Citation Nr: 1803727 Decision Date: 01/19/18 Archive Date: 01/29/18 DOCKET NO. 14-09 267 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for a right shoulder disability. 3. Entitlement to service connection for a left shoulder disability. 4. Entitlement to service connection for hypertension. 5. Entitlement to an initial disability rating in excess of 10 percent for the service-connected duodenal ulcer. 6. Entitlement to service connection for an acquired psychiatric disorder to include depression. 7. Entitlement to service connection for a cervical spine disability. 8. Entitlement to service connection for a right knee disability. 9. Entitlement to service connection for a left knee disability. 10. Entitlement to service connection for a right wrist disability. 11. Entitlement to an initial disability rating in excess of 10 percent for the service-connected right ankle disability. 12. Entitlement to an initial compensable disability rating prior to February 13, 2017, and a disability rating in excess of 10 percent thereafter, for the service-connected left wrist disability. 13. Entitlement to an initial disability rating in excess of 10 percent for the service-connected left ankle disability. 14. Entitlement to an effective date prior to April 10, 2014 for the grant of service connection for a left ankle disability. REPRESENTATION Appellant represented by: J. Michael Woods, Attorney ATTORNEY FOR THE BOARD L. B. Cryan, Counsel INTRODUCTION The Veteran served on active duty from August 1978 to February 1985. This case is before the Board of Veterans' Appeals (Board) on appeal from September 2012, January 2015 and January 2017 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In the September 2012 rating decision, the RO granted service connection for a duodenal ulcer and assigned an initial 10 percent rating, effective from August 20, 2012; and, denied service connection for disabilities of the right and left shoulder, and the back. In the January 2015 rating decision, the RO granted service connection for a right ankle disability and a left wrist disability, and assigned 10 percent ratings for each, effective from April 10, 2014, the date of claim. The RO denied claims of service connection for an acquired psychiatric disorder, hypertension, a neck disability, a bilateral knee disability, a right wrist disability, and a left ankle disability. In December 2016, the Board granted service connection for a left ankle disability; denied effective dates prior to April 10, 2014 for the grants of service connection for a right ankle disability and a left wrist disability; and remanded the remaining claims on appeal to the Board at that time (Issues 1-10 above, and the claim for a compensable disability rating for the service-connected left wrist disability). In a January 2017 rating decision, the RO effectuated the Board's grant of service connection for a left ankle disability and assigned an initial 10 percent rating, effective from April 10, 2014, the date of claim. The Veteran disagreed with the effective date of the award as well as the initial 10 percent rating assigned. Before the case was returned to the Board on appeal, the RO issued a rating decision in February 2017 which increased the noncompensable rating for the service-connected left wrist disability to 10 percent, effective from February 13, 2017. As the award is not a complete grant of benefits, the issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). (CONTINUED ON NEXT PAGE) FINDINGS OF FACT 1. The Veteran's current disabilities of the back, neck, bilateral shoulders, bilateral knees and right wrist are unrelated to service. 2. Hypertension had its onset many years following service discharge and is not otherwise related to any disease or injury in service. 3. The Veteran's depression is unrelated to service. 4. The Veteran's service-connected duodenal ulcer is manifested by recurrent symptoms of abdominal pain, nausea and vomiting 4 or more times per year with an average duration of 1 to 9 days; and, no more than 3 incapacitating episodes per year, resulting in an overall disability picture that more nearly approximates moderate impairment rather than mild impairment. 5. The Veteran's service-connected right ankle disability has never been manifested by marked limitation of motion or ankylosis. 6. The Veteran's service-connected left ankle disability has never been manifested by marked limitation of motion or ankylosis. 7. For the entire period covered by this claim, the Veteran's left wrist disability has been manifested by painful motion, but without evidence of ankylosis. 8. The Veteran's initial claim for service connection for a left ankle disability was received on April 10, 2014. CONCLUSIONS OF LAW 1. The criteria for service connection for disabilities of the back, neck, bilateral shoulders, bilateral knees and right wrist have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307,3.309 (2017). 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. § § 3.303, 3.307, 3.309 (2017). 3. The criteria for service connection for depression have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. § 3.303 (2017). 4. The criteria for the assignment of a disability rating of 20 percent, but no higher, for the service-connected duodenal ulcer have been met since the effective date of service connection. 38 U.S.C. § 1155; 38 C.F.R. § 4.114 Diagnostic Code 7305 (2017). 5. The criteria for the assignment of an initial disability rating in excess of 10 percent for the service-connected right ankle disability have not been met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2017). 6. The criteria for the assignment of an initial disability rating in excess of 10 percent for the service-connected left ankle disability have not been met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2017). 7. The criteria for the assignment of an initial 10 percent rating for the service-connected left wrist disability have been met since the effective date of service connection; the criteria for a rating in excess of 10 percent for the service-connected left wrist disability have not been met or approximated at any time covered by this claim. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5215 (2017). 8. The criteria for the assignment of an effective date prior to April 10, 2014 for the grant of service connection for a left ankle disability have not been met. 38 U.S.C. §§ 5103, 5110 (2012); 38 C.F.R. § 3.400 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. § 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. § 3.102, 3.156(a), 3.159, 3.326(a) (2017). This matter was initially filed as a Fully Developed Claim (FDC). The notice that accompanies the FDC form informs a veteran what evidence is required to substantiate a claim for service connection, a veteran's and VA's respective duties for obtaining evidence, and information on how VA assigns disability ratings in the event that service connection is established. See VA Form 21-526EZ. The Veteran filed additional claims in April 2014, and a notice letter with respect to those claims was issued to the Veteran in April 2014. The Veteran has received all essential notice and has had a meaningful opportunity to participate in the development of the claim. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Thus, VA's duty to notify has been satisfied. Regarding the earlier effective date claim and the claims for higher initial disability ratings for the service-connected duodenal ulcer, right and left ankle disabilities, and left wrist disability, these claims arise from a disagreement with the initial disability rating and/or effective date that was assigned following the grants of service connection. Once service connection is granted, the claim is substantiated, and additional notice is not required; and, any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board is satisfied that VA has made reasonable efforts to obtain relevant records and evidence. The Veteran's service treatment records (STRs), VA treatment records and Social Security Disability records have been associated with the record. The Veteran's claims were remanded by the Board in December 2016 to obtain outstanding records and to obtain adequate medical opinions. There has been substantial compliance with the Board's remand directives. In June 2017, the Veteran submitted a private opinion from a licensed psychologist regarding whether the Veteran had a currently diagnosed psychiatric disorder. As the Veteran submitted a waiver of AOJ consideration of this new evidence in the first instance, the Board may proceed without prejudice. In sum, the Board is satisfied that the originating agency properly processed the Veteran's claims after providing the required notice and that any procedural errors in the development and consideration of the claims by the originating agency were insignificant and non-prejudicial to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, to establish service connection, there must be lay or medical evidence of (1) a current disability, (2) incurrence or aggravation of a disease or injury in service, and (3) a nexus between the in-service injury or disease and the current disability. See 38 U.S.C. § 1110; Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed .Cir.2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed.Cir.2004); 38 C.F.R. § 3.303. In this case, the Veteran asserts that service connection is warranted for disabilities of the back, neck, both shoulders, both knees, and his right wrist. He also claims service connection for hypertension and depression, asserting that these conditions had their onset during service. The Veteran's service treatment records (STRs) are negative for complaints or treatment for knee pain, shoulder pain, right wrist pain, or back pain. Similarly, there is no indication that the Veteran had hypertension during service and consistently high blood pressure readings are not shown in the STRs. The STRs note that the Veteran sought treatment for neck pain after being hit with a football in August 1981; however, there was no in-service follow-up treatment and the Veteran's discharge examination was negative for neck pain or a neck injury. The Veteran underwent a series of VA examinations in February 2017. Based on a review of the Veteran's claims file, as well as examination of the Veteran, the examiner indicated that the Veteran had current diagnoses of hypertension, degenerative arthritis of the thoracolumbar spine, degenerative arthritis of both knees, residuals of cervical (neck) fusion, and bilateral acromioclavicular joint (shoulder) osteoarthritis. Regarding the right wrist, the examination report first notes that the Veteran injured his right wrist in 1979, but a review of the STRs shows that the Veteran injured his left wrist, not his right, in 1979. The examiner subsequently corrected this error in her medical opinion when she noted that the STRs did not indicate that the Veteran was seen or treated for complaints of a right wrist problem during service or within the first post-service year. Regarding the current disabilities, the examiner opined that the Veteran's current hypertension, degenerative arthritis of the thoracolumbar spine, degenerative arthritis of both knees, residuals of cervical (neck) fusion, bilateral acromioclavicular joint (shoulder) osteoarthritis, and right wrist pain were less likely than not incurred in service or caused by any in-service disease or injury. The examiner noted that none of these conditions were first shown in service or for many years following discharge. With regard to the back, neck, knees, shoulders and right wrist, the examiner opined that the current disabilities were most likely due to normal wear and tear. Regarding the hypertension, the examiner found that blood pressure readings in the STRs were not consistently elevated, and there was no diagnosis of hypertension during service or for years following service discharge. There is no competent medical evidence to the contrary. Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). While the Veteran is competent to report pain in his joints and the onset thereof, the causation of his current arthritis of the spine, neck, knees, and shoulders is not the type of medical question subject to lay observation. Similarly, hypertension requires a medical diagnosis, and where, as here, the STRs neither show consistently high blood pressure readings or a diagnosis of hypertension, the Board finds that the medical opinion outweighs the Veteran's contentions. Likewise, regarding the arthritis of the back, neck, knees and shoulders, as well as the right wrist pain, the VA examiner's opinion outweighs the Veteran's lay assertions as to continuity of symptoms. The Veteran did not report any pain in his back, neck, knees, shoulders or right wrist at the time of discharge, and the record does not otherwise show that the current disabilities existed until many years following service discharge. Accordingly, the medical findings outweigh the Veteran's contentions because the Veteran's current assertions are inconsistent with what was reported more contemporaneous in time to service discharge. It is the Board's responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In essence, the only evidence to support the Veteran's claims is his self-reported history of in-service injuries and events, which he believes led to his current arthritis and hypertension. However, his statements are not consistent with the findings on the separation examination; and, moreover, the February 2017 VA examiner opined that the Veteran's current hypertension and arthritis of the back, neck, knees, shoulders and right wrist had their onset many years following service, and were more likely related to normal wear and tear rather than in-service injuries or other in-service events. There is no competent evidence to the contrary. Accordingly, the Board finds that the Veteran's current contentions are outweighed by the other evidence of record as explained above. Accordingly, the preponderance of evidence against the claims, and therefore the claims must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Regarding the claim of service connection for a depressive disorder, the Veteran's STRs are negative for complaints or findings of a psychiatric disorder. The post-service medical evidence of record contains conflicting findings as to whether the Veteran has a currently diagnosed acquired psychiatric disorder. More specifically, a VA examiner in February 2017 opined that the Veteran did not meet the Diagnostic and Statistical Manual of Mental Disorders (DSM) definition of an acquired psychiatric disorder including a depressive disorder. This finding is consistent with the Veteran's own self-reported history in June 2014 that he had no mental health concerns. However, the Veteran submitted a private psychological report (prepared in March 2016 and received at VA in June 2017) which indicates a diagnosis of unspecified depressive disorder in conformance with the DSM definition of such. In support of his claim, the Veteran submitted two lay statements, received at VA in June 2017. One lay statement is dated in February 2016 and is from a longtime friend of the Veteran. The other lay statement is dated in April 2016 and is from the Veteran's younger brother. These lay statements indicate that the Veteran's behavior and demeanor changed after he came home from service. He appeared on edge and irritable, and less dependable than before he entered service. While these lay observations may be considered competent for the purpose of describing the Veteran's behavior changes following service, the lay statements do not provide competent evidence of a DSM diagnosis of depressive disorder, as this is a complex medical question not capable of lay observation. Moreover, there is no supporting medical evidence of a diagnosed psychiatric disorder for many years following service discharge. In the March 2016 private psychological assessment received at VA in June 2017, the licensed psychologist, H.H.G. noted a review of the Veteran's claims file, VA records, and that she conducted a mental status examination of the Veteran. According to H.H.G., the Veteran had a current diagnosis of unspecified depressive disorder; however, the findings on the mental status examination are internally inconsistent. For example, H.H.G. indicated (by checking the corresponding box) that the Veteran had an inability to establish and maintain effective relationships; yet, in the narrative report, H.H.G. noted that the Veteran has been in a significant relationship with a woman since 2010. While the Veteran reported significant isolation from others, he did not indicate that he was unable to maintain an effective relationship with his significant other. Notably, H.H.G.'s narrative report indicates that the Veteran had been married twice and was currently divorced, with two adult children; yet, the report fails to disclose that the Veteran was widowed from his first wife in 2003 and that his relationship with his children was described as "close," according to a June 2014 VA psychology consult report. Moreover, records obtained from the Social Security Administration reveal that the Veteran is unable to work due to his back disability and hypertension, and the accompanying medical records make no mention of any acquired psychiatric disorder. This is consistent with VA outpatient treatment records from February and May 2014 which show that the Veteran's depression screens were negative. In June 2014, the Veteran reported that he did not have any current mental health concerns in conjunction with a psychology consultation that was conducted to help facilitate coping with his pain from physical conditions. This is also consistent with the VA examiner's February 2017 opinion that no such current psychiatric disorder exists. Rather, the examiner indicated that the Veteran was having a "phase of life problem" and did not have a DSM conforming psychiatric disorder. The examiner noted that the Veteran was looking for work, had a debt problem, and had recently filed for bankruptcy. The February 2017 VA examiner indicated that the Veteran had recently received a Bachelor's degree in healthcare administration management, and that he left his last job due to pain following a cervical discectomy in April 2012. H.H.G.'s report indicates that the Veteran has chronic sleep impairment; yet, the report fails to disclose that the chronic sleep impairment is due to neck and back pain, and not due to nightmares. See February 2017 VA examination report. Attached to H.H.G.'s March 2016 assessment is a summary of the evidence submitted in conjunction with the actual assessment. It is not clear whether the assessment summary was prepared by H.H.G. or the Veteran's attorney, but it is notable that while H.H.G. signed the actual assessment form, her signature does not appear at the end of the assessment summary. In any event, the assessment summary suggests that the Veteran does not attend to his personal hygiene as well as he did in the past, but there is no indication from the Veteran that this is the case, and it is not shown anywhere else in the record. Additionally, the assessment summary indicates that the Veteran cannot sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his depressive disorder; yet, the February 2017 VA examiner specifically noted that the Veteran was able to obtain a bachelor's degree, presumably in a competitive environment, and was actively looking for work. Additionally, the Veteran, himself, believed that his only obstacle to finding work was his physical limitation. Finally, the assessment summary refers to a body of medical literature addressing the connection between military service and a psychiatric disorder, as well as the connection between medical issues and a psychiatric disorder; however, this literature is general in nature and does not address the Veteran's particular condition. As such, it is not particularly probative in this case. The assessment summary also indicates the following: "It is the belief of this examiner, based on interview and the C-File that [the Veteran] suffers from unspecified depressive disorder more likely than not began in military service, continues uninterrupted to the present and is aggravated by his ulcer, right ankle deltoid ligament sprain and left wrist sprain." The summary assessment further suggests that the Veteran is unemployable as a result of his depressive disorder; yet, this is in complete contrast to the Veteran's own admission that the only impediment to obtaining and maintaining employment is physical impairment. He specifically went back to school to obtain a degree in health care administration so that he could work in an administrative position that did not require physical labor. Even if the Board concedes that the narrative summary of the assessment (which followed the actual assessment form) was provided by H.H.G., there is no adequate rationale as to why she believes that the diagnosed depressive disorder more likely than not began in military service and continued uninterrupted to the present. While it is certainly plausible that the Veteran's physical pain affects his mental status, the preponderance of the evidence is against a finding that the Veteran incurred a depressive disorder during service that has continued to the present day, particularly where, as here, the Veteran denied any mental health concerns in June 2014, and had two negative depression screens that same year. In summary, the findings in H.H.G.'s assessment are not supported by the other evidence of record, and in some cases, are actually inconsistent with the other evidence of record, as noted above. By contrast, the February 2017 VA examiner's opinion contains greater detail with respect to the Veteran's mental health status history, and the examiner based his opinion on a review of that history, including the Veteran's self-reports as noted above. The examiner pointed to specific instances in the record to support the opinion. In light of the foregoing, the Board finds that the opinion of the VA examination outweighs the opinion of H.H.G. Accordingly, the preponderance of evidence against the claim of service connection for an acquired psychiatric disorder, and therefore the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, given the highly probative findings by the February 2017 examiner, in conjunction with the Veteran's self-reported history in 2014 as noted above, the Board finds that the evidence against service connection on the basis of aggravation outweighs H.H.G.'s opinion in favor of such a finding. III. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). See also Fenderson v. West, 12 Vet. App. 119, 126 (1999) (applying this concept to initial ratings). Duodenal Ulcer Under 38 C.F.R. § 4.114, Diagnostic Code 7305, which rates duodenal ulcers, provides a 10 percent rating for mild impairment with recurring symptoms once or twice yearly. A 20 percent rating is provided for moderate overall impairment, with recurring episodes of severe symptoms two or three times a year averaging 10 days or more in duration or for continuous moderate manifestations. A 40 percent rating is authorized for moderately severe manifestations with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. VA examination in September 2012 indicates that the Veteran's treatment plan did not include taking continuous medication for his ulcer. The examiner indicated that the Veteran's duodenal ulcer was manifested by recurring episodes of symptoms that are not severe, which recur 4 or more times per year, and have an average duration of 1 to 9 days. The Veteran reported periodic abdominal pain occurring at least monthly, unrelieved by standard ulcer therapy. Baseline weight was 190 and weight at the time of examination was 175. The Veteran also reported mild recurrent nausea recurring 4 or more times per year with an average duration of 1 to 9 days; and, transient vomiting occurring 4 or more times per year with an average duration of 1 to 9 days. Finally, the Veteran reported 3 incapacitating episodes of stomach/duodenal pain in the previous year, lasting an average of 1 to 9 days. Another VA examination was conducted in February 2017. Findings from that examination were no worse than the findings in September 2012. In comparing the Veteran's duodenal ulcer symptoms to the rating criteria, the Board finds that the overall disability picture more nearly approximates that of moderate impairment rather than mild impairment. The Veteran has recurring symptoms more than once or twice yearly, which is more frequent than the criteria for a 10 percent rating, which only requires that recurring symptoms once or twice yearly. In the Veteran's case, he has symptoms which occur 4 or more times per year. However, to warrant the next higher, 20 percent rating, the overall disability must be moderate in degree, with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or, with continuous moderate manifestations. In this case, the Veteran's symptoms were found to be less than severe by the September 2012 examiner; and, the recurring symptoms (of abdominal pain, nausea, and vomiting) had an average duration of less than 10 days. Further, the Veteran's symptoms do not appear to be continuous. Nonetheless, the Veteran's symptoms recur 4 or more times per year, and include nausea and vomiting in addition to abdominal pain. Moreover, the Veteran reported that his symptoms are not fully relieved with standard ulcer therapy, and that he endured 3 incapacitating episodes in the year prior to the September 2012 VA examination. Based on these findings, the Board finds that the Veteran's overall disability picture is more than mild; and, while the manifestations do not fully meet the criteria for the assignment of the next higher, 20 percent rating, they more nearly approximate the criteria for that 20 percent rating compared to the 10 percent rating. Significantly, whereas here, two disability evaluations are potentially applicable, the higher evaluation 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. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. For the foregoing reasons, the Board finds that in resolving all doubt in the Veteran's favor, the criteria for the assignment of an initial 20 percent rating, but not higher, for the service-connected duodenal ulcer are more nearly approximated since the effective date of service connection. Right Ankle, Left Ankle, Left Wrist When assigning a disability rating for orthopedic disabilities, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on movements. See DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). The rating for an orthopedic disorder should reflect functional limitation due to pain which is supported by adequate pathology and evidenced by the visible behavior of the Veteran undertaking the motion. Weakness is also as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. See 38 C.F.R. § 4.40. The factors of disability reside in reductions of their normal excursion of movements in different planes. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight bearing are related considerations. See 38 C.F.R. § 4.45. It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). The Veteran is competent to provide evidence of observable symptoms, including pain. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). See also Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). Limitation of motion of the ankle is assigned a 10 percent rating for "moderate" limitation and a 20 percent rating for "marked" limitation. 38 C.F.R. § 4.71a, Diagnostic Code 5271. While the schedule of ratings does not provide any information as to what manifestations constitute "moderate" or "marked" limitation of ankle motion, guidance from VBA's M21-1 Adjudication Procedures Manual states that moderate limitation of ankle motion is present when there is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, while marked limitation of motion is demonstrated when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. See VBA Manual M21-1, III.iv.4.A.3.k. Degenerative or traumatic arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific major joints or minor joint groups involved. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. When, however, the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic codes, a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. The Veteran's right and left ankle range of motion is normal. See October 2014 and February 2017 VA examination reports. These examinations were not conducted during any periods of flare, but a 10 percent rating has been assigned for each ankle based on the Veteran's reports of increased painful motion during a flare-up. Marked limitation of ankle motion has never been shown and the Veteran has not asserted that the motion of his right and/or left ankle is markedly limited during a period of flare-up such that a rating in excess of 10 percent is warranted. Similarly, ankylosis of the right and left ankle has not been shown. Accordingly, there is no basis on which to assign ratings in excess of 10 percent for the right and left ankles at any time covered by this claim. Limitation of the wrist is rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5215. A 10 percent disability rating is warranted where palmar flexion is limited in line with the forearm, or where dorsiflexion is less than 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5215. This is the maximum schedular rating based on limitation of motion of the wrist under this diagnostic code. A higher schedular rating is only warranted when there is evidence of ankylosis (frozen joint). 38 C.F.R. § 4.71a, Diagnostic Code 5214 (2017). In this case, the Veteran's left wrist is rating as noncompensable prior to February 13, 2017 and rated as 10 percent thereafter. The 10 percent rating was assigned an effective date of February 13, 2017 because that is the date of the most recent VA examination; however, the Board finds that the Veteran's left wrist symptoms have been fairly consistent since the effective date of service connection. VA examination reports in October 2014 and February 2017 both note the Veteran's reports of left wrist pain, and both indicate that the range of motion of the left wrist was normal. The more recent VA examination in February 2017 notes an additional symptom of crepitus, and specifically indicates that the Veteran has pain with palmar flexion and dorsiflexion; however, the Board does not find that the overall disability picture significantly increased in severity between the time of the April 2014 examination and the February 2017 examination. Rather, the Veteran's range of motion remained in the normal range, and the Veteran continued to assert pain in the left wrist, which has been noted since the effective date of service connection. Accordingly, the Board finds that the left wrist manifestations have been fairly consistent since the effective date of service connection. Accordingly, the 10 percent rating should be assigned effective from April 10, 2014, the effective date of service connection. The Veteran asserts that a rating in excess of 10 percent is warranted for the left wrist disability; however, the evidence of record does not support this assertion. The 10 percent rating has been assigned for noncompensable limitation of motion, and it is the highest schedular rating assigned for limitation of motion of the wrist. The Veteran does not have other manifestations of the left wrist, such as ankylosis, that would warrant the assignment of a higher rating. Accordingly, an initial 10 percent rating is warranted for the left wrist disability since the effective date of service connection, but a rating in excess of 10 percent is not warranted at any time covered by this claim. Finally, a claim for individual unemployability is not raised by the record in this case. The Veteran maintains that he is unable to work in a job that requires physical labor, but is looking for a new job in health care administration since obtaining a bachelor's degree in this field and believes that he is capable of administrative sedentary work. See February 2017 VA examination report. III. Effective Date - Grant of Service Connection Left Ankle Generally, the effective date for an award based on, inter alia, an original claim or a claim reopened after a final adjudication shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefore. 38 U.S.C. § 5110 (a). The effective date for an award based on an original claim of compensation shall be the "[d]ay following separation from active service or date entitlement arose if [the] claim is received within 1 year after separation from service; otherwise, date of receipt of claim, or date entitlement arose, whichever is later." 38 C.F.R. § 3.400(b)(2)(i). In this case, the Veteran's original claim of service connection for a left ankle disability was received at the RO on April 10, 2014. In a January 2017 rating decision, the RO granted service connection for a left ankle disability pursuant to the Board's December 2016 decision. The RO assigned an effective date of April 10, 2014 for the grant of service connection based on the date the Veteran's original claim was received at the RO. The April 10, 2014 claim was not received within a year of the Veteran's discharge from service, and no claim of service connection for a left ankle disability was filed prior to April 10, 2014. Accordingly, there is no basis on which to assign an effective date prior to April 10, 2014, for the grant of service connection for a left ankle disability. ORDER Service connection for a back disability is denied. Service connection for a right shoulder disability is denied. Service connection for a left shoulder disability is denied. An initial disability rating of 20 percent, but no higher, for the service-connected duodenal ulcer is granted, subject to the laws and regulations governing the payment of monetary benefits. Service connection for an acquired psychiatric disorder to include depression is denied. Service connection for a cervical spine disability is denied. Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. Service connection for a right wrist disability is denied. An initial disability rating in excess of 10 percent for the service-connected right ankle disability is denied. An initial 10 percent rating, but not higher, for the service-connected left wrist disability is granted prior to February 13, 2017; a disability rating in excess of 10 percent for the service-connected left wrist disability is denied. An initial disability rating in excess of 10 percent for the service-connected left ankle disability is denied. An effective date prior to April 10, 2014 for the grant of service connection for a left ankle disability is denied. ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs