Citation Nr: 18146872
Decision Date: 11/01/18	Archive Date: 11/01/18

DOCKET NO. 15-12 556
DATE:	November 1, 2018
ORDER
An effective date prior to September 10, 2012, for the grant of service connection for pseudofolliculitis barbae (PFB) is denied.
An effective date prior to September 10, 2012, for the grant of service connection for left knee patellofemoral syndrome is denied.
A compensable rating for PFB is denied.
A rating in excess of 10 percent for left knee patellofemoral syndrome is denied.
Service connection for a left-hand disorder is denied.
Service connection for a left arm disorder, to include a left elbow contusion and left upper extremity radicular pain, is denied.
FINDINGS OF FACT
1. The Veteran had active service from December 2000 to August 2004.  
2. In an unappealed May 2008 rating decision, the Regional Office (RO) denied service connection for left knee patellofemoral syndrome and PFB.
3. The initial application to reopen the claims of service connection for left knee patellofemoral syndrome and PFB was received by VA on September 10, 2012.  
4. There are no documents or communications of record dated prior to September 10, 2012, that constitute an application to reopen the claims of service connection for left knee patellofemoral syndrome and PFB.  
5. For the entire period on appeal, the Veteran’s PFB has been manifested by subjective complaints of irritated bumps on his neck and constant bumps and bleeding that got worse with shaving; objective findings include an affected total body area of at most less than one percent, an affected total exposed body area of at most less than one percent, use of oral or topical medications for 6 weeks or more on a non-constant basis, and no use of corticosteroids or immunosuppressive drugs.  
6. For the entire period on appeal, the Veteran’s left knee patellofemoral syndrome has been manifested by subjective complaints of swelling, locking, flare-ups resulting in difficulty sitting and bending, weakness, swelling, and numbness; objective findings include no recurrent subluxation, lateral instability, meniscal conditions, tibial or fibular impairments, ankylosis, and range of motion measured, at worst, as flexion to 80 degrees and normal extension.
7. The Veteran’s left-hand calluses are not etiologically or causally related to active service.
8. The Veteran’s left arm disorder, to include a left elbow contusion and left upper extremity radicular pain, is not etiologically or causally related to active service. 
CONCLUSIONS OF LAW
1. The criteria for an effective date prior to September 10, 2012, for the grant of service connection for PFB have not been met.  38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.157, 3.400 (2017). 
2. The criteria for an effective date prior to September 10, 2012, for the grant of service connection for left knee patellofemoral syndrome have not been met.  38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.157, 3.400 (2017).  
3. The criteria for an initial compensable rating for PFB have not been met.  38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.130, Diagnostic Code (DC) 7806 (2017).
4. The criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome have not been met.  38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, DCs 5256 - 5262 (2017).  
5. A left-hand disorder was not incurred in service.  38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310 (2017). 
6. A left arm disorder, to include a left elbow contusion and left upper extremity radicular pain, was not incurred in service.  38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310 (2017).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
As an initial matter, in connection with this appeal, the Veteran testified at a hearing before the undersigned Veterans Law Judge in June 2018.  A transcript of that hearing has been associated with the claims file.
Effective Date Claims 
The effective date of an award based on a claim for increase of compensation “shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application.”  38 U.S.C. § 5110(a).  The effective date for increased rating shall be the earliest date of which it is factually ascertainable that an increase in disability had occurred, if the claim is received within one year from such date; otherwise, the effective date for increased ratings shall be the date of receipt of claim or date entitlement arose, whichever is later.  38 C.F.R. § 3.400(o)(1).  
An effective date for an increased rating may be assigned later than the date of receipt of the claim, if the evidence shows that the increase in disability actually occurred after the claim was filed, but never earlier than the date of receipt of the claim for increase.  In general, “date of receipt” means the date on which a claim, information or evidence was received in VA.  38 C.F.R. § 3.1(r).  A claim is a “formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit.”  38 C.F.R. § 3.1(p).
The record shows that the Veteran filed an original claim for service connection for left knee patellofemoral syndrome and PFB in May 2007.  The RO denied service connection in May 2008; however, he did not appeal the May 2008 decision.  The next document of record after the May 2008 decision was a formal application to reopen the claims which was received on September 10, 2012.  
The RO granted a 10 percent rating for left knee patellofemoral syndrome and a noncompensable rating for PFB, both effective September 10, 2012, the date of the Veteran’s claim.  There were no earlier claims received subsequent to the unappealed May 2008 rating decision which denied service connection for left knee patellofemoral syndrome and PFB.  
For these reasons, an effective date prior to September 10, 2012, is not warranted for the grant of service connection and the appeals are denied.  Because the preponderance of the evidence is against the appeal for an earlier effective date, the benefit of the doubt doctrine is not for application.  
Increased Rating Claims
Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity.  Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability.  38 C.F.R. § 4.1.  Separate diagnostic codes identify the various disabilities.  
Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating; otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran.  38 C.F.R. § 4.3. 
PFB
PFB is rated at 0 percent under DC 7806.  The Board will consider all relevant diagnostic codes.  Under the relevant regulations, a higher rating will be warranted when the objective medical evidence shows the following: 
•	at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent but less than 20 percent of exposed areas affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period (10 percent under DC 7806).  
In a September 2013 VA examination, the Veteran reported that he developed PFB in 2001.  The examiner noted that he had no history of benign or malignant skin neoplasms, no systemic manifestations resulting from PFB, no oral or topical medications used over the previous year, and no urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis.  The examiner observed that the Veteran treated the PFB by using hair trimmers instead of razors.  
Upon examination, the examiner observed some macular papular lesions bilaterally at the Veteran’s jaw line, but identified no acne, chloracne, vitiligo, alopecia, hyperhidrosis, tumors, or neoplasms.  Ultimately, the examiner opined that it was at least as likely as not that his PFB was a continuation of symptoms noted in service.  
In a November 2013 medical treatment note, the Veteran reported irritated bumps on his neck that got worse with shaving.  He said that he tried cutting back on shaving and found that it helped, but that he still got bumps on his neck.  Upon examination, the clinician identified erythematous and hyperpigmented scaly papules and pustules on the neck, and diagnosed PFB.  The clinician instructed the Veteran to continue to limit his shaving and to use clindamycin lotion on his neck once a day.  
In a July 2018 VA examination, the Veteran reported experiencing constant bumping and bleeding that worsened with shaving.  He said that he was prescribed topical cream and “cleansing pads.”  The examiner observed that PFB did not cause scarring or disfigurement of his head, face, or neck, and that there were no benign or malignant skin neoplasms or systemic manifestations due to skin diseases.
The examiner found that the Veteran treated his PFB with a topical medication over the previous 12 months for a period of six weeks or more, but not on a consistent basis.  However, the Veteran did not have any treatments or procedures other than the use of topical medications over the previous 12 months.
The examiner observed that the Veteran had a fully-grown beard and found one single perifollicular papule measuring between 1 and 3 millimeters with central ingrown hair apparent on his left upper neck.  No pustules, papules, or scarring was found.  Furthermore, the nape of his neck was clear.  His PFB affected less than 1 percent of his total body area and less than 1 percent of his exposed body area.  
In a September 2018 VA examination, the Veteran reported with a full beard but said that he still had bumps and black spots under his beard, as well as an area where hair did not grow.  The examiner noted that he had not been treated with medication over the previous 12 months for a skin condition, and found that PFB did not impact either his total body area or his exposed body area.  The examiner found that the Veteran did not shave and that as a result, there was no evidence of active PFB.  However, the examiner opined that if the Veteran resumed shaving, his PFB would likely recur and become active again.  
Based on the above, an initial compensable rating is not warranted for PFB.  In this regard, the July 2018 VA examination identified that the Veteran was treated with topical cream for a period of 6 weeks, but not continuously.  However, the examinations did not establish that he uses corticosteroids or immunosuppressive drugs.  Furthermore, the examinations established that PFB impacted at most less than 1 percent of his total body area and less than 1 percent of his total affected area.  Accordingly, the medical evidence does not support a compensable rating.  
Left Knee Disorder
The Veteran’s left knee disability is rated at 10 percent under DC 5260.  The Board will consider all relevant diagnostic codes.  Under the relevant regulations, a higher rating will be warranted when the medical evidence shows the following: 
•	moderate recurrent subluxation or lateral instability (20% under DC 5257);
•	dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint (20% under DC 5258);
•	flexion between 15 and 30 degrees (20% under DC 5260);
•	extension measured between 15 and 20 degrees (20% under DC 5261);
•	impairment of the tibia and fibula with a moderate knee or ankle disability (20% under DC 5262);
•	ankylosis of the knee with a favorable angle in full extension or in slight flexion between 0 and 10 degrees (30% under DC 5256).  

In a July 2013 VA examination, the Veteran reported that his left knee swelled, locked, but did not give way.  He reported no history of subluxation or dislocation, but stated that he experienced flare-ups resulting in increased difficult sitting and bending his knee.  
Upon examination, the range of motion of the Veteran’s left knee was measured as flexion between 0 and 80 degrees and extension to 0 degrees.  Pain, stiffness, and weakness were observed with flexion.  The examiner noted that he walked with a slow gait and identified functional loss secondary to pain, stiffness, weakness, and a diminished range of motion.  The Veteran had tenderness to palpation over his medial joint line and patellar tendon, as well as in the middle of his shin.  
Testing revealed no history of recurrent patellar subluxation or dislocation, stress fractures, compartment syndrome, meniscal conditions, or other tibial or fibular impairments.  Additionally, the Veteran had no swelling or crepitus.  Ultimately, the examiner diagnosed patellofemoral syndrome and opined that it was at least as likely that his current knee disorder was a continuation of pain noted while in service.  
 In a July 2018 VA examination, the Veteran reported that his left knee swelled from time to time and that he had numbness and neuropathy.  He said that he was provided with medicine to treat the neuropathy and naproxen for pain.  He noted that his left knee was weak and that he had a rollator and knee brace.  
Upon examination, the range of motion of his left knee was found to be normal.  The examination revealed no evidence of crepitus or ankylosis, no history of recurrent subluxation, lateral instability, and recurrent effusion, and no joint instability.  
The examiner noted that the Veteran did not have and had never had recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, other tibial or fibular impairments, and meniscus conditions.  The examiner ultimately diagnosed resolved left knee patellofemoral pain and mild degenerative changes in the left knee unrelated to the resolved patellofemoral pain.  
In a September 2018 VA examination, the Veteran reported that his knees click when he bends them, were weak and sore, and sometimes felt numb.  He noted that the left knee tightened up after driving for a long time and hurt when straightening.  He said that he felt like his bones were brittle and that, while he underwent physical therapy, it did not help the condition of his left knee improve.  However, he did not report experiencing any flare-ups or functional loss.
Upon examination, the range of motion of his left knee was again found to be normal.  The examiner found no evidence of pain with weight bearing, in non-weight bearing, or on passive range of motion testing.  The examination also revealed no evidence of localized tenderness or pain on palpation of the joints and no objective evidence of crepitus.  The examiner noted that the Veteran had no muscle atrophy and no history of recurrent subluxation, lateral instability, recurrent effusion, medial or lateral instability, patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, tibial or fibular impairments, and meniscus conditions.  Ultimately, the examiner diagnosed left knee patellofemoral pain syndrome.
Based on the above, a rating in excess of 10 percent for left knee patellofemoral syndrome is not warranted.  In this regard, the VA examinations revealed that the range of motion of the left knee is measured at no worse than flexion to 80 degrees with normal extension.  Furthermore, the examinations established that the Veteran did not have recurrent subluxation, lateral instability, meniscal conditions, tibial or fibular impairments, and ankylosis in his left knee.  Accordingly, the medical evidence does not support a rating in excess of 10 percent.  
With respect to both increased rating claims, the Board has also considered the Veteran’s lay statements that his disabilities are worse.  While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, Layno v. Brown, 6 Vet. App. 465, 470 (1994), he is not competent to identify a specific level of disability of these disorders according to the appropriate diagnostic codes.
Such competent evidence concerning the nature and extent of the Veteran’s PFB and knee disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations.  
The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which these disabilities are evaluated.  Moreover, as the examiners had the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinions great probative value.  
As such, these records are more probative than the Veteran’s subjective complaints of increased symptomatology.  In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable and the appeals are denied.
Service Connection Claims
Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service.  See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). 
Service connection may be granted on a presumptive basis for diseases listed in § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service.  See 38 C.F.R. § 3.307.
Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310.  Allen v. Brown, 7 Vet. App. 439 (1995).  In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability.  See Wallin v. West, 11 Vet. App. 509, 512 (1998).
 
Left-Hand Calluses
As an initial matter, the Veteran’s left-hand calluses are not a chronic disease under 38 C.F.R. § 3.309(a); therefore, presumptive service connection is not for application.  Additionally, he has not asserted that his calluses are secondary to a service-connected disability; accordingly, secondary service connection will not be considered.  However, direct service connection will be addressed. 
Turning to direct service connection, the Veteran has been diagnosed with a left-hand disorder.  Specifically, a July 2013 VA examination diagnosed hand calluses and a March 2014 VA examination diagnosed friction burns to the hands.  Accordingly, a current disorder has been established and the first element of service connection has been met.  
A review of the service treatment records (STRs) reveals that in a July 2004 treatment note, the Veteran reported that he was handling lines when a heavy line slipped from out of his hands and that he had friction burns as a result.  The clinician noted blistering on the fingertips and palms of both hands and decreased range of motion with decreased strength.  The clinician ultimately diagnosed abrasion and friction burns.  Accordingly, an in-service incident has been shown and the second element of service connection has been met.  
As to medical nexus, in a July 2013 VA examination, the examiner noted that the Veteran had calluses on the palmar aspect of his left hand just proximal to the PIP joint and that one of his calluses was painful.  The examiner acknowledged the July 2004 STR diagnosing in-service friction burns.  However, the examiner opined that an opinion could not be made without resort to speculation regarding the relationship between the Veteran’s calluses and the in-service blistering of his left hand.  The examiner explained that it was unknown whether the locations of his then-current calluses were the locations of the in-service blistering on the palms of his hands.  
In a March 2014 VA examination, the Veteran reported that he received friction burns in service that were treated conservatively and that his hands peeled.  The examiner diagnosed hand eczema and friction burns to the hands, but opined that his then-current friction burns were less likely than not caused by or a result of his in-service friction burns, explaining that no scars were found and that STRs at the time of separation were negative for any skin condition.  
In a June 2018 hearing before the undersigned Veterans Law Judge, the Veteran testified that he got left hand keratosis as a result of his in-service friction burns.  He explained that he was never issued gloves and that he told his petty officer that his hands were burning.  He said that he was issued a callus remover and started scraping them, but that they kept coming back.  He opined that his hand issue was also due to holding firearms, noting that he felt the irritation in his hand due to the rough style of the butt of the gun in his hands.  He said that he continuously went to the doctor for his left-hand calluses while in service and after separation.  
Based on the above, service connection for left-hand keratosis is not warranted.  In this regard, left-hand calluses have been diagnosed and STRs establish that the Veteran had complaints of left-hand calluses while in active service.  However, the medical evidence does not establish a relationship between the two. One examiner was unable to render an opinion and the other examiner found that there was no connection. Therefore, the medical evidence does not support the claim.
Left Arm Disorder
As an initial matter, a left elbow contusion and radicular pain are not chronic diseases under 38 C.F.R. § 3.309(a); therefore, presumptive service connection is not for application.  Additionally, the Veteran has not asserted that his left arm disorder is secondary to a service-connected disability; accordingly, secondary service connection will not be considered.  However, direct service connection will be addressed.  
Turning to direct service connection, the Veteran has been diagnosed with a left arm disorder.  Specifically, a July 2013 VA examination diagnosed a left elbow contusion and an August 2013 medical treatment note diagnosed left upper extremity radicular pain and trapezius discomfort.  Accordingly, a current diagnosis has been established and the first element of service connection has been met.  
A review of the STRs reveals that in a March 2002 service treatment note, the Veteran reported that he was injured when falling 4 to 5 feet through an open hatch aboard ship and that he struck his left forearm when he fell.  The clinician diagnosed a left elbow laceration.  Accordingly, an in-service incurrence has been shown and the second element of service connection has been met.  
As to medical nexus, in a July 2013 VA examination, the Veteran recounted his in-service fall and stated that his elbow locked, swelled, and gave way.  He said that the pain in his elbow worsened with activity and was relieved by rest and elevation.  He reported experiencing flare-ups that made it more difficult for him to lift and that impacted his range of motion.  
The examiner diagnosed an elbow contusion, however opined that it was less likely than not that the Veteran’s then-current elbow contusion was related to his in-service elbow pain.  The examiner explained that, outside the March 2002 STR, elbow pain was not sufficiently documented to establish a relationship between his elbow contusion and in-service elbow laceration.  
In a July 2013 medical treatment note, imaging revealed no fracture, dislocation, bony lesion, or soft tissue abnormality of the elbow, and the clinician found the left elbow to be normal.  In a subsequent August 2013 note, the Veteran stated that he was told he had possible nerve damage in his left upper extremity and that he had pain that radiated from his ulnar forearm to his lateral arm, his shoulder, and his posterior scapula region.  He further stated that he had numbness in the same area.  The clinician diagnosed left upper extremity radicular pain and trapezius discomfort.  
In a September 2013 VA examination, the Veteran reinforced that his elbow locked, swelled, and gave way.  He reported that his elbow symptoms were made worse by lifting and improved by lying down, and that while he had no loss of range of motion, he experienced increased pain.  The examiner again opined that it was less likely than not that his then-current elbow pain was a continuation of any in-service elbow pain.  The examiner reiterated that chronicity was not established and that the March 2002 STR was the only evidence of elbow pain. 
In a March 2018 medical treatment note, the clinician reported to the Veteran that an EMG and nerve conduction test found no evidence for left brachial plexopathy, ulnar compression neuropathy at the elbow and wrist, or motor radiculopathy at the C5-T1 joint.  The clinician stated that testing also found no definitive evidence for carpal tunnel syndrome.   
In June 2018 testimony before the undersigned Veterans Law Judge and in subsequent statements, the Veteran explained that his elbow condition was the result of his in-service fall.  He related that, after the fall he was treated and placed on light duty.  He said that ever since the fall, he experienced pain and numbness in his left side.  
Based on the above, service connection is not warranted.  In this regard, a left elbow contusion and left upper extremity radicular pain have been diagnosed and STRs establish that the Veteran had complaints of a left elbow laceration while in service.  However, the medical evidence does not establish a nexus between the two.  Therefore, the medical evidence does not support the claim for service connection.
With respect to both service-connection claims, the Board has considered the Veteran’s lay statements and sworn testimony, and statements from fellow servicemembers and his family regarding the etiology and current severity of the disorders addressed above.  Lay witnesses are competent to report symptoms and describe their observations because this requires only personal knowledge as it comes to them through their senses.  Layno v. Brown, 6 Vet. App. 465, 469 (1994).
However, lay witnesses are not competent to offer opinions as to the etiology or current severity of any current disorder due to the medical complexity of the matters involved.  Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007).   
Such competent evidence has been provided by the medical personnel who have examined the Veteran during his current appeal.  Here, the Board attaches greater probative weight to the clinical findings than to the lay statements that have been submitted.  Therefore, the appeals are denied.
Finally, the Veteran has not raised any other outstanding issues, nor have any other issues been reasonably raised by the record for the Board’s consideration.  See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).  
 
 
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. Spigelman, Associate Counsel