Citation Nr: 0003137 Decision Date: 02/08/00 Archive Date: 02/15/00 DOCKET NO. 98-11 242 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to an initial, compensable rating for residuals of fracture of the 3rd and 4th metatarsals of the right foot. 2. Entitlement to service connection for a chronic low back disability. 3. Entitlement to service connection for a chronic right knee disability. 4. Entitlement to service connection for a chronic left knee disability. 5. Entitlement to service connection for chronic bilateral arch disability. 6. Entitlement to service connection for bilateral shin splints. 7. Entitlement to service connection for residuals of left hand puncture injury. 8. Entitlement to service connection for residuals of right hand crush injury. 9. Entitlement to service connection for residuals of injury to the chest and ribs. 10. Entitlement to service connection for a chronic skin disorder (claimed as tinea versicolor). 11. Entitlement to service connection for residuals of excision of nevi from the right leg. 12. Entitlement to service connection for left inguinal hernia and swollen testicles. 13. Entitlement to service connection for chronic bilateral eye disability. ATTORNEY FOR THE BOARD Artur F. Korniluk, Associate Counsel INTRODUCTION The veteran had active military service from August 1993 to August 1997. This matter comes to the Board of Veterans' Appeals (Board) from the Department of Veterans Affairs (VA) Salt Lake City Regional Office (RO) January 1998 rating decision which granted service connection for residuals of fracture of the 3rd and 4th metatarsals of the right foot, assigning a noncompensable rating, and denied service connection for low back, bilateral knee, and bilateral arch disabilities, bilateral shin splints, residuals of left and right hands injuries, residuals of chest and ribs injury, residuals of right leg incision, tinea versicolor, left inguinal hernia and swollen testicles, and vision impairment. Appellate consideration of entitlement to an initial, compensable rating for residuals of right 3rd and 4th metatarsals fracture is held in abeyance pending completion of the development requested in the remand below. FINDINGS OF FACT 1. There is a current medical diagnosis of bilateral chondromalacia patella, bilateral shin splints, residuals of left hand puncture injury, right leg scarring, and left inguinal hernia (associated with intermittent testicular swelling), which are shown to have had their onset during the veteran's active service. 2. It is plausible that low back and right hand disabilities and a skin disorder (claimed as tinea versicolor) may be linked to the veteran's period of active service. 3. There is no current medical diagnosis of chronic organic disability involving the veteran's foot arches, chest, ribs, or eyes. CONCLUSIONS OF LAW 1. The veteran's right knee chondromalacia patella was incurred during active service. 38 U.S.C.A. §§ 1110, 5107(b) (West 1991). 2. The veteran's left knee chondromalacia patella was incurred during active service. 38 U.S.C.A. §§ 1110, 5107(b) (West 1991). 3. The veteran's bilateral shin splints were incurred during active service. 38 U.S.C.A. §§ 1110, 5107(b) (West 1991). 4. Residuals of left hand puncture injury, manifested by a scar, were incurred during active service. 38 U.S.C.A. §§ 1110, 5107(b) (West 1991). 5. Residuals of right leg incisions, manifested by two scars, were incurred during active service. 38 U.S.C.A. §§ 1110, 5107(b) (West 1991). 6. Left inguinal hernia, associated with intermittent testicular swelling, was incurred during active service. 38 U.S.C.A. §§ 1110, 5107(b) (West 1991). 7. The claim of service connection for a chronic low back disability is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 8. The claim of service connection for a chronic right hand disability is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 9. The claim of service connection for a chronic skin disorder (claimed as tinea versicolor) is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 10. The veteran has not presented a well-grounded claim of service connection for chronic bilateral arch disability. 38 U.S.C.A. § 5107(a) (West 1991). 11. The veteran has not presented a well-grounded claim of service connection for residuals of injury to the chest and ribs. 38 U.S.C.A. § 5107(a) (West 1991). 12. The veteran has not presented a well-grounded claim of service connection for chronic bilateral eye disability. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be allowed for a chronic disability, resulting from an injury or disease, incurred in or aggravated by the veteran's period of active wartime service. 38 U.S.C.A. § 1110. Service connection may also be allowed on a presumptive basis for arthritis, if the disability becomes manifest to a compensable degree within one year after the veteran's separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). For a showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required when the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). The U.S. Court of Appeals for Veterans Claims (the Court) has held that lay observations of symptomatology are pertinent to the development of a claim of service connection, if corroborated by medical evidence. See Rhodes v. Brown, 4 Vet. App. 124, 126-127 (1993). The Court established the following rules with regard to claims addressing the issue of chronicity. Chronicity under the provisions of 38 C.F.R. § 3.303(b) is applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded if (1) the condition is observed during service, (2) continuity of symptomatology is demonstrated thereafter and (3) competent evidence relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488, 495 (1997). A lay person is competent to testify only as to observable symptoms. A lay person is not, however, competent to provide evidence that the observable symptoms are manifestations of chronic pathology or diagnosed disability. Falzone v. Brown, 8 Vet. App. 398, 403 (1995). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between the disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1994). However, service connection may be granted for a post-service initial diagnosis of a disease that is established as having been incurred in or aggravated by service. 38 C.F.R. § 3.303(d) (1999). The threshold question is whether the veteran has presented evidence that his claim is well grounded. See 38 U.S.C.A. § 5107(a). A well-grounded claim is a plausible claim. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A mere allegation that a disability is service connected is not sufficient; the veteran must submit evidence in support of his claim which would justify a belief by a fair and impartial individual that the claim is plausible. In order for a claim to be well grounded, there must be competent evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in- service injury or disease and a current disability (medical evidence). See Caluza v. Brown, 7 Vet. App. 498 (1995). Where the determinative issue involves a question of medical diagnosis or causation, competent medical evidence to the effect that the claim is plausible is required to establish a well-grounded claim. Libertine v. Brown, 9 Vet. App. 521 (1996); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). A lay person is not competent to make a medical diagnosis or to relate a medical disorder to a specific cause. See Grivois v. Brown, 6 Vet. App. 136, 140 (1994). Thus, lay statements regarding a medical diagnosis or causation do not constitute evidence sufficient to establish a well-grounded claim under 38 U.S.C.A. § 5107(a). Pre-service medical records reveal that the veteran sustained head trauma in February 1991, resulting in blurred vision. An undated medical examination report indicates, in pertinent part, that he experienced blurred vision and decreased temporal field vision in the left eye; a history of left knee and right ankle injuries was indicated on examination. On follow-up examination in April 1991, left eye vision was 20/30; it was indicated that examination was normal. On medical examination in December 1991, a history of concussion in March 1991 was noted, but no residual disability was indicated. The veteran's service medical records reveal a report of history of concussion on service entrance medical examination in August 1993; on examination, it was indicated that his post-concussion syndrome resolved completely; uncorrected vision in the left eye was 20/20. On head, eyes, ears, nose, and throat examination in October 1993, visual fields were full to confrontation. In May 1994, he sought treatment for white, scaly, and itchy spots on his shoulders and chest; on examination, tinea versicolor was diagnosed. In June 1994, he indicated he had two moles on the right leg, one centimeter (cm) each; nevo-cellular nevi, in the right popliteal region and at the right calf, were diagnosed; excision of the nevi was performed in August 1996 (in August 1996, the nevi were noted to have increased in size, to 8 cm by 1 cm, and 5 cm by 5 cm each). In July 1995, he reported a 3-week history of a swollen right testicle, but examination revealed no abnormality. In March 1997, he indicated that his eyes were very sensitive to light; on examination, vision in the eyes was 20/20, and photophobia was diagnosed; it was indicated that internal and external health was normal. On service separation medical examination in June 1997, he reported a history of "bad" stomach pain with vomiting and head trauma, and uncorrected visual acuity in the eyes was 20/20. The service medical records reveal a December 1993 report of a 3-week history of radiating low back pain, reportedly having had its onset during weight-lifting exercises. On examination, range of motion of the low back was decreased and associated with discomfort, and mechanical low back pain was diagnosed. In March 1994, the veteran fell on the right knee, contusing the right patella and resulting in knee pain. In September 1994, he complained of pain and erythema of the left hand following a pinching injury by a tracked vehicle equipment; on examination, a 1 cm by 1 cm open sore was noted on the left hand, and left hand cellulitis was diagnosed. In October 1994, he reported bilateral shin pain due to trauma; on examination, shin splints were diagnosed. In March 1995, he sustained left knee contusion in a motor vehicle accident resulting in pain and requiring intermittent follow-up treatment. In November 1995, he sustained low back trauma during field exercises resulting in pain; on examination, low back strain was diagnosed. In March 1996, he contused both shins at work, resulting in pain and bruising of the shins. In April 1996, he reportedly dropped a 120-pound object on his chest resulting in ribs and chest pain, increasing with inspiration. In May 1996, he sustained a crushing injury to the right hand when a vehicle tire fell on his hand; on follow-up examination later in May 1996, it appeared that the hand had been fractured, but a fracture was unconfirmed by X- ray. In July 1996, he reported a one week history of pain in both arches after a 7-mile run during training; on examination, he denied prior history of arch symptoms, but noted a history of shin splints; on examination, there was no evidence of bone or joint fracture and possible stress process was diagnosed; he received intermittent follow-up treatment due to pain in the feet. In September 1996, he indicated that his knees were painful. On service separation medical examination in June 1997, he reported a history of swollen or painful joints, broken bones, recurrent back pain, and foot trouble. On VA eye examination in October 1997, the veteran complained of "twitching" of the left eye and intermittent decreased vision, improved with "blinking" of the eye. On examination, uncorrected distant vision was 20/25 (pin hole) to 20/20 in the left eye, and 20/20 on the right. The examiner indicated that the eye examination was normal, but the veteran may have dry eyes. On VA genitourinary examination in October 1997, it was indicated that the veteran developed left inguinal hernia in 1993 which was occasionally symptomatic since that time (left testicle swelling and pain). On examination, a small left inguinal hernia was present to palpation; the testicles were non-tender and of normal size and contour. Left inguinal hernia was diagnosed. The examiner indicated that the occasional testicle swelling was due to hernia with herniation into the scrotum. On VA orthopedic examination in October 1997, the veteran indicated that he sustained multiple injuries in service, including to the right leg, right and left hand, low back, the ribs, knees, feet, and ankles. On examination, paraspinal muscle tenderness was noted at L4-5; range of motion of the knees was reduced, and there was evidence of bilateral lateral patellar tilt; two well-healed scars were noted at the posterior aspect of the right leg, not associated with muscle defect or dysfunction; examination of the chest and rib cage revealed no evidence of sternoclavicular or other sternal subluxation; the chest was intact with no particular point tenderness to touch; examination of the left hand revealed evidence of a small puncture wound at the distal radial aspect of the index metacarpal; the ring finger metacarpophalangeal joint was mildly tender; examination of the right hand revealed no evidence of any residuals of injury; examination of the shins revealed some discomfort in the anterior compartment, bilaterally. X-ray studies of the knees, lumbar spine, the right hand, and rib cage were normal. The examiner indicated that the veteran sustained multiple injuries during service; in his opinion, such injuries were productive of "very minimal disability." The clinical assessment was: (1) overuse stress-pull injury to both feet with no current evidence of any stress-pulls on either foot; (2) two post- incision scars of the right leg, well-healed and not associated with muscle or vascular defect; (3) bilateral shin splints (an overuse injury), currently under control; (4) bilateral chondromalacia patella (an overuse injury, currently under control); (5) right hand crush fracture with "no significant sequelae" and full range of motion of the wrist and fingers; (6) puncture injury to the left hand with a residual scar, but no significant neurologic or vascular impairment; (7) low back strain, productive of intermittent pain; and (8) chest contusion with apparent "cracking" of the 10th and 11th rib, with no residual disability. On VA general medical examination in October 1997, the veteran indicated that his eyes were sensitive to bright sunlight and that he wore over-the-counter sunglasses while outdoors in bright sun; he denied having prescribed corrective lenses. He indicated that he experienced an itchy rash on his neck, chest and shoulders during the summer, noting that the rash disappeared almost completely during the winter. On examination, there were no acute or chronic skin lesions, but a 2-millimeter pigmented papule was noted over the right lower lateral neck; examination of the eyes was normal. Photosensitivity to bright sunlight and scaly itchy rash occurring only during hot summer months with a residual single lesion representing skin allergy to exposure to hot, bright sun were diagnosed. In July 1998, the veteran submitted to the RO color photographs (reportedly depicting himself) showing faint scars on the right leg, left ankle, and left hand. Based on the foregoing, the Board finds that the evidence supports service connection for bilateral knee disability diagnosed as chondromalacia patella, bilateral shin splints, left hand scar (a residual of left hand puncture injury), two scars at the right leg (residuals of right leg nevi excision), and left inguinal hernia with intermittent swelling testicles. Although a history of left knee injury was indicated during an (undated) medical examination prior to the veteran's active service period, disability or impairment involving the knees, shins, left hand, right leg, and/or inguinal hernia were not found on service entrance medical examination in August 1993. As discussed above, he received intermittent medical treatment for the aforementioned disabilities/injuries during active service and, although no pertinent chronic disabilities were diagnosed on service separation medical examination in June 1997, such disabilities were clearly diagnosed on VA medical examinations immediately (within about two months) after service separation. The Board notes that the VA examiners suggested in October 1997, that the veteran's disability, overall, was productive of only minimal impairment. Nevertheless, chronic disabilities involving both knees (chondromalacia patella), bilateral shin splints, residuals of left hand injury (manifested by a well-healed scar), residuals of nevi excision from the right leg (manifested by two well-healed scars), and left inguinal hernia (productive of intermittent testicular swelling) were diagnosed on examination. As the entirety of the evidence of record indicates, such disabilities were not evident prior to his active service period, they necessitated medical treatment during active service, and they were diagnosed within a short time after service separation. Thus, resolving the benefit of any doubt in the veteran's favor, the Board finds that his current bilateral chondromalacia patella, bilateral shin splints, left hand scar, two scars at the right leg, and left inguinal hernia (productive of intermittent testicular swelling) developed during active service. 38 C.F.R. § 3.102 (1999). With regard to the claims of service connection for chronic low back and right hand disabilities and a skin disorder (claimed as tinea versicolor), the Board finds that the claims are well grounded as they are capable of substantiation. 38 U.S.C.A. § 5107(a). This finding is based on the veteran's assertion that he experienced recurrent symptoms of low back and right hand pain since injuries in service, and that he experienced recurrent dermatological symptoms during the summer months since active service. The Board notes that although he is not competent to provide a medical diagnosis of a chronic disability, or to relate current disability to a specific cause, he is competent to state that he experienced personally observable symptoms in service. See Cartright v. Derwinski, 2 Vet. App. 24 (1991). As discussed above, the veteran's service medical records reveal intermittent treatment for low back and right hand pain following injury and trauma; he was also treated for dermatologic symptoms (diagnosed as tinea versicolor) in May 1994; post service medical evidence, consisting of VA medical examination reports in October 1997, reveals that there was "no significant sequelae" following the in-service right hand injury, that he experienced intermittent pain due to low back strain, and that he experienced an itchy and scaly rash during the summer months. Although only a single lesion on the skin was noted on dermatologic evaluation in October 1997, the veteran's skin disorder may have been in an inactive stage at the time of the examination; such examination was not performed during a hot summer month, and the veteran's contention that chronic dermatologic disorder manifests itself during the summer is supported by his service medical records showing treatment for tinea versicolor in May 1994. As the evidence of record reveals that the veteran sustained low back and right hand trauma in service and experienced low back and right hand symptomatology within a short time after service separation, and that he initially sought medical treatment for a skin disorder during active service, his claims are deemed well grounded. 38 U.S.C.A. § 5107(a). Regarding the claims of service connection for chronic bilateral arch disability, residuals of chest/rib-cage injury, and vision impairment, the Board finds that such claims are not well grounded. In particular, while service medical records reveal reports of pain and discomfort involving the feet, that he sustained trauma to the chest/rib-cage when a heavy object fell on his chest in April 1996, and that his eyes were sensitive to bright sunlight, chronic organic disability involving the arches of the feet, chest and/or rib-cage, or the eyes was not found at the time of the June 1997 service separation medical examination, on VA medical examination in October 1997, or indeed at any other time since separation from service. As noted above, the pertinent medical history was discussed and evaluated on VA medical examinations in October 1997; yet, the examiners opined that there was no evidence of stress-pull injury involving either foot, that there was no residual disability from in-service chest contusion and reported cracking of the ribs, and that there was no disability involving the eyes (but it was noted that his eyes were sensitive to bright sunlight and he wore over-the-counter sunglasses). Accordingly, as there is no current confirmed diagnosis of organic disability of the veteran's arches, chest and/or rib- cage, or eyes, the claims must be denied as not well grounded. See Rabideau, 2 Vet. App. 14; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992) (in the absence of proof of a present disability there can be no valid claim). The Board is mindful of the veteran's contention that he currently has chronic disabilities involving the arches, chest and rib-cage, and eyes, and that such disability is related to service. While the credibility of his contention is not challenged and his competence to testify with regard to observable symptoms of recurrent pain and vision impairment is noted, consistent with Cartright, 2 Vet. App. 24, he is simply not competent, as a layman, to render a medical diagnosis of chronic organic disability of the arches, chest/rib-cage, or eyes, or to provide an etiological link between in-service symptoms and any current symptomatology. See Grivois, 6 Vet. App. at 140, citing Espiritu, 2 Vet. App. at 494. Finally, the evidence of record does not show, nor is it contended by or on behalf of the veteran, that the claimed disability involving the arches, chest/rib-cage, or eyes is related to combat service; thus, 38 U.S.C.A. § 1154(b) is inapplicable to such claims. If a claim is not well grounded, the Board does not have jurisdiction to adjudicate the claim. Boeck v. Brown, 6 Vet. App. 14 (1993). A not well-grounded claim must be denied. Edenfield v. Brown, 8 Vet. App. 384 (1995). If the initial burden of presenting evidence of a well-grounded claim is not met, VA does not have a duty to assist the veteran in the development of the claim. 38 U.S.C.A. § 5107(a); Murphy, 1 Vet. App. at 81-82. The RO has advised the veteran of the evidence necessary to establish a well-grounded claim, and he has not indicated the existence or availability of any medical evidence (not already of record) that would well ground his claims of service connection for chronic disabilities involving the arches, chest/rib-cage, or the eyes. Epps v. Brown, 9 Vet. App. 341, 344 (1996), aff'd sub nom. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). ORDER Service connection for right and left knee chondromalacia patella, bilateral shin splints, residuals of left hand injury manifested by a scar, residuals of nevi excision from the right leg manifested by scars, and left inguinal hernia with intermittent testicular swelling is granted. The claims of service connection for a chronic low back disability, right hand disability, and skin disorder (claimed as tinea versicolor) are well grounded. Service connection for chronic bilateral arch disability, chest/rib-cage disability, and bilateral eye disability is denied. REMAND If a claim is well grounded (as are the veteran's claims of service connection for chronic low back and right hand disability and a skin disorder, claimed as tinea versicolor), VA has a duty to assist the veteran in the development of facts pertinent to his claim, see 38 U.S.C.A. § 5107(b), which includes a thorough VA examination. Hyder v. Derwinski, 1 Vet. App. 221 (1991); Green v. Derwinski, 1 Vet. App. 121 (1991). Although he underwent VA medical examination in October 1997, at which time the pertinent history and contemporaneous complaints referable to the claimed low back and right hand disability and skin disorder were discussed, the nature of such disability is unclear; with regard to the low back disability, the examiner indicated in October 1997 that the veteran experienced intermittent pain due to low back strain; with regard to the right hand, it was indicated that that there was "no significant sequelae" following in-service injury; with regard to the skin disorder, it was indicated that he had scaly and itchy rash during the summer months (the examination was performed in the Fall). Thus, the Board believes that clarification should be sought, including a review of the veteran's entire claims file to determine the nature and etiology of any chronic low back and right hand disability and skin disorder which may now be present. See Suttmann v. Brown, 5 Vet. App. 127, 137 (1993). It should be noted that neither the veteran nor the Board may make medical determinations. Grottveit v. Brown, 5 Vet. App. 91 (1993). The evidence of record indicates that the veteran's recurrent skin disorder may manifest itself during certain times of the year and may be dormant during other times. Thus, an attempt should be made to conduct a VA dermatological examination requested below during an active stage of the disability, see Ardison v. Brown, 6 Vet. App. 405 (1994). With regard to the claim of a compensable rating for the veteran's service-connected residuals of right 3rd and 4th metatarsal fractures, the Board finds that the claim is well grounded as it is capable of substantiation. Murphy, 1 Vet. App. 78. This finding is based on his assertion that impairment from such disability is greater than the currently assigned noncompensable evaluation reflects. Shipwash v. Brown, 8 Vet. App. 218 (1995). If a claim is well grounded, VA has a duty to assist in the development of facts pertinent to the claim (38 U.S.C.A. § 5107(b)) including a pertinent, thorough VA medical examination. Hyder, 1 Vet. App. 221. Most recent VA orthopedic examination, performed in October 1997, showed a healed fracture of the 3rd and 4th metatarsals of the right foot (without evidence of degenerative changes). The examiner indicated that the fracture healed without "significant" deformity and he did not "expect" the veteran to experience "significant" pain due to the disability. The aforementioned medical opinion regarding the severity of the service-connected residuals of a fracture of the right 3rd and 4th metatarsals does not adequately address the extent of any functional impairment resulting therefrom, including during flare-ups of symptoms in relation to objective manifestations of the service-connected right foot disability. Thus, re-examination of the veteran's service- connected right foot disability is warranted in compliance with all applicable sections of 38 C.F.R. Part 4, particularly §§ 4.40 and 4.45, as well as DeLuca v. Brown, 8 Vet. App. 202 (1995). In view of the foregoing, the remaining issues on appeal are REMANDED for the following action: 1. The RO should obtain from the veteran the names, addresses, and approximate dates of treatment of all medical care providers who treated him for the service-connected residuals of right 3rd and 4th metatarsal fractures and any low back, right hand, and dermatologic disorders since service. After any necessary information and authorizations are obtained from the veteran, any such pertinent records of treatment, VA or private, (not already of record) should be obtained and added to the claims folder. 2. Then, the veteran should be afforded a VA orthopedic examination to determine the nature and etiology of all low back and right hand disabilities now present, and the nature and severity of the service-connected residuals of right 3rd and 4th metatarsal fractures. The claims folder must be made available to the examiner for review in conjunction with this request for medical opinion, and any report must reflect the examiner's review of pertinent evidence in the claims folder. Regarding the claimed low back and right hand disabilities, the examiner should be asked to provide an opinion whether it is at least as likely as not that any back or right hand disability found is causally related to service, keeping in mind the nature of the veteran's service (to the extent possible, the examiner should be asked to comment on whether in-service back and right hand pathology may be distinguished from post-service pathology, and if so, the examiner should be requested to explain such distinction). If any of the foregoing cannot be determined, the examiner should so state for the record. With regard to the service-connected residuals of right 3rd and 4th metatarsal fracture, any pertinent pathology present should be discussed, and all appropriate testing conducted. The examiner should elicit all of the veteran's subjective complaints concerning his right foot disability and provide an opinion as to whether there is adequate pathology present to support each of his subjective complaints of pain. The examiner should comment on the severity of these manifestations on the veteran's ability to function in the employment arena. Symptomatology associated with the service-connected right foot disability should be distinguished from any nonservice-connected right foot symptomatology. If it is impossible to distinguish the symptoms, the examiner should so state for the record. The examiner should also comment on whether there are other objective indications of the extent of the veteran's pain, such as visible manifestations on movement of the right foot and functional impairment due to pain. 3. The veteran should be afforded a VA dermatological examination to determine the nature and etiology of skin disorders which may now be present. The claims folder must be made available to the examiner for review in conjunction with the examination; the examination report must reflect the examiner's review of the claims folder. Any testing and/or clinical studies, deemed necessary, should be performed. The examiner is requested to provide an opinion as to the origin/etiology and likely date of onset of any skin disorder, including whether it is at least as likely as not that there is a causal relationship between any such disorder and active service (to the extent possible, the examiner should be asked to comment on whether in-service symptomatology may be distinguished from post-service symptoms, and if so, the examiner should be requested to explain such distinction), keeping in mind the nature and circumstances of the veteran's service. If any of the foregoing cannot be determined, the examiner should so state for the record. 4. The RO review of the veteran's increased rating claim should include in its readjudication of the evidence consideration of 38 C.F.R. §§ 4.40 and 4.45, and should specifically document consideration of 38 C.F.R. § 3.321(b)(1) (1999). See Floyd v. Brown, 9 Vet. App. 88, 96 (1996) (the Board is precluded from assigning an extraschedular rating in the first instance). 5. The RO should carefully review the examination reports and the other development requested above to ensure compliance with this remand. If any development requested above is not accomplished, remedial action should be undertaken. See Stegall v. West, 11 Vet. App. 268 (1998). If the benefits sought on appeal are not granted, the veteran should be provided a supplemental statement of the case and afforded an opportunity to respond. The case should then be returned to the Board review. The veteran has the right to submit additional evidence and argument on the matters remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). J. F. Gough Member, Board of Veterans' Appeals