Citation Nr: 18149918 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 14-34 898A DATE: November 14, 2018 ORDER New and material evidence having been received, the Veteran’s claim for entitlement to service connection for a left knee condition is reopened. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for sciatica of the bilateral lower extremities is denied. Entitlement to a disability rating in excess of 40 percent for traumatic arthritis of the lumbar spine is denied. Entitlement to a disability rating in excess of 10 percent for residuals, right knee injury, is denied. Entitlement to a compensable disability rating for right inguinal hernia is denied. Entitlement to a compensable disability rating for tinea versicolor is denied. Entitlement to a compensable disability rating for a fracture of the left index finger is denied. Entitlement to an initial disability rating of 50 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for a left knee disorder, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for a cervical spine disorder is remanded Entitlement to service connection for cephalgia is remanded. Entitlement to a compensable disability rating for iritis of the left eye is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Service connection for a left knee disorder was denied in an April 2007 Board decision. 2. Evidence received since the April 2007 Board decision is new and material and raised a reasonable possibility of substantiating the Veteran’s claim. 3. The Veteran’s hearing loss did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not; and the disability is not otherwise etiologically related to an in-service injury, event, or disease. 4. The Veteran has experienced tinnitus since his separation from service. 5. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of a neurological condition of the bilateral lower extremities. 6. Throughout the course of the appeal, the Veteran’s traumatic arthritis of the lumbar spine has not been productive of ankylosis or incapacitating episodes lasting six weeks or more in a 12-month period. 7. Throughout the course of the appeal, the Veteran’s residuals, right knee injury, has not been productive of ankylosis, recurrent subluxation, lateral instability, dislocated semilunar cartilage, removal of semilunar cartilage, impairment of the tibia or fibula, genu recurvatum, a flexion of 45 degrees or less, or an extension of 10 degrees or more. 8. Throughout the course of the appeal, the Veteran’s right inguinal hernia was not productive of postoperative recurrent readily reducible and well supported by truss or belt; a small postoperative recurrent or unoperated irremediable or not well supported by truss or not readily reducible; or an inguinal hernia that is large, postoperative, recurrent, not well supported under ordinary conditions and not readily reducible when considered inoperable. 9. Throughout the course of the appeal, the Veteran’s tinea versicolor was not productive of five percent or more of the entire body or the affected area; or required the use of systemic therapy or other immuno-suppressive therapy. 10. Throughout the course of the appeal, the Veteran’s fracture of the left index finger has not been productive of ankylosis or limitation of motion with a gap of more than one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm with the finger flexed to the extent possible or with extension limited by more than 30 degrees. 11. From the date of award of service connection, the Veteran’s PTSD has been productive of occupational and social impairment with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas or total occupational and social impairment. CONCLUSIONS OF LAW 1. The April 2007 Board decision that denied service connection for a left knee disorder is final. 38 U.S.C. § 7104 (2006); 38 C.F.R. § 20.1100 (2006). 2. The criteria for reopening the Veteran’s previously denied claim of service connection for a left knee disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. 5. The criteria for service connection for sciatica of the bilateral lower extremities have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. 6. The criteria for a disability rating in excess of 40 percent for traumatic arthritis of the lumbar spine have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5242. 7. The criteria for a disability rating in excess of 10 percent for residuals, right knee injury have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, and 5256-5263. 8. The criteria for a compensable disability rating for a right inguinal hernia have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Code 7338. 9. The criteria for a compensable disability rating for tinea versicolor have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Code 7806. 10. The criteria for a compensable disability rating for a fracture of the left index finger have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5225 & 5229. 11. Effective September 7, 2010, the criteria for a disability rating of 50 percent, but no more, for an acquired psychiatric disorder have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.130, Diagnostic Codes 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1968 to July 1970 and from September 1990 to May 1991. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) made in Newark, New Jersey in June 2011 and made in St. Petersburg, Florida March 2013. 1. Whether new and material evidence has been submitted to reopen a claim for service connection for a left knee condition. At issue is whether the Veteran has submitted new and material evidence to reopen a previously denied claim of entitlement to service connection for a left knee condition. As explained below, new and material evidence sufficient to reopen the claim has been submitted. In order to reopen a claim which has been denied by a final decision, new and material evidence must be received. 38 U.S.C. § 5108. New and material evidence means evidence not previously submitted to agency decision makers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, “credibility” of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The evidence to be considered in making this new and material evidence determination is that added to the record since the last final denial on any basis. Evans v. Brown, 9 Vet. App. 27 (1996); see also Shade v. Shinseki, 24 Vet. App. 110, 120 (2010) (new and material evidence need not be received as to each previously unproven element of a claim in order to justify reopening thereof). Regardless of whether the RO determined new and material evidence had been submitted, the Board must address the issue of the receipt of new and material evidence in the first instance, because it determines the Board’s jurisdiction to reach the underlying claims and to adjudicate the claims de novo. In April 2007, the Board denied the Veteran service connection for a left knee condition. The Veteran subsequently filed a claim to reopen the issue, and, in March 2013, the RO denied the claim. The Veteran appealed. In the April 2007 Board decision, the Board denied the Veteran’s claim, because the evidence of record did not establish that the Veteran’s left knee condition was caused by a period of service or proximately due to a previously service-connected condition. In December 2011, the Veteran subsequently submitted a private medical opinion indicating that the Veteran’s left knee condition was due to an altered gait caused by the Veteran’s previously service-connected back disorder and right knee disorder. Therefore, the evidence submitted since the last final denial is new and material, and the Veteran’s claim for service connection for a left knee disorder is reopened. Service Connection In seeking VA disability compensation, a veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131. “Service connection” basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Service connection can also be established through application of statutory presumptions, including for chronic diseases such as organic diseases of the nervous system (sensorineural hearing loss, tinnitus, and sciatica of the bilateral lower extremities), when manifested to a compensable degree within one year of separation from service; or when continuity of symptomology since separation of service has been established. 38 C.F.R. §§ 3.307, 3.309. 2. Entitlement to service connection for bilateral hearing loss. In additional to the general requirements for service connection, there are also specific requirements regarding what constitutes a hearing loss disability under VA law. The threshold for normal hearing is from 0 to 20 decibels. Hensley v. Brown, 5 Vet. App. 155 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hz is 40 dB or greater; when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 dB or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran’s service treatment records are silent for reports of or treatment for bilateral hearing loss. In an examination conducted upon separation from the Veteran’s second period of service, the Veteran’s ears were evaluated as normal, and, in a survey of medical history conducted contemporaneously with the separation examination, the Veteran denied having or ever having had ear trouble of hearing loss. The Veteran’s pure tone thresholds are below: HERTZ 500 1000 2000 3000 4000 RIGHT 10 20 15 15 20 LEFT 20 25 5 10 15 The record does not contain additional audiometric testing until a VA examination which was conducted in December 2012. The Veteran underwent a VA examination in December 2012. Hearing loss for VA purposes was demonstrated. The Veteran reported that he was a truck driver while as in the army. The Veteran denied recreational noise exposure as well as any ear disease or a family history of hearing loss. The examiner concluded that the Veteran’s bilateral hearing loss was not at least as likely as not due to a period of service. Reference was made to the absence of complaints, treatment, or diagnosis of hearing loss during either period of active service or when the Veteran was in the Reserves. Consideration was given to shifts in hearing acuity that over time but those shifts were not found to be significant. The weight of the evidence indicates that the Veteran is not entitled to service connection for bilateral hearing loss. The Veteran has a current diagnosis of bilateral hearing loss, and the evidence suggests that the Veteran may have incurred military noise exposure while operating trucks during a period of service. However, upon separation from his second period of service, the Veteran’s ears were evaluated as normal, and the Veteran’s audiometric testing did not suggest that the Veteran met VA’s criteria for bilateral hearing loss. Further, while he identified multiple health problems approximate to his discharge, the Veteran denied having or ever having had a history of hearing loss or ear trouble. Such undermines any contention that he was experiencing hearing loss/problems in service. Additionally, the Veteran underwent a VA examination wherein it was determined that there was no relationship between the Veteran’s current hearing loss disability and his active service, to include noise exposure. There is no competent medical evidence to the contrary. The Veteran’s lay assertion that his hearing loss is related to service is not competent; and, to the degree that he reports that he has had hearing loss since service, that history is not deemed credible due to his earlier statements that denied any hearing problems. In short, the evidence of record does not establish that the Veteran manifested a disability within one year of separation from service or continuity of symptomology since separation from service; and a medical nexus has not been established between and in-service incurrence and a current diagnosis. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to service connection for bilateral hearing loss is denied. 3. Entitlement to service connection for tinnitus. With regard to the claim for tinnitus, the analysis and the result are different. The Court has specifically held that tinnitus is a type of disorder associated with symptoms capable of lay observation. See Charles v. Principi, 16 Vet. App. 370 (2002). As such, the primary role of the Board in adjudicating the tinnitus claim, is to assess the credibility of the Veteran’s statements. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Veteran has been diagnosed with tinnitus, and he has consistently reported that his tinnitus began in-service and continues to this day. The Veteran has not attempted to bolster or exaggerate his symptoms, and based on his reports of ringing, the Veteran was diagnosed with tinnitus. As such, the criteria for service connection for tinnitus have been met. In reaching this conclusion, the Board acknowledges that a VA examiner found that it was not likely that the Veteran’s tinnitus was related to his military service, because tinnitus is not documented in the service treatment records. However, because the Board finds the Veteran’s statements to be credible as to the onset and continuity of ear ringing, the statements sufficiently refute the basis of the examiner’s conclusion. Thus, resolving any reasonable doubt in the Veteran’s favor, the Board finds that service connection for tinnitus is warranted and the Veteran’s claim is granted. 3. Entitlement to service connection for sciatica of the bilateral lower extremities At issue is whether the Veteran is entitled to service connection for sciatica of the bilateral lower extremities. The weight of the evidence indicates that the Veteran is not entitled to service. The Veteran’s treatment records indicate that the Veteran was diagnosed with sciatica prior to the period on appeal, but the Veteran’s treatment records are otherwise silent for reports of or treatment for a neurological condition of the bilateral lower extremities during the pendency of the appeal. The Veteran underwent a VA examination in April 2011. The Veteran was evaluated for a back condition, and the Veteran denied back pain that radiated down his legs. The Veteran submitted an opinion from a private chiropractor that was dated December 2011. The Veteran reported pain in the right and left sciatic distributions. The chiropractor opined that the Veteran’s “pain” was caused by the Veteran’s low back condition and was due to military service. The Veteran underwent another VA examination in December 2012. The Veteran reported paint radiating down both his legs, but the examiner did not diagnose the Veteran with a neurological condition impacting the bilateral lower extremities. The examiner indicated that there was insufficient evidence to warrant a diagnosis of an acute or chronic peripheral nerve disorder or residuals thereof, and the Veteran’s examination was unremarkable and does not support a diagnosis of radiculopathy. The weight of the evidence indicates that the Veteran is not entitled to service connection for sciatica of the bilateral lower extremities. The evidence does not establish that the Veteran has a current neurological disability of the bilateral lower extremities. The Veteran does have a diagnosis of sciatica prior to the period on appeal in approximately 2009. Nevertheless, this diagnosis does not appear to be based on clinical testing, but rather the Veteran’s own report of pain radiating down his left leg. Moreover, this pain appears to have resolved, because, in an April 2011 VA examination, the Veteran denied pain radiating down his lower extremities from his back. The Veteran did report a recurrence of pain radiating down his back in December 2012, but a VA examiner ultimately indicated that the evidence was insufficient to demonstrate that the Veteran had a current diagnosis of a neurological disability of the bilateral lower extremities. The Board notes that the Veteran’s chiropractor indicated that the pain that radiated down the Veteran’s bilateral lower extremities was due to a back condition and related to a period of service. Nevertheless, this is not strictly speaking a diagnosis of a separate neurological condition, and the Veteran is already being compensated for pain that results from his service-connected back disability. The existence of a current disability or a disability during the pendency of the appeal is the cornerstone for a claim for service connection. Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). As such, the Veteran cannot sustain a claim for service connection based on the evidence of record. In short, the evidence of record does not establish that the Veteran has a current diagnosis of a neurological condition of the bilateral lower extremities. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to service connection for a neurological condition of the bilateral lower extremities is denied. Increased Disability Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 4. Entitlement to a disability rating in excess of 40 percent for traumatic arthritis of the lumbar spine. At issue is whether the Veteran is entitled to a disability rating in excess of 40 percent for his low back disorder. The weight of the evidence indicates that the Veteran is not entitled to an increased disability rating. The Veteran first filed for service connection for a back condition in July 1970, and, in October 1999, the RO granted service connection and assigned a disability rating of 10 percent effective October 28, 1993, and a disability rating of 20 percent effective December 19, 1998. Subsequently, the Veteran’s disability rating was increased to 40 percent effective December 30, 2002. The Veteran filed an increased rating claim in September 2010, and, in June 2011, the RO denied the Veteran’s claim. The Veteran appealed. Back disability ratings are assigned pursuant to the General Rating Formula for Diseases and Injuries of the Spine and the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. 38 C.F.R. § 4.71a. The Formula for Rating IVDS Based on Incapacitating Episodes is not raised by the record, because the VA examinations and medical evidence of record do not indicate that the Veteran manifested incapacitating episodes due to IVDS; and, therefore, the Formula for Rating IVDS based on incapacitating episodes does not provide an adequate basis for an increased disability rating. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. The General Rating Formula for Diseases and Injuries of the Spine is not raised by the record either, because the criteria for a disability rating in excess of 40 percent requires the Veteran to manifest ankylosis of either the thoracolumbar spine or of the entire spine. The VA examinations and medical evidence of record do not establish that the Veteran manifested ankylosis of either the thoracolumbar spine or entire spine, and, therefore, the Formula for Rating IVDS based on incapacitating episodes is not raised by the record either. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. The Board notes that, normally, the Board must consider whether or not the Veteran is manifesting additional functional impairment when it is evaluating the Veteran’s claim for musculoskeletal injuries such as this low back condition. DeLuca v. Brown, 8 Vet. App. 202 (1995). When, as in this case, the Veteran has been assigned the maximum disability rating based on limitation of motion (40 percent for a back disability) additional DeLuca analysis is foreclosed. Johnston v. Brown, 10 Vet. App. 80 (1997). Here, the weight of the probative evidence of record simply fails to demonstrate that the Veteran is entitled to a disability rating in excess of 40 percent for traumatic arthritis of the lumbar spine. Therefore, the evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to a disability rating in excess of 40 percent is denied. 5. Entitlement to a disability rating in excess of 10 percent for residuals, right knee injury. At issue is whether the Veteran is entitled to a disability rating in excess of 10 percent for his right knee disorder. The weight of the evidence indicates that the Veteran is not entitled to an increased disability rating. The Veteran’s right knee disability has been rated under Diagnostic Codes 5003 and 5256-5263. Diagnostic code 5003 is not raised by the record, because, in order to meet the criteria for a disability rating in excess of 20 percent the Veteran must manifest painful motion in at least two major joint or two minor joint groups. The Veteran’s disability rating for the right knee is only evaluating one major joint (the right knee) and all other service-connected disabilities related to a joint (such as the Veteran’s back disability) are being evaluated under different criteria. Therefore, Diagnostic 5003 does not provide an adequate basis for an increased disability rating. Diagnostic Codes 5256 (ankylosis), 5257 (recurrent subluxation or lateral instability), 5258 (dislocated semilunar cartilage), 5259 (removal of semilunar cartilage), 5262 (impairment of tibia or fibula), and 5263 (genu recurvatum) are not raised by record, because the record does not establish that the Veteran’s right knee manifested ankylosis, recurrent subluxation, lateral instability, dislocated semilunar cartilage, removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum; and, therefore, Diagnostic Codes 5256-5259, & 5262-5263 do not provide an adequate basis for an increased disability rating. 38 C.F.R. § 4.71a. A disability rating of 10 percent is assigned when flexion is limited to 45 degrees, and a disability rating of 20 percent is assigned when flexion is limited to 30 degrees. A disability rating of 30 percent is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A disability rating of 10 percent is assigned when extension is limited to 10 degrees, and a disability rating of 20 percent is assigned when extension is limited to 15 degrees. A disability rating of 30 percent is assigned when extension is limited to 20 degrees, and a disability rating of 40 percent is assigned when extension is limited to 30 degrees. A disability rating is limited to 50 percent is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Veteran’s Social Security Administration (SSA) records indicate that the Veteran was provided a medical consultant’s review of a physical residual functional capacity assessment in January 2010. The Veteran reported increased knee pain. The provider indicated that data supported effusions, and his knees have buckled on several occasions. Additionally, the provider noted that the Veteran had been previously prescribed hinged braces. The provider opined that the Veteran should avoid standing and walking long distances. The Veteran underwent a VA examination in April 2011. The Veteran reported occasional pain and discomfort with standing or walking long distances and positive locking, but the Veteran denied: locking; incapacitating episodes; flare-ups; recent physical therapy; hospitalizations or surgeries; instability; or repetitive use. The examiner noted that the Veteran had bilateral knee braces. The Veteran’s flexion was to 130 degrees and his extension was to zero degrees. The Veteran reported pain on motion, but the examiner indicated that there was no: objective evidence of pain; atrophy; deformity; guarding of motion; or positive instability testing results. Motor strength testing and muscle tone were both normal. There was no additional limitation of motion after repetitive range of motion testing. The Veteran submitted an opinion from a private chiropractor that was dated December 2011. The Veteran reported pain and swelling, which increased significantly with walking as well as clicking, popping, locking, and giving out. The Veteran’s flexion was to 90 degrees with pain at 45 degrees. The weight of the evidence indicates that the Veteran is not entitled to a disability rating in excess of 10 percent or an additional compensable disability rating for a right knee disability. In order to meet the criteria for an increased disability rating, the Veteran needed to manifest a flexion limited to 30 degrees or less or an extension limited to 15 degrees or more. In order to meet the criteria for an additional compensable disability rating, the Veteran needed to manifest an extension limited to 10 degrees or more and a flexion limited to 45 degrees or less. The Veteran’s range of motion was tested during the pendency of the appeal, but the Veteran never met the criteria for an increased disability rating or an additional compensable disability rating. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45. Even if range of motion was slightly limited by pain however, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Id. The Veteran did not manifest additional functional impairment. The Veteran denied flare-ups and incapacitating episodes during a VA examination. The Veteran was able to perform repetitive range of motion testing without additional loss of range of motion, and the Veteran’s muscle strength and tone were normal. Therefore, the additional functional impairment does not provide an adequate basis for an increased disability rating. Here, the weight of the probative evidence of record simply fails to demonstrate that the Veteran is entitled to a disability rating in excess of 10 percent for a right knee condition. Therefore, the evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to a disability rating of in excess of 10 percent for a right knee condition is denied. 6. Entitlement to a compensable disability rating for right inguinal hernia. At issue is whether the Veteran is entitled to a compensable disability rating for a right inguinal hernia. The weight of the evidence indicates that the Veteran is not entitled to a compensable disability rating. The Veteran filed for service connection in July 1970, and, in September 1970, the RO granted service connection and assigned a noncompensable disability rating effective the day after separation from service. The Veteran filed an increased rating claim in September 2010, and, in June 2011, the RO denied the Veteran’s claim. The Veteran appealed. The Veteran’s disability rating is assigned pursuant to Diagnostic Code 7338. A noncompensable disability rating is assigned for a remediable, but unoperated inguinal hernia or an inguinal hernia that is small, reducible, or without true hernia protrusion, and a disability rating of ten percent is assigned for postoperative recurrent readily reducible and well supported by truss or belt. A disability rating of 30 percent is assigned for an inguinal hernia that is small postoperative recurrent or unoperated irremediable or not well supported by truss or not readily reducible, and a disability rating of 60 percent is assigned for an inguinal hernia that is large, postoperative, recurrent, not well supported under ordinary conditions and not readily reducible when considered inoperable. The Veteran underwent a VA examination in March 2011. The Veteran reported that he underwent a right hernia repair in 1968, and, since surgery, there have been no recurrences thereafter. The record is otherwise silent for reports of the severity of the Veteran’s inguinal hernia. The weight of the evidence indicates that the Veteran is not entitled to a compensable disability rating. In order to meet the criteria for a compensable disability rating, the Veteran must manifest an inguinal hernia that is severe enough to require support by a truss or belt, small postoperative recurrent or unoperated irremediable, large, postoperative, recurrent, or not well supported under ordinary conditions and not readily reducible when considered inoperable. The evidence establishes that the Veteran previously underwent a hernia repair; however, no residuals are documented in the Veteran’s medical records during the pendency of the appeal. Here, the weight of the probative evidence of record simply fails to demonstrate that the Veteran is entitled to a compensable disability rating for a right inguinal hernia. Therefore, the evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to a compensable disability rating for a right inguinal hernia. 7. Entitlement to a compensable disability rating for tinea versicolor. At issue is whether the Veteran is entitled to compensable disability rating for tinea versicolor. The weight of the evidence indicates that the Veteran is not entitled to a compensable disability rating. The Veteran filed for service connection in July 1970, and, in September 1970, the RO granted service connection and assigned a noncompensable disability rating effective the day after separation from service. The Veteran filed an increased rating claim in September 2010, and, in June 2011, the RO denied the Veteran’s claim. The Veteran appealed. The Veteran’s disability rating is assigned pursuant to Diagnostic Code 7806. Under Diagnostic Code 7806, a noncompensable disability rating is assigned for skin disorders that manifest less than five percent of the entire body or less than five percent of the exposed areas affected and no more than topical therapy required during a 12-month period, and a disability rating of 10 percent is assigned for skin disorders that manifest at least five percent but less than 20 percent of the body or at least five percent but less than 20 percent of the affected area; or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during a 12-month period. A disability rating of 30 percent is assigned for skin disorders that manifest at least 20 percent to 40 percent of the entire body or 20 to 40 percent of the entire effected area; or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more but not constantly during a 12-month period, and a disability rating of 60 percent is assigned for skin disorders that manifest more than 40 percent of the entire body or more than 40 percent of the entire effected area; or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs in a 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806. The Veteran underwent a VA examination in April 2011. The Veteran reported that he had a history of tinea versicolor that only manifested on his hands, and that physicians prescribed him topical creams and over-the-counter medication; but he was not prescribed systemic treatment. The examiner did not observe the Veteran manifesting any active symptomology at that time. Moreover, there was no functional impairment from the tinea versicolor. The Veteran submitted an opinion from a private examiner that was dated December 2011. The chiropractor indicated that the Veteran manifested frequent exacerbations of the condition. However, the chiropractor did not give any further information concerning the severity of the Veteran’s skin disorder for rating purposes. The record is otherwise silent for reports of the severity of the Veteran’s tinea versicolor. The Veteran is not entitled to a compensable disability rating for a skin disorder. In order to meet the criteria for a compensable disability rating, the Veteran need to manifest a skin disorder that covered more than five percent of his entire body or the entire effected area or required the use of some level of systemic therapy or immunosuppressive drugs. The evidence of record does not establish that either of these things manifested during the period on appeal. Here, the weight of the probative evidence of record simply fails to demonstrate that the Veteran is entitled to a compensable disability rating for a tinea versicolor. Therefore, the evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to a compensable disability rating for tinea versicolor is denied.   8. Entitlement to a compensable disability rating for a fracture of the left index finger. At issue is whether the Veteran is entitled to a compensable disability rating for a fracture of the left index finger. The weight of the evidence indicates that the Veteran is not entitled to a compensable disability rating. The Veteran filed for service connection in February 1998, and, in October 1999, the RO granted service connection and assigned a noncompensable disability rating effective the day the claim was received. The Veteran filed an increased rating claim in September 2010, and, in June 2011, the RO denied the Veteran’s claim. The Veteran appealed. Disability ratings for the index finger are assigned pursuant to Diagnostic Codes 5225 and 5229. Under Diagnostic Code 5225, a disability rating of 10 percent is assigned for ankylosis of the index finger. Under Diagnostic Code 5229, a noncompensable disability rating is assigned for limitation of motion of the index finger with a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm with the finger flexed to the extent possible and extension is limited by no more than 30 degrees, and a disability rating of 10 percent is assigned with limitation of the index finger with a gap of more than one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm with the finger flexed to the extent possible or with extension limited by more than 30 degrees. 38 C.F.R. § 4.71a. The Veteran underwent a VA examination in April 2011. The Veteran reported that his previously service-connected fracture of the left index finger had healed well, and that he did not manifest pain, discomfort, interference with job or daily activity, problems with repetitive use, or difficulty gripping. The examiner observed that the Veteran’s flexion was to 90 degrees and his extension was to zero degrees. Muscle strength testing yielded normal results. There was no additional loss of range of motion after repetitive range of motion testing. The examiner ultimately characterized the Veteran’s left finger as normal. The record is otherwise silent for reports of the severity of the Veteran’s fracture of the left index finger. The Veteran does not meet the criteria for a compensable disability rating. In order to meet the criteria, the Veteran must either manifest ankylosis or limitation of the index finger with a gap of more than one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm with the finger flexed to the extent possible or with extension limited by more than 30 degrees. The Veteran does meet any of these conditions, because the Veteran had full range of motion and his left index finger was evaluated as normal. The Board notes that it is the intention of the rating schedule that healed fractures that manifest in painful motion must be productive of at least a minimally compensable disability rating. 38 C.F.R. § 4.59. In this case however, the Veteran has not reported painful motion, and, therefore, the Veteran does not meet this criteria for a minimal compensable rating. As previously noted, the Board must consider whether or not the Veteran is manifesting additional functional impairment when it is evaluating the Veteran’s claim for musculoskeletal injuries such as this fracture of a left index finger condition. DeLuca v. Brown, 8 Vet. App. 202 (1995). The medical evidence, however, does not establish that the Veteran manifested flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. Additionally, the Board notes that the Veteran was able to perform repetitive range of motion testing without and additional loss of range of motion and muscle strength testing was normal. Therefore, the Veteran does not meet the criteria for an increased disability rating based on additional functional impairment. Here, the weight of the probative evidence of record simply fails to demonstrate that the Veteran is entitled to a compensable disability rating for a fracture of the left index finger. Therefore, the evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to a compensable disability rating for a fracture of the left index finger is denied 9. Entitlement to a disability rating of 30 percent for PTSD. At issue is whether the Veteran is entitled to a disability rating in excess of 30 percent for an acquired psychiatric disorder. The weight of the evidence indicates that the Veteran is entitled to a disability rating of 50 percent, but no more, for an acquired psychiatric disorder. The Veteran first filed for service connection for an acquired psychiatric disorder in September 2010, and, in June 2011, the RO granted service connection and assigned a disability rating of 30 percent effective the date the claim was received. The Veteran appealed his initial disability rating. Disability ratings for acquired psychiatric disorders are evaluated using the General Rating Formula for Mental Disorders. Under the General Rating Formula for Mental Disorders, a disability rating of 30 percent is assigned when a mental disorder causes occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. A disability rating of 50 percent is assigned when a mental disorder causes occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. Id. A disability rating of 70 percent is assigned when a mental disorder causes occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A total disability rating is assigned when a mental disorder causes total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the Veteran’s symptoms, but it must also make findings as to how those symptoms impact the Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating, because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list. See Mauerhan. Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. See Vazquez-Claudio. The Veteran’s treatment records indicate that the Veteran manifested psychiatric symptoms throughout the period on appeal. The Veteran’s global assessment of functioning (GAF) scores ranged from to 45 to 68. GAF is a scale indicating the psychological, social, and occupational functioning on a hypothetical continuum of mental health and illness. Richard v. Brown, 9 Vet. App. 266 (1996). GAF scores from 41 to 50 suggests serious symptoms, and GAF scores from 51 to 60 suggest moderate symptoms. GAF scores from 61 to 70 suggest some mild symptoms. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). A January 2010 SSA disability determination and transmittal indicates that the Veteran was unable to work, but due to diabetes and prostate problems rather than an acquired psychiatric disorder. The Veteran submitted a written notice in October 2010. The Veteran reported the following symptoms: nightmares; cold sweats; trouble sleeping; self-isolation; argumentative tendencies; an estranged relationship with his wife (whom the Veteran indicated he was no longer together with) and his child; and severe headaches. In an October 2010 application for TDIU, the Veteran claimed he was no longer able to secure and maintain substantially gainful employment, but the Veteran indicated that this was mainly due to his back and knee conditions. The Veteran underwent a VA examination in April 2011. The Veteran reported the following symptoms: mood disturbance involving depression and anxiety; irritability; easily angered; interpersonal difficulties; difficulty relating to people; socially isolating; nightmares; flashbacks; sleep disturbance; hypervigilance; and exaggerated startle response. The examiner made the following observations: appropriately groomed and dressed; unremarkable motor activity; calm, controlled, and generally appropriate behavior; cooperative during interview; constricted affect and appropriate to content; alert and oriented to time, place, and person; neutral mood; unremarkable rhythms and speech patterns; clear, coherent, and goal-directed speech; no evidence of auditory or visual hallucinations; grossly intact insight, judgment, impulse control, attention, concentration skills, and abstract reasoning skills. The Veteran indicated that currently he spends time with this daughter and grandchildren, and that he socializes with his friends. The examiner opined that the Veteran was currently employable, but the Veteran’s work history indicated that he had been retired since 2009. The Veteran was assigned a global assessment of functioning score of 58. The Veteran submitted an opinion from a private chiropractor that was dated December 2011. The chiropractor opined that the Veteran left his job in 2009 due to his acquired psychiatric disorder, which manifested in violent ideation towards coworkers as well as insomnia, anger, and rage. For the record, the Board does not attach any weight to the chiropractor’s opinion on the severity of occupational or social impairment caused by the Veteran’s acquired psychiatric disorder, because, although a medical professional, chiropractors have no demonstrated expertise in psychiatry or psychology. Symmetrically, the Board would not afford much weight to an orthopedic opinion submitted by a psychologist. On the other hand, the Board has not reason to doubt the chiropractor’s diligence of reporting the Veteran’s claimed symptoms and have taken his reports into consideration accordingly. The Veteran underwent an evaluation from a private psychologist in January 2012. The Veteran reported a number of psychiatric symptoms including: intrusive thoughts; flashbacks; nightmares; night sweats; cognitive and physiological responses to trauma cues; avoidance of feelings, conversations, activities, places, and people associated with trauma; markedly diminished interest in social activities; feelings detachment or estrangement; restricted range of affect; insomnia; difficulty concentrating; hypervigilance; exaggerated startle response; suicidal ideation; and homicidal ideation of fellow employees. The provider observed the following: extremely pleasant and cooperative; difficulties with long-term recall; impulse control below normal limits; somewhat rambling speech; circumstantiality thoughts; inconsistent thought content; blunted affect; oriented to all three spheres; immediate memory within normal limits; remote memory intact; but judgement and insight fell below normal limits. The Veteran was assigned a GAF score of 44. Based on the evidence of record and when resolving the benefit of the doubt in favor of the Veteran, the Board finds that a 50 percent rating is warranted since the award of service connection. In order to meet the criteria for a disability rating of 50 percent the Veteran needed to manifest occupational and social impairment with reduced reliability and productivity. The Veteran’s treatment records indicate that the Veteran manifested GAF symptoms associated with moderate and sometimes serious symptoms during the period on appeal. GAF is not dispositive, but it is probative evidence that the Board can rely on. A January 2012 private evaluation noted a number of psychiatric symptoms and observations that would impair productivity including: feelings detachment or estrangement; restricted range of affect; difficulty concentrating; exaggerated startle response; and homicidal ideation of fellow employees; difficulties with long-term recall; impulse control below normal limits; somewhat rambling speech; circumstantiality thoughts; inconsistent thought content; and below normal judgement and insight. The Board notes that a VA examination indicated that the Veteran was still employable, but employable does not necessarily mean that there are no lapses in productivity. The evidence of record, therefore, indicates that the Veteran’s psychiatric symptoms most closely approximate the criteria for a disability rating of 50 percent. However, the preponderance of the evidence shows that the Veteran does not meet the criteria for a higher rating. In order to meet the criteria for a disability rating of 70 percent the Veteran has to manifest deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. The Veteran did not manifest deficiencies in work, because, despite his psychiatric symptoms, the Veteran was able to secure and maintain gainful employment until retirement. The Veteran reported that in an application for TDIU that his physical conditions rather than his psychological symptoms prevented employment, and a VA examiner indicated that the Veteran’s psychiatric symptoms did not prevent the Veteran from being employable. Finally, SSA records indicate that the Veteran cannot work due to diabetes and prostate problems rather than psychiatric symptoms. The record does indicate that the Veteran was estranged from his wife, but that he was ultimately able to maintain a relationship with his child and grandchild. A January 2012 private evaluation indicating that judgement and insight were below normal limits, but the Veteran’s judgement and thinking is not deficient; because a VA examination indicated that the Veteran’s insight and judgement was grossly intact. The Veteran’s mood was not deficient, because he was consistently observed as cooperative during evaluations, and, although disturbances in mood were reported, the Veteran’s mood was evaluated as neutral. In sum, the weight of the evidence shows that the Veteran is entitled to a disability rating of 50 percent. Therefore, the evidence in this case is so evenly balanced enough as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to a disability rating of 50 percent, but no higher, for PTSD is granted, effective September 7, 2010. REASONS FOR REMAND 1. Entitlement to service connection for a left knee disorder is remanded. The Veteran contends that he is entitled to service connection for a left knee disorder. The Veteran previously underwent a VA examination in February 2006, and the examiner indicated that the Veteran’s left knee condition was not “related” to the Veteran’s service-connected right knee condition; because the Veteran was not manifesting an altered gait. There was no commentary with respect to aggravation. In January 2010, a SSA medical consultant noted that the Veteran manifested an antalgic gain. Moreover, the December 2011 private opinion indicated that the Veteran’s left knee condition was secondary to his low back and right knee conditions. In light of the above, a supplementary examination/opinion is necessary. See Barr. 2. Entitlement to service connection for a cervical spine disorder is remanded. The Veteran was provided a VA examination in October 2012. The examiner diagnosed degenerative disc disease, but found it was not caused by his service-connected low back condition. However, the examiner failed to offer a sufficient rationale for this opinion or opine whether the Veteran’s cervical spine disorder was aggravated by his low back disorder. Moreover, a February 2013 VA opinion indicated that the Veteran’s cervical spine disability was not related to a period of service; because the Veteran’s service treatment records did not indicate that the Veteran sought treatment for a neck condition. However, the Veteran’s service treatment records indicate that the Veteran sought treatment for neck pain in 1969. Once VA undertakes to provide the Veteran with a VA examination, it must provide the Veteran with an adequate one; see Barr v. Nicholson, 21 Vet. App. 303 (2007); and, under these circumstances, an adequate examination must explain whether or not a medical nexus exists between a documented in-service incurrence and a confirmed diagnosis of a disability. 3. Entitlement to service connection for cephalgia is remanded. The Veteran contends that he is entitled to service connection for cephalgia. In support of his contention he has submitted a private opinion from his chiropractor that he has a diagnosis of cephalgia that is secondary to his neck condition. Therefore, this issue is inextricably intertwined with the Veteran’s claim for service connection for a neck condition, and it must be remanded as well. Harris v. Derwinski, 1 Vet. App. 180 (1991). 4. Entitlement to a compensable disability rating for iritis of the left eye is remanded. The Veteran contends that he is entitled to a compensable disability rating for iritis of the left eye. Disability ratings for iritis is assigned pursuant to the total length of incapacitating episodes occurring in a 12-month period or level of visual impairment due to iritis; whichever is higher. 38 C.F.R. § 4.79. The Veteran underwent a VA examination in April 2011 which indicated that the Veteran manifested a number of ocular conditions including iritis, and that the Veteran manifested visual impairment. Unfortunately, the examination did not discuss to what extent, if any, the Veteran’s visual impairment was caused by his service-connected iritis. The examination was also silent on whether or not the Veteran manifested incapacitating episodes due to his iritis. As previously noted, once VA undertakes to provide the Veteran with a VA examination, it must provide the Veteran with an adequate one; see Barr; and, under these circumstances, an adequate examination must indicate what if any level of visual impairment and what if any length of incapacitating episodes is caused by the Veteran’s iritis. 5. Entitlement to TDIU is remanded. The Veteran contends that he is entitled to TDIU. The issue is inextricably intertwined with the above issues. See Harris. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to address the etiology of any left knee disorder. The examiner should opine whether the Veteran has an altered gait, and, if so, whether it is at least as likely as not that the Veteran’s left knee condition is proximately due to or aggravated by his service-connected right knee and/or low back disabilities. Why or why not? 2. Schedule the Veteran for a VA examination to address the etiology of any diagnosed cervical spine disorder. The examiner should opine whether it is at least as likely as not that (a.) a medical nexus exists between an in-service incurrence (to include seeking treatment during a period of service for a neck condition in January 1969) and a current diagnosis; (b.) any diagnosed cervical spine disorder is proximately due to his service-connected low back disorder; or (c.) any cervical spine disorder has been aggravated beyond its natural progression by his service-connected low back disorder. Why or why not? 3. Schedule the Veteran for a VA examination to address the severity of his service connected iritis. The examiner should determine whether the Veteran’s iritis result in visual impairment. If so, please describe the level of visual impairment caused by the Veteran’s iritis. The examiner should also determine whether the Veteran’s iritis results in incapacitating episodes. If so, please describe the level of incapacitating episodes cause by the Veteran’s iritis. 4. Schedule the Veteran for appropriate VA examinations to address the functional impairment the Veteran’s other service-connected disabilities have on his activities of daily living and the effect on his employment. J.N. MOATS Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD David R. Seaton, Associate Counsel