Citation Nr: 1310867 Decision Date: 04/02/13 Archive Date: 04/11/13 DOCKET NO. 07-11 203 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a low back disorder. 2. Entitlement to service connection for a bilateral knee disorder. 3. Entitlement to an initial disability rating in excess of 10 percent for degenerative arthritis of the left hip. 4. Entitlement to an initial disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1977 to June 1981, April 1985 to March 1994, and September 1994 to July 1999. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from an October 2005 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which denied reopening the claims of service connection for a low back disorder and a bilateral knee disorder. Additionally, the RO granted service connection for degenerative arthritis of the left hip and GERD, and assigned each a 10 percent disability rating, effective from December 29, 2004. The Veteran filed a notice of disagreement (NOD) with these determinations in December 2005, and timely perfected his appeal in March 2007. In January 2011, the Board found that new and material evidence had been received to reopen the claims of service connection for a low back disorder and a bilateral knee disorder. Additionally, the Board remanded the issues on appeal for further examination. That development has been completed and the issues on appeal are ready for appellate review. With respect to the issue of entitlement to an initial disability rating in excess of 10 percent for GERD, the Veteran did not submit a substantive appeal or provide any indication that he wanted to appeal the October 2005 rating decision granting a 10 percent rating after the March 2007 SOC was sent to him. However, the claim was included in the January 2011 Board Decision such that the Veteran had been led to believe that the issue of entitlement to an increased disability rating for GERD was on appeal. See Percy v. Shinseki, 23 Vet. App. 37 (2009) (VA waives objection to timeliness of substantive appeal by taking actions that lead the Veteran to believe that an appeal was perfected). Therefore, the Board will adjudicate the issue of entitlement to an initial disability rating in excess of 10 percent for GERD. The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the above claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. Resolving all doubt in the Veteran's favor, his currently diagnosed low back disability, variously diagnosed as lumbosacral strain and lumbar spondylosis, had its onset during his active military service. 2. Resolving all doubt in the Veteran's favor, his currently diagnosed bilateral knee disability, variously diagnosed as degenerative joint disease (DJD), had its onset during his active military service. 3. The Veteran's GERD is manifested by such symptoms as dysphagia, heartburn, reflux, regurgitation of stomach contents, nausea, and vomiting, but negative for substernal or arm or shoulder pain, productive of conservable impairment of health, material weight loss, hematemesis, or melena with moderate anemia. 4. The Veteran's left hip arthritis was manifested by flexion of 70 degrees and above and extension from 5 degrees and above, and no ankylosis, malunion, nonunion, or fracture of the femur, flail joint, or impairment of the thigh. 5. Throughout the course of the appeal, the Veteran's left hip disability has been manifested by degenerative changes of the joint shown on x-ray. 6. The competent and probative medical evidence of record does not show that the Veteran's service-connected left hip disability and GERD are so exceptional or unusual that referral for extraschedular consideration by designated authority is required. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for a grant of service connection for a low back disorder, variously diagnosed as lumbosacral strain and lumbar spondylosis, have been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.304 (2012). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for a grant of service connection for a bilateral knee disorder, variously diagnosed as DJD of the knees, have been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 3. The criteria for an initial disability rating in excess of 10 percent for GERD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Codes 7399-7346 (2012). 4. The criteria for an initial disability rating in excess of 10 percent for left hip arthritis have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5251 (2012). 5. Application of the extraschedular rating provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 U.S.C.A. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In light of the favorable disposition, a discussion as to whether VA's duties to notify and assist the appellant in reference to his claims of service connection for a bilateral knee condition and a low back disorder have been satisfied is not required. The Board finds that no further notification or assistance is necessary, and deciding the appeal at this time is not prejudicial to the Veteran. The Veteran's additional claims arise from his disagreement with the initial evaluation assigned following the grant of service connection for a left hip disability and GERD. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), Goodwin v. Peake, 22 Vet. App. 128, 134 (2008), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required for these claims. VA must also make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claim for the benefit sought unless no reasonable possibility exists that such assistance would aid in substantiating the claim. This duty includes assisting with the procurement of relevant records, including pertinent treatment records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The VA has also done everything reasonably possible to assist the Veteran with respect to his claims for benefits, such as obtaining private and VA medical records and providing the Veteran with VA examinations in October 1999, August 2005, March 2011, July 2011, and May 2012. In July 2012, the Veteran indicated that he did not have any additional evidence regarding his appeal. As the Veteran has not indicated that he has received additional treatment for the issues on appeal, the Board thus concludes that there are no additional treatment records outstanding with respect to these claims. Consequently, the duty to notify and assist has been satisfied as to the claim now being finally decided on appeal. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Service Connection Service connection may be granted for a disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). However, the absence of a documented disability while in service is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). When a Veteran does not meet the regulatory requirements for a disability at separation, he can still establish service connection by submitting evidence that a current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 159-60 (1993). Certain chronic diseases, such as arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). This is also a direct service connection theory of entitlement. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for the evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). 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. A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App 370, 374 (2002). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the Veteran. A. Bilateral Knee Condition The Veteran contends that his bilateral knee condition was a result of playing rugby in-service, and every day wear and tear of his military assignment as an infantryman and working on a light armored vehicle as a Vehicle Commander. The Veteran's service treatment records (STR) show that in August 1980, he injured his right knee and continued to have pain. In a January 1981 record, the Veteran was noted to have medial collateral ligament laxity with pain on stress, and the assessment was of a possible partial tear of that ligament with a questionable meniscal injury. In February 1981, he received continuing treatment for his right knee. In March 1981, an assessment of recurrent right knee medial collateral ligament stresses was indicated. In April 1981, it was noted that four months earlier the Veteran had injured his right knee; a right medial collateral ligament injury was suspected. In April 1984 the Veteran again injured his right knee. In April 1985 he injured his left knee and was hospitalized in April and May 1985, during which time an X-ray revealed a left hip dislocation. In July 1988 the Veteran again injured his right knee. There was tenderness of his right medial collateral ligament. The assessment was a right knee sprain. A right knee X-ray in July 1988 was normal. A February 1991 examination noted no pertinent abnormality of the knees, but in an adjunct medical history questionnaire it was reported that the Veteran had or had had a trick or locked knee. In February 1994 the Veteran injured his left knee and the impression was "ITB" (iliotibial band) syndrome. That same month it was noted that he had injured his left knee years ago and had intermittent left knee pain since then. Additionally, overuse of the left knee and old trauma, as well as a possible lateral meniscus tear was noted. A February 1994 examination noted that the Veteran had a chronic lateral collateral ligament strain of the left knee. In an adjunct medical history questionnaire it was reported that he had or had had a trick or locked knee. He also reported chronic left knee pain. A September 1998 examination found that the Veteran had bilateral patellar crepitus. It was noted that he had a history of multiple orthopedic injuries with arthralgias. In an adjunct medical history questionnaire it was reported that he wore a left knee brace when running. He had pain in his knees, greater in the left knee than in the right. An April 1999 examination for retirement found that the Veteran had bilateral patellar crepitus. In the medical history questionnaire, the Veteran reported that he had bilateral knee pain. In a supplemental report it was noted that he had used a hinged left knee brace. He had pain in both knees, greater in the left knee than the right. He also had locking of the left knee about once a week, and giving out of both knees, greater in the left knee than the right. At the October 1999 VA examination, the Veteran complained of multiple joint pains from in-service injuries, and occasional locking of his knees. On examination, his musculoskeletal system was normal. There was no heat, redness, swelling, effusion, drainage, abnormal movement, instability or weakness of the knees. Flexion was to 140 degrees and extension was to 0 degrees in each knee. Drawer's and McMurray's tests were normal, bilaterally. X-rays of the knees were essentially normal. The examiner remarked that there was insufficient evidence on examination to warrant a diagnosis relative to the Veteran's knees. October 2004 x-rays of the Veteran's bilateral knees were negative. VA outpatient treatment records show that in July 2004 the Veteran complained of pain in his knees. The records of the naval medical facility show that in November 2004 it was reported that the Veteran had generalized arthritis. In the Veteran's December 2005 NOD he reported that he had injured his knees from an in-service fall in 1981, which was so severe that he was out for over 30 days. September 2008 VA treatment records document, after an examination, that the Veteran's assessment was primary osteoarthritis/degenerative arthritis of multiple joints. The Veteran was afforded a VA examination in March 2011 to assess his bilateral knee condition. The Veteran reported that his left knee got caught and twisted in-service, and while doing maneuvers he injured his right knee. Additionally, he reported that he also injured his knees while playing rugby and normal wear and tear of an infantry man. Upon examination, the Veteran was found to have tenderness, abnormal motion, and guarding of movement of his bilateral knees. March 2011 x-rays showed very mild medial compartment joint space narrowing bilaterally. The VA examiner diagnosed the Veteran with degenerative joint disease (DJD) of the bilateral knees. The examiner concluded that the Veteran's mild DJD of the bilateral knee was less likely than not caused by or a result of his statements of post-service continuity of symptomatology, particularly in light of the treatment records. The Veteran's bilateral knee x-rays did not reveal any significant pathology to be able to determine a relationship from an injury, which happened in service more than 20 years ago. In an addendum, the examiner noted that he agreed with the opinion previously expressed in August 2005 that an opinion as to whether it was at least as likely as not that the Veteran had a disability of the knees which was of service origin would require a resort to mere speculation. In an August 2012 statement, the Veteran reported that during his first seven years of service, he carried a pack, rifles, machineguns, radios, and 60 mm mortar on his back. Additionally, he had physical training three to five times a week, two to three weeks in the field a month. In 1980 while in Wisconsin, he hurt his left leg and knee while in the field. In 1981, while in Norway, he fell down a mountain injuring his back and leg. He was given Motrin, rested for a couple of days, and was then sent back to work. Additionally, when he was transferred to Light Armored Vehicle (LAV) Battalion he rode and carried his gear in a wheeled vehicle. On the highway, as a Vehicle Commander, he was always standing in the turret or vehicle commander hatch. When the vehicle got in the field, his knees were jarred from the bouncing, his back was compressed and stretched from the bumpy trails, and most of the time he was beat up from hitting the sides of the hatch. He also reported developing back and knee problems from crouching, bending, and twisting of his body, and getting around the inside of the vehicle while loading, unloading, and doing preventive maintenance. While with the LAV Battalion, he got his leg caught in a turret, had a hatch dropped on his back by one of his crewmen, and had a crewman fall on him from a vehicle at Fort Benning after his vehicles main gun exploded. The Veteran also reported that his body had been hurting him ever since he retired and was slowly getting worse. Having considered the above evidence in a light most favorable to the Veteran, the Board concludes that he is entitled to service connection for a bilateral knee disability. As already noted, service connection is warranted when there is: (1) a medical diagnosis of a current disability; (2) medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Hickson, 12 Vet. App. at 252. In the present case, the Veteran has been diagnosed with a bilateral knee disability, to include osteoarthritis/degenerative arthritis. There is also clear evidence of symptomatology involving both knees during military service, as service treatment records confirm that the Veteran was treated for multiple orthopedic injuries to his knees, noting pain, strains, meniscal problems, and arthralgias. Finally, the Veteran has continued to seek treatment for his knee complaints since his separation from active duty. Continuity of symptomatology is evidenced by the Veteran's lay statements that he experiences the same symptoms currently as he did in service, and by a combination of these same symptoms that have resulted in a medical diagnosis of bilateral knee arthritis. On balance, the Veteran's documented symptoms in service are consistent with his current symptoms and diagnoses as documented in the medical evidence of record, which tend to indicate evidence relating the present bilateral knee condition to the symptomatology in service. Resolving all reasonable doubt in the Veteran's favor, the Board finds that the record evidence supports a finding that the Veteran's degenerative joint disease of both knees began during service and has persistent to date. In making this determination, the Board recognizes that no disability was found in the knees during earlier examinations. Nonetheless, the record reflects continuity of symptomatology of a chronic bilateral knee disorder since military service, and a current diagnosis consistent with those same continuing symptoms has now been established. The Veteran also reported in multiple lay statements that he had suffered from continuing symptomatology since military service, and the evidence of record fully supports the Veteran's testimony. In addition, the Board is aware of the August 2005 and March 2011 VA examiners who opined that they were unable to provide an etiological opinion for the Veteran's bilateral knee DJD without resorting to mere speculation. The Board notes that relying on the VA examiners' hesitance to offer a definitive opinion "without resort to speculation" is disfavored by the courts, see Jones v. Shinseki, 23 Vet. App. 382, 390 (2009), and such an opinion by itself provides neither positive nor negative support for the claim. Fagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009). Thus, these opinions are of no probative value as to the question of a nexus between the claimed bilateral knee conditions and the Veteran's service. There is competent and credible evidence with regard to whether there is a nexus, which consists of the Veteran's reports of a continuity of symptomatology and the documented onset of bilateral knee conditions during service. As the evidence is at least in equipoise, and resolving all doubt in the Veteran's favor, entitlement to service connection for a bilateral knee condition, variously diagnosed to include degenerative joint disease of both knees, is granted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. B. Lumbosacral Strain The Veteran contends that his back condition had its onset in-service and has continued to the present day. Specifically, the Veteran reported that his back condition was due to in-service incidents, to include falling down a mountain, and every day wear and tear of being an infantryman and Vehicle Commander. The Veteran's STRs show that in 1980 he injured his back. In January 1981, he had right lower lumbar pain and on examination had good range of motion, but some tenderness. The assessment was of bursitis and a muscle strain. In August 1986, he complained of upper middle back pain. X-rays in May 1993 revealed that he had six (6) lumbar-type vertebral bodies. In June 1993 he had an episode of back pain and was seen at an acute care clinic. On examination, he had tenderness of the left paravertebral muscles. The assessment was renal colic versus a lumbar strain. A February 1994 examination noted that the Veteran had mechanical low back pain. In the adjunct medical history questionnaire, the Veteran reported that he had low back pain, intermittently, for three years. On examination in September 1998, the Veteran had left thoracic paraspinous pain and spasm. The assessment was mechanical lumbar back pain. On the medical history questionnaire, the Veteran reported that he had early morning back stiffness and occasional spasm, as well as back pain. The April 1999 service retirement examination found no pertinent abnormality, however, the report of medical history questionnaire at that time noted that the Veteran had a back injury. In a supplemental report it was noted that he had used a back brace, as needed. He had recurrent back pain with stiffness in the morning, which loosened up after 30 minutes of activity. He occasionally had spasm, but no incapacitating pain. A private October 1999 x-ray of the Veteran's lumbosacral spine found normal alignment and normal interspaces. At the October 1999 VA examination, the Veteran complained of multiple joint pains from in-service injuries. On examination his musculoskeletal system was normal. There was no pain on motion of the lumbar spine or evidence of muscle spasm, weakness or tenderness. Flexion was to 95 degrees, extension to 30 degrees, right lateral bending to 40 degrees, left lateral bending to 35 degrees, right rotation to 35 degrees and left rotation to 25 degrees. The examiner remarked that there was insufficient evidence on examination to warrant a diagnosis relative to the Veteran's lumbar pain. VA outpatient treatment records show that in July 2004 the Veteran complained of multiple joint pains, including pain in his back. The records from a naval medical facility show that in November 2004 it was reported that the Veteran had generalized arthritis. In December 2004 and in January 2005 it was reported that the Veteran had lumbar spondylosis. The Veteran was afforded a VA examination in August 2005 to assess his spine condition. The Veteran reported a back condition since 1980. The pain in the Veteran's back was sharp and aching in nature, localized, occurred two times per week, and lasted for one to two hours. He reported that his condition did not cause incapacitation or lost time from work. The current treatment for his back was Motrin three times, daily. He also had no prosthetic implants of the joint. His functional impairment included limitation of motion and activities. X-rays of the lumbar spine showed findings within normal limits. The VA examiner diagnosed the Veteran with lumbosacral strain. The examiner concluded that he could not resolve the issue of whether the Veteran's lumbar and thoracic spondylosis were related to an injury and complaints of low back pain while on active service without resorting to mere speculation. The rationale was that these conditions may and often do, occur independently of each other. In the Veteran's December 2005 NOD he reported having strained his back during service from carrying back packs as an infantryman and now had lower extremity radicular symptoms of numbness. In his March 2007 VA Form 9 he reported that he continued to experience the same back complaints that he had during his active service. VA outpatient treatment records show that in September 2008, after an examination, the assessment was primary osteoarthritis/degenerative arthritis of multiple joints. September 2009 treatment records show that the Veteran complained of low back pain with no history of an injury, but trauma from the days in-service. The Veteran was treated with Motrin for his multiple joint pains. The Veteran was afforded a VA examination in March 2011 to assess his low back disability. He reported that his low back pain developed in 1981 when he fell off a mountain and also due to strain from carrying heavy gear. The Veteran reported such symptoms as pain, stiffness, fatigue, and decreased motion. The examiner noted that the March 2011 x-ray of the lumbar spine was unremarkable. The VA examiner diagnosed the Veteran with a lumbosacral strain. The examiner concluded that the Veteran's lumbosacral strain was less likely than not caused by or a result of his statements of post-service continuity of symptomatology, particularly in light of the treatment records. The Veteran's lumbar spine x-rays did not reveal any significant pathology to be able to determine a relationship from an injury, which happened in service more than 20 years ago. In an addendum, the examiner concluded that he agreed with the opinion previously expressed in August 2005, that an opinion as to whether it was at least as likely as not that the Veteran had a disability of the low back which was of service origin would require a resort to mere speculation. After a careful review of the evidence, the Board finds that the Veteran's service treatment records, private treatment records, VA outpatient treatment records, and pertinent lay evidence demonstrate that his currently diagnosed lumbosacral strain is related to his period of military service. Additionally, the Board notes that back pain, and the symptomatology thereof, are the type of condition subject to lay observation. The Board also wishes to note the holding of Jandreau vs. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007), that lay evidence, such as that provided by the Veteran in this case, can be competent and sufficient to establish a diagnosis of a condition when lay testimony describing symptoms at the time supports a later diagnosis by a medical professional, as is the case here with the August 2005 and March 2011 VA examiners. See also Davidson v. Shinseki, 2009-7075 (Fed. Cir. Sep. 14, 2009). Further, the Board is of the opinion that this case law is of particular significance in a case, such as this, where the Veteran indicated the presence of relevant symptomatology prior to his separation from active service, current diagnosis and treatment for the same in-service condition, and nothing in the record explicitly refuting the Veteran's account of his medical history regarding this disability. In addition, the Board is aware of the August 2005 and March 2011 VA examiners who opined that they were unable to provide an etiological opinion for the Veteran's lumbar strain without resorting to mere speculation. The Board notes that relying on the VA examiners' hesitance to offer a definitive opinion "without resort to speculation" is disfavored by the courts, see Jones v. Shinseki, 23 Vet. App. 382, 390 (2009), and such an opinion by itself provides neither positive nor negative support for the claim. Fagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009). Thus, this opinion is of no probative value as to the question of a nexus between the claimed back strain and the Veteran's service. Given that the Board finds that the Veteran is competent to report that he had back pain in-service and that the Veteran credible in this regard, that the Veteran complained of back pain after service and was again diagnosed with a back strain post service, and that there is no reported post service intercurrent injury, the Board finds that the evidence is at least in equipoise. For the foregoing reasons, the Board concludes that the balance of positive and negative evidence is in relative equipoise with respect to the Veteran's lumbosacral strain claim. He is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. Indeed, where the evidence supports a claim or is in relative equipoise, the appellant prevails. 38 U.S.C.A. 5107 (b); Gilbert, 1 Vet. App. at 53. Accordingly, the Board finds that service connection for a lumbosacral strain is warranted. III. Initial Increased Ratings Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § Part 4 (2012). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). In Fenderson v. West, 12 Vet. App 119 (1999), the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case (such as this one) in which the Veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14. It is possible, however, for a Veteran to have separate and distinct manifestations attributable to the same injury, which would permit a rating under several diagnostic codes. The critical element permitting the assignment of multiple ratings under several diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board has reviewed all of the evidence in the Veteran's claims file, including his VA treatment records, private treatment records, VA examination reports, and statements submitted in support of his claim. In this regard, the Board notes that, although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, all of the extensive evidence of record. Indeed, it has been held that while the Board must review the entire record, it need not discuss each piece of evidence in rendering a decision. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board's analysis will focus specifically on the evidence that is needed to substantiate the Veteran's claims for increased disability ratings for left hip arthritis and GERD. A. GERD The Veteran contends that his currently assigned 10 percent disability rating does not adequately reflect the current symptomatology associated with his GERD. The Veteran was initially granted service connection and assigned a 10 percent disability rating for GERD, effective December 29, 2004, in accordance with the criteria set forth in the Schedule for Rating Disabilities, 38 C.F.R. Part 4.114, Diagnostic Code (DC) 7399-7346 (2012). When a particular disability is not listed among the diagnostic codes, a code ending in "99" is used; the first two numbers are selected from the portion of the schedule most approximating a Veteran's symptoms. See 38 C.F.R. § 4.27 (2012). As the Veteran's GERD is not assigned a specific number, code 7399 is applied to allow for rating the disability with other disorders of the digestive system. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. See 38 C.F.R. § 4.27 (2012). In this case, Diagnostic Code 7399 refers to digestive disorders in general, while the more specific Diagnostic Code 7346 refers to hiatal hernias. Pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7346, a 10 percent evaluation is warranted when there is evidence of persistently recurrent epigastric distress manifested by two or more of the following symptoms (adding the qualifier that they be symptoms of "less severity"): dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal arm or shoulder pain which is productive of considerable impairment of health. A 30 percent evaluation is assigned based on evidence of all of these symptoms. A 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. As outlined below, the preponderance of the evidence of record demonstrates that the Veteran's GERD has been no more than 10 percent disabling at any time during the pendency of this claim. As such, the claim must be denied. VA treatment records show that the Veteran tried multiple medications to treat his GERD, including Prilosec, Rabeprazole, Zantac, Omeprazole, and Rolaids. He reported experiencing stomach problems if he took too many Motrin. Multiple VA outpatient treatment records show that upon gastrointestinal examination, there was no nausea, vomiting, dyspepsia, abdominal pain, cramping, abdominal distension, belching, increased flatus, diarrhea or constipation. At the October 1999 VA examination, the Veteran complained of occasional heartburn relieved with over the counter medications. The examiner also noted a diagnosis of GERD. Upon examination, the Veteran was found to be well nourished and developed. The Veteran underwent an upper GI (gastrointestinal) with air contrast in August 2005. The preliminary films demonstrated a non-obstructive gas pattern with a mild amount of stool. The Veteran was challenged with effervescent granules of thick, then thin barium. The esophagus demonstrated a normal mucosal pattern without evidence of stricture, ulceration, or external compression. A large amount of reflux was identified with the Veteran in a recumbent position. Esophageal reflux was identified to the clavicular heads. The stomach and duodenum demonstrated a normal mucosal pattern without evidence of ulcerations, filling defect, or external compression. The impression was that there was a large amount of esophageal reflux, otherwise negative. The Veteran was afforded a VA examination in August 2005 to assess GERD. The Veteran reported that this condition existed since 1981, and affected his general body health by causing night time vomiting and pain. He reported such symptoms as dysphagia, heartburn, reflux, and regurgitation of stomach contents, nausea, and vomiting. Specifically, the symptoms occurred nightly and he had to take medicine. The symptoms described occurred intermittently, as often as four times per week, with each occurrence lasting 30 minutes. The Veteran reported 60 attacks within the past year. The ability to perform daily functions during flare-ups was limited due to the pain and acid reflux. The current treatment was antacids. There was no functional impairment resulting for GERD and it did not result in time lost from work. The examiner noted that upper GI series was abnormal; findings showed large amount of esophageal reflux, otherwise negative. The VA examiner diagnosed the Veteran with GERD, with subjective and objective factors of reflux and heartburn. In the December 2005 NOD, the Veteran reported that his daily acid indigestion was severe, and frequent acid reflux at night, resulting in regurgitation. The Veteran was afforded a VA examination in March 2011 to assess his GERD. Since 2004, the Veteran was being treated for GERD with Ranitidine for the last two to three years and over the counter Rolaids. He frequently used Motrin for his orthopedic pains, which could aggravate the GERD. In the past four months, he noticed deteriorating symptoms, such as epigastric burning sensation, and used more pillows to sleep with head elevation to reduce the regurgitation. He also reported occasional nausea and rare vomiting. In approximately 2006, a radiology study determined the Veteran had a hiatal hernia. Upon examination, the Veteran was found to have no history of hospitalization or surgery relating to the esophagus, trauma to the esophagus, dysphagia, esophageal distress, hematemesis, melena, esophageal dilation, or esophageal neoplasm. The Veteran reported a history of vomiting associated with GERD less than weekly, when in a reclining position. There was a history of heartburn or pyrosis of several times a week. There was also a history of regurgitation less than weekly. The Veteran's overall health was noted to be good, with no signs of anemia. There were no signs of significant weight loss or malnutrition. The examiner diagnosed the Veteran with GERD. He noted that the Veteran stated that he had persistently recurrent epigastric distress, heartburn, and regurgitation, accompanied by substernal discomfort with no dysphagia or arm or shoulder pain. These symptoms of GERD due to his Hiatal Hernia could be productive of significant discomfort, but did not likely have significant effects on his occupation or activities of daily living. The preponderance of the above evidence demonstrates that the Veteran is not entitled to a disability evaluation in excess of 10 percent for his service-connected GERD at any time during the pendency of this claim. Throughout the pendency of this claim, there has been no evidence of malnutrition, material weight loss, hematemesis, melena or anemia. The Board recognizes that the Veteran has experienced symptoms of pyrosis, regurgitation, vomiting, and dysphagia. However, the evidence demonstrates that these symptoms did not result in arm or shoulder pain, or considerable or severe impairment to health. At the October 1999 VA examination, the Veteran complained of occasional heartburn relieved with over the counter medications, and was found to be well nourished and developed. The Veteran reported at the August 2005 VA examination such symptoms as dysphagia, heartburn, reflux, regurgitation of stomach contents, nausea, and vomiting. The VA examiner noted that upper GI series was abnormal; findings showed large amount of esophageal reflux, but otherwise negative. The VA examiner noted that the Veteran had GERD with subjective and objective factors of reflux and heartburn. At the March 2011 VA examination, the Veteran reported such symptoms as epigastric burning sensation, regurgitation, occasional nausea, substernal discomfort, and rare vomiting, with no dysphagia or arm or shoulder pain. The examiner noted that the Veteran was found to have no history of hospitalization or surgery relating to the esophagus, trauma to the esophagus, dysphagia, esophageal distress, hematemesis, melena, esophageal dilation, or esophageal neoplasm. While there was a history of heartburn or pyrosis of several times a week, regurgitation was noted to be less than weekly. Additionally, the Veteran's overall health was noted to be good, with no signs of anemia, significant weight loss, or malnutrition. This evidence demonstrates that the Veteran's GERD has not resulted in considerable or severe impairment of health. Therefore, the preponderance of the evidence of record demonstrates that the Veteran is not entitled to a disability evaluation in excess of 10 percent for his service-connected GERD at any time during the pendency of this claim. Based upon the guidance of the Court in Hart v. Mansfield, 21 Vet. App. 505 (2007), the Board has considered whether a staged rating is appropriate. However, as outlined above, there is no evidence of considerable impairment of health due solely to the Veteran's GERD symptomatology at any time during the pendency of the claim. As such, staged ratings are not warranted. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to a disability evaluation in excess of 10 percent for GERD must be denied. For the sake of brevity, the matter of possible entitlement to an extraschedular rating will be addressed below in regards to all increased rating issues on appeal. B. Left Hip The Veteran contends that his currently assigned 10 percent disability rating does not adequately reflect the current symptomatology associated with his left hip disability. The Veteran was initially granted service connection and assigned a 10 percent disability rating for left hip degenerative arthritis, effective December 29, 2004, in accordance with the criteria set forth in the Schedule for Rating Disabilities, 38 C.F.R. Part 4.71a, Diagnostic Code (DC) 5252-5010 (2012). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2012). Diagnostic Code 5010 contemplates degenerative arthritis, while DC 5252 pertains to thigh limitation of flexion. 38 C.F.R. § 4.71a, DCs 5010, 5252. Diagnostic Code 5010 provides that arthritis due to trauma, substantiated by x-ray findings should be rated as arthritis, degenerative, under Diagnostic Code 5003. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group 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. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under these codes. 38 C.F.R. § 4.71a. When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. 38 C.F.R. § 4.45. In general, 38 C.F.R. § 4.71 , Plate II provides a standardized description of hip movement, to include showing that normal hip flexion is from zero to 125 degrees, and that normal hip abduction is from zero to 45 degrees. Under Diagnostic Code 5250, a 60 percent disability rating is assigned for favorable ankylosis in flexion at an angle between 20 degrees and 40 degrees, and slight adduction or abduction. 38 C.F.R. § 4.71a . A 70 percent disability rating is assigned for intermediate hip ankylosis. A 90 percent disability rating is assigned for unfarvorable, extremely unfavorable ankylosis, the foot not reaching ground, crutches necessitated. Id. Under Diagnostic Code 5251, for limitation of extension of the thigh, a maximum rating of 10 percent is assigned for limitation of extension to 5 degrees. 38 C.F.R. § 4.71a . Under Diagnostic Code 5252, a 10 percent disability rating is assigned for flexion of the thigh limited to 45 degrees. Id. A 20 percent disability rating is assigned for flexion of the thigh limited to 30 degrees. A 30 percent disability rating is assigned for flexion of the thigh limited to 20 degrees. A 40 percent disability rating is assigned for flexion of the thigh limited to 10 degrees. Id. Under Diagnostic Code 5253, a 10 percent disability rating is assigned when there is limitation of abduction of the thigh such that the legs cannot be crossed or there is limitation of rotation such that it is not possible to toe-out more than 15 degrees. Id. Where there is limitation of thigh abduction with motion lost beyond 10 degrees, a 20 percent disability rating is assigned. Id. Under Diagnostic Code 5254, an 80 percent disability rating is assigned for a flail hip of the hip. As outlined below, the preponderance of the evidence of record demonstrates that the Veteran's left hip arthritis has been no more than 10 percent disabling at any time during the pendency of this claim. As such, the claim must be denied. VA outpatient treatment records show reports of chronic hip pain. Additionally, treatment records show diagnoses and treatment for osteoarthritis and arthropathy of the hip. An October 2004 x-ray showed moderate osteoarthropathy of the left hip with associated joint space narrowing, subarticular bone sclerosis, and cystic changes within the femoral head, presumably a degenerative process. At the October 1999 VA examination, the Veteran complained of multiple joint pains, secondary to an injury while a member of the Armed Forces. He complained of morning aches and pains, and sore muscles. He claimed that his hip slipped out every once in awhile. Examination of the Veteran's hip joints showed no findings regarding heat, redness, swelling, effusion, drainage, abnormal movement, or instability of weakness. The range of motion of the left hip was flexion to 70 degrees, extension to 20 degrees, adduction to 20 degrees, abduction to 35 degrees, external rotation to 40 degrees, and internal rotation to 30 degrees. X-rays of the pelvis and hip showed subcutaneous fat, as well as a small bone island within the head of the left femur, which was of no clinical significance. The Veteran was afforded a VA examination in August 2005 to assess his left hip condition. The Veteran reported that his hip disability was a result of injuries while playing rugby for the Marine Corps. His symptoms included pain and decreased range of motion of the hip, which occurred constantly. He reported that his condition did not cause incapacitation or lost time from work. The current treatment was Motrin three times, daily. He also had no prosthetic implants of the joint. His functional impairment was the inability to stand or walk for prolonged periods of time. The Veteran's left hip flexion was to 90 degrees and extension was to 30 degrees, with painful motion. Additionally, adduction was to 25 degrees, abduction to 30 degrees, external rotation to 40 degrees, and internal rotation to 30 degrees. On the left, the joint function was additionally limited by the following after repetitive use: pain, fatigue, weakness, lack of endurance, and pain had the major functional impact. The examiner stated that he was unable to make a determination without resorting to speculation on whether pain, fatigue, weakness, lack of endurance and incoordination additionally limited the joint function in degrees. X-ray findings of the left hip showed degenerative arthritic changes. The VA examiner diagnosed the Veteran with degenerative arthritis. The Veteran was afforded another VA examination in May 2012 to assess the currently severity of his left hip disability. The Veteran was diagnosed with osteoarthritis of the left hip. The Veteran complained of progressive pain, stiffness, and weakness. He also reported that flare-ups impacted the function of the hip and/or thigh by limiting prolonged walking/standing, squatting, stairs, jogging, jumping, lifting, and carrying. The Veteran's left hip flexion was to 110 degrees and extension to 5 degrees, with painful motion. Additionally, abduction was not lost beyond 10 degrees, adduction was not limited to such that the Veteran could not cross his legs, and rotation was not limited such that the Veteran could not toe-out more than 15 degrees. Upon repetitive use testing, the Veteran did not have additional limitation in ROM of the hip and thigh. The left hip functional loss or impairment of the left hip was less movement than normal. Further, the Veteran was noted to have localized tenderness or pain to palpation for joints/soft tissue of the left hip. The Veteran's muscle strength of the hips was found to be normal. The Veteran did not have ankylosis of the hip joint, malunion or nonunion of the femur, flail hip joint, leg length discrepancy, or a total hip joint replacement. Additionally, he did not use an assistive device for his hip. There was no functional impairment of the hip such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The Veteran's hip disability was noted to not impact his ability to work. The examiner also documented the October 2004 x-rays of the left hip, which showed moderate osteoarthropathy of the left hip with associated joint space narrowing, subarticular bone sclerosis, and cystic changes within the femoral head presumably a degenerative process. In light of the evidence, the Veteran is not entitled to an increased rating in excess of 10 percent for left hip arthritis. The Veteran has limited left hip motion in several different planes. Although various manifestations of a single disability may be assigned separate disability evaluations, VA regulations preclude the evaluation of the same manifestations of a disability under different diagnoses, a process called pyramiding. See 38 C.F.R. § 4.14 (2012). In this case, limitations of the distinct motions of the hip do not constitute duplicative or overlapping symptoms. Thus, the Veteran can be awarded separate ratings for limitation of flexion, extension, abduction, adduction, and rotation of the hips. Cf. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004) (holding that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint). The Veteran's left hip disability is rated under Diagnostic Code 5010. As stated above, when there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint (like the knee, see 38 C.F.R. § 4.45) or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. However, the Veteran has met a compensable rating for limitation of extension of the thigh under DC 5251 because extension was limited to 5 degrees. 38 C.F.R. § 4.71a . As noted above, when there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under these codes. 38 C.F.R. § 4.71a. Therefore, the more appropriate diagnostic code to rate the Veteran's left hip disability as of the May 19, 2012 VA examination is DC 5251. The Board notes that the maximum rating allowed under DC 5251is a 10 percent rating. Therefore, the Veteran would not be subject to a higher disability rating under these diagnostic codes. Additionally, even considering the effects of pain and repetitive use, the Veteran's left hip flexion was limited at most to 70 degrees. Such range of motion represents flexion much greater than 30 degrees, which is required for a 20 percent disability rating under Diagnostic Code 5252. Thus, a rating in excess of 10 percent is not warranted for limitation of flexion due to left hip arthritis. See 38 C.F.R. § 4.71a, Diagnostic Code 5252. Moreover, even considering the effects of pain and repetitive use, abduction was limited at the most to 30 degrees. The May 2012 VA examination report indicates that the Veteran did not have abduction lost beyond 10 degrees, could cross his legs, and toe out greater than 15 degrees at that time. Thus, separate ratings for left hip abduction, adduction, and rotation are not warranted. See 38 C.F.R. § 4.71a, Diagnostic Codes 5253. The Board has considered whether there is additional functional loss due to fatigability, incoordination, pain on movement, deformity, or atrophy of disuse, and notes that, throughout the appeal, the Veteran has reported having left hip problems affecting his ability to stand for prolonged periods, walk distances, squat, or climb stairs. In this regard, the Board acknowledges that the Veteran experiences recurrent pain and stiffness as a result of his left hip disability. However, the severity of his left hip disability is contemplated in the current disability rating. Moreover, even when considering pain and functional impairment, the Veteran's flexion of the left hip is limited only to 70 degrees, and as such, his range of motion findings do not approach the criteria for a 20 percent rating under DC 5252 (i.e., 30 degrees of flexion). As such, the pain experienced on motion has been considered in assigning the 10 percent evaluation and there is no additional documented range of motion lost that would warrant a higher rating due to pain. Therefore, a 10 percent evaluation is appropriate for the left hip disability. Additionally, the evidence of record fails to demonstrate such symptomatology as hip ankylosis, hip flail joint, and impairment of the femur. Specifically, VA examinations and x-ray reports noted above showed no history of impairment of the femur or flail joint. Additionally, the May 2012 VA examiner noted that the Veteran did not have ankylosis of the hip joint, malunion or nonunion of the femur, flail hip joint, leg length discrepancy, or a total hip joint replacement. Therefore, the Veteran is not entitled to an increased rating under DC 5250, 5254, or 5255. Finally, the Board is mindful that the Veteran reported in an August 2012 statement that multiple physicians indicated that he will likely require a total hip replacement in the future. However, such a statement, while rendered by a medical professional, addresses a problem that has not yet occurred and, thus is inherently speculative and lacking probative value. As such, it cannot form the basis for assigning a higher rating for the Veteran's left hip disability. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Significantly, at the May 2012 VA examination, the examiner noted that the Veteran had not undergone a totally hip joint replacement at that time. For the reasons and bases provided above, the preponderance of the evidence in this case is against the Veteran's claim for a disability rating in excess of 10 percent for left hip arthritis. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Accordingly, the Veteran's claim for an increased rating for left hip arthritis is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. Ortiz v. Principi, 274 F. 3d. 1361, 1365 (Fed. Cir. 2001). For the sake of brevity, the matter of possible entitlement to an extraschedular rating will be addressed below in regards to all increased rating issues on appeal. IV. Extraschedular Consideration The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b). To afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's service-connected left hip disability include pain, stiffness, weakness, limiting prolonged walking/standing, squatting, stairs, jogging, jumping, lifting, carrying, and limitation of motion. The symptoms associated with the Veteran's GERD include epigastric discomfort, regurgitation, vomiting, and pyrosis. However, these symptoms of the Veteran's left hip and GERD are not shown to cause any impairment that is not already contemplated by the rating criteria, and the Board finds that the rating criteria reasonably describes his disabilities. See 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5252; 38 C.F.R. § 4.114, Diagnostic Codes 7399-7346. For this reason, referral for consideration of an extraschedular rating is not warranted for this claim. ORDER Service connection for a low back disorder, variously diagnosed as lumbosacral strain and lumbar spondylosis, is granted. Service connection for a bilateral knee disorder, variously diagnosed as degenerative joint disease of the knees, is granted. An initial disability rating in excess of 10 percent for degenerative arthritis of the left hip is denied. An initial disability rating in excess of 10 percent for gastroesophageal reflux disease is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs