BVA9504663 DOCKET NO. 91-49 046 DATE JAN 31 1995 On appeal from the decision of the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a left shoulder disability. 3. Entitlement to an increased rating for residuals of a fracture of the left ankle currently evaluated as 20 percent disabling. 4. Entitlement to an increased rating for varicose veins of the left leg, currently evaluated as 20 percent disabling. 5. Entitlement to an effective date for an award of service connection for varicose veins of the left leg, prior to October 26, 1990. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD James R. Siegel, Counsel INTRODUCTION The veteran served on active duty from February 1967 to June 1970. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from decisions from the Regional Office (RO). In a rating decision dated in July 1990, the RO denied the veteran's claim of entitlement to an increased rating for residuals of a fracture of the left ankle. By rating action of January 1991, the RO granted service connection for varicose veins of the left leg and assigned a 20 percent evaluation for it. The effective date of the award of service connection was October 26, 1990. In this rating decision, the RO also denied service connection for a back disability and for a left shoulder disorder. The veteran has disagreed with the assigned ratings for his service-connected disabilities, with the denial of service connection for back and left shoulder disabilities and with the effective date of the award of service connection for varicose veins of the left leg. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that service connection should be established for back and left shoulder disabilities. He claims that as a result of his service-connected left ankle disability, he walked with an unnatural gait and that this caused his back disability. He reports that he began to have back problems following the second surgery on his left ankle. He maintains that he was told that his back disorder could be due to the way he had to walk because of the left ankle disability. He also states that when he originally injured his left ankle, he was hanging onto a railing with both arms and that he subsequently developed left shoulder problems. He notes that his left shoulder has always had a "cracking" to it. The veteran also asserts that his left ankle disability and his varicose veins have increased in severity. He argues that he has problems with stability of the left ankle, limitation of motion, as well as increased pain in the joint. He notes that his symptoms have required the use of a brace. He reports that his varicose veins are painful and that the leg swells. Finally, the veteran argues that an earlier effective date should have been assigned for the grant of service connection for varicose veins. He insists that the effective date should at least be March 1990, the date of the Department of Veterans Affairs (VA) examination. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the weight of the evidence supports the grant of service connection for a back disability and the claim for an earlier effective date for an award of service connection for varicose veins of the left leg. It is also the decision of the Board that the weight of the evidence is against the claims for an increased raring for residuals of a fracture of the left ankle and for varicose veins of the left leg. Finally, it is the decision of the Board that the veteran has not met the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim of entitlement to service connection for a left shoulder disability is well-grounded. FINDINGS OF FACT 1. With respect to all issues except for entitlement to service connection for a left shoulder disability, all relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. Service connection is in effect for residuals of a fracture of the left ankle and for varicose veins. 3. The veteran was noted to have chronic low back strain on recent VA examination. 4. The competent medical evidence of record establishes that his back disability, which was first noted following service, is related to the service-connected residuals of a left ankle fracture. 5. A left shoulder disorder was first present many years after service. 6. There is no competent medical evidence of record linking the left shoulder disability to an event in service or to either of the veteran's service-connected disabilities. 7. The veteran's left ankle disability is manifested by limitation of motion. 8. Ankylosis of the left ankle is not present. 9. The veteran's varicose veins involve most of the left leg and are large. 10. There is no evidence of swelling or ulceration associated with the varicose veins. 11. The varicose veins of the left leg are not more than moderately severe. 12. The veteran was noted to have a history of varicose veins of the left leg secondary to an old ankle fracture when he was seen in a VA outpatient treatment clinic on November 13, 1989. 13. He submitted a formal claim for service connection for varicose veins of the left leg on October 26, 1990. CONCLUSIONS OF LAW 1. A low back disability is proximately due to or the result of a service-connected disease or injury. 38 U.S.C.A. 5107 (West 1991); 38 C.F.R. 3.3 10(a) (1993). 2. The veteran has not submitted evidence of a well-grounded claim of entitlement to service connection for a left shoulder disability. 38 U.S.C.A. 1110, 5107 (West 1991); 38 C.F.R. 3.310(a). 3. A rating in excess of 20 percent for residuals of a left ankle fracture is not warranted. 38 U.S.C.A. 1155, 5107 (West 1991); 38 C.F.R. 3.321(b)(1), 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, Part 4, Code 5271 (1993). 4. A rating in excess of 20 percent for varicose veins of the left leg is not warranted. 38 U.S.C.A. 1155, 5107; 38 C.F.R. 3.321(b)(1), 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, Part 4, Code 7120 (1993). 5. The criteria for an effective date of November 13, 1989 for an award of service connection for varicose veins of the left leg have been met. 38 U.S.C.A. 5107, 5110 (West 1991); 38 C.F.R. 3.157, 3.400 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION The initial question before the Board is whether the veteran has submitted a well-grounded claim as required by 38 U.S.C.A. 5107. The United States Court of Veterans Appeals (the Court) has held that a well-grounded claim is one which is plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78 (1990). In this case, the veteran's evidentiary assertions concerning the onset and severity of the symptoms of his disabilities that are within the competence of a lay party to report, and the competent medical evidence of record as to the etiology of his back disorder, are sufficient to conclude that, with respect to all claims now before the Board except for the claim of entitlement to service connection for a left shoulder disability, the claims are well- grounded. Proscelle v. Derwinski, 2 Vet.App. 629; Espiritu v. Derwinski, 2 Vet.App. 492 (1992), King v. Brown, 5 Vet.App. 19 (1993). As to the well-grounded claims, the record has been adequately developed by the RO. Accordingly, no further assistance is required in order to comply with the duty to assist mandated by 38 U.S.C.A. 5107. The veteran has been granted service connection for residuals of a fracture of the left ankle and for varicose veins of the left leg. Under the law, service connection may be granted for disease or injury incurred in or aggravated by wartime service. 3 8 U.S.C.A. 1110. Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. 3.310(a). Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). These include 38 C.F.R. 4.1, 4.2, 4.10, 4.40. The requirements set forth in these regulations for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based on a single, incomplete or inaccurate report, and to enable the VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath, 1 Vet.App. at 593-94. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. 4.2, 4.41, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet.App. 55 (1994). I. Service connection for a Low Back Disability The veteran has not argued, and the evidence does not otherwise establish, that he sustained a back disorder in service. Rather, he claims that the current low back disability developed as a result of the inservice injury to his left ankle. VA outpatient treatment records show that when he was seen in January 1974, the veteran reported that he had been involved in an accident in service in which he fractured his left ankle. He related that he had experienced only occasional back ache until some months earlier. While at work, he gradually developed a back ache with radiation down his left leg as far as the knee. There was an occasional feeling of numbness in the left thigh. He had no real symptoms below the knee. He was never totally free of pain. An examination showed loss of the lumbar lordosis. Flexion was to the ankles with pain. Straight leg raising was to 85 degrees on the right and to 75 degrees on the left. There was no sensory or motor change. The impression was organic back disease. A chiropractor reported in a statement dated in May 1991, that he had first seen the veteran in December 1986 for treatment of low back pain. The diagnosis was chronic lumbar facet syndrome with an associated lumbar sprain. The chiropractor opened that as a result of the inservice accident, the subsequent surgeries, and the resultant disuse atrophy, a compensatory lumbar scoliosis and pelvic unlevelling occurred. As a result thereof, the veteran developed a chronic lumbar back disorder. When the veteran was examined by the VA in March 1990, a clinical history noted on an X-ray report indicated that the veteran was status post a back injury two "days" earlier. It was indicated that his back gave out frequently. An X-ray of the lumbosacral spine was normal, except for very slight spur formation. When the veteran was examined by the VA in January 1993, he related that his low back began to hurt in 1971, although there was no specific injury. The pertinent diagnosis was low back pain, precise nature undetermined, with a negative examination. The veteran was again examined by the VA in February 1994. He described the inservice left ankle injury and stated that he began to have lower back pain in 1972. He attributed it to favoring the left ankle. The pain was located primarily on the left side of his low back and occasionally would go into his left leg. An examination disclosed tenderness over the left posterior iliac crest. Flexion was restricted to 75 degrees by pain and spasm. Right and lateral bending were restricted to 20 degrees and to 15 degrees on the left. Straight leg raising was positive on the left. The diagnoses were chronic lower back strain, possible degenerative disc disease and possible herniated disc. The examiner commented that it was his opinion that the veteran's back problem was related to the inservice injury to the left ankle. As noted above, the veteran has claimed that his back disorder is related to the inservice fracture of the left ankle. The record contains competent medical evidence supporting this allegation. In this regard, both the veteran's private chiropractor and the VA physician following the 1994 VA examination have confirmed that the back disorder is the result of the ankle fracture. There is no evidence in the record contradicting this conclusion. Accordingly, the Board finds that the weight of the evidence supports the claim for service connection for a low back disability. II. Service Connection for a Left Shoulder Disability The threshold question as to this issue is whether the appellant has presented evidence of a well-grounded claim, that is, one which is plausible or capable of substantiation. If not, his appeal must fail and there is no duty to assist him further in the development of his claim, since any such development would be futile. 38 U.S.C.A. 5107; Murphy v. Derwinski, 1 Vet.App. 78 (1990). In Tirpak v. Derwinski, 2 Vet.App. 609 (1992), the Court held that a claim must be accompanied by evidence (emphasis in original). As will be explained below, the appellant has not submitted competent evidence to support his claim for service connection for a left shoulder disability. Thus, the Board finds that his claim is not well-grounded. Accordingly, there is no duty to assist him in the development of this claim. When the Board addresses in its decision a question that has not been addressed by the RO, it must consider whether the appellant has been given adequate notice to respond and, if not, whether he has been prejudiced thereby. Bernard v. Brown, 4 Vet.App. 384 (1993). In light of the appellant's failure to meet the initial burden of the adjudication process, and the fact that by dismissal of his claim he is not burdened with the prior final adjudication on the merits, the Board finds that he is not prejudiced by its consideration of these issues. Thus, if he is able to submit a well-grounded claim in the future, he will not be faced with the higher hurdle of providing new and material evidence to reopen his claim after a prior final adjudication. 38 U.S.C.A. 5108, 7104, 7105 (West 1991); McGinnis v. Brown, 4 Vet.App. 239,244 (1993). The veteran has alleged that his left shoulder disability developed as a result of his service-connected left ankle fracture. He testified that when he was originally injured in 1969, there was a pulling on his left side and that all his subsequent problems, including his left shoulder, have been on the left. The service medical records contain no complaints or findings concerning a disability of the left shoulder. During a VA examination in March 1990, an X-ray of the veteran's left shoulder was normal. The veteran was seen in a VA outpatient treatment clinic in May 1990 and reported that his left shoulder snapped and popped. Following an examination, the assessment was partial tear of the rotator cuff, left. When he was seen in October 1991, it was noted that the popping that he complained of was at the superior angle of the scapula. He had a "snapping scapula." There was some crepitus in the supraspinatus tendon area. The assessment was snapping scapula. During a VA examination in January 1993, the veteran reported that his left shoulder began to bother him about nine or ten years earlier. He recalled it being constant for two to three months and aggravated by motion. He was treated with heat, and the condition was essentially cured. He noted that he had mild recurrence of pain if he rotated the arm. He had not been treated since the initial episode. An examination of the left shoulder showed excellent motor power. The arm elevated laterally to 180 degrees. Forward flexion was 160 degrees and backwards extension was about 70 degrees. Passively, he had 90 degrees of internal and external rotation of the shoulder. All movements were without pain. It was noted that he had about the same range of motion in the left shoulder as in the right shoulder. There was no obvious instability or impingement of the left shoulder. Reflexes were normal. The diagnosis was history of left shoulder pain, precise nature undetermined, with a negative examination. The only evidence in support of the veteran's assertion that his left shoulder problems are related either to service or to his left ankle disability consists of his testimony at a hearing and the various statements he has made in his own behalf. He has not submitted any competent medical evidence linking any left shoulder disability to his period of service or a service connected disorder. As a lay person, the veteran lacks the capability to provide evidence that requires specialized knowledge, skill, experience, training or education. See Espiritu, 2 Vet.App. 492. The Court has held that if the determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required. Grottveit v. Brown, 5 Vet.App. 91 (1993). Indeed, in Moray v. Brown, 5 Vet.App. 211 (1993), the Court noted that lay persons are not competent to offer medical opinions and, therefore, those opinions do not even serve as a basis for a well-grounded claim. Furthermore, in Brammer v. Derwinski, 3 Vet.App. 223 (1992), Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. In this regard, it is significant to point out that, following the January 1993 VA examination, it was noted that the veteran had a history of left shoulder pain, but that the findings on examination at that time were normal. In short, there was no current evidence that he has a left shoulder disability. In the absence of proof of a present disability, there can be no valid claim. The evidence of record establishes that the veteran first reported the onset of left shoulder pain many years after service. In the absence of competent medical evidence demonstrating that there exists any current left shoulder disability that was present in service or that it is clinically related to a service-connected disability, the Board must find that his claim for service connection is not well-grounded. III. An Increased Rating for Residuals of a Fracture of the Left Ankle The service medical records disclose that the veteran was hospitalized in June 1969 for a fractured left leg. He had been working on a ship when his left leg was caught in a tow line and he was thrown into the air and landed on the deck. X-rays revealed trimalleolar fracture of the left ankle. X-rays during the hospitalization showed fractures involving the distal fibula, the tip of the medial malleolus and the posterior aspect of the tibia. The veteran underwent a closed reduction of the fracture and casting. An attempted pinning of the distal fragment of the fibula was unsuccessful, but a reduction of the fibula was accomplished with good position and adequate alignment. The diagnosis was trimalleolar fracture of the left ankle. The cast was removed in September 1969. It was noted the following month that he had about 20 degrees total motion with 5 degrees of dorsiflexion. Residual swelling was noted in January 1970. He had pain over the malleolus with activity. Dorsiflexion was to 10 degrees. By rating decision dated in August 1970, the RO granted service connection for residuals of a trimalleolar fracture of the left ankle. A 20 percent evaluation was assigned pursuant to Diagnostic Code 5271 of the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4. This schedular evaluation has remained in effect since 1970. When the veteran was hospitalized by the VA in August 1971, he reported infrequent pain with ankle motion. Dorsiflexion of the left ankle was to 10 degrees, planter flexion was to 20 degrees, inversion was to 10 degrees and eversion was to 5 degrees. X-rays of the left ankle revealed a non-united fragment of the medial malleolus located medially and inferiorly to the usual position. While hospitalized, several fragments were removed. A 20 percent evaluation may be assigned for marked limitation of motion of the ankle. Code 5271. A 30 percent evaluation may be assigned for ankylosis of the ankle in planter flexion, between 30 degrees and 40 degrees, or in dorsiflexion, between 0 degrees and 10 degrees. Code 5270 (1993). When the veteran was seen in a VA outpatient treatment clinic in October 1989, it was noted that there was no ankle edema. Range of moron disclosed that inversion was to 20 degrees, with other ranges of motion normal. On VA examination in March 1990, it was noted that the veteran walked with a left ankle limp. He was limited in his ability to walk on toes and heels. No local tenderness was noted except for one area out to the medial malleolus. Dorsiflexion of the left ankle was to 20 degrees, planter flexion was to 0 degrees (he had about 10 degrees of midtarsal planter flexion) and inversion and eversion were to 10 degrees. An X-ray of the left ankle showed a deformity of the distal tibia and fibula consistent with a healed fracture. There were minor degenerative changes. The diagnosis was residuals of a trimalleolar fracture of the left ankle. VA outpatient treatment records disclose that when the veteran was seen in February 1991, he could dorsiflex the left ankle 5 degrees and planter flex it 30 degrees. The veteran was again examined by the VA in January 1993. He stated he still had pain in the ankle when he was on the leg very much. He complained of poor motion and that the motion was often painful. He related that he had been advised that a fusion operation might improve the condition. He wore a rigid type of right-angled support for the left ankle. On examination, his gait was normal and he did not limp. He walked on his toes and heels without difficulty or pain. Grossly, all motions of the left ankle and foot looked diminished as compared to the right. Active and passive motions were all painless. There was no motion whatsoever in the left subtalar joint. Dorsiflexion was to 4 degrees, planter flexion was to 24 degrees, mid-tarsal inversion was to 25 degrees and mid-tarsal eversion was to 12 degrees. There was no obvious instability. There was a moderately pronounced irregularity involving the lateral malleolus of the left ankle and the anterior protruding piece of bone is reportedly tender. An X-ray of the left ankle showed no change since the previous examination. There was osteoarthritis of the talotibial joint. The diagnosis was status post multiple malleolar fracture of the left ankle with resulting degenerative arthritis. The veteran was most recently examined by the VA in February 1994. He reported that he had been fitted with a drop foot brace for the left ankle in 1986, in order to relieve giving out and stiffness of the ankle. An examination of the left ankle showed that range of motion was from 5 degrees at dorsiflexion to 15 degrees at planter flexion. Motion was accompanied by crepitus. There was swelling of the left ankle. The diagnosis was status postoperative fracture of the left ankle with degenerative arthritic changes. As noted above, in order to assign a higher rating for the left ankle fracture residuals, the record must show that ankylosis is present. While the Board acknowledges that recent examinations have demonstrated significant limitation of motion, the fact remains that motion in the left ankle is present. Moreover, there is no clinical evidence of ankylosis. The veteran's allegations concerning increased severity of the left ankle have been considered, but they are of less probative value than the clinical findings on examination. The weight of the evidence is against the claim for an increased rating for residuals of a fracture of the left ankle. There are no unusual facts or circumstances presented with regard to this issue that would render the regular scheduler standards inapplicable. 38 C.F.R. 3.321(b)(1). IV. An Effective Date for an Award of Service Connection for Varicose Veins of the Left Leg and an Increased Rating for Varicose Veins of the Left Leg By rating decision dated in August 1972, the RO denied the veteran's claim of entitlement to service connection for varicose veins. This was based on a determination that a clinical relationship was not demonstrated between the veteran's service- connected residuals of a fracture of the left ankle and varicose veins. He was notified of this decision and of his right to appeal by a letter dated the next month, but a timely appeal was not received. Except as otherwise provided, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C.A. 5110; 38 C.F.R. 3.400. The effective date of pension or compensation benefits, if otherwise in order, will be the date of receipt of a claim or the date when entitlement arose, whichever is the later. A report of examination or hospitalization which meets the requirements of this section will be accepted as an informal claim for benefits under an existing law or for benefits under a liberalizing law or VA issue, if the report relates to a disability which may establish. entitlement. 38 C.F.R. 3.157(a). Once a formal claim for pension or compensation has been allowed or a formal claim for compensation disallowed for the reason that the service-connected disability is not compensable in degree, receipt of one of the following will be accepted as an informal claim for increased benefits or an informal claim to reopen. (1) The date of outpatient or hospital examination or date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of a claim. The provisions of this paragraph apply only when such reports relate to examination or treatment of a disability for which service-connection has previously been established or when a claim specifying the benefit sought is received within one year from the date of such examination, treatment or hospital admission. 38 C.F.R. 3.157(b). The veteran has argued that an earlier effective date should be assigned for the award of service connection for varicose veins of the left leg. He has not argued that the August 1972 rating decision was clearly and unmistakably erroneous. Varicose veins of the left lower extremity were apparently first noted when the veteran was examined by the VA in June 1976. The veteran was seen in a VA outpatient treatment clinic on October 2, 1989 for varicose veins of the left leg. He reported that they were noted initially following a trauma to the left ankle twenty years previously. An examination disclosed greater saphenous varicosities and some lesser saphenous varicosities. The assessment was left venous insufficiency. He was again seen on November 13, 1989 with a history of varicose veins of the left leg secondary to an old ankle fracture. No pertinent diagnosis was made. During a VA examination in March 1990, it was noted that the veteran had marked varicosities of the left leg extending to the mid-thigh. There were mild varicosities below the left knee. The veteran submitted a claim for service connection for varicose veins on October 26, 1990. By rating decision dated in January 199 1, the RO granted the veteran entitlement to service connection for varicose veins of the left leg, and assigned a 20 percent evaluation under the provisions of Diagnostic Code 7120 of the VA's Schedule for Rating Disabilities. The grant of service connection was effective October 26, 1990, the date the veteran's claim was received. However, as noted above, the date of an outpatient treatment examination can be considered to be an informal claim for benefits. 38 C.F.R. 3.157. In this case, the veteran was seen in a VA outpatient clinic on November 13, 1989. At that time, he was seen for varicose veins of the left leg. Since he submitted a formal claim for service connection for varicose veins on October 26, 1990, this claim was received within one year from the date of the outpatient examination. Accordingly, the date of the informal claim (November 13, 1989) can be accepted as the effective date of the grant of service connection. Thus, even though the veteran was seen on October 2, 1989 for varicose veins, the formal claim for service connection was received more than one year from that date. Therefore, the Board finds that November 13, 1989 is the proper effective date for the award of service connection for varicose veins of the left leg. A 40 percent evaluation may be assigned for unilateral varicose veins which are severe; involving superficial veins above and below the knee, with involvement of the long saphenous, ranging over 2 cm. in diameter, marked distortion and sacculation, with edema and episodes of ulceration; no involvement of the deep circulation. Where moderately severe; involving superficial veins above and below the knee, with varicosities of the long saphenous, ranging in size from 1 to 2 cm. in diameter, with symptoms of pain or cramping on exertion; no involvement of the deep circulation, a 20 percent evaluation may be assigned. VA outpatient treatment records show that the veteran was seen in January 1990 and it was noted that he had severe varicose veins. Jobst stockings had been ordered, but he had not received them. They were issued the next week. He was noted to be doing well with the stockings in February and March 1990. In July 1990, he was noted to be status post venogram which revealed two varicosities and reflux. It was recommended that he stay on stockings as the benefit/risk ratio of surgery was pretty low. Letters dated in February and March 1991 were received from a VA physician. The letters were to the combined effect that he had treated the veteran for the previous two years for venous stasis disease. The veteran required support stockings secondary to this disability, which was most likely a result of a deep venous thrombosis suffered as a complication of the severe ankle fracture in service. The physician also commented that the veteran should stay on his feet as little as possible and that he would benefit from leg elevation. Additional VA outpatient treatment records reveal that the veteran was seen in February 1991. It was indicated that vascular non- invasive studies showed valvular reflux on the left. A venogram showed 2 varicosities and reflux. The greater saphenous vein valve was patent at the saphenous femoral junction. An examination disclosed left greater saphenous varicosities and some lesser saphenous varicosities. It was noted that the veteran had left venous insufficiency with varicosities. When seen in November 1991, it was noted that he had initially received Jobst thigh- length stockings. However, he was seen by another physician who felt that knee-high Jobst stockings were sufficient. When the veteran was examined by the VA in January 1993, huge varicose veins involving most of the left leg were noted. No pertinent diagnosis was made. As noted above, in order to assign a higher rating for varicose veins, it must be established that they result in a severe disability. While the veteran's varicose veins of the left leg have been described as "huge," the record is devoid of any evidence that there is edema or episodes of ulceration. Indeed, while the veteran initially received thigh length Jobst stockings, he subsequently was found to only require knee length Jobst stockings. There is no indication in the record that the veteran has even asserted that ulceration is present or that there is marked distortion and sacculation. The Board concludes that the explicit clinical findings are of greater probative value than the unsubstantiated assertions of increased severity made by the veteran. Accordingly, the Board finds that the clear weight of the evidence is against the claim for an increased rating for varicose veins of the left leg. In addition, the evidence does not show that the veteran's left ankle disability or varicose veins of the left leg presents such an exceptional or unusual disability picture as to render impractical the application of the regular scheduler standards so as to warrant the assignment of an extraschedular rating under 38 C.F.R. 3.321(b)(1). In this regard, the Board points out that the record shows that the veteran worked as a house painter and that he retired as a police officer in 1993 due to hypertension. There is no indication that his retirement was related to either of his service-connected disabilities. The record does not show that he was ever hospitalized as a result of varicose veins or that he has been hospitalized for many years due to the left ankle fracture. Accordingly, an extraschedular evaluation is not warranted. Finally, the symptoms of his left ankle disability and the varicose veins of the left leg most closely approximate the evaluations now in effect. 38 C.F.R. 4.7. ORDER Service connection for a low back disability is granted. The claim of entitlement to service connection for a left shoulder disability is not well-grounded and, accordingly, the appeal as to this issue is dismissed. An increased rating for residuals of a fracture of the left ankle and for varicose veins of the left leg is denied. An effective date of November 13, 1989 for an award of service connection for varicose veins of the left leg is granted, subject to the governing regulations pertaining to the payment of monetary benefits. RICHARD B. FRANK Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, 6, 108 Stat. 740, _ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.