Citation Nr: 1306140 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 09-32 556 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial disability rating (evaluation) higher than 10 percent for service-connected hypothyroidism. 2. Entitlement to a higher (compensable) initial disability rating (evaluation) for service-connected restless leg syndrome of the right lower extremity. 3. Entitlement to a higher (compensable) initial disability rating (evaluation) for service-connected restless leg syndrome of the left lower extremity. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from May 1987 to May 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which granted service connection for hypothyroidism with a 10 percent rating and bilateral restless leg syndrome with separate noncompensable (i.e., zero percent) ratings for each extremity effective June 1, 2007, the day following service separation. The Board has reviewed the Veteran's physical claims file, as well as the Veteran's electronic file on the "Virtual VA" system, to ensure a complete review of the evidence in this case. In January 2010, the Veteran presented testimony relevant to the appeal at a Decision Review Officer (DRO) hearing. A transcript of the hearing is of record. In October 2012 and February 2013, the Veteran submitted additional medical evidence in support of the increased rating claims accompanied by waiver. Accordingly, the Board will consider this evidence in the first instance during the course of appellate review. 38 C.F.R. §§ 19.9, 20.1304(c) (2012). FINDINGS OF FACT 1. For the entire rating period, the service-connected hypothyroidism requires continuous medication for control, and has not manifested in fatigability, constipation, or sluggishness. 2. The service-connected restless leg syndrome of the right lower extremity is manifested by subjective intermittent numbness, ache, and tingling without any objective sensory or motor deficit or muscular weakness/atrophy. 3. The service-connected restless leg syndrome of the left lower extremity is manifested by subjective intermittent numbness, ache, and tingling without any objective sensory or motor deficit or muscular weakness/atrophy. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 10 percent for service-connected hypothyroidism are not met or approximated for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.119, Diagnostic Code 7903 (2012). 2. The criteria for a compensable disability rating for restless leg syndrome of the right lower extremity are not met or approximated for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8699-8620 (2012). 3. The criteria for a compensable disability rating for restless leg syndrome of the left lower extremity are not met or approximated for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8520 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her 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). 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. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran is challenging the initial disability ratings assigned following the grant of service connection for hypothyroidism and bilateral restless leg syndrome in the November 2007 rating decision. The U.S. Court of Appeals for Veterans Claims (Court) has held that, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has in fact been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess v. Nicholson, 19 Vet. App. 473, 490-91; Dunlap v. Nicholson, 21 Vet. App. 112, 117 (2007). Furthermore, under 38 C.F.R. § 3.159(b)(3)(i), there was no duty to provide the Veteran with VCAA notice upon receipt of a Notice of Disagreement, such as in this case. For these reasons, the Board finds that no further notice, beyond that afforded in the context of the claim for service connection, is needed under the VCAA. Moreover, the Veteran has been provided with copies of the above rating decision, as well as the SOC and SSOC issued during the course of the appeal, which include discussion of the facts of the claims, pertinent laws and regulations, notification of the bases for the decisions, and a summary of the evidence considered to reach the decisions. The Veteran has demonstrated ample understanding of the evidence needed to substantiate the claims through correspondence submitted during the course of the appeal. See, e.g., January 16, 2013 Appellant's Brief (including the applicable rating criteria for hypothyroidism and bilateral restless leg syndrome). Regarding VA's duty to assist in claims development, the RO afforded the Veteran with medical examinations in connection with the initial rating claims in August 2007, September 2007, and January 2010. The medical examination reports include all relevant findings and medical opinions needed to evaluate fairly the Veteran's claims. The medical examiners took a thorough history of the disabilities from the Veteran, including history of onset, diagnosis, report of symptomatology, other limitations, and treatment. The medical examiners had adequate facts and data regarding the history and condition of the disabilities. See VAOPGCPREC 20-95 (interpreting that in some cases an accurate history by a veteran may be a valid basis for an examination report rather than claims file review); see also Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). The medical examiners also considered the Veteran's subjective complaints as it related to current symptomatology and its effects on his daily life and performed a thorough physical evaluation of the Veteran, to include laboratory tests. There has been no credible allegation or indication that there has been a material change in condition of the Veteran's disabilities since the examination. For these reasons, the Board finds that the medical examination report is adequate for rating purposes, and there is no need for further medical examination. Also, the Veteran's complete service treatment records and post-service treatment records adequately identified as relevant to the claims have been obtained, or otherwise submitted, and are associated with the record. There are no additional treatment records pertinent to the Veteran's claims found in the Virtual VA folder. The Veteran has also submitted lay statements in support of the appeal and offered testimony before the DRO. The Veteran has not made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal, and no further development is required to comply with the duty to assist in developing the facts pertinent to the claims decided herein. In view of the foregoing, the Board will proceed with appellate review. Disability Rating Criteria It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). The Board has thoroughly reviewed all the evidence in this case. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to a veteran). Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of a veteran's condition. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In November 2007, the RO granted service connection for hypothyroidism with a 10 percent initial rating effective June 1, 2007. The RO also granted service connection for restless leg syndrome of the right and left lower extremities with separate noncompensable ratings for each extremity effective June 1, 2007. The Veteran has appealed the initial ratings assigned for all of the disabilities. In a claim for a higher original rating after an initial award of service connection, all the evidence submitted in support of a veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. Initial Rating for Hypothyroidism The Veteran seeks an initial rating higher than 10 percent for service-connected hypothyroidism. Hypothyroidism is rated under Diagnostic Code 7903. Under the diagnostic code, a 10 percent rating is warranted for fatigability, or; continuous medication required for control. A 30 percent rating is warranted for fatigability, constipation, and mental sluggishness. A 60 percent rating is warranted for muscular weakness, mental disturbance, and weight gain. A 100 percent rating is warranted for cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. 38 C.F.R. § 4.119. The Board has reviewed the evidence, both lay and medical, to determine whether the Veteran is entitled to receive a higher initial rating for hypothyroidism; however, upon review, the Board finds that the weight of the evidence is against finding that a higher initial rating is warranted. The Veteran's hypothyroidism is shown to be controlled by continuous medication, which is consistent with the schedular criteria for the currently assigned 10 percent disability rating. For the entire rating period, the hypothyroidism has not manifested in fatigability, constipation, and mental sluggishness. The Veteran has asserted that he experiences a number of symptoms attributable to hypothyroidism throughout the course of the claim and appeal. For example, at the August 2007 VA medical examination, the Veteran told the VA medical examiner that his hypothyroidism had initially improved after being diagnosed and treated in service but had worsened over the past nine months. He then reported experiencing symptoms of weight gain, bowel constipation, and extreme evening fatigue. At the January 2010 DRO hearing, the Veteran reportedly had daily symptoms of fatigue, poor memory, emotional instability, depression, slowing of thought, constipation, once the effects of his medication wore off, as well as weight gain due to the hypothyroidism. January 2010 DRO hearing transcript, pages 2-7. Nonetheless, other evidence, lay and medical, is inconsistent with and outweighs the Veteran's account regarding the onset of worsened hypothyroidism symptomatology. Approximately four months before the Veteran filed the service connection claim for hypothyroidism with VA and six months before the medical examination, he completed a service retirement report of medical history. On the report, the Veteran checked "Yes" when asked if he then had or ever had had "thyroid trouble or goiter" and later explained that he had thyroid trouble that had been diagnosed as hypothyroidism in 2004; however, he specifically checked "No" when asked if he then had or ever had had recent unexplained gain or loss of weight and made no mention of any current symptomatology associated with hypothyroidism. Also, in the portion of the report designated for the examiner's summary and elaboration of pertinent data, the service medical examiner noted that the Veteran's hypothyroidism was under good control with Synthroid. The February 2007 service retirement medical examination report similarly noted that the Veteran's hypothyroidism was "controlled" and not considered disabling at that time. The service medical evidence, which shows hypothyroidism under good control with medication without complaint of any symptomatology believed to be attributable to hypothyroidism and an affirmative denial of any recent weight gain by the Veteran at the time of the service retirement examination, contradicts the Veteran's more recent account that he began to experience worsened symptoms of hypothyroidism approximately nine months before the VA medical examination (i.e., in December 2006), which was first made after filing his claim with VA. Upon review, the Board finds the service medical evidence to be more credible as it is likely that the Veteran would have accurately reported any symptomatology that he believed was attributable to his hypothyroidism at the time of his retirement medical examination, particularly since the Veteran described symptomatology believed to be related to other disabilities at that time. Also, the statements made by the Veteran at the time of the retirement examination and several months before filing the claim with VA were less likely to have been influenced by the desire for pecuniary gain. The Board also notes that post-service lay and medical evidence provides further evidence against the initial rating claim. When the August 2007 VA medical examiner considered the Veteran's complaints together with the lab results from the examination, she wrote that the Veteran demonstrated inappropriate thyroid replacement and found that the "hypothyroid-over replacement" may have been playing a small role in the Veteran's daytime fatigue and shortness of breath. The VA medical examiner recommended that the Veteran decrease his medication dosage until he could consult with his treating physician, and noted that appropriate replacement may help his symptoms. The VA medical examiner attributed the Veteran's hypersomnolence and sleep disruption to the diagnosed disability of restless leg syndrome, not to hypothyroidism. In September 2007, the Veteran underwent a VA (QTC) medical examination in connection with the claim. The September 2007 medical examination report notes that the Veteran told the contract medical examiner that his condition had existed since 2003 and was then in remission. It was also noted that the Veteran reportedly denied having any current symptoms at that time and told the contract medical examiner that he was being treated for hypothyroidism with 200 micrograms (mcg) of Synthroid daily with good results and no side effects. The report further notes that the Veteran told the contract medical examiner that the functional impairment when the condition was active included excess weight, emotional irritability, memory loss, and recall. Upon physical examination, the contract medical examiner noted that the Veteran demonstrated no signs of malaise, which weighs against finding that he has fatigue due to hypothyroidism. The contract medical examiner also noted that there were no eye signs of hyper or hypothyroidism and thyroid function studies were all within normal limits with the exception of minimal elevation of the "free T4 index at 3.9, upper limits of normal is 3.8." The medical examiner added that the T3 uptake was 34, the T4 total was 11.4, and the TSH was 0.56. The contract medical examiner diagnosed "hypothyroidism, in remission" based on the Veteran's reported history, physical examination, and laboratory findings. The September 2007 examination report is evidence against finding that the assignment of a higher initial rating for hypothyroidism is warranted. The Board has considered the Veteran's assertion that the VA (QTC) contract medical examiner did not accurately report his described symptomatology at the time of the September 2007 contract medical examination. The Veteran has specifically denied reporting that hypothyroidism was in remission at the contract medical examination and referenced the QTC medical questionnaire wherein he answered "Yes" when asked if the condition was still active and identified constipation as a condition affected by the condition as evidence that the reported symptomatology was not accurately noted or considered. He also stated that he told the contract medical examiner that he experienced mental sluggishness, difficulties in concentration, and anger issues due to difficulties in finding the appropriate dosage of medication to manage the hypothyroidism. See November 2008 VA Form 21-4138. Upon review of the September 2007 medical examination report, the Board notes that the contract medical examiner specifically wrote that the history for hypothyroidism was obtained from the Veteran. The Board also observes that the medical history noted by the examiner is essentially consistent with other evidence of record. Indeed, the Veteran's service treatment records reflect that the Veteran began treatment for hypothyroidism in 2003 and was noted to be asymptomatic on 200 mcg of Synthroid daily in July 2005. In September 2005, it was noted that the Veteran's most recent lab results for hypothyroidism were within normal limits. At the time of the February 2007 service retirement examination, hypothyroidism was noted to be under good control with medication and the Veteran articulated no complaints of any symptomatology believed to be related to hypothyroidism, as stated above. At the August 2007 VA medical examination, the Veteran reported treatment with Synthroid 100 mcg two tablets daily with no side effects. The service medical evidence, as well as the evidence shortly after service, indicates that hypothyroidism had existed since 2003 and was currently being controlled adequately with medication without any symptoms or side effects. As the noted medical history is consistent with other evidence of record and would not have been obtained by a source other than the Veteran, the Board does not find the Veteran's assertion that the September 2007 contract medical examiner misreported his symptomatology at the time of the medical examination to be credible. Although the Veteran reported having certain symptomatology on the QTC questionnaire that he believed was attributable to hypothyroidism, the Board finds that the Veteran, in fact, provided a different account of the symptomatology believed to be experienced due to hypothyroidism at the medical examination. There is no indication that the medical examination is not adequate despite the inconsistent statements from the Veteran regarding his experienced symptomatology (or lack thereof). Significantly, the contract medical examiner based the conclusion that the Veteran's hypothyroidism was in remission on physical examination of the Veteran and laboratory findings, in addition to the Veteran's reported history. There were no objective findings to show current symptoms of hypothyroidism. Furthermore, the Board finds the medical examination report, which was based on both subjective and objective factors and does not support the Veteran's assertion that he experienced current hypothyroidism symptomatology such as fatigue, constipation, and mental sluggishness/disturbance, to be more credible and affords it far greater probative weight than the Veteran's inconsistent lay account regarding purported symptoms he believes are attributable to hypothyroidism. The Veteran, while competent to report his symptomatology, is not competent to attribute that symptomatology to the diagnosis of hypothyroidism, and his inconsistent accounts of hypothyroidism symptomatology undermine his credibility. Furthermore, the Board notes that the May 2008 statement submitted from the Veteran's own treating medical provider (V.K., CNP) supports the currently assigned disability rating of 10 percent for hypothyroidism. While the private nurse noted that the Veteran's hypothyroidism was a lifelong health malady and will never be in remission, which appeared to contradict the September 2007 contract medical examiner's finding above to some degree, the nurse also wrote that the Veteran's hypothyroidism was "controlled by medication with biannual monitoring." As the Veteran's currently assigned 10 percent rating already contemplates that continuous medication for hypothyroidism was needed for control, the private medical provider's statement provides further evidence against the appeal seeking a higher initial rating. At the DRO hearing, the Veteran indicated that he and his private medical provider were still trying to "nail down" the exact dosage to better manage symptoms and side effects associated with the hypothyroidism. See January 2010 DRO hearing transcript, page 5. However, the August 2007 VA medical examination report and the September 2007 contract medical examination report both show that the Veteran denied having any side effects associated with the medication used to treat hypothyroidism at those times. While the Veteran has reported having current symptoms such as fatigue, constipation, mental sluggishness and/or disturbance, and weight gain that he believes are attributable to hypothyroidism, he has offered inconsistent statements regarding his experience of symptomatology, and the evidence submitted does not support a rating in excess of 10 percent. The Veteran's own treating medical provider noted that the hypothyroidism was controlled with continuous medication and only required biannual monitoring without mention of any problems or symptoms attributable to hypothyroidism, despite acknowledging that the letter was submitted in response to the September 2007 medical examination report. It is likely that the medical provider would have mentioned any problems that the Veteran was then suffering from hypothyroidism, particularly when providing a statement to contradict the findings of the contract medical examiner. The fact that she did not identify any symptoms related to hypothyroidism and only stated that it was controlled by medication is significant and weighs against the Veteran's claim for a higher initial rating. For these reasons, the Board does not find the Veteran's hearing testimony alleging that hypothyroidism is not adequately controlled by medication to be credible. Moreover, regarding purported weight gain due to hypothyroidism, the Board observes that the Veteran denied having a history of weight change at the August 2007 VA medical examination. As noted above, the Veteran had previously denied having a history of recent weight gain or loss at the February 2007 service retirement examination. Also, it is significant the difference in the Veteran's weight among the three medical examinations conducted in connection with the claims is no more than eight pounds (i.e., from the September 2007 to the January 2010 medical examinations). There was even a decrease of five pounds from time of the August 2007 VA medical examination to the September 2007 contract medical examination. This evidence does not support the Veteran's assertion that he has had significant weight gain due to hypothyroidism and is afforded significant probative weight. The Board has considered the February 2013 statement from the Veteran's wife, who has reportedly been married to the Veteran since June 2003. In the statement, the Veteran's wife wrote that the Veteran suffered from constant fatigue, uncontrolled weight gain without change in his diet (i.e., having gained 60 pounds in the last four years without decrease in exercise regime), loss of hair, and uncontrolled mood swings and has had the symptoms since service. She also wrote that the Veteran's current level of 200 mcg a day for Synthroid would be increased at the Veteran's next appointment. Nevertheless, because the assertions are inconsistent with other evidence of record, they are not deemed credible. Although the Veteran's wife stated that the Veteran had "constant" fatigue, the September 2007 contract medical examiner noted that the Veteran demonstrated no signs of malaise, which weighs against the finding. As explained above, the Veteran's prior assertions of significant weight gain due to hypothyroidism are unsupported by other evidence of record and are not deemed credible. The Veteran himself has not alleged hair loss due to hypothyroidism and even denied having any symptomatology he believes is attributable to hypothyroidism at the September 2007 medical examination. Although the Veteran's wife is competent to assert that the Veteran has experienced significant weight gain over the last four years, as well as describe any other observable symptomatology, she is not competent to attribute the weight gain or any other purported symptomatology to the diagnosis of hypothyroidism. Furthermore, as the lay assertions of current symptoms of hypothyroidism are inconsistent with other evidence of record, they are not deemed credible, as explained above. Furthermore, while the Veteran's wife asserted that the Veteran's medication dosage would be increased at the next appointment, she did not indicate when the appointment would take place or explain why she believed that the medication dosage would be increased. The May 2008 private medical provider statement reveals that the Veteran is only seen twice per year. The Veteran's wife's bare assertion without explanation does not show that the Veteran's hypothyroidism is not adequately controlled by continuous medication, and the Veteran has not provided credible evidence to show that the current hypothyroidism symptomatology more closely approximates the criteria for a higher initial rating. In consideration of the foregoing, the Board finds that the manifestations of the Veteran's hypothyroidism do not meet or more nearly approximate the schedular criteria for a higher initial rating under Diagnostic Code 7903. The most credible and probative evidence shows that the Veteran's hypothyroidism is controlled with continuous medication throughout the period, which is contemplated in the currently assigned 10 percent schedular rating. The assertion by the Veteran and his wife that he experiences symptoms such as constipation, fatigue, mental sluggishness/disturbance, and weight gain due to hypothyroidism is inconsistent with other, more credible evidence of record, to include the statements made by the Veteran at the time of the service retirement examination. For these reasons, the Board finds that the weight of the evidence is against the assignment of a higher initial rating for hypothyroidism on a schedular basis. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has further considered whether the initial rating claim warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, it must be determined whether the disability picture is such that the schedular criteria are inadequate, i.e., whether there are manifestations or impairment that are not encompassed by the schedular criteria. If those criteria are not inadequate, the analysis does not need to proceed any further. In this case, the Board does not find any symptoms or functional impairment that is not already encompassed by the currently assigned 10 percent rating. As stated above, the Veteran's hypothyroidism is controlled by continuous medication. The 10 percent rating under Diagnostic Code 7903 specifically considers hypothyroidism that requires continuous medication for control; therefore, the Board finds that manifestations of the Veteran's disability are fully contemplated in the currently assigned 10 percent rating under Diagnostic Code 7903. For these reasons, the Board finds that the schedular criteria are not inadequate to rate the Veteran's hypothyroidism, and referral for consideration of extraschedular rating is not necessary. Initial Rating for Restless Leg Syndrome The Veteran's restless leg syndrome of the left lower extremity is currently evaluated as noncompensable (i.e., zero percent disabling) under the criteria found at 38 C.F.R § 4.124a, Diagnostic Code 8520 as analogous to impairment of the sciatic nerve. Similarly, restless leg syndrome of the right lower extremity is evaluated as noncompensable under the criteria found at 38 C.F.R § 4.124a with hyphenated Diagnostic Code 8699-8620 as analogous to sciatic neuritis. Upon review of the rating schedule, the Board finds no alternate diagnostic code under which it would be more appropriate the evaluate the disabilities. Under the criteria, a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve; a 20 percent rating requires moderate incomplete paralysis of the sciatic nerve; a 40 percent rating requires moderately severe incomplete paralysis; a 60 percent rating requires severe incomplete paralysis with marked muscular atrophy; and an 80 percent rating requires complete paralysis of the sciatic nerve. When there is complete paralysis of the sciatic nerve, the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Upon review of the evidence, both lay and medical, the Board finds that the disability picture associated with the Veteran's restless leg syndrome of the left lower extremity does not more closely approximate the criteria for a higher rating. Although the Veteran has complained of numbness and tingling, ache, involuntary movement, and burning of the left lower extremity, with increased symptoms due to prolonged sitting and driving, he told the September 2007 and January 2010 contract medical examiners that the symptoms only occurred on an intermittent basis and that he did not receive any treatment for the condition. Also, the evidence has not objectively demonstrated any muscular weakness or atrophy or any motor or sensory deficit of the left lower extremity on neurological examinations performed as part of the September 2007 and January 2007 contract medical examinations. Furthermore, the Veteran's own private treating provider suggested that the Veteran only experienced symptoms of restless leg syndrome during sleep and that the symptoms "may" worsen and affect him throughout the day with age (i.e., in the future). Thus, as the current evidence shows that the Veteran's restless leg syndrome of the left lower extremity is manifested by subjective intermittent numbness, ache, and tingling without any objective sensory or motor deficit or muscular weakness/atrophy, the Board finds that the preponderance of the evidence throughout the period weighs against finding that a higher initial rating is warranted for the disability. The current noncompensable disability rating is, therefore, appropriately assigned and no staged rating is warranted. Regarding restless leg syndrome of the right lower extremity, the Board notes that the Veteran similarly complained of intermittent numbness and tingling, ache, involuntary movement, and burning of the right lower extremity, with increased symptoms due to prolonged sitting and driving, at the September 2007 and January 2010 contract medical examinations. Also, as with the left lower extremity, the Veteran reported that the right lower extremity symptoms only occurred on an intermittent basis and that he did not receive any treatment for the condition. He has consistently demonstrated motor function within normal limits and has not shown any muscular weakness or atrophy of the right lower extremity at medical examinations conducted during the period. The Veteran's coordination was additionally noted to be within normal limits at the January 2010 contract medical examination. Although the Veteran objectively demonstrated decreased sensation to the back of the right thigh on pin prick testing at the January 2010 contract medical examination, the contract medical examiner attributed the findings to the Veteran's intervertebral disc syndrome with degenerative arthritis changes and sciatic nerve involvement affecting the right side of the body and did not attribute the findings to restless leg syndrome. Thus, as the current evidence shows that the Veteran's restless leg syndrome of the right lower extremity is manifested by subjective intermittent numbness, ache, and tingling without any objective sensory or motor deficit or muscular weakness/atrophy, the Board finds that the preponderance of the evidence throughout the period weighs against finding that a higher initial rating is warranted for the disability. The current noncompensable disability rating is, therefore, appropriately assigned and no staged rating is warranted. 38 C.F.R. §§ 4.3, 4.7. The Board has further considered whether the initial rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. In this case, the Board does not find any symptoms or functional impairment that is not already encompassed by the currently assigned noncompensable ratings. The Veteran's bilateral restless leg syndrome is manifested by intermittent numbness, ache, and tingling without any objective sensory or motor deficit or muscular weakness/atrophy. Although the August 2007 VA medical examiner attributed the Veteran's hypersomnolence and sleep disruption to restless leg syndrome, the medical examiner based the opinion on the fact that the Veteran did not have sleep apnea. The August 2012 private polysomnography report shows a diagnosis of moderate obstructive sleep apnea and that the Veteran's sleep difficulties were attributed to the diagnosis. Therefore, the Board affords this evidence greater probative weight than the earlier evidence indicating that the Veteran did not have sleep apnea. The January 2010 contract medical examiner noted that the Veteran's loss of stability/control to muscles in the right leg were due to degenerative disc disease of the lumbar spine. The Veteran's decreased range of motion of the knees and related tenderness and crepitus, as well as difficulty walking up stairs, squatting, pain and other related symptoms pertaining to the knees were attributed to the diagnoses of degenerative joint disease of the left and right knees. This medical opinion is also afforded significant probative value as it was based on subjective and objective factors and there is no contrary medical opinion in the record. Furthermore, the Veteran has identified decreased concentration, poor social interactions, an inability to sit for more than 45 minutes during a meeting, and traveling as functional impairment associated with the disabilities; however, the decreased concentration and poor social interactions are reportedly related to sleep disruption, which has been attributed to nonservice-connected sleep apnea. Regarding difficulty sitting for prolonged periods or traveling, the schedular criteria under Diagnostic Code 8520 does not delineate such symptomatology in the criteria and, instead, more generally considers the overall disability picture, without limitation of factors for consideration; therefore, these more specific findings and impairments may be considered when assessing the overall degree of severity for a rating under Diagnostic Code 8520. In this case, the Board finds that the Veteran's bilateral restless leg syndrome, symptoms of which occur only intermittently and primarily at night/during sleep and are not shown to interfere significantly with the Veteran's ability to instruct Navy sailors in river equipment and tactics, is appropriately considered to more nearly approximate a noncompensable level of impairment and, accordingly, contemplates all of the encompassed symptomatology. For these reasons, the Board finds that the schedular criteria are not inadequate to rate the Veteran's disabilities, and referral for consideration of extraschedular rating is not necessary. For these reasons, the Board finds that the schedular criteria are not inadequate to rate the Veteran's bilateral restless leg syndrome, and referral for consideration of extraschedular rating is not necessary. Moreover, the Board has considered whether the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) was reasonably raised by the record in this case. In this case, neither the Veteran nor the evidence suggests unemployability due to service-connected disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran is shown to have been employed throughout the period at issue in this case. The August 2007 VA medical examination report notes that the Veteran was employed full-time as a contractor/instructor for Navy sailors and had lost no time from work during the last 12-month period. There has been no evidence to the contrary presented in the record since the examination. Therefore, as the issue of individual unemployability is not reasonably raised by the record, it is not part of the rating appeal. ORDER An initial disability rating (evaluation) higher than 10 percent for service-connected hypothyroidism is denied. A higher (compensable) initial disability rating (evaluation) for service-connected restless leg syndrome of the right lower extremity is denied. A higher (compensable) initial disability rating (evaluation) for service-connected restless leg syndrome of the left lower extremity is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs