Citation Nr: 18151719 Decision Date: 11/20/18 Archive Date: 11/19/18 DOCKET NO. 16-24 371 DATE: November 20, 2018 ORDER Entitlement to service connection for diabetes is denied. Entitlement to service connection for an acquired mental disorder is denied. Entitlement to service connection for a left knee disorder is denied. Entitlement to service connection for a heart disorder is denied. Entitlement to a disability rating in excess of 10 percent for a right knee disorder is denied. Entitlement to a disability rating in excess of 10 percent for a right ankle disorder is denied. Entitlement to a disability rating in excess of 10 percent for tinnitus is denied. Entitlement to a disability rating in excess of 0 percent for bilateral hearing loss is denied. Entitlement to a disability rating in excess of 0 percent for a right middle finger disorder is denied. Entitlement to an effective date earlier than June 7, 2013, for the grant of service connection for the service-connected right knee disorder is denied. Entitlement to an effective date earlier than June 7, 2013, for the grant of service connection for the service-connected right ankle disorder is denied. Entitlement to an effective date earlier than June 7, 2013, for the grant of service connection for the service-connected tinnitus is denied. Entitlement to an effective date earlier than June 7, 2013, for the grant of service connection for the service-connected bilateral hearing loss is denied. Entitlement to an effective date earlier than June 7, 2013, for the grant of service connection for the service-connected right middle finger disorder is denied. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. Diabetes is not related to service. 2. An acquired mental disorder is not related to service. 3. A left knee disorder is not related to service. 4. A heart disorder is not related to service. 5. The service-connected right knee disorder has been manifested by painful motion of the right knee, with flexion measured to at least 90 degrees, with normal extension, and with no lateral instability, recurrent subluxation or meniscal conditions. 6. The service-connected right ankle disorder has been manifested by painful and limited motion, with dorsiflexion to at least 10 degrees and with plantar flexion to at least 45 degrees, with resulting impairment in sitting, standing, walking, climbing, and lifting. 7. The service-connected tinnitus has been manifested by constant or intermittent ringing perceived in the ears. 8. The service-connected bilateral hearing loss has been manifested by level I acuity in the right ear and level III acuity in the left ear. 9. The service-connected right middle finger disorder has been manifested by pain associated with flexion of the finger, and decreased range of motion of the finger, with a gap of less than one inch between the fingertip and the proximal transverse crease of the palm, and with no limitation of extension. 10. The earliest date of a pending claim of entitlement to service connection for a right knee disorder June 7, 2013. 11. The earliest date of a pending claim of entitlement to service connection for a right ankle disorder June 7, 2013. 12. The earliest date of a pending claim of entitlement to service connection for tinnitus June 7, 2013. 13. The earliest date of a pending claim of entitlement to service connection for bilateral hearing loss June 7, 2013. 14. The earliest date of a pending claim of entitlement to service connection for a right middle finger disorder is June 7, 2013. 15. The schedular criteria for TDIU have not been met; the Veteran’s service-connected disabilities do not render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for service connection for an acquired mental disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 3. The criteria for service connection for a left knee disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 4. The criteria for service connection for a heart disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 5. The criteria for a disability rating higher than 10 percent for the service-connected right knee disorder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003 (2017). 6. The criteria for a disability rating higher than 10 percent for the service-connected right ankle disorder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003 (2017). 7. The criteria for a disability rating higher than 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.85, Diagnostic Code 6260 (2017). 8. The criteria for a disability rating higher than 0 percent for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.85, Diagnostic Code 6100 (2017). 9. The criteria for a disability rating higher than 0 percent for a right middle finger disorder have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5229 (2017). 10. The criteria for an effective date earlier than June 7, 2013, for the grant of service connection for a right knee disorder have not been met. 38 U.S.C. §§ 5101, 5103, 5103A, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.102, 3.151, 3.400 (2017). 11. The criteria for an effective date earlier than June 7, 2013, for the grant of service connection for a right ankle disorder have not been met. 38 U.S.C. §§ 5101, 5103, 5103A, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.102, 3.151, 3.400 (2017). 12. The criteria for an effective date earlier than June 7, 2013, for the grant of service connection for tinnitus have not been met. 38 U.S.C. §§ 5101, 5103, 5103A, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.102, 3.151, 3.400 (2017). 13. The criteria for an effective date earlier than June 7, 2013, for the grant of service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 5101, 5103, 5103A, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.102, 3.151, 3.400 (2017). 14. The criteria for an effective date earlier than June 7, 2013, for the grant of service connection for a right middle finger disorder have not been met. 38 U.S.C. §§ 5101, 5103, 5103A, 5107, 5110 (West 2014); 38 C.F.R. §§ 3.102, 3.151, 3.400 (2017). 15. The criteria for TDIU have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from April 1974 to October 1982. This appeal comes before the Board of Veterans’ Appeals (Board) from a January 2014 and September 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran submitted, and VA obtained, additional medical evidence subsequent to the most recent adjudication of his appeal by the agency of original jurisdiction (AOJ), and he provided a written waiver of initial adjudication of additional evidence by the AOJ. The Board has considered a claim of entitlement to TDIU as a component of the rating claims on appeal in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). Service Connection VA law provides that, for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, or other than a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation, except if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C. §§ 1110, 1131 (West 2014). Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310(a),(b); Wallin v. West, 11 Vet. App. 509, 512 (1998). For specific enumerated diseases designated as “chronic” there is a presumption that such chronic disease was incurred in or aggravated by service even though there is no evidence of such chronic disease during the period of service. In order for the presumption to attach, the disease must have become manifest to a degree of 10 percent or more within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Presumptive service connection for chronic diseases may alternatively be established by way of continuity of symptomatology under 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a) Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a) (West 2014). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2017). A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Entitlement to service connection for diabetes. Entitlement to service connection for an acquired mental disorder. Entitlement to service connection for a left knee disorder. Entitlement to service connection for a heart disorder. Upon review of the service treatment records, a May 30, 1979, Clinical Note reveals complaint of chest pain for 2 or 3 months, which was attributed to myalgia or an intercostal muscle strain. The Veteran noted that he had a family history of heart problems (Record 10/02/2013 at 17). A report of medical history completed by the Veteran on December 19, 1979, reveals the Veteran’s account that he had no history of, or current, trick or locked knee, depression or excessive worry, or nervous trouble of any sort. While the Veteran reported a history of chest pain, he reported no history of, or current, heart trouble. He reported that he had pain in his chest and the doctor told him it was a strained muscle (Record 03/20/2014 at 36). A report of medical examination performed on December 19, 1979, reveals normal clinical findings for the psychiatric examination, as well as for the lower extremities, heart, and endocrine system (Record 03/20/2014 at 40). A report of medical examination performed on September 24, 1980, reveals normal clinical findings for the psychiatric examination, as well as for the lower extremities, heart, and endocrine system. Physical profile ratings of P-1, L-1, and S-1 were assigned (Record 03/20/2014 at 11). PULHES is the six categories into which a physical profile is divided. The P stands for physical capacity or stamina. This factor normally includes conditions of the heart; respiratory system; gastrointestinal system, genitourinary system; nervous system; allergic, endocrine, metabolic and nutritional diseases; diseases of the blood and blood forming tissues; dental conditions; diseases of the breast, and other organic defects and diseases that do not fall under other specific factors of the system. The L stands for lower extremities. This factor concerns the feet, legs, pelvic girdle, lower back musculature and lower spine (lower lumbar and sacral) in regard to strength, range of motion, and general efficiency. The S stands for psychiatric. This factor concerns personality, emotional stability, and psychiatric diseases. The number 1 indicates that an individual possesses a high level of medical fitness and, consequently, is medically fit for any military assignment. See 9–3(c)(1) Army Regulation 40–501, Change 35; Hanson v. Derwinski, 1 Vet. App. 512 (1991); Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). The Veteran was separated from active duty on October 6, 1982. The separation reason was unsuitability-apathy; defective attitude or inability to expand effort constructively (Record 06/07/2013). A report of medical examination performed on July 12, 1997, reveals normal findings for the psychiatric examination, as well as for the lower extremities, heart, and endocrine system. Physical profile ratings of P-1, L-1, and S-1 were assigned (Record 08/07/2001 at 6). A report of medical history completed by the Veteran on July 12, 1997, reveals the Veteran’s account that he had no history of, or current, heart trouble, trick or locked knee, depression or excessive worry, or nervous trouble of any sort (Record 08/07/2001 at 8). A March 9, 2010, Nursing Note reveals the Veteran’s mental status was oriented. He had no dementia, organic brain syndrome, Alzheimer’s, delusions, hallucinations, anxiety disorder, depression, manic depression, or schizophrenia (Record 01/21/2014 at 463); A March 10, 2010, History and Physical included a mental status examination and noted that the Veteran was in no apparent distress (Record 01/21/2014 at 446); on March 11, 2010, he was alert and oriented x 3 (Record 01/21/2014 at 432). An October 25, 2010, Neurological Consult reveals the Veteran’s mental status was alert and oriented, with no aphasic errors, and no cognitive deficit (Record 01/21/2014 at 376). On March 22, 2011, the Veteran was noted as alert and oriented X 3 (Record 01/21/2014 at 346). An April 1, 2011, Depression Screen was negative. The Veteran reported not feeling down, depressed or hopeless at all (Record 01/21/2014 at 311). A January 18, 2012, VA Primary Care Note reveals a finding that the Veteran did not have mental impairments that increase his risk of harm to self or others. A depression screen was negative (Record 01/21/2014 at 263). The Veteran filed claims for service-connected compensation in June 2013 and October 2013. A February 4, 2013, VA Psychology Consult notes that the Veteran had been having trouble coping with his son’s death while he was in the military. The Veteran reported that he had been prompted to attend the appointment after meeting with disability representative who suggested he be evaluated for PTSD due to the death of his child while he was in the military. The Veteran reported tossing and turning in his sleep and low energy, which was suggested to be evaluated in the sleep lab for possible sleep apnea. He reported significant medical problems including low energy related to chronic heart disease. The veteran denied any problematic intrusive thoughts or nightmares regarding the death of his 2-year old son while he was in the military. He reported no avoidance symptoms or increased physiological arousal related to the event. Instead, he noted that he thinks of his son at times, but not often, and feels some normal sadness at the loss. A PTSD screen was negative. A mental health assessment showed that he had a neutral mood; his affect was appropriate and full; his thought processes were appropriate; and his speech was appropriate. The examiner concluded that no diagnosis was warranted (Record 01/21/2014 at 90). The report of a January 2014 VA Heart Conditions Examination reveals diagnoses of coronary artery disease, congestive heart failure, and acute, subacute, or old myocardial infarction, in 2009, with implantation of a defibrillator in 2011. The etiology of the diagnoses was atherosclerosis (Record 01/03/2014 at 37). The examiner opined that it is less likely as not that the heart condition is related to service. The examiner reasoned that the Veteran was treated in service only for chest wall muscle strain, which is not related to the current heart disease (Record 01/03/2014 at 49). The report of a January 2014 VA General Medical Examination reveals a diagnosis of ischemic heart disease and type II diabetes mellitus. There was no diagnosis for the left knee (Record 01/03/2014 at 1). An April 9, 2014, VA Primary Care Note reveals a negative depression screen (Record 04/01/2017 at 135). A January 13, 2015, VA Primary Care Note reveals a negative depression screen (Record 04/01/2017 at 115). A May 25, 2016, VA Clinical Note reveals the Veteran had no complaints of depression, anxiety, nervousness, or difficulty falling asleep (Record 04/01/2017 at 35). A Nursing Note of the same date reveals a negative depression screen (Record 04/01/2017 at 42). A childhood friend stated in November 2016 that, when the Veteran got out of the service, he was visibly depressed, struggled to maintain existing relationships and was unable to establish new ones. He now displays symptoms of panic, anxiety, irritability, and social withdrawal. According to the Veteran’s friend, these issues keep him from getting and maintaining employment (Record 10/24/2018 at 21). In a January 2017 opinion, Dr. Henderson-Galligan, opined that the Veteran suffers from an unspecified depressive disorder that more likely began in service and continued uninterrupted to the present time, and is aggravated by his service-connected disabilities (Record 10/24/2018 at 28). The report of a March 2017 VA Knee Examination reveals a diagnosis of left knee degenerative arthritis. The Veteran reported that his left knee condition began in service at the same time as the right knee (Record 03/20/2017). The examiner opined that the left knee condition was less likely than not related to service. The rationale was that service treatment records are silent for a left knee condition (Record 03/20/2017). A July 3, 2017, VA Primary Care Note reveals a negative depression screen (Record 07/03/2018 at 18). The report of an April 2018 VA Mental Disorders Examination reveals that no mental disorder diagnosis was deemed appropriate. The Veteran reported he married while in in the service, and there were three children born of this marriage, which ended in divorce in or around 1982. He remarried 30 years ago, and there was one child born of that marriage. While in the service, a son died from complications related to a brain surgery. His wife is currently on disability, and they have had significant financial difficulties. The Veteran reported that he performed adequately in school, but dropped out in the 9th grade. He worked in a shoe factory in adolescence. After discharge, the Veteran worked as a construction worker, truck driver, from 2002 to 2008, on the range on Fort Hood, as a police office, as a trailer manufacturer, and at other jobs. He went on disability in 2010 due to his physical ailments. The Veteran reported that he has never sought or received psychiatric care. The Veteran reported a periodic depressed mood. The examiner noted that this does not appear to have affected his ability to work, as his employment difficulties were directly attributed to other causes, or his ability to maintain his relationship with his wife (Record 04/02/2018). The examiner opined that there is no clear causative association between the Veteran’s self-reported periodic depressed mood and his service-connected ailments. Indeed, it does not appear that the self-reported periodic mood causes impairment. Rather, it would seem that the Veteran’s impairments, secondary to his physical ailments, cause some mood complaints. There is no significant temporal association between the onset of the service-connected physical ailments and the onset of psychiatric symptoms. The examiner further opined that a mental disorder was not aggravated by the service-connected disabilities. The rationale was that there is no psychiatric diagnosis, and that the Veteran denied psychiatric symptoms in service, and had no history of seeking or receiving psychiatric care (Record 04/02/2018). In a June 2018 addendum report, Dr. Henderson-Galligan stated that the diagnosis of unspecified depressive disorder originated while the Veteran was in the service when his son passed away, and that the Veteran’s discharge from service was only a little over a year after the death of his son. She opined that the Veteran’s discharge was directly related to the unresolved grief of his son’s death. She stated that the Veteran’s impairments secondary to his physical ailments cause mood complaints, however “it is impossible to separate the amount of his mood complaints caused by his service connected problems, his non-service connected problems and the mood complaints which started in service.” She reiterated that depression did start in service and was aggravated by his physical problems (Record 10/24/2018 at 26). A June 2018 letter from the Veteran’s sister states that the Veteran was very moody when he returned from the service had symptoms of irritability and social withdrawal. She believes the Veteran has a mental disorder that is related to his service and his service-connected disabilities (Record 10/24/2018 at 24). After a review of all of the evidence, the Board finds that there is no current chronic psychiatric mental disorder, and that diabetes mellitus, a right knee disorder, and a heart disorder are not related to service, and are not related to a service-connected disability or disabilities. The presumption of service connection for specified chronic diseases is applicable to diabetes, cardiovascular-renal disease, psychoses, and arthritis. In this case, there is no notation of diabetes, cardiovascular-renal disease, a psychosis, or left knee arthritis in service; and, there is no manifestation of these conditions to a degree of 10 percent or more within one year of service separation. While the Veteran asserts that he had similar symptoms in service for his left knee as he had for his left, manifestation of arthritis to a degree of 10 percent or more requires X-ray evidence of arthritis. See 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010. Such is not demonstrated here. The Board acknowledges a reference to a left knee injury in the service treatment records, in July 1978; however, the March 2017 examiner has interpreted this as an error, in light of other treatment reports during the surrounding period, which refer to a right knee injury (Record 03/20/2017). While the Veteran submitted a private opinion addressing the claimed mental disorder, this opinion does not address the etiology of his diabetes mellitus, heart disease, or left knee disorder. While the Board acknowledges the Veteran’s assertions relating these current disorders to service, the Veteran is not shown to have the medical training required to offer an etiology opinion. Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 (‘sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer’); 38 C.F.R. § 3.159(a)(2). The Board finds that relating current diseases processes such as diabetes mellitus, heart disease, and arthritis, to service, is not the equivalent of relating a broken bone to a concurrent injury to the same body part (Jandreau, at 1377). Such opinions require specialized medical knowledge and training. These are not matters which are capable of lay observation. Accordingly, the Veteran’s lay statements are not competent evidence of an etiologic relationship between the claimed diabetes mellitus, heart disease, and left knee arthritis and service. Regarding the claimed depression, the Board finds the February 2013 and April 2018 VA opinions to be probative and persuasive evidence the presence of a current chronic mental/psychiatric disorder. In other words, to the extent the Veteran may have experienced symptoms of depression, or other psychiatric symptoms in service or since service, there is no current disability, as a current psychiatric/mental diagnosis is not deemed appropriate. The Board acknowledges the conflicting opinions of Dr. Henderson-Galligan. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App 171 (1991). Dr. Henderson-Galligan’s opinion regarding direct service incurrence is explicitly based on the onset of chronic disability during service; and, on ongoing symptoms after service. However, a review of the post-service outpatient and inpatient treatment records reveals findings that are inconsistent with this scenario. Notably, psychiatric examination findings were consistently normal during service, and the Veteran repeatedly denied symptoms of a psychiatric disorder during service, i.e., symptoms of depression, excessive worry, or nervous trouble of any sort. In addition, the Veteran was examined 15 years after service in July 1997, and again was found to be psychiatrically normal, and he again denied psychiatric symptoms. The Veteran’s mental status was assessed in March 2010, October 2010, and March 2011, and the findings were also normal. The Veteran repeatedly denied psychiatric symptoms during depression/PTSD screens during the later post-service period, and these screens were all determined to be negative. In sum, the opinion of Dr. Henderson-Galligan is in direct conflict with a substantial volume of pertinent clinical evidence, which she neither discussed nor acknowledged in her report. On the other hand, the opinion of the February 2013 and April 2018 VA examiners is consistent with this clinical evidence. The weight of a medical opinion is diminished where that opinion is based on an inaccurate factual premise, or where the basis for the opinion is not adequately stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). As the private opinion is explicitly based on the onset of a depressive disorder in service, which continued after service, and as the opinion does not adequately acknowledge or discuss this significant contradictory evidence, the Board accords the VA opinions greater probative weight than the opinion of Dr. Henderson-Galligan. Consistent with the VA opinions, the Board accordingly finds that there is no current psychiatric/mental disability. The Board acknowledges the written observations of the Veteran, his friends, and his family members, in support of his claim. However, none of this evidence is competent with respect to establishing a mental diagnosis. To the extent it supports a history of symptoms dating back to service, the Board must also consider the personal interest a claimant, his friends, and his family, have in a particular case. See Pond v. West, 12 Vet. App. 341, 345 (1999); and see Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest may affect the credibility of testimony). There is no question that the Veteran is competent to relate a history of symptoms, and that his friends and family are competent to relate their observations. However, these statements also conflict materially with the evidence cited above, including the Veteran’s own repeated denial of psychiatric symptoms to medical examiners during routine clinical evaluations. In weighing the conflicting statements provided by the Veteran, the context of the statement is important. The “medical diagnosis or treatment” exception to the hearsay rule (Fed. R. Evid. 803) provides that “statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care.” Recourse to the Federal Rules of Evidence is appropriate where they will assist in articulation of the Board of Veterans’ Appeals’ reasons. Rucker v. Brown, 10 Vet. App. 67 (1997). There is no question that lay evidence is competent to relate observable events. Thus, the competency of this evidence is not at issue. Rather, it is the credibility and accuracy of the written accounts submitted in support of the Veteran’s claim for compensation which the Board finds is lacking. In so finding, the Board does not imply that the Veteran experienced no psychiatric symptoms during this period. However, the presence of symptoms must be distinguished from the presence of a psychiatric/mental disorder. Here, the lay statements provide an account that conflicts with more reliable evidence. This more reliable evidence substantiates the VA opinions cited above. The Board further finds that the private opinion regarding aggravation of a mental disorder by the Veteran’s service-connected disabilities presumes that there is a psychiatric/mental disability subject to aggravation. The Board has found against such a disability. In light of these findings, the Board concludes that service connection for the claimed diabetes mellitus, psychiatric disorder, heart disorder, and left knee disorder, is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Increased Rating Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Entitlement to a disability rating in excess of 10 percent for a right knee disorder. The current appeal arises from a claim of entitlement to service connection for a right knee disorder received at VA on June 7, 2013. In a January 2014 rating decision, VA granted service connection for degenerative joint disease of the right knee, and assigned an initial disability rating of 10 percent under Diagnostic Code 5003-5260, effective June 7, 2013. Under Diagnostic Code 5257, recurrent subluxation or lateral instability of the knee is assigned a rating of 30 percent if severe; a rating of 20 percent if moderate; and a rating of 10 percent if slight. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Lateral is defined as denoting a position farther from the median plan or midline of the body or structure. See Dorland's Illustrated Medical Dictionary 1022 (31st ed. 2007). Under Diagnostic Code 5258, a rating of 20 percent is assigned for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a rating of 10 percent is assigned for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5260, limited flexion merits a rating of 30 percent where flexion is limited to 15 degrees; 20 percent where flexion is limited to 30 degrees; 10 percent where flexion is limited to 45 degrees; and 0 percent where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limited extension merits a rating of 50 percent where extension is limited to 45 degrees; 40 percent where extension is limited to 30 degrees; 30 percent where extension is limited to 20 degrees; 20 percent where extension is limited to 15 degrees; 10 percent where extension is limited to 10 degrees; and 0 percent where flexion is limited to5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Board notes that the criteria under Diagnostic Codes 5257, 5260, and 5261 are not considered to be overlapping, and therefore separate ratings can be assigned where appropriate symptomatology is shown. An April 23, 2012, VA Primary Care Note reveals complaint of bilateral knee pain for the past 2 or 3 months. On examination, there was no swelling; range of motion was not limited; there was no crepitus (Record 01/21/2014 at 218). The Veteran underwent removal of a foreign body from the right knee on May 15, 2012, after the Veteran was struck by a wire in the knee while mowing his lawn (Record 01/21/2014 at 166). A May 22, 2012, VA Orthopedic Clinic Note reveals no erythema over right knee, no effusion, and no warmth. Full flexion and extension of right knee with active and passive range of motion. Three wounds noted with sutures with wound well approximated without edema or induration. No purulence noted (Record 01/21/2014 at 162). The report of a January 2014 VA Knee Examination reveals a diagnosis of right knee degenerative joint disease. The Veteran described pain and giving way of the joint. He described swelling and flares several times per week which decrease his activities. On examination, flexion was measured to 90 degrees, with pain at the limit of motion, and extension was measured to 0 degrees with objective evidence of painful motion. There was no change in motion after 3 repetitions. Functional loss was described as pain on motion and reduced motion. Pain makes it difficult for the Veteran to perform physical activity with flares and with repeated use over time. Muscle strength was full. All joint stability tests were normal, including tests of lateral instability. There was no history of patellar subluxation. There was no history of meniscal conditions. The Veteran’s ability to lift was not limited; he could walk up to ¼ mile at one time or during an 8-hour day; he could sit or stand for an unlimited time if he could extend his leg while sitting and/or shift his weight while standing (Record 01/03/2014 at 17). The report of a May 2016 VA Knee Examination reveals the Veteran’s report of sharp burning pain 3 to 4 times per week. During flares, he cannot run, jump, or climb and has difficulty squatting or putting on pants, shoes, and socks. Flexion was measured to 110 degrees. Extension was measured to 0 degrees. After 3 repetitions, there was no change in range of motion. Pain was present with weight-bearing. The Veteran was experiencing a flare at the time of the examination, so the results represent his functional impairment during flares. Muscle strength was full, with no decrease, and with no muscle atrophy. There was no ankylosis. There was no history of recurrent subluxation. There was no joint instability. Tests of anterior, posterior, medial, and lateral instability were normal. There was no history of meniscal conditions (Record 05/02/2016). The report of a March 2017 VA Knee Examination reveals a diagnosis of degenerative arthritis. Right knee pain was described with bending, climbing, prolonged walking, squatting and kneeling. Frequent stumbling was noted by the Veteran. There were no flares reported. Flexion was measured to 110 degrees and extension was measured to 0 degrees. There was no evidence of pain with weight-bearing or with non-weight-bearing. There was pain with passive range of motion, but it did not result in functional loss. There was no additional limitation of motion after 3 repetitions. There was no ankylosis. Muscle strength testing was full, with no atrophy. There was no history of lateral instability or recurrent subluxation. Testing of joint stability was normal. There were no meniscal conditions (Record 03/20/2017). After a review of all of the evidence, the Board finds that the criteria for a disability rating higher than 10 percent for the service-connected right knee disorder have not been met. The service-connected right knee disorder has been manifested by painful, weakened motion of the right knee, with flexion measured to at least 90 degrees, with normal extension, and with no lateral instability, recurrent subluxation or meniscal conditions. The Veteran experiences pain, give-way weakness, and swelling. These symptoms affect sitting, kneeling, crouching, standing, walking, climbing, and lifting. Regarding pain, it is important to note that, while pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). 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. at 38; see 38 C.F.R. § 4.40. This functional loss is measured by testing of range of motion in accordance with the rating schedule. In this case, the testing does not demonstrate functional loss greater than is compensated by the currently assigned rating. While the provisions of 38 C.F.R. § 4.59 establish that the Veteran is entitled to compensable evaluation for his painful motion, such has already been assigned for the entire period. Evaluations in excess of the minimum compensable rating must be based on demonstrated functional impairment. While the Veteran reported flares on the first examination, the Board considers the May 2016 report to be an accurate depiction of his functional impairment as he was having a flare at the time of the examination. Moreover, at the time of the March 2017 report, the Veteran reported that he did not experience flares. Although the examiners did not provide an opinion regarding functional loss with repeated user over time, the January 2014 examiner provided the Veteran’s description of such loss as making it difficult to perform physical activity. This description does not imply any specific degree of additional loss. In light of these findings, the Board concludes that a disability rating higher than 10 percent for the service-connected right knee disorder is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Board finds that the record includes an examination which is compliant with Correia v. McDonald, 28 Vet. App. 158 (2016), in that it includes tests for pain on both active and passive motion, in weight-bearing and non-weight-bearing. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Entitlement to a disability rating in excess of 10 percent for a right ankle disorder. The current appeal arises from a claim of entitlement to service connection for a right ankle disorder received at VA on June 7, 2013. In a January 2014 rating decision, VA granted service connection for degenerative joint disease of the right ankle, and assigned an initial disability rating of 10 percent under Diagnostic Code 5003-5271, effective June 7, 2013. Under Diagnostic Code 5270 ankylosis of the ankle warrants a rating of 40 percent if in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion or eversion deformity . A rating of 30 percent is warranted if in plantar flexion, between 30 and 40 degrees, or in dorsiflexion, between 0 and 10 degrees. A rating of 20 percent is warranted if ankylosis is present in plantar flexion, less than 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5270. Under Diagnostic Code 5271 limited motion of the ankle warrants a rating of 20 percent if marked, and a rating of 10 percent if moderate. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Normal range of motion of the ankle is from 45 degrees plantar flexion to 20 degrees dorsiflexion. 38 C.F.R. § 4.71a, Plate II. While the schedule of ratings does not provide any information as to what manifestations constitute “moderate” or “marked” limitation of ankle motion, guidance can be found in VBA’s M21-1 Adjudication Procedures Manual. Specifically, the M21-1 states that moderate limitation of ankle motion is present when there is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, while marked limitation of motion is demonstrated when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. See VBA Manual M21-1, III.iv.4.A.6.m. The Board finds that it is reasonable to rely on the guidance provided in the VA Manual, as it is consistent with the general definition of moderate as tending toward the mean, middle, or average. Webster’s Collegiate Dictionary, 798 (11th Ed. 2007). The adjective “marked” is defined as having a distinctive or emphasized character. Id., at 760. The report of a January 2014 VA Ankle Examination reveals a diagnosis of right ankle degenerative joint disease. The Veteran reported that the ankle pops and twists a lot and gives way. He tries to keep the ankle extended. It bothers him while walking and he walks with a limp. He reported that it is difficult to get up from sitting and is hard to sleep. He reported flares of pain several times per week which decrease his activities. On examination, plantar flexion was measured to 45 degrees or greater and dorsiflexion was measured to 10 degrees. Pain was noted at the extents of motion. After 3 repetitions, there was no change in these measurements. Functional loss consisted of painful motion and limited motion, as well as disturbance of locomotion. Pain makes it difficult for the Veteran to perform physical activity with flares and with repeated use over time. Muscle strength was full and there was no laxity. There was no ankylosis. The Veteran’s ability to lift was not limited; he could walk up to ¼ mile at one time or during an 8-hour day; he could sit or stand for an unlimited time if he could extend his leg while sitting and/or shift his weight while standing (Record 01/03/2014 at 8). The report of a May 2016 VA Ankle Examination reveals the Veteran’s report of flares of catching 2 or 3 times per day and stabbing pain 2 times per week. The Veteran reported difficulty with squatting and climbing, and that he cannot drive more than 2 or 3 hours. Dorsiflexion was measured to 15 degrees and plantar flexion was measured to 45 degrees. After 3 repetitions, there was no change in motion. There was pain on weight-bearing. The Veteran was experiencing a flare at the time of the examination, so the results represent his functional impairment during flares. Muscle strength was full, with no decrease, and with no muscle atrophy. There was no ankylosis. Testing of joint stability was normal (Record 05/02/2016). After a review of all of the evidence, the Board finds the criteria for a disability rating higher than 10 percent for the service-connected right ankle disability have not been met. The service-connected right ankle disability is manifested by painful and limited motion, with dorsiflexion to at least 10 degrees and with plantar flexion to at least 45 degrees, with resulting impairment in sitting, standing, walking, climbing, and lifting. There is no ankylosis in any degree. The Board finds that the Veteran’s complaints of “catching” are a type of limitation of motion. The fact that the Veteran was experiencing a flare at the time of the May 2016 examination indicates that the range of motion measurements reported on that report reasonably represent limitation of motion due to catching. Although the examiners did not provide an opinion regarding functional loss with repeated user over time, the January 2014 examiner provided the Veteran’s description of such loss as making it difficult to perform physical activity. This description does not imply any specific degree of additional loss. In light of range of plantar flexion which is normal, and range of dorsiflexion which is about half of normal, the Board finds that the Veteran’s range of motion is moderately impaired, but not markedly impaired. The Board has considered whether any other diagnostic codes applicable to the ankle would be more appropriate. However, there is no evidence or assertion of ankylosis of the subastragalar or tarsal joint (Diagnostic Code 5272), malunion of the os calcis or astragalus (Diagnostic Code 5273), or astragalectomy (Diagnostic Code 5274). In light of these findings, the Board concludes that a disability rating for the service-connected right ankle disability higher than 10 percent is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Board finds that the record includes an examination which is compliant with Correia, 28 Vet. App. 158, in that it includes tests for pain on both active and passive motion, in weight-bearing and non-weight-bearing. Neither the Veteran nor his representative has raised any other issues, nor are other issues reasonably raised by the record. See Doucette, 28 Vet. App. at 371. Entitlement to a disability rating in excess of 10 percent for tinnitus. The current appeal arises from a claim of entitlement to service connection for tinnitus received at VA on June 7, 2013. In a January 2014 rating decision, VA granted service connection for tinnitus, and assigned an initial disability rating of 0 percent under Diagnostic Code 6260, effective June 7, 2013. The veteran’s service-connected tinnitus has been assigned the maximum schedular rating available for tinnitus. 38 C.F.R. §4.87, Diagnostic Code 6260. As there is no schedular basis upon which to award more than a single, 10 percent rating for tinnitus, the veteran’s appeal must be denied. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Entitlement to a disability rating in excess of 0 percent for bilateral hearing loss. The current appeal arises from a claim of entitlement to service connection for hearing loss received at VA on June 7, 2013. In a January 2014 rating decision, VA granted service connection for left ear hearing loss, and assigned an initial disability rating of 0 percent under Diagnostic Code 6100, effective June 7, 2013. In an April 2017 rating decision, VA granted service connection for right ear hearing loss and assigned an initial disability rating of 0 percent effective February 20, 2017. Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenman v. Principi, 3 Vet. App. 345 (1992). The rating schedule establishes 11 auditory hearing acuity levels based on average pure tone thresholds and speech discrimination. See 38 C.F.R. §§ 4.85. When the pure tone threshold at each of the four specified frequencies (1,000, 2,000, 3,000 and 4,000 hertz) is 55 decibels or more, the rating specialist will determine the Roman Numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. When the pure tone threshold is 30 decibels or less at 1,000 hertz, and 70 decibels or more at 2,000 hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86 (2017). The report of an August 2013 VA Audiology Examination reveals pure tone thresholds as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 10 10 15 35 18 LEFT 15 40 80 80 54 Speech recognition ability was 96 percent in the right ear and of 88 percent in the left ear. Applying these values to Table VI results in level I in the right ear and level II in the left ear. Application to Table VII at 38 C.F.R. § 4.85 produces a 0 percent rating (Record 08/15/2013). The report of a February 2017 VA Audiology Examination reveals pure tone thresholds as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 15 20 15 30 20 LEFT 20 75 80 90 66 Speech recognition ability was 92 percent in the right ear and of 88 percent in the left ear. Applying these values to Table VI results in level I in the right ear and level III in the left ear. Application to Table VII at 38 C.F.R. § 4.85 produces a 0 percent rating. The functional effect of the disability, as described by the Veteran, was that his wife and daughter say he can’t hear anything. He can’t hear anything on the phone. At a loud restaurant, he can hear the music, but he can’t have a conversation at the table (Record 02/21/2017). The report of an April 2018 VA Audiology Examination reveals pure tone thresholds as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 15 20 15 35 21 LEFT 20 70 80 80 63 Speech recognition ability was 98 percent in the right ear and of 92 percent in the left ear. Applying these values to Table VI results in level I in the right ear and level II in the left ear. Application to Table VII at 38 C.F.R. § 4.85 produces a 0 percent rating. The veteran stated: “I just don’t hear a lot when my wife or daughter are talking. I have the TV real loud and my wife complains. I don’t hear the alarm if I’m lying on my right side” (Record 04/25/2018). After a review of all of the evidence, the Board finds that the criteria for a compensable disability rating for bilateral hearing loss have not been met. The Veteran has been provided multiple tests of auditory acuity in this case and none has produced a combination of measurements that would warrant a compensable disability rating. Moreover, his functional impairment is entirely related to a difficulty in hearing and recognizing speech or other sounds. See Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). In light of these findings, the Board concludes that a compensable rating is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor his representative has raised any other issues, nor are other issues reasonably raised by the record. See Doucette, 28 Vet. App. at 371. Entitlement to a disability rating in excess of 0 percent for a right middle finger disorder. The current appeal arises from a claim of entitlement to service connection for a right middle finger disorder received at VA on June 7, 2013. In a January 2014 rating decision, VA granted service connection for a right middle finger strain, and assigned an initial disability rating of 0 percent under Diagnostic Code 5229, effective June 7, 2013. Under Diagnostic Code 5229, a rating of 10 percent is available with a gap of 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. A rating of 0 percent is appropriate 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. See 38 C.F.R. § 4.71a, Diagnostic Code 5229. The report of a January 2014 VA Hand and Finger Examination reveals a diagnosis of residual strain of the right middle finger. The Veteran reported that it bothers him while bowling. He has a throbbing ache when it bothers him, which is not every day. He reported that it does not really keep him from any activities. On examination, there was no gap between the thumb and middle finger or between the fingertip and the proximal transverse crease of the palm. He experienced pain with a gap of less than 1 inch. Extension was not limited. There was no change in motion after 3 repetitions. Functional loss was described as pain on motion and reduced motion. Pain made it difficult for the Veteran to perform physical activity with flares, and with repeated use over time. Muscle strength was full. There was no ankylosis. There was no impact of the condition on the Veteran’s ability to work (Record 01/03/2014 at 27). The report of a March 2017 VA Hand and Finger Examination reveals a diagnosis of residuals of right (dominant) middle finger fracture. Symptoms included pain, if twisted the wrong way, and tightness. There were no flares reported. On examination, there was a 0.5-centimeter gap between the tip of the finger and the proximal transverse crease. Extension was measured to 0 degrees. There was no evidence of pain with use of the hand. There was no pain with passive range of motion. There was no pain with weight-bearing. There was no additional limitation of motion after 3 repetitions. There was no ankylosis. Muscle strength testing was full, with no atrophy. There was no impact of the condition on employment (Record 03/20/2017). After a review of all of the evidence, the Board finds that the criteria for a compensable disability rating for the service-connected right middle finger fracture residuals have not been met. The service-connected right middle finger fracture residuals consist of pain associated with flexion of the finger, and decreased range of motion of the finger. However, on no examination has there been a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm; and, extension has not been limited by more than 30 degrees. Although the examiners did not provide an opinion regarding functional loss with repeated user over time, the January 2014 examiner provided the Veteran’s description of such loss as making it difficult to perform physical activity. This description does not imply any specific degree of additional loss. Accordingly, the criteria for a rating of 10 percent have not been met. Moreover, as there is no rating higher than 10 percent, it cannot be said that the criteria for a rating of 10 percent are more nearly approximated than are the criteria for the current rating of 0 percent. See 38 C.F.R. § 4.7. In light of these findings, the Board concludes that a compensable rating is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Board finds that the record includes an examination which is compliant with Correia, 28 Vet. App. 158, in that it includes tests for pain on both active and passive motion, in weight-bearing and non-weight-bearing. Neither the Veteran nor his representative has raised any other issues, nor are other issues reasonably raised by the record. See Doucette, 28 Vet. App. at 371. Effective Date Entitlement to an effective date earlier than June 7, 2013, for the grant of service connection for the service-connected right knee disorder. Entitlement to an effective date earlier than June 7, 2013, for the grant of service connection for the service-connected right ankle disorder. Entitlement to an effective date earlier than June 7, 2013, for the grant of service connection for the service-connected tinnitus. Entitlement to an effective date earlier than June 7, 2013, for the grant of service connection for the service-connected bilateral hearing loss. Entitlement to an effective date earlier than June 7, 2013, for the grant of service connection for the service-connected right middle finger disorder. Unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a). The effective date of an award of disability compensation to a veteran shall be the day following the date of discharge or release if application therefor is received within one year from such date of discharge or release. 38 U.S.C. § 5110(b)(1). This statutory provision is implemented by a regulation which provides that the effective date of an evaluation and award of compensation based on an original claim or a claim reopened after final disallowance, will be the date of receipt of the claim or the date entitlement arose, whichever is the later. See 38 C.F.R. § 3.400. A specific claim in the form prescribed by the Secretary of VA must be filed in order for benefits to be paid to any individual under the laws administered by VA. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a). The Veteran submitted a claim for service connection on June 7, 2013, citing multiple disorders, including a right knee disorder, a right ankle disorder, tinnitus, hearing loss and a right finger disorder. In a January 2014 rating decision, VA granted service connection for each of the claimed disorders, effective June 7, 2013, the date of receipt of his claim. There are no prior claims of entitlement to service connection for a right knee disorder, a right ankle disorder, tinnitus, hearing loss and a right finger disorder, and there are no prior adjudications of service connection for these claims. The Veteran has articulated no specific argument as to why he believes he is entitled to earlier effective dates, and as to what those dates should be. He has not asserted that he filed any earlier claim than the one received on June 7, 2013. It is well settled law that an intent to apply for benefits is an essential element of any claim, whether formal or informal, and, further, that the intent must be communicated in writing. Criswell v. Nicholson, 20 Vet. App. 501 (2006), citing MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed.Cir.2006) (holding that the plain language of the regulations requires a claimant to have an intent to file a claim for VA benefits); also citing Rodriguez v. West, 189 F.3d 1351, 1353 (Fed.Cir.1999) (noting that even an informal claim for benefits must be in writing); also citing Brannon v. West, 12 Vet. App. 32, 35 (1998). Even if VA had constructive or actual possession of medical records documenting pertinent diagnoses prior to the claim here on appeal, the mere existence of medical records generally cannot be construed as an informal claim; rather, there must be some intent by the claimant to apply for a benefit. Criswell, supra, citing Brannon, 12 Vet. App. at 35; 38 C.F.R. § 3.155(a). In sum, the Board finds that, prior to June 7, 2013, there was no pending claim for service connection for a right knee disorder, a right ankle disorder, tinnitus, hearing loss, or a right finger disorder, pursuant to which service connection could have been granted. As such, an effective prior to the date of receipt of the Veteran’s claim for service connection for a right knee disorder, a right ankle disorder, tinnitus, hearing loss and a right finger disorder is legally precluded. The controlling statute and regulation provide that the effective date for a grant of service connection is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). Here, again, there is no dispute. The Veteran has asserted that entitlement, i.e., the onset of disability, arose prior to the date of claim. Therefore, the Board concludes that the date of claim, June 7, 2013, is the later of the two dates, and is the appropriate effective date. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. TDIU Entitlement to TDIU It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a)(1), 4.15. A claim for a total disability rating based upon individual unemployability presupposes that the rating for the service-connected disability is less than 100 percent, and only asks for TDIU because of subjective factors that the objective rating does not consider. Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In evaluating a veteran's employability, consideration may be given to his level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The term substantially gainful occupation is not specifically defined for purposes of the regulations governing TDIU. However, marginal employment is not considered substantially gainful employment. Marginal employment includes situations in which an individual’s annual income does not exceed the poverty threshold for one person. Employment may be marginal even when the individual’s earned income exceeds the poverty threshold if such individual is employed in a protected environment such as a family business or sheltered workshop. 38 C.F.R. § 4.16(a). A total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a). In this case, service connection is in effect for disabilities of the right knee and right ankle, as well as for tinnitus. Each of these disabilities is assigned a rating of 10 percent. Service connection is also in effect for several noncompensable disabilities, including bilateral hearing loss, and a right middle finger disorder. As the combined service-connected disability rating is 30 percent, consideration for TDIU under the schedular criteria of3 8 C.F.R. § 4.16(a) is not warranted. Pursuant to 38 C.F.R. § 4.16(b), when a claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), such case shall be submitted for extraschedular consideration to the Director of the Compensation service. For a veteran to prevail on a claim for a total compensation rating based on individual unemployability on an extraschedular basis, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In Hatlestad v. Derwinski, 1 Vet. App. 164 (1991), the Court referred to apparent conflicts in the regulations pertaining to individual unemployability benefits. Specifically, the Court indicated there was a need to discuss whether the standard delineated in the controlling regulations was an “objective” one based on the average industrial impairment or a “subjective” one based upon the veteran's actual industrial impairment. In a pertinent precedent decision, the VA General Counsel opined that the controlling VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a subjective standard. It was also determined that “unemployability” is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91. After a review of all of the evidence, the Board finds that the criteria for extraschedular referral have not been met because the evidence does not indicate that the Veteran’s service-connected disabilities has rendered him unable to secure or follow a substantially gainful occupation. Indeed, the Veteran’s assertions and medical evidence submitted on his behalf rely heavily on the impact of additional claimed disabilities which are denied above. Therefore, the effect of the claimed diabetes mellitus, heart disease, left knee disorder, and psychiatric/mental disorder, cannot be considered in determining whether extraschedular referral is warranted. Here, the Board finds that there is no factor identified in the record regarding the right knee and ankle disabilities beyond the musculoskeletal functional impairments addressed in detail above, and there is no impact of tinnitus beyond the perception of ringing in the ears addressed above. See Van Hoose v. Brown, 4 Vet. App. 361, at 363 (1993). Moreover, the Veteran’s right middle finger disorder has been found not to result in any impact on his ability to engage in employment. In light of these findings, the Board concludes that referral of the claim for extraschedular consideration is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Cramp