Citation Nr: 21067185 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 18-06 612 DATE: November 3, 2021 ORDER Entitlement to an initial compensable rating on a schedular basis for epididymitis is denied. New and material evidence having been submitted, the previously denied and final claim of service connection of rheumatoid arthritis is reopened. New and material evidence having been submitted, the previously denied and final claim of service connection of degenerative disc disease of the spine is reopened. New and material evidence having been submitted, the previously denied and final claim of service connection of a hernia is reopened. New and material evidence having been submitted, the previously denied and final claim of service connection of an acquired psychiatric disability is reopened. Entitlement to service connection of rheumatoid arthritis is denied. Entitlement to service connection of degenerative disc disease of the lumbar spine is denied. Entitlement to service connection of a hernia is denied. Entitlement to service connection of bilateral flatfoot is granted. Entitlement to service connection of tinnitus is granted. REMANDED Entitlement to service connection of a migraine headache disorder is remanded. Entitlement to service connection of an acquired psychiatric disorder, to include depression, anxiety and alcohol abuse is remanded. Entitlement to an initial rating in excess of 10 percent for a left ankle strain is remanded. Entitlement to an initial compensable rating on an extraschedular basis for epididymitis is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's epididymitis with hydrocele has resulted in swelling of the scrotal sac with pain on palpation and interference with ambulation; he has not experienced recurrent urinary tract infections, required hospitalization, or intensive management of the condition; he does not have renal dysfunction. 2. New and material evidence has been associated with the claims file sufficient to reopen previously denied and final claims of service connection of a rheumatoid arthritis, degenerative disc disease, a hernia and acquired psychiatric disorder disabilities. 3. The Veteran's rheumatoid arthritis was not incurred in service and did not have onset until many years after service; it is not related to any incident of active service. 4. The Veteran's degenerative disc disease of the lumbar spine did not have onset during active service or within one year of separation from active service; he did not suffer an in-service incident or injury to his low back, and there is no competent and credible evidence of record linking the condition to any incident of active service. 5. The Veteran does not have a present hernia condition; he did not suffer an in-service incident or injury to which any such condition could be etiologically linked if it existed. 6. The Veteran's bilateral flatfoot had onset during active service. 7. Affording the Veteran the benefit of the doubt, his tinnitus had onset during active service with continuity to the present. CONCLUSIONS OF LAW 1. The criteria for a compensable schedular disability rating for epididymitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.115a, 4.115b, DCs 7523, 7525. 2. New and material evidence has been received to reopen the previously denied and final claims of service connection for rheumatoid arthritis, degenerative disc disease, a hernia and acquired psychiatric disorder disabilities. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 3. The criteria for service connection for rheumatoid arthritis are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for degenerative disc disease of the lumbar spine are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for a hernia are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for bilateral flatfoot are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for entitlement to service connection for tinnitus are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1979 to September 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2015 and March 2016 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2020, the Veteran testified before the undersigned Veterans Law Judge at a hearing held virtually. A transcript of that hearing is of record. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the Veteran's ankle strain and epididymitis, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, "[w]here 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." 38 C.F.R. § 4.7. 1. Entitlement to an initial compensable rating on a schedular basis for epididymitis The Veteran has been granted service connection of epididymitis with a noncompensable rating. The Board finds that an increased disability rating is not supported at this time on a schedular level. Initially, the Board notes that there is no specific rating criteria which compensates for hydrocele or epididymitis. The Veteran's epididymitis with hydrocele is presently assigned a noncompensable rating based on Diagnostic Code (DC) 7523, which compensates based on atrophy of the testes. Under that rating criteria, a noncompensable rating is assigned for atrophy of a single teste, and a 20 percent rating is assigned based on atrophy of both testes. 38 C.F.R. § 4.115b, DC 7523. Also potentially (and arguably more) applicable in this matter, is DC 7525, which compensates for epididymo-orchitis, chronic only. It is noted that the Veteran is not specifically diagnosed with epididymo-orchitis, but rather epididymitis with hydrocele, however, epididymo-orchitis is defined as "inflammation of the epididymis and testes; called also orchiepididymitis." Dorland's Illustrated Medical Dictionary, 32d Ed., 632 (2012). Epididymitis, for which the Veteran is service-connected, is defined as "inflammation of the epididymis." Id. Hydrocele is defined as "a circumscribed collection of fluid, especially a collection of fluid, especially a collection of fluid in the tunica vaginalis testis or along the spermatic cord. Id., at 877. Under DC 7525, epididymo-orchitis is instructed to be rated as a urinary tract infection. Such disabilities are rated under the criteria set forth in 38 C.F.R. § 4.115a, which specifically provide the rating criteria for dysfunctions of the genitourinary system. Under the applicable criteria, a 10 percent rating is assigned for urinary tract infections requiring long-term drug therapy, 1-2 hospitalizations per year, and/or requiring intermittent intensive management. A 30 percent rating is assigned for recurrent symptomatic infection requiring drainage/frequent hospitalizations (greater than two times per year), and/or requiring continuous intensive management. Only if poor renal function is shown is the condition is to be rated as a renal dysfunction. 38 C.F.R. § 4.115a; 4.115b, DC 7525. Multiple VA examinations are of record in this matter. The Veteran was afforded a VA examination in June 2015. At that time chronic epididymitis was diagnosed. Although drainage of a hydrocele was noted in 1979, he continued to have a swollen scrotum at the time of the examination. He did not require continuous medication. He had not undergone an orchiectomy. He did not have any signs of renal dysfunction. He did not have a voiding dysfunction. He did have erectile dysfunction, although it was of undetermined etiology. Although chronic epididymitis was identified, he did not require treatment for that condition. The epididymitis resulted in tenderness to palpation and hydrocele, bilaterally. The examiner found the condition to result in moderate disability, although did not find the condition to impact his ability to work. In January 2016, he was afforded a new VA examination. The external appearance of the penis was normal, but he did present with significant swelling throughout the scrotal area, with the external circumference measuring approximately 32 cm. It was unclear whether that enlargement was due to swelling, fluid, or a combination thereof. He did report significant tenderness on palpation in the area of the testicles and epididymis, bilaterally. He did not require continuous medication. He had not had an orchiectomy. He did not have any renal dysfunction. There was no voiding dysfunction. Any erectile dysfunction was of unknown etiology. He did not have retrograde ejaculation. While his epididymitis did require intermittent intensive management in the past, in the prior 12 months he had not undergone or required any treatment for the condition. His epididymis was tender to palpation. No other pertinent physical findings were noted. He was not found to have any type of chronic infections. Functionally, he reported pain while walking, but could tolerate work that falls into the sedentary range of physical demands. The Veteran has submitted a private evaluation, completed on a VA examination document, which was signed by two separate doctors, first in July 2018, and amended in November 2018. He was diagnosed with epididymitis with hydrocele but was not undergoing any treatment for the condition at the time. He had not required an orchiectomy. He did not have a voiding dysfunction. He did not have recurrent or symptomatic urinary tract or kidney infections. He did not use any treatment for urinary symptoms. Erectile dysfunction was noted, but the private examiner found it unrelated to the service-connected condition. Notably, the examiner did not find a history of "chronic" epididymitis. The penis and testes were normal, although hydrocele resulted in significant swelling in the scrotal sac. The epididymis was normal. The prostate was normal. Upon ultrasound in March 2018, bilateral hydrocele without evidence of epididymitis was found. Functionally, the condition resulted in discomfort with walking. In November 2018, a different examiner updated the document to indicate a severe chronic condition which severely affects his ability to work. For his part, during his hearing, the Veteran testified to swelling and pain in the scrotal area, which he asserted interfered with ambulation. Based on the available evidence, the Board does not find a premise upon which to assign a schedular compensable rating. The Veteran's testes are generally found to be normal. Rather, the condition affects the scrotal sac, and therefore, a rating based on testicular atrophy is not supported. Likewise, while he could be rated based on urinary tract infections, there is no evidence of any type of chronic infection of the urinary tract or scrotal sac. Despite ongoing symptoms, he has not required significant, or even intermittent treatment for the condition. He has not been hospitalized. Throughout the appeal period he has not been found to require even intermittent intensive management. He has not required drainage of the area. Finally, there is no evidence of any renal dysfunction. As such, the Board must deny an increased rating on a schedular basis. In reaching this conclusion, the Board notes that this decision is limited to an increased rating in a schedular basis. Because the Board has found that the schedular criteria applicably in this matter do not fully address the Veteran's reported symptoms, the issue of entitlement to an extraschedular rating for epididymitis with hydrocele is remanded below for consideration in the first instance. However, because the rating criteria does not support a compensable rating at this time, the claim on a schedular basis is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. New and Material Evidence If a claim was previously denied by a RO or Board decision, and that RO or Board decision became final, then the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108; see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); 38 C.F.R. § 3.156. Even if the RO (in a rating decision, statement of the case, or supplemental statement of the case) has already determined that new and material evidence has been submitted, in the appeal, a new and material evidence analysis must still be completed by the Board. The requirement for the submission of new and material evidence is a jurisdictional prerequisite in order for a claimant to obtain review of a previously denied and final decision. 38 U.S.C. §§ 5108, 7104(b). The Board is under the statutory obligation to conduct a de novo review of the new and material evidence issue. Butler v. Brown, 4 Vet. App. 167, 171 (1996). Under 38 C.F.R. § 3.104 (a), a decision of the rating agency shall be final and binding as to conclusions based on the evidence on file at the time VA issues written notification in accordance with 38 U.S.C. § 5104. An unappealed decision by the RO is final one year from the date notification of the determination is mailed to the claimant. 38 C.F.R. §§ 20.302, 20.1103. In general terms, "new" evidence is evidence that was not of record at the time that the prior final RO or Board decision was issued. "Material" evidence is evidence that addresses the element(s) of service connection that were deficient (and therefore the basis of denial) in the prior final RO or Board decision. See 38 C.F.R. § 3.156 (a). The United States Court of Appeals for the Federal Circuit (Federal Court) has indicated that evidence may be considered new and material if it contributes, "to a more complete picture of the circumstances surrounding the origin of a Veteran's injury or disability, even where it will not eventually convince the Board to alter its rating decision." Hodge v. West, 115 F. 3d. 1356, 1363 (Fed. Cir. 1998). 2. Whether new and material evidence was submitted to reopen a previously denied and final claim of service connection of rheumatoid arthritis 3. Whether new and material evidence was submitted to reopen a previously denied and final claim of service connection of degenerative disc disease of the lumbar spine 4. Whether new and material evidence was submitted to reopen a previously denied and final claim of service connection of a hernia 5. Whether new and material evidence was submitted to reopen a previously denied and final claim of service connection of an acquired psychiatric disability The Veteran's claims of service connection of rheumatoid arthritis, degenerative disc disease, hernia and depression were previously denied in an August 2013 rating decision. He did not timely file a notice of disagreement with those issues and the decision became final. He now seeks to reopen those appeals. In May 2020, the Veteran testified before the undersigned Veterans Law Judge at a virtual hearing. The testimony from that hearing is new in that it was not of record at the time of the prior decision. It is material in that it addresses previously deficient criteria of service connection. As such, the claims are reopened. To this limited extent only, the claims are granted. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, certain chronic diseases, including arthritis and tinnitus, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Regardless of whether a disability is listed as "chronic" for presumptive purposes, a continuity of symptoms from the time of service is a factor to consider in assessing any service-connection claim. A disability may also be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. 6. Entitlement to service connection of rheumatoid arthritis The Veteran seeks service connection of rheumatoid arthritis. The Board finds the claim should be denied. Initially, the Board recognizes a present diagnosis of rheumatoid arthritis, as confirmed by the Veteran's VA treatment records, which he has testified affects primarily his hands. However, upon review of his claims file, the Board finds no evidence of any incident, illness or injury to which the present rheumatoid arthritis may be etiologically linked. He did not complain of any rheumatoid symptoms in service, despite reporting significant other issues throughout service. Upon separation he denied any joint pain or other rheumatoid-type issues. For his part, the Veteran has alleged that his rheumatoid arthritis is caused by heavy activity in the service such as marching and running. It is noted that he was diagnosed with an ankle strain in service. In his 2018 hearing before the undersigned, the Veteran testified that he was diagnosed with that condition approximately 12 years earlier, around 2006, which is approximately 26 years after separation from active duty. Despite this lack of in-service incident, the Veteran was afforded a rheumatology examination in connection with his initial claim in 2013. At that time he reported daily pain in all major joints, commencing several years earlier, with an official date of diagnosis in October 2011. Based on this testimony and evidence, the Board is satisfied that the Veteran's rheumatoid arthritis did not have onset until many years after separation from service, and there is no reported history of continuity from the time of service. After a careful examination of the Veteran and his medical history, the 2013 examiner concluded that the present rheumatoid arthritis is less likely than not related to his in-service ankle sprains and in-service activity because the nature of rheumatoid arthritis is that of a systemic autoimmune disease that attacks the joints and therefore would be unrelated to any single or multiple physical injuries such as a strain or tenonitis. The Board finds this opinion to be persuasive. It was given by a medical specialist in contemplation of the complete medical record and a physical examination. It applied the facts of this specific matter to known medical principles. The Board has reviewed the evidence, but found no medical evidence or opinions to contradict this opinion. The Board does acknowledge the Veteran's own firmly held belief that his condition is related to his in-service activity, but finds this opinion to be of limited probative value in adjudicating this claim. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his rheumatoid arthritis, especially in light of the VA physician's conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of rheumatoid arthritis loss in service. See id. In sum, the Board finds that the Veteran's rheumatoid arthritis was not incurred in service and did not have onset until many years after service. It is not related to any incident of active service. As such, the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 7. Entitlement to service connection of degenerative disc disease of the lumbar spine The Veteran seeks service connection of a low back disability, diagnosed as degenerative disc disease of the lumbar spine. The Board finds that the claim should be denied. Initially, the Board does recognize a present diagnosis of degenerative disc disease throughout the lumbar spine, as diagnosed in January 2012. At that time he was noted to have significant stenosis throughout the lumbar spine with disc bulges noted at L3-4 and L4-5. No focal lesions were noted. Bilateral foraminal stenosis was worse at L5-S-1. His VA treatment records generally report "routine" degenerative disc disease. For his part, the Veteran asserts his condition first began during active service when he fell down a hill while wearing a backpack and, per his testimony before the undersigned, dislocated his back and causing a hernia. He asserts that he was told it was just a bruise while seeking medical treatment. He states that his condition began during service with continuity to the present. The Board has carefully reviewed the Veteran's medical history, to include his service treatment records and military personal records. It finds no evidence of any such incident during active service. There are no complaints of a low back injury or symptoms. Upon separation from service, the Veteran did not report any low back pain and no low back pathology was found on examination. The Board does recognize that the Veteran is competent to report observable symptoms such as back pain. However, once basic competency to provide that evidence is met, the Board must assess the credibility of this evidence. In this case, the Veteran did not report or seek treatment for low back symptoms until many years after active service. Despite his present testimony of significant pain following a significant injury in service, there is no evidence that he ever suffered such an injury or sought treatment. His service treatment records, on the other hand, are voluminous and record multiple other complaints throughout service for myriad conditions. Had the Veteran actually injured his back and/or caused a hernia, as he has alleged in his testimony, and experienced ongoing repercussions of that injury, it would expected that it would be of record. It is not. Given this lack of supporting medical evidence, plus the Veteran's self-interest in the outcome of the claim, as well as the fact that the present medical evidence finds his condition to be routine, age related disc disease, the Board finds that the Veteran's testimony about onset during service with continuity to the present is less than credible for purposes of adjudicating this appeal. See Caluza v. Brown, 7 Vet. App. 498 (1995) (giving factors to consider in assessing credibility of lay evidence, to include facial plausibility, internal consistency, consistency with other evidence, self-interest, bias, bad character, malingering, lay statements made during medical treatment, and timing of the creation of evidence). The Board further notes that there is no evidence in the record to establish a diagnosis of "arthritis" during service or within one year of separation from service. The earliest evidence of an actual diagnosis is in 2012 32 years after separation from active duty. Even presuming the Veteran's statements about symptoms during and from the time of service were credible, which the Board has established they are not, there is no proof of any diagnosis of arthritis in the intervening years between separation and the actual medical diagnosis, the Veteran, as a lay person, is not competent to provide such a diagnosis. Layno v. Brown, 6 Vet. App. 465, 471 (1994). The Board notes that the Veteran has not been provided a VA examination in connection with his claim. VA's duty to assist only requires it provide such an examination when the evidence suggests an in-service incident, illness or injury to which the present disability may be etiologically linked. 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, as the evidence does not establish an in-service incident or injury, VA's is not obligated to provide such an examination. The Board has reviewed the Veteran's claims file but finds no medical opinion or evidence linking the present condition to any incident of active service. The Board does recognize the Veteran's own assertions that his condition is related to active service, but finds this of minimal probative value. Again, the Board notes that while lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his degenerative disc disease, especially in light of the fact that the evidence fails to demonstrate the onset of any low back symptoms or that the Veteran ever suffered a low back injury or incident in service. See id. In sum, the Board finds that the Veteran's present low back disability, to the extent that it falls under the diagnostic umbrella of "arthritis," did not have onset during active service or within one year of separation from active service. He did not suffer an in-service incident or injury to his low back, and there is no competent and credible evidence of record linking that condition to any incident of active service. As such, the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 8. Entitlement to service connection of a hernia The Veteran has filed a claim of service connection of a hernia. The Board finds that the claim should be denied. The Board has carefully reviewed the evidence of record and finds no evidence of any present diagnosis of a hernia. In his hearing before the undersigned Veterans Law Judge, the Veteran testified to pain in his groin area. However, he has not sought treatment for a hernia, and various diagnostic studies throughout the appeal period have not found any evidence of a hernia. Most recently, a November 2016 VA treatment record pertaining to his service-connected epididymitis with hydrocele found chronic scrotal and groin pain related to that condition, but no evidence of any herniated bowel loops in the right or left inguinal canals. The Board has also reviewed the Veteran's service treatment records and finds no evidence of any hernia or injury which could cause such a condition. Indeed, in August 1979, while complaining of right sided groin pain, and ultimately diagnosed with epididymitis, a hernia was explicitly ruled out as a diagnosis. Upon separation he did not report any hernia or hernia-related symptoms. The Veteran has testified that he sustained a hernia in the same incident which injured his low back in service, but as the Board has addressed above, the Board does not find the testimony credible to establish that such an incident ever occurred, particularly an incident resulting in both a low back injury and hernia. See Caluza v. Brown, 7 Vet. App. 498 (1995). The Board notes that the Veteran has not been afforded a VA examination in connection with this claim. Absent evidence of a presently diagnosed hernia, and/or any evidence of an in-service incident, illness or injury to which it or any possible symptoms of a hernia may be etiologically linked, the duty to assist does not require an examination in this matter. 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board does acknowledge the Veteran's own convictions related to his claim, but finds them of limited value. In this matter, the Veteran is a lay person and thus not competent to diagnose a present hernia, particularly given the competent medical evidence ruling out such an injury. Layno v. Brown, 6 Vet. App. 465, 471 (1994). Neither is he competent to opine on the etiology of such a condition, particularly given the lack of evidence of any in-service incurrence of a hernia and the lack of any evidence that the Veteran has ever sustained a hernia. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) In sum, the Board finds that the Veteran does not have a present hernia condition, and did not suffer an in-service incident or injury to which any such condition could be etiologically linked if it existed. As such, the claim is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 9. Entitlement to service connection of bilateral flatfoot The Veteran seeks service connection of bilateral flatfoot. The Board finds that the claim should be granted. Initially, the Board recognizes a present diagnosis of bilateral flatfoot. A review of his service treatment records includes complaints of pain and discomfort in his feet. To date, the Veteran's claim has been denied because his service treatment records failed to explicitly diagnose flat foot during service, despite his seeking treatment for foot pain. However, in June 2015, the Veteran was afforded a VA examination in connection with his claim. The examiner reviewed the Veteran's medical history and conducted an examination. He then concluded that the Veteran's bilateral flat foot was first incurred in 1979, during active service. Specifically, the examiner noted the presence of flat feet, hallux valgus and bunions from wearing heavy combat boots and running/marching in service. He noted continuity of symptoms from the time of service. For his part the Veteran has also testified as to the onset of symptoms in service with continuity to the present. Affording the Veteran the benefit of the doubt, the Board will find that his bilateral flatfoot had onset during active service, with continuity to the present. Notably, there is no medical evidence or opinion of record which explicitly contradicts the conclusion of the 2015 VA examiner. As such, the evidence is at least in equipoise as to when the Veteran's claimed condition had onset; when the evidence is in equipoise, the claimant prevails. Therefore, the claim is granted. 10. Entitlement to service connection of tinnitus The Veteran seeks service connection of tinnitus. The Board finds that the claim should be granted. The Veteran has a present diagnosis of tinnitus, which VA has conceded, and is confirmed by the Veteran's testimony before the undersigned. During his hearing, he asserted that he first experienced tinnitus during active service while firing weapons, with symptoms continuing to the present. The Court of Appeals for Veterans Claims (Court) has held that a Veteran is competent to testify to in-service acoustic trauma, in-service symptoms of tinnitus, and post-service continuous symptoms of tinnitus "because ringing in the ears is capable of lay observation." Charles v. Principi, 16 Vet. App. 370, 374 (2002). While the Board does acknowledge that the Veteran did not complain of hearing loss or tinnitus during active service, he is competent to report those symptoms, and the Board does not find adequate evidence to find his competent statements less than credible for purposes of adjudicating this specific claim. Ultimately, when weighing the evidence, the Veteran is competent to diagnose his own tinnitus, and he is also competent to report the date of onset during service, and continuity of symptoms from that time. Therefore, affording the Veteran the complete benefit of the doubt, service connection of tinnitus is granted. REASONS FOR REMAND 1. Entitlement to service connection of a headache disorder is remanded. The Veteran seeks service connection of a headache disorder, which he asserts began during service due to stress during boot camp, with continuity to the present. Although he did not seek treatment for headaches explicitly during service, he did seek treatment for other stress-related issues such as depression. Additionally, in his hearing before the undersigned, the Veteran testified that the pain from his various service-connected conditions aggravates his headache disorder, resulting in increased symptoms. To the extent that this raises the possibility of secondary service connection, and examination should be conducted which assesses the Veteran's claim. 2. Entitlement to service connection of an acquired psychiatric disorder, to include alcohol abuse disorder 3. Entitlement to service connection of an acquired psychiatric disorder, to include depression and anxiety The Veteran claims service connection of an acquired psychiatric disability, which he asserts had onset during active service. Although an examination was conducted in 2013, which opined against a link to active service, the Board finds it inadequate to fully assess the claim for several reasons. Initially, the Board notes that the opinion given relies on the premise that the Veteran did not seek ongoing treatment for depression during active service, but does not discuss his reports of fluctuating symptoms from the time of service. It also noted inconsistencies in the record as to when the Veteran began drinking during service, and does not discuss the Veteran's claim that he used alcohol to dull his symptoms, with his depression returning after he stopped drinking in 2010. Additionally, in his hearing, the Veteran asserted that his in-service epididymitis with hydrocele was an impetus for his depression in service, and that the pain from his condition, as well as his other service-connected conditions have recently led to increased feelings of depression and despair. There is no opinion of record addressing any etiological link to his other service-connected disabilities either on a direct or secondary basis. As such, a new examination should be obtained which fully assesses the claim. 4. Entitlement to an initial rating in excess of 10 percent for a left ankle strain is remanded. The Veteran's left ankle was most recently evaluated in January 2016, nearly six years ago, at which time he was found to have full range of motion in the joint. In his hearing before the undersigned, he testified to increased symptoms now resulting in complete immobility of the ankle. As the Veteran has asserted that his condition has worsened since the time of his prior examination, the Board will remand this appeal so that a new examination may be conducted. 5. Entitlement to an initial compensable rating on an extraschedular basis for epididymitis is remanded. As discussed above, the Board has found that the schedular criteria which apply to the Veteran's epididymitis with hydrocele do not support a compensable rating throughout the appeal period. While the Ratings Schedule is designed to be robust and adaptive, there will be occasions where the ratings provisions do not adequately describe and compensate a particular disability. Consideration of referral for extraschedular rating is required in a disability rating case. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). The Board is precluded, however, from assigning an extraschedular rating in the first instance. Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). Accordingly, a procedure exists to assign extraschedular ratings. Under the holding in Thun, a three part analysis is given to determine whether such referral is warranted. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In this matter, the Board is satisfied that the symptoms, as described by the Veteran and the various examiners of record are not fully contemplated by the rating schedule. As discussed above, the schedule requires rating based on urinary tract infection, however, the Veteran does not suffer from chronic or even frequent urinary tract infections, but rather painful swelling of the testes and interference with movement. As such, the first criteria of the Thun analysis is met. Next, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Generally, the "governing norms" described as a disability picture that has related factors such as marked interference with employment or frequent periods of hospitalization. See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Again, the Board recognizes that the Veteran has testified that his condition frequently precludes engagement in activities of daily living, as well as employment due to frequent pain and significant swelling such that ambulation may be hindered. This was confirmed by a 2018 private examiner who found significant interference with employment. As such, the second criteria of the Thun analysis is also met. Finally, if the rating schedule is inadequate to evaluate a Veteran's disability picture, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The Board remands when the first two prongs are satisfied. The Under Secretary then determines whether an extraschedular rating is warranted. If so, one is simply assigned. If not, the Board may review the extraschedular determination and grant if warranted. Anderson v. Shinseki, 22 Vet. App. 423 (2009). In this case, it is clear that no specific rating criteria exist which address the specific symptoms and residuals of the Veteran's epididymitis with hydrocele, and the evidence at least suggests that his condition interfered with his ability to work and engage in the activities of daily living. As such, the Board will remand the question of an extraschedular compensable rating for his condition to the Director of the Compensation and Pension Service for extraschedular consideration in the first instance. 6. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Because the outcome of the increased rating claim for epididymitis with hydrocele, as well as any ratings assigned for bilateral flatfoot and tinnitus may directly impact the Veteran's schedular entitlement to TDIU, the Board must remand this issue as intertwined with those claims. The matters are REMANDED for the following action: 1. Invite the Veteran to submit any additional evidence in support of his appeals. 2. Schedule the Veteran for a VA examination for his claimed headache disorder. The examiner must review the claims file. Should the examiner confirm a diagnosed headache disability, as documented in his present treatment records, the examiner should take a medical history from the Veteran and give a date of onset of the condition. The examiner should then state the following: Did the disability have onset during active service with continuity to the present? Is it at least as likely as not that his headache disability is related to any incident of active service, to include in-service psychological stress? If not directly incurred in or related to active service, is it at least as likely as not that the Veteran's present headache disorder is either (a) caused by, or (b) aggravated by his various service-connected disabilities, to include his epididymitis, left ankle, bilateral flatfoot, or tinnitus? In answering this question, the examiner should be careful to address both causation and aggravation. A rationale should be provided for all opinions given. 3. Schedule the Veteran for a VA examination for his claimed psychiatric disability. The examiner must review the claims file. The examiner is requested to provide a diagnosis which may specifically address the Veteran's variously claimed symptoms to include anxiety, depression and alcohol use disorder. For each diagnosed condition, the examiner is requested to answer the following: Is the disability at least as likely as not related to service, including his 1980 treatment for severe depression, or his in-service diagnoses with epididymitis with hydrocele? Is the disability at least as likely as not proximately due to and/or aggravated by a service-connected disability, to include his epididymitis, left ankle, bilateral flatfoot, or tinnitus? In answering this question, the examiner should be careful to address both causation and aggravation. A rationale should be provided for all opinions given. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left ankle strain. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner should test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner should also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. 5. Forward the Veteran's claims file to the Director of the Compensation and Pension Service for consideration of an extraschedular rating in the first instance for service-connected epididymitis with hydrocele. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Pryce, Counsel