Citation Nr: 1047811 Decision Date: 12/23/10 Archive Date: 12/30/10 DOCKET NO. 05-18 269 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 10 percent for chondromalacia and degenerative arthritis of the left knee. 2. Entitlement to a compensable rating for chondromalacia of the right knee. 3. Entitlement to a compensable rating for residuals of a right ulna fracture. 4. Entitlement to service connection for a chronic disability manifested by fatigue, weight loss and sleep problems, to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD O. Lee, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1983 to May 1990 and January 1991 to February 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2003 and January 2004 rating decisions of the RO in St. Petersburg, Florida. The September 2003 decision, in pertinent part, assigned a separate disability rating of 10 percent for chondromalacia and degenerative arthritis of the left knee, effective April 14, 2003. The January 2004 rating decision continued noncompensable ratings for chondromalacia of the right knee and status post fracture of the distal right ulna with deformity (major) and denied service connection for fatigue, weight loss and sleep problems due to Gulf War service. The Board remanded this case in August 2008 and April 2009. It now returns for appellate consideration. In December 2008, a Travel Board hearing was held at the RO before the undersigned Veterans Law Judge. A transcript of that proceeding has been associated with the claims file. Subsequent to the issuance of the February 2010 supplemental statement of the case (SSOC), the Veteran submitted additional evidence which was not considered by the RO. The Veteran, through his representative, has waived RO consideration of that evidence in a November 2010 submission. The Board may consider the appeal. 38 C.F.R. § 20.1304 (2010). FINDINGS OF FACT 1. The Veteran's chondromalacia and degenerative arthritis of the left knee is manifested by degenerative arthritis (established by X-ray findings), painful motion, tenderness, and range of motion to full extension and at worst limited to 105 degrees flexion. 2. The Veteran's chondromalacia of the right knee is manifested by painful motion, tenderness, and range of motion to full extension and at worst limited to 105 degrees flexion. 3. The Veteran is right hand dominant. 4. The Veteran's residuals of a right ulna fracture are manifested by a ganglion cyst over the ulnar styloid, pain, tenderness, limitation of motion of the wrist ranging from 10 to 70 degrees dorsiflexion (extension) and 5 to 80 degrees palmar flexion, ulnar neuropathy, and carpal tunnel syndrome. 5. The Veteran did not have active military service in the Southwest Asia Theater of operations during the Persian Gulf War. 6. The preponderance of the evidence is against a finding that a chronic disability manifested by fatigue, weight loss and sleep problems that had its onset in service, manifested within one year of service separation, or is otherwise related to the Veteran's active military service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for chondromalacia and degenerative arthritis of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2010). 2. The criteria for a compensable rating for chondromalacia of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2010). 3. The criteria for an increased rating of 30 percent, but no higher, for residuals of a right ulna fracture with ulnar neuropathy and carpal tunnel syndrome are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5211, 5215; 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8516 (2010). 4. A chronic disability manifested by fatigue, weight loss and sleep problems was not incurred in or aggravated by active service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In the interest of clarity, the Board will first discuss certain preliminary matters. The Board will then render a decision. The Board has thoroughly reviewed all the evidence in the appellant's claims file, and has an obligation to provide reasons and bases supporting the decision. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As noted above, the Board remanded the issues currently on appeal in April 2009. The Board instructed the RO to provide the Veteran with a corrective VCAA notice letter, and readjudicate the claims in light the new evidence received since the issuance of the February 2008 supplemental statement of the case (SSOC). As further discussed below, the Veteran was issued a corrective VCAA letter in May 2009, and the Veteran's claims were readjudicated in a February 2010 SSOC. Thus, there is compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). I. The Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2010). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. The requirement of requesting that the claimant provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Any error related to this element is harmless. Prior to and following the initial adjudication of the Veteran's claims, letters dated in April 2003, December 2004 and May 2009 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187; Pelegrini II, 18 Vet. App. at 120-21. The letters advised the Veteran of the information necessary to substantiate the claims, to include for Gulf War undiagnosed illnesses, and of his and VA's respective obligations for obtaining specified different types of evidence. The Veteran was informed of the specific types of evidence he could submit, which would be pertinent to his claims, and told that it was ultimately his responsibility to support the claims with appropriate evidence. In addition, a March 2006 letter provided the Veteran with notice concerning the assignment of disability ratings and effective dates. See Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). During the pendency of the appeal, the VCAA notice requirements were interpreted as follows. For an increased compensation claim, the veteran must be notified that he must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) (Vazquez-Flores I). The United States Court of Appeals for the Federal Circuit (Federal Circuit) subsequently held that the notice described in 38 U.S.C. § 5103(a) need not be veteran specific, i.e., it need not notify the veteran of alternative diagnostic codes, and that that the statutory scheme does not require 'daily life' evidence for proper claim adjudication. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (Vazquez-Flores II) (vacating and remanding in part Vazquez- Flores I). Most recently, the Court clarified that the notice must advise the veteran to submit evidence demonstrating the effect that the worsening of his disability has on his employment. Vazquez-Flores v. Shinseki, No. 05-0355, (U.S. Vet. App. October 22, 2010) (Vazquez-Flores III). The Veteran was given proper notice pursuant to the Vazquez requirements in the May 2009 letter and provided ample opportunity to respond. No response was received. Subsequent to the issuance of the December 2004, March 2006 and May 2009 notice letters, the claims were readjudicated in the February 2010 SSOC. Thus, there was no deficiency in notice and a harmless error analysis is not necessary. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). The Board also concludes that VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the claims file. Private medical records identified by the Veteran have been associated with the file. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. With respect to service connection claims, the duty to assist includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. The Board concludes an examination is not needed for the Veteran's service connection claim because there is no indication that his claimed symptoms of fatigue, weight loss and sleep problems may be related to an in-service event. While the Veteran contends that such symptoms are a result of the vaccination shots he was given in service, he is not competent to offer such an opinion, and he has failed to provide any evidence to suggest that there may be a link between the two. As the record is not indicative of an association between the claimed symptoms of fatigue, weight loss and sleep problems and any vaccination shots administered in service, a VA examination is not warranted. See 38 C.F.R. § 3.159(c)(4); see also McLendon, supra. Furthermore, there is no evidence indicating the Veteran otherwise "suffered an event, injury or disease in service" or that he served in the Southwest Asia theater of operations during the Persian Gulf War. See 38 U.S.C.A. § 1117(f); 38 C.F.R. § 3.317(d)(1); see also Paralyzed Veterans of America v. Secretary of Veterans Affairs, 345 F.3d 1334, 1355-57 (Fed. Cir. 2003) (holding that 3.159(c)(4)(i) is not in conflict with § 5103A(d) and evidence of record "establishing that the veteran suffered an event, injury, or disease in service," is required to trigger VA's duties pursuant to § 5103A(d)); Wells v. Principi, 326 F.3d 1381, 1384 (Fed. Cir. 2003) (holding that the Secretary's obligations under § 5103A to provide a veteran with a medical examination or to obtain a medical opinion is triggered if the evidence of record demonstrates "some casual connection between his disability and his military service"). In this regard, there is no reasonable possibility that a medical opinion would aid in substantiating the Veteran's claim since it could not provide evidence of a past event. As to increased rating claims, the duty to assist also includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2010). The RO provided the Veteran appropriate VA orthopedic examinations in July 2003 and February 2008. The Board finds these examination reports to be comprehensive and sufficient in addressing the severity of the Veteran's bilateral knee and right wrist disabilities. In this regard, it is noted that the most recent February 2008 opinion was rendered by a medical professional following a review of the claims file, thorough examination and interview of the Veteran, and review of the X-ray studies. Additionally, the Veteran recently submitted a private evaluation report dated in July 2010, which addresses the current severity of the Veteran's service-connected disabilities in detail. Altogether, the VA and private medical reports on file are adequate upon which to base the decisions in this case. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). II. Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating 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). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Board acknowledges that the Veteran is competent to give evidence about what he experienced; for example, he is competent to report that he experiences certain symptoms. See, e.g., Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Competency, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997). He is not, however, competent to diagnose any medical disorder or render an opinion as to the severity of any current disorder because he does not have the requisite medical knowledge or training. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). a. Left Knee The Veteran is service-connected for chondromalacia and degenerative arthritis of the left knee. He contends that his disability is more severe than reflected in his currently- assigned 10 percent evaluation. The Veteran was afforded a VA orthopedic examination in July 2003. Physical examination of the left knee revealed range of motion from 0 to 140 degrees with guarding. No redness, heat or swelling was noted. There was increased pain on motion. The examiner noted it was conceivable that pain could further limit function during flare-ups or with increased use, however it was not feasible to attempt to express any of this in terms of additional limitation of motion as such matters could not be determined with any degree of medical certainty. X-rays demonstrated mild degenerative disease with no evidence of acute injury. The impression was chondromalacia patella. VA treatment records dated in April 2004 show that range of motion in both knees was 15 to 120 degrees. There was no effusion or crepitance, and it was noted that all ligaments were stable. There was no joint line tenderness, a negative McMurray's test, and normal patellofemoral tracking. X-rays of the bilateral knees demonstrated normal findings. The diagnosis was arthralgia. It was noted that there were no abnormalities found on examination or X-ray. In November 2004, both knees were again found to be normal on examination. Bilateral knee arthralgia was noted. Subjective complaints were found to outweigh objective findings. An October 2006 MRI revealed thickening of the quadricep tendons and vastus lateralis bilaterally, indicating a chronic tendinopathy. The medial and lateral menisci in the left knee were intact showing no MR evidence of a tear. The ACL, PCL, MCL and LCL were intact. The joint space and cartilage appeared normal. There was no significant joint effusion. The marrow signal throughout the imaged osseous structures appeared normal. Private treatment notes dated in November 2006 showed that the Veteran continued to complain of knee pain that was somewhat worse medially. It was noted that the Veteran had a fair amount of some diffuse chronic tendonitis of his quadriceps and patellar tendon. At a subsequent VA orthopedic examination in February 2008, the Veteran complained of discomfort in the left knee of a level 6 or 7, three or four times a week, off and on throughout the day. On physical examination, range of motion testing, after three repetitions, revealed flexion from 0 to 140 degrees with complaints of discomfort from 90 to 140 degrees. Findings were negative for Lachman's anterior-posterior drawer, McMurray and grind test. There was no medical or lateral joint line tenderness. There was no difficulty or discomfort with range of motion testing, effusion, erythema, tenderness, palpable deformity or instability found except as noted. Additional limitations due to flare-ups could not be determined without resorting to mere speculation. Upon review of diagnostic tests, no significant abnormality was identified. The diagnosis was chondromalacia patella, resolved without residuals. It was noted that there was no objective evidence to support the diagnosis of chondromalacia patella at this time and that there were no objective findings of osteoarthritis at this time. A private treatment report dated in January 2009 notes that the Veteran walked with a bit of a stiff gait. Physical examination revealed some degree of atrophy of the thigh muscles, tenderness in the peripatellar tissues on both knees, and tenderness medially greater than laterally on the joint line areas of both knees. There was no obvious effusion in the knees. The Veteran had active range of motion in the left knee from -10 degrees to 110 degrees. The examiner could push beyond that but only with pain and guarding. There was no ligamentous instability. The examiner opined that the Veteran had some degenerative meniscal changes and probably some mild patellofemoral arthritis as well. (Given that this opinion was based in part on a review of the previous MRI, it is unclear whether this opinion was in reference to the right knee only or to both knees.) It was noted that the Veteran did not have an obvious inflammatory arthropathy picture but that his stiffness was certainly greater than what would be expected just from the X-ray appearance. In September 2009, physical examination revealed tenderness diffusely in the anterior aspect of both knees and a little bit in the medial aspect as well. It was noted that the Veteran might have degenerative meniscal changes and the option of arthroscopy was discussed. A private medical report dated in July 2010 shows further evaluation of the Veteran's bilateral knees. Physical examination revealed full extension with crepitation of the knees with active movement. Flexion was limited to 105 degrees. There was normal patellar tracking, no medial-lateral instability, and no anterior Drawer's sign. The impression was history of bilateral traumatic osteoarthritis of the knees. As previously noted, the Veteran is currently assigned a 10 percent rating under Diagnostic Code 5099-5003 for chondromalacia and degenerative arthritis of the left knee. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. However, when limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or groups of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. A compensable evaluation under Diagnostic Code 5003 and 38 C.F.R. § 4.59 (for painful motion) is in order where arthritis is established by X- ray findings and no actual limitation of motion of the affected joint is demonstrated. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Limitation of flexion of the leg to 45 degrees is rated as 10 percent disabling; flexion limited to 30 degrees is rated as 20 percent disabling; and flexion limited to 15 degrees is rated at 30 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of the leg to 10 degrees is rated as 10 percent disabling; extension limited to 15 degrees is rated as 20 percent disabling; extension limited to 20 degrees is rated as 30 percent disabling; extension limited to 30 degrees is rated as 40 percent disabling; and extension limited to 45 degrees is rated as 50 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal (full) range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71a, Plate II. Separate ratings may be awarded for limitation of flexion and limitation of extension of the same knee joint. VAOPGCPREC 09-04 (Sept. 17, 2004). In order to receive a rating in excess of 10 percent based on limitation of motion, the Veteran would have to have flexion limited to 30 degrees or extension limited to 15 degrees. See 38 C.F.R. § 4.71a, DCs 5260, 5261. The evidence, as discussed above, demonstrates that the range of motion in the Veteran's left knee is at worst limited to 105 degrees flexion (most recently in July 2010) and 15 degrees extension (back in April 2004). The Veteran clearly does not meet the criteria for a noncompensable rating based on limitation of flexion. 38 C.F.R. § 4.71a, DC 5260. Even accounting for the DeLuca criteria, his flexion has never been shown to be limited to less than 90 degrees. In addition, although the Veteran was shown to have limitation of extension to 15 degrees on one occasion in April 2004, he has at all other times been found to have full extension, including at the most recent private evaluation in July 2010. In this regard, the Board finds that a rating based on limitation of extension is not warranted. 38 C.F.R. § 4.71a, DC 5261. As such, under Diagnostic Code 5003, the Veteran is entitled to no more than a 10 percent rating in recognition of the April 2004 X-ray findings of arthritis with noncompensable limitation of motion. It is noted that under Diagnostic Code 5003, a 20 percent rating may be assigned in absence of limitation of motion where there is X-ray evidence of involvement of 2 or more major joints with occasional incapacitating exacerbations. Here, only 1 joint is involved (as discussed below, there are no X-ray findings of arthritis in the right knee), and there are no incapacitating exacerbations. Higher ratings under Diagnostic Codes 5003, 5260 and 5261 are therefore not available. Separate ratings may be assigned for arthritis with limitation of motion of a knee (DCs 5003-5010) and for instability of a knee (DC 5257). VAOPGCPREC 23-97 (July 1, 1997), published at 62 Fed. Reg. 63,604 (1997) and VAOPGCPREC 9-98 (August 14, 1998), published at 63 Fed. Reg. 56,704 (1998); see also Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition.). Under Diagnostic Code 5257, a 10 percent rating is warranted for impairment of the knee with slight recurrent subluxation or lateral instability; a 20 percent rating for impairment with moderate recurrent subluxation or lateral instability; and a 30 percent rating for impairment with severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. Subluxation of the patella is "incomplete or partial dislocation of the knee cap." Rykhus v. Brown, 6 Vet. App. 354, 358 (1993) (citing Dorland's Illustrated Medical Dictionary at 1241, 1599 (27th edition 1988)). The Board observes that the words "slight," "moderate," and "severe," as used in the various diagnostic codes, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Here, there are no objective findings in the record indicative of lateral instability or recurrent subluxation. Although the Veteran reported at the December 2008 hearing that his knee had gone out a couple times when climbing flights of stairs, physical examinations, to include anterior drawer tests, have consistently been negative for any findings of instability, and ligaments shown to be intact. In this regard, as the Veteran does not have any instability that can be objectively elicited, any instability that he does have does not rise to a level that can be considered "slight." A separate rating under Diagnostic Code 5257 is therefore not warranted. The Board must also consider other possible avenues for a higher rating. Knee impairment with cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint is rated at 20 percent. 38 C.F.R. § 4.71a, DC 5258. Similarly, Diagnostic Code 5259 assigns a 10 percent rating for surgically removed cartilage that is symptomatic. A "semilunar cartilage" is one of the menisci of the knee joint. Stedman's Medical Dictionary, 296 (27th ed., 2000). Although there is evidence of degenerative meniscal changes, as noted in the January 2009 private treatment report, it is unclear whether this was in reference to just the right knee or to both knees. If anything, the October 2006 MRI showed the medial and lateral menisci to be intact with no MR evidence of a tear. Additionally, physical examinations have consistently been negative for McMurray's test and for any significant findings of effusion. Absent any evidence of a dislocated semilunar cartilage or a surgically removed cartilage, the Board concludes that a higher rating is not available under these diagnostic codes. The Board has considered the application of other diagnostic codes. The Ratings Schedule provides ratings for ankylosis (DC 5256), tibia and fibula impairment (DC 5262), and genu recurvatum (DC 5263). 38 C.F.R. § 4.71a. The Board notes that ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)); Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (Ankylosis is "stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint", citing Stedman's Medical Dictionary 87 (25th ed. 1990)). In this regard, the medical evidence of record does not show the Veteran to have ankylosis. The aforementioned range of motion findings clearly demonstrate that the Veteran's left knee is not fixed or immobile. With regard to malunion or nonunion of tibia and fibula, the Board notes that there is no evidence of fracture or dislocation in any of the laboratory studies on file. There is likewise no evidence that the Veteran has, or ever had, genu recurvatum. As such, further inquiry into the remaining diagnostic codes is moot. Furthermore, the Board has considered the possibility of staged ratings. See Fenderson, supra; Hart, supra. The Board, however, concludes that the criteria for a rating in excess of 10 percent have at no time been met. Accordingly, staged ratings are inapplicable. In light of the foregoing, the Board concludes that an increased rating for chondromalacia and degenerative arthritis of the left knee is not warranted. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). b. Right Knee The Veteran also seeks an increased rating for his service- connected chondromalacia of the right knee, currently evaluated as noncompensable. For the reasons that follow, the Board concludes that an increase evaluation is not warranted. On VA orthopedic examination in July 2003, physical examination revealed range of motion from 0 to 140 degrees with guarding. There was tenderness to palpation of the patellofemoral joint. No redness, heat or swelling was noted. There was increased pain on motion. The examiner noted it was conceivable that pain could further limit function during flare-ups or with increased use, however it was not feasible to attempt to express any of this in terms of additional limitation of motion as such matters could not be determined with any degree of medical certainty. X-rays demonstrated a normal right knee. The impression was chondromalacia patella. VA treatment records dated in April 2004 show that range of motion in both knees was 15 to 120 degrees. There was no effusion or crepitance, and it was noted that all ligaments were stable. There was no joint line tenderness, a negative McMurray's test, and normal patellofemoral tracking. X-rays of the bilateral knees revealed normal findings. The diagnosis was arthralgia. It was noted that there were no abnormalities found on examination or X-ray. In November 2004, both knees were again found to be normal on examination. Bilateral knee arthralgia was noted. Subjective complaints were found to outweigh objective findings. An October 2006 MRI revealed an irregularity of the tibial surface of posterior horn of the medial meniscus within the right knee, to include a possible small surface tear of the posterior medial meniscus; thickening of the MCL of the right knee, likely representing sequel of old trauma; and thickening of the quadricep tendons and vastus lateralis bilaterally, indicating a chronic tendinopathy. The lateral meniscus was intact showing no MR evidence of a tear. The ACL, PCL and LCL were intact. The joint space and cartilage appeared normal, and there was no significant joint effusion. The marrow signal throughout the imaged osseous structures appeared normal. Private treatment notes dated in November 2006 showed that the Veteran continued to complain of knee pain that was somewhat worse medially. Based on a review of the recent MRI, it was noted that there was some degree of changes in the medial meniscus, probably a tear of the posterior horn on the underside. The Veteran remained tender in that location. It was also noted that the Veteran had a fair amount of some diffuse chronic tendonitis of his quadriceps and patellar tendon. At the February 2008 examination, the Veteran complained of daily pain in the right knee of a level 7 to 8, worse in the morning for about two hours with stiffness. There was no locking, subluxing or dislocating. The discomfort was under the kneecaps and medially. The Veteran reported that it worsened by walking one quarter mile and going up three flights of stairs. On physical examination, range of motion testing, after three repetitions, revealed flexion from 0 to 140 degrees with complaints of discomfort from 90 to 140 degrees. Findings were negative for Lachman's anterior-posterior drawer, McMurray and grind test. There was no medical or lateral joint line tenderness. There was no difficulty or discomfort with range of motion testing, effusion, erythema, tenderness, palpable deformity or instability found except as noted. Additional limitations due to flare-ups could not be determined without resorting to mere speculation. Upon review of diagnostic tests, no significant abnormality was identified. The Veteran was diagnosed with chondromalacia patella, resolved without residuals. It was noted that there was no objective evidence to support the diagnosis of chondromalacia patella at this time. Also diagnosed was minor right medial meniscal tear, not caused by or related to the first diagnosis. The examiner was unable to say without resorting to mere speculation the precise onset. A private treatment report dated in January 2009 shows that the Veteran was found to walk with a bit of a stiff gait. Physical examination revealed some degree of atrophy of the thigh muscles, tenderness in the peripatellar tissues on both knees, and tenderness medially greater than laterally on the joint line areas of both knees. There was no obvious effusion in the knees. The Veteran had active range of motion in the right knee from -10 degrees to 115 degrees. The examiner could push beyond that but there was pain and guarding. There was no ligamentous instability. The examiner opined that the Veteran had some degenerative meniscal changes and probably some mild patellofemoral arthritis as well. It was noted that the Veteran did not have an obvious inflammatory arthropathy picture but that his stiffness was certainly greater than what would be expected just from the X-ray appearance. In September 2009, physical examination revealed tenderness diffusely in the anterior aspect of both knees and a little bit in the medial aspect as well. It was noted that the Veteran might have degenerative meniscal changes and the option of arthroscopy was discussed. A private medical report dated in July 2010 shows further evaluation of the Veteran's bilateral knees. Physical examination revealed full extension with crepitation of the knees with active movement. Flexion was limited to 105 degrees. There was normal patellar tracking, no medial-lateral instability, and no anterior Drawer's sign. The impression was history of bilateral traumatic osteoarthritis of the knees. As noted above, the Veteran is currently assigned a noncompensable percent rating under Diagnostic Code 5099-5257 for chondromalacia of the right knee. In order to receive a compensable rating based on limitation of motion, the Veteran would have to have flexion limited to 45 degrees or extension limited to 10 degrees. See 38 C.F.R. § 4.71a, DCs 5260, 5261. The evidence, as discussed above, demonstrates that the range of motion in the Veteran's right knee is at worst limited to 105 degrees flexion (most recently in July 2010) and 15 degrees extension (back in April 2004). The Veteran clearly does not meet the criteria for a noncompensable rating based on limitation of flexion. 38 C.F.R. § 4.71a, Diagnostic Codes 5260. Even accounting for the DeLuca criteria, his flexion has never been shown to be limited to less than 90 degrees. In addition, although the Veteran was shown to have limitation of extension to 15 degrees on one occasion in April 2004, he has at all other times been found to have full extension, including at the most recent private evaluation in July 2010. In this regard, the Board finds that a rating based on limitation of extension is not for application. 38 C.F.R. § 4.71a, DC 5261. Furthermore, while the medical evidence contains some general references to probable arthritis or a history of arthritis, X-ray studies have been negative for arthritis in the right knee. As such, a compensable rating based on X-ray findings of arthritis with noncompensable limitation of motion under Diagnostic Code 5003 cannot be assigned. As to Diagnostic Code 5257, there are no objective findings in the record indicative of lateral instability or recurrent subluxation. Although the Veteran reported at the December 2008 hearing that his knee had gone out a couple times when climbing flights of stairs, physical examinations, to include anterior drawer tests, have consistently been negative for any findings of instability. In this regard, as the Veteran does not have any instability that can be objectively elicited, any instability that he does have does not rise to a level that can be considered "slight." A separate rating under Diagnostic Code 5257 is therefore not warranted. The Board also finds that a higher rating is not warranted under Diagnostic Codes 5258 and 5259. Although an October 2006 MRI revealed a possible small surface tear of the posterior medial meniscus, the February 2008 VA examiner opined that this was not caused by or related to the Veteran's service-connected chondromalacia patella. Additionally, physical examinations have consistently been negative for McMurray's test and for any significant findings of effusion. As such, the Board concludes that a higher rating is not available under these diagnostic codes. The Board has considered the application of Diagnostic Codes 5256, 5262 and 5263. 38 C.F.R. § 4.71a. However, the medical evidence of record does not show that the Veteran has ankylosis. The aforementioned range of motion findings clearly demonstrate that the Veteran's left knee is not fixed or immobile. With regard to malunion or nonunion of tibia and fibula, the Board notes that there is no evidence of fracture or dislocation in any of the laboratory studies on file. There is likewise no evidence that the Veteran has, or ever had, genu recurvatum. As such, further inquiry into the remaining diagnostic codes is moot. The Board has considered the rule of Fenderson, supra. As the Board concludes that neither a compensable rating is warranted, the rule of Fenderson is not for application. As such, the Board finds that the preponderance of the evidence is against the Veteran's claim for a compensable rating for chondromalacia of the right knee. Consequently, the benefit-of- the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). c. Right Ulna The Veteran further seeks an increased rating for his service- connected residuals of a right ulna fracture, currently evaluated as noncompensable. For the reasons that follow, the Board concludes that an increased evaluation is warranted. On VA examination in July 2003, it was noted that the right wrist had a slight enlargement over the area of the ulnar styloid as compared to the left. There was tenderness to palpation over this area as well as over the dorsum of the wrist. The Veteran demonstrated guarding on range of motion testing of the wrist. He initially demonstrated 45 degrees of dorsiflexion and 45 degrees of palmar flexion with increased pain on range of motion. He was later able to relax, and have the wrist palmar flexed to 80 degrees. The Veteran made a satisfactory fist in the hand. Grip strength was demonstrated as approximately 4/5, but it was noted that this was possibly submaximal effect as there was no measurable atrophy of the forearm. X-rays revealed a normal right wrist. The impression was residuals of a fracture of the right distal ulna. VA treatment records show that the Veteran was seen in February 2004 with complaints of worsening pain in the right wrist. X- rays demonstrated a normal right wrist with no evidence of a recent fracture. In April 2004, an assessment of probable right wrist carpal tunnel was noted. In May 2004, sensory tests revealed diminished protective sensation in all fingers of the right hand. Range of motion in the right wrist was 20 degrees flexion, 30 degrees extension, 3 degrees ulnar deviation, and 3 degrees radial deviation. In July 2004, an assessment of acquired right wrist deformity and probable carpal tunnel was given. It was noted that the Veteran had a brace for the wrist but that it occluded the deformity and caused pain. The Veteran seen in February 2005 for evaluation of carpal tunnel of the right forearm, among other things. The assessment was acquired right wrist deformity and probable carpal tunnel. In September 2006, right wrist range of motion was found to be decreased by 50 percent and painful in all planes. Strength testing revealed flexion/extension 2/5, abduction/adduction 2/5 and grip 3/5. At the February 2008 examination, the Veteran reported a level 7 rate of pain that was constant and worsened by writing or typing for more than an hour, requiring him to stop for 20 minutes before he could restart. There were no other significant flare- ups and no locking, subluxing or dislocating. On physical examination, range of motion testing, after three repetitions, revealed dorsiflexion from 0 to 70 degrees, palmar flexion from 0 to 80 degrees, radial deviation from 0 to 20 degrees and ulnar deviation from 0 to 45 degrees. There was a three quarter centimeter high by 2.3 centimeter circumferential prominence to the ulnar styloid. There was no difficulty or discomfort with range of motion testing, effusion, erythema, tenderness, palpable deformity or instability found except as noted. Additional limitations due to flare-ups could not be determined without resorting to mere speculation. Upon review of diagnostic tests, no abnormality of the right wrist was identified. The diagnosis was right wrist distal ulnar fracture, healed without residuals. It was noted that despite the subjective complaints, minor fractures such at the Veteran's distal ulnar styloid fracture heal without chronic sequel; the subjective complaints could not be adequately explained by the service-connected conditions or by their level of severity. Private treatment records show that the Veteran's right wrist was evaluated in January 2009. It was noted that an MRI study from February 2007 had demonstrated mild degeneration of the ulnar attachment to the triangular fibrocartilage and a 4 mm interosseous ganglion cyst within the capitate. The Veteran reported numbness and tingling in the fifth finger and sometimes in the third finger. On examination, the Veteran was guarded with extension, but his flexion was intact and there was no pain significantly with ulnar and radial deviation. There was fairly diffuse tenderness over the ulnar aspect of the wrist, particularly dorsally. The pisiform triquetral region was mildly tender. There were some problems of the ulnar styloid, possibly a ganglion cyst dorsally to the area. The TFCC area was tender to palpation as well. The assessment was right wrist pain with probable TFCC injury and mild ganglion cyst. The Veteran was further evaluated for right wrist pain and tingling in the hand several weeks later. On physical examination, there was tenderness to palpation everywhere on the wrist. It was difficult to assess accurate range of motion because there was a lot of guarding and apprehension. Range of motion seemed to be variable; the Veteran seemed to be particularly protective and limited in range of motion on active measurement. Extension was 10 degrees and flexion was 20 degrees. Every area to palpate along the wrist was tender dorsally on the radial aspect, ulnar aspect and the palmar aspect. There was some tenderness over the TFCC. The radioulnar ligament was also somewhat tender. Nerve conduction study and EMG revealed right carpal tunnel syndrome (mild to moderate motor and sensory involvement) and right ulnar neuropathy involving the distal motor (deep palmar branch greater than the hypothenar branch). In August 2009, physical examination revealed wrist motion lacking about 20 degrees of extension and about 5 to 10 degrees of flexion. There was tenderness to palpation over the TFCC region and the ulnar styloid. The pisiform triquetral joint was minimally tender. The radial aspect of the wrist was not as tender. Compression of the carpal tunnel produced some numbness in the fourth and fifth fingers, and palpation of the cubital tunnel produced some pain in the fourth and fifth fingers. A private medical report dated in July 2010 shows further evaluation of the Veteran's right wrist. Physical examination revealed extension of 30 degrees, flexion of 40 degrees, ulnar deviation of 25 degrees and radial deviation of 10 degrees. The right handgrip was 42 pounds, compared to the left handgrip of 80 pounds. There was obvious significant elevation of the right ulnar styloid, some hypothenar atrophy of the right hand, and some intrinsic atrophy on the right. The impression was right carpal tunnel and right distal ulnar nerve entrapments. Later that month, the Veteran underwent a thorough evaluation by Occupational Therapy for right upper extremity carpal tunnel syndrome and ulnar neuropathy. The Veteran reported that his biggest challenge working as a railroad inspector was lifting, pulling and gripping. A sustained grip strength test revealed a 69 percent right side deficit compared to the opposite hand. Range of motion testing of the right upper extremity showed active wrist flexion of 39 degrees (70% of norm), active wrist extension of 16 degrees (29% of norm), active elbow flexion of 89 degrees (66% of norm), and active elbow extension of 2 degrees. Muscle strength testing demonstrated muscle strength difference of 72 percent on the right as compared to the left on both elbow extension and wrist flexion. The Veteran's right ulna fracture residuals are assigned a noncompensable rating under Diagnostic Code 5211. He testified at the December 2008 Travel Board hearing that he is right- handed. See also VA examination report, July 2003. As his right arm and wrist are among his major extremities, they will be rated as such. Diagnostic Code 5211 provides for ratings based on impairment of the ulna. Malunion of the ulna with bad alignment is rated 10 percent for the major side and 10 percent for the minor side; nonunion of the ulna in the lower half is rated 20 percent for the major side and 20 percent for the minor side; nonunion of the ulna in the upper half, with false movement, without loss of bone substance or deformity is rated 30 percent for the major side and 20 percent for the minor side; nonunion of the ulna in the upper half, with false movement, with loss of bone substance (1 inch (2.5cms) or more) and marked deformity is rated 40 percent for the major side and 30 percent for the minor side. 38 C.F.R. § 4.71a. While the relevant evidence of record, as summarized above, shows that the Veteran has an acquired deformity of the right wrist-a ganglion cyst over the right ulnar styloid-as well as a probable triangular fibrocartilage complex (TFCC) injury, it does not reflect any findings of malunion or nonunion of the ulna. Indeed, X-rays show a normal right wrist. As such, a compensable rating is not for application under Diagnostic Code 5211. The Board will now consider whether a compensable rating may be assigned under Diagnostic Code 5215 based on limitation of motion of the wrist. Limitation of palmar flexion in line with the forearm is rated 10 percent disabling for the major wrist and 10 percent for the minor wrist; limitation of dorsiflexion to less than 15 degrees is rated 10 percent disabling for the major wrist and 10 percent for the minor wrist. 38 C.F.R. § 4.71a. The evidence shows that limitation of motion in the right wrist has widely ranged from 10 to 70 percent dorsiflexion (extension) and 5 to 80 degrees palmar flexion. Although dorsiflexion was found to be limited to 10 degrees on one occasion, in January 2009, limitation of dorsiflexion has at all other times been found to be greater than 15 degrees. In addition, palmar flexion has not been shown to be limited to being in line with the forearm. For the aforementioned reasons, the Board finds that the assignment of a compensable rating is not warranted under Diagnostic Code 5215. In this case, the medical evidence of record establishes that the Veteran's right ulnar fracture residuals have resulted in right carpal tunnel and right distal ulnar nerve entrapment. See private medical report, July 15, 2010. The Board will now consider whether a compensable rating can be assigned under Diagnostic Code 8515 for paralysis of the median nerve or Diagnostic Code 8516 for paralysis of the ulnar nerve. Diagnostic Code 8515 provides that mild incomplete paralysis is rated 10 percent disabling on the major side and 10 percent on the minor side; moderate incomplete paralysis is rated 30 percent disabling on the major side and 20 percent on the minor side; and severe incomplete paralysis is rated 50 percent disabling on the major side and 40 percent on the minor side. Complete paralysis of the median nerve, with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances, is rated 70 percent disabling on the major side and 60 percent on the minor side. Diagnostic Code 8516 provides that mild incomplete paralysis is rated 10 percent disabling on the major side and 10 percent on the minor side; moderate incomplete paralysis is rated 30 percent disabling on the major side and 20 percent on the minor side; and severe incomplete paralysis is rated 40 percent disabling on the major side and 30 percent on the minor side. Complete paralysis of the ulnar nerve, the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers, cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened, is rated 60 percent disabling on the major side and 50 percent on the minor side. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. Based on the objective medical findings of record, the Board finds the Veteran's symptoms of neurological impairment in the upper right extremity to be, at most, reflective of moderate incomplete paralysis. 38 C.F.R. § 4.124a, Diagnostic Codes 8515, 8516. Significantly, the January 2009 nerve conduction study and EMG revealed carpal tunnel syndrome of mild to moderate motor and sensory involvement. There is no evidence to support an assessment of severe incomplete paralysis, nor are there any findings that would meet the criteria for either complete paralysis of the median nerve or complete paralysis the ulnar nerve. Id. As the Veteran's neurological symptoms most closely approximate incomplete paralysis of moderate severity, the Board finds that an increased rating of 30 percent, but no higher, for ulnar neuropathy and carpal tunnel syndrome of the upper right extremity is warranted. Id. The Board has considered the rule for staged ratings. Fenderson, supra; Hart, supra. However, as the evidence does not show that the criteria for a rating in excess of 30 percent have been met at any time during the period on appeal, staged ratings are inapplicable here. As such, the Board concludes that an increased rating of 30 percent, but no higher, is warranted for the Veteran's residuals of a right ulna fracture with ulnar neuropathy and carpal tunnel syndrome. The benefit-of-the-doubt rule has been applied in arriving at this decision. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). d. Extraschedular Ratings Finally, the Board has considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extraschedular consideration referral). The schedular evaluations for the Veteran's chondromalacia and degenerative arthritis of the left knee, chondromalacia of the right knee, and residuals of right ulna fracture with ulnar neuropathy and carpal tunnel syndrome are not inadequate. His complained-of symptoms are those contemplated by the rating criteria. There are no symptoms left uncompensated or unaccounted for by the assignment of a schedular rating. The evidence shows that the Veteran works for the federal government as a railroad inspector and that his knee disabilities present difficulties with kneeling, squatting, walking and climbing. The biggest challenge with his upper right extremity impairment is lifting, pulling and gripping. The Board has considered the Veteran's testimony at the December 2008 Travel Board hearing, his lay statements as well as the lay statement of Ms. S. [redacted], all of which attest to the severity of his service- connected disabilities. However, it does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluations for his level of impairment. In other words, he does not have any symptoms from his service-connected conditions that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for those service-connected disabilities are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is moot. See Thun, supra. III. Service Connection The Veteran seeks service connection for fatigue, weight loss and sleep problems, to include as due to an undiagnosed illness, claiming that these conditions are symptoms of an undiagnosed illness under the provisions of 38 C.F.R. § 3.317 (2010). However, for the reasons that follow, the Board concludes that service connection is not warranted. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110 (West 2002). For the showing of chronic disease in service there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. See 38 C.F.R. § 3.303(b) (2010). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). Service connection may also be granted for a chronic disease, including an organic disease of the nervous system, when it is manifested to a compensable degree within one year of separation from service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.307, 3.309 (2010). In order to establish service connection for the claimed disorder, there must generally be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be established for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability, provided that such disability: (1) became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011, and (2) by history, physical examination and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). The term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 U.S.C.A. § 1117(f); 38 C.F.R. § 3.317(d)(1). Unlike the elements for direct service connection given above, for claims under 38 C.F.R. § 3.317, competent evidence linking a current disability to an event during service need not be provided. Gutierrez v. Principi, 19 Vet. App. 1 (2004). A "qualifying chronic disability" means a chronic disability resulting from either of the following (or any combination of the following): an undiagnosed illness; and a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms. 38 U.S.C.A. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i); Presumptions of Service Connection for Persian Gulf Service, 75 Fed. Reg. 59,968-72 (Sept. 29, 2010) (removing 38 C.F.R. § 3.317(a)(2)(i)(C)). The term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(2-5). Signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, fatigue, joint pain, sleep disturbances and abnormal weight loss. 38 U.S.C.A. § 1117(g); 38 C.F.R. § 3.317(b). Medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation; lay assertions of medical status do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay assertions may serve to support a claim for service connection by supporting the occurrence of lay- observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). As an initial matter, the Board notes that the Veteran in this case is not a Persian Gulf veteran. See 38 U.S.C.A. § 1117(f); 38 C.F.R. § 3.317(d)(1). His service records reflect that he did not have active service in the Southwest Asia Theater of operations during the Persian Gulf War. Service treatment records dated in February 1991 show that the Veteran, upon evaluation for deployability, was found to have disabilities (to include low back pain and fractured right wrist) that rendered him "non-deployable." Indeed, the Veteran acknowledges that he never actually deployed to the Southwest Asia Theater during his period of service. Therefore, the provisions of 38 C.F.R. § 3.317 for establishing service connection on a presumptive basis are not applicable here. The Board will now consider whether service connection may be established on a direct basis for the Veteran's claimed disability. See Hickson, supra. The Board has reviewed the claims file and finds that there is no evidence that any of the claimed symptoms had their onset in service. Service treatment records are silent concerning any complaints, treatment or a diagnosis of fatigue, weight loss or sleep problems. At a periodic examination in October 1989, there were no complaints of fatigue, weight loss or sleep problems, and findings on clinical evaluation were normal. Notwithstanding the foregoing, the Veteran asserts that his symptoms of fatigue, weight loss and sleep problems are the result of the inoculation/vaccination shots he was given in anticipation of deployment to the Persian Gulf. Service treatment records show that the Veteran was administered the typhoid vaccine, influenza vaccine, meningococcalm (MGC) immunization, and immune serum globulin (ISG) immunization in February 1991. However, the evidence of record fails to show that the Veteran has a chronic disability manifested by fatigue, weight loss and sleep problems as a result of these vaccines/immunizations. The only medical evidence even remotely pertinent to this issue are duplicate letters from G.A. Williams, D.O., dated in February 2009 and July 2010, which state that the Veteran has been prescribed Cyproheptadine for his history of weight loss related to his diagnosis of "Gulf War Syndrome." As explained above, the Veteran did not serve in the Southwest Theater; thus to the extent there may be a medical diagnosis of Gulf War Syndrome, such a diagnosis is based on an inaccurate history and cannot be afforded any probative weight. Aside from the letters from Dr. Williams, there is no medical evidence showing that Veteran has been diagnosed with a chronic disability manifested by fatigue, weight loss or sleep problems, let alone any evidence linking these claimed symptoms to the vaccines and immunizations administered in service. Furthermore, it is noted that there is no evidence showing that these claimed symptoms manifested in service or within one year following service separation. In this case, the only evidence of record supporting the Veteran's claim is his own lay opinion that he has a chronic disability manifested by fatigue, weight loss and sleep problems and that such a disability was caused by his vaccines/immunizations in service. The Veteran is certainly competent to attest to factual matters of which he has first-hand knowledge; for example, he is competent to report that he has experienced symptoms of fatigue, weight loss and sleep problems, and that he was given immunization shots in anticipation of his deployment to the Southwest Theater. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, in this case, he is not competent to render a medical diagnosis concerning his symptomatology or a medical opinion regarding the etiology of his currently claimed symptoms. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology that is not medical in nature); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (certain disabilities are not conditions capable of lay diagnosis). Thus, the Veteran's lay opinion does not constitute competent medical evidence and lacks probative value. See Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd, 142 F.3d 1434 (Fed. Cir. 1998); YT v. Brown, 9 Vet. App. 195, 201 (1996); Espiritu, supra. Taking into account all of the relevant evidence of record, the Board concludes that a preponderance of the evidence is against a finding that the Veteran has a chronic disability manifested by fatigue, weight loss and sleep problems that is related to service. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER A rating in excess of 10 percent for chondromalacia and degenerative arthritis of the left knee is denied. A compensable rating for chondromalacia of the right knee is denied. An increased rating of 30 percent, but no higher, for residuals of a right ulna fracture with ulnar neuropathy and carpal tunnel syndrome is granted, subject to the laws and regulations controlling the award of monetary benefits. Service connection for a chronic disability manifested by fatigue, weight loss and sleep problems, to include as due to an undiagnosed illness is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs