Citation Nr: 1308089 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 06-35 013 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent prior to August 8, 2005, 20 percent from August 8, 2005 to October 27, 2011, and 40 percent thereafter for lumbar strain with degenerative joint disease. 2. Entitlement to an initial rating in excess of 20 percent from October 28, 2011 for left lower extremity radiculopathy. 3. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease (GERD). 4. Entitlement to a rating in excess of 10 percent prior to October 28, 2011, and 30 percent thereafter for residuals, fracture, left distal fibula and medial malleolus. 5. Entitlement to service connection for a right ankle disability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Ogilvie, Counsel INTRODUCTION The Veteran served on active duty from July 1961 to July 1981. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2005 rating decision of the Waco, Texas Department of Veterans Affairs (VA) Regional Office (RO). In May 2010, the Board remanded the case to schedule the Veteran for a Board hearing. The hearing was held before the undersigned in September 2010, and a transcript of this hearing is of record. The Board subsequently remanded the case for additional development in August 2011. While on remand, the Agency of Original Jurisdiction (AOJ), granted an increased initial rating for lumbar strain with degenerative joint disease, assigning a 40 percent rating effective October 28, 2011, and granted an increased rating for residuals, fracture, left distal fibula and medial malleolus, assigning a 30 percent rating effective October 28, 2011. In a September 2012 rating decision, the AOJ also granted a separate, compensable rating for left lower extremity radiculopathy, assigning a 20 percent rating effective October 28, 2011. The case is once again before the Board for appellate review. The Board has characterized the claims regarding an increased initial rating for lumbar strain with degenerative joint disease and for residuals, fracture, left distal fibula and medial malleolus as stated in the Issues section of this decision for the following reasons. The AOJ has assigned "staged ratings" for lumbar strain with degenerative joint disease of 10 percent from August 31, 2004 through August 7, 2005, 20 percent from August 8, 2005 through October 27, 2011, and 40 percent from October 28, 2011. The AOJ has also assigned "staged ratings" for residuals, fracture, left distal fibula and medial malleolus of 10 percent from September 7, 2004 through October 27, 2011, and 30 percent from October 28, 2011. In correspondence received in August 2005, the Veteran filed an informal claim for increased ratings for the Veteran's lumbar strain with degenerative joint disease and left ankle disability. In February 2006, the Veteran filed a timely Notice of Disagreement with the initial rating of lumbar strain with degenerative joint disease and the denial of an increased rating of service-connected residuals, fracture, left distal fibula and medial malleolus in a May 2005 rating decision. In a December 2005 rating decision, the RO granted the Veteran's claim for an increased initial rating for lumbar strain with degenerative joint disease, assigning a 20 percent rating, effective August 8, 2005, the date of the receipt of the informal claim. The claim for an increased rating for the Veteran's service-connected residuals, fracture, left distal fibula and medial malleolus was deferred at this time. As the Veteran filed a timely Notice of Disagreement with the May 2005 rating decision, the Board finds that the issues on appeal stem from this rating decision, rather than the December 2005 rating decision. Therefore, the Board has characterized the issue for an increased initial rating for lumbar strain with degenerative joint disease to reflect staged ratings originating from the May 2005 rating decision. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). See also AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board has also included the matter of an increased initial rating for left lower extremity radiculopathy, consistent with what the RO has adjudicated. FINDINGS OF FACT 1. Prior to August 8, 2005, the Veteran's lumbar strain with degenerative joint disease was manifested by forward flexion of the lumbar spine greater than 60 degrees and a combined range of motion greater than 120 degrees, without incapacitating episodes due to intervertebral disc syndrome; the lumbar spine was not ankylosed. 2. From August 8, 2005 through October 27, 2011, the Veteran's lumbar strain with degenerative joint disease was manifested by forward flexion of the lumbar spine greater than 30 degrees, without incapacitating episodes due to intervertebral disc syndrome; the lumbar spine was not ankylosed. 3. From October 28, 2011, the Veteran's lumbar strain with degenerative joint disease has been manifested by forward flexion of the spine of 30 degrees or less; ankylosis of the lumbar spine or incapacitating episodes having a total duration of at least 6 weeks during a 12-month period due to intervertebral disc syndrome have not been shown. 4. From October 28, 2011, the Veteran's left lower extremity radiculopathy has been manifested by moderate symptoms of pain and weakness, but not by moderately severe incomplete paralysis. 5. The Veteran's GERD is manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain. 6. Prior to October 28, 2011, the Veteran's service-connected residuals, fracture, left distal fibula and medial malleolus were manifested by no more than moderate limitation of motion; there is no evidence of ankylosis or marked impairment. 7. From October 28, 2011, the Veteran's service-connected residuals, fracture, left distal fibula and medial malleolus have not been manifested by ankylosis in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion, or eversion deformity. 8. A preponderance of the evidence of record does not demonstrate the existence of a current right ankle disability. CONCLUSIONS OF LAW 1. Prior to August 8, 2005, the criteria for a rating in excess of 10 percent for lumbar strain with degenerative joint disease were not met. 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, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5242-5237, 5243 (2012). 2. From August 8, 2005 through October 27, 2011, the criteria for a rating in excess of 20 percent for lumbar strain with degenerative joint disease were not met. 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, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5242-5237, 5243 (2012). 3. From October 28, 2011, the criteria for a rating in excess of 40 percent for lumbar strain with degenerative joint disease have not been met. 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, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5242-5237, 5243 (2012). 4. From October 28, 2011, the criteria for a rating in excess of 20 percent for left lower extremity radiculopathy have not been met. 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, 4.3, 4.6, 4.7, 4.124a, Diagnostic Code 8520 (2012). 5. The criteria for an initial 30 percent disability rating for GERD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7399-7346 (2012). 6. Prior to October 28, 2011, the criteria for a rating in excess of 10 percent for residuals, fracture, left distal fibula and medial malleolus were not met. 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, 4.3, 4.6, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2012). 7. From October 28, 2011, the criteria for a rating in excess of 30 percent for residuals, fracture, left distal fibula and medial malleolus have not been met. 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, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5270 (2012). 8. Service connection for a right ankle disability is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim 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, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice 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) (2012). The VCAA notice requirements apply to all five elements of a claim: Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. VA has satisfied its VCAA duty to notify obligations with respect to the Veteran's claims for an increased initial rating for lumbar strain with degenerative joint disease, left lower extremity radiculopathy, and GERD. The United States Court of Appeals for Veterans Claims (Court) has held that in cases 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 been proven, thereby rendering § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess at 490-91. Thus, because the aforementioned claims stem from the Veteran's disagreement with the initial disability ratings following the grants of service connection, VA's duty to notify has been satisfied with respect to these issues. Id.; see 38 C.F.R. § 3.159(b)(3) (2012). Regarding the claims for an increased rating for service-connected residuals, fracture, left distal fibula and medial malleolus and service connection for a right ankle disability, in an October 2004 letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claims, as well as what information and evidence must be submitted by him, and what information and evidence would be obtained by VA. Subsequent to the May 2005 rating decision, a March 2006 letter provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess. After issuance of this notice, the claims were adjudicated several times and most recently in September 2012. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (finding that the issuance of a fully compliant notification followed by readjudication of the claim, such as a Supplemental Statement of the Case, is sufficient to cure a timing defect). All relevant evidence necessary for an equitable resolution of the Veteran's claims have also been identified and obtained. The evidence of record includes VA and private outpatient treatment records, reports of multiple VA examinations, statements from the Veteran, and the transcript of a September 2010 hearing before the undersigned. The Veteran and his representative have not identified any other outstanding relevant evidence. The Veteran was afforded VA examinations to assess the severity of his spine (with radiculopathy) in March 2005, September 2005, July 2006, December 2006, and October 2011; the severity of his GERD in March 2005, July 2006, December 2006, and October 2011; the severity of his left distal fibula and medial malleolus disability in March 2005, December 2005, July 2006, December 2006, and October 2011, and the nature and etiology of a claimed right ankle disability in March 2005 and October 2011. The reports of these examinations are adequate for rating purposes as they reflect the examiners interviewed and examined the Veteran, reviewed the claims file, reported the clinical findings in detail, and provided complete rationales for the opinions or conclusions stated. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Board also notes that the case was remanded in August 2011 to provide the Veteran with examinations, to include with an opinion as to the etiology of his claimed right ankle disability. On remand, as noted above, the Veteran was afforded VA examinations in October 2011. Accordingly, the Board finds that there was substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Increased Ratings Disability evaluations are determined by the application of the Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). 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 disorders in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). In both initial rating claims and normal increased rating claims, the Board must discuss whether "staged ratings" are warranted. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2012). 38 C.F.R. § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Court has held that evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See generally DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that the disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. According to this regulation, it is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 (2012). The provisions of 38 C.F.R. § 4.45 state that when evaluating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). In addition to evaluating the evidence and rating criteria below, the Board has also considered whether referral for extraschedular consideration is appropriate for each disability on appeal. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant'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." 38 C.F.R. § 3.321(b)(1) (2012). Related factors include "marked interference with employment" and "frequent periods of hospitalization." Id. When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. A. Initial Evaluation of Lumbar Strain with Degenerative Joint Disease The Veteran was initially granted service connection for lumbar strain with degenerative joint disease in a May 2005 rating decision. A 10 percent disability rating was assigned, effective September 7, 2004. In a December 2005 rating decision, the Veteran's lumbar strain with degenerative joint disease was increased to 20 percent disabling, effective August 8, 2005. In a September 2012 rating decision, the Veteran's spine disability was again increased, to 40 percent disabling, effective October 28, 2011. The Veteran maintains that a higher rating is warranted for each rating period on appeal. The Veteran's lumbar strain with degenerative joint disease is currently evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5242-5237. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27 (2012). Here, the hyphenated diagnostic code indicates arthritis (Diagnostic Code 5242) is rated under the criteria for lumbosacral strain (Diagnostic Code 5237). See 38 C.F.R. § 4.20 (2012). Degenerative arthritis of the spine is to be evaluated under the general rating formula for rating diseases and injuries of the spine. 38 C.F.R. § 4.71a (2012). The general rating formula for rating diseases and injuries of the spine applies with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease. Id. The Veteran has also been diagnosed with degenerative disc disease. Intervertebral disc syndrome will be evaluated under the general formula for rating diseases and injuries of the spine or under the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). There are several notes set out after the diagnostic criteria, which provide the following, in relevant part: First, associated objective neurologic abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is to 240 degrees. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2012). Note five provides that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. 1. Rating Period Prior to August 8, 2005 For the period prior to August 8, 2005, the Veteran's lumbar strain with degenerative joint disease was evaluated as 10 percent disabling, under 38 C.F.R. § 4.71a, Diagnostic Code 5242-5237. The next highest rating of 20 percent is assigned under the general rating formula for rating diseases and injuries of the spine if forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2012). Alternatively, a 20 percent rating is assigned for incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months. Id., Diagnostic Code 5243. Note (1) provides that for the purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. Note 1. After reviewing the medical and lay evidence of record, the Board finds that, for the rating period prior to August 8, 2005, the Veteran's lumbar strain with degenerative joint disease symptoms did not meet the criteria for a 20 percent rating outlined above. During this period, on VA examination in March 2005, the Veteran's forward flexion was to 90 degrees, extension was to 30 degrees, left lateral flexion was to 20 degrees, right lateral flexion was to 30 degrees, and left and right lateral rotation was each to 45 degrees. There was no additional limitation by pain, fatigue, weakness, or lack of endurance following repetitive movement or during flare-ups. No muscle spasm, weakness, tenderness, or guarding was found. The Veteran's gait was also normal. The examiner found that the Veteran's spinal contour was normal appearing, although there was evidence of some loss of normal curvature of the lower back. Ankylosis was not found. The Veteran also did not meet the criteria for a 20 percent rating based on incapacitating episodes. On March 2005 VA examination, the Veteran denied requiring bed rest due to back problems over the past year. The Veteran has also not exhibited any symptoms during this rating period that would warrant a rating in excess of 10 percent, to include favorable or unfavorable ankylosis. In short, the criteria for a 20 percent rating, or higher, have not been shown during this period. The Board also notes that the Veteran is not entitled to a separate, compensable rating for radiculopathy of the left lower extremity or right lower extremity, as due to degenerative disc disease, for this period on appeal. The medical and lay evidence of record reflects that while the Veteran complained of radiating pain to the right lower extremity, objective findings of the bilateral lower extremities indicated motor, sensory, and reflex examinations were primarily within normal limits. On March 2005 VA examination, the Veteran complained of radiating pain to his right lower extremity. Neurological examination revealed that the Veteran walked with a slight limp favoring the left ankle, but posture and balance were normal. Deep tendon reflexes were normal and symmetrical. Vibratory, proprioception, and tactile sensations remained intact. There was no evidence of sensory or motor impairment on examination. Muscle atrophy was not found. Thus, absent objective findings of neurological symptoms of the lower extremities, a separate, compensable rating is not warranted during this rating period. 2. Rating Period From August 8, 2005 Through October 27, 2011 For the period from August 8, 2005 through October 27, 2011, the Veteran's lumbar strain with degenerative joint disease was evaluated as 20 percent disabling, under 38 C.F.R. § 4.71a, Diagnostic Code 5242-5237. The next highest rating of 40 percent is assigned under the general rating formula for rating diseases and injuries of the spine if forward flexion of the thoracolumbar spine is 30 degrees or less; or, if there is favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5235-5243 (2012). Alternatively, a 40 percent rating is assigned for incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months. Id., Diagnostic Code 5243. After reviewing the medical and lay evidence of record, the Board finds that, for the rating period from August 8, 2005 through October 27, 2011, the Veteran's lumbar strain with degenerative joint disease symptoms did not meet the criteria for a 40 percent rating outlined above. On September 2005 VA examination, the Veteran's forward flexion was to 60 degrees. The Veteran had pain throughout flexion, which increased as it approached the end of flexion. Repetitive flexions did not decrease range of motion or spine function. Ankylosis was not found. The examiner did not discuss whether the Veteran had undergone any incapacitating episodes within the past year. On July 2006 VA examination, the Veteran's forward flexion was to 50 degrees. The examiner noted that the Veteran was able to flex to 75 degrees after repetitions and when he was tying his shoes. The Veteran had objective symptoms of pain and grimacing noted from 40 to 50 degrees, but not noted from 50 to 75 degrees. Repeated and resisted motion did not further limit range of motion or function. The examiner noted that repetitive motion actually improved the range of motion, which indicated to the examiner that there was muscle tightness that improved with stretching. No ankylosis was found. The Veteran reported that he had no incapacitating episodes causing forced bed rest or lost days from work. In December 2006, the Veteran underwent another VA examination. The examiner noted that the examination was very similar to the July 2006 examination, with little change noted. The Veteran's forward flexion was to 70 degrees, with pain at the end point. No further limitation or pain was found with repeated efforts. The Veteran noted that he had not missed any time from work due to his back disability. The Veteran reported flare-ups, but noted that they did not impair his daily functional activities for self care or cause him to miss work. Ankylosis was not found. The Veteran's back disability did not cause any episodes of incapacitation during the past 12 months. As described above, for this rating period, the Veteran's forward flexion remained greater than 30 degrees, even after repetitive testing, and he had no evidence of ankylosis of the lumbar spine. The Veteran also denied any episodes of incapacitation during this entire rating period. Thus, he has not met the criteria for a 40 percent, or higher, rating during the period from August 8, 2005 through October 27, 2011. The Board also notes that the Veteran is not entitled to a separate, compensable rating for radiculopathy of the left lower extremity or right lower extremity, as due to degenerative disc disease, for this period on appeal. The medical and lay evidence of record reflects that while the Veteran had some complaints of radiating pain to the right lower extremity, objective findings of the bilateral lower extremities indicated motor, sensory, and reflex examinations were primarily within normal limits. VA outpatient treatment from February 2006 revealed normal neurological testing, bilaterally. On July 2006 VA examination, the Veteran acknowledged that he had suffered from symptoms of right lower extremity radiation in the past, but denied any current symptoms of radiation into the right lower extremity. Neurological examination revealed intact sensation in the lower extremities to pinprick and light touch. The Veteran had normal power bulk and tone of the lower extremities. Straight leg raising was normal. On December 2006 VA examination, the Veteran reported no change to his neurological symptoms since his last examination, and as a result, neurological examination was not performed. Thus, absent objective findings of neurological symptoms of the lower extremities, a separate, compensable rating is not warranted for radiculopathy during this rating period. 3. Rating Period From October 28, 2011 For the period from October 28, 2011, the Veteran's lumbar strain with degenerative joint disease has been evaluated as 40 percent disabling, under 38 C.F.R. § 4.71a, Diagnostic Code 5242-5237. The next highest rating of 50 percent is assigned under the general rating formula for rating diseases and injuries of the spine if there is unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5235-5243 (2012). Alternatively, a 60 percent rating is assigned for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Id., Diagnostic Code 5243. After reviewing the medical and lay evidence of record, the Board finds that, for the rating period from October 28, 2011, the Veteran's lumbar strain with degenerative joint disease symptoms did not meet the criteria for a 50 percent rating outlined above. On October 2011 VA examination, the Veteran was not found to have any ankylosis of the thoracolumbar spine. The Veteran also did not have any incapacitating episodes over the past 12 months due to intervertebral disc syndrome. No other lay or medical evidence from this rating period indicates that the Veteran suffers from ankylosis or incapacitating episodes having a duration of at least 6 weeks over the past 12 months. While the Veteran testified at his hearing that he had been prescribed bed rest from his physician, he estimated that it was less than two weeks per year. See Board Hearing Tr. at 10. As such, a rating of 50 percent, or higher, is not warranted for lumbar strain with degenerative joint disease. As noted in the Introduction, the AOJ assigned a separate, compensable rating for the Veteran's left lower extremity radiculopathy for this rating period, which is discussed below. Therefore, for the rating period from October 28, 2011, the Board will only address whether the Veteran is entitled to a separate, compensable rating for radiculopathy of the right lower extremity. Here, the Veteran is not entitled to a separate, compensable rating for radiculopathy of the right lower extremity, as due to degenerative disc disease, for this period on appeal. The medical and lay evidence of record reflects that while the Veteran had some complaints of radiating pain to the right lower extremity, see Board Hearing Tr. at 10-11, objective findings of the right lower extremity indicated motor, sensory, and reflex examinations were within normal limits. On October 2011 VA examination, the Veteran denied constant or intermittent pain, paresthesias and/or dysesthesias, or numbness of the right lower extremity. The Veteran was found to have no right lower extremity radiculopathy. Strength testing was normal, with no muscle atrophy. Reflex testing revealed hypoactive deep tendon reflexes at the ankle and normal findings at the knee. Sensory examination was normal. Straight leg raising testing was negative. Thus, absent objective findings of neurological symptoms of the right lower extremity, a separate, compensable rating is not warranted for radiculopathy during this rating period. 4. All Rating Periods As indicated, the AOJ has already granted staged ratings for the Veteran's spine disability under consideration. In addition to the Board's consideration of the propriety of the rating assigned at each stage, as discussed above, the Board has also considered whether any further staged rating of the disability is warranted. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Here, the Board finds that the Veteran's lumbar strain with degenerative joint disease symptoms have been consistent with the ratings that have been assigned for each rating period on appeal. The record indicates significant increase in the Veteran's symptoms of restriction of range of motion during the entire appellate period, and these changes are reflected in the ratings currently assigned. Accordingly, further staged ratings are not warranted and the ratings the Board has assigned are appropriate for the respective periods here on appeal. The Board has also considered whether referral for an extraschedular rating is appropriate. As noted above, the Veteran's lumbar symptoms primarily involve pain and restriction of range of motion. Such impairment is specifically contemplated by the rating criteria. Hence, the rating criteria reasonably describe the Veteran's disability. In short, there is no indication in the record that the average industrial impairment from the Veteran's lumbar spine strain with degenerative joint disease would be in excess of that contemplated by the ratings assigned for each rating period; the Veteran's disability picture is not shown to be exceptional or unusual. Therefore, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). B. Initial Evaluation of Radiculopathy of the Left Lower Extremity From October 28, 2011 The Veteran was initially granted service connection for left lower extremity radiculopathy in a September 2012 rating decision. A 20 percent disability rating was assigned, effective October 28, 2011. The Veteran's left lower extremity radiculopathy is currently evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8520. The next highest rating of 40 percent is assigned for moderately severe incomplete paralysis. Words such as "moderate" and "severe" are not defined in VA's Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6 (2012). After reviewing the medical and lay evidence of record, the Board finds that, for the rating period from October 28, 2011, the Veteran's left lower extremity radiculopathy has not met the criteria for a 40 percent rating outlined above. On October 2011 VA examination, the Veteran described experiencing sharp pains in his left leg, usually while driving. Muscle strength testing revealed normal findings in the left lower extremity. The Veteran did not have muscle atrophy. Deep tendon reflexes of the left knee were normal and were absent at the left ankle. A sensory examination of the left lower extremity was normal. Straight leg raising was negative on the left side. The Veteran reported moderate constant pain, paresthesias and/or dysesthesias, and numbness in the left lower extremity. While the Veteran reported that he attributed his stumbling to his service-connected residuals of a left distal fibula and medial malleolus fracture, the examiner implied that this was instead due to the Veteran's left lower extremity radiculopathy. The examiner determined that the radiculopathy involved the Veteran's sciatic nerve and was moderate in severity. The Veteran did not have any bowel or bladder problems or pathologic reflexes. As such, the criteria for a rating of 40 percent, or higher, is not warranted for lumbar strain with degenerative joint disease. Notably, the Veteran's left lower extremity radiculopathy was assessed as moderate, due to his descriptions of constant pain, paresthesias, and numbness, as well as an objective finding of absent left ankle reflexes. The Veteran did not have any atrophy of the left lower extremity or any other objective findings indicating moderately severe radiculopathy. In sum, the Board finds that the Veteran's left lower extremity radiculopathy symptomatology has not met the criteria for a rating of 40 percent or higher. The Board has considered whether staged ratings are appropriate. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board finds that the Veteran's left lower extremity radiculopathy symptoms have been consistent with a 20 percent rating for the entire relevant time period here on appeal. The Veteran's objective symptoms of radiculopathy in the left lower extremity were first found on examination in October 2011, and the record does not indicate any significant increase or decrease in such symptoms during the appeal period. Moreover, as explained above, symptoms warranting a 40 percent rating have not been shown. Accordingly, staged ratings are not warranted and the currently assigned 20 percent rating is appropriate for the period from October 28, 2011. The Board has also considered whether referral for an extraschedular rating is appropriate. As noted above, the Veteran's symptoms primarily involve pain, numbness, and paresthesias. Such impairment is specifically contemplated by the rating criteria. Hence, the rating criteria reasonably describe the Veteran's disability. In short, there is no indication in the record that the average industrial impairment from the Veteran's left lower extremity radiculopathy would be in excess of that contemplated by the 20 percent rating; the Veteran's disability picture is not shown to be exceptional or unusual. Therefore, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). C. Initial Evaluation of GERD The Veteran was initially granted service connection for GERD in a May 2005 rating decision. A 10 percent disability rating was assigned, effective September 7, 2004. The Veteran maintains that a higher rating is warranted. The Veteran's GERD is currently evaluated as 10 percent disabling under 38 C.F.R. § 4.114, Diagnostic Code 7399-7346. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27 (2012). Here, the hyphenated diagnostic code indicates unlisted digestive disorders (Diagnostic Code 7399) rated, by analogy, under the criteria for hernia hiatal (Diagnostic Code 7346). See 38 C.F.R. § 4.20 (2012). The next highest rating of 30 percent is assigned under Diagnostic Code 7346 where there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. After reviewing the medical and lay evidence of record, the Board finds that the Veteran's GERD symptoms are congruent with the criteria for a 30 percent rating outlined above. The Veteran has reported a history of frequent indigestion, heart burn, and reflux. On March 2005 VA examination, the Veteran reported epigastric discomfort associated with his GERD. On July 2006 VA examination, the Veteran reported a daily occurrence of regurgitation of food after eating. The Veteran was diagnosed with GERD, moderately symptomatic despite treatment. In December 2006, a VA examiner found the Veteran to have daily epigastric, substernal, and arm pain, but no dysphagia. The Veteran denied hematemesis and melena. He reported daily episodes of regurgitation. The Veteran had no enema and no recent weight gain or loss. He was diagnosed with severely symptomatic GERD despite treatment. On October 2011 VA examination, the examiner noted that the Veteran had persistently recurrent epigastric distress, with pyrosis, reflux, regurgitation, and substernal arm or shoulder pain. The Veteran also reported transient nausea and recurrent vomiting, four times or more per year. Given the frequency of the Veteran's occurrences of pyrosis and regurgitation, as well as his complaints of epigastric discomfort and substernal and arm pain, the criteria for a 30 percent disability rating for GERD have been satisfied for the entire rating period on appeal. The Veteran's GERD symptoms do not, however, warrant the assignment of an even higher 60 percent rating. A 60 percent rating is assigned when there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. While in his most recent examination in October 2011, the Veteran reported vomiting, on prior examinations in March 2005 and July 2006, the Veteran denied vomiting and nausea. Further, at no point during the entire period on appeal, has the Veteran suffered from material weight loss and hematemesis or melena with moderate anemia, or equivalent symptoms indicating a severe impairment of health. On March 2005, July 2006, and October 2011 VA examinations, the Veteran had not lost any weight. While the Board recognizes that on December 2006 VA examination, the Veteran's GERD was described as "severely symptomatic," there is no indication that the Veteran's impairment of health was severe at any time during the rating period. As noted above, he did not suffer from any weight loss or hematemesis or melena. The Veteran remained employed full time, and there is no indication of record that the Veteran was ever hospitalized for symptoms related to GERD. In short, although the Veteran's GERD is productive of symptoms consistent with a 30 percent rating, the criteria for a 60 percent rating have not been shown. The Board has considered whether staged ratings are appropriate. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board finds that the Veteran's GERD symptoms have been consistent with a 30 percent rating for the entire relevant time period here on appeal. The Veteran's key GERD symptoms-particularly his frequent indigestion, heart burn, reflux, and epigastric pain/discomfort-have been longstanding in nature, and the record does not indicate any significant increase or decrease in such symptoms during the appeal period. Moreover, as explained above, symptoms warranting a 60 percent rating have not been shown. Accordingly, staged ratings are not warranted and the 30 percent rating the Board has assigned is appropriate for the entire period here on appeal. The Board has also considered whether referral for an extraschedular rating is appropriate. As noted above, the Veteran's symptoms primarily involve frequent indigestion, heart burn, reflux, and epigastric discomfort. Such impairment is specifically contemplated by the rating criteria. Hence, the rating criteria reasonably describe the Veteran's disability. In short, there is no indication in the record that the average industrial impairment from the Veteran's GERD would be in excess of that contemplated by the 30 percent rating; the Veteran's disability picture is not shown to be exceptional or unusual. Therefore, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). In summary, the evidence supports an initial rating of 30 percent, and no higher, for the Veteran's GERD. To that extent, the appeal is granted. D. Evaluation for Residuals, Fracture, Left Distal Fibula and Medial Malleolus The Veteran filed his claim for a rating in excess of 10 percent for residuals, fracture, left distal fibula and medial malleolus in August 2004. In a September 2012 rating decision, the AOJ increased the Veteran's evaluation for this disability to 30 percent, effective October 28, 2011. The Veteran maintains that a higher rating is warranted for each stage on appeal. 1. Rating Period Prior to October 28, 2011 For the rating period prior to October 28, 2011, the Veteran's residuals, fracture, left distal fibula and medial malleolus were evaluated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5271. The next highest rating of 20 percent is assigned under Diagnostic Code 5271 where there marked limited motion of the ankle. Standard range of ankle dorsiflexion is from 0 to 20 degrees, and plantar flexion from 0 to 45 degrees. See id., Plate II. Words such as "moderate" and "marked" are not defined in VA's Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6 (2012). After reviewing the medical and lay evidence of record, the Board finds that, for the rating period prior to October 28, 2011, the Veteran's residuals, fracture, left distal fibula and medial malleolus did not meet the criteria for a 20 percent rating outlined above because he did not have marked limitation of motion of the ankle. On March 2005 VA examination, the Veteran complained of a chronic dull ache of the left ankle with increased pain with prolonged standing and walking, as well as recurrent minor swelling. The Veteran did not require assistive devices or supports. On examination, range of motion testing revealed dorsiflexion to 20 degrees and plantar flexion to 45 degrees. There was no additional limitation by pain, fatigue, weakness, or lack of endurance following repetitive use. No flare-ups were reported. There was no objective evidence of pain on motion, edema, effusion, instability, weakness, tenderness, redness, heat, abnormal movement, or guarding of movement. The Veteran had a slight limp favoring the left ankle. The Veteran had no history or evidence of ankylosis. X-ray of the left ankle was normal. On December 2005 examination, the Veteran reported that his left ankle gave way easily, felt weak, and was extremely painful at all times, with increased pain with ambulation. On physical examination, range of motion testing revealed dorsiflexion to 20 degrees and plantar flexion to 45 degrees, without pain. Range of motion was not additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups. There was no objective evidence of pain, tenderness, swelling, effusion, instability, weakness, abnormal movement, or guarding of movements. The Veteran's gait was normal. Ankylosis was not present. In July 2006, the Veteran was afforded another VA examination, where he complained of pain, swelling, a sensation of giving way, and weakness in the left ankle. The Veteran sometimes used a cane to walk. The Veteran did not have any flare-ups. On physical examination, range of motion testing of the left ankle was described as "almost normal" with dorsiflexion to 20 degrees and plantar flexion to 45 degrees, with pain at these endpoints. After repeatedly rising on his toes of the left foot, the Veteran plantar flexion decreased to 20 degrees due to weakness and pain. The Veteran had no heat, redness, or effusion, but his left ankle and medial and lateral malleloli were tender. No ankylosis was found. On December 2006 VA examination, the Veteran reported pain at rest, swelling, fatigue, and lack of endurance of the left ankle. He also noted that he had daily flare-ups, which impaired his ability to shower, but did not result in any time lost from work in the last 12 months. The Veteran used a cane and brace for his left ankle. On physical examination, range of motion testing revealed dorsiflexion to 10 degrees and plantar flexion to 35 degrees, with pain at the endpoints, and no further limitations after repetitions. Fatigue, weakness, lack of endurance, pain, and incoordination were not found on testing. Ankylosis was not found. X-rays revealed some local bony proliferation on the lateral side of the distal left tibia probably secondary to old trauma. No significant fracture deformity was identified on either side. Scattered vascular calcifications were also noted. As noted, the Board finds that the Veteran's residuals, fracture, left distal fibula and medial malleolus symptomatology has not met the criteria for a rating of 20 percent or higher because at no time prior to October 28, 2011, did the evidence reflect that the Veteran suffered from marked limitation of motion of the left ankle. In this regard, range of motion testing conducted during the March 2005, December 2005, and July 2006 VA examinations revealed that the Veteran had full dorsiflexion and plantar flexion. In July 2006, the Veteran lost only plantar flexion after repetitive testing of left toe raises. In December 2006, range of motion testing revealed that the Veteran had a loss of 50 percent of dorsiflexion (10 out of a possible 20 degrees), but his loss of plantar flexion was only 10 degrees (specifically, 35 out of a possible 45 degrees), including after repetitive testing. As such, the Board finds that marked limitation of ankle motion for the period prior to October 28, 2011 has not been shown. The Board also has considered the Veteran's functional impairment due to pain and other factors during the period in question. While the record clearly reflects that the Veteran suffers from pain and some weakness of the left ankle, the Board finds that the medical and lay evidence during the period in question simply does not reflect greater than overall moderate functional loss due to this symptomatology. As such, the Board finds that the DeLuca factors provide no basis for assignment of a rating in excess of 10 percent during the period in question. Additionally, the Board has considered the applicability of alternative diagnostic codes for evaluating the Veteran's residuals, fracture, left distal fibula and medial malleolus. While ratings in excess of 10 percent are available for ankylosis of the ankle, ankylosis of the subastragalar or tarsal joint in poor weight-bearing position, malunion of the os calcis or astragalus with marked deformity, or astragelectomy, the diagnostic codes evaluating these conditions are simply not applicable to the Veteran's service-connected residuals, fracture, left distal fibula and medial malleolus during this period. It is neither contended nor shown that the Veteran's disability involves any of the aforementioned conditions. As such, evaluation of the disability under Diagnostic Codes 5270, 5272, 5273, or 5274, respectively, is not warranted. While ratings in excess of 10 percent are available for nonunion or malunion of the tibia and fibula, the diagnostic code evaluating this condition is simply not applicable to the Veteran's service-connected residuals, fracture, left distal fibula and medial malleolus during this period. It is neither contended nor shown that the Veteran's disability involves either malunion or nonunion of the fibula. Notably, the Veteran's X-rays have not revealed any such condition. As such, evaluation of the disability under Diagnostic Code 5262 is also not warranted. 2. Rating Period From October 28, 2011 For the rating period from October 28, 2011, the Veteran's residuals, fracture, left distal fibula and medial malleolus were evaluated as 30 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5270. The next highest rating of 40 percent is assigned where there is ankylosis of the ankle in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion, or eversion deformity. Standard range of ankle dorsiflexion is from 0 to 20 degrees, and plantar flexion from 0 to 45 degrees. See id., Plate II. After reviewing the medical and lay evidence of record, the Board finds that, for the rating period from October 28, 2011, the Veteran's residuals, fracture, left distal fibula and medial malleolus did not meet the criteria for rating with the criteria for a 40 percent rating outlined above. On October 2011 VA examination, the Veteran complained of the left ankle giving way, resulting in falls approximately four times per week. Range of motion testing of the left ankle revealed plantar flexion to 30 degrees with pain at the end point, and zero degrees of dorsiflexion with pain. There was no additional limitation in range of motion on repetitive testing. The Veteran was found to have ankylosis of the ankle in dorsiflexion between zero and 10 degrees. The Veteran's gait was normal, and he was able to walk on his toes and heels. No abduction, adduction, inversion, or eversion deformity was found. As noted, the Board finds that the Veteran's residuals, fracture, left distal fibula and medial malleolus symptomatology has not met the criteria for a rating of 40 percent or higher because at no time from October 28, 2011, did the evidence reflect that the Veteran suffered from ankylosis of the left ankle in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. In this regard, range of motion testing conducted during the October 2011 VA examination revealed that the Veteran had ankylosis in dorsiflexion, between zero and 10 degrees. Thus, the Board finds that the criteria for a 40 percent rating for the period from October 28, 2011 have not been shown. The Board also has considered the Veteran's functional impairment due to pain and other factors during the period in question. While the record reflects that the Veteran suffers from pain and giving way of the left ankle, the Board finds that the medical and lay evidence during the period in question simply does not reflect functional loss due to this symptomatology. On October 2011 VA examination, while the Veteran was found to have pain on movement and less movement than normal in the left ankle, he was not found to have any other functional impairment of the left ankle, including excess fatigability, incoordination, swelling, deformity, atrophy, instability, or weakened movement. Notably, on October 2011 VA examination for the spine, the examiner found the Veteran's description of his stumbling to be related to radiculopathy, although the Veteran believed it was due to his left ankle. For these reasons, the Board finds that the DeLuca factors provide no basis for assignment of a rating in excess of 30 percent during the period in question. Additionally, the Board has considered the applicability of alternative diagnostic codes for evaluating the Veteran's residuals, fracture, left distal fibula and medial malleolus. While a rating in excess of 30 percent is available for nonunion of the tibia and fibula, the diagnostic code evaluating this condition is simply not applicable to the Veteran's service-connected residuals, fracture, left distal fibula and medial malleolus during this period. It is neither contended nor shown that the Veteran's service-connected residuals, fracture, left distal fibula and medial malleolus involves a nonunion of the fibula. Notably, the Veteran's X-rays have not revealed any nonunion. As such, evaluation of the disability under Diagnostic Code 5262 is not warranted. 3. Both Rating Periods As indicated, the AOJ has already granted staged ratings for the Veteran's residuals, fracture, left distal fibula and medial malleolus disability under consideration. In addition to the Board's consideration of the propriety of the rating assigned at each stage, as discussed above, the Board has also considered whether any further staged rating of the disability is warranted. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Board finds that the Veteran's residuals, fracture, left distal fibula and medial malleolus symptoms have been consistent with a 10 percent rating for the entire time period prior to October 28, 2011, and with a 30 percent rating for the entire time period from October 28, 2011. The record does not indicate any significant increase or decrease in such symptoms during the appeal period. Moreover, as explained above, symptoms warranting the next higher rating have not been shown for each rating period on appeal. Accordingly, staged ratings are not warranted and the ratings the AOJ has assigned is appropriate for the rating periods discussed above. The Board has also considered whether referral for an extraschedular rating is appropriate. As noted above, the Veteran's residuals, fracture, left distal fibula and medial malleolus symptoms primarily involve pain, some weakness, and loss of motion. Such impairment is specifically contemplated by the rating criteria. Hence, the rating criteria reasonably describe the Veteran's disability. In short, there is no indication in the record that the average industrial impairment from the Veteran's residuals, fracture, left distal fibula and medial malleolus would be in excess of that contemplated by the ratings assigned above; the Veteran's disability picture is not shown to be exceptional or unusual. Therefore, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). III. Service Connection For Right Ankle Disability The Veteran alleges that he has a right ankle disability that is related to his service. He has alleged that his right ankle started bothering him in Germany, when he served as a military police officer and was standing on his feet for long periods of time. Board Hearing Tr. at 23-25. Service treatment records reflect that in May 1979, the Veteran suffered a right ankle injury while running. He had tissue swelling over the lateral malleolus, consistent with a sprain. The bony structures were within normal limits. The Veteran has alternatively asserted that he has a right ankle disability caused or aggravated by a service-connected disability. Service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). In order to establish service connection for the claimed disorder, generally, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be granted for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2012). That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). [The Board notes that, effective October 10, 2006, VA amended 38 C.F.R. § 3.310 with regard to the requirements for establishing secondary service connection on an aggravation basis. See 71 Fed. Reg. 52,744-47 (Sept. 7, 2006). However, given the basis for the denial as noted below, any further discussion of the amendment is unnecessary.] Crucial to the award of service connection is the first Hickson element, existence of a current disability. Without it, service connection cannot be granted. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (finding that the requirement of having a current disability is met "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim"); Brammer v. Derwinski, 3 Vet. App. 233, 225 (1992) (noting that service connection presupposes a current diagnosis of the claimed disability). A July 2003 statement from Dr. B.M., VA outpatient treatment records, and March 2005, July 2006, December 2006, and October 2011 VA examination reports address the first Hickson element. When evaluating the evidence of record, the Board must analyze its credibility and probative value, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the Veteran. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Although the Board may appropriately favor the opinion of one competent medical authority over another, see Wensch v. Principi, 15 Vet. App. 362, 367 (2001), it must consider and weigh all medical evidence, keeping in mind the command of Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), that the benefit of the doubt in resolving such issues shall be given to the Veteran. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). Although outside the period on appeal, in a July 2003 letter, private physician B.M. states that the Veteran's "current right ankle condition is at least likely as not related to the right ankle condition treated while in service." On March 2005 VA examination, the Veteran reported a history of right ankle pain that started three years ago and consisted of a chronic full ache of the right ankle with increased pain with prolonged standing and walking. X-ray of the right ankle was normal. The Veteran was found to have a history of right ankle pain, but no disease was found. VA outpatient treatment records in August 2005 reflect that the Veteran complained of trouble with the right ankle and requested disabled parking status. The Veteran was scheduled for an X-ray of the right ankle and prescribed pain medication. On July 2006 VA examination of the left ankle, the examiner also provided information regarding the Veteran's right ankle. The Veteran's right ankle appeared normal without redness or effusion. The right ankle had normal range of motion without pain on motion. The Veteran was able to rise on the toes of the right foot. The Veteran was diagnosed with a left ankle disability only. On December 2006 VA joint examination for the left ankle, the Veteran underwent an X-ray of the right ankle, which revealed negative findings. In October 2011, the Veteran underwent VA examination for the right ankle to determine whether he had a current disability. The Veteran reported swelling and pain in his right ankle. The Veteran's gait was normal, and he was able to walk on his toes and heels. The examiner found that the Veteran did not have a right ankle condition except pain with unknown etiology. Since he did not have a diagnosed right ankle condition, it could not be related to or aggravated by his lumbar spine, left ankle disability, or disability of the right toes. In evaluating this evidence, the Board places substantial probative weight on the October 2011 VA examination report that concluded the Veteran did not have a current ankle disability and on the March 2005 and December 2006 X-rays of the right ankle which were normal. The October 2011 VA examiner reviewed the Veteran's medical records and provided a full examination with range of motion, strength, and stability testing, but concluded that there was no evidence the Veteran currently had a right ankle disability. While the examiner did not provide the Veteran with a new X-ray, based on the examination findings and the previous X-rays reflecting a normal right ankle, the examiner found that the evidence showed that the Veteran did not have a current disability. The examiner's opinion is based on an examination of the Veteran and elicitation of his relevant medical history. The report also reflects that pertinent evidence was considered in reaching his conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that it is the reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion). Additionally, the VA treatment records throughout the appeal period showing normal right ankle findings on physical examinations and X-rays support the examiner's conclusion that the Veteran does not have a current right ankle disability. The Board places little probative value on Dr. B.M.'s July 2003 letter noting that the Veteran's "current right ankle condition is at least likely as not related to the right ankle condition treated while in service" because the letter does not provide a rationale for the statement and does not explain whether this statement means that the Veteran has a current right ankle disability. The Court has held that "a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion." See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); see also Miller v. West, 11 Vet. App. 345, 348 (1998). Since Dr. B.M. did not support his conclusion with an analysis the Board could weigh against any contrary opinion, the opinion does not provide sufficient detail and rationale to allow the Board to make a fully informed decision regarding the issue of whether the Veteran has a current right ankle disability. As noted above, other competent and credible evidence of record-notably, dated subsequent to the July 2003 letter-indicates that the Veteran, in fact, does not have a current right ankle disability. Such evidence undermines the probative value of Dr. B.M.'s statement. Specifically, the March 2005 and October 2011 VA examiners did not find any objective evidence in the records or on examination that the Veteran had a current right ankle disability, and Dr. B.M. has not provided any documentation of any current diagnosis. Although the lack of contemporaneous medical evidence does not in and of itself undermine the credibility of an account, such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of Veteran's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). It is for these reasons that the Board places little probative weight on Dr. B.M.'s July 2003 letter. Specifically, all competent and credible medical evidence of record during the appeal period has not revealed evidence of a right ankle disability. In deciding this appeal, the Board has also considered the Veteran's lay statements of record. The Veteran's statements at the September 2010 Board hearing focused on his right ankle and foot pain in service due to standing long hours on his feet. Board Hearing Tr. at 23-25. The Veteran did not discuss whether he currently has been diagnosed with a disability. While the Veteran has reported pain at his VA examinations, pain, alone, without evidence of underlying pathology, does not constitute a disability for VA purposes. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999); Evans v. West, 12 Vet. App. 22, 31-32 (1998). The law clearly provides that claimants in the VA system have "the responsibility to present and support" their claims. 38 U.S.C.A. § 5107(a) (West 2002). In the instant case, the Veteran has failed to provide credible and probative medical evidence that may demonstrate that he has a current right ankle disability. Therefore, in the absence of credible evidence of a right ankle, the first Hickson element has not been met and the Veteran's claim fails on this basis alone. The benefit sought on appeal is accordingly denied. (CONTINUED ON THE NEXT PAGE) ORDER For the rating period prior to August 8, 2005, an initial rating in excess of 10 percent for residuals of lumbar strain with degenerative joint disease is denied. For the rating period from August 8, 2005 through October 27, 2011, an initial rating in excess of 20 percent for residuals of lumbar strain with degenerative joint disease is denied. For the rating period from October 28, 2011, an initial rating in excess of 40 percent for residuals of lumbar strain with degenerative joint disease is denied. For the rating period from October 28, 2011, an initial rating in excess of 20 percent for left lower extremity radiculopathy is denied. An initial 30 percent disability rating for GERD is granted, subject to controlling regulations applicable to the payment of monetary benefits. For the rating period prior to October 28, 2011, a rating in excess of 10 percent for residuals, fracture, left distal fibula and medial malleolus disability is denied. For the rating period from October 28, 2011, a rating in excess of 30 percent for residuals, fracture, left distal fibula and medial malleolus disability is denied. Entitlement to service connection for a right ankle disability is denied. ____________________________________________ Donnie R. Hachey Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs