Citation Nr: 1614221 Decision Date: 04/07/16 Archive Date: 04/25/16 DOCKET NO. 10-41 105 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a right wrist disability. 2. Entitlement to service connection for a low back disability. 3. Entitlement to service connection for bronchitis. 4. Entitlement to a rating in excess of 30 percent for neurofibromatosis. 5. Entitlement to a rating in excess of 20 percent for a disability of the right pectoralis muscle, major. 6. Entitlement to a rating in excess of 10 percent for a right knee disability. 7. Entitlement to a rating in excess of 10 percent for a left knee disability. 8. Entitlement to an initial compensable rating for bilateral hearing loss. REPRESENTATION Appellant represented by: Christine A. Coronado, attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD M. Mills, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1991 to January 1996. These matters come to the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Veteran provided testimony at a November 2013 hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This matter was most recently before the Board in April 2014, at which time it was remanded for further development. It is now returned to the Board. A December 2014 rating decision increased the rating of the pectorales muscle disability to 20 percent, effective May 5, 2009, the date VA received the claim for an increased rating. However, as that increase does not represent a total grant of benefits sought on appeal, the claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The issues of entitlement to service connection for a brain tumor lesion and insomnia have been raised by the record in December 2015 and February 2016, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over those issues, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). The issues of entitlement to increased ratings for neurofibromatosis and left and right knee disabilities, and entitlement to service connection for bronchitis, are REMANDED to the AOJ. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has a diagnosed right wrist disability. 2. The preponderance of the evidence is against a finding that the Veteran has a diagnosed low back disability. 3. Since May 5, 2009, the effective date of the grant of service connection, the Veteran has had, at worst, Level III hearing in the right ear and Level III hearing in the left ear. 4. A right (major) pectoralis muscle disability has resulted in consistent findings of weakness, lowered threshold of fatigue, and loss of muscle substance, most nearly approximating moderately severe disability of Muscle Group II. CONCLUSIONS OF LAW 1. The criteria for service connection for a right wrist disability are not met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). 2. The criteria for service connection for a low back disability are not met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). 3. The criteria for an initial compensable rating for bilateral hearing loss are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.383, 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100 (2015). 4. Resolving all reasonable doubt in favor of the Veteran, the criteria for a rating of 30 percent, but not higher, for a disability of the right (major) pectoralis muscle have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.71a, Diagnostic Code 5302 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 3.159 (2015); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from any notice error. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letter dated May 2009. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing an error is harmful or prejudicial falls on party attacking agency decision); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by claimant or representative that demonstrate awareness of what is necessary to substantiate claim). Thus, VA has satisfied the duty to notify the appellant and had satisfied that duty prior to the adjudication in the June 2015 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained an examination with respect to the claim for increased ratings for hearing loss and muscle injury. Thus, the Board finds that VA has satisfied the duty to assist. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection 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). To establish service connection for a disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427 (2006). Service connection for arthritis may be established on a presumptive basis by showing that arthritis manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2015). Where arthritis manifests to a compensable degree within one year following separation from service, it is presumed to have had its onset in service even though there is no evidence of arthritis during service. 38 C.F.R. § 3.307(a) (2015). If the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2015). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic, including arthritis. 38 C.F.R. § 3.309(a) (2015); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When a claimant seeks benefits and the evidence for and against the claim is in relative equipoise, the claimant prevails. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for a claim to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran contends that a right wrist disability and low back disability are due to service. After considering the evidence of record, the Board finds that the most persuasive evidence of record shows no diagnosed right wrist or low back disabilities. A review of the service medical records shows the Veteran had complaints of right wrist numbness in January 1994 and complaints of low back pain following lifting and weight training in September 1994. There was no evidence of a diagnosed right wrist or low back disability in the service medical records. In a March 2012 VA examination, the Veteran reported that during weight training in 1993 that he felt a pop in his lower back and had pain. He reported continued pain since that time. He reported that his right wrist began to hurt a couple of weeks following a right shoulder injury in service. He reported continued pain since that time and weakened grip. The examiner noted a review of the claims folder. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that the Veteran's lumbar strain would likely have resolved since 1993. Further, the examiner noted that Veteran had a normal wrist on examination. Although the Veteran asserts in-service right wrist pain and low back pain and continues to assert continued disability, the Board finds that there is no evidence to demonstrate that the Veteran's in-service complaints were anything more than acute and transitory in nature. The Board notes that while the Veteran is competent to provide testimony or statements relating to symptoms he has personally experienced, such as pain. However, he is not competent to provide evidence regarding that which would require specialized knowledge or training. Layno v. Brown, 6 Vet. App. 465 (1994). While the Veteran has complained of pain to VA examiners, the Board finds that the weight of the evidence is against a finding that a diagnosis of a right wrist or low back disability is warranted. The Board observes that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Thus, because of the lack of medical evidence of record showing any currently diagnosed right wrist disability or low back disability, the Board finds that the preponderance of the evidence is against a finding that the Veteran has any right wrist disability, or low back disability. The Veteran has not submitted any evidence showing that a diagnosis of any right wrist or low back disability is warranted. Congress has specifically limited entitlement to service connection to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board finds that the preponderance of the evidence is against the claim and service connection for a right wrist and low back disability must be denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings Disability ratings are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2015). Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2015). The determination of whether an increased rating is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107 (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hearing Loss The Veteran's bilateral hearing loss disability has been assigned a 0 percent rating under Diagnostic Code 6100. Assignments of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are conducted. 38 C.F.R. §§ 4.85, 4.86, Tables VI, VIA, VII (2015). Audiometric evaluations are conducted using the controlled speech discrimination tests together with the results of the pure tone audiometry test. 38 C.F.R. § 4.85(a) (2015). Numeric designations of Levels I through XI are assigned by application of Table VI, in which the percentage of discrimination is intersected with the pure tone decibel loss. 38 C.F.R. § 4.85, Table VI (2015). The results are then applied to Table VII, for a percentage rating. Pure tone threshold average, as used in Tables VI and VIA, is the sum of the pure tone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. This average is used in all cases, including those in 38 C.F.R. § 4.86, to determine the Roman numeral designation for hearing impairment from Table VI or Table VIA. 38 C.F.R. § 4.85(d) (2015). Where pure tone thresholds are 55 decibels or more at each of the four specified frequencies of 1000, 2000, 3000, and 4000 Hertz, either Table VI or Table VIA is applied, and whichever results in the higher numeral shall be applied. 38 C.F.R. § 4.86(a) (2015). When the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, the higher numeral of Table VI or Table VIA is also applied. 38 C.F.R. § 4.86(b) (2015). In an August 2009 VA examination, pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 55 50 45 LEFT 30 30 45 50 45 Those results show an average pure tone threshold of 43.75 in the right ear and 42.5 in the left ear. Speech recognition ability was 80 percent in the right ear and 80 percent in the left ear. Applying those values to Table VI results in a numeric designation of Level III in the right ear and Level III in the left ear. 38 C.F.R. § 4.85, Table VI (2015). Application of those levels of hearing impairment in each ear to Table VII at 38 C.F.R. § 4.85 results in a 0 percent rating. An exceptional pattern of hearing loss was not shown. In an October 2010 letter, the Veteran's employer indicated that if the Veteran could not hear, then he could not properly diagnose client's automobile problems. In an April 2012 VA examination, pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 30 25 35 30 35 LEFT 35 25 30 25 25 Those results show an average pure tone threshold of 31 in the right ear and 26 in the left ear. Speech recognition was determined as not appropriate for the Veteran because of language difficulties, cognitive problems, inconsistent speech discrimination, that made the combined use of pure tone average and speech discrimination scores inappropriate. Applying those values to Table VIA results in a numeric designation of Level I in the right ear and Level I in the left ear. 38 C.F.R. § 4.85, Table VIA (2015). Application of those levels of hearing impairment in each ear to Table VII at 38 C.F.R. § 4.85 results in a 0 percent rating. An exceptional pattern of hearing loss was not shown. Regarding functional impact, the Veteran reported that he worked as a service writer and had trouble hearing understanding customer complaints. In a November 2014 VA examination, pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 25 25 30 LEFT 15 20 25 15 30 Those results show an average pure tone threshold of 25 in the right ear and 23 in the left ear. Speech recognition ability was 92 percent in the right ear and 88 percent in the left ear. Applying those values to Table VI results in a numeric designation of Level I in the right ear and Level II in the left ear. 38 C.F.R. § 4.85, Table VI (2015). Application of those levels of hearing impairment in each ear to Table VII at 38 C.F.R. § 4.85 results in a 0 percent disability rating. An exceptional pattern of hearing loss was not shown. Regarding functional impact of hearing loss, during the November 2014 VA examination, the Veteran reported a difficulty understanding words. He indicated that the words became jumbled and that he could not hear people at work because he could not wear hearing aids in a shop environment. The examiner stated that the Veteran's hearing loss did not preclude gainful employment. It was noted the Veteran had near-normal hearing sensitivity in both ears and would be expected to hear well in most listening environments. After a review of the evidence, the Board finds that that Veteran's disability is shown to be no worse than Level III in the right ear and Level III in the left ear. The Veteran's hearing loss does not meet criteria for exceptional patterns of hearing impairment. 38 C.F.R. §§ 4.85(c), 4.86 (2015). Therefore, a compensable rating for the period under review is not warranted. 38 C.F.R. § 4.85, Diagnostic Code 6100 (2015). Consideration has been given to assigning any staged ratings. However, at no time during the period under review has the disability warranted a higher schedular rating than those ratings currently assigned. In addition to providing objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in the final report because of the potential application of 38 C.F.R. § 3.321(b) in considering whether referral for an extra-schedular rating is warranted. Unlike the rating schedule for hearing loss, 38 C.F.R. § 3.321(b) does not rely exclusively on objective test results to determine whether a referral for an extra-schedular rating is warranted. Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Board has considered the Veteran's statements regarding the severity of his hearing loss and his difficulty hearing customers at work. The Board does not discount the difficulties that the Veteran experiences as a result of bilateral hearing loss. However, disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned based on audiometric evaluations. The Board has no discretion in the matter. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1) (2015). In this case, the rating criteria for the ear reasonably describe the Veteran's disability level and symptomatology, and provide for consideration of greater disability and symptoms than currently shown by the evidence. The evidence does not show anything unusual or exceptional that would make the schedular criteria inadequate in this case. Here the record shows that the manifestations of the disability are contemplated by the schedular criteria. The symptoms difficulty in hearing are contemplated in the assigned schedular rating. There is no indication that the average industrial impairment from the hearing loss is in excess of that contemplated by the assigned ratings, even in conjunction with the other service-connected disabilities. A higher rating is available for more severe levels of impairment, but the Veteran does not meet the criteria for the higher rating. The evidence does not show frequent hospitalization due to hearing loss of that any interference with employment rises to the level of marked. Therefore, the Board finds that referral for extra-schedular consideration is not in order. Accordingly, the Board finds that the preponderance of the evidence is against the claim of entitlement to an initial compensable rating for bilateral hearing loss disability. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right (Major) Pectoralis Muscle The Veteran's right major pectoralis muscle disability has been assigned a 20 percent rating under Diagnostic Code 5302. The medical evidence of record shows that the Veteran is right-handed. Therefore, his disability is rated for the major arm. 38 C.F.R. § 4.69 (2015). Under Diagnostic Code 5302, a 20 percent rating applies for moderate disability of either the dominant or non-dominant side or for moderately severe disability of the non-dominant side. A 30 percent rating applies for moderately severe disability of the dominant side or for severe disability of the non-dominant side. A maximum 40 percent rating applies for severe disability of the dominant side. 38 C.F.R. § 4.73, Diagnostic Code 5302 (2015). The severity of a muscle disability is rated pursuant to 38 C.F.R. § 4.56 according to the type of injury, history, and complaint, and objective findings. A moderate muscle disability is characterized by a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. The history shows a record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objective findings consisted of entrance and exit scars, small or liner, indicating a short track of the missile through muscle tissue. There is some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue as compared to the sound side. A moderately severe disability of the muscles in characterized by a through and through or deep penetrating wound by a small high velocity missile or large low-velocity missile with debridement, prolonged infection, or sloughing of soft parts and intramuscular scarring. The history shows hospitalization for a prolonged period for treatment of the wound. There is a record of consistent complaints of cardinal signs and symptoms of muscle disability and, if present, inability to keep up with work requirements. Objective findings include entrance and exit scars indicating the track of the missile through one or more muscle groups. There are indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles as compared with the sound side. Tests of strength and endurance compared with the sound side demonstrate positive evidence of impairment. A severe disability of the muscles consists of a through and through or deep penetrating wound due to a high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intramuscular binding and scarring. There is a history showing hospitalization for a prolonged period for treatment of the wound. There is a record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries and, if present, evidence of inability to keep up with work requirements. Objective findings include ragged, depressed and adherent scars indicating wide damage to muscle groups in the missile track. Palpation shows loss of deep fascia of muscle substance, or soft flabby muscles in the wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present the following are also signs of severe muscle disability: (a) x-ray evidence of minute multiple scattered foreign bodies indicating intramuscular trauma and explosive effect of the missile; (b) adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (c) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (d) visible or measurable atrophy; (e) adaptive contraction of an opposing group of muscles; (f) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle, and (g) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d) (2015). In applying those rating criteria, a through and through injury with muscle damage shall be rated as no less than a moderate muscle injury to the group of muscles damaged. 38 C.F.R. § 4.56(b). An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as the wrist or over the tibia, evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(a). On VA examination in June 2009, the Veteran rated his right pectoralis major pain as 7 out of 10 on a scale of 10 if he was working for longer than 30 minutes using the muscle. He noted that affected his abilities as a mechanic and reported that physical therapy and anti-inflammatory medication helped. He denied use of a crutch, cane, or brace. He had not had to resort to use of his minor hand for hygiene and personal care, but reported that he was no longer able to work in the yard or perform household chores with the right arm, secondary to pain and weakness. Physical examination found tenderness to palpation within the pectoralis major muscle belly. The examiner noted the Veteran had a 4 out of 5 weakness. Range of motion revealed extension to 0 degrees, flexion to 180 degrees, and adduction to 180 degrees. Repetition of range of motion revealed no loss in range of motion and no increased pain in forward flexion and abduction. With the arm abducted to 90 degrees, he had 10 degrees of external rotation at which he had pain within the pectoralis major insertion and 30 degrees of internal rotation without pain. Upon repetition, the Veteran had the same range of motion but had increasing pain at the pectoralis insertion with greater than 10 degrees of external rotation. The examiner noted that pain could further limit the Veteran's function, particularly after being in use all day, but noted additional limitation of motion could not be determined with any degree of medical certainty. In an October 2010 letter, the Veteran's employer indicated that his job as a mechanic required frequent lifting overhead and that the shoulder disability created discomfort and slowed the Veteran's production time in some cases. VA treatment records in July 2013 noted that the Veteran complained of pain that started in the right shoulder blade two or three days prior. The Veteran indicated the pain was worse with lifting or reaching overhead. He indicated that lifting heavy, large tires for work worsened the pain. The examiner noted the Veteran had good range of motion of the shoulder with pain on movement and pain with palpation of the subscapular areas. X-rays were unremarkable. The examiner diagnosed subscapular pain. On VA examination in September 2014, physical evaluation revealed some loss of muscle substance and visible or measurable atrophy affecting muscle substance or function. The cardinal signs and symptoms of muscle disability were loss of power, consistent weakness, consistent lowered threshold of fatigue, and occasional fatigue-pain all on the right side. Muscle strength testing showed less than normal shoulder abduction on the right. Muscle atrophy was noted on the right pectoralis in muscle groups II and III with the normal side muscle bulk measuring 34 centimeters and the atrophied side measuring 32 centimeters. The Veteran reported regular use of a cane. The functional impact of the disability was noted as easy fatigability with the right arm and inability to lift heavier items with the right arm. The examiner noted that Veteran has no pain, weakness, fatigability, or incoordination that significantly limited function during flare-ups or when the joint was used repetitively over time. After a review of the evidence, the Board finds that a 30 percent rating is warranted for the right pectoralis muscle disability under Diagnostic Code 5203. That is because the Veteran's symptoms, as described on VA examination and in his reports, most nearly approximate moderately severe disability. The Veteran displayed consistent complaints of cardinal signs and symptoms of muscles disability, such as loss of power and lowered threshold of fatigue in the affected muscle, and objective findings specifically noted in the criteria characteristic of moderately severe muscle injury, such as loss of muscle tissue and weakness in the affected muscle group. The Board, does not find that, at any time during the appeal, that the Veteran displayed signs or symptoms of a severe muscle disability. The Board finds that the initial in-service injury did not result in shattered bone, open comminuted fracture, prolonged infection, or sloughing of soft parts. Further, there is no indication that the Veteran has ragged, depressed, or adherent scars, soft flabby muscles in the wound area, or severe impairment of strength, endurance, or coordinated movements. There has been no showing that the Veteran has adhesion of scars with epithelial sealing over bone, diminished muscle excitability, visible muscular atrophy, or any other symptoms to warrant the assignment of a 40 percent disability rating under Diagnostic Code 5302. The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1) (2015). In this case, the rating criteria for the muscle reasonably describe the Veteran's disability level and symptomatology, and provide for consideration of greater disability and symptoms than currently shown by the evidence. The evidence does not show anything unusual or exceptional that would make the schedular criteria inadequate in this case. Here the record shows that the manifestations of the disability are contemplated by the schedular criteria. The symptoms of pain are contemplated in the assigned schedular rating. The Veteran has not reported any limitation of motion. Moreover, the Veteran has been able to maintain full-time employment. There is no indication that the average industrial impairment from the pes planus is in excess of that contemplated by the assigned ratings, even in conjunction with the other service-connected disabilities. A higher rating is available for more severe levels of impairment, but the Veteran does not meet the criteria for the higher rating. Therefore, the Board finds that referral for extra-schedular consideration is not in order. Accordingly, the Board finds that a 30 percent rating, and not higher, for the right pectoralis muscle disability is warranted and the preponderance of the evidence is against the assignment of any higher rating. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a right wrist disability is denied. Entitlement to service connection for a low back disability is denied. Entitlement to a 30 percent rating for a disability of the right pectoralis muscle, major is granted. Entitlement to an initial compensable rating for bilateral hearing loss is denied. REMAND The Veteran requested that he be scheduled for a Board hearing at the RO for increased rating claims for a neurofibromatosis disability and bilateral knee patellofemoral pain syndrome in September 2015 and November 2015 substantive appeals. There is no indication from the record that the Veteran has been scheduled for the requested hearings. As a result, remand is required. 38 C.F.R. § 20.700, 20.704 (2015). With respect to the claim of entitlement to service connection for bronchitis, the Veteran was provided a VA examination to address the etiology of any bronchitis disability. However, there appears to be a conflict within the findings and the Board finds that further clarification is needed. In March 2012, a VA examiner noted the Veteran had episodes of bronchitis two to three times a year after service with no significant residuals. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. However, there was no clearly articulated rationale nor any clear discussion regarding the episodes of post-service acute bronchitis and any in-service bronchitis. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a remand is necessary to obtain an opinion with supporting rationale. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a Board hearing at the RO on the increased rating claims for neurofibromatosis, and bilateral knee disabilities. Notify the Veteran and representative of the date, time, and location of the hearing. 2. Schedule the Veteran for a VA examination with an examiner who has not previously examined him. The examiner must review the claims file and should note that review in the report. The examination report should include discussion of the Veteran's documented medical history and assertions. All necessary tests and studies should be accomplished. The examiner should set forth all examination findings, with a clear rationale for the conclusions reached, to include a discussion of any pertinent medical literature reviewed. The examiner should opine as to whether it is at least as likely as not 50 percent probability or greater) that any bronchitis disability was incurred in service or is otherwise related to service? The examiner should discuss the Veteran's post-service episodes of bronchitis and the significance on those episodes in providing the opinion. 2. Then, readjudicate the claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. 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 claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs