Citation Nr: 0004482 Decision Date: 02/18/00 Archive Date: 02/23/00 DOCKET NO. 94-31 570 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for headaches. 2. Entitlement to an increased rating for post-traumatic stress disorder, currently rated as 30 percent disabling. 3. Entitlement to an increased rating for defective vision of the right eye, currently rated as 10 percent disabling. 4. Entitlement to an increased rating for the post-operative residuals of a right knee injury, currently rated as 10 percent disabling. 5. Entitlement to an increased rating for residuals of injury to the left (non-dominant) arm, shoulder and wrist with vein graft, currently rated as 10 percent disabling. 6. Entitlement to an increased rating for residuals of fractures of the facial bones, currently rated as 10 percent disabling. 7. Entitlement to an increased (compensable) rating for right maxillary sinusitis, secondary to trauma. 8. Entitlement to an increased (compensable) rating for residuals of injury to the right ankle and heel. 9. Entitlement to an increased (compensable) rating for an insect bite scar of the right (dominant) hand. The issue of entitlement to waiver of recovery of an overpayment of compensation, in the amount of $1,624, will be the subject of a separate decision. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Clifford R. Olson, Counsel INTRODUCTION The veteran served on active duty from October 1967 to October 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In June 1997, a hearing was held, at the RO, before Constance B. Tobias, who is the Board member making this decision and who was designated by the Chairman to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West Supp. 1999). In January 1998, the Board Remanded the case for VA medical records and psychiatric examination of the veteran. The requested development has been completed. The Board now proceeds with its review of the appeal. In August 1999, a video conference hearing was held with Constance B. Tobias, the Board member making this decision, designated to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West Supp. 1999). The veteran withdrew his request for a personal hearing before a Board member. It was agreed that the file would be held open for the veteran to submit additional evidence after the hearing and the veteran waived initial consideration of the additional evidence by the RO. Cf. 38 C.F.R. § 20.1304(c) (1999). The veteran's submissions have been received. At the August 1999 video conference hearing, the representative raised the issue of entitlement to a total disability rating based on individual unemployability. Such a rating can only be granted if the schedular rating is less than total. 38 C.F.R. § 4.16(a) (1999). Since this decision grants a total rating on a schedular basis, there is no legal basis for such a claim and the Board takes no further action on the matter. Also at the August 1999 video conference hearing, the veteran and representative expressed disagreement with the January 1999 rating decision which considered that veteran's jaw complaints, granted service connection for bilateral temporomandibular joint (TMJ) dysfunction and rated the disability at 10 percent. A notice of disagreement with a rating decision must be submitted to the RO. 38 C.F.R. § 20.300 (1999). The record before the Board does not disclose that a timely notice of disagreement with the January 1999 rating decision was filed with the RO, and the veteran and his representative have not informed the Board that such timely notice of disagreement was filed. The Board can not discern any issue from the January 1999 rating decision which is currently within its jurisdiction and takes no action on these matters at this time. 38 U.S.C.A. § 7105 (West 1991). The issue of entitlement to an increased rating for the post- operative residuals of a right knee injury will be the subject of a remand at the end of this decision and will not be otherwise discussed herein. FINDINGS OF FACT 1. Except for the rating of the right knee injury residuals, the RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal. 2. In October 1979, the RO denied the veteran's claim for service connection for headaches. He was notified in November 1979 and did not appeal. 3. Evidence received since the October 1979 rating decision, includes private and VA medical records showing headaches and treatment, without associating the headaches with a service- connected disability or with disease or injury in service. The veteran has made numerous statements to the effect that he believes his headaches are related to his service- connected disability; however, he does not have the medical training and experience to present competent opinion evidence on the medical question of etiology. 4. The evidence presented since the October 1979 rating decision is cumulative. 5. The service-connected post-traumatic stress disorder (PTSD) results in total occupational and social impairment and renders the veteran demonstrably unable to obtain or retain employment. 6. The service-connected defective vision of the right eye is manifested by loss of the inferior or lower half of the field of vision. Corrected visual acuity is 20/40 or better in each eye and the left eye does not have a service- connected disability. 7. The residuals of injury to the left (non-dominant) arm, shoulder and wrist with vein graft approximate a severe injury to Muscle Group V. 8. The service-connected residuals of fractures of the facial bones result in disfigurement which is no more than moderate and in slight nasal symptoms without interference with the breathing space. 9. The service-connected right maxillary sinusitis, secondary to trauma, is manifested by mild or occasional symptoms and does not approximate a moderate disability with associated discharge, crusting or scabbing. Headaches are not a symptom of the service-connected disability. There are no incapacitating episodes. The veteran does not have three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. 10. The residuals of injury to the right ankle and heel do not approximate a moderate limitation of ankle motion or moderate foot injury residuals. 11. The insect bite scar of the right (dominant ) hand is not poorly nourished, ulcerated, or tender and painful on objective demonstration, and it does not affect the functioning of the wrist or hand. CONCLUSIONS OF LAW 1. The October 1979 rating decision is final. Evidence received since the RO's 1979 decision is not new and material and the veteran's claim of entitlement to service connection for headaches is not reopened. 38 U.S.C.A. §§ 5108, 7105 (West 1991); 38 C.F.R. §§ 3.156, 20.1103 (1999). 2. The criteria for a 100 percent rating for the service- connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, including §§ 4.7, 4.130 and Code 9411 (1996, 1999). 3. The criteria for a rating in excess of 10 percent for defective vision of the right eye have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, including §§ 4.7, 4.14, 4.20, 4.75 and Codes 6079, 6080 (1999). 4. The criteria for a 30 percent rating for residuals of injury to the left (non-dominant) arm, shoulder and wrist with vein graft, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, including §§ 4.7, 4.20 and Code 5305 (1999). 5. The criteria for a rating in excess of 10 percent for residuals of fractures of the facial bones have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, including § 4.7 and Codes 6502, 7800 (1999). 6. The criteria for a compensable rating for right maxillary sinusitis, secondary to trauma, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, including § 4.7 and Codes 6513 (1996, 1999). 7. The criteria for a compensable rating for residuals of injury to the right ankle and heel have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, including §§ 4.7, 4.31 and Codes 5271, 5284 (1999). 8. The criteria for a compensable rating for an insect bite scar of the right (dominant) hand have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, including §§ 4.7, 4.31 and Codes 7803, 7804, 7805 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. Whether New and Material Evidence has been Submitted to Reopen a Claim of Entitlement to Service Connection for Headaches In October 1979, the RO considered the veteran's claim for service connection for headaches. In addition to the service medical records and post service VA examination reports, the veteran submitted private medical records. These included a summary from a private medical center, which reported treating the veteran for headaches on numerous occasions from 1976 to 1979. In an opinion dated in July 1976, a private neurologist expressed the opinion that the headaches sounded like tension headaches, rather than migraine. The RO denied the claim on the basis that the evidence did not show an etiologic relationship between the headaches and injury in service. The veteran was notified in November 1979 and did not appeal. Decisions of the RO which are not appealed are final. 38 U.S.C.A. § 7105(c) (West 1991); 38 C.F.R. § 20.1103 (1999). The United States Court of Appeals for the Federal Circuit has held that this is a jurisdictional matter. That is, VA has no jurisdiction to consider the claim unless the appellant submits new and material evidence. Therefore, the first determination which the Board must make, is whether the veteran has submitted new and material evidence to reopen the claim. See Barnett v. Brown, 83 F.3d 1380 (Fed.Cir. 1996). In analyzing a claim that new and material evidence has been submitted to reopen a claim, the first determination is whether new and material evidence has been presented under 38 C.F.R. § 3.156(a); second, if new and material evidence has been presented, immediately upon reopening it must be determined whether, based upon all the evidence and presuming its credibility, the claim as reopened is well grounded pursuant to 38 U.S.C. § 5107(a); and third, if the claim is well grounded, the claim will be evaluated on the merits after ensuring the duty to assist under 38 U.S.C. § 5107(a) has been fulfilled. See Winters v. West; 12 Vet. App. 203 (1999); Elkins v. West; 12 Vet. App. 209 (1999). The first analysis is whether new and material evidence has been presented to reopen the claim. See Hodge v. West, 155 F.3d 1356, 1360-62 (Fed.Cir. 1998). New and material evidence means evidence not previously submitted to agency decision makers that 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 (1999). At the time of the October 1979 rating decision denying service connection for headaches, the record contained the veteran's statements that he was in a VA medical center (VAMC) in July and August 1979. Those records were not obtained. VAMC summaries were received in August 1988. The summary of the VA hospitalization in July and August 1979 showed the veteran complained of frequent and intense headaches. He said that during the last 3 to 4 years, he had developed bitemporal as well as occipital area headaches, once or twice a week, lasting 1 to 3 days. The diagnosis was marital maladjustment. There was no diagnosis of headaches or medical opinion connecting headaches to service or service-connected disability. There was no report of headaches during the hospitalization. The summaries of 2 VA hospitalizations in 1986 do not show any complaints of headaches, that headaches or related symptoms were noted during hospitalization, or any other information on headaches. The veteran had 2 VA mental examinations in November 1991. These primarily diagnosed PTSD and also diagnosed organic mental disorder. One doctor related the organic mental disorder to head trauma in service. However, neither report mentions any complaints of headaches or made any diagnosis as to headaches. In May 1993, the veteran claimed service connection for headaches due to head damage. He did not submit evidence or assert that new and material evidence was available to support the claim. At his February 1994 RO hearing, the veteran testified of a head injury in service and of post service treatment for headaches by private physicians in 1973. He stated that he still had headaches and described them. In June 1994, the RO received private medical records showing a diagnosis of migraine headaches in May 1976 with further complaints of headaches recorded in June, July, and August 1976. The reports did not indicate a cause or associate the headaches with any service-connected disability. The records continued through 1991 without further report of headaches, although large portions of the records were covered. At the September 1994, RO hearing, the veteran testified of sinusitis symptoms. Among the sinusitis symptoms, he reported headaches. A February 1996 VA clinical note shows the veteran complained of frontal headaches. Ear and otopharyngeal findings were normal. The left nostril was clear while there was pus on the right. A computerized tomography scan disclosed thickening of the right maxillary sinus and the remaining sinuses were clear. The assessment was that the headaches were most likely not sinusitis. On follow up later in February 1996, the veteran continued to complain of frontal headaches, but the diagnosis was rhinitis of unclear etiology. At his June 1997 Board hearing, the veteran testified of severe headaches occurring 2 to 4 times a week. The pain was described as coming from the back of the neck and up the middle of the head. He said that it seemed his head was going around and around starting from the right ear and across the front of his face. They were said to last as much as a couple of days. He could not deal with people during that time and had been jailed for his actions during his headaches. He also became sick of the stomach. He told of previously using alcohol to deal with his headaches, but found that caused additional problems. He reported that various diagnoses had been considered, including migraine headaches, brain tumor, concussion residuals, and a blood clot. Various treatments had been tried. During the August 1999 video conference hearing, the veteran testified to this Board member that he continued to have headaches and received treatment at a VAMC. He reported that a VA physician had told him the headaches were related to his service-connected facial injuries and sinus disorder. He stated that he had not seen that doctor since the 1970's and early 1980's. The United States Court of Appeals for Veterans Claims (Court) has held that lay assertions of medical causation cannot serve as the predicate to reopen a claim under 38 U.S.C.A. § 5108. See Robinette v. Brown, 8 Vet. App. 69, 74 (1995), quoting Moray v. Brown, 7 Vet. App. 211, 214 (1993). The Court has particularly determined that a veteran's statements as to what a doctor said are not competent as new and material evidence to reopen a claim. Warren v. Brown, 6 Vet. App. 4 (1993). Here, the veteran seeks to reopen his claim for service-connection for headaches by restating his previous assertions. This is cumulative and is not new. Further, as the veteran does not have the necessary medical training and experience to provide an opinion on a medical question of causation, his statements are not competent evidence on that question. See Grottveit v. Brown, 5 Vet. App. 91 (1993). The evidence shows that, several times, the veteran told examiners about headaches. However, none of the medical personnel linked the headaches to sinusitis or any other service-connected disability. On one occasion, the doctor even expressed the opinion that such a connection was unlikely. The Board's review does not disclose anything which is evidence and which is new. Since the veteran has not submitted new and material evidence, VA does not have jurisdiction to reopen the claim and consider it again. 38 U.S.C.A. §§ 5108, 7105 (West 1991). See Barnett. The Board notes that the veteran served in Vietnam and his awards include a Combat Action Ribbon and a Purple Heart. 38 U.S.C.A. § 1154(b) assists combat veterans in the adjudication of well grounded claims. However, evidence of a well grounded claim is required. Since 1979, there have been several Court decisions clarifying the role of Section 1154(b). See Kessel v. West, 13 Vet. App. 9 (1999) (en banc), appeal docketed (Fed. Cir.); Arms v. West 12 Vet. App. 188 (1999). Nevertheless, even under the current case law, the veteran has not submitted new evidence 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 his claim for service connection for headaches. Increased Ratings The veteran's increased rating claims are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, his assertion that his service-connected disabilities have worsened raises plausible claims. See Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). All relevant facts have been properly developed. VA has completed its duty to assist the veteran in the development of his increased rating claims. See 38 U.S.C.A. § 5107(a). The veteran has not reported that any other pertinent evidence might be available. See Epps v. Brown, 9 Vet. App. 341, 344 (1996). Service-connected disabilities are rated in accordance with a schedule of ratings which are based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). Where the law changes after a claim has been filed or reopened but before the administrative or judicial process has been concluded, the version most favorable will apply unless Congress provided otherwise or permitted the Secretary to provide otherwise and the Secretary did so. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). In considering the severity of a disability, the Board has reviewed the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2 (1999). The current rating is based on the current extent of the disability, so this discussion will focus on the recent evidence, which is the most probative source of information as to the current extent of the disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). 2. Entitlement to an Increased Rating for PTSD Extensive out patient treatment records are in evidence. VA outpatient treatment records for October 1986 contain a diagnosis of PTSD. The summary of VA hospitalization in December 1986 included a diagnosis of PTSD. The claim for service connection for PTSD was received in June 1988. Psychologic testing in March 1989 led to diagnoses of PTSD, dysthymia, psychoactive substance abuse, and personality disorder. In March 1990, a VA psychologist stated that the veteran was engaged in treatment for PTSD since March 1987. In November 1991, two VA psychiatrists diagnosed PTSD. These medical records did not express an opinion as to the extent of the disability. A June 1992 rating decision granted service connection for PTSD and rated the disability at 30 percent. The veteran did not make a timely appeal of that rating. The veteran had a periodic examination for his PTSD in January 1994. On Axis V, the examiner described the veteran's functioning as fair. An April 1994 rating decision continued the 30 percent rating. The notice of disagreement was received in May 1994. The statement of the case was issued in August 1994 and the appeal was received later that month. During the course of the claim and appeal, the rating criteria for evaluation psychiatric disorders changed on November 7, 1996. Where the law changes after a claim has been filed or reopened but before the administrative or judicial process has been concluded, the version most favorable will apply unless Congress provided otherwise or permitted the Secretary to provide otherwise and the Secretary did so. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). The Board finds that review of the veteran's claim is warranted under the old and new rating criteria. See 38 U.S.C.A. § 5110(b)(1) (West 1991). The RO provided the veteran with both rating criteria. Prior to November 7, 1996, psychoneurotic disorders were evaluated as 100 percent disabling where the attitudes of all contacts except the most intimate were so adversely affected as to result in virtual isolation in the community; with totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior; with the veteran demonstrably unable to obtain or retain employment. A 70 percent evaluation required that the ability to establish and maintain effective or favorable relationships with people was severely impaired, with the psychoneurotic symptoms of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. A 50 percent rating required that the ability to establish or maintain effective or favorable relationships with people was considerably impaired; and by reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels A 30 percent rating required definite impairment in the ability to establish or maintain effective and wholesome relationships with people, so that the psychoneurotic symptoms resulted in such reduction in initiative, flexibility, efficiency and reliability levels as to produce definite industrial impairment. 38 C.F.R. Part 4, Codes 9400-9411 (1996) (effective prior to November 7, 1996). Effective on and after November 7, 1996, the General Rating Formula for Mental Disorders, including anxiety, dissociative, somatoform, mood and chronic adjustment disorders and PTSD, is: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name..................................... ......100 Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships............................ ....................................70 Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships............................ ....................50 61 Fed. Reg. 52701, 52702 (1996). 38 C.F.R. §4.130 (1999). A VA psychiatric examination was performed in September 1994. The doctor commented that even though the veteran was attending the PTSD clinic, the doctor did not believe the veteran had PTSD. Diagnoses were alcohol dependence and narcissistic personality. Symptoms such as difficulty sleeping were associated with alcohol abuse and the veteran's anger was related to his personality disorder. The examiner reiterated that he did not find any mental illness other than alcohol dependence and narcissistic personality disorder. Also during September 1994, the veteran testified before a hearing officer at the RO. He described limited social activity. He would occasionally go to a bar or shoot a game of pool. He said he basically stayed to himself. He reported periods of increased anxiety on a daily basis. He described bouts of depression. He detailed episodes of anger and occasional violence. He was currently receiving counseling. A January 1996 clinical record shows the veteran complained of an inability to control anger, depression, nightmares, intrusive ideation, and other symptoms of PTSD. He was suspicious and some what combative. Thought processes were mildly tangential. He stuttered when anxious. He had little insight. At his June 1997 Board hearing, the veteran said that his PTSD made him feel that he was crazy. He stated that he did not go out much and had 4 friends that he had grown up with. He described his days as lonely and his nights as lonelier. In June 1998, the veteran was examined by the same psychiatrist who examined him in September 1994. In this occasion, the doctor admitted a diagnosis of PTSD. The GAF was 65-70, which the doctor explained was some mild symptoms generally functioning pretty well, mild insomnia with some symptoms of PTSD. At his August 1999 Board video conference hearing, the veteran testified that he continued to have weekly treatment for PTSD at a VAMC. He received individual treatment because he could not control himself in a group. He stated that his anger had become worse and he had recently been incarcerated as a result. He stated that he had not worked since 1984. He said no one would employ him because of his eyesight. The veteran's wife testified that his temper had gotten worse in the last 18 months and his lost his temper over simple things. In a letter received in October 1999, the supervising psychologist at a VAMC, reported that the veteran had been treated for chronic and severe PTSD since January 1995, with only modest gains. Symptoms include chronic anger, alienation, distrust bordering on paranoia, and difficulty dealing with authority figures. He had attempted to gain income by repairing rental property but difficulty in concentration, sleep disturbance, intrusive thoughts and physical problems interfered. The veteran's declining health had exacerbated his PTSD so that it would be extremely difficult for him to engage in vocational activities. The doctor felt the veteran was unable to profit from vocational rehabilitation. Symptoms were exacerbated under stress. He had an inability to assess situations with perspective and cycles of extreme or inappropriate behavior. These episodes were accompanied by intrusive memories. The doctor was not sanguine about the possibility that the veteran would ever be able to function in a normal work environment. One VA psychiatrist examined the veteran twice; in September 1994 he felt that the veteran did not have PTSD and in June 1998 he accepted the PTSD diagnosis but felt the veteran had mild impairment. The psychologist who has been working with the veteran for several years appears to have much greater experience with the veteran and so, the psychologist is in a much better position to diagnosis the veteran's psychiatric disability and determine its extent. The psychologist was basically of the opinion that the service-connected PTSD prevented the veteran from working. He acknowledged that there were physical disabilities involved, but the PTSD exacerbated the impact of these disabilities, so VA must consider the aggravation in assessing the impact of the PTSD. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). While there is evidence to the contrary, giving the veteran the benefit of the doubt, the Board finds that the PTSD prevents the veteran from working. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. § 4.7 (1999). This meets the old criteria which provided a 100 percent rating where the PTSD rendered the veteran demonstrably unable to obtain or retain employment. 38 C.F.R. Part 4, Code 9411 (1996) (effective prior to November 7, 1996). It also meets the new criteria which provides a 100 percent rating if there is total occupational and social impairment. 61 Fed. Reg. 52701, 52702 (1996). 38 C.F.R. §4.130 (1999). 3. Entitlement to an Increased Rating for Defective Vision of the Right Eye The service medical records show that the veteran sustained a severe injury to the right eye in the March 1970 automobile accident, and initially could not perceive light. It was felt that he had retinal hemorrhage and edema with traumatic damage to the eye. The diagnosis was traumatic choroidal rupture with retinal and preretinal hemorrhage and macula edema of the right eye. A service department medical board report shows the veteran's vision was 20/200 on the right and 20/25 on the left, in March 1970. Subsequently, hemorrhages around the optical disc and macula organized into a band of gliosis which ran from the center of the macula slightly superior to the disc and ended approximately at the disc. In July 1970, right eye vision was 5/400 and could not be improved with corrective lens. Left eye vision was 20/20. The diagnosis was blindness of the right eye, secondary to macular scar. The veteran was given a special VA eye examination in October 1973. There was a Y-shaped scar just temporal to the outer angle of the right eye, which was well healed and slightly disfiguring. There was slight depression of the malar eminence. Other external eye findings were normal. The fundi disclosed a healed choroidal rupture of the macula, scarring, and isolated areas of healed pigment degeneration. There was a right visual defect inferiorly, involving most of the inferior half of the field. Vision was correctable to 20/100 on the right and 20/20 on the left. A December 1973 rating decision granted service connection for defective vision and rated the disability at 10 percent under Code 6079. A claim for an increased rating for loss of vision was received in May 1993. The September 1993 VA optometry clinic record shows visual acuity of 20/20 on the left and 20/50 on the right, with and without correction. A loss of inferior visual field of the right eye was diagramed. The left eye had a full field of vision. Diagnoses were myopic astigmatism with presbyopia, bilateral blepharitis, and decreased visual acuity secondary to retina trauma by history. At his February 1994 RO hearing, the veteran testified of being examined by VA and given new glasses. He said he was able to drive. VA optometry clinic notes show the veteran's eyes were examined on many occasions from 1994 through 1997. Corrected vision in the right eye varied but was always 20/40 or better. In June 1997, the veteran testified at a Board hearing. He described a loss of right eye vision below the center line. He felt his remaining vision was worse. When seen at the VA optometry clinic in September 1997, corrected visual acuity in the right eye was 20/30. A detailed ophthalmology and optometry examinations were done in March 1998 and the corrected vision in the right eye was 20/30. A March 1999 VA optometry clinic note shows that the veteran's eyes were examined and corrected visual acuity was 20/20 in each eye. An inferior visual field defect was noted on the right. The non-service-connected left eye had a full field of vision. Clinic notes dated in June 1999 and August 1999 show mild blepharitis. The loss of the lower half of the visual field in the right eye remained constant. Right eye corrected visual acuity was 20/30 in June and August 1999. In August 1999, the veteran testified at his Board video conference hearing, that VA had recently prescribed trifocal lens for visual correction and some kind of ointment had also been prescribed. Visual acuity for rating purposes is determined based on corrected vision; that is, with glasses. 38 C.F.R. § 4.75 (1999). The most recent eye examinations consistently demonstrate that the veteran's corrected visual acuity is 20/40 or better in each eye. This does not approximate the limitation of visual acuity to 20/50 which is required for a compensable rating. 38 C.F.R. §§ 4.7, 4.84a, Code 6079 (1999). While the veteran is competent to assert that his vision is worse, the most accurate measure of corrected visual acuity is determined by trained medical personnel using specialized equipment. 38 C.F.R. § 4.75 (1999). Since the medical findings consistently show that the veteran's visual acuity does not meet the requirements for a compensable rating, the preponderance of evidence is against an increased rating based on decreased visual acuity. 38 U.S.C.A. § 5107(b) (West 1991). The record establishes that the veteran does not have a concentric contraction of visual fields ratable under 38 C.F.R. §§ 4.76, 4.76a, Code 6080 (1999). The current rating criteria provides a 10 percent rating where the temporal half of the field of vision is lost in one service-connected eye. This is the outer half which would involve a loss of peripheral vision. A 30 percent rating is provided for loss of the temporal half of the field of vision in both eyes. [Both eyes must be service-connected. 38 C.F.R. § 4.14] A 10 percent rating is also provided for loss of the inner or nasal half of the field of vision. A 20 percent rating is provided for loss of the nasal half of the field of vision in both eyes. [Again, both eyes must be service-connected. 38 C.F.R. § 4.14] The current rating criteria do not provide compensable ratings for loss of the upper or lower half of the field of vision. 38 C.F.R. Part 4, Code 6080 (1999). VA has proposed a change in the rating criteria for diseases of the eye. 64 Fed. Reg. 25246-25258, May 11, 1999. The proposal explained that in order to make the evaluations for visual field defects under diagnostic code 6080 more comprehensive, as suggested by consultants, VA proposed to add evaluations for loss of superior and inferior altitudinal fields. Inferior field loss will be evaluated at 10 percent for the unilateral and 30 percent for the bilateral condition (or impaired visual acuity of 20/70 (6/21) for each affected eye), and superior field loss will be evaluated at 10 percent for both the unilateral and bilateral conditions (or impaired visual acuity of 20/50 (6/15) for each affected eye). While the proposal to assign a 10 percent rating for a loss of the lower or inferior visual field has not yet taken effect, the Board finds the explanation for the proposal persuasive. The Board finds that the loss of the lower half of the visual field could be rated by analogy to loss of the temporal or nasal half under Code 6080. 38 C.F.R. § 4.20 (1999). Functions affected, anatomical localization and symptomatology are closely analogous. However, this supports the current 10 percent rating and does not warrant any higher rating. Specifically, Code 6080 provides the next higher rating if both eyes have limitation of visual field. In this case only one eye is service-connected and the non-service- connected left eye has no limitation of visual field. 38 C.F.R. § 4.14 (1999). Therefore, the limitation of the field of vision in the right eye is not analogous to the criteria for a higher rating. 38 C.F.R. § 4.20 (1999). The Board has considered all aspects of the service-connected right eye disability and finds, for the reasons discussed above, that the preponderance of evidence establishes the service-connected right eye disability is not analogous to and does not approximate any applicable criteria for a higher rating. 38 C.F.R. §§ 4.7, 4.20 (1999). 4. Entitlement to an Increased Rating for Residuals of Injury to the Left (Non-Dominant) Arm, Shoulder and Wrist with Vein Graft The service medical records show that the veteran sustained a nondisplaced fracture of the left scapula in the March 1970 automobile accident. X-rays of the left wrist were negative. There was a markedly weak radial pulse. A left subclavian arteriogram revealed a thrombosis of the brachial artery. Surgery was performed with a left saphenous vein graft connected to the left axillary artery and brought down to the region of the left elbow. The brachial artery was found to be entirely thrombosed. Postoperatively, there was a good pulse which slowly diminished to a weak radial pulse. It was asymptomatic and the color of the hand and nails was good. The pertinent diagnoses were fracture of the left scapula and contusion of the left brachial artery. On the October 1973 VA examination, it was noted that the veteran was right handed. There was no limitation of motion in the left shoulder, arm or hand. The left radial pulse was diminished. There was no swelling of the wrist and wrist motion was not limited. The diagnoses were residuals of blood clot of the left arm, vein graft, arterial impairment, residuals of injury left shoulder, and no residuals sprain of left wrist. X-rays showed no abnormalities of the left shoulder or wrist. The December 1973 rating decision granted service connection for injury of left arm, shoulder, wrist with vein graft, rated as 10 percent disabling by analogy to Code 5305. Muscle Group V functions in elbow supination (1) (long head of biceps is stabilizer of shoulder joint) and flexion of elbow (1, 2, 3). It includes the flexor muscles of elbow: (1) Biceps; (2) brachialis; and (3) brachioradialis. A injury to Muscle Group V will be rated as noncompensable if slight and as 10 percent disabling if moderate. A moderately severe injury will be rated as 30 percent disabling if involving the major extremity and as 20 disabling if involving the minor extremity. A severe injury will be rated as 40 percent disabling if involving the major extremity and as 30 disabling if involving the minor extremity. 38 C.F.R. Part 4, Code 5305 (1999). The original injury included a fracture of the scapula. Impairment of the clavicle or scapula with dislocation will be rated as 20 percent disabling. A nonunion will be rated as 20 percent disabling where there is loose movement and as 10 percent disabling without loose movement A malunion will be rated as 10 percent disabling. Or the disability may be rated on impairment of function of contiguous joint. 38 C.F.R. Part 4, Code 5203 (1999). Considering the shoulder joint, the Board notes that there is no evidence of actual ankylosis. There was no left shoulder abnormality on the April 1999 X-rays. Further, no physician has analogized the left shoulder restrictions to ankylosis. Consequently, there is no basis for rating the disability as ankylosis of the left shoulder under Code 5200. Looking to the rating for restriction of motion, Limitation of motion of the arm to 25° from the side will be rated as 40 percent disabling for the major arm and as 30 percent disabling for the minor arm. Limitation of motion of the arm to midway between side and shoulder level will be rated as 30 percent disabling for the major arm and as 20 percent disabling for the minor arm. Limitation of motion of the arm at shoulder level will be rated as 20 percent disabling for the major or minor arm. 38 C.F.R. Part 4, Code 5201 (1999). Private medical records show the veteran caught his left arm in a roller belt at work, in July 1983. This resulted in anterior laceration requiring stitches and a dirty abrasion over the medial side of the elbow. There was tenderness along the ulnar nerve and paresthesia, limitation of elbow movement and tenderness at the base of the 4th metacarpal. X-rays showed an old spur at the elbow but no bony injury of the hand. The diagnosis was infected lacerations and ulnar neuritis. Records from the Barnesville Hospital show complaints of neck and shoulder pain, from 1988 to 1991, were treated with medication, physical therapy and injection. A claim for an increased rating for loss of feeling in the arms and hands and loss of grip was received in May 1993. During his February 1994 RO hearing, the veteran testified of burning and aching sensations in his left arm. He told of surgery in service. He stated that he currently had a lot of pain and frequently could not raise his arms. His hands felt the way they did right after the surgery. He had numbness in the 3rd and 4th fingers, as well as difficulty holding things. The pain was said to be getting worse and more frequent. The arm was not being treated. He stated that he was right handed. The report of a April 1996 VA examination shows the veteran complained of problems with both shoulders. No joint swelling was noted and the upper extremities had a fair range of motion. There were thickened white scaling lesions over the left elbow, which the veteran associated with pinning of the joint. No other symptomatology for the service-connected left upper extremity disability was reported. In June 1997, the veteran testified that there were times when he could not lift his left arm. He told of numbness in the fingers and dropping things. He reported that arthritis and nerve deficits affected his shoulder. He said that he was sometimes unable to raise his arm. He said he had trouble lifting and dropped things. He reported numbness in his hand and fingers. He stated that he had pain throughout the extremity. On the June 1998 VA examination of his joints, the veteran complained of right shoulder disability. Concerning the service-connected disability, neither the veteran nor the examiner reported any current left upper extremity symptoms. In August 1999, the veteran testified for his Board video conference hearing that he was currently receiving some ultra sound treatment, from VA, for his left shoulder arm and wrist. He said that surgery to remove a chip had been postponed because of kidney problems. He reported that he had trouble raising his arm above his shoulder, at times. He described right shoulder symptoms. He also said that his left upper extremity was limited so that he could not raise it to put his clothes on. He described it as locking or something. He said it was so painful that it woke him up at night. He further stated that he had problems holding things. Service connection for the right shoulder was previously denied by the RO in an unappealed rating decision. The 1999 VA clinical records show that the right shoulder was symptomatic and did not indicate any active left upper extremity symptomatology. The April 1999 X-rays indicated a possible chip fracture on the right, while no fracture, dislocation or other abnormality of the left shoulder was identified. The service-connected left upper extremity injury residuals present a complex picture which is not limited to the left shoulder, but includes vein graft residuals and the wrist. After considering the various applicable rating criteria the Board concurs with the RO that the disability is most closely rated by analogy to a muscle wound of the left upper extremity, in both location and symptomatology. 38 C.F.R. § 4.20 (1999). Giving the veteran the benefit of the doubt, the Board finds that the disability picture as described by the veteran and the evidence of record approximates a severe injury for which a 30 percent rating is appropriate. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. Part 4, § 4.7, Code 5305 (1999). This is the highest rating assignable under this Code, for the non-dominant extremity. A higher rating is not provided under Code 5203 and 30 percent is the highest rating for the non-dominant extremity under Code 5201. The veteran has not contended nor does the evidence show that any other rating criteria would be more closely analogous to the service-connected left upper extremity injury residuals; or that there are other rating criteria which would warrant an additional rating. 38 C.F.R. §§ 4.1, 4.2, 4.14, 4.20 (1999). 5. Entitlement to an Increased Rating for Residuals of Fractures of the Facial Bones The veteran has asserted that he has various symptoms as the result of his facial injury in service. Some residuals have been separately rated, such as the TMJ syndrome and sinusitis. Here, the Board finds that the facial deformity and nose aspects of the injury do not warrant an increased rating. The service medical records show that the veteran sustained a fracture of the right frontozygomatic suture with fracture of the right and left infraorbital ridges and the floor of the right orbit in the March 1970 automobile accident. The nasal bones were fractured. There was a La Forte I fracture of the maxilla. There were multiple abrasions of the face. Procedures included closed reduction of fracture of the nasal bones, a right Caldwell-Luc procedure including antrostomy, open reduction of the right frontomalar suture line, and bilateral suspensory wires from zygomatic-frontal process. On release, the facial fractures were considered well healed. On the VA eye examination in October 1973, there was slight depression of the malar eminence and a Y-shaped scar just temporal to the outer angle of the right eye, which was well healed and slightly disfiguring. The dental examiner described some facial asymmetry as the right side appeared somewhat caved in. On the special ear, nose and throat examination, the veteran complained of difficulty breathing through the nose and pain over the bridge of the nose. The examiner found the nasal septum was relatively in the midline. Breathing spaces were adequate. The mucosa and turbinates appeared normal. It was commented that the veteran tended to exaggerate his symptoms. October 1973 VA X-rays disclosed evidence of a previous fracture of the lateral wall of the right orbit, probably a separation of a suture with a single wire suture in the area. There was no definite evidence of fracture of the floor of the right orbit and position and alignment of the bones of the lateral wall of the right orbit were good. The left orbit appeared normal. The nasal septum was very slightly deviated to the left with adequate airways on either side. No definite fracture of the zygomatic arches was seen. The doctor's impression was old fracture of the lateral wall of the right orbit at the line fixed with a wire suture loop in good position and alignment but no definite fracture noted of the orbit nor maxillary bones. The December 1973 rating decision granted service connection for residuals of fracture of the facial bones and rated the disability at 10 percent under Code 7800. In September 1992, the veteran asserted that his nose was worse following an infection after VA nasal surgery in November 1990. On examination in January 1994, the veteran asserted that he continued to have septal pain and had to put his finger in his nose and push the septum to relieve the pain. Examination showed the nose was without deformity. The septum was in the midline. The doctor listed numerous normal findings particular to the nose. There was diffuse erythema of the nasal mucosa. There was tap tenderness to the bilateral submaxillary sinuses. The diagnosis was chronic recurrent sinusitis. No nasal or other fracture residuals were reported. The report of the September 1994 VA examination contains the veteran's complaints of nasal septum pain. The examiner noted diffuse erythema of the nasal mucosa. Otherwise, the nose findings, including the septum, were normal. In September 1994, the veteran testified before a hearing officer at the RO. He stated that he was currently having problems with his jaw and nose. He reported a tingling sensation and numbness. He stated that his jaw locked. The pain was mostly located in the jaw and up through the ears. The pain was described as steady and dull, but sharp at times. He told of biting his tongue and having difficulty chewing food. When seen at the ear, nose and throat clinic in December 1995, the veteran's complaints included facial pain. His nose was seen to have a very deviated septum. His left ear had fluid behind the tympanic membrane. The diagnoses were sinusitis and hearing loss. No facial injury residuals were diagnosed. In March 1996, the assessment was rhinitis without mention of facial injury residuals. Examination in April 1996 disclosed the nasal septum deviation. There were no other facial injury residuals reported. In January 1997, the veteran was seen for snoring, which he asserted was due to the head injury in service. The diagnosis was sleep apnea. That diagnosis was confirmed on a polysomnogram in May 1997. Corrective surgery, a uvulopalatopharyngoplasty, was later performed. This did not involve any structures which had surgery for the service- connected facial injury. The doctors did not indicate that there was any connection to the injury in service. During his June 1997 Board hearing, the veteran testified that his facial injuries resulted in his jaw locking, a broken bone in the nose which interfered with wearing glasses and caused pain in the nose. He said that scar tissue caused irritation. He ascribed a vulnerability to infections to the injury residuals. He reported pain around his ears. Respiratory examination in August 1998 did not disclose any facial injury residuals. The August 1998 dental examination revealed bilateral TMJ dysfunction, more pronounce on the right and the examiner expressed the opinion that it was due to the accident in service. The RO granted service connection for the TMJ dysfunction with a separate 10 percent rating. As discussed above, the record does not contain a notice of disagreement on that issue. The dentist did not identify any other facial injury residuals. In his August 1999 video hearing testimony, the veteran reported his jaw locking or catching, as well as pain and a tingling sensation in the area. Since his nose surgery, he felt pressure on his nose. He could put his finger in his nose to hold the cartilage and relieve the symptoms, although it looked to others as though he was picking his nose. He reported lip irritation. He said that his face was redder, like a rash. The current 10 percent evaluation is assigned under Code 7800. That code provides that disfiguring scars of the head, face or neck will be rated as noncompensable if slight; 10 percent disabling if moderately disfiguring; and 30 percent disabling if severe, especially if producing a marked and unsightly deformity of eyelids, lips or auricles. A 50 percent rating will be assigned for complete or exceptionally repugnant deformity of one side of the face or marked or repugnant bilateral disfigurement. 38 C.F.R. Part 4, Code 7800 (1999). The preponderance of evidence shows that there is some deformity around the eye and that this is no more than moderately disfiguring. The record establishes that the asymmetry does not approximate the severe disfigurement required for the next higher, 30 percent rating. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. § 4.7 (1999). The veteran's nose symptoms have also been considered in light of the history of nose surgery associated with the injury. Here, the rating code provides a 10 percent rating if nasal deflection results in marked interference with breathing space. The evidence shows that further surgery was required and that there is no current interference with breathing space. The veteran has described slight continuing symptoms for which the rating code provides a non-compensable rating. 38 C.F.R. Part 4, Code 6502 (1999). Therefore, the preponderance of the evidence establishes that the nasal aspects of the injury do not approximate the criteria for an increased rating. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. § 4.7 (1999). 6. Entitlement to an Increased Rating for Right Maxillary Sinusitis, Secondary to Trauma The service medical records show that the veteran sustained a fracture of the lateral walls of both maxillary sinuses in the March 1970 automobile accident. On the VA special ear, nose and throat examination, in October 1973, the veteran complained of sinus trouble and fleeting pains throughout his head. He reported a watery discharge which was sometimes red, sometimes green, and sometimes yellow. The doctor reported that he found no clinical evidence of sinusitis at that time. X-rays revealed slight widening of the mucoperiosteal lining of the right maxillary sinus, probably recurrent sinusitis, without any evidence of a retention cyst or gas-fluid level. The X-ray examination of the paranasal sinuses was otherwise negative. There was no definite fracture of the sinuses. The December 1973 rating decision granted service connection for right maxillary sinusitis, secondary to trauma and rated the disability as noncompensable, 0 percent, under Code 6513. Prior to October 7, 1996, a 50 percent rating for sinusitis was assigned for a postoperative status, following radical operation with chronic osteomyelitis requiring repeated curettage, or severe symptoms after repeated operations. A 30 percent rating required frequently incapacitating recurrences, severe and frequent headaches, purulent discharge or crusting reflecting purulence. A 10 percent rating was assigned for moderate sinusitis with discharge or crusting or scabbing, infrequent headaches. A noncompensable rating was assigned where there were X-ray manifestations only, symptoms mild or occasional. 38 C.F.R. Part 4, Code 6513 (1996). As of October 7, 1996, sinusitis will be rated as 50 percent disabling following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A 30 percent rating requires three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 10 percent rating will be assigned for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A noncompensable rating will be assigned where the sinusitis is detected by X-ray only. An incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. Part 4, Code 6513, effective October 7, 1996 (61 Fed. Reg. 46720- 46731, Sep. 5, 1996). A November 1992 VA clinical note shows the nose decongested well and was negative for mucopus; throat findings led to a diagnosis of upper respiratory infection. On examination in January 1994, there was diffuse erythema of the nasal mucosa and tap tenderness to the bilateral submaxillary sinuses. No discharge was noted. The diagnosis was chronic recurrent sinusitis. On the September 1994 VA examination, the veteran had tap tenderness to the left maxillary and frontal sinuses. X-rays disclosed a wire suture in the right frontal zygoma for stabilization. There was mucosal thickening to the posterior ethmoidal sinuses. The diagnosis was chronic recurrent sinusitis. At the September 1994, RO hearing, the veteran testified that his sinusitis was active with frequent drainage. There was also stuffiness. He was symptomatic every day, some days worse. He stated that his nose was sore with mucus scabbing inside. He stated that he did not have outside crusting. He stated that he had swelling over his sinuses and around the eyes. He reported headaches, dizziness and balance problems. It affected his hearing and there was ear pain. The symptoms occurred once a month, although they had not occurred for 3 or 4 months. It varied with the weather. When seen at the ear, nose and throat clinic in December 1995, the veteran's complaints included sinusitis. That was the assessment and medication was recommended. A February 1996 VA clinical note shows the veteran complained of frontal headaches. Ear an otopharyngeal findings were normal. The left nostril was clear while there was put on the right. A computerized tomography scan disclosed thickening of the right maxillary sinus and the remaining sinuses were clear. The assessment was that the headaches were most likely not sinusitis. On follow up later in February 1996, the veteran continued to complain of frontal headaches, but the diagnosis was rhinitis of unclear etiology. In March 1996, the assessment was rhinitis, without mention of sinus findings or diagnosis of sinusitis. Examination in April 1996 disclosed the nasal septum deviation. There were no sinus findings. In his June 1997 Board hearing, the veteran testified of frequent nasal drainage. He said that he had sinus infections very, very often. On a VA respiratory examination in August 1998, the veteran reported sleep apnea and that he had undergone a uvulopalatopharyngoplasty. Examination of his throat disclosed the surgical residuals. There were no sinus complaints or findings. In his August 1999 video hearing testimony, the veteran described facial symptoms. He reported that since his nose surgery, he felt pressure on his nose. He could put his finger in his nose to hold the cartilage and relieve the symptoms, although it looked to others as though he was picking his nose. He reported being treated with antibiotics for chronic sinusitis. He stated that he had a lot of drainage since the surgery, although it was intermittent. He acknowledged that the surgery helped his breathing. Although the veteran is competent to assert that his sinusitis warrants a higher rating, the findings of the trained medical professionals are more probative as to the extent of the disability. In this case, the evidence shows mild or occasional symptoms for which the rating code provides a non-compensable or 0 percent rating. The preponderance of evidence shows that the disability does not approximate a moderate disability with associated discharge or crusting or scabbing. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. § 4.7 (1996). A 10 percent rating could be assigned for a moderate sinusitis with infrequent headaches. 38 C.F.R. Part 4, Code 6513 (1996). While the veteran has asserted that he has sinus headaches, the only medical opinion as to a connection indicated it to be unlikely. Further, service-connection for headaches was denied by a final rating decision and in this decision, the Board concludes that no new and material evidence has been presented to reopen this claim. The preponderance of evidence is against infrequent headaches as a manifestations of the veteran's sinusitis. 38 U.S.C.A. § 5107(b) (West 1991). Looking to the new criteria, there is no evidence of incapacitating episodes. The preponderance of evidence is against the veteran having sinusitis characterized by headaches and pain. The preponderance of evidence also demonstrates that the veteran does not experience purulent discharge or crusting often enough to approximate the new requirements for a compensable rating. 38 C.F.R. Part 4, Code 6513 (1999). The veteran is competent to assert that the disability is worse and should be assigned a compensable rating; however, the findings of the trained medical personnel are more probative and, as discussed above, these show that the service-connected sinusitis does not approximate any applicable criteria for a compensable rating. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. § 4.7 (1996). 7. Entitlement to an Increased Rating for Residuals of Injury to the Right Ankle and Heel The service medical records show injury in the March 1970 automobile accident. X-rays of the right ankle were negative. On the October 1973 VA examination, it was noted that the veteran's right ankle had been injured in service and he reported occasional pain with use. There was no swelling or deformity in the right ankle or heel. Motion in the ankle was not limited. The diagnosis was residuals of injury of the right ankle, by history. The October 1973 VA X-ray examination of the right ankle disclosed that the posterior process of the talus had never united and formed an accessory bone, the os trigonum, which, the doctor stated, was a developmental anomaly of no clinical importance. There was also a very small spur inferiorly on the plantar aspect of the calcaneus, posteriorly, but no soft tissue swelling at the ankle or heel. The doctor concluded that it was a negative examination of the ankle. The December 1973 rating decision granted service connection for residuals of trauma to the right ankle and heel, rated as noncompensable, 0 percent. The veteran again injured his right lower extremity in 1981. December 1981 X-rays were interpreted as showing no evidence of that trauma; although there was an accessory ossicle inferior to the medial malleolus and a small calcaneal spur. January 1982 X-rays were read a showing bony fragments near the medial malleolus probably related to old trauma. Private clinical records described limping, swelling and puffiness in 1982; the diagnosis was an old strain of the right ankle. A claim for an increased rating for ankle swelling and pain was received in May 1993. At his February 1994 RO hearing, the veteran testified that he occasionally used a stocking type brace on his ankle; although he felt it caused swelling and aggravation more than helping. On examination in April 1996, the veteran complained of foot pain. He complained of pain from a knot under the right toes. He also reported radiating pain down the right leg from the hip to the foot. Objectively, no joint swelling was noted. There was some limitation of motion with pain in the lower extremities. There was no pedal edema. A tender, inflamed and slightly reddened area beneath the toes of the right foot suggested a neuroma. There were no ankle or heel findings. At his June 1997 Board hearing, the veteran testified that he used an elastic ankle brace, until the throbbing in the extremity became too bad to use it. He stated that he twisted the ankle every time he walked on it and had swelling. He reported that he wore tied boots because of ankle weakness. Recent X-rays were said to disclose arthritis. At the August 1999 Board video conference hearing, the veteran testified that he had been given a 1/4 inch lift pad to treat his ankle and heel conditions. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (1999). Looking to the criteria for rating ankle disabilities, there is no evidence of ankylosis ratable under Code 5270 or 5272, malunion ratable under Code 5273 or surgery residuals ratable under Code 5274. 38 C.F.R. § 4.71a (1999). Limited motion of the ankle will be rated as 20 percent disabling if marked and 10 percent disabling if moderate. 38 C.F.R. Part 4, Code 5271 (1999). The rating criteria do not provide a compensable rating for the mild or slight limitations described by the veteran. 38 C.F.R. § 4.31 (1999). The veteran has reported using a 1/4 inch lift for his ankle and heel symptoms. There is no evidence that there is actual shortening of the leg or that it approximates the 11/4 inches required for a compensable rating. 38 C.F.R. Part 4, Code 5275 (1999). Looking to the other aspects of the service-connected disability, the condition could be rated under Code 5284 for foot injuries. Other foot injuries may be rated as 10 percent disabling where moderate, 20 percent disabling where moderately severe and 30 percent disabling where severe. 38 C.F.R. Part 4, Code 5284 (1999). With actual loss of use of the foot, the disability will be rated as 40 percent disabling. 38 C.F.R. § 4.31 (1999). Here again, the disability must approximate the moderate level to be compensable. 38 C.F.R. § 4.7 (1999). A noncompensable rating must be assigned for the slight or mild symptoms described by the veteran. 38 C.F.R. § 4.31 (1999). While the veteran may feel that his service-connected heel and ankle disability is so symptomatic that it warrants a compensable rating, the findings of the trained medical personnel are more probative and establish that the symptoms do not approximate the moderate disability required for a higher, compensable, rating under any applicable criteria. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 4.7, 4.31 (1999). 8. Entitlement to an Increased Rating for an Insect Bite Scar of the Right (Dominant) Hand In May 1969, the veteran sustain a centipede bite on the radial aspect of the right forearm at the wrist. Itching, blisters, cellulitis and secondary infection followed. In July 1969, it was noted that the symptoms were subsiding. On the March 1989 VA examination, there was normal range of motion in all parameters and grip was 4/4. The right hand had a freely movable U shaped scar, 8 millimeters by 8 millimeters by 8 millimeters. The August 1989 rating decision granted service connection for scar, right hand, residual of insect bite, rated as noncompensable, 0 percent disabling, under Code 7805. A May 1992 VA dermatology clinic note shows the veteran had erythema, blanching and papules on the right arm. A June 1992 note discloses that a biopsy had diagnosed folliculitis, that it had responded to treatment and the skin was clear. The diagnosis was folliculitis, resolved. In November 1992, there were a few erythematous papules on the arms. The diagnosis was resolved folliculitis. On follow-up in April 1993, there was no activity. A claim for an increased rating for swelling of insect bites was received in May 1993. In February 1994, the veteran testified at an RO hearing that he kept getting sores in the area of the bite. He told of an aching sensation and tenderness to pressure. At the VA clinic in March 1994, the veteran complained that his skin condition was not being documented. Physical examination disclosed papules on the left forearm, left upper arm, and right forearm. The assessment was folliculitis. No right wrist abnormality was reported. The March 1995 VA dermatology clinic record shows hyperkeratosis on the elbows and stucco keratoses/xerosis on the upper arms. In September 1995, there were excoriations on the left forearm. No right wrist abnormality was reported on either occasion. On general examination in April 1996, there were multiple scars, although no specific findings as to the right wrist. The April 1996 VA dermatology examination determined that there were no lesions. The October 1996 dermatology clinic record shows the skin was clear. No lesions were seen on clinical evaluation in January 1997. No lesions were present on the subsequent 6 month evaluation in 1997 and in March 1998. In June 1997, the veteran testified at a Board hearing and told of pain in the wrist, in the area of the bite. At his August 1999 Board video conference hearing, the veteran testified that the bite scar itched and became tender and red. It responded to Benadryl. He was under the care of a dermatologist. The initial insect bite was apparently very painful and slow to heal. However, the preponderance of the evidence establishes that there are no current compensable manifestations for which compensation could be awarded. It is not contended nor does the evidence show that a residual scar is poorly nourished or ulcerated as required for a compensable rating under Code 7803. While the veteran has complained of pain in the area, no residual scar has been identified and no medical professional has found the bite residuals to be tender and painful on objective demonstration, as required for a compensable rating under Code 7804. Further, while the veteran has asserted that bite residuals affect the functioning of the wrist, the medical evidence shows that there is no functional limitation. Consequently, a compensable rating is not warranted under Code 7805. The preponderance of evidence on this issue demonstrates that the insect injury residuals do not approximate any applicable criteria for a compensable rating. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 4.7, 4.31 (1999). Other Criteria and Extraschedular Rating The potential application of various provisions of Title 38 of the Code of Federal Regulations (1998) have been considered whether or not they were raised by the veteran as required by the holding of the United States Court of Veterans Appeals in Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991), including the provisions of 38 C.F.R. § 3.321(b)(1) (1999). The Board, as did the RO, finds that the evidence of record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1) (1999). In this regard, the Board finds that there has been no showing by the veteran that any of his service-connected disabilities has resulted in marked interference with employment or necessitated frequent periods of hospitalization beyond that contemplated by the rating schedule. In the absence of such factors, the Board finds that criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER The petition to reopen a claim of entitlement to service connection for headaches is denied. A 100 percent rating for PTSD is granted. A 30 percent rating for residuals of injury to the left (non-dominant) arm, shoulder and wrist with vein graft is granted. These grants are subject to the law and regulations governing the payment of monetary awards. An increased rating for defective vision of the right eye is denied. An increased rating for residuals of fractures of the facial bones is denied. An increased rating for right maxillary sinusitis, secondary to trauma, is denied. An increased rating for residuals of injury to the right ankle and heel is denied. An increased rating for an insect bite scar of the right (dominant ) hand is denied. REMAND The Court has held that there must be examination reports containing sufficient information to rate a disability in accordance with the applicable rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). In DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court discussed the applicability of 38 C.F.R. §§ 4.40 and 4.45 to examinations of joint motion. In Arnesen v. Brown, 8 Vet. App. 432 (1995) the Court applied the principles of DeLuca to the rating of knees. An examiner should evaluate the veteran's left knee in accordance with the guidance of the Court and the applicable regulations. The veteran is advised that if he fails to report for such examination without good cause, his claim for increase shall be denied. 38 C.F.R. § 3.655 (1999). The issue of entitlement to an increased rating for the post- operative residuals of a right knee injury is REMANDED to the RO for the following: 1. The RO should schedule the veteran for a VA orthopedic examination. The entire claims folder, must be made available to and be reviewed by the examiner . All necessary tests and studies should be conducted and the examiner should review the results of any testing prior to completion of the report. The physician should provide complete rationale for all conclusions reached and should specifically express an opinion on the following questions: a. What is the range of right knee motion, describing any limiting factors. If the veteran experiences pain on motion, the physician should express an opinion as to the credibility of the complaints and the specify the evidence on which he bases his assessment. The doctor should report at what point in the range of motion any pain appears and how it affects motion. b. Describe all functional loss affecting the right knee including more movement than normal (instability), any locking, weakened movement, fatigability and lack of endurance, incoordination, swelling, deformity, atrophy of disuse, disturbance of locomotion or interference with weight bearing. If possible, the examiner should describe the functional impairment in terms of the degree of additional range- of-motion lost. 2. The RO should review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the examination report. If the requested examination report does not include fully detailed descriptions of pathology and all test reports, special studies or adequate responses to the specific opinions requested, the report must be returned for corrective action. Thereafter, the RO should review the claim for an increased rating for the right knee. In accordance with the current appellate procedures, the case should be returned to the Board for completion of appellate review. The Board intimates no opinion as to the ultimate outcome of this case. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. CONSTANCE B. TOBIAS Member, Board of Veterans' Appeals