Citation Nr: 18151472 Decision Date: 11/19/18 Archive Date: 11/19/18 DOCKET NO. 16-06 061 DATE: November 19, 2018 ORDER Entitlement to service connection for residuals of a right eye injury is denied. Entitlement to service connection for bilateral sensorineural hearing loss (SNHL) is denied. Entitlement to service connection for left bundle branch block is denied. Entitlement to service connection for diabetes mellitus, type II is denied. Entitlement to at least a 10 percent evaluation for residuals of a left groin injury is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to an initial compensable evaluation for erectile dysfunction secondary to right testicular torsion is denied. Entitlement to an initial compensable evaluation for residuals of a right testicular torsion injury with surgical correction is denied. Entitlement to an initial compensable evaluation for a scar due to removal of a cyst on the back of the head is denied. REMANDED Entitlement to service connection for a left shoulder condition is remanded. Entitlement to service connection for a right shoulder strain with dislocation and degenerative joint disease is remanded. Entitlement to service connection for a left hip condition is remanded. Entitlement to service connection for a right knee condition is remanded. Entitlement to service connection for a left ankle condition is remanded. Entitlement to an initial compensable rating in excess of 10 percent for a residual left groin injury condition is remanded. FINDINGS OF FACT 1. The competent medical evidence does not demonstrate that the Veteran has a residual condition attributable to an in-service incident when his right eyeball came out its socket. 2. The competent medical evidence does not demonstrate that the Veteran has bilateral hearing loss as defined by VA regulation. 3. The preponderance of the competent evidence of record is against a finding that the Veteran’s left bundle branch block, which was diagnosed after service, is attributable to his active service or any incident of service. 4. Diabetes mellitus type II was not present during active duty; was not manifested to a compensable degree within one year from the date of separation from service in June 1994; and diabetes mellitus type II, first diagnosed after service beyond the one-year presumptive period for a chronic disease, is unrelated to an injury, disease, or event of service origin. 5. The Veteran’s residuals of a left groin injury condition has been at least manifested by severe pain, weakness, and impairment of coordination. 6. The most probative evidence of record does not show that the Veteran has a deformed penis. 7. Throughout the entire period of appeal, the Veteran’s right testicular torsion injury with surgical correction manifested as chronic pain and tenderness without requiring long term drug therapy, frequent hospitalizations, or intermittent intensive management; moreover, no voiding dysfunction, renal dysfunction, or recurring urinary infection has been associated with the condition. 8. The Veteran’s scar on the back of his head is 4.5 centimeters long by 0.3 centimeters wide; throughout the appeal period, the scar has never been painful or unstable and has not exhibited any characteristics of disfigurement. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a right eye injury have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113, 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385. 3. The criteria for service connection for left bundle branch block have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1113, 5107; 38 C.F.R. § 3.303. 4. The criteria for service connection for diabetes mellitus type II have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. 5. The criteria for an increased rating of at least 10 percent for residuals of a left groin injury have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.56, 4.73, Diagnostic Code 5315. 6. The criteria for an initial compensable evaluation for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.20, 4.31, 4.115b, Diagnostic Code 7522. 7. The criteria for an initial compensable rating for residuals of a right testicular torsion injury with surgical correction are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.115a, 4.115b, Diagnostic Code 7525. 8. The criteria for entitlement to an initial compensable disability rating for a scar due to removal of a cyst on the back of the head have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7800. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1981 to June 1994. He also served in the Army National Guard, with periods of Active Duty for Training (ACDUTRA) and Inactive Duty for Training (INACDUTRA), from July 2006 to January 2011. The Board has considered whether a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) has been raised by the Veteran during the pendency of this appeal. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that VA must address the issue of entitlement to a TDIU in increased-rating claims when the issue of unemployability either is raised expressly or by the record. A review of the Veteran’s most recent VA medical records indicates that the Veteran is currently employed. Furthermore, none of the VA examiners who have evaluated his service-connected disabilities have determined that those conditions preclude him from securing and maintaining substantially gainful employment. Accordingly, a claim for entitlement to TDIU has not been raised by the record. The Board notes that separate issues addressed in Statements of the Case from May and June of 2018 have not yet been certified for appeal, and will not be addressed in this decision. Service Connection 1. Entitlement to service connection for residuals of a right eye injury is denied. The Veteran contends that he currently has a right eye condition that is attributable to an incident in service where his right eye came out of its socket. The question for the Board is whether the Veteran has a right eye condition that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a nuclear cataract in the right eye, the preponderance of the evidence is against a finding that the Veteran has a right eye condition that is attributable to the in-service incident of his right eye coming out of its socket. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). A review of the Veteran’s service treatment records shows that he did complain of experiencing pain and discomfort in his eyes while in service in 1982. Thereafter, an May 1986 outpatient report reflects that the Veteran’s right eye came out of its socket during a routine laser exam, after which he returned it to its normal position. Subsequent service records do not reveal any treatment for any diagnosed right eye condition. Specifically, a March 1993 optometric examination did not show any diagnosed right eye condition, and no eye abnormalities were listed on a December 1989 general medical examination. Post-service, the Veteran was afforded a VA eye examination in August 2013 to evaluate the nature and etiology of any right eye condition. According to the Veteran, he had cataracts in both eyes that were diagnosed after he was diagnosed with diabetes mellitus, type II. The examiner confirmed a diagnosis of bilateral cataracts, and detailed that the cataracts had no impact on the Veteran’s visual acuity. Regarding the etiology of the claimed eye condition, the examiner stated only that the Veteran did not have any right eye condition that was associated with his orb coming out of its socket while in service. Available records pertaining to the Veteran’s period of duty with the Army Reserves do not show any diagnosis of or treatment for a right eye condition. On a July 2008 prescreen of medical health the Veteran reported experiencing no issues with his right eye and no history of treatment for any right eye condition. Similarly, VA and private medical records do not show any diagnosis of or treatment for a right eye condition, to specifically include a cataract. In summation, the Board finds that there is no evidence that the Veteran has a right eye condition that is attributable to the in-service incident of his eye coming out of its socket. While there is no doubt that this injury occurred, subsequent treatment records both in-service and post-discharge do not reflect that the Veteran has ever been diagnosed with a condition related to his right eye coming out of its socket. On numerous occasions the Veteran has undergone eye examinations and at no point has any right eye condition been diagnosed. While the Veteran’s account of the in-service incident is credible, there is no evidence in the record which indicates that he possesses the training or credentials to competently conclude that he currently has a right eye condition that is attributable to that in-service incident. Jandreau v. Nicholson, 491 F.3d 1372 (Fed. Cir. 2007). Ultimately, the most probative evidence of record is the August 2013 VA examination and opinion, which reflects that the Veteran does not have any right eye condition that is associated with the one incident of the Veteran’s right eye coming out of its socket while in service. The examiner’s opinion is probative, because it is based on an accurate medical history and supported by a clear rationale. See Sklar v. Brown, 5 Vet. App. 140 (1993). With no medical evidence in support of the Veteran’s claim, the preponderance of the evidence is against a determination that he has a right eye condition that was incurred in service or is otherwise attributable to service. Accordingly, service connection for a right eye condition must be denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 2. Entitlement to service connection for bilateral sensorineural hearing loss (SNHL) is denied. The Veteran contends that he was exposed to excessive noise while in service as a part of his duties working as a power generator equipment repairman which resulted in bilateral SNHL. Without addressing the merits of this assertion, however, the Board finds that there is no objective medical evidence to support that the Veteran has a diagnosis of bilateral SNHL for VA purposes, and that consequently, service connection must be denied for the condition. 38 U.S.C. §§ 1110, 1131, 5107(b); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). For the purposes of applying the laws administered by VA, impaired hearing will be considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory threshold for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels 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 was first afforded a VA audiology examination in August 2013, with testing that revealed the following pure tone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 15 25 25 LEFT 25 15 15 20 15 Speech discrimination scores using the Maryland CNC Test were 96 percent bilaterally. Audiometric testing on the most recent VA audiology examination in January 2016 revealed the following pure tone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 30 25 25 25 30 LEFT 35 20 15 10 15 Speech discrimination scores using the Maryland CNC Test were 96 percent in the right ear and 100 percent in the left ear. The Board also notes that VA and private medical records do not show any diagnosis of or treatment for a sensorineural hearing loss disability in either ear. Based on these examination results and the lack of a diagnosis in the available medical records, the Veteran has not had a bilateral hearing loss disability at any point during the pendency of the appeal under VA standards pursuant to 38 C.F.R. § 3.385. The Board recognizes that the Veteran, as a lay person, is competent to describe the symptoms of bilateral hearing loss. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the audiometric results from the August 2013 and January 2016 VA examinations, undisturbed as they are by any contrary medical evidence, have far more probative weight than the lay testimony as to the Veteran’s hearing difficulty. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Lay persons such as the Veteran are not competent to provide the audiometric findings necessary for a finding of a hearing loss disability as defined by 38 C.F.R. § 3.385. The fact remains that the post-service medical records do not contain a diagnosis of bilateral hearing loss for VA purposes pursuant to 38 C.F.R. § 3.385. Without a diagnosis by a medical professional, there is no valid claim of service connection under 38 C.F.R. § 3.303(a) for such disability. Brammer, supra. As indicated above, the Veteran lacks the training or credentials to competently provide a diagnosis. There is no evidence of a hearing loss disability for VA purposes during any period under appeal. The claim is accordingly denied. 3. Entitlement to service connection for left bundle branch block is denied. The Veteran contends generally that his left bundle branch block condition, which was diagnosed after service, is attributable to an in-service incident or injury. The question for the Board is whether the Veteran has a left bundle branch block that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a left bundle branch block, the preponderance of the evidence is against a finding that the condition began during active service, or is otherwise related to an in-service injury, event, or disease, to include on an aggravation basis. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). A review of the Veteran’s service treatment record does not reveal any complaints, findings, treatment, or diagnoses relating to a left bundle branch block. Specifically, he was not evaluated as having any abnormalities regarding his heart on a December 1989 examination, which is the most contemporary available general medical examination in the service treatment records. Post-service, the Board highlights that no heart abnormalities were noted on an August 2006 examination administered upon the Veteran’s entrance into the Army Reserves. That being said, outpatient treatment records pertaining to his period of service in the Reserves indicate that he was first diagnosed with the condition in 1996, although there are no available records in the claims file which can corroborate this time of diagnosis. Those records, as well as VA medical records and additional private medical records from the period of time after he completed his duty with the Army Reserves show that the left bundle branch block has continued to be listed as an active diagnosis. Recent medical records dating from November 2016 show that the left bundle branch block has been asymptomatic since the original diagnosis. The Veteran has not been afforded an examination in connection with his left bundle branch block service connection claim, but VA does not have a duty to provide one here, as there is no persuasive indication that the condition may be associated with the Veteran’s service. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). There is no competent evidence in the claims file that the condition, which was apparently diagnosed after service in 1996, was incurred in service or is otherwise attributable to an in-service injury or event. The Veteran has presented no specific testimony in support of his claim, and at no point in his long documented medical history has the condition ever been associated with his service. Accordingly, the Board finds that the preponderance of the evidence is against granting entitlement to service connection for a left bundle branch block. Consequently, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 4. Entitlement to service connection for diabetes mellitus, type II is denied. The Veteran contends generally that his diabetes mellitus, type II, which was diagnosed after service, is attributable to an in-service incident or injury. The question for the Board is whether the Veteran has diabetes mellitus, type II that manifested in service or to a compensable degree within the applicable presumptive period, or whether the diabetes is otherwise attributable to an in-service injury, event, or disease. The Board concludes that, while the Veteran has diabetes mellitus, type II, it did not manifest to a compensable degree in service or within a presumptive period, and continuity of symptomatology is not established. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Post-service treatment records pertaining to the time period during which the Veteran served in the Army Reserves indicate that he was first diagnosed with diabetes mellitus, type II in August 2009, several years after his separation from service and far outside the applicable presumptive period. 38 U.S.C. § 1112, 38 C.F.R. §§ 3.307, 3.309. Moreover, there is not continuity of symptomatology after service to support the Veteran’s claim under 38 C.F.R. § 3.303(b). The service treatment records lack the documentation of the combination of manifestations sufficient to identify diabetes mellitus type II symptomatology and sufficient observation to establish chronicity during service. Thus, as there is no evidence of continuity of symptomatology to support the claim of service connection for diabetes mellitus type II, the preponderance of the evidence is against the claim of service connection for diabetes mellitus type II based on continuity of symptomatology under 38 C.F.R. § 3.303(b). There is no specific allegation or evidence of record linking this diagnosis to a period of ACDUTRA. Service connection for diabetes mellitus, type II may still be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s diabetes mellitus type II and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Of particular note, there is no medical opinion in the record that relates the Veteran’s diabetes mellitus type II directly to his service, and there is insufficient evidence to trigger VA’s duty to obtain such an opinion. McLendon, supra. The Veteran has not submitted any such evidence, nor has he suggested that an opinion exists. As indicated above, the Veteran lacks the training or credentials needed to provide a competent diagnosis or etiology opinion regarding this disability. In summation, there is no competent evidence that the Veteran’s diabetes mellitus type II, first documented after service beyond the one-year presumptive period, is otherwise related to an injury, disease, or event of service origin. In view of the foregoing, the preponderance of the evidence is against the claim for service connection for diabetes mellitus, type II, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple (“staged”) ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In every instance where the rating schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Neither the Veteran nor his representative has raised any additional issues, and no issues have been found to be raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). 1. Entitlement to an initial compensable evaluation for residuals of a left groin injury. The Veteran’s service-connected residuals of a left groin injury condition is currently rated as noncompensable. He seeks a compensable rating for the entire period of the appeal. The left groin condition is rated as an injury to Muscle Group XV, pursuant to 38 C.F.R. § 4.73, Diagnostic Code 5315. For muscle injury rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). Under Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe. 38 C.F.R. § 4.56(d). The type of injury associated with a “moderate” muscle disability is a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. A history with regard to this type of injury should include service department evidence or other evidence of in-service treatment for the wound and consistent complaints of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use affecting the particular functions controlled by the injured muscles. Objective findings should include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue and some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). The type of injury associated with a “moderately severe” muscle disability is a through and through or deep penetrating wound by a small high-velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intramuscular scarring. A history with regard to this type of injury should include prolonged hospitalization in service for treatment of wound, consistent complaints of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements. Objective findings should include entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups, and indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side. Tests of strength and endurance compared with sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). The type of injury associated with a “severe” muscle wound is a through and through or deep penetrating wound due to high velocity missile or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection or sloughing of soft parts, intramuscular binding and scarring. A history with regard to this type of injury should include evidence showing hospitalization for a prolonged period for treatment of the wound, and a record of consistent complaint of cardinal signs and symptoms of muscle disability worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings of a severe muscle wound are manifested by ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track; palpation showing loss of deep fascia or muscle substance, or soft flabby muscles in wound area; muscles swelling and hardening abnormally in contraction; and tests of strength, endurance, or coordinated movements compared with corresponding muscles of the uninjured side indicating severe impairment of function. 38 C.F.R. § 4.56(d)(4). Under Diagnostic Code 5315, a 10 percent is warranted for a moderate disability, 20 percent is warranted for a moderately severe disability, and 30 percent is warranted for a severe disability. Upon review of the available evidence, the Board finds that the left groin condition is at least moderate in severity and thus warrants at least a 10 percent initial rating. VA treatment records dated in late 2017 show that the Veteran was evaluated at the pain clinic in order to undergo physical therapy to help alleviate pain throughout his left lower extremity. In an outpatient record dated in September 2017, he reported that he fell twice in the past week due to his favoring of his left lower extremity. A November 2017 evaluation shows that he experienced severe pain in his left hip and could not engage in range of motion testing as the pain was too intense. The examiner also noted that there was muscular weakness throughout the left lower extremity. According to the Veteran, while working his left hip pain would increase gradually, such that by the time he was done for the day he could barely walk and would have to use a cane to ambulate. These outpatient records alone support at least a 10 percent initial rating for a left hip muscle injury pursuant to 38 C.F.R. § 4.56, as the Veteran has exhibited several cardinal signs and symptoms of muscle disability, to include weakness, fatigue-pain, impairment of coordination, and uncertainty of movement. However, the Board is unable to determine the exact severity of the Veteran’s left groin condition, especially in light of the most recently available VA examination dated in January 2016, in which the examiner found no evidence of any cardinal signs of muscle disability. The determination of whether a rating in excess of 10 percent is thus warranted is addressed in the REMAND section below. 2. Entitlement to an initial compensable evaluation for erectile dysfunction secondary to right testicular torsion is denied. The Veteran’s service-connected erectile dysfunction is currently rated as noncompensable. He contends that a compensable rating is warranted. The Board notes that the Veteran is already in receipt of special monthly compensation for loss of use of a creative organ for this disability. The Veteran’s erectile dysfunction is rated by analogy under 38 C.F.R. § 4.115b, Diagnostic Code 7522, for penile deformity. See 38 C.F.R. §§ 4.20, 4.27. Diagnostic Code 7522 provides for a 20 percent rating for deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b. Based on the Veteran’s diagnosis and symptoms, which relate to the penis and include loss of erectile power, the Board finds Diagnostic Code 7522 to be the most appropriate diagnostic code. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). The Board finds no other applicable rating criteria, and the Veteran has not requested evaluation under any alternative rating criteria. Following a review of the record, the Board finds that a higher 20 percent initial rating is not warranted for erectile dysfunction. 38 C.F.R. § 4.31. Although there is evidence that the Veteran has loss of erectile power, the record is negative for evidence of penis deformity, which is necessary for a compensable rating under 38 C.F.R. § 4.115b, Diagnostic Code 7522. During the most recent VA examination in January 2016 to evaluate the severity of the erectile dysfunction, the examiner noted that the Veteran’s right testicle was softer than normal and that he experienced pain when his right testicle was manipulated; however, no deformity was noted. There are no other records available in the claims file which suggest that the Veteran’s penis is deformed, and the Veteran has not asserted as much himself. Accordingly, there is no lay or medical support for a compensable disability rating for the Veteran’s erectile dysfunction under Diagnostic Code 7522. Moreover, the Board notes that he is already in receipt of special monthly compensation for loss of use of a creative organ. Therefore, a separate compensable rating for erectile dysfunction is not warranted. The appeal as to this claim is denied. 3. Entitlement to an initial compensable evaluation for residuals of a right testicular torsion injury with surgical correction is denied. The Veteran’s service-connected residuals of a right testicular torsion injury with surgical correction are currently rated as noncompensable. He contends that a compensable rating is warranted. The Board notes that the Veteran is already in receipt of a separate disability rating for erectile dysfunction as well as special monthly compensation for loss of use of a creative organ for this disability; as such, any loss of use of his creative organ that would be considered a residual of the right testicular torsion injury will not be considered in the determination of the proper rating to assign to the condition. As there are no specific rating criteria for residuals of a testicular torsion injury, the Veteran’s right testicular condition has been rated by analogy to chronic epididymo-orchitis, or inflammation of the testes, pursuant to 38 C.F.R. § 4.115b, Diagnostic Code 7525. Under Diagnostic Code 7525, chronic epididymo-orchitis is to be rated using the criteria for rating urinary tract infections. Urinary tract infections requiring long-term drug therapy, one to two hospitalizations a year and/or requiring intermittent intensive management are rated as 10 percent disabling; a recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management are rated as 30 percent disabling; infections resulting in poor renal function are to be rated as renal dysfunction. The severity of the Veteran’s right testicular condition was first evaluated in an August 2013 reproductive system examination. He reported experiencing constant pain in his right testicle relieved by applying ice. He declined to have the examiner physically examine his right testicle, and so no symptomatology other than what the Veteran reported was noted on the examination. It was the examiner’s impression that the right testicular condition had no functional impact on the Veteran’s ability to work. The Veteran was more recently afforded a VA reproductive system examination in January 2016 to again evaluate the severity of the right testicular condition. He reported experiencing an increase in pain since the prior examination, and that he began wearing a truss daily to support his right testicle. He detailed a self-treatment regimen consisting of frequent stretching, use of pain medication, and warm baths. The examiner noted a history of voiding dysfunction, but stated that the dysfunction was attributable to the Veteran’s enlarged prostate and was not related to the right testicular condition. On this examination, the Veteran allowed the examiner to physically examine his testicle, and thus it was confirmed that the right testicle was softer than normal and painful to the touch. No other symptomatology was documented. It was the examiner’s impression that the right testicular condition limited the Veteran’s ability to climb in and out of trucks due to pain, which was one of the physical actions he had to carry out regularly as part of his work duties. A review of available post-service medical records, to include both VA and private records, does not indicate that the Veteran receives any specific treatment for his right testicular condition, although VA medical records do show that the Veteran regularly takes pain medication to alleviate pain throughout his body. The Board finds that a compensable disability rating is not warranted. Neither VA examination shows that the right testicular condition requires long-term drug therapy, drainage and/or frequent hospitalization, and/or continuous intensive management. These criteria are also not reflected in the available medical records. Although the Veteran reports that he experiences chronic pain in his right testicle, he appears to alleviate this pain through a variety of methods not prescribed by his treating physicians. Moreover, the January 2016 VA examiner found that the only functional impact that the right testicular condition had on the Veteran’s ability to work was that it hindered his ability to maneuver in and out of trucks. A compensable initial rating is therefore not warranted. 38 C.F.R. § 4.115b, Diagnostic Code 7525. The Veteran has not been diagnosed with a neoplasm, renal dysfunction, renal stones, renal tubular disorder, or voiding disorder attributable to the service-connected epididymo-orchitis that would allow a higher rating under Diagnostic Codes 7508, 7509, 7529, or 7532. As stated, the January 2016 VA examiner attributed any voiding dysfunction to the non-service-connected enlarged prostate. The clinical evidence does not otherwise suggest, and neither the Veteran nor representative has contended that he suffers from a specific diagnosed voiding dysfunction that is the result of the service-connected right testicular condition. Moreover, this disability is not shown to involve any other factors that would warrant evaluation of the disability under any other provisions of the rating schedule. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of any higher rating. Therefore, the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to an initial compensable evaluation for a scar due to removal of a cyst on the back of the head The Veteran is service-connected for a scar on the back of his head resulting from a cyst that was removed during service. The scar is rated as noncompensable, and he seeks a compensable rating for the entire period of the appeal. The rating for the scar was assigned pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7800, which corresponds to scars of the head, neck or face. Diagnostic Code 7800 provides that a 10 percent rating is warranted for scars that are located on the head, face, or neck when there is one characteristic of disfigurement. A 30 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, or lips), or; with two or three characteristics of disfigurement. A 50 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. An 80 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. For purposes of evaluation of under 38 C.F.R. § 4.118, the eight characteristics of disfigurement are: a scar that is five or more inches, or thirteen centimeters, in length; a scar that is at least one-quarter of an inch, or 0.6 centimeters, wide at the widest part; surface contour of the scar that is elevated or depressed on palpation; a scar that is adherent to underlying tissue; skin that is hypo- or hyper-pigmented in an area exceeding six square inches, or 39 square centimeters; skin texture that is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches, or 39 square centimeters; underlying soft tissue that is missing in an area exceeding six square inches, or 39 square centimeters; and skin that is indurated and inflexible in an area exceeding six square inches, or 39 square centimeters. 38 C.F.R. § 4.118, Diagnostic Code 7800, Note 1. VA is to consider unretouched color photographs when evaluating under these criteria. Id. at Note 3. Additionally, VA is to separately evaluate disabling effects other than disfigurement that are associated with individual scars of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply 38 C.F.R. § 4.25 to combine the evaluation(s) with the evaluation assigned under Diagnostic Code 7800. Id. at Note 4. Finally, the characteristics of disfigurement may be caused by one scar or by multiple scars; the characteristics that are required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. Id. at Note 5. The Board will consider additional diagnostic codes pertinent to the evaluation of scar disabilities in order to determine the highest possible evaluation for the scars detailed above. However, in considering the applicability of those diagnostic codes, the Board finds that Diagnostic Codes 7801 and 7802 are not applicable in this instance, as the Veteran’s scar is clearly contemplated by Diagnostic Code 7800. There is also no showing that the scar is painful or unstable, per Diagnostic Code 7804, or that there are other disabling effects as a consequence of scarring, per Diagnostic Code 7805. Accordingly, the Board will maintain the evaluation of the scar pursuant to Diagnostic Code 7800. The Veteran has been afforded two VA examinations to evaluate the severity of the scar, once in August 2013 and again in January 2016. On both occasions the scar was measured at 4.5 centimeters long by 0.3 centimeters wide. Both examiners found no evidence of any elevation, depression, adherence to underlying tissue, or missing underlying soft tissue, nor did they detail any abnormal pigmentation or texture. The Veteran did not report that the scar was painful or unstable on either examination. Moreover, no other characteristics of disfigurement were noted on either examination. Finally, it was the impression of both examiners that the scar did not result in any functional impairment. The Board has reviewed the available evidence, and finds that an initial compensable rating is not warranted for the scar. The scar is not wide enough to qualify as disfiguring, and no other characteristics of disfigurement were noted during either VA examination. The Veteran has never reported that the scar was painful or unstable, and in fact has presented no specific testimony regarding the scar. The Board also notes that its review of the available VA medical records did not reflect that the Veteran received any particular treatment for the scar. In summation, an initial compensable disability rating is not warranted for the scar due to removal of a cyst on the back of the head. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to an increased rating. 38 U.S.C. § 5107. REASONS FOR REMAND 1. Entitlement to service connection for a left shoulder condition is remanded. The Veteran was afforded a VA examination in August 2013 to evaluate the nature and etiology of his claimed left shoulder condition. After an in-person physical examination, the examiner found no evidence that the Veteran experienced a left shoulder condition, and accordingly declined to offer an opinion as to the etiology of any such condition. The service connection claim was denied on the basis of this examination. A review of the claims file shows that the Veteran has been diagnosed with left shoulder arthrosis with impingement syndrome by his private treating physician, a Dr. M.H., as early as August 2010, and has continued to received treatment for the same through his private doctor as well as through VA. As there is evidence that the Veteran has a qualifying diagnosis, he must be afforded a new VA examination to properly diagnose his left shoulder condition and then elicit an opinion as to its likely etiology. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Entitlement to service connection for a right shoulder strain with dislocation and degenerative joint disease is remanded. The Veteran was afforded a VA examination in August 2013 to evaluate the nature and etiology of his claimed right shoulder condition. He reported that he injured his shoulder in service while playing football. After confirming a diagnosis of right shoulder strain with degenerative joint disease, the examiner found that it was less likely than not that the condition was incurred in service or was otherwise attributable to service. In support thereof, the examiner noted that the Veteran only complained of experiencing shoulder pain in-service on one occasion in July 1981 that was diagnosed as a right shoulder strain, as opposed to a ligament tear or a dislocation. This opinion is deficient, as it overlooks multiple incidences of the Veteran having complained of joint pain while in service, to specifically include an October 1991 outpatient record which reflects that the Veteran sought treatment for right shoulder pain that he had been experiencing for the past three months. After a physical examination the impression was right shoulder subacromial bursitis. This in-service diagnosis suggests that the Veteran may have incurred a right shoulder injury in service with residuals that either continued after service or led to the development of a right shoulder condition after service. Accordingly, the Veteran is entitled to have the claims file reviewed by a new examiner for the purpose of eliciting an opinion as to the likely etiology of his diagnosed right shoulder strain with degenerative joint disease. 3. Entitlement to service connection for a left hip condition is remanded. The Veteran contends that he has a left hip condition that is secondary to his service-connected residuals of a left groin condition. This is corroborated by VA medical records which show treatment for left hip pain associated with his left groin injury. The Veteran has never been afforded an examination to evaluate the nature and etiology of his purported left hip condition. Accordingly, the Veteran is entitled to a be scheduled for a VA examination in order to properly diagnose his left hip condition and to elicit an opinion as to the etiology of any diagnosed left hip condition, to include a determination of whether it is either directly attributable to a service-connected disability or was permanently aggravated by one. See McLendon, supra; see also 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). 4. Entitlement to service connection a right knee condition is remanded. The Veteran was afforded a VA examination in August 2013 to evaluate the nature and etiology of his claimed right knee condition. After an in-person physical examination, the examiner found no evidence that the Veteran experienced a right knee condition, and accordingly declined to offer an opinion as to the etiology of any such condition. The service connection claim was denied on the basis of this examination. A review of the claims file shows that the Veteran has been diagnosed with right knee chondromalacia by a Dr. R.S. as early as August 2010, and has continued to received treatment for the same through his private treating physicians. As there is evidence that the Veteran has a qualifying diagnosis, he must be afforded a new VA examination to properly diagnose his right knee condition and then elicit an opinion as to its likely etiology. Barr, supra. 5. Entitlement to service connection for a left ankle condition is remanded. The Veteran was afforded a VA examination in August 2013 to evaluate the nature and etiology of his claimed left ankle condition. After an in-person physical examination, the examiner found no evidence that the Veteran experienced a left ankle condition, and accordingly declined to offer an opinion as to the etiology of any such condition. The service connection claim was denied on the basis of this examination. A review of VA medical records show treatment for left ankle pain associated with his left groin injury. As there is evidence that the Veteran has a qualifying diagnosis, he must be afforded a new VA examination to properly diagnose his left ankle condition and then elicit an opinion as to its likely etiology, to include whether it is either directly attributable to a service-connected disability or was permanently aggravated by one. Barr, supra. 6. Entitlement to an increased initial rating for residuals of a left groin injury is remanded. On the most recent VA examination to evaluate the severity of the left groin injury dated in January 2016, the examiner found no evidence of any of the cardinal signs and symptoms of muscle disability. This does not accord with the objective medical evidence of record, which shows that the Veteran experiences severe pain, weakness, and incoordination due to his left groin injury residual condition. A new examination should therefore be conducted in order to properly evaluate the severity of the condition. The matters are REMANDED for the following action: Schedule the Veteran for a VA orthopedic examination to evaluate the nature and etiology of his bilateral shoulder, left hip, left ankle and right knee conditions, as well as the severity of the left groin injury residual condition. The entire claims file, to include a complete copy of this REMAND, must be made available to the individual designated to examine the Veteran, and the submitted report should include discussion of the Veteran’s documented medical history and assertions relating to any symptoms of the conditions listed above. The examiner should note in the examination report that the claims folder and the remand have been reviewed. All indicated tests should be performed and all findings should be reported in detail. For the bilateral shoulder, left hip, left ankle and right knee conditions, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the condition began in service or is otherwise caused or aggravated by active service. Specifically, with regards to the right shoulder condition claim, the examiner is asked to consider, and comment upon as necessary, an October 1991 in-service outpatient record which shows that the Veteran sought treatment for right shoulder pain and weakness and was ultimately diagnosed with subacromial bursitis in his right shoulder. In addition, regardless of the determination of the examiner to the above query, the examiner must also opine as to whether it is it at least as likely as not (a 50 percent probability or higher) that the left hip and/or left ankle condition was caused or aggravated by one or more service-connected disabilities (as listed in an June 2018 rating decision), notably the residuals of left groin injury condition. The examiner should note that the term “aggravated by” refers to a chronic or permanent worsening of the underlying condition, as contrasted to mere temporary or intermittent flare-ups of symptoms that resolve and return to the baseline level of disability. If the opinion is that a service-connected disability or combination of service-connected disabilities aggravated either the left hip and/or the left ankle condition, the examiner should specify, so far as possible, the degree of disability resulting from such aggravation. As for the left groin injury residual condition, the examiner must describe the nature and severity of all residual manifestations of the Veteran’s left groin injury. If the examiner is unable to conduct the required testing, he or she should clearly explain why that is so. The examiner must provide any and all opinions as to etiology in the form of a probability, and must provide a complete rationale for any opinion expressed. The Board notes the anatomical distinctions between the several conditions on appeal and recognizes that separate opinions may be necessary in this case. However, the Board leaves this to the discretion to the RO and/or the examining medical facility. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Christopher M. Collins, Associate Counsel