Citation Nr: 0006652 Decision Date: 03/13/00 Archive Date: 03/17/00 DOCKET NO. 97-17 522 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to an increased rating for residuals of a fracture of the left leg, currently evaluated as 20 percent disabling. 2. Entitlement to an increased rating for residuals of a fracture of the right leg, currently evaluated as 10 percent disabling. 3. Entitlement to service connection for a psychiatric disorder, diagnosed as schizophrenia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The veteran and his mother. ATTORNEY FOR THE BOARD Wm. Kenan Torrans, Associate Counsel INTRODUCTION The veteran served on active duty from June 1975 to June 1978, and from April 1981 to July 1982. This matter arises from an August 1995 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota, which denied the benefits sought. The veteran filed a timely appeal, and the case has been referred to the Board of Veterans' Appeals (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. The veteran's residuals of a left leg fracture are objectively shown to involve shortening of the left leg, a varus deformity of the tibia, laxity of the left knee, and only slight limitation of motion of the knee. In addition, the veteran's left knee is not objectively shown to have arthritis, and is not shown to be ankylosed. 2. The veteran's residuals of a right leg fracture are objectively shown to involve limitation of extension to 10 degrees and traumatic arthritis in the knee. 3. The veteran sustained a skull fracture in service. 4. The veteran has been diagnosed with paranoid schizophrenia. 5. The veteran has presented competent medical evidence of a nexus or link between his currently diagnosed paranoid schizophrenia and a skull fracture he sustained in service. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for the veteran's residuals of a left leg fracture have not been met. 38 U.S.C.A. §§ 5107, 1155 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5257, 5258, 5260, 5261, 5262 (1999). 2. The criteria for an increased evaluation of 20 percent for the veteran's residuals of a right leg fracture have been met. 38 U.S.C.A. §§ 5107, 1155 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5261 (1999). 3. Paranoid schizophrenia was incurred as a result of the skull fracture the veteran sustained in service. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.303 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Ratings; Left and Right Legs A. Introduction The preliminary question before the Board is whether the veteran has submitted a well-grounded claim for assignment of an increased rating for his residuals of a fracture of the left tibia, to include knee laxity, within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). In addition, the Board must also consider whether the VA has properly assisted the veteran in the development of his claim. A mere 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 a claim that is well grounded. 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, a transcript of personal hearing testimony given by the veteran and his mother before a Hearing Officer at the RO, and personal statements by the veteran in his own behalf. The Board is not aware of any additional evidence which is available in connection with this appeal. Therefore, no further assistance to the veteran regarding the development of evidence is required. Disability ratings are determined by evaluating the extent to which the veteran's service-connected disabilities affect 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). 38 U.S.C.A. § 115 (West 1991); 38 C.F.R. §§ 4.1. 4.2. 4.10 (1999). In addition, where entitlement to service connection has already been established, and an increase in a disability evaluation is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 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 examination 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 (1998). Under DeLuca v. Brown, 8 Vet. App. 202, 206-7 (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. B. Residuals of a Left Tibia Fracture to Include Knee Laxity Historically, service connection for residuals of a fracture of the left tibia with secondary varus deformity and shortening of the left lower extremity was granted by a rating decision of April 1983, and a 10 percent evaluation was assigned, effective from July 29, 1982. In December 1994, the veteran filed a claim for an increased evaluation, contending in substance, that he now has traumatic arthritis in both knees in addition to constant pain, and that he has instability in his left knee requiring a knee bandage wrap. The veteran's claim was denied by an August 1995 rating decision, and this appeal followed. In May 1995, the veteran underwent a VA rating examination. The report of that examination shows that the veteran had an angular deformity of the varus type. The left leg was one centimeter (cm) shorter than the right leg, and range of motion was from 0 to 135 degrees, bilaterally. The examiner concluded with diagnoses of status-post fracture of the left mid-tibia with varus deformity in 1981, and left leg shorter than the right leg. In September 1996, the veteran and his mother appeared at a personal hearing at the RO, and testified before a Hearing Officer. The veteran testified that he had been wrapping his left knee with an Ace bandage on a daily basis for the past 13 years due to what he characterized as instability in the knee joint. He indicated that if he did not do so, his knee would likely give out. He testified that his knee had buckled and had given out on him in the past. According to the veteran, looseness and pain were his primary complaints with respect to his knees. He indicated that he was able to walk for approximately one mile before he would have to sit down and rest. A VA treatment record dated in June 1997 shows that the veteran was seen for complaints of chronic bilateral knee pain. At the time, he was observed to have an adequate gait and had a functional range of motion in flexion and extension. The treating physician concluded with a diagnosis of chronic bilateral knee pain, old fracture, with knee buckling on the left. An X-ray report shows that there was an old fracture deformity of the proximal tibia. The joint space of the knee appeared to be relatively normal. There was minimal narrowing of the medial joint space, but there was no associated subchondral sclerosis or eburnative change at the joint margins. The patellofemoral relationships appeared normal on the plain films. The examiner concluded with his impression of an old fracture deformity of the proximal tibia. No other significant abnormality was indicated. In September 1999, the veteran underwent an additional VA rating examination. The report of that examination shows that the veteran reported wearing a knee brace on his left knee because his knee would "wobble." In addition, the veteran complained of experiencing increased pain in the left knee because he favored that knee, and that he only wore a knee brace on his left knee. Also, he indicated that he did not use any other assistive devices. Further, the veteran stated that he was unable to run, but that he rode a bicycle in high gear in an attempt to compensate for his inability to run. On examination, the veteran was observed to walk with a limp on his left leg. His left leg was shown to have a varus deformity at the proximal tibia. There was angulation of the varus deformity of about 15 degrees to the left. The left leg was also found to be approximately one inch shorter than the right leg. There was no articular involvement in the left knee except for some crepitation with anterior flexion and extension. There was no nonunion or any false motion of the knee, though it was characterized as being somewhat "lax" or loose. There was no local tenderness or effusion noted in the left knee. In addition, the left knee was somewhat weaker than the right, having 3/5 strength. Left knee flexion was from 0 to 140 degrees, with extension to 10 degrees. The examiner concluded with a diagnosis of status- post fracture of the left tibia with varus deformity and shortening of the leg. The examiner also observed that the veteran complained of pain on motion. While such pain and/or weakness was not indicated on the examination, the examiner stated that pain could limit the veteran's range of motion and muscle strength if present. It does not appear that X- ray films were taken pursuant to the September 1999 rating examination. The Board has evaluated the above-discussed evidence, and concludes that the criteria for an evaluation in excess of 20 percent for the veteran's residuals of a left tibia fracture to include laxity of the knee have not been met. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1999), slight recurrent subluxation or lateral instability warrants assignment of a 10 percent evaluation. Moderate recurrent subluxation or lateral instability warrants assignment of a 20 percent evaluation, and a 30 percent evaluation, the highest rating available under Diagnostic Code 5257, is contemplated upon a showing of severe recurrent subluxation or lateral instability. Id. Limitation of flexion of the leg is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (1999). Under Diagnostic code 5261, a 10 percent evaluation is warranted where flexion is limited to 45 degrees. Where flexion is limited to 30 degrees, a 20 percent evaluation is warranted, and a 30 percent evaluation, the highest available, is warranted for limitation of flexion to 15 degrees. Id. Limitation of extension of the leg is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5261 (1999). Under Diagnostic Code 5261, a 10 percent evaluation is contemplated where extension is limited to 10 degrees. A 20 percent evaluation is warranted where extension is limited to 15 degrees, and a 30 percent evaluation is contemplated where extension is limited to 20 degrees. Where extension is limited to 30 degrees, a 40 percent evaluation is contemplated, and a 50 percent evaluation, the highest rating available under Diagnostic Code 5261, is assigned where extension is limited to 45 degrees. Id. Impairment of the tibia and fibula is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5262 (1999). Under Diagnostic Code 5262, impairment of the tibia and fibula with slight knee or ankle disability warrants assignment of a 10 percent evaluation. A 20 percent evaluation is warranted for manifestations involving moderate knee or ankle disability, and a 30 percent evaluation is contemplated for malunion of the tibia and fibula with marked knee or ankle disability. For assignment of a 40 percent evaluation, there must be a showing of nonunion of the tibia and fibula with loose motion and requiring a brace. A 40 percent evaluation is the highest rating available under Diagnostic Code 5262. Id. In the present case, the veteran's left leg disability, resulting from his service-connected residuals of a fracture of the left tibia, primarily involves a slight shortening of the left leg and laxity of the knee. The veteran has complained of chronic and constant pain in his left leg and knee, but such has not objectively been shown on examination. Moreover, none of the medical evidence shows him to have arthritis in his left knee. The report of the most recent X- ray examination dated in July 1997 shows the veteran to have had a slight narrowing of the medial joint space, but no arthritis per se. The Board notes that the report of the September 1999 VA rating examination includes the examiner's observation that the veteran's history of arthritis of the knees (necessarily including the left knee) was the result of his in-service leg injuries. However, this opinion does not appear to be based on a review of any available objective medical evidence of record, but rather, appears to be based on the veteran's self reported account of having arthritis in his left knee. In addition, the examiner offered that the pain, if present, would likely cause limitation of motion and weakness in the veteran's left knee. However, the Board notes that objective evidence of pain on motion has not been documented. The examiner who conducted the September 1999 rating examination noted that objective evidence of pain on motion, or actual limitation of motion due to pain, was not found on examination. The veteran was shown to have from 0 to 140 degrees of flexion by the report of the September 1999 rating examination. However, that same report includes the examiner's finding that the veteran's extension was limited to 10 degrees. Notwithstanding the apparent conflict in the examiner's findings here, after resolving all reasonable doubt in favor of the veteran, the Board finds that under Diagnostic Code 5261, a 10 percent evaluation is warranted for a showing of extension limited to 10 degrees. The Board also finds that a 10 percent evaluation is warranted under Diagnostic Code 5257 for slight recurrent subluxation or lateral instability in the left knee. This laxity has not objectively been shown to be moderate, and a 20 percent evaluation for laxity per se is therefore not warranted. In addition, the veteran was not shown to have swelling or effusion in his left knee, and it appears that most of the problems noted above have resulted from the approximately one-inch difference in length between the right and left legs in addition to the varus deformity of the left tibia. Accordingly, additional higher ratings based on the shortness of the left leg or the varus deformity of the left tibia are not warranted here. Further, inasmuch as the veteran has complained of experiencing chronic pain in his left leg and knee due to his service-connected residuals of a left tibia fracture, the Board has considered whether a higher rating is warranted based upon pain on motion or upon functional impairment or weakness due to pain. On examination, the veteran was found to have completely normal flexion, but had extension limited to 10 degrees. No other functional impairment was found. In addition, he was not objectively found to have pain on motion during the course of his examinations. The Board finds, therefore, that the veteran's objectively demonstrated functional impairment warrants assignment of a 20 percent evaluation, and that a higher rating based on functional limitation due to pain is not warranted. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra. There is not an approximate balance of positive and negative evidence regarding the merits of the veteran's claim with respect to his left leg disability. Therefore, the veteran is not entitled, under 38 U.S.C.A. § 5107(b) (West 1991), to the benefit of the doubt in resolving his claim. The Board points out, however, that in the event that the veteran's overall disability picture with respect to his left leg disability changes in the future, he may apply at any time for an increase in his assigned disability rating. See 38 C.F.R. § 4.1 (1999). At present, however, the Board finds no basis upon which to grant a rating in excess of 20 percent for the veteran's residuals of a left tibia fracture with left knee laxity. C. Residuals of Fracture of the Right Leg Historically, service connection for what was initially characterized as status-post intra articular fracture of the right proximal tibia and fibula with open reduction and internal fixation with traumatic arthritis of the right knee was granted by an April 1983 rating decision. A 10 percent evaluation was assigned, effective from July 29, 1982. In December 1994, the veteran filed a claim for an increased evaluation for his residuals of a right tibia fracture, stating that his service-connected residuals had increased in severity, and that an evaluation in excess of 10 percent was therefore warranted. His claim was denied by an August 1995 rating decision, and this appeal followed. The veteran underwent a VA rating examination in May 1995. The report of that examination shows that the veteran had a residual non-tender and asymptomatic scar on the anterior portion of his calf, and that his knee could be fully extended and flexed to 135 degrees. Some tenderness in the medial and lateral joint spaces was noted, but no significant instability was found, and muscle strength and sensation were intact. The examiner concluded with a diagnosis of status- post fracture of the right proximal tibia and fibula with open reduction internal fixation. The veteran and his mother appeared at a personal hearing before a Hearing Officer at the RO in September 1996. The veteran testified that he had two steel plates in his right leg, which were connected by nine screws resulting in pain and discomfort. The veteran stated that his left leg felt as if it were going to give out, but not his right leg. He indicated that he did not put any weight on his right leg due to pain. The veteran offered that he had not been advised by treating physicians that he could not bear weight on his right leg, but that that such opinion was his own observation. The veteran testified that walking up or down stairs caused pain due to the screws and plates in his right leg, and that he could only walk for a mile before having to sit down to rest. The report of an examination of the veteran's right knee conducted in June 1997 shows that the veteran had bilateral side plates in his right tibia secured with compression screws. The joint space of the tibial plateaus appeared relatively congruous. There was no significant joint space narrowing, and no eburnative changes were identified at the joint margins. The examiner concluded with a diagnosis of an old internally fixed proximal tibial fracture. There was an old healed proximal fibular fracture. No other significant post-traumatic degenerative changes were identified. The veteran underwent a VA rating examination in September 1999. The report of that examination shows that the right knee appeared to be grossly normal. There was no bulkiness or bony deformity. In addition, there was no local tenderness or effusion, and no crepitation on flexion or extension. The examiner noted that the veteran's strength was good on hamstring and quadriceps testing in addition to heel-toe gait. The veteran had flexion from 0 to 140 degrees, but the examiner also noted that is extension was limited to 10 degrees. No X-rays were conducted pursuant to the September 1999 examination, and the examiner concluded with a diagnosis of status-post fractures to the right proximal tibia and fibula with traumatic arthritis. As with the left knee, the examiner noted that pain was not objectively found on examination, but if present, pain would likely limit the veteran's range of motion in his right knee. The Board has evaluated the foregoing and concludes that after resolving all reasonable doubt in favor of the veteran, the evidence supports assignment of an additional 10 percent evaluation for traumatic arthritis of the right knee. The veteran's demonstrated symptomatology in his right knee is roughly commensurate with the symptomatology in his left knee, albeit without the laxity complained of in connection with the left knee. The veteran has a full range of flexion in his right knee and a 10-degree limitation on extension. Such is consistent with a 10 percent evaluation under Diagnostic Code 5261. Further, while he was noted to have steel plates and compression screws in his proximal right tibia, the veteran was not found to have any recurrent subluxation or lateral instability in the knee joint. In addition, there was no indication of other impairment of the tibia and fibula, involving any malunion or nonunion. The Board notes, however, that the VA General Counsel, in an opinion dated July 1, 1997, (VAOPGPREC 23-97) held that a claimant who has arthritis and instability of the knee may be rated separately under diagnostic codes 5003 and 5257. The General Counsel stated that when a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion which at least meets the criteria for a zero-percent rating under Diagnostic Code 5260 or 5261 in order to obtain a separate rating for arthritis. Moreover, in a later opinion by the General Counsel dated August 14, 1998, (VAOPGPREC 9-98), even in situations in which the claimant technically has full range of motion, but where the motion is inhibited by pain, a compensable rating for arthritis under Diagnostic Codes 5003 and 38 C.F.R. § 4.59 (1999) would still be available. Here, the veteran's symptomatology with respect to his right knee is not consistent with the evaluative criteria of Diagnostic Code 5257. However, he is objectively shown to have traumatic arthritis in his right knee, and he is limited in extension to 10 degrees. Accordingly, while the severity of the veteran's right leg disability is not shown to warrant an evaluation in excess of 10 percent under the applicable schedular criteria, even after taking the effects of functional limitation due to pain into consideration, the Board finds that he is entitled to a separate 10 percent rating under Diagnostic Codes 5003 and 5010. See VAOPGPREC 23-97, 9-98; see generally Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). D. Conclusion The potential application of the various provisions of Title 38 of the Code of Federal Regulations (1999) have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Here there is no showing that the disabilities under consideration have caused marked interference with employment, have necessitated frequent periods of hospitalization, or otherwise render impracticable the regular schedular standards. The Board notes that the veteran has been hospitalized and otherwise treated for a psychiatric disorder on numerous occasions in the recent past, and that he has been unemployed for extended periods as a result. However, issues with respect to the veteran's psychiatric disabilities will be addressed below. The veteran has not been shown to be unable to obtain or retain gainful employment as a result of his service- connected left and right leg disabilities. The veteran has indicated that he would prefer to work at a job not requiring prolonged standing, such as a desk job involving computers. However, as indicated in the report of the most recent VA rating examination of September 1999, the veteran reported that due to his psychiatric disability he has had to work in a fast-food restaurant, and that his duties primarily involved frying hamburgers. In any event, the fact that the veteran is unable to obtain the type of job he desires is not indicative of an inability to obtain or retain gainful employment, per se. The fact that he is currently employed on a regular basis tends to refute such an assertion. Therefore, 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. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). II. Service Connection; Schizophrenia The veteran has claimed entitlement to service connection for a psychiatric disorder, diagnosed as paranoid schizophrenia. In general, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303 (1999). As a preliminary matter, the Board finds that the veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990); Gilbert v. Derwinski, 1 Vet. App. 48, 55 (1990). That is, the Board finds that the veteran has presented a claim which is not implausible when his contentions and the evidence of record are viewed in the light most favorable to his claim. The Board is also satisfied that all relevant facts have been properly and sufficiently developed. Accordingly, no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107. See generally McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997). The veteran's service medical records show that while in service in July 1981, he was involved in an automobile accident, and sustained a fracture to the left side of the basilar skull. The veteran reportedly lost consciousness for a period of several days, and was noted to be confused and agitated upon regaining consciousness. However, during the course of his initial treatment, the veteran's sensorium cleared up after approximately 10 days, and he became fully alert and oriented. In December 1981, the veteran complained of experiencing headaches, periods of extended confusion, and loss of "distant" memory. The report of his service separation physical examination notes that the veteran was seen for a paranoid personality disorder, and that he had a history of amnesia after his July 1981 accident. The records show that the veteran had a monotone affect, he was found to be lethargic as manifested by a general lack of energy and motivation. The treating physician observed that there was no evidence of psychosis, and concluded with a diagnosis of adjustment disorder with disturbance of mood. The veteran's service personnel records dated prior to his July 1981 accident do not disclose any aberrant or unusual behavior. However, after he had been involved in the accident, the records characterized the veteran's "mental state" was noted to "be in other places. He walks around in a daze, and when questioned, usually does not know what he is doing or where he is going." The veteran's attitude and motivation were found to be below standards, and a counseling statement indicates that his drill sergeant had assigned him a "guard" to monitor his movements. The Board also observes that during this period, the veteran was noted to have experienced difficulty in getting along with his peers, had been found sleeping during duty hours, and had been issued an Article 15 for having been absent from a duty post without permission. He was subsequently issued a general discharge in July 1982. Shortly after his discharge from service, the veteran underwent a VA rating examination in October 1982. The report of the neurological portion of that examination shows that his diagnoses included anxiety and mild depression with status-post basilar skull fracture. The veteran complained of experiencing headaches and neck pains, and was observed to have a "great deal of apathy and a flat affect." He was noted to have been rendered unconscious after the automobile accident, and the examiner noted that his headaches could have been the result of the skull fracture. In addition, he noted that the veteran had an "unusual personality," but that he was unable to determine if the veteran's behavior was "erratic" prior to the July 1981 accident. However, the examiner stated that the veteran's current behavior might warrant a psychiatric evaluation. In addition, the veteran was noted to experience irritability, outbursts of rage, and a short temper, which the examiner offered could have been related to the head injury, but that a psychiatric examination would be necessary to verify this theory. Based upon the report of the October 1982 VA rating examination, service connection for residuals of a left basilar skull fracture with residual cephalalgia was granted by an April 1983 rating decision. A 10 percent evaluation was assigned, effective from July 29, 1982. The record does not show that a psychiatric examination was ever conducted at that time. In September 1984, the veteran underwent a second VA rating examination. At that time, he complained of having experienced headaches since the time of the injury. He indicated that he experienced brief "numbing pain" in the occipital region of his head, greater on the left side. In addition, the veteran was noted to be a poor historian, and the examiner indicated that it was difficult to obtain an accurate history from the veteran. On examination, the examiner noted that the veteran appeared very withdrawn and uninterested in the examination. The cranial nerves were found to be intact, and the veteran was diagnosed with status-post left basilar skull fracture with secondary cephalalgia. No other findings relating to the veteran's psychiatric status were indicated. In December 1994, the veteran filed a claim for service connection for a psychiatric disorder he contended was the result of the skull fracture he had sustained in service. The veteran submitted a Social Security Administration (SSA) disability report dated in December 1994. The SSA disability report indicates that the veteran reported having suffered from schizophrenia since November 1994, and that he experienced audio hallucinations at that time. The veteran indicated that he had been hospitalized at the Woodland Center Crisis Program for two days, and that his medications included Haldol and Cogentin. The form also indicated that the veteran lived in a supervised living facility. The veteran's mother submitted a statement, dated in January 1995, in which she expressed her opinion that the veteran's currently diagnosed psychiatric disorders were incurred as a result of the head injury he sustained in service in July 1981. She stated that the veteran experienced no problems in service during his first period of enlistment, but that after the July 1981 head injury, he underwent a personality change manifested by a greatly diminished interest in working or pursuing his career goals. SSA treatment records dated in December 1994 show that the veteran was diagnosed with schizophrenia at that time. A CT scan of the brain yielded negative results for any structural abnormalities resulting from the July 1981 skull fracture, which the veteran and his parents felt might have caused the diagnosed schizophrenia The CT scan report showed that the unenhanced brain image was unremarkable, and there was no evidence of acute intracranial hemorrhage or midline shift. The veteran underwent a VA rating examination in May 1995. The report of that examination shows that the veteran reported having been in a "coma" for two weeks following his motor vehicle accident in July 1981, and that afterwards, he lost interest in anything and was usually apathetic. The veteran reported having increased his alcohol intake in 1989, but that he had been sober for the past two years. The veteran indicated that he began to hear voices in 1988, and thought people were talking about the weather. He indicated that in 1994 he was diagnosed with schizophrenia, and that by November 1994 the voices became more intense and were accompanied by ringing in his ears. The veteran was reportedly delusional, and fostered the belief that he could control the barometric pressure by "walking on 'lay lines.'" The veteran lived in the Red Castle Group Home for individuals with mental disabilities. He characterized himself as a schizophrenic and a recovering alcoholic, and indicated that he was unhappy because of too much rain. On examination, the veteran was found to be alert with a clear sensorium and adequate personal hygiene. His affect was flat, mood was neutral, and his speech was clear, albeit slow and almost monotone. The veteran denied experiencing any current hallucinations, but retained the delusional belief that he could change the weather. The veteran was fully oriented, and his memory was intact. The examiner stated that given the veteran's history of head trauma and alcoholism, and a family history of schizophrenia, it was difficult to assess whether the head injury was the cause or a contributing factor for the veteran's psychiatric disorder. The examiner concluded with a diagnosis of Axis I paranoid type schizophrenia and alcohol dependence in remission. In further support of his claim, the veteran submitted a report dated in August 1996 from Lyle W. Wagner, Ph.D., and Licensed Psychologist. Dr. Wagner stated that the veteran's mother had hired him for purposes of evaluating the etiology of the veteran's psychiatric disorder, and to determine whether it was related to the head injury the veteran had sustained in service. According to Dr. Wagner, the veteran indicated that he had sustained a skull fracture after having been struck by an automobile. Dr. Wagner stated that he had been involved with the veteran since December 1994, and that the veteran's diagnoses included undifferentiated schizophrenia and alcohol dependence in full remission. He indicated that the veteran informed him that he had seen an Army psychiatrist for depression on two separate occasions during his first period of enlistment in 1978, and that he had not been issued any medication at that time. Dr. Wagner stated that a review of the veteran's service medical and service personnel records dated after the July 1981 accident showed the onset of a psychiatric disorder. Specifically, Dr. Wagner referred to the entries characterizing the veteran as having been in a daze and not knowing what he was doing or where he was going, having to be told what to do, and then be constantly supervised in any given task, and generally showing no motivation. Dr. Wagner also noted that the report of the veteran's service separation examination showed that the veteran had been seen for a paranoid personality disorder. With respect to the veteran's current mental state, Dr. Wagner offered that based upon his review of the service medical records, his conversations with the veteran, and inspection of other psychiatric records, the veteran manifested psychiatric symptoms during his period of active service. According to Dr. Wagner, the veteran's exhibited behavior during service suggested a level of faulty adaptive functioning during that period. In September 1996, the veteran and his mother appeared at a personal hearing before a Hearing Officer at the RO, and testified that he was first diagnosed with schizophrenia in September 1994 at the Willmar Clinic. He stated that he believed that the disease first began in service subsequent to the automobile accident in July 1981, because he first began experiencing problems shortly afterwards. The veteran also expressed his belief that the in-service diagnosis of paranoid personality disorder was actually an indication of the onset of his paranoid schizophrenia. The veteran indicated that this belief was due to his contention that his currently manifested symptoms were the same as those he experienced in service. The veteran testified that he was not afforded a psychiatric examination in October 1982, and that had such an examination been conducted, he would likely have been diagnosed with a psychiatric disorder. He stated that after his discharge from service, he did not undergo any psychiatric evaluation until 1994. The veteran also testified that he was a recovering alcoholic, and that he had hidden his schizophrenia behind his drinking. The veteran's mother testified that following his discharge from service in 1982, the veteran had won an unstated amount of money from a lawsuit originating from the July 1981 accident, and spent his time and money traveling. She testified that the veteran had become an alcoholic, and that she and her husband attributed the veteran's erratic behavior to his drinking. However, after he became sober, she indicated that in approximately 1994, the veteran called her from a local police station, having been detained for sleeping in a park. According to the veteran's mother, the veteran indicated at the time that he continually heard ringing in his ears and other noises in his apartment, and that he had elected to sleep in the park instead. She stated that the veteran was subsequently hospitalized and that he was diagnosed with schizophrenia at that time. She indicated that the veteran's interests during this time included collecting items found in garbage cans and dumpsters. The veteran's mother also clarified an error in an earlier diagnosis which suggested that the veteran had a family history of schizophrenia. She stated that the veteran's aunt had experienced some "nervous" problems in the past, but that no one in the veteran's family had ever been diagnosed with schizophrenia. The veteran's mother also indicated that he had experienced both auditory and visual hallucinations, and that he believed himself to be able to control the weather by "walking his lay lines" to control barometric pressure. The veteran testified that he had been "walking on lay lines" for approximately 13 years. In September 1996 and in January 1997, the veteran underwent VA psychiatric examinations conducted by two VA psychiatrists. The report of the September 1996 examination shows that the veteran was struck by a vehicle in July 1981 while he was intoxicated, and that he suffered from a skull fracture as a result. The examiner noted the veteran's medical history, as indicated above, and observed that the veteran had not been gainfully employed since his second period of service, other than brief part-time jobs. Further, given the veteran's claimed experiences with "lay lines" the examiner noted that the veteran was attempting to obtain employment as a meteorologist. The examiner noted that it was difficult to make an exact diagnosis, in view of the fact that an organic psychosis and a functional psychosis could be very similar. However, the examiner found that the veteran was able to retain full-time employment prior to his second period of service, and that he was apparently found to have been acceptable for reenlistment for his second period of service. Following the July 1981 accident, the examiner noted that the veteran had been initially diagnosed with depression and a paranoid personality disorder. Even so, the examiner stated that he could find nothing of record to suggest symptomatology of paranoia. Further, the examiner noted that the report of the post-service October 1982 rating examination indicated that the veteran had been apathetic, was withdrawn, and was a very poor historian. Accordingly, he concluded, there appeared to have been a personality change following the July 1981 accident. In addition, the examiner observed that hallucinations and delusions were not indicated until 1994. However, while noting Dr. Wagner's assessment of paranoid schizophrenia, the VA examiner stated that he did not find any indication in the record regarding any psychological testing or neuropsychological testing to rule in or rule out the presence of organic brain impairment. The VA examiner concluded that he believed that the veteran actually had three relevant diagnoses. First, he indicated a personality disorder, probably secondary to head trauma. Second, the veteran had chronic undifferentiated schizophrenia, and third, alcohol dependence in remission. The examiner offered his opinion that the major problem was schizophrenia, but that the veteran's head injury caused personality and perhaps cognitive changes while he was in the service. The examiner opined that the veteran's head injury predisposed him to develop a schizophrenic illness later on. The veteran's diagnoses included Axis I chronic, undifferentiated schizophrenia, alcohol dependence, in remission, and an Axis II personality disorder, secondary to head trauma. The examiner who conducted the second VA rating examination of January 1997 failed to reach the same conclusions as the examiner who conducted the previous rating examination of September 1996. The examiner who conducted the January 1997 rating examination emphasized the veteran's problems in service, and appears to suggest that such behaviors were actually evidence of malingering. She cited the veteran's military superiors' assessments of his having no motivation, "drifting around the post" for a year, "hiding behind a temporary profile," and sleeping in the barracks during duty hours. She stated that while the veteran had multiple diagnoses of schizophrenia, his alleged treatment for this disease was not consistent with such a diagnosis. She further cited inconsistent statements made by the veteran regarding the length of time he spent unconscious after the July 1981 accident. The examiner concluded with an assessment that noted the veteran's well-documented history of making contradictory statements. She stated unequivocally that not only did the veteran not have paranoid schizophrenia in service, he had not met the criteria for such a diagnosis since that time. Given that the psychiatrists' evaluative board arrived at differing conclusions as to the veteran's psychiatric disorder, the RO requested that the veteran's psychiatric disorder be reevaluated and the diagnoses reconciled. Pursuant to the RO's request, the veteran was again evaluated in February 1997 and in May 1997. Unfortunately, the examiner who had conducted the September 1996 examination was unavailable, and an additional examining psychiatrist evaluated the veteran in February 1997. The examiner who had conducted the January 1997 examination was again available, but unfortunately, the examination reports were not reconciled. The examiner who conducted the February 1997 rating examination concluded that there were a number of discrepancies in the record. However, given that the veteran was noted to have been a poor historian, and since the veteran had a history of schizophrenia, the examiner observed that the veteran's schizophrenia may have been the cause of such historical discrepancies, and would have prevented the veteran from providing a coherent historical narrative. Even so, the examiner indicated that certain aspects of the veteran's case history remained constant. In this regard, he noted that there was some evidence that the veteran may have suffered from symptoms of depression and paranoid ideation prior to his July 1981 head injury. In addition, there was a documented history of alcohol dependence, currently in remission. Of the greatest significance, the examiner noted that the veteran sustained a head injury in 1981, and that there was evidence to suggest some neurologic and potential psychiatric complications thereafter. Further, on numerous occasions, the examiner observed that the veteran had been diagnosed with undifferentiated chronic schizophrenia. The only exception to this was the examiner who had conducted the January 1997 rating examination who concluded that the veteran did not have schizophrenia. In addition, the veteran was consistently shown to experience bizarre ideation including his apparent fixation with walking on "lay lines." The examiner stated that the veteran's prior multiple diagnoses of schizophrenia in addition to his bizarre ideation might lead to the conclusion that the veteran did have schizophrenia. However, with respect to other potential diagnoses including a paranoid or other personality disorders and cognitive disorders, the examiner stated that such diagnoses could not be distinguished or confirmed without extensive neurological testing. Further, the examiner indicated that his analysis was based solely upon a review of the record, and did not involve an actual interview of the veteran. Therefore, without extensive neurological and psychiatric testing, the examiner stated that it was not possible for him to offer any definitive conclusions as to the veteran's diagnoses. The May 1997 VA rating examination was conducted by the same examiner who had conducted the earlier January 1997 examination. She continued to assert that the veteran's demonstrated symptoms and behavior patterns in service were merely evidence suggestive of malingering, and were not indicative of any psychiatric disorder, per se. The examiner reemphasized that by his own admission, the veteran was drunk when he was struck by the automobile and sustained the skull fracture in July 1981. She offered her opinion that the veteran's injury was due to his own willful misconduct, and that as such, service connection for the injuries resulting from the July 1981 accident should not have been granted. The examiner offered her opinion that statements made by the previous two examiners, to the effect that there was evidence of psychiatric abnormalities following the July 1981 accident, and that the skull fracture resulted in a personality disorder that left the veteran predisposed to schizophrenia, were contraindicated by the evidence of record. To this end, she cited contemporaneous clinical treatment records and examination reports dated in 1982 which stated that there was no evidence of any organic brain damage or encephalopathy at that time. The examiner stated that there was no evidence of record to suggest that the veteran had incurred a psychiatric disorder due to his head injury. She stated that the type of treatment received from Dr. Wagner was inapplicable to schizophrenic disorders, and that the onset of schizophrenia rarely occurred as late as age 37. She further noted that the veteran did not, as the first examiner stated, have a consistent work history prior to having sustained the skull injury. The examiner showed that the veteran had moved from state to state, and that he had held numerous jobs, and had attended school prior to his second period of enlistment. She also reiterated that the medical evidence did not show symptomatology supportive of a diagnosis of schizophrenia. She noted that the CT scan of December 1994 did not disclose the presence of abnormalities suggestive of a psychiatric disorder incurred as a result of head trauma. Moreover, the examiner stated that there is no evidence that head trauma or personality disorders precipitate schizophrenia. She further indicated that there were no symptoms suggestive of schizophrenia, and insufficient current data to make a personality disorder diagnosis. The examiner's Axis I diagnoses included malingering and alcohol dependence in apparent remission. She further opined that an extensive MRI scan of the veteran's head would likely be as inconclusive as the previous multiple rating examinations. In further support of his claim for service connection for schizophrenia, the veteran submitted VA clinical treatment records dating from May 1995 through July 1997. These records show that the veteran resided in a supervised living setting, and that he received treatment for schizophrenia. Treatment notes dated in June and September 1996 indicate that the veteran was diagnosed with Axis I paranoid schizophrenia with prominent negative symptoms. The records show that the veteran continued to be preoccupied with controlling the weather by "walking the lay lines" and that in this regard, in August 1996, he offered his services to the local female television weather reporter. Following his subsequent conversations with his treating physicians and the local police, it was determined that the veteran did not pose a direct threat to the meteorologist as he had offered her his friendship. He indicated that his interest in the local meteorologist arose from a solicitation for "weather spies." (Prior to this, in July 1996, the veteran had contacted the local news "I-Team" and advised the local media that he was a weather terrorist, and had been controlling the weather since 1983). A treatment note also dated in September 1996 indicates that the veteran continued to call the local weather station approximately twice per week, and that in so doing, he lowered his anxiety. The veteran's time was otherwise spent watching television with a girlfriend, and rummaging through the trash collecting garbage. The veteran's medications during this period included Haldol, Prozac, and other antidepressant drugs. The Board has evaluated the foregoing, and finds that while there may be some serious doubt regarding the validity of the veteran's diagnoses of schizophrenia, the evidence is at least in equipoise. Accordingly, resolving all reasonable doubt in favor of the veteran, the Board finds that the evidence supports a grant of service connection for schizophrenia. The Board recognizes that the veteran was not given a proper diagnosis of a psychiatric disorder until 1994, but he has presented medical evidence of a nexus or link between his diagnosed schizophrenia and his active service, to include the skull fracture sustained therein. As noted above, following the head injury sustained in July 1981, the veteran appeared to have undergone a personality change of some sort. He was noted to walk around in a daze, and could not respond to queries as to where he was going or what he was doing. Further, during this period, although as one VA rating examiner pointed out, the veteran's service separation examination report indicates that he had been seen for a paranoid personality disorder, but that the evidence does not indicate what circumstances or symptomatology warranted such a diagnosis. Even so, some three months after his discharge from service, the veteran underwent a VA rating examination in October 1982. While the neurological portion of the examination did not include any actual diagnosis of a psychiatric disorder, the examining physician noted that the veteran's erratic behavior, manifested by outbursts of temper, flat affect, and other symptoms, should be evaluated by a psychiatrist. However, no psychiatric examination was performed until May 1995. The report of the May 1995 examination concluded with a diagnosis of schizophrenia, but the examiner indicated that she was unable to determine whether or not such schizophrenia had been incurred in or aggravated by the veteran's active service. In addition, the Board recognizes that in January and May 1997, the veteran was diagnosed with Axis I "malingering" because the examiner who conducted the review of the veteran's medical and service records could find no symptomatology consistent with a diagnosis of schizophrenia, or that otherwise indicated the presence of a psychiatric disorder in service. However, the report of the rating examination conducted in September 1996 establishes a plausible nexus between the veteran's head injury sustained in service and his diagnosed schizophrenia. The examiner who conducted the September 1996 review of the veteran's records concluded that the evidence showed that the veteran developed a personality disorder after the July 1981 head injury, and that the head injury and subsequent personality disorder left him susceptible to schizophrenia. Given the testimony by the veteran and his mother, in addition to the report of he October 1982 neurological rating examination suggesting continuity of symptomatology of a psychiatric disorder, the Board finds the opinion by the examiner who conducted the September 1996 examination to carry the most probative weight in this case. The Board further recognizes that the examiner who found the veteran to be a chronic malingerer supported her assessment by a thorough discussion of the medical evidence, which suggests that her views have substantial merit. However, based on its review of all of the medical evidence, the Board concludes that her findings are nonetheless outweighed by the preponderance of the evidence consisting of the VA clinical treatment records dating from May 1995 through July 1997, which conclude with diagnoses of schizophrenia, the medical statement of August 1996 submitted by Dr. Wagner, and by the examination report of September 1996. The treatment records support the veteran's and his mother's testimony that the veteran has lived for an extended period in a supervised living environment, and the clinical diagnoses of schizophrenia have been rendered by psychiatrists who presumably had the benefit of actually meeting with and evaluating the veteran. In sum, the Board finds that the evidence discussed here is at least in equipoise, and while the examination reports of January and May 1997, suggesting that the veteran's diagnoses of schizophrenia are not valid and that the veteran is, in fact, a malingerer are persuasive, such reports do not outweigh or provide conclusive proof that the veteran's diagnosed schizophrenia was not caused, at least in part, by his July 1981 skull fracture. Therefore, after resolving all reasonable doubt in favor of the veteran, the Board concludes that his psychiatric disorder, diagnosed as paranoid schizophrenia, was incurred in service. Accordingly, service connection for schizophrenia, variously diagnosed as chronic undifferentiated or as paranoid schizophrenia, is granted. ORDER Entitlement to an evaluation in excess of 20 percent for residuals of a left leg fracture is denied. Subject to the applicable statutes and regulations governing the award of monetary benefits, assignment of a 20 percent evaluation for residuals of a right leg fracture is granted. Service connection for paranoid schizophrenia is granted. WARREN W. RICE, JR. Member, Board of Veterans' Appeals