Citation Nr: 0003386 Decision Date: 02/10/00 Archive Date: 02/15/00 DOCKET NO. 97-11 238 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for residuals of asbestos exposure. 3. Entitlement to service connection for a gastrointestinal disorder. 4. Entitlement to service connection for a bilateral foot disorder. 5. Entitlement to service connection for residuals of a cystoscopy with blockage of the urethra and urinary dysfunction. 6. Determination of a proper initial rating for obstructive lung disease, currently evaluated as 30 percent disabling. 7. Determination of a proper initial rating for a ganglion of the left wrist, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: John Stevens Berry, Attorney ATTORNEY FOR THE BOARD Wm. Kenan Torrans, Associate Counsel INTRODUCTION The veteran served on active duty from April 1981 to August 1981, and from April 1986 to August 1995. This matter arises from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) which granted the veteran's claims for service connection for moderate obstructive lung disease, and for a ganglion of the left wrist, and denied the remaining claims. The veteran filed a timely appeal, and the case was referred to the Board of Veterans' Appeals (Board) for review. By a June 1999 Remand Order, the Board referred the claim back to the RO for further development. Pursuant to the development undertaken as a result of the Board's Remand Order, the an increased initial rating of 10 percent was granted for the veteran's ganglion of the left wrist. The remaining claims were denied. The case has been returned to the Board for resolution. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable resolution of the issues on appeal has been obtained by the RO. 2. There is no competent medical evidence of a nexus or link between any diagnosed bilateral hearing loss and the veteran's active service. 3. There is no competent medical evidence of a diagnosis showing that the veteran currently suffers from residuals of asbestos exposure. 4. There is no competent medical evidence of a nexus or link between any currently diagnosed gastrointestinal disorder, to include a hiatal hernia and gastroesophageal reflux disease, and the veteran's active service. 5. There is no competent medical evidence of a nexus or link between any currently diagnosed bilateral foot disorder and the veteran's active service. 6. There is no competent medical evidence, including a diagnosis, that the veteran currently suffers from residuals of a cystoscopy, or that establishes a nexus or link between any currently diagnosed urethral blockage or urinary dysfunction and the veteran's active service. 7. The veteran's moderate obstructive lung disease is objectively shown to be productive of no more than moderate symptoms with considerable pulmonary fibrosis and moderate dyspnea on slight exertion, confirmed by PFTs, and FEV-1 of 56- to 70-percent predicted, FEV-1/FVC of 56- to 70 percent, or; DLCO(SB) of 56- to 65-percent predicted. 8. The veteran's left wrist is not shown to involve ankylosis, and his ganglion cyst of the left wrist is objectively shown to be productive of no more than a slight limitation of motion and subjective complaints of painful motion on extended or heavy use. CONCLUSIONS OF LAW 1. The veteran's claim for service connection for bilateral hearing loss is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The veteran's claim for service connection for residuals of asbestos exposure is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The veteran's claim for service connection for a gastrointestinal disorder is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The veteran's claim for service connection for a bilateral foot disorder is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 5. The veteran's claim for service connection for residuals of a cystoscopy, with urethral blockage and urinary dysfunction, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 6. The criteria for an initial assignment of a disability evaluation in excess of 30 percent for the veteran's moderate obstructive lung disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1- 4.14, 4.97, Diagnostic Code 6845 (1999); 38 C.F.R. § 4.97, Diagnostic Code 6802 (1996). 7. The criteria for an initial assignment of a disability evaluation in excess of 10 percent for a ganglion cyst of the left wrist have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5215 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection The law provides that service connection may be granted for a disability resulting from a disease or injury that was incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). If a condition noted during service is not shown to be chronic, then continuity of symptomatology after service is generally required for service connection. See 38 C.F.R. § 3.303(b) (1999). In addition, regulations provide that a pre-existing injury or disease will be considered to have been aggravated by active duty where there is an increase in a disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. See 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. § 3.306(b) (1999). Further, a veteran who served during a period of war or during peacetime after December 31, 1946, is presumed to be 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. See 38 U.S.C.A. §§ 1111, 1137 (West 1991); 38 C.F.R. § 3.304(b) (1999). The threshold question which must be answered in this case is whether the veteran has presented well-grounded claims for service connection. The veteran has "the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." See 38 U.S.C.A. § 5107(a) (West 1991); Robinette v. Brown, 8 Vet. App. 69, 73 (1995). A well-grounded claim is a "plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive, but only possible to satisfy the initial burden of § [5107]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1995). To establish that a claim for service connection is well grounded, the claimant must satisfy three elements. First, there must be evidence of an incurrence or aggravation of an injury or disease in service. Second, there must be competent (i.e. medical) evidence of a current disability. Third, there must be evidence of a nexus or link between the in-service injury or disease and the current disability, as shown through the medical evidence. See Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). Lay or medical evidence, as appropriate, may be used to substantiate service incurrence. See Caluza v. Brown, 6 Vet. App. 489, 507 (1995); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Alternatively, a claim may be well grounded based on the application of the rule for chronicity and continuity of symptomatology, set forth in 38 C.F.R. § 3.303(b). See Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). Service connection for bilateral hearing loss, residuals of asbestos exposure, a gastrointestinal disorder, and a bilateral foot disorder were denied by a November 1996 rating decision. The veteran filed a timely appeal with respect to these issues, and they were addressed by the Board in a June 1999 Remand Order. Service connection for what was then characterized as urethral blockage, residuals of a cystoscopy with urinary dysfunction was denied by a January 1998 rating decision. The veteran's substantive appeal with respect to this issue, dated in June 1998, was apparently received after the case was initially referred to the Board for resolution, and was not considered in its June 1998 Remand Order. In any event, the issue of service connection for what is now characterized as residual of a cystoscopy with urethral blockage and urinary dysfunction will be addressed here. With respect to the veteran's claim for service connection for bilateral hearing loss, the Board observes that in April 1985, a National Guard medical examination, conducted approximately one year before the veteran entered active duty, showed that the veteran experienced bilateral hearing loss within the meaning of 38 C.F.R. § 3.385 (1999). However, subsequent audiological examinations conducted after the veteran entered active duty, and dated in October 1986, December 1988, August 1990, and upon separation from active duty in July 1995 failed to disclose any such disability as defined by 38 C.F.R. § 3.385. In July 1996, approximately one year after the veteran was discharged from service, he was afforded a VA rating examination. The report of the audiological portion of that examination shows his puretone thresholds, in decibels, to be as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 15 20 10 LEFT 5 15 20 20 15 The average puretone hearing loss in the right ear was 15 decibels, and in the left ear, was 17 decibels. Speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 84 percent in the left ear. While the veteran's puretone thresholds clearly did not indicate the presence of a hearing loss disability, per se, he was nonetheless shown to have a hearing loss disability in his left ear by virtue of the 84 percent speech recognition score under 38 C.F.R. § 3.385. The examiner concluded that the veteran's puretone sensitivity was within normal limits bilaterally, and that word recognition was within normal limits in the right ear, but slightly reduced in the left. The veteran underwent an additional VA audiological examination in April 1997 in which his puretone hearing loss was shown to be essentially consistent with the results shown in the report of the previous July 1996 audiological examination. However, the report of the April 1997 examination shows his speech audiometry results to be 90 percent in the right ear, and 94 percent in the left ear. Such results are inconsistent with the July 1996 results, and indicate a hearing loss disability in the right ear solely on the basis of the speech recognition score of 90 percent, but no disability in the left ear under 38 C.F.R. § 3.385. In any event, where a veteran served for 90 days or more on active duty, and an organic disease of the central nervous system, including sensorineural hearing loss, develops to a degree of 10 percent or more within one year from the date of separation from service, such disease may be service connected, even though there is no evidence of such disease in service. See 38 U.S.C.A. §§ 1101, 1112 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). The Board has reviewed the medical evidence pertaining to bilateral hearing loss, and concludes that the veteran's claim for service connection for bilateral hearing loss is not well grounded. The veteran claims that exposure to noise from tanks and other acoustic trauma in service resulted in bilateral hearing loss. He was not shown to experience hearing loss during his actual period of active duty. Following service, per the results of the July 1996 VA audiological examination, he was shown to have a hearing disability in his left ear under 38 C.F.R. § 3.385, by virtue of the 84 percent Maryland speech recognition score. However, the report of the subsequent VA rating examination of April 1997, showed that the veteran had a right ear hearing loss disability, but no disability in the left ear under 38 C.F.R. § 3.385. While the veteran may be shown to have hearing disabilities in his left and right ears in July 1996 and April 1997, respectively, such disabilities were not shown to have been manifest to a degree of 10 percent or more following his discharge from service under the criteria for evaluating hearing loss. See 38 C.F.R. § 4.85, Diagnostic Code 6100 (1999). In addition, aside from noting the veteran's self- reported history of exposure to acoustic trauma, there is no medical opinion of record establishing the required nexus or link between any diagnosed hearing loss and the veteran's active service. The Board notes that the report of the January 1997 rating examination contains the examiner's stated opinion that the veteran's tinnitus was the result of exposure to acoustic trauma during service. However, he did not state that the veteran's hearing loss, to the extent that such could be established, was a result of any exposure to acoustic trauma. Absent such a medical opinion, the Board finds that the veteran's claim for bilateral hearing loss is not well grounded, and must be denied on that basis. With respect to the veteran's claim for service connection for residuals of asbestos exposure, his service medical records do not disclose any medical symptoms shown to be the result of exposure to asbestos, and do not include any evaluations or treatment based on complaints of exposure to asbestos. He contends, in substance, that while serving on active duty status in the Nebraska Army National Guard, he was assigned to a Naval Guard building in Lincoln, Nebraska, which contained large quantities of asbestos. The veteran indicated that he had received a letter from the National Guard advising him of the dangers of asbestos exposure, and that he may have been at some health risk as a result of such exposure. The veteran underwent a series of VA rating examinations in which he was noted to have a history of having worked in a building containing asbestos products, but which failed to contain any diagnoses related to asbestos exposure, or disclose any findings relating to asbestos. The report of a July 11, 1996 VA rating examination includes the veteran's history of having worked for one year in a building that had been condemned due to asbestos. However, he was not found to have any diseases known to be associated with asbestos. The examiner's diagnoses included asbestos exposure by history, and chronic obstructive pulmonary disease (COPD). The report of an April 1997 VA rating examination shows that some five years previously, the veteran had worked for approximately one year in a building that had been condemned for asbestos. The veteran was noted to smoke one pack of cigarettes every two days, and that he had a history of smoking over the past thirty years. There was no evidence of any malignancies at that time, but the veteran was shown to have mild COPD based on a pulmonary function test (PFT), which the examiner determined was related to the veteran's history of smoking. The examiner noted the veteran's past history of asbestos exposure some five years previously, but also observed that it was difficult to determine the significance of such exposure, given that the veteran only worked in an area where asbestos was present, and did not actually work with asbestos itself. In any event, the examiner stated that the X-ray results did not disclose any residuals of asbestos exposure, although it was then too early for such symptoms to be manifested. The report of an August 1998 rating examination also notes the veteran's reported history of asbestos exposure, but fails to contain any indication that the veteran suffered from any residuals of such exposure. However, aside from problems noted with COPD due to smoking, no residuals of asbestos exposure were found. Chest X-ray results showed that the veteran had what was characterized as an antecedent granulomatous disease, but that there was no mention of a portal plaque suggestive of asbestosis. The examiner concluded with final diagnoses of a history of asbestos exposure with no X-ray evidence of asbestosis, and COPD per pulmonary function tests, probably due to smoking. The veteran underwent an additional rating examination in August 1999. The report of that examination shows that the examiner noted the veteran's previous history of asbestos exposure, but that prior X-rays failed to disclose any evidence of residuals of such exposure. The veteran was shown to have an antecedent granulomatous disease with a small-calcified granuloma, which was observed in the right lung base. The examiner concluded with diagnoses of mild obstructive lung disease, probably due to smoking, and a history of asbestos exposure. The Board has reviewed the above-discussed evidence, and must conclude that the veteran has failed to present evidence of a well-grounded claim for asbestosis. The only lung or respiratory disease with which he is diagnosed, mild to moderate COPD, has been attributed to smoking. In addition, service connection for mild to moderate COPD is already in effect. The Board acknowledges the veteran's history of exposure to asbestos, and recognizes that he is in possession of a letter from the National Guard warning him that he may have been at risk due to such exposure. However, in the absence of any medical evidence that the veteran currently suffers from residuals of asbestos exposure, or that otherwise establishes a nexus or link between any currently diagnosed lung or other disorders and such exposure, the Board finds that his claim is not well grounded, and must be denied on that basis. With respect to the veteran's claim for service connection for a gastrointestinal disorder, the Board observes that his service medical records reflect periodic complaints of gastrointestinal upset. The service medical records show that the veteran experienced what appeared to be acute episodes of occasional gastroenteritis, irregularity, diarrhea, and constipation. He received treatment for these disorders, including Pepto Bismol and enemas, and the episodes appear to have been resolved. The report of the veteran's service separation examination of July 1995 did not note any chronic gastrointestinal problems, and the veteran specifically indicated that he did not experience any stomach, liver, or intestinal problems, or problems with indigestion. The report of a July 1996 VA rating examination shows that the veteran reported having experienced several episodes of abdominal cramping, nausea, vomiting, and diarrhea. The veteran indicated that he had been diagnosed with gastroenteritis. On examination, the veteran was not found to have any abdominal abnormalities. The examiner concluded with diagnoses of gastroenteritis by history and gastroesophageal reflux disease. The X-ray results showed evidence of a sliding-type hiatal hernia with mild gastroesophageal reflux, and possible mild duodenitis. However, the report of the rating examination fails to include any medical opinion linking the diagnosed gastroesophageal reflux disease or possible mild duodenitis to the veteran's active service. The Board has evaluated the objective medical evidence, and concludes that the veteran has failed to submit competent medical evidence of a well-grounded claim for service connection for any gastrointestinal disorder. While the Board recognizes that the veteran was seen periodically during his active service for irregularity, diarrhea, and constipation, and was diagnosed with acute gastroenteritis on several occasions, he was not shown during service to have any gastroesophageal reflux disease, duodenitis, or any symptoms suggestive of such disorders. The report of the July 1996 rating examination contains the examiner's observation that the veteran had been diagnosed with gastroenteritis in service. However, on examination, there were no active symptoms attributable to gastroenteritis. The examiner did note gastroenteritis in his final diagnosis, but only by history. The Board emphasizes that there were no active symptoms of gastroenteritis found. Moreover, while the examiner noted that symptoms of a sliding-type hiatal hernia with gastroesophageal reflux and possible duodenitis were indicated, he did not offer any opinion suggesting that these disorders were related to the veteran's active service. In this regard, no symptoms relating to gastroesophageal reflux disease, hiatal hernia, or possible duodenitis were noted in service. Therefore, the Board concludes that in the absence of a medical opinion suggesting a nexus or link between the diagnosed esophageal reflux disease, sliding-type hiatal hernia, or possible duodenitis, the veteran's claim for service connection is not well grounded, and is denied. Regarding the veteran's claim for service connection for a bilateral foot disorder, the report of his initial service entrance examination included the notation that the veteran had experienced problems with his feet. A National Guard periodic physical examination report, dated in April 1985 before the veteran's second period of active duty, shows that the veteran was diagnosed with bilateral flat feet. Further, the report of the April 1986 service entrance examination from the veteran's second period of service shows that he indicated that he experienced problems with his feet. During service, the veteran was apparently able to perform his duties satisfactorily despite alleged foot pain. The report of a July 1996 rating examination shows that the veteran indicated that he had been required to run during service, and that he developed bilateral ankle and foot pain as a result. He stated that he had been told in service that he had "fallen arches" but that he was not issued any orthotics. The veteran further reported that following service, he had remained fairly sedentary, and experienced very little pain. On examination, the veteran was found to have mild pes planus with the weight bearing lines over the first metatarsal. There was no bowing of the Achilles' tendon, no calluses, but a mild hallux valgus deformity was noted. The X-ray results showed normal feet bilaterally. The examiner concluded with a diagnosis of mild pes planus and hallux valgus, bilaterally. He did not offer any opinion to suggest that the veteran's bilateral mild pes planus had been aggravated by his active duty. The Board has evaluated this evidence, and concludes that the veteran has failed to present evidence of a well-grounded claim for service connection for a bilateral foot disorder. As noted, the veteran was found to have experienced foot problems at the time he underwent his initial service entrance examination in January 1981. He was diagnosed with bilateral flat feet in April 1985, prior to his second period of active service. There is no evidence of record to show that the veteran's diagnosed bilateral pes planus was incurred in or aggravated by his active service. As noted, the evidence strongly suggests that the veteran's bilateral pes planus predated his initial entry into service in April 1981, and clearly predated his entry into his second period of active duty, beginning in April 1986. The Board emphasizes that the veteran's bilateral pes planus was not shown by the service medical records to have been aggravated by the veteran's initial four month period of service, nor was it shown to have been aggravated by his second period of service. Moreover, while the report of the July 1986 VA rating examination shows that the veteran had bilateral pes planus with related symptoms including a mild hallux valgus deformity, he did not indicate that this disability had been incurred in or aggravated during the veteran's active service. Accordingly, absent competent medical evidence showing that the veteran's bilateral foot disorder was either incurred in or aggravated by his active service, the Board finds that his claim for service connection is not well grounded, and his appeal with respect to this issue is denied. Regarding the veteran's claim for service connection for residuals of a cystoscopy with urethral blockage and urinary dysfunction, the Board observes that the veteran's service medical records show that he was seen on numerous occasions during his active service for urethral discharge, burning urination, and related problems, which were attributed to prostatitis. Symptomatology involving urethral discharge was noted as early as May 1981, after the veteran's initial four- month period of active duty, and before his second period of active duty, beginning in April 1986. In October 1988, the records show that the veteran underwent a cystoscopy which the service medical records indicate was "tolerated very well." Pursuant to the cystoscopy, the veteran was found to have a very tight bladder neck, and was also found to have a hypertrophied cyst for which surgical correction was recommended. No residuals attributable to the veteran's cystoscopy were noted in the service medical records, and all urinary tract problems he experienced before and after the cystoscopy were found to be the result of chronic, recurrent prostatitis. The RO denied the veteran's claim for service connection for prostatitis by a February 1996 rating decision. The RO denied the veteran's claim on the grounds that prostatitis was found to have existed prior to service, and that there was no evidence of any aggravation of this disease in service. The veteran filed a timely notice of disagreement, and a statement of the case was issued in May 1996. However, he failed to perfect a timely appeal with respect to that issue, and as the February 1996 rating decision is now final, it can only be reopened by submission of new and material evidence. See generally 38 U.S.C.A. §§ 5108, 7105 (West 1991); 38 C.F.R. §§ 3.104, 3.160(d), 20.302, 20.1103 (1999). From a review of the record, it is unclear whether the veteran has attempted to reopen the previously denied claim. Rather, it appears that the veteran has modified his claim seeking a grant of service connection for urinary tract disorders to include as a result of the cystoscopy undergone in October 1998. The Board notes that there may be some question as to whether this "modified" claim for service connection actually involves the same issue which was previously denied by the February 1996 final decision. However, the Board finds that to the extent that the veteran has alleged an additional or separate basis for service connection, this new submission constitutes a new claim, and may be adjudicated as such. The report of an October 1995 VA rating examination shows that the veteran reported having incurred prostatitis in service, but that he did not experience any associated symptoms including dysuria, frequency, urgency, back or flank pain at that time. No symptoms relating to residuals of a cystoscopy, urethral blockage, or urinary tract dysfunction were noted. The examiner concluded with a diagnosis of status-post prostatitis. Residuals of cystoscopy, urethral blockage, or urinary tract dysfunction were not included in the final diagnoses. In support of his claim, the veteran submitted contemporaneous clinical treatment records from the University of Nebraska Hospital and Medical Center, dated in March 1997, and signed by Suzanne J. G. Cornwall, M.D., for complaints of back pain and urinary dysfunction. The veteran reported the onset of back pain after having "pulled a tree down" using ropes and saws in his backyard. In addition, he reported increased frequency and a burning sensation with his urination. He was noted to have a history of chronic prostatitis, and reported that he had not seen a urologist for the past five years. The veteran also reported having undergone a cystoscopy which had revealed urethral strictures, and that after that procedure, his problems flared-up. On examination, his urine was found to be completely normal, and while his prostate was not found to be enlarged, it was noted to be tender and somewhat "boggy." The treating physician concluded with diagnoses of acute prostatitis with a history of chronic prostatitis and low back strain. He was advised that "the strictures may have recurred" but no specific findings related to a cystoscopy were indicated, and his urinary problems were related to prostatitis. The Board has reviewed the medical evidence, and concludes that the veteran has not submitted evidence of a well- grounded claim for service connection for residuals of a cystoscopy with urethral blockage and urinary dysfunction. As noted, his urinary dysfunction and urethral discharges were previously found to have been the result of chronic prostatitis, which, in turn, was determined to have existed prior to service. The Board recognizes that in his March 1997 treatment at the University of Nebraska Clinic, the veteran reported that the cystoscopy, presumably conducted in October 1988, disclosed urethral strictures, and that he experienced "flare-ups" of some sort following the procedure. However, the Board finds that the veteran's service medical records, discussed above, tend to contraindicate the veteran's self-reported history. As noted, the report of the October 1988 cystoscopy includes the notation that the veteran tolerated the procedure well. He was found to have a very tight bladder neck and a hypertrophied cyst, but no urethral strictures, per se. Moreover, the service medical records dated after October 1988 fail to show that the veteran experienced increased problems related to his urinary tract than he did prior to the cystoscopy. In addition, the treating physician of March 1997, Dr. Cornwall, did not specifically indicate that the veteran suffered from any residuals of a cystoscopy or urethral blockage, and attributed the veteran's apparent urinary dysfunction to prostatitis. Dr. Cornwall's comment that the veteran may have experienced a "recurrence" of his strictures does not constitute a definitive diagnosis, fails to establish that any such strictures were present, or if they were, that such strictures were related to the October 1988 cystoscopy or were otherwise incurred in service. Moreover, the Board notes that the October 1988 treatment record detailing the findings pursuant to the cystoscopy did not note the presence of strictures, per se. Rather, it appears that Dr. Cornwall's comment regarding strictures was based on a history as provided by the veteran, rather than a review of his service medical records. Accordingly, the Board finds that absent a medical opinion that the veteran currently suffers from residuals of a cystoscopy, or that his alleged urethral blockage or his urinary dysfunction were incurred in service or as a result of the cystoscopy, his claim is not well grounded, and must be denied on that basis. In addition, lay statements by the veteran that the above- discussed disorders were incurred in or aggravated by service do not constitute medical evidence. As a lay person, lacking in medical training and expertise, the veteran is not competent to address issues requiring expert medical opinions, to include medical diagnoses or opinions as to medical etiology. See Moray v. Brown, 5 Vet. App. 211, 214 (1995); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). For the above reasons, it is the opinion of the Board that the veteran has failed to meet his initial burden of submitting evidence of well-grounded claims for service connection for bilateral hearing loss, residuals of asbestos exposure, a gastrointestinal disorder, a bilateral foot disorder, and for residuals of a cystoscopy with urethral blockage and urinary dysfunction. The Board has not been made aware of any additional relevant evidence which is available which could serve to well ground the veteran's claims. As the duty to assist is not triggered here by well- grounded claims, the Board finds that the VA has no duty or obligation to further develop these claims. See 38 U.S.C.A. § 5103 (West 1991); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps, supra; Grivois v. Brown, 6 Vet. App. 136 (1994). Therefore, as he has failed to submit evidence sufficient to well ground his claims for service connection, the veteran's assertions that he is entitled to "thorough and contemporaneous medical examinations" with respect to the above claims for service connection are without any merit. Id. The Board also views its discussion as sufficient to inform the veteran of the evidence necessary to complete well-grounded claims for service connection with respect to the issues addressed above. II. Determination of a Proper Initial Ratings The preliminary question before the Board is whether the veteran has submitted well-grounded claims within the meaning of 38 U.S.C.A. § 5107, and if so, whether the VA has properly assisted him in the development of his claims. An allegation that a service-connected disability has become more severe is sufficient to establish a well-grounded claim for an increased rating. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 628, 632 (1992). Accordingly, the Board finds that the veteran has presented well-grounded claims. Once a claimant has presented a well-grounded claim, the VA has a duty to assist him in developing facts which are pertinent to that claim. See 38 U.S.C.A. § 5107(a). The Board finds that all relevant facts have been properly developed, and that all evidence necessary for an equitable resolution of the issue on appeal has been obtained. The evidence includes the veteran's service medical records, records of treatment following service, reports of VA rating examinations, and personal statements offered by the veteran and his attorney acting on the veteran's behalf. The Board is not aware of any additional relevant evidence which is available in connection with the present appeal. Therefore, no further assistance to the veteran regarding the development of evidence is required. See 38 U.S.C.A. § 5107(a); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997). Disability evaluations are determined by evaluating the extent to which the veteran's service-connected disability affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.10 (1999). Moreover an appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates staged ratings where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). In addition, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise the lower rating will be assigned. A. Obstructive Lung Disease The record shows that service connection for what was then characterized as a "respiratory condition" was granted by a November 1996 rating decision, and a 30 percent evaluation was assigned, effective from September 1, 1995. This decision was based on the results of a July 1996 VA rating examination which found that the veteran had a moderate obstructive lung disease with significant improvement after the use of bronchodilators. The veteran filed a timely appeal, contending, in substance, that the severity of his now service-connected lung disorder warranted assignment of an initial evaluation in excess of 30 percent. The report of the July 1996 rating examination shows that the veteran reported experiencing some dyspnea on exertion and he was having simultaneous problems with allergies. Chest X- rays were normal. A pulmonary function test (PFT) was conducted which showed FEV-1 of 68 percent predicted, an FEV- 1/FVC reading of 69 percent, and an DLCO reading of 90 percent predicted. As noted, the examiner concluded that these results showed a moderate obstructive disease with significant improvement after bronchodilators, with lung volumes, diffusion capacity, and ABGs all within normal limits. The report of a subsequent VA rating examination dated in April 1997 shows that the veteran did not complain of experiencing any acute problems relating to his respiratory disorder at that time. The examiner observed that it was difficult to determine whether the veteran experienced exertional dyspnea, because he jogged until the previous fall without any reported problems. The veteran reported being able to perform daily activities such as climbing stairs, carrying groceries, and walking extended distances without difficulty. In addition, the veteran reported a long history of smoking, and indicated that he regularly smoked one pack of cigarettes every two days. X-rays of the chest disclosed a calcified old granulomatous lesion which the examiner noted might represent an old incidental finding. The X-ray was otherwise unremarkable. The examiner observed that a PFT performed in March 1997 showed normal lung and diffusion volumes. FEV-1 was 95 percent predicted, and FEF/FVC was 89 percent predicted, and DLCO was 92 percent predicted. Based on the PFT, the examiner concluded that the veteran had a mild obstructive lung disease. The examiner stated that no malignancies were found, but that the veteran's obstructive lung disease could be related to his smoking history. The veteran underwent a VA rating examination in May 1998. The report of that examination shows that he reported experiencing a nonproductive tickling cough about twice per week, and that he ran approximately three times per week for "a couple of miles" at a time. He reported that it appeared increasingly difficult to pass the military physical fitness test administered by the Army Reserves. The examiner stated that a pulmonary examination was unremarkable with vesicular breath sounds without adventitial sounds, and no prolongation of the expiratory phase. However, it does not appear that any PFT results were associated with this examination report. The examiner concluded with a relevant diagnosis of obstructive lung disease, per PFTs, probably due to smoking. The report of a VA rating examination conducted in August 1999 shows that the veteran had a history of obstructive lung disease, probably due to smoking. He was noted to have undergone previous PFTs which showed moderate obstructive lung disease with significant improvement after bronchodilators were employed. The veteran denied any history of cough, sputum production, hemoptysis, or anorexia. He did indicate that he experienced dyspnea on exertion, and reported that on performing yard or farm work, he would become short of breath. He denied experiencing any periods of incapacitation. On examination, the chest was clear, heart sounds were normal, and other than a 10-pound weight gain over the previous year, no abnormalities were found. PFT test results showed an FEV-1 reading of 97 percent predicted, an FEV-1/FVC reading of 96 percent predicted, and a DLCO reading of 91 percent predicted. The examiner indicated that the PFT and X-ray results were within normal limits other than showing the old calcified granulomata noted previously in the right lung. The examiner concluded with a relevant diagnosis of mild obstructive lung disease, probably due to smoking. Under the regulations in effect for restrictive lung diseases when the veteran filed the claim on which this appeal is based, assignment of a 30 percent rating required a showing of moderate symptoms with considerable pulmonary fibrosis and moderate dyspnea on slight exertion, confirmed by PFTs. For assignment of a 60 percent evaluation, a showing of severe symptomatology with extensive fibrosis, severe dyspnea on slight exertion with corresponding ventilatory deficit confirmed by PFTs, with marked impairment of health was required. Upon a showing of pronounced symptoms with extent of lesions comparable to far advanced pulmonary tuberculosis or PFTs confirming a markedly severe degree of ventilatory deficit, with dyspnea at rest and other evidence of severe impairment of bodily vigor producing total incapacity, a 100 percent evaluation was contemplated. See 38 C.F.R. § 4.97, Diagnostic Code 6802 (1996). By regulatory amendment which became effective from October 7, 1996, substantive changes were made to the schedular criteria for evaluating respiratory disorders such as that for which the veteran is service connected, previously set forth at 38 C.F.R. § 4.97, Diagnostic Code 6802 (1996, now codified at 38 C.F.R. § 4.97, diagnostic Code 6845 (1999). Under the revised criteria for restrictive lung diseases, assignment of a 30 percent is contemplated where there is FEV-1 of 56- to 70-percent predicted, FEV-1/FVC of 56- to 70 percent, or; DLCO(SB) of 56- to 65-percent predicted. A 60 percent evaluation is appropriate where there is FEV-1 of 40- to 55-percent predicted, or FEV-1/FVC of 40 to 55 percent, or; DLCO(SB) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit). For assignment of a 100 percent evaluation, there must be a showing of FEV-1 of less than 40 percent of predicted value, or; FEV-1/FVC of less than 40 percent, or; DLCO(SB) of less than 40-percent predicted, or; maximum exercise capacity of less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or; requirement of outpatient oxygen therapy. See 38 C.F.R. § 4.97, Diagnostic Code 6845 (1999). As the revised regulations came into effect during the pendency of the veteran's claim, the issue of an increased rating for the veteran's respiratory disorder must be evaluated under both the former and the revised schedular criteria. See Karnas v. Derwinski, 1 Vet. App. 301 (1991). However, in Rhodan v. West, 12 Vet. App. 55 (1998), the United States Court of Appeals for Veterans Claims (Court) noted that, where compensation is awarded or increased "pursuant to any Act or administrative issue, the effective date of the Act or administrative issue, the effective date of such an award or increase. . . shall not be earlier than the effective date of the Act or administrative issue." Id. at 57. See also 38 U.S.C.A. § 5110(g) (West 1991). As such, the Court found that this rule prevents the application of a later, liberalizing law to a claim prior to the effective date of the date of the liberalizing law. Applying the criteria for the veteran's obstructive lung disease to the evidence of record, the Board concludes that the initially assigned 30 percent evaluation is appropriate, and that the preponderance of the evidence is against assignment of a higher evaluation under any diagnostic code. Under the former criteria, after resolving all reasonable doubt in the veteran's favor, he could objectively be found to have what could be characterized as a moderate obstructive lung disease, manifested by subjective complaints of dyspnea on exertion and PFT results. Such symptomatology is consistent with assignment of a 30 percent evaluation under the former rating criteria. However, the veteran was not shown to remotely have what is described as "severe" symptomatology, despite any assertions to the contrary. In fact, the veteran only complained of experiencing slight to moderate dyspnea on exertion, and during the course of his rating examinations, generally denied experiencing any real problems resulting from his restrictive lung disease. Under the revised criteria, which contemplates evaluating a restrictive lung disease, such as the veteran's obstructive lung disease, on more of a mechanical basis, the Board finds that the veteran's symptomatology was not consistently shown, over the course of several rating examinations, to have risen to the degree of severity warranting assignment of a 30 percent evaluation. However, again considering all of the evidence of record, and after resolving all reasonable doubt in favor of the veteran, the Board finds that the evidence supports an initial assignment of a 30 percent evaluation for "moderate" obstructive lung disease. As noted, the results of the PFT conducted in July 1996 showed results consistent with a 30 percent evaluation under Diagnostic Code 6845. The veteran's FEV-1 reading was 68 percent predicted, and his FEV-1/FVC reading was 69 percent. Such readings fall within the criteria for assignment of a 30 percent evaluation under Diagnostic Code 6845. However, the Board also notes that the veteran did not complain of any other symptomatology, other than subjective and unconfirmed complaints of mild dyspnea on exertion. In addition, the Board also notes that the PFT results from the April 1997 and the August 1999 VA rating examinations fail to show a disability picture to the degree of severity warranting assignment of even a 10 percent evaluation under Diagnostic Code 6845. His respiratory disorder appears to have improved significantly over time. In any event, given the results of the July 1996 examination, the Board concludes that the initially assigned 30 percent evaluation for the veteran's moderate obstructive lung disorder is appropriate. See Fenderson, supra. However, the veteran is advised that this determination does not necessarily apply to future rating decisions, which will be based solely on the revised criteria under 38 C.F.R. § 4.97, Diagnostic Code 6845 (1999), particularly in view of later PFT results of April 1997 and August 1999, which fail to show a disability picture warranting assignment of a compensable evaluation. In short, the objective medical evidence fails to disclose the presence of an overall disability picture to the degree of severity the veteran has reported. Accordingly, the Board concludes that the preponderance of the evidence is against the veteran's present claim for assignment of an initial evaluation in excess of 30 percent for his obstructive lung disease, and his appeal with respect to that issue is denied. B. Ganglion Cyst of the Left Wrist Historically, service connection for what was characterized as a ganglion, left wrist, was granted by a November 1996 rating decision, and an initial zero-percent evaluation assigned, effective from September 1, 1995. The veteran filed a timely appeal, contending that the severity of this disorder warranted initial assignment of a compensable evaluation. The case was referred to the Board, and by a June 1999 Remand Order, the case was referred back to the RO for further development. Pursuant to the development undertaken at the Board's request, an increased initial rating of 10 percent for the veteran's ganglion cyst of the left wrist was granted by a September 1998 rating decision. The veteran now appears to contend that the initially assigned 10 percent rating for his ganglion cyst does not adequately reflect the severity of this disorder, and that a higher initial rating is therefore warranted. Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examinations upon which ratings are based adequately portray the anatomical damage, and the functional loss with respect to all of these elements. The functional loss may be due to the absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. See 38 C.F.R. §§ 4.40, 4.45 (1999). Under DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995), the Board, in addition to applying the regular schedular criteria, may consider granting a higher evaluation in certain areas in which functional loss due to pain is demonstrated. The report of the July 1996 VA rating examination, which first evaluated the veteran's ganglion cyst of the left wrist, shows that the veteran indicated having developed a "lump on his left wrist" approximately six years previously, and was diagnosed with a ganglion. In addition, he stated that he experienced pain in the area of the ganglion cyst during cold weather and upon repetitive use. On examination, there was a 4-centimeter (cm) cystic structure of the medial aspect of the left wrist. There was full active range of motion of the left wrist. The examiner concluded with a diagnosis of ganglion, left wrist. The veteran underwent an additional VA rating examination in April 1997 in which he reported having "strained" his wrist during service, but did not incur any direct trauma to the left wrist, per se. He indicated that a "mass popped up" on the ulnar side of his left wrist, and had been growing slightly over the years. He stated that the mass became painful on heavy use, and that he experienced occasional tingling sensations in his fingers. He was reported since 1995 to be employed as a computer operator in software technical support requiring use of a keyboard. Examination of the left wrist disclosed a prominent lesion on the ulnar side of the wrist just proximal to the wrist crease itself. The examiner stated that the mass was more prominent with ulnar deviation of the wrist, and measured approximately 3-cm in diameter. The mass was tender to deep palpation, was fluctuant, and was not adherent to the underlying skin. There was no mottling of the skin observed. Range of motion in the left wrist included 25 degrees abduction, dorsiflexion of 60 degrees, and volar flexion of 80 degrees. Wrist strength was not affected, and was found to be 5/5 in all movements. X-rays of the wrist did not disclose any bony abnormality. The veteran was diagnosed with a left middle wrist ganglion and carpal tunnel syndrome in the left wrist. The examiner continued to observe that the left wrist ganglion was tender, but was relieved with anti-inflammatory medications. No treatment was indicated, but the examiner offered his opinion that if the cyst continued to grow, excision would be a viable option. The report of a May 1998 rating examination shows that the veteran reported that his left wrist was essentially unchanged since the last rating examination. He reported experiencing daily discomfort over the area of the ganglion, which was exacerbated by keyboard activities. The veteran also indicated that he took Motrin approximately once per month for his pain. According to the veteran, performing strenuous activities resulted in fatigue in his left wrist and hand. On examination, the veteran was observed to have a 3 x 3-cm fluctuant, nonerythematous mass just proximal to the ulnar styloid, which was nontender. Some mild dorsal and lateral tenderness was shown. Range of motion was 55 degrees of dorsiflexion, 65 degrees of palmar flexion, 45 degrees of ulnar deviation, and 10 degrees of radial deviation of the right wrist. The left wrist was shown to have 60 degrees of dorsiflexion, 62 degrees of palmar flexion, 55 degrees of ulnar deviation, and 15 degrees of radial deviation. Tinel's sign was negative bilaterally. Grip strength was symmetric and appeared normal. Flexion and extension of the forearms was normal. Fine movement of the hands appeared normal. The examiner concluded with a diagnosis of a ganglion of the left wrist. The Board has reviewed the objective medical evidence, and concludes that the initially assigned 10 percent evaluation for the veteran's ganglion cyst of the left wrist is appropriate, and that the preponderance of the evidence is against assignment of a higher rating under any diagnostic code. Under 38 C.F.R. § 4.71a, Diagnostic Code 5215 (1999), a 10 percent evaluation is assigned for limitation of motion of the wrist (either major or minor) with palmar flexion limited in line with the forearm. In addition, a 10 percent evaluation is warranted where dorsiflexion is less than 15 degrees. Under Diagnostic Code 5215, 10 percent evaluations are the only available ratings available absent a showing of ankylosis. Id. The Board observes that the veteran's left wrist ganglion cyst is not shown to be ankylosed, is not objectively shown to involve weakness, but only some mild tenderness on palpation. The veteran's range of motion in his left wrist is roughly equal to the range of motion in his right wrist, and at most, only shows a very slight loss of motion as compared with wrist motion depicted in 38 C.F.R. § 4.71, Plate I (1999). However, the veteran has complained consistently of experiencing pain on repeated or heavy use of his left wrist. The Board concludes, therefore, that after resolving all reasonable doubt in favor of the veteran, the evidence supports an initial grant of a 10 percent evaluation based on pain on motion. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra. However, as the veteran's wrist is not otherwise shown to be impaired, the Board finds that the preponderance of the evidence is against assignment of an initial evaluation in excess of 10 percent under any other diagnostic code. Accordingly, inasmuch as an initial 10 percent evaluation is currently in effect for the veteran's left wrist ganglion cyst, his claim for assignment of an initial evaluation in excess of 10 percent is denied. C. Conclusion The potential application of Title 38 of the Code of Federal Regulations (1999) has been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Board has carefully considered the evidence presented and the veteran's contentions, but finds that there has been no showing that the service-connected disabilities discussed above have necessitated frequent (or any) hospitalization, have resulted in marked interference with employment, or otherwise render impracticable the regular schedular standards. In this regard, the Board observes that the veteran has apparently retired from active duty National Guard service, and has, since 1995 been employed as a computer technical support staff member. The Board finds, therefore, that the evidence fails to show that the veteran is incapable of obtaining or retaining gainful employment as a result of his service- connected disabilities. Accordingly, in the absence of factors suggestive of an unusual disability picture, further development in keeping with the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) (1999) is not warranted here. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). As the preponderance of the evidence is against the veteran's claims for higher initial ratings, the benefit of the doubt doctrine is not applicable here, and the claims for initial evaluations in excess of 30 percent for a respiratory disability, and in excess of 10 percent for a left wrist disability are denied. See 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Should the veteran's disability picture change, of course, he may apply at any time for increases in his assigned disability ratings. See 38 C.F.R. § 4.1. At present, however, the Board finds no basis upon which to grant increased ratings for the disabilities discussed in Part II of this decision. ORDER Evidence of a well-grounded claim not having been submitted, service connection for bilateral hearing loss is denied. Evidence of a well-grounded claim not having been submitted, service connection for residuals of asbestos exposure is denied. Evidence of a well-grounded claim not having been submitted, service connection for a gastrointestinal disorder is denied. Evidence of a well-grounded claim not having been submitted, service connection for a bilateral foot disorder is denied. Evidence of a well-grounded claim not having been submitted, service connection for residuals of a cystoscopy with urethral blockage and urinary dysfunction is denied. The initially assigned 30 percent evaluation for the veteran's moderate obstructive lung disease is appropriate, and entitlement to an evaluation in excess of 30 percent for that disorder is denied. The initially assigned 10 percent evaluation for the veteran's ganglion cyst of the left wrist is appropriate, and entitlement to an evaluation in excess of 10 percent for that disorder is denied. WARREN W. RICE, JR. Member, Board of Veterans' Appeals