. Service connection for hearing loss on a direct basis (38 C.F.R. § 3.303(a)) is not warranted. There is also no evidence of hearing loss within a year of service discharge or for many years thereafter. Such would preclude a finding for service connection on a presumptive basis (38 C.F.R. § 3.307, 3.309(a) as well. The question then becomes whether is competent medical evidence linking the Veteran's current hearing loss to his complaints of hearing loss and noise exposure in service. The August 2012 VA examination related that the Veteran's current hearing loss was not related to his active service, but failed to address the in-service threshold shifts. The October 2015 VA examiner opined that the Veteran's current bilateral hearing loss was not related to his active service, as the results were not consistent with hearing loss which results from noise exposure, as hearing loss due to noise exposure generally results in better hearing in the low frequencies and poorer hearing in the higher frequencies, which is not a pattern exhibited by the Veteran. The examiner also stated that the in-service threshold shifts showed "no high frequency change which is typically where you would find hearing loss caused by noise exposure." The examiner explained that the threshold shifts could have been caused by cerumen or fluid in the middle ear, or could have reflected error on part of the participant or the examiner. As indicated above, a finding of a nexus between the Veteran's current bilateral hearing loss disability and in-service noise exposure and hearing threshold shift is needed to satisfy Shedden element (3). Such is not shown. First, the record includes no competent medical opinion establishing a causal relationship between the post-service complaints of hearing loss to any established event in service, including claimed in-service noise exposure. The Veteran has not identified or even alluded to the existence of any such opinion. In fact, the October 2015 VA examiner specifically opined that it was less than likely that the Veteran's bilateral hearing loss was the result of noise exposure during military service based on his normal hearing on separation. The examiner fully explained the threshold shift that the Veteran experienced in service, as well as the Veteran's current bilateral hearing loss, were not the results of noise exposure, as noise exposure results in a different hearing loss pattern (hearing loss at different frequencies than those exhibited by the Veteran). Evidence of record also includes the Veteran's statements asserting in-service noise exposure, continuity of symptomatology since service, and a causal connection between his claimed disability and service. The Board must also analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). The Federal Circuit recently held in Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010) and in Waters v. Shinseki, 601 F.3d 1274, 1278 (2010) that the Board errs when it suggests that lay evidence can never be sufficient to satisfy the requirement of 38 U.S.C.A. § 5103A(d)(2)(B) that there be a nexus between military service and a claimed condition. In this case, the Veteran is competent to describe his in-service recollections of noise exposure as well as his current manifestations of hearing loss because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. However, to the extent that the Veteran generally recalls that he has experienced noise exposure in service, the Veteran is not competent to diagnose the etiology of his current bilateral hearing loss and to state that his current hearing loss was caused by the said noise exposure. The Board, therefore, accords limited probative weight to such assertions. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). While the Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, the Board may, however, in the present case, consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). The Veteran's service treatment records do not include any complaints of hearing-related issues. While a threshold shift was noted on his separation examination, the Veteran did not mention any hearing issues or complaints, or anything at all that was ear-related, on said examination. In fact, he checked "no" for "ear, nose, or throat trouble" and "hearing loss" on the separation examination forms he filled out. Additionally, in this case, the Board emphasizes the multi-year gap between discharge from active duty service (1972) and the lack of any mentions of hearing loss in the Veteran's private and VA treatment records until he was examination by VA in 2012 in relation to his claim (this was approximately 40 years after separation from active service). The Board also cannot ignore the significance of the fact that the Veteran first filed his claims for service connection in 2009, over 35 years after leaving service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Veteran's failure to report any complaints of hearing loss during the interceding 35-plus years is some evidence that he was not then experiencing any relevant problems and outweighs his present recollection to the contrary. The Board therefore finds that the Veteran's current statements, made in connection with his pending claims for VA benefits, that he has had bilateral hearing loss since service are inconsistent with the contemporaneous evidence. Thus, the Veteran's lay assertions of continuity of bilateral hearing loss symptomatology are less credible and persuasive in light of the other evidence of record, and are, in fact, outweighed by this evidence. Further, the Board accords the Veteran's statements regarding the etiology of the claimed disability have no probative value as he is not competent to opine on such complex medical questions. The Board assigns no probative value to the Veteran's purported assertions of continuity of hearing loss symptomatology since service, and a causal connection between each of his claimed disability and service. The Board simply does not find the Veteran's historical recollections to be consistent and accurate. See, e.g. Madden v. Gober, 125 F.3d 1477, 1481 (1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration a Veteran's statements, it may consider whether self-interest may be a factor in making such statements). For the foregoing reasons, the claims of entitlement to service connection for bilateral hearing loss must be denied. The criteria to establish entitlement to service connection for the claimed disability have not been established, either through medical or lay evidence. In arriving at the decision to deny the claims, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2015); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). As such, the appeal is denied. Extraschedular Considerations The Board has considered whether an extraschedular evaluation is warranted for the Veteran's back and left wrist disabilities. 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) (2015) (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 impairment caused by the Veteran's back and left wrist disabilities are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria for those disabilities specifically consider the symptoms which the Veteran has reported, such as frequent pain. In this case, considering the lay and medical evidence for the entire period on appeal, the Veteran's disabilities are manifested by such symptoms. As noted, these symptoms are part of the schedular rating criteria. Finally, in Rice v. Shinseki, 22 Vet. App., 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In the instant case, the holding of Rice is inapplicable since the evidence of record does not demonstrate that the Veteran has in any way been rendered unemployable due solely to his service-connected left wrist and back disabilities, nor have the Veteran or his representative so alleged. In fact, the Veteran has reported to the April 2015 VA examiner that he retired from his long-term employment in 2011. Thus, at this point, there is no cogent evidence of unemployability and entitlement to increased compensation based on TDIU is not warranted. VA Duty to Notify and Assist The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA), which includes an enhanced duty on the part of VA to notify a Veteran of the information and evidence necessary to substantiate claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015). The VCAA also redefines the obligations of VA with respect to its statutory duty to assist Veterans in the development of their claims. 38 U.S.C.A. §§ 5103, 5103A (West 2014). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2015); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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 v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In this case, the Veteran was provided multiple notice letters informing him of both his and VA's obligations. Therefore, additional notice is not required and any defect in notice is not prejudicial. With respect to the duty to assist, the Board finds that all necessary assistance has been provided to the Veteran. The Veteran has also been provided with many VA examinations for his various claims. Upon review of this examination reports, the Board observes that the examiners reviewed the Veteran's past medical history, recorded his current complaints and history, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The VA examination reports are therefore adequate for the purpose of rendering a decision on appeal. 38 C.F.R. § 4.2 (2015); Barr v. Nicholson, 21 Vet. App. 303 (2007). In addition, VA must also make reasonable efforts to assist the appellant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015). VA's duty to assist includes assisting the claimant in the procurement of service and other relevant records. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015). The RO associated with the claims file the Veteran's available service treatment records (STRs), service personnel records (SPRs), private treatment records, and VA treatment records. The Veteran has not identified any relevant records aside from those that are already in evidence. As such, Board concludes that VA has made every reasonable effort to obtain all records relevant to the Veteran's claims. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the above-cited claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Claim for entitlement to service connection for headaches is dismissed. Entitlement to an initial rating in excess of 10 percent for left wrist disability is denied. Entitlement to a rating higher than 10 percent for a back disability for the period prior to July 31, 2012, is denied. Entitlement to a rating higher than 20 percent for a back disability for the period after July 31, 2012, is denied. Entitlement to service connection for bilateral hearing loss is denied. REMAND The Veteran asserts that his GI disorder is related to the GI conditions he had in active service - viral gastroenteritis and abdominal pain (which was determined to be musculoskeletal in nature). In the alternative, he has argued that his current GI disorder (peptic ulcer and/or GERD) stems from, and/or is aggravated by, the medicine the Veteran takes for his service-connected back disability. The Veteran was diagnosed with peptic ulcer at some point during the 1990s, and with GERD in 2004. See May 2015 VA examination report. The May 2015 VA examiner confirmed the peptic ulcer diagnosis and noted that "Ibuprofen can certainly aggravate peptic ulcer disease and occasionally causes ulcers, but does not cause or aggravate GERD." The examiner also opined that he found "no relationship of this disorder to any medication the Veteran is taking for his back pain." This is an internally inconsistent, contradictory opinion. The examiner related that Ibuprofen (which the Veteran takes for his service-related back disability) can aggravate or cause ulcers, yet opined that the peptic ulcer was not caused by or related to Ibuprofen use. The only support that the examiner provided for his opinion was the fact that there was "no history of peptic ulcer disease or GERD while on active duty in the 1970s." Given the evidence outlined above, the file should be returned to the May 2015 VA examiner, if available, in order to obtain an addendum opinion clarifying his statements regarding the etiology of the Veteran's GI disorder. Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the examiner who conducted the May 2015 VA GI examination for an addendum opinion, if available. A complete and detailed rationale should be given for all opinions and conclusions expressed. The examiner should once again review the claims file and provide an addendum opinion clarifying the following: a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's GI disorders (peptic ulcer and/or GERD - if any at this time) were caused or aggravated (made worse by) by the medication, to include, Ibuprofen that the Veteran has been taking since approximately 1972 for his service-connected back disability? 2. Then, readjudicate the claim, considering all evidence added to the file since the last supplemental statement of the case. If any decision is adverse to the Veteran, issue a SSOC and allow the applicable time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs