BVA9512421 
DOCKET NO.  91-54 529     )       DATE
          )
          )

On appeal from the decision of the
Department of Veterans Affairs Regional Office in Jackson,
Mississippi

THE ISSUES

1.  Entitlement to service connection for a skin disorder of
the elbows, hands, and feet, secondary to exposure to Agent
Orange.

2.  Entitlement to service connection for a skin disorder of
the elbows, hands, and feet.

3.  Entitlement to service connection for bilateral hearing
loss.

4.  Entitlement to service connection for a right hip
disorder secondary to the veteran’s service-connected left
knee condition.

5.  Entitlement to service connection for post-traumatic
stress disorder (PTSD).

6.  Entitlement to an increased rating for the residuals of a
right ankle injury, currently evaluated as 10 percent
disabling.

7.  Entitlement to a separate evaluation for retained
metallic foreign bodies of the right foot.

8.  Entitlement to an effective date earlier than May 2,
1990, for the granting of a 10 percent evaluation for the
residuals of a right ankle injury.

ATTORNEY FOR THE BOARD

Patrick J. Costello, Associate Counsel

INTRODUCTION

The veteran had active military service from December 1968 to
July 25, 1970.

This matter came before the Board of Veterans' Appeals
(hereinafter the Board) on appeal from a July 1990 rating
decision of the Department of Veterans Affairs (VA) Regional
Office (RO), in Jackson, Mississippi, that denied service
connection for a skin condition of the elbow, hands, and
feet, and confirmed a noncompensable evaluation for a right
ankle injury.  Upon reviewing the claims folder, the Board
then determined that additional medical information was
needed prior to the issuance of a final decision.  Hence, the
claim was remanded in April 1991.

Through a Rating Decision of August 1991, the RO increased
the veteran’s noncompensable right ankle evaluation to 10
percent.  The RO returned the case to the Board.
Notwithstanding the Board’s initial remand action, the Board
determined that, during the appellate process, the veteran
had voiced disagreement with the effective date of the 10
percent evaluation for a right ankle injury.  See VA Form 21-
6796, Rating Decision, August 22, 1991.  Since this issue had
not been fully developed by the RO, the Board concluded that
the claim should be remanded to the RO.  The Board thus
remanded the case in May 1993.

It was also decided that the issues of service connection for
a right hip disability secondary to a service-connected left
knee condition and whether new and material evidence had been
presented to reopen a claim for entitlement to service
connection for PTSD should be further developed by the RO and
subsequently the Board.  Additionally, the Board concluded
that the veteran had noted his disagreement with the rating
action of August 1991 that denied service connection for a
bilateral hearing loss.  Because this issue was also not
fully developed, the RO was instructed to further develop
this issue.  Finally, the Board, in its remand, instructed
the RO to inform the veteran of his rights concerning his
contentions that he should receive a separate disability
rating for retained foreign objects in his right foot.

Upon completion of the requested development, the RO returned
the claims folder to the Board for final appellate
consideration.  In addition to the above discussed issues,
the veteran’s appeal of his claim for entitlement to service
connection for a skin condition secondary to exposure to
Agent Orange was forwarded to the Board for consideration.
This is the result of a Rating Decision of April 1994 by the
RO that applied the newly established rules and regulations
regarding dioxins.  Thus, eight issues are now before the
Board, and each is ready for final disposition.

CONTENTIONS OF APPELLANT ON APPEAL

The veteran maintains that he should receive a higher
disability rating for the residuals of a right ankle injury.
He states that the injury restricts his movement, and causes
him pain and discomfort.  Additionally, he avers that the RO
should have assigned an effective date earlier than May 2,
1990, when it granted a 10 percent disability evaluation for
the disorder.

The veteran further contends that he should be service-
connected for a skin condition, for PTSD, and for bilateral
hearing loss.  He claims that all three conditions are the
result of his military service that includes a tour in
Vietnam.  Finally, because of his service-connected left knee
condition, the veteran contends that he now suffers from a
right hip disorder that causes him pain, limitation of
movement, and restricts his ability to obtain gainful
employment.  He therefore requests VA benefits for his hip
disorder and a separate disability rating for his right foot
condition.

DECISION OF THE BOARD

The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991), has reviewed and considered all of the
evidence and material of record in the veteran's claims file.
Based on its review of the relevant evidence in this matter,
and for the following reasons and bases, it is the decision
of the Board that the issues of service connection for a skin
disorder of the elbows, hands, and feet secondary to exposure
to Agent Orange, and for a right hip condition, are not well-
grounded.  Furthermore, it is the decision of the Board that
the preponderance of the evidence is against the veteran’s
claim for entitlement to service connection for a skin
condition of the elbows, hands, and feet and PTSD.  We do
however believe that the evidence supports his claim for
entitlement to service connection for bilateral hearing loss.

It is also the decision of the Board that the preponderance
of the evidence is against the veteran’s claim for an
increased rating for the residuals of a right ankle injury,
currently evaluated as 10 percent disabling.  Furthermore, we
conclude that the evidence does not support the veteran’s
petition for entitlement to a separate evaluation for
retained metallic foreign bodies of the right foot.  Finally,
it is our conclusion that the preponderance of the evidence
is against the granting of an effective date earlier than May
2, 1990, for the granting of a 10 percent evaluation for the
residuals of a right ankle injury.

FINDINGS OF FACT

1.  All relevant evidence necessary for an equitable
disposition of the veteran's appeal has been obtained by the
agency of original jurisdiction.

2.  The veteran had active military service in the Republic
of South Vietnam during the Vietnam Era.

3.  Tinea pedis, keratosis pilaris, and deyshidrori [sic] are
not recognized by the VA as etiologically related to exposure
to chemical dioxins used in Southeast Asia during the Vietnam
Era.

4.  There is no credible evidence proffered that tinea pedis,
keratosis pilaris, and deyshidrori [sic] were caused by
exposure to Agent Orange or any other chemical dioxins.

5.  The service medical records are negative for any findings
of a right hip disability.

6.  The veteran currently suffers from degenerative arthritis
of the right hip.

7.  Post-service medical records are negative for any
etiological relationship between the hip condition and his
service-connected disabilities.

8.  While in service, the veteran was diagnosed and treated
for a possible sebaceous cyst on his neck, acne of the face
and neck with secondary lymphadenitis, and pseudofolliculitis
barbae with submental adenopathy.  He was not treated for a
chronic skin condition of the elbows, hands, and feet while
in service.

9.  In 1990, the veteran was diagnosed as suffering from an
acute and transitory dermatological condition of the hands
and elbows.  On his most recent VA medical examination in
1993, the veteran has been diagnosed as suffering only from
tinea pedis.  No dermatological condition or abnormality was
found of the elbows or hands.

10.  The veteran's pre-enlistment physical shows that he was
suffering from right ear hearing loss in the 1000 hertz
range, and bilateral hearing loss in the 500 and 4000 hertz
range, upon his entrance onto active duty.

11.  Service medical records are negative for any medical
treatment, findings, or diagnosis of a bilateral hearing
loss.

12.  A whispered spoken voice test, conducted at the end of
the veteran’s tour of duty, provided results within normal
limits.

13.  A VA audiological examination conducted shortly after
the veteran’s discharge from active duty showed diminished
hearing in the 500, 1000, 2000, and 4000 hertz range.  Except
for the right ear at the 500 hertz range, all results were
greater than the results obtained upon his induction to
active duty.

14.  An audiological examination, conducted twenty-one years
after the veteran's discharge from service, shows bilateral
hearing loss.

15.  While in service, the veteran was not treated for any
type of psychological problems, diseases, or disorders.

16.  In Vietnam, the veteran earned a Combat Action Ribbon
(CAR).  This ribbon was awarded to individuals who had
actively participated in ground combat, been under enemy
fire, and performed satisfactorily while under said enemy
fire.

17.  The veteran has related many different accounts of his
tour in Vietnam.  These accounts have changed over the years
and the incidents related therein have been unverified.

18.  The veteran has been diagnosed as suffering from mild
PTSD.

19.  The residuals of the veteran’s right foot injury produce
some limitation of motion and pain.  However, nerve paralysis
and foot drop are not shown upon examination.

20.  Neither an exceptional nor unusual disability picture
has been presented so as to render impractical the
application of the regular schedular standards.

21.  The veteran is service-connected for the amputation of
the right little toe with retained metallic fragment bodies
and painful tender scar.

22.  The retained metallic fragment bodies do not restrict
the movement of the foot.  Muscle and nerve damage due to the
fragments are also not shown.

23.  Service connection was originally granted for a right
ankle injury in May 1971; a noncompensable evaluation was
assigned.

24.  Over the next nineteen years, the veteran repeatedly
petitioned to have this disability rating raised.  However,
because symptomatology indicative of a more severe condition
was not shown, the RO denied the veteran’s requests.  The
veteran was notified but did not appeal any of those
decisions.

25.  In 1990, the veteran claimed that his service-connected
right ankle condition was more debilitating than previously
rated and requested an increased rating.

26.  After undergoing a VA medical examination, and upon
reviewing the proffered records, the RO determined that the
veteran's ankle injury should be evaluated as 10 percent
disabling.  The effective date for this award was May 20,
1990 -- the date the claim was received at the RO.

CONCLUSIONS OF LAW

1.  The veteran has not submitted evidence of a well-grounded
claim for service connection for a skin disorder of the
elbows, hands, and feet, secondary to exposure to Agent
Orange.  38 U.S.C.A. §§ 1110, 5107(a), 7104 (West 1991); 38
C.F.R. §§ 3.102, 3.303; 3.307(a), 3.309(e) (1994).

2.  The claim for entitlement to service connection for a
right hip disorder is not well-grounded.  38 U.S.C.A.
§§ 1110, 5107(a) (West 1991); 38 C.F.R. §§ 3.303, 3.306
(1994).

3.  The veteran's acute and transitory skin condition of the
elbows, hands, and feet was not incurred in or aggravated by
active service.  38 U.S.C.A. §1110 (West 1991); 38 C.F.R.
§3.303 (1994).

4  Bilateral hearing loss was incurred in service.
38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303, 3.385
(1994).

5.  The veteran's PTSD was not incurred in or aggravated by
active service.  38 U.S.C.A. § 1110 (West 1991); 38 C.F.R.
§ 3.303 (1994).

6.  The criteria for an evaluation in excess of 10 percent
for the residuals of a right ankle injury have not been met.
38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R.
§§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, Part 4, Diagnostic Code
5271 (1994).

7.  The criteria for separate evaluations for a right foot
condition manifested by amputation of the right small toe
with painful and tender scar along with retained metallic
foreign bodies have not been met.  38 U.S.C.A. §§ 1155, 5107
(West 1991); Esteban v. Brown, 6 Vet.App. 259 (1994); 38
C.F.R. Part 4, §§ 4.14, 4.59, Diagnostic Codes 5217, 7804
(1994).

8.  The criteria for an effective date earlier than May 20,
1990, for a 10 percent schedular rating for a right ankle
injury, have not been met.  38 U.S.C.A. §§ 5107, 5110 (West
1991); 38 C.F.R. § 3.400(o) (1994).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I.  Service Connection

A.  Not-Well Grounded Claims

i.  Agent Orange Exposure

During this veteran's active duty military service, he served
in Vietnam and because of that service, he was awarded a
Vietnam Service Medal with One Device, a Vietnam Campaign
Medal with One Device, a Combat Action Ribbon, and a Republic
of Vietnam Medal Unit Citation with Gallantry Cross and Palm.
From his service in Southeast Asia, the veteran now claims
that he suffers from a skin condition of the elbows, hands,
and feet secondary to exposure to chemical dioxins.

Initially, one who submits a claim for benefits under a law
administered by the VA has the burden of submitting evidence
sufficient to justify a belief by a fair and impartial
individual that the claim is well-grounded.  38 U.S.C.A. §
5107 (West 1991).  Only when that initial burden has been met
does the duty of the Secretary to assist such a claimant in
developing the facts pertinent to the claim attach.  Id.  The
United States Court of Veterans Appeals (the Court) has
further defined a well-grounded claim as a ". . . plausible
claim, one which is meritorious on its own or capable of
substantiation."  Murphy v. Derwinski, 1 Vet.App. 78, 81
(1990).  Considering these criteria, we find that the veteran
has not met his statutory burden of submitting evidence of a
well-grounded claim for service connection for his claimed
skin condition of the elbows, hands, and feet, secondary to
exposure to Agent Orange.

A veteran who, during active military, naval, or air service,
served in the Republic of Vietnam during the Vietnam era,
shall be presumed to have been exposed during such service to
a herbicide agent, unless there is affirmative evidence to
establish that the veteran was not exposed to any such agent
during that service.  38 C.F.R. § 3.307(a) (1994).  If a
veteran was exposed to a herbicide agent during active
military, naval, or air service, the following diseases shall
be service-connected, if the requirements of 38 C.F.R.
§ 3.307(a) (1994) are met, even if there is no record of such
disease during service:  chloracne or other acneform diseases
consistent with chloracne, Hodgkin's disease, multiple
myeloma, non-Hodgkin's lymphoma, porphyria cutanea tarda,
respiratory cancers, and soft-tissue sarcomas.  38 C.F.R.
§ 3.309(e) (1994).  However, if the rebuttable presumptions
of 38 C.F.R. § 3.307(d) (1994) are also not satisfied, then
the veteran's claim shall fail.  The Secretary of the
Department of Veterans Affairs has determined that a
presumption of service connection based on exposure to
herbicides used in the Republic of Vietnam during the Vietnam
era is not warranted for any condition for which the
Secretary has not specifically determined a presumption of
service connection is warranted.  See Notice, 59 Fed.Reg. 341
(1994).

Here, the veteran avers that he suffers from a skin condition
of the elbows, hands, and feet secondary to exposure to Agent
Orange.  He has been most recently diagnosed as suffering
from tinea pedis.  General Medical Examination, July 6, 1993.
He has also suffered from keratosis pilaris of the elbows and
forearm, and deyshidrori [sic] of the hands.  SF 508,
Progress Notes, June 15, 1990.  However, there is no evidence
of record, other than the veteran's allegations, that these
skin disorders were caused by exposure to dioxins.  The
Secretary has not specifically determined that a presumption
of service connection for these skin conditions is warranted
for Agent Orange exposed veterans, and, thus, such a
presumption is not warranted.

We would additionally add that the only support for the
veteran's claim that these skin conditions resulted from
Agent Orange exposure are his statements that this is the
case.  The Court has said that claimants unversed in medicine
are not competent to make medical determinations.  In other
words, since the veteran has had no medical training, his
statement that Agent Orange caused his disability carries no
weight.  See Espiritu v. Derwinski, 2 Vet.App. 492 (1992).
See also Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990) (Where
the determinative issue involves medical causation or a
medical diagnosis, competent medical evidence to the effect
that claim is "plausible" or "possible" is required.).
Therefore, we find that the veteran has failed to meet his
initial burden of producing evidence of a well-grounded claim
concerning the issue of entitlement to service connection for
a skin disorder of the elbows, hands, and feet secondary to
Agent Orange exposure.

In two recent decisions, Grottveit v. Brown, 5 Vet.App. 92
(1993), and Grivois v. Brown, 6 Vet.App. 136 (1994), the
Court has held that claims for service connection denied on
the merits by the Board and, preceding the Board's decisions,
by the Regional Office, were not well-grounded, and that "the
[Board] and the Regional Office erred in not so deciding the
claim."  Grottveit, at 92.

The governing law, 38 U.S.C.A. § 5107(a) (West 1991),

[R]eflects a policy that implausible
claims should not consume the limited
resources of the VA and force into even
greater backlog and delay those claims
which - as well-grounded - require
adjudication. . . Attentiveness to this
threshold issue is, by law, not only for
the Board but for the initial
adjudicators, for it is their duty to
avoid adjudicating implausible claims at
the expense of delaying well-grounded
ones.

Grivois, 6 Vet.App. at 139.

The Court expressed its concern that a decision on the
merits, if deemed final, could constitute an unwarranted
impediment to the appellant should he seek to reopen the
claim because new and material evidence would be required to
reopen.  The Court deemed it appropriate, where the Board
denied on the merits a claim that was not well-grounded, to
"recognize the nullity of the prior decisions and allow
appellant to begin, if he can, on a clean slate."  Grottveit,
at 93; Grivois, 6 Vet.App. at 140.  In both cases, the Court
vacated the Board's decision and remanded with instructions
to vacate the decision of the RO.  Id.; Grivois, 6 Vet.App.
at 141.

In view of the clear direction given by the Court, it is
imperative that finality in accordance with 38 C.F.R. § 3.104
(1994), not attach to the rating decision of April 12, 1994,
as regards this claim.

ii.  Right Hip Disorder

The veteran has repeatedly claimed that because of his
service-connected disabilities, he has developed a right hip
disorder.  At various times, he has claimed that his right
hip condition is due to his service-connected left knee
disability, and at other times, he has just stated that his
hip condition is the result of his various leg and foot
disorders.

Based on the veteran’s most recent examination, the Board
acknowledges that the veteran currently suffers from
degenerative arthritis of the hip.  We further note that this
disability produces pain and limitation of motion.  However,
before we may discuss whether this hip disability is related
to the veteran’s service-connected disabilities, we must
determine whether he has presented a well-grounded claim.
Upon reviewing the evidence, it is our determination that he
has not done so.

Under 38 U.S.C.A. §§ 1110, 1131 (West 1991), compensation
will be provided if it is shown that the veteran suffers from
a disease or injury incurred in or aggravated by service.  In
addition, service connection may be granted for any disease
diagnosed after discharge, when all of the evidence including
that pertinent to service, establishes that the disease was
incurred in service.  38 C.F.R. § 3.303(d) (1994).  In
addition, per 38 C.F.R. § 3.310 (1994), a disability that is
proximately due to or the result of a service-connected
disease or injury shall be service-connected.  When service
connection is established for a secondary condition, the
secondary condition shall be considered as part of the
original condition.  Nevertheless, before service connection
may be decided, the initial question for resolution is
whether the veteran has submitted a well-grounded claim in
accordance with 38 U.S.C.A. § 5107 (West 1991), and Murphy v.
Derwinski, 1 Vet.App. 78 (1990).

Per 38 U.S.C.A. § 5107 (West 1991), and subsequently Tirpak
v. Derwinski, 2 Vet.App. 609 (1992), a well-grounded claim
requires more than just a mere allegation.  The appellant
must submit supporting evidence that would justify the belief
that the claim is plausible.  In this instance, the appellant
asserts that his right hip condition is the result of his
service-connected disabilities.  However, the record does not
contain any medical evidence corroborating the veteran’s
claim.  The veteran's service medical records do not
chronicle any diagnosis of or treatment for a hip condition
while he was in service.  Post-service medical evidence does
acknowledge that he suffers from degenerative arthritis of
the right hip, but none of the medical experts, between 1970
and the present, etiologically link the hip condition with
any other condition from which the veteran now suffers.  SF
513, Consultation Sheet, April 17, 1990.  Additionally,
radiological testing suggests that the degenerative changes
may be secondary to aseptic necrosis or trauma unrelated to
the veteran’s other conditions.  See Radiologic Consultation
Request/Report, July 31, 1990; Radiology Report, August 1,
1993.  Again while the post-service medical records do show
various treatments for said condition, they do not attribute
the condition to the veteran's service.

Nevertheless, the veteran asserts that somehow his right hip
condition is related to his other disabilities.  It must be
stressed that the Board has no doubt that the veteran suffers
from pain and discomfort, along with reduced movement, as a
result of the degenerative arthritis of the hip.  However,
despite the extent of pain and suffering endured by the
veteran, in order for a grant of service connection for the
claimed disability, the record must contain evidence
corroborating his claim.  In this instance, there are only
his statements in support of his claim.  Mere contentions of
the veteran, no matter how well-meaning, without supporting
evidence, do not constitute a well-grounded claim.  King v.
Brown, 5 Vet.App. 19 (1993).

Additionally, the veteran is not medically qualified to make
a determination that his hip condition is related to his
other disabilities. He has no medical training that would
qualify him as an expert; therefore, he may not be permitted
to make such a diagnosis and conclusion.  Espiritu v.
Derwinski, 2 Vet.App. 492, 494 (1992).  We find that the
absence of recent medical records or physicians' statements
showing an etiological link between hip and service-connected
disabilities outweighs his assertions that they are related.
Therefore, we find that this claim is not well-grounded.

In view of the clear direction given by the Court in Grivois
and Grottveit, and discussed above, it is imperative that
finality in accordance with 38 C.F.R. § 3.104 (1994), not
attach to the rating decision of May 14, 1990, as regards the
veteran’s claim for entitlement to service connection for a
right hip disorder.

B.  Well-Grounded Claims

In accordance with 38 U.S.C.A. § 5107 (West 1991), and Murphy
v. Derwinski, 1 Vet. App. 78 (1990), we find that the
appellant has presented a well-grounded claim.  In this
regard, while the veteran's service medical records are
negative for a discernible bilateral hearing loss and PTSD,
his current medical records do show pertinent complaints of
both conditions.  Moreover, with regards to the veteran’s
skin condition claim, the veteran’s service medical records
do show treatment for some type of skin condition while in
service.  In conjunction with this, his current medical
records also show various findings of skin conditions of the
hands, feet, and elbows.  Thus, the Board finds that the
veteran has presented a plausible claim which we may find
well-grounded.  Additionally, the facts relevant to this
appeal have been properly developed and the obligation of the
Department of Veterans Affairs (VA) to assist the veteran in
the development of his claim has been satisfied.  Id.

Under 38 U.S.C.A. §§ 1110, 1131 (West 1991), compensation
will be provided if it is shown that the veteran suffers from
a disease or injury incurred in or aggravated by service.  In
addition, service connection may be granted for any disease
diagnosed after discharge, when all of the evidence,
including that pertinent to service, establishes that the
disease was incurred in service.  38 C.F.R. § 3.303(d)
(1994).

i.  Skin Disorder of the Elbows, Hands, and Feet

Besides claiming that he has a skin disorder of the elbows,
hands, and feet secondary to Agent Orange, the veteran claims
that he should be granted service connection for a skin
disorder on a direct basis.  That is, he states that he had a
skin condition in service, he has a skin condition now, and
the two conditions are related to one another.

Prior to entrance into the Marine Corps, the veteran
underwent a physical examination in October 1968.  See SF 88,
Report of Medical Examination, October 8, 1968.  Three scars
were found on examination; however, no other skin defects,
disorders, or conditions were noted.  Two months later, in
December 1968, he underwent a spot physical to ensure that he
was still physically qualified to join the Marine Corps.
Again, no skin abnormalities were noted.

Then, while in service, the service medical records chronicle
that he was treated for a possible sebaceous cyst on his
neck, acne of the face and neck with secondary lymphadenitis,
and pseudofolliculitis barbae with submental adenopathy.
However, during the rest of the veteran’s military
enlistment, his service medical records are negative for any
type of chronic skin disorder of the elbows, hands, and feet.
On separation, a scar on the right side of the neck and
pseudofolliculitis barbarosae with submental adenopathy were
the only two noted skin conditions.  SF 88, Report of Medical
Examination, July 13, 1970.

Immediately following service, the veteran applied for a
variety of VA benefits and in support of his claim, he
introduced his VA outpatient treatment records.  A request
for service connection benefits for a skin condition of the
hands, feet, and elbows was not mentioned in the petition for
benefits.  Moreover, the VA medical records only showed a
diagnosis of acne of the face; no other chronic skin
condition of any other body part was noted.  The veteran then
underwent a VA Compensation and Pension Examination in
December 1970.  VA Form 2545, Report of Medical Examination
for Disability Evaluation, December 24, 1970.  We would note
that there were no findings of any type of skin condition of
the hands, feet, and elbows at that examination.

Twenty years later, the veteran submitted a formal claim for
benefits for a skin condition of the hands, feet, and elbows.
In response to his claim, he was scheduled for and underwent
a dermatological examination.  SF 508, Progress Notes, June
15, 1990.  Upon examination, the veteran was diagnosed as
having keratosis pilaris of one elbow and deyshidrori [sic]
of the hands.  His feet were clear of any skin condition.  In
October 1990, the veteran was seen again at the VA Medical
Center for an unrelated claim.  He was subjected to a
complete physical at which time the only skin condition found
was that of keratosis pilaris of the forearm.  VA Form 2545,
Report of Medical Examination for Disability Evaluation,
October 30, 1990.  Three years later, a physical examination
was conducted.  General Medical Examination, July 6, 1993.
Tinea pedis was the only skin condition found.

In determining whether service connection is warranted, the
VA must determine whether the evidence supports the claim or
is in relative equipoise, with the veteran prevailing in
either event, or whether the preponderance of the evidence is
against the claim, in which case service connection must be
denied.  38 U.S.C.A. § 5107 (West 1991); Gilbert v.
Derwinski, 1 Vet.App. 49 (1990).  While the veteran has
provided statements attesting to the chronicity of a chronic
skin condition of the hands, feet, and elbows, he has failed
to provide evidence that would corroborate his claim.
Furthermore, the veteran has unsuccessfully identified any
persistent pattern, since service, of a chronic,
nontransitory skin condition of the feet, elbows, and hands.
The evidence of record does not show post-service continuity
of complaints, findings, or diagnoses of a skin condition so
as to reasonably relate current complaints to a period of
service ending many years earlier.  Such chronicity ought to
be found if the individual was suffering from a remarkable
chronic dermatological condition of the elbows, hands, and
feet.

Since evidence has not been proffered showing that the
veteran's condition was present during service nor has
chronicity been established, the Board is of the opinion that
the veteran's condition may not be associated with his
military service in the Marine Corps.  Service connection for
a skin condition of the hands, feet, and elbows is denied.

ii.  Bilateral Hearing Loss

The veteran has requested that his current bilateral hearing
loss be associated with his military service.  As we have
stated previously, service connection may be granted through
the mechanisms provided by 38 U.S.C.A. §§ 1110, 1113(b) (West
1991) and 38 C.F.R. § 3.303 (1994). Service connection for
certain diseases such as sensorineural hearing loss may also
be granted if the disability is demonstrated to a degree of
10 percent disabling or more within one year following
service separation.  38 U.S.C.A. §§ 1101, 1112, 1113 (West
1991); 38 C.F.R. §§ 3.307, 3.309 (1994).

Notwithstanding the above, entitlement to service connection
for impaired hearing is subject to the additional
requirements of 38 C.F.R. § 3.385 (1994), which provide:

Service connection for impaired hearing
shall not be established when hearing
status meets pure tone and speech
recognition criteria.  Hearing status
shall not be considered service-connected
when the thresholds for the frequencies
of 500, 1000, 2000, 3000, and 4000 Hertz
are all less than 40 decibels; the
thresholds for at least three of these
frequencies are 25 decibels or less; and
the speech recognition scores using the
Maryland CNC Test are 94 percent or
better.

In other words, the provisions of 38 C.F.R. § 3.385 (1994)
indicate that a hearing loss disability exists if there is at
least one 40-decibel threshold at 500, 1,000, 2,000, or 4,000
Hertz; or a hearing loss disability exists if speech
recognition scores are less than 94 percent; or a hearing
loss disability exists if three of the frequencies (500,
1,000, 2,000, 3,000 or 4,000 Hertz) have thresholds greater
than 25 decibels.

Presumptive periods are not intended to limit service
connection to diseases so diagnosed when the evidence
warrants direct service connection.  38 C.F.R. § 3.303(d)
(1994).  To establish service connection for a hearing loss,
the veteran is not obligated to show that his hearing loss
was present during active military service.  The evidence of
record need only demonstrate a medical relationship between
the veteran's inservice exposure to loud noise and his
current disability.  Godfrey v. Derwinski, 2 Vet.App. 352
(1992).  Moreover, if the veteran had "normal" hearing upon
his discharge, but developed hearing loss measurably to the
criteria stated in 38 C.F.R. § 3.385 (1994), and if the
veteran can now establish a causal relationship between his
hearing loss and service, service connected benefits will be
granted.

The veteran took a pre-induction physical in October 1968.
This examination included an audiometric examination, the
results of which are listed below

HERTZ

500
1000
2000
3000
4000

RIGHT
0
+5
0
/
0

LEFT
0
+5
0
/
+5

A spot examination conducted two months later produced the
following results:

HERTZ

500
1000
2000
3000
4000

RIGHT
15
5
0
/
5

LEFT
10
0
0
/
5

These examinations show that the veteran had some type of
hearing loss [but his hearing was within normal limits] prior
to his entry onto active duty.  Two years later, at the time
of his discharge, he was given a whispered voice hearing
test.  See SF 88, Report of Medical Examination, July 13,
1970.  He was able to detect 15 out of 15 noises for both the
right and left ear.  The spoken voice test was not
administered.

Within five months of his discharge from service, the veteran
applied for VA benefits for the residuals of an ear
infection.  Although bilateral hearing loss was not one of
the conditions he requested compensation for, an audiological
examination was conducted.  VA Form 10-2364, Audiological
Examination, December 24, 1970.  On the authorized
audiological evaluation, pure tone thresholds, in decibels,
were as follows:

HERTZ

500
1000
2000
3000
4000

RIGHT
10
15
15
/
20

LEFT
15
10
20
/
30

Speech audiometry revealed speech recognition ability of 96
percent in the right ear and of 90 percent in the left ear.
This examination showed decreased hearing since 1968 in all
ranges of the left ear, and decreased hearing in the right
ear at the 1000, 2000, and 4000 hertz range.

Four years later, the veteran again underwent an audiological
examination.  VA Form 10-2364, Audiometric Examination,
September 24, 1974.  On the authorized audiological
evaluation, pure tone thresholds, in decibels, were as
follows:

HERTZ

500
1000
2000
3000
4000

RIGHT
5
15
15
/
10

LEFT
5
15
15
/
15

Speech audiometry revealed speech recognition ability of 94
percent in the right ear and of 94 percent in the left ear.
In comparison with the audiological examination conducted
four years previously, the veteran showed hearing improvement
in the right ear at 500 and 4000 hertz range and in the left
ear at 500, 2000, and 4000 hertz range.  The hearing in the
left ear at 1000 hertz was decreased and the remaining
readings were unchanged.

In April 1991, the veteran petitioned for an increased rating
for his “hearing condition”, i.e., his service-connected
tinnitus.  However, the RO assumed that the veteran was
applying for service connection for bilateral hearing loss
and denied his claim since a hearing loss condition was not
shown in service.  Letter of denial, September 17, 1991.
This was the first time that the RO formally issued a
decision concerning bilateral hearing loss.

Since that denial, the veteran submitted to an audiological
test on July 3, 1992.  Pure tone thresholds, in decibels,
were as follows

HERTZ

500
1000
2000
3000
4000

RIGHT
15
20
30
/
30

LEFT
20
25
40
/
40

Speech audiometry revealed speech recognition ability of 100
percent in the right ear and of 100 percent in the left ear.
Given these latest results, we may conclude that the evidence
presented clearly shows that the veteran currently suffers
from a bilateral hearing loss pursuant to 38 C.F.R. § 3.385
(1994).  Yet, this does not automatically mean that the
veteran’s hearing loss is related to his military service.

A veteran will be presumed in sound condition except for
defects noted when examined and accepted for service.  Clear
and unmistakable evidence that the disability, manifested in
service, existed before service will rebut the presumption.
38 U.S.C.A. §§ 1111, 1137 (West 1991).  The record is clear
when the veteran was examined upon entrance into the service,
hearing loss was present in the right ear at 1000 hertz, and
there was bilateral hearing loss in the 500 and 4000 hertz
ranges.  Therefore, the presumption of soundness on entry is
not applicable.  This lack of hearing was not considered
disqualifying and the veteran entered onto active duty.

A pre-existing injury or disease will be considered to have
been aggravated by active service, where there is an increase
in disability during such service, unless there is a specific
finding that the increase in disability is due to the natural
progression of the disease.  38 U.S.C.A. § 1153 (West 1991);
38 C.F.R. § 3.306(a) (1994).  The service medical records are
negative for any showing of increased hearing loss during
service.  Moreover, those records do not indicate that the
veteran ever complained of or was treated for any injuries to
the ear including noise trauma.  While the veteran did
undergo a hearing test upon his discharge, the hearing test
was a spoken, not audiometric examination.  The hearing was
within normal limits.

Because the veteran did not undergo an audiological
examination upon his release from active service, we are
unable to determine whether, at the time of his discharge,
his previously noted hearing impairments had become more
severe while in service.  Yet, per Ledford v. Derwinski, 3
Vet.App. 87, 89 (1992), the lack of audiometric scores upon
separation from service is not fatal to the claim.  This
means that while the veteran may not be able to prove via
audiological testing that his hearing diminished while in
service, he may be able to show such a loss through other
means.

We would further note that in Hensley v. Brown, 5 Vet.App.
155 (1993), the Court reported that 38 C.F.R. § 3.385, "does
not preclude service connection for a current hearing
disability where hearing was within normal limits on
audiometric testing at separation from service."  5 Vet.App.
at 159.  The Court explained that:

[W]hen audiometric test results at a
veteran's separation from service do not
meet the regulatory requirements for
establishing a "disability" at that time,
he or she may nevertheless establish
service connection for a current hearing
disability by submitting evidence that
the current disability is causally
related to service.

5 Vet.App. at 160.

As we have noted earlier, the veteran underwent a VA
audiological examination in December 1970.  This examination
showed not only some hearing impairment but that the
veteran’s hearing had decreased during the prior two years.
Under the one year presumption of 38 U.S.C.A. § 1112 (1994),
the veteran could have been considered for possible service
connection.  Yet, his hearing loss at that time was not
sufficiently severe enough to have qualified him VA benefits
under 38 C.F.R. § 3.385 (1994).

In determining whether service connection is warranted, the
VA must determine whether the evidence supports the claim or
is in relative equipoise, with the veteran prevailing in
either event, or whether the preponderance of the evidence is
against the claim, in which case service connection must be
denied.  38 U.S.C.A. § 5107 (West 1991); Gilbert v.
Derwinski, 1 Vet.App. 49 (1990).  The Board points out that
there is a lack of medical evidence that corroborates the
veteran's claim that his hearing loss increased in severity
during service.  Yet, there is the VA audiological
examination conducted shortly after his discharge that does
indicate that the veteran’s hearing had become worse sometime
during the previous two years.  But the claims folder does
contain a hearing test conducted four years after his initial
VA examination that shows improved hearing.

The question therefore becomes whether we may attribute this
worsening to his military service.  The claims file indicates
that during service the veteran was exposed to loud noises
such as small arms fire, exploding artillery shells, and
other types of explosions.  In light of the high noise levels
to which the veteran was exposed in service in the course of
his duties, as well as the evidence that some type of
bilateral hearing loss probably began in service or within
the presumptive period, we find that the record supports the
veteran's claim that his current bilateral hearing impairment
began in service.  Thus a grant of service connection for
bilateral hearing loss is warranted.  38 U.S.C.A. §§ 1110,
1131 (West 1991); 38 C.F.R. § 3.303(d), 3.385 (1994).

iii.  PTSD

This Vietnam Era veteran has, on four separate occasions,
requested that Board grant him service connection benefits
for PTSD.  In each of those instances, the Board has denied
his request.  The veteran now comes again before the Board
claiming that he does suffer from PTSD and that this disorder
is related to the “atrocities” he experienced while in
Vietnam as a U.S. Marine.

In reviewing this issue, we must make a determination as to
whether the veteran has presented a well-grounded claim.
Because this issue is essentially a new and material claim,
the standards for well-groundedness for new and material
claims applies.  "'New and material evidence' is, by its
nature, well-grounded, i.e., evidence that, if believed,
would provide a 'reasonable possibility' that the outcome
would be changed."  Gobber v. Derwinski, 2 Vet.App. 470, 472
(1992).  Thus, since the veteran has proffered medical
evidence not previously reviewed that raises the possibility
of a change in the outcome of the final decision, we, like
the RO, find that the veteran has presented a well-grounded
claim.  38 U.S.C.A. § 5107 (West 1991); Murphy v. Derwinski,
1 Vet.App. 78 (1990); Moray v. Brown, 5 Vet.App. 211 (1993).
The facts relevant to this appeal have been properly
developed and the obligation of the Department of Veterans
Affairs (VA) to assist the veteran in the development of
claim has been satisfied.  Id

Again, the tenets of 38 U.S.C.A. § 1110, 1131 (West 1991),
and 38 C.F.R. § 3.303 (1994) apply.  Additionally, in order
to establish service connection for PTSD, there must be
objective medical evidence showing a diagnosis of, or
symptomatology consistent with, the condition, and an
evidentiary link between the claimed inservice stressor and
the current PTSD symptomatology.  For the purposes of
establishing service connection, a stressor is an event
experienced by the veteran during active service that is
outside the range of normal human experience and that would
be markedly disturbing to almost anyone.  Examples of such
events are experiencing an immediate threat to one's life, or
witnessing another person being seriously injured or killed.
It is the distressing event, rather than the mere presence in
a "combat zone" that may constitute a valid stressor for the
purposes of supporting a diagnosis of PTSD.  See Zarycki v.
Brown, 6 Vet.App. 91, 99 (1993); Wood v. Derwinski, 1
Vet.App. 190, 193 (1991).

Additionally, VA Manual M21-1 outlines the specific
procedures required for the VA to follow in evaluating claims
for service connection based on PTSD.  Essentially, this
regulation requires evidence that the veteran served in the
area in which the stressful event was alleged to have
occurred and evidence to support the description of the
event.  If the claimed stressor is related to combat, in the
absence of information to the contrary, receipt of the Purple
Heart, Combat Infantryman Badge, Bronze Star, or other
similar citations is considered supportive evidence of
participation in a stressful episode.  Other types of
supportive evidence, such as plane crash, ship sinking,
explosion, rape or assault, duty on a burn ward or in a
graves registration unit may be accepted.  POW status is
conclusive evidence of an in-service stressor.

Relative to PTSD, if the evidence shows that the veteran was
engaged in combat with the enemy and the claimed stressor was
related to combat, no further development for evidence of a
stressor is necessary.  If the claimed stressor is not
related to combat with the enemy, a history of a stressor as
related by the veteran is, in itself, insufficient.  Service
records must support the assertion that the veteran was
subjected to a stressor of sufficient gravity to evoke the
symptoms in almost anyone.  Thus, the existence of a
recognizable stressor or accumulation of stressors must be
supported.  It is important that the stressor be described as
to its nature, severity, and date of occurrence.  Manual M21-
1, Part VI, para. 7.46(e),(f) (Dec. 21, 1992).

As we have said above, the veteran has repeatedly sought
service connection for PTSD, and on each occasion that his
claim has been before the Board, his petition has been
denied.  Board Decisions, May 6, 1985; November 20, 1986;
February 2, 1988; February 28, 1990.  The veteran then
petitioned to reopen his claim in 1991.  The veteran
underwent a psychiatric examination in July 1993 that
concluded that he was suffering from a “mild form of post-
traumatic stress disorder”.  VA Form 2507, Psychiatric
Examination, July 20, 1993.  The examination was forwarded to
the RO.  On the basis of that examination, the RO determined
that the veteran had submitted new and material evidence
sufficient to reopen his claim for entitlement to service
connection for PTSD.  However, having decided that new and
material evidence had been presented, the RO further ruled
that because the veteran’s “stressors” were unverified, the
diagnosis of PTSD could not be related to his military
service.  VA Form 21-6796, Rating Decision, April 12, 1994.
Hence, service connection for PTSD was denied.

Prior to this appeal, the RO denied the veteran’s claim for
PTSD in August 1990.  The veteran was informed of that
decision, but did not appeal.  This decision is a final
decision in accordance with 38 U.S.C.A. § 7103 (West 1991).
We further note that the Board has recently denied his claim
and that most recent decision is February 20, 1990.  The
veteran was notified of that decision but did not request
reconsideration.  Therefore, this decision then became final
per 38 U.S.C.A. § 7104 (West 1991).  Because the RO’s
decision was on the merits and it is more recent than the
Board’s decision also on the merits, we shall examine whether
new and material evidence has been presented since the RO’s
decision on the merits.  We would further add that although a
decision is final, the claim shall be reopened, and the
former disposition reviewed if new and material evidence is
secured or presented.  38 U.S.C.A. §§ 5108, 7104(b), 7105(c)
(West 1991).

When a veteran seeks to reopen a previously denied claim
based upon new evidence, a two-step analysis is required.
The first step is to determine if the evidence is new and
material; if so, the case is reopened and the merits of the
claim must be evaluated on the basis of all of the evidence,
both new and old.  Manio v. Derwinski, 1 Vet. App. 140, 145
(1991).  New and material evidence means evidence not
previously submitted to agency decision makers which bears
directly and substantially upon the specific matter under
consideration, which is neither cumulative nor redundant, and
which, by itself or in connection with evidence previously
assembled, is so significant that it must be considered in
order to fairly decide the merits of the claim.  38 C.F.R. §
3.156(a) (1994).  To justify a reopening on the basis of new
and material evidence, there must be a reasonable possibility
that the new evidence, when viewed in the context of all of
the evidence, both new and old, would change the outcome.
Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991). If new and
material evidence has not been submitted, the Board does not
need to address the merits of the claim.  Sanchez v.
Derwinski, 2 Vet. App. 330 (1992).  For the limited purpose
of determining whether to reopen a claim, the Board must
accept the new evidence as credible and entitled to full
weight.  Justus v. Principi, 3 Vet.App. 510 (1992).  This
presumption no longer attaches in the adjudication that
follows reopening.  Id.

As we have stated, the RO reopened the claim in accordance
with Colvin v. Derwinski, 1 Vet.App. 171 (1991); 38 C.F.R. §
3.156(a) (1994).  However, the RO found that, while the new
medical evidence opined that the veteran suffered from PTSD,
evidence was not presented which would verify a stressor
which would produce symptoms in most individuals.  Thus, a
change in the previous decision was not warranted.

Reviewing these newly presented pieces of evidence, it is
clear to the Board that they are new and material pieces of
evidence, in that they show that the veteran possibly suffers
from PTSD.  In order words, there is indeed a reasonable
possibility that this new evidence, in the context of all of
the evidence, might change the prior outcome.  Colvin v.
Derwinski, 1 Vet.App. 171, 174 (1991); 38 C.F.R. § 3.156(a)
(1994).

Prior to a de novo review of the evidence, the Board must
determine whether the veteran's claim should be remanded to
the RO for further development and adjudication.  The basis
for such a determination is whether the appellant would be
prejudiced by the lack of such development and adjudication
at the RO level. Bernard v. Brown, 4 Vet.App. 384, 394
(1993).

The record reveals that this case was reopened and then
denied on the merits of the claim.  It is clear that the
appellant has been fully apprised of all applicable laws and
regulations, and has been afforded ample opportunity to
present argument to the RO and the Board.  The appellant has,
in fact, been consistently thorough and specific in his
contentions.  We conclude that a de novo review of the
evidence and a decision on the merits will not prejudice the
claimant or violate VA's statutory duty to assist, based on
the history of this case.  38 U.S.C.A. § 5107(a)(West 1991);
O.G.C. Prec. 6-92 (March 6, 1992).

Having decided that the evidence is new and material, we now
consider whether the entire record permits a favorable
disposition of the ultimate issue of service connection.
That is, we must decide whether the veteran suffers from PTSD
resulting from stressors incurred while in service.  The
Board's function is to weigh and analyze the evidence; we
must also make determinations on the credibility of the
evidence.  38 U.S.C.A. § 5107(b) (West 1991); Sanden v.
Derwinski, 2 Vet.App. 97, 100 (1992).  Where the
preponderance of the evidence is for the veteran's claim or
the evidence for and against the claim is in equipoise, the
benefit sought is to be granted.  38 U.S.C.A. § 5107(b) (West
1991); Gilbert v. Derwinski, 1 Vet.App. 49 (1990).  We
conclude that the preponderance of the evidence does not
support his claim.

The veteran first started complaining about combat-related
intrusive thoughts in the summer of 1982.  When questioned at
the RO, while he mentioned combat, he remained elusive
concerning the specific events that were bothering him.  One
year later the veteran sought counseling for his recurring
thoughts of Vietnam and the reported stressors he experienced
there.  He submitted to repeated psychological testing
concerning the events of Vietnam and the psychological impact
these “stressors” were having on his everyday life.  A
diagnosis of PTSD was given but it was noted that the veteran
appeared to have prior knowledge of the testing procedure.
It was questionable as to whether he was truly suffering from
PTSD or providing the “correct” answers in order to obtain a
diagnosis of PTSD.  SF 509, Progress Notes, June 6, 1983.

Following this diagnosis, the veteran was subsequently
admitted to a VA facility for observation.  See VA Form 10-
1000, Hospital Summary, July 25, 1984.  While at the
hospital, three psychiatrists reviewed the veteran’s clinical
file, observed his behavior on the ward, spoke with him, and
then concluded that he was not suffering from PTSD.  The
psychiatrists reasoned that while he complained of
nightmares, nervousness, flashbacks, anxiety, and difficulty
in sleeping, he did not exhibit any of these symptoms while
on the ward.  Moreover, anxiety, hypervigilance, or any other
emotional problems were not observed.  In the end, the
examiners determined that the veteran did not have an actual
mental disorder; he did however possess narcissistic
personality traits.

Over the next four years, the veteran was seen repeatedly at
the VA hospital.  He continued to claim that he had recurring
thoughts of Vietnam but he admitted that he was also
depressed due to his home situation.  Medical Certificate,
October 26, 1985.  In 1987, a VA psychologist wrote the
Mississippi Employment Security Commission that the veteran
was suffering from PTSD symptoms.  Letter to Mississippi
Employment Security Commission, February 25, 1987.  The
psychologist concluded that these symptoms would interfere
with certain jobs he could perform.  However, while the
psychologist noted he met the criteria for a diagnosis of
PTSD, he could not assign him an actual diagnosis of PTSD.

During this period, the veteran twice appeared before a
Hearing Officer at the RO to proffer evidence in support of
his claim.  He maintained that:

(1) he had been shot at by the
enemy;

(2) he was subjected to booby traps;
and

(3) he saw people being killed.

In addition to his testimony, he was seen by a psychiatrist
for treatment in August 1988.  SF 509, Progress Notes, August
3, 1988.  At that time, he was diagnosed as suffering from an
adjustment disorder, not PTSD.

Then in 1990, the veteran was seen at the Medical Center for
the purpose of determining what, if any, type of psychiatric
disorder he had.  Psychiatric Examination, October 30, 1990.
The examiner specifically wrote that the veteran did “. . .
not satisfy the criteria for [a] diagnosis of PTSD”.  The
examiner additionally wrote:

It is noteworthy that he did not complain
of current dreams of combat, that he did
not describe current flashbacks of
combat, that he appears to relate well to
others, that his affect was appropriate,
that he described no decrease in
interest, that he described no increase
startle response.  He did not describe
guilt about surviving Vietnam.  He
exhibited no impairment of concentration
or memory.  He did not describe
situations that he avoided because they
resembled Vietnam. . . He may suffer for
dysthymic disorder.

In conjunction with this appeal, the veteran then underwent a
VA examination in October 1993 to learn whether he had PTSD.
The veteran provided a history that included removing mines
from roadways, performing various perimeter guard duty
functions, and being a wireman.  The veteran related some
aspects of service in Vietnam that he found stressful,
including seeing people die and being near exploding “booby
traps” and mines.  The examiner noted previous psychological
testing of the veteran that diagnosed him as suffering from
narcissistic personality traits, an anxiety disorder, and
PTSD.  While the veteran did not exhibit any overt anxiety
during his examination, and despite the varied previous
diagnoses given to the veteran along with his poor scoring on
various mental tests, the examiner concluded that essentially
the veteran was suffering from mild PTSD, as well as a
personality disorder not otherwise specified with passive
aggressive and narcissistic traits.

The veteran has referred to many alleged stressor events;
yet, he has been unable to provide much detail when relating
these events.  The veteran says that he was in an area where
there was repeated enemy fire.  Yet, it is a particularly
distressing event, rather than the mere presence in a "combat
zone" which may constitute a valid stressor for purposes of
supporting a diagnosis of PTSD.  See Zarycki v. Brown, 6
Vet.App. 91, 99 (1993).

The Court, in Zarycki, provided an analytical framework for
establishing the presence of a recognizable stressor, which
is an essential element in a diagnosis of PTSD.  Based on VA
regulations, including 38 C.F.R. § 3.304(f) (1993), the Court
noted that the first question that needed to be answered was
whether the veteran had "engaged in combat with the enemy."
If there is evidence that the veteran engaged in combat with
the enemy, such as recognized military citations or other
supportive evidence, and the claimed stressor is related to
such combat, the veteran's lay testimony regarding his
stressor must be accepted as conclusive as to their actual
occurrence and no further development for corroborative
evidence will be required, as long as the veteran's testimony
is considered "satisfactory."

Where, however, the VA determines that the veteran did not
engage in combat with the enemy, or that the claimed stressor
is not related to verified combat, the veteran's lay
testimony, by itself, will not be sufficient to establish the
occurrence of the alleged stressor.  Rather, there must be
service records or other information that corroborates the
veteran's testimony as to the occurrence of the stressor.

We would further note that the Board is not bound to accept
an uncorroborated account of stressors, nor is the Board
required to accept an unsubstantiated medical opinion that
alleged PTSD had its origin in service.  This is especially
true where there is considerable passage of time between the
putative stressful events recounted by the veteran and the
onset of claimed PTSD.  Wood v. Derwinski, 1 Vet.App. 190
(1991); Wilson v. Derwinski, 2 Vet.App. 614 (1992); Hayes v.
Brown, 5 Vet.App. 60 (1993); Swann v. Brown, 5 Vet.App. 229
(1993).

The evidence shows that the veteran was engaged in combat
with the enemy although his military occupational specialty
was that of wireman.  The proof of this engagement is the
awarding to the veteran a Combat Action Ribbon (CAR).  The
veteran was awarded the Combat Action Ribbon in November
1969.  NAVMC 118(9) (Rev. 6-65), Combat History - Expeditions
- Awards Record (1070), Awards.  A CAR is awarded to members
of the Marine Corps who have actively participated in ground
or surface combat.  The individual must have been under enemy
fire and his performance while under fire must have been
satisfactory.  Additionally, personnel assigned to areas
subjected to sustained mortar and artillery attacks and who
have actively participated in retaliatory or offensive
actions are eligible.  VA Monograph, A Guide to Awards and
Decorations, April 1984.

The veteran has alleged that he was involved in incidents in
service that he cites as stressors resulting in his alleged
PTSD.  Yet, none of these incidents could be verified, and
the veteran has remained vague with regard to such pertinent
facts as names, dates, and locations.  In conjunction with
this, the Board recognizes that the VA has a duty to assist
the veteran in obtaining additional information that may
benefit or support his claim.  See Wood v. Derwinski, 1
Vet.App. 190 (1991).  The RO has attempted to obtain
additional information from the veteran concerning his
claimed stressors.  However, the veteran never thoroughly
responded to the RO’s inquiries.  It appears that the veteran
has remained passively disinterested in providing assistance
and has not provided information that is essential in
obtaining the verifying evidence he alludes to.  See also
Gobber v. Derwinski, 2 Vet.App. 470 (1992); Olson v.
Principi, 3 Vet.App. 480 (1992).

With regard to diagnoses of PTSD, it is apparent that these
were made following a recitation by the veteran of his
alleged combat "stressors", which, as we have discussed, may
have resulted from engagement in combat with the enemy but
have not been verified.  Moreover, when the veteran initially
started to receive treatment by the VA, we note that even
after being provided with an unsubstantiated military history
by the veteran, the VA examiner did not indicate that the
veteran's mental problems could be identified solely as PTSD,
and based on the veteran's experiences while in Southeast
Asia.  Rather, the record indicates an impression that the
veteran suffered from narcissistic personality traits, a
dysthymic disorder, or an anxiety condition.

It is uncertain to what extent the impression that the
veteran meets the criteria for PTSD is based on the veteran's
own recitation of his alleged service history.  Where,
however, the VA determines that the veteran did not engage in
combat with the enemy, or that the veteran did engage in
combat with the enemy but the claimed stressor is not related
to such combat, the veteran's lay testimony, by itself, will
not be enough to establish the occurrence of the alleged
stressor.  Zarycki v. Brown, 6 Vet.App. 106 (1993).  We note
that during the veteran’s repeated interviews with various
psychiatrists, he often has not referred to any specific
service experiences; or, when he has, he has been extremely
vague in recounting those events.  Moreover, during these
sessions, the veteran has often changed his accounting of how
he lost his small toe, where he served and patrolled, the
duties he performed, and the types of enemy he engaged.  In
other words, he has been remarkably inconsistent with his
recounting of events including stressful situations he
encountered.

The Court has held, in West v. Brown, 7 Vet.App. 70 (1994),
in effect, that a psychiatric evaluation that is based on an
incomplete or questionable history is inadequate for rating
purposes and frustrates the efforts of judicial review.
Reviewing Zarycki and West together, it appears that in
approaching a claim for service connection for PTSD, the
question of the existence of an event claimed as a
recognizable stressor must be resolved by adjudicatory
personnel and, once such a stressor is established, whether
it is sufficient to give rise to PTSD is a medical
determination.  Thus, if an examiner renders a diagnosis of
PTSD that is not clearly based upon stressors in service
whose existence the adjudicators have accepted, the
examination would be inadequate for rating purposes.

In determining whether service connection is warranted, the
Board must determine whether the evidence supports the claim
or is in relative equipoise, with the veteran prevailing in
either event.  If however the preponderance of the evidence
is against the claim, service connection must be denied.  38
U.S.C.A. § 5107 (West 1991); Gilbert v. Derwinski, 1 Vet.App.
49 (1990).  In this case, a verifiable stressor to support a
diagnosis of PTSD has not been shown.  While we note that
PTSD has been diagnosed, the veteran has not provided
sufficiently detailed believable information relating to his
examples of stressors to allow for corroboration even though
his record indicates that he did engage the enemy in combat.
We find therefore that there is not sufficient evidence to
place the evidence in equipoise as to whether the veteran
suffers from PTSD related to his military service.  On the
basis of these findings and following a full review of the
record, the Board finds that the record before us does not
show that the veteran has PTSD related to his experiences in
Vietnam.  Consequently, service connection for PTSD is not
warranted.

II.  Increased Rating for a Right Ankle Condition

The veteran has been awarded a 10 percent disability rating
for the residuals of a right ankle injury under 38 C.F.R.
Part 4, Diagnostic Code 5271 (1994).  This disability award
is a result of a rating action of August 1991.  VA Form 21-
6796, Rating Decision, August 22, 1991.  The veteran has
disagreed with this evaluation and has asked for a higher
compensation amount.

In order to abide by the Court of Veteran's Appeals
directives stated in Murphy v. Derwinski, 1 Vet.App. 78
(1990), and thus 38 U.S.C.A. § 5107 (West 1991), the
appellant must present a well-grounded claim.  A well-
grounded claim for an increased rating requires a plausible
claim that a service-connected disability has increased in
severity since the prior rating.  Proscelle v. Derwinski, 2
Vet.App. 629 (1992).  To be well-grounded when filed, a claim
for an increased rating must necessarily assert that the
disability increased in severity before the date on which the
claim was filed.  Since the veteran has proffered medical
records that suggest that the disability may have increased
in severity, the veteran's claim is well-grounded.

Disability evaluations are based upon the average impairment
of earning capacity as determined by a schedule for rating
disabilities.  38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part
4 (1994).  Separate rating codes identify the various
disabilities.  38 C.F.R. Part 4 (1994).  In determining the
current level of impairment, the disability must be
considered in the context of the whole recorded history,
including service medical records.  38 C.F.R. §§ 4.2, 4.41
(1994).  An evaluation of the level of disability present
also includes consideration of the functional impairment of
the veteran's ability to engage in ordinary activities,
including employment, and the effect of pain on the
functional abilities.  38 C.F.R. §§ 4.10, 4.40, 4.45, and
4.59 (1994).

The veteran received service connection for his right ankle
injury in May 1971.  VA Form 21-6796, Rating Decision, May
19, 1971.  Between that time and until August 1991, the
disability was rated as noncompensable.  Then in 1990, the
veteran reopened his claim stating that the residuals of his
service-connected right ankle injury were more debilitating.
In response to his petition, the veteran was examined in June
1991.  See Orthopaedic Compensation and Pension Examination,
June 5, 1991.  At that examination, the physician noted the
following:

PHYSICAL EXAMINATION:  Station and gait:
He walks with a limp on the right. . .
Examination of the ankle reveals 5
degrees of dorsiflexion and 30 degrees of
plantar flexion.  There is no swelling of
the ankle, but he has complaints of
generalized subjective tenderness to
palpation.  No instability was noted.
There was good subtalar motion, although
he complains of pain on this portion of
the examination also.  He says he is
unable to toe walk secondary to the pain
underneath the toes.  It is noted from
pervious examination that he was able to
toe walk.  He was able to take no more
than one to two steps on the right heel
secondary to complaints of pain.  He was
noted on the last examination also to be
able to heel walk.  He demonstrated poor
ability to walk on the inner or outer
border of the right foot.

Three years later, in conjunction with this claim, the
veteran underwent another orthopaedic examination.  Joints
Examination, July 28, 1993.  Upon examination, the physician
found that the right ankle, and the reported limitations
thereof, were no different from the left ankle.  The VA
Physician's Guide, in sections 2.13 through 2.18, sets out
the requirements for an examination of a joint.  The general
provisions are set out in section 2.13, and the implementing
provisions are in section 2.14--2.18.  The general provisions
establish that the purpose of the examination is to find out
if there is present:  More or less than normal joint
movement, reduced motor power, rapid fatigue, incoordination,
impaired ability to execute skilled movement, pain on
movement, swelling deformity, or atrophy.  Instability of
station, disturbance of locomotion or balance, interference
with sitting, standing, working, and weight-bearing functions
are listed as related concerns.

In this instance, no notations were made concerning the
limitations of the ankle.  The ankle did not show swelling
and the muscles surrounding the right ankle were not
atrophied.  Additionally, the records are negative for any
symptomatology indicative of right ankle nerve damage.
Radiographic studies of the right ankle in both 1991 and 1993
reported that there was no significant bone or joint injury
or other abnormality.  Throughout the medical records, there
has never been an indication that the veteran suffers from
full or even partial footdrop.

Disability evaluations are based upon a comparison of
clinical findings with the applicable schedular criteria.  38
U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1994).  The
right ankle disorder can be rated based either on its
limitation of motion under 38 C.F.R. Part 4, Diagnostic Code
5271 (1994), or the degree of neurological pathology present
under 38 C.F.R. Part 4, Diagnostic Code 8521 (1994).
However, the evaluation of the same disability under various
diagnoses is to be avoided.  See 38 C.F.R. § 4.14 (1994).

Per 38 C.F.R. Part 4, Diagnostic Code 5271 (1994), a 10
percent evaluation for a right ankle disability will be
deemed warranted when there is moderate limitation of motion.
A 20 percent evaluation requires marked limitation of motion.
The rate of compensation takes into account the pain,
weakness and other disability manifestations associated with
a limitation of motion.  For a rating higher than 20 percent,
ankylosis (bony fixation) of the ankle must be shown.  See 38
C.F.R. Part 4, Diagnostic Code 5271 (1994).  Diagnostic Code
8521 contemplates rating symptomatology generated by
paralysis of the common peroneal nerve.  38 C.F.R. Part 4,
Diagnostic Code 8521 (1994).  Under that code, a 40 percent
evaluation is warranted where there is paralysis indicating a
complete footdrop inclusive of slight droop of the first
phalanges of all toes, along with not being able to dorsiflex
the foot, extension (dorsal flexion) of proximal phalanges of
toes loss; abduction of foot loss, adduction weakened, and
with anesthesia covering the entire dorsum of the foot and
toes.  Severe incomplete paralysis warrants a 30 percent
evaluation.  Moderate incomplete paralysis warrants a 20
percent evaluation.  Mild incomplete paralysis warrants a 10
percent evaluation.

In the instant case, there has been no objective medical
evidence indicative of any neurological paralysis including
foot drop.  Therefore, an evaluation under 38 C.F.R. Part 4,
Diagnostic Code 8521 (1994) would, at this time, be
inappropriate.  Physical findings, although not consistent,
have indicated that the veteran suffers from some limitation
of range of motion.  Moreover, the Compensation and Pension
Examination physicians have implied that the veteran limps
because of this restriction of motion and that the veteran is
unable to ambulate for long distances because of the pain
produced by the ankle.  Under these circumstances, while the
ankle does cause some disability, the Board believes the
ankle does not display symptomatology indicative of a more
severe condition.  Thus, the veteran’s request for an
increased rating for this disability, currently rated as 10
percent disabling, is denied.

III.  Extraschedular Evaluation

Consideration has also been given to the potential
application of the extraschedular evaluation provisions of 38
C.F.R. § 3.321(b) (1994).  The evidence does not present such
an exceptional or unusual disability picture as to render
impractical the application of the regular schedular
standards.  Specifically, there has not been a demonstration
of marked interference with employment or frequent periods of
hospitalization so as to render impractical the application
of the regular schedular criteria.

IV.  Pyramiding

While in service, the veteran accidentally unloaded a M-16
round through his right foot.  Upon his release from active
duty, he applied for VA benefits for his right foot
condition.  The RO, in its May 1991 Rating Decision, granted
service connection and awarded him a noncompensable
evaluation.  VA Form 21-6796, Rating Decision, May 19, 1971.
It should be noted that he was granted service connection for
the amputation of the right little toe with retained foreign
bodies.  Since that decision, the RO has redefined this
disability as amputation of the right little toe with
retained foreign bodies and painful tender scar.  Because of
the painful tender scar, a 10 percent disability rating has
been assigned under 38 C.F.R. Part 4, Diagnostic Code 7804.
VA Form 21-6796, Rating Decision, May 18, 1981.  The veteran
has now come before the RO claiming that he should be
entitled to a separate evaluation for retained metallic
foreign bodies of the right foot.

In accordance with 38 U.S.C.A. § 5107 (West 1991), and Murphy
v. Derwinski, 1 Vet. App. 78 (1990), the appellant has
presented a well-grounded claim.  The facts relevant to this
appeal have been properly developed and the obligation of the
Department of Veterans Affairs (VA) to assist the veteran in
the development of his claim has been satisfied.  Id.  Per 38
U.S.C.A. § 1155 (West 1991), the VA will compensate a veteran
for reductions in earning capacity due to specific injuries.

The Court, in its decision in Brady v. Brown, 4 Vet.App. 203,
206 (1993), noted that the veteran could not be compensated
twice, or more, for symptomatology resulting from the same
disability.  The VA promulgated 38 C.F.R. § 4.14 (1994) in
response to Brady that specifies that the RO will avoid
pyramiding of claims.  This means that pyramiding shall be
avoided where it results in the evaluation of the same
symptoms and manifestations under different diagnoses.
Fanning v. Brown, 4 Vet.App. 229 (1993); 38 C.F.R. § 4.14
(1994).

Yet, the Court has also recently ruled, however, that a
veteran may be rated separately for each of several
conditions of the same area of the body, e.g., facial scars
and facial muscle damage, if those conditions do not have
duplicative or overlapping symptomatology.  Esteban v. Brown,
6 Vet.App. 259 (1994).  In balancing these two provisions of
the rating schedule, the Court held that the critical element
for allowing separate evaluations would be that none of the
symptomatology from a single disability would be duplicative
or overlapping with the symptomatology of another disability.

In view of the holding of Esteban, we find it necessary to
analyze each aspect of the veteran's service-connected foot
condition, and determine whether separate ratings should be
assigned.  However, it must be remembered that since this
disorder is associated with the veteran's right lower
extremity, the amputation rule comes into play.  "The
combined rating for disabilities of an extremity shall not
exceed the rating for the amputation at the elective level,
were amputation to be performed."  38 C.F.R. § 4.68 (1994).

In this situation, the veteran’s small right toe is amputated
and there are retained metallic fragments in his foot.  The
area in which the toe was amputated produced a scar that is
painful and tender.  Per the medical records, the area where
the retained fragment wounds are found has not produced
muscle damage, nerve restrictions, or lack of mobility of the
foot.  In fact, other than actually being able to see the
fragments via x-rays, there is no discernible indication that
the metallic objects affect the function of the foot.
Therefore, because the facts in the case do not indicate that
separate disability evaluations stemming from different
symptoms are warranted in accordance with Esteban, we find
that 38 C.F.R. § 4.14 (1994) controls.

It is therefore our conclusion that separate ratings for the
retention of metallic foreign bodies in the right foot would
constitute pyramiding on the service-connected disability of
amputation of the right little toe with retained foreign
bodies and painful tender scar.  Because the evaluation of
the same disability under various diagnoses is not
permissible under 38 C.F.R. § 4.14 (1994), separate ratings
may not be issued.  To do so would overcompensate the veteran
for the actual impairment of his working capacity.

V.  Earlier Effective Date

As stated above, in August 1991, the RO determined that the
veteran's right ankle residuals warranted a 10 percent
evaluation.  VA Form 20-6796, Rating Decision, August 22,
1991.  The effective date of the increased rating was the
date that the veteran reopened his claim, or May 2, 1990.
Since the issuance of that rating decision, the veteran has
appealed the effective date of the decision claiming that his
effective date should be before May 1990.  He has not been
specific as far as a date is concerned.

In accordance with 38 U.S.C.A. § 5107 (West 1991), and Murphy
v. Derwinski, 1 Vet. App. 78 (1990), the appellant has
presented a well-grounded claim.  The facts relevant to this
appeal have been properly developed and the obligation of the
Department of Veterans Affairs (VA) to assist the veteran in
the development of his claim has been satisfied.  Id.  While
the Board is sympathetic to the veteran's claim, an earlier
effective date is not warranted.  The governing statutory and
regulatory provisions expressly stipulate that the effective
date for the granting of increased disability compensation is
as follows:

§ 3.400  General.

Except as otherwise provided, the
effective date of an evaluation and award
. . . [for] a claim for increase will be
the date of receipt of the claim or the
date entitlement arose, whichever is the
later.  (Emphasis added).

....

          (o)  Increases . . . (1)  General.
Except as provided in paragraph (o)(2) of
this section and § 3.401(b) [which
applies to increases for dependents],
date of receipt of claim or date
entitlement arose, which is later. . . .

          (2)  Disability compensation.
Earliest date as of which it is factually
ascertainable that an increase in
disability had occurred if claim is
received within 1 year from such date
otherwise, date of receipt of claim.

38 C.F.R. § 3.400 (1994); see also 38 U.S.C.A. § 5110 (West
1991).

The veteran was originally granted a noncompensable rating
for the residuals of a right ankle injury in May 1971.  VA
Form 21-6796, Rating Decision, May 19, 1971.  Since the
veteran applied for benefits within one year of his discharge
from the Marine Corps, the effective date of the
noncompensable rating was deemed to be the day after he was
discharged from active duty.  This date was July 26, 1970.
Between 1971 and 1990, the veteran petitioned the RO for an
increased rating on numerous occasions, but because a more
severe condition was not demonstrated, the RO denied his
petitions.  The RO notified the veteran, but he did not
appeal the confirmed noncompensable evaluation.  Therefore,
his claim for an increased rating in May 1990 was a reopened
claim and, as such, subject to the regulations, cited above.
If, in May 1990, evidence in the file within the year
preceding that date showed that his condition had
deteriorated, the effective date of the increased rating
could have been the date that deterioration became apparent;
but there is no such evidence.  The decision to grant an
increased rating was based on medical evidence that became
available in 1990 and 1991.  While the medical evidence
received shows a worsening of the right ankle condition, the
medical evidence does not chronicle a more severe condition
during the year preceding the veteran's petition for an
increased rating.  Thus the earliest possible effective date
is the date of receipt of claim, May 2, 1990.

It must be therefore concluded that May 2, 1990, is the
appropriate effective date for the granting of a 10 percent
evaluation for the veteran's bronchial condition, and that an
effective date earlier than May 2, 1990, is not warranted.
38 U.S.C.A. § 5110 (West 1991); 38 C.F.R. § 3.400 (1994).

ORDER

1.  A well-grounded claim for service connection for a skin
condition of the elbows, hands, and feet secondary to
exposure to Agent Orange, not having been submitted, the
claim is dismissed, and the rating decision of April 12,
1994, insofar as the claim for entitlement to service
connection for a skin disorder of the elbows, hands, and feet
secondary to exposure to Agent Orange is concerned, is
vacated.

2.  A well-grounded claim for service connection for a right
hip condition, not having been submitted, the claim is
dismissed, and the rating decision of May 14, 1990, insofar
as the claim for entitlement to service connection for a
right hip condition is concerned, is vacated.

3.  Entitlement to service connection for a skin condition of
the elbows, hands, and feet is denied.

4.  Entitlement to service connection for bilateral hearing
loss is granted.

5.  Entitlement to service connection for PTSD is denied.

6.  Entitlement to an increased rating for the residuals of a
right ankle injury, currently evaluated as 10 percent
disabling, is denied.

7.  Entitlement to a separate evaluation for retained
metallic foreign bodies of the right foot is denied.

8.  Entitlement to an effective date earlier than May 2,
1990, for the granting of a 10 percent evaluation for the
residuals of a right ankle injury, is denied.

          JACK W. BLASINGAME
          Member, Board of Veterans' Appeals

The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination.  This proceeding has been assigned to an
individual member of the Board.

NOTICE OF APPELLATE RIGHTS:  Under 38 U.S.C.A. § 7266 (West
1991), a decision of the Board of Veterans' Appeals granting
less than the complete benefit, or benefits, sought on appeal
is appealable to the United States Court of Veterans Appeals
within 120 days from the date of mailing of notice of the
decision, provided that a Notice of Disagreement concerning
an issue which was before the Board was filed with the agency
of original jurisdiction on or after November 18, 1988.
Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402
(1988).  The date which appears on the face of this decision
constitutes the date of mailing and the copy of this decision
which you have received is your notice of the action taken on
your appeal by the Board of Veterans' Appeals.