Citation Nr: 1319726 Decision Date: 06/19/13 Archive Date: 06/27/13 DOCKET NO. 09-31 362 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for a lumbar spine disability. 2. Entitlement to an initial compensable rating for a right knee disability prior to November 24, 2008, and in excess of 10 percent thereafter. 3. Entitlement to an initial compensable rating for a left knee disability prior to November 24, 2008, and in excess of 10 percent thereafter. 4. Entitlement to an initial compensable rating for a right ankle disability. 5. Entitlement to an initial compensable rating for a left ankle disability. 6. Entitlement to an initial compensable rating for migraine headaches. 7. Entitlement to an initial compensable rating for pseudofolliculitis barbae, to include keloid on back of scalp, prior to November 24, 2008, and in excess of 30 percent thereafter. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from July 1998 to July 2006. This case comes before the Board of Veterans' Appeals (the Board) on appeal from an August 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In March 2009, the Veteran testified during a hearing before a Decision Review Officer (DRO) at the RO; a transcript of that hearing is of record. In his substantive appeal, the Veteran requested a hearing before a Veterans Law Judge. An April 2013 letter informed him that his hearing was scheduled for May 2013. Although the hearing notification was not returned by the U.S. Postal Service as undeliverable, the Veteran failed to report for the scheduled hearing, and has not requested rescheduling of the hearing. As such, his hearing request is deemed withdrawn. See 38 C.F.R. § 20.704(d) (2013). Although the RO has granted higher ratings during the pendency of the appeal for the Veteran's bilateral knee and pseudofolliculitis barbae disabilities, inasmuch as higher ratings for these disabilities are available, and the Veteran is presumed to seek the maximum available benefit for a disability, the claims for higher ratings remain viable on appeal. See Fenderson, 12 Vet. App. at 126; AB v. Brown, 6 Vet. App. 35, 38 (1993). The record reflects that the Veteran's combined service connected disability rating is 90 percent. At a July 2011 hearing on an unrelated issue, the Veteran's representative noted that the Veteran was unemployed due to disability. Thus, the issue of entitlement to a total disability rating based on individual unemployability (TDIU) has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Throughout the period of appeal, the evidence of record indicates that the Veteran's lumbar spine disability is manifested by pain and limitation of motion with forward flexion no worse than 70 degrees and combined range of motion no worse than 220 degrees; the evidence does not show muscle spasm or guarding severe enough to result in abnormal gait or spinal contour. 2. Prior to November 24, 2008, the Veteran's right knee disability is manifested by pain and stiffness, but not by objective evidence of flexion limited to 45 degrees or less; extension limited to 10 degrees or more; recurrent subluxation or objective evidence of slight lateral instability; dislocated semilunar cartilage with frequent locking, pain, or effusion into the joint; or impairment of the tibia or fibula. 3. From November 24, 2008, the Veteran's right knee disability is manifested by pain and stiffness, but not by objective evidence of flexion limited to 30 degrees or less; extension limited to 15 degrees or more; recurrent subluxation or objective evidence of slight lateral instability; dislocated semilunar cartilage with frequent locking, pain, or effusion into the joint; or impairment of the tibia or fibula. 4. Prior to November 24, 2008, the Veteran's left knee disability is manifested by pain and stiffness, but not by objective evidence of flexion limited to 45 degrees or less; extension limited to 10 degrees or more; recurrent subluxation or objective evidence of slight lateral instability; dislocated semilunar cartilage with frequent locking, pain, or effusion into the joint; or impairment of the tibia or fibula. 5. From November 24, 2008, the Veteran's left knee disability is manifested by pain and stiffness, but not by objective evidence of flexion limited to 30 degrees or less; extension limited to 15 degrees or more; recurrent subluxation or objective evidence of slight lateral instability; dislocated semilunar cartilage with frequent locking, pain, or effusion into the joint; or impairment of the tibia or fibula. 6. Throughout the period of appeal, the Veteran's right ankle disability is manifested by symptoms of no more than mild severity, with range of dorsiflexion limited to 20 degrees, and plantar flexion to 45 degrees; ankylosis of the right ankle, and malunion of the os calcis or astragalus, are not shown. 7. Throughout the period of appeal, the Veteran's left ankle disability is manifested by symptoms of no more than mild severity, with range of dorsiflexion limited to 20 degrees, and plantar flexion to 45 degrees; ankylosis of the left ankle, and malunion of the os calcis or astragalus, are not shown. 8. Throughout the period of appeal, the Veteran's migraine headaches have not resulted in prostrating attacks. 9. Prior to November 24, 2008, the Veteran's skin disability is manifest by skin lesions affecting less than 5 percent of his entire body, and he has not been shown to require corticosteroids or other immunosuppressive drugs. 10. From November 24, 2008, the Veteran's skin disability is manifest by skin lesions affecting less than 40 percent of his entire body, and he has not been shown to require corticosteroids or other immunosuppressive drugs. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for the Veteran's service-connected lumbar spine disability have not been met at any time during the period of appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5242 (2012). 2. The criteria for a compensable disability rating prior to November 24, 2008, and in excess of 10 percent thereafter, for a right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2012). 3. The criteria for a compensable disability rating prior to November 24, 2008, and in excess of 10 percent thereafter, for a left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2012). 4. The criteria for a compensable disability rating for the Veteran's service-connected right ankle disability have not been met at any time during the period of appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2012). 5. The criteria for a compensable disability rating for the Veteran's service-connected left ankle disability have not been met at any time during the period of appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2012). 6. The criteria for a compensable disability rating for The Veteran's migraine headaches have not been met at any time during the period of appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8100 (2012). 7. The criteria for a compensable disability rating prior to November 24, 2008, and in excess of 30 percent thereafter, for a skin disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7806 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. The Veterans Claims Assistance Act (VCAA) With regard to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5102, 5103(a), 5103A, 5106 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Under the Veterans Claims Assistance Act of 2000 (VCAA), when VA receives a complete or substantially complete application for benefits, it is generally required to "notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided . . . that is necessary to substantiate the claim." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). As part of that notice, VA must "indicate which portion of that information and evidence, if any, is to be provided by the claimant and which portion, if any, the Secretary . . will attempt to obtain on behalf of the claimant." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). With respect to his initial claims for service connection, the Veteran was furnished with VCAA compliant notice by a letter dated in October 2007. Among other things, this letter informed the Veteran of the process in which VA assigns initial ratings and effective dates as required under the VCAA. . Furthermore, with respect to the appeal of initial disabilities ratings, such as those addressed herein, where service connection has been granted and the initial rating has been assigned, the claim of service connection has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement (NOD) with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Accordingly, the Board concludes that the RO has complied with the duty to notify under the VCAA. The Board also concludes that VA's duty to assist has been satisfied. All of the Veteran's VA and private treatment records have been obtained to the extent possible and associated with the claims file. The Veteran has at no time referenced any further outstanding records that he wanted VA to obtain. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran when necessary to evaluate the severity of his disability. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran with VA examinations with regard to his service-connected lumbar spine, bilateral knee, bilateral ankle, migraine headache, and skin disabilities, most recently in November 2008. There is no objective evidence indicating that there has been a material change in the severity of any of these service-connected disabilities since he was last examined. See 38 C.F.R. § 3.327(a) (2012). In this matter, the Board notes that the Veteran has had opportunities to indicate that there has been a material change in his disabilities and has not done so. For example, the Veteran was scheduled for a hearing before a Veterans Law Judge in May 2013, and the Veteran failed to report to the scheduled hearing. VA's duty to assist the Veteran in the development of his claim is not a one-way street. Olsen v. Principi, 3 Vet. App. 48 (1992). If a veteran wants help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 406 (1991). As the Veteran has not asserted that there has been a material change in any of the disabilities on appeal since his last VA examination, the Board will decide the issues on appeal based on the evidence of record. The Board additionally notes that the duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. The report of the November 2008 examination reflects that the examiner reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate testing, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The information obtained during this examination is sufficient to rate the Veteran's disabilities under the appropriate diagnostic criteria. In light of the foregoing, the Board concludes that this examination report is adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Increased Initial Ratings A. General Law and Regulations Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002). Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's 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 practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath, 1 Vet. App. at 589. As these claims are on appeal from a decision that granted service connection and assigned an initial rating, "staged" ratings may be assigned, if warranted by the evidence. Fenderson v. West, 12 Vet. App. 119 (1999). If there is a question as to which evaluation to apply to the Veteran's disability, 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 (2012). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In general, 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 DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. See 38 C.F.R. § 4.45. B. Lumbar Spine Disability The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a (2012). Notes appended to the rating formula for diseases and injuries of the spine specify that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Id., Note (2). Provided, however, that, 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 generally recognized by VA. Id., Note (3). Further, the term "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"; provided, however, that the aforementioned normal ranges of motion for each component of spinal motion, as recognized by VA, are the maximum that can be used for calculation of the combined range of motion, and each range of motion measurement is to be rounded to the nearest five degrees. Id., Notes (2) and (4). Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, 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. Note (6) provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Id. These criteria are to be applied irrespective of whether there are symptoms such as pain (whether or not it radiates), stiffness, or aching in the affected area of the spine, id, and they "are meant to encompass and take into account the presence of pain, stiffness, or aching, which are generally present when there is a disability of the spine." 68 Fed. Reg. 51,455 (August 27, 2003) (Supplementary Information). Spine conditions rated under DC 5243, for intevertebral disc syndrome, may be rated alternatively based on incapacitating episodes. The criteria provide for a 10 percent rating where intevertebral disc syndrome is manifested with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating was warranted where incapacitating episodes have a total duration of at least two weeks but less than 4 weeks during the past 12 months. "Incapacitating episodes" was defined in Note (1) as a period of acute signs and symptoms due to intevertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) also allowed the Veteran to be rated separately for musculoskeletal and neurological manifestations under appropriate diagnostic codes if it would result in a higher combined evaluation for the disability. Service connection was originally granted for a lumbar spine disability in August 2007. This decision established a 10 percent disability rating, effective August 1, 2006 (the day following the Veteran's discharge from active duty). The Veteran requested an increased rating within one year of that decision, and he has pursued the claim continuously since that time. On VA fee-basis compensation and pension examination in May 2007, the Veteran reported experiencing low back pain constantly. No stiffness or weakness was reported. He said that his lower back pain rated a 7 on a 1 (low) to 10 (high) pain scale. The Veteran stated that he was not receiving any treatment, and his spine disability did not cause incapacitation. The examiner observed that the Veteran's posture and gait were within normal limits, and there was no evidence of radiating pain, muscle spasm, or tenderness. Additionally, no ankylosis was noted. Forward flexion of the lumbar spine was to 90 degrees. Extension was to 30 degrees. Right and left lateral flexion were to 30 degrees. Right and left rotation were to 30 degrees. All ranges of motion were not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The examiner found no signs of intevertebral disc syndrome. Motor and sensory examination of the lower extremities was within lower limits. An X-ray revealed L5-S1 narrowing. On VA compensation and pension examination in November 2008, the Veteran reported stiffness but no numbness, loss of bladder control, or loss of bowel control. He complained of pain in his lower back which occurred four to five times per month. He rated the pain as a 7 on a 1 (low) to 10 (high) pain scale. It was noted that the Veteran could function without medication when he had pain. The Veteran further indicated that he was not receiving any treatment, and his condition had not resulted in any incapacitation. The examiner noted that the Veteran limped, but his posture was normal. The examiner found no evidence of radiating pain, muscle spasm, or ankylosis. Forward flexion of the thoracolumbar spine was to 70 degrees with pain at 70 degrees. Extension was to 30 degrees. Right and left lateral flexion were to 30 degrees. Right and left rotation were to 30 degrees. Pain was present after repetitive use; however, no additional limitation of motion was found after repetitive use. The examiner found no signs of intevertebral sic syndrome. Motor and sensory neurological examination of the lower extremities yielded normal results. January and May 2009 VA treatment records contain the Veteran's complaint of ongoing back pain. At his March 2009 hearing before a DRO, the Veteran reported experiencing back pain that rated a 6 on a 1 (low) to 10 (high) pain scale. He said he had been prescribed a back brace. He said that he experienced incapacitating episodes every morning. With regard to assigning a rating greater than 10 percent under the General Rating Formula for Diseases and Injuries of the Spine, the Board notes that that there is no evidence of record reflecting that the Veteran has forward flexion of the thoracolumbar spine limited to 60 degrees or less or a combined range of motion of the thoracolumbar spine of 120 or less degrees at any time during the course of the appeal as contemplated by a higher rating. Additionally, there is no objective evidence of record reflecting that the Veteran has muscle spasm or an abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. The Board notes that, even with pain, the Veteran was able to perform forward flexion to 70 degrees (or greater) throughout the period of appeal, and the criteria of the General Rating Formula are to be applied with or without symptoms such as pain and stiffness. Thus, the Board concludes that the weight of the evidence is against a finding of symptomatology sufficient to result in an abnormal gait or abnormal spinal contour. Accordingly, a rating in excess of 10 percent increased rating cannot be assigned under the General Rating Formula for Disease and Injuries of the Spine at any time during the course of the appeal. With regard to applying the Formula for Rating Intevertebral Disc Syndrome Based on Incapacitating Episodes, the Board finds no objective medical evidence in the record reflecting that the Veteran has been prescribed bedrest by a physician for his service-connected lumbar spine disability for any period of time on appeal. Although the Veteran stated during his DRO hearing that he experienced incapacitating episodes every morning, the evidence does not show that these incapacitating episodes required bed rest prescribed by a physician. As such, an increased rating cannot be assigned at any time for the period of appeal under the Formula for Rating Intevertebral Disc Syndrome Based on Incapacitating Episodes. With regard to assigning a higher disability rating according to 38 C.F.R. § 4.40 and 4.45, the Board notes that the Veteran has reported a history of stiffness and pain. However, the examination reports show that even with pain, there was no additional limitation of motion after multiple repetitions of range of motion. See May 2007 and November 2008 VA examination reports. Therefore, as there is no objective evidence of record reflecting that the Veteran experiences additional functional loss or limitation of motion due to symptoms such as pain, weakness, weakened movement, excess fatigability, or incoordination, the Board concludes that the greater weight of evidence is against assigning an evaluation in excess of 10 percent at any time throughout the period of appeal as contemplated by the holding in Deluca. The Board also notes that, according to Note (1), any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, must be evaluated separately under the appropriate diagnostic code. In this case, the Veteran has not claimed to experience neurologic abnormalities due to his lumbar spine disability. Additionally, both the May 2007 and the November 2008 VA examiners indicated that neurological examination of the lower extremities was normal. As such, the preponderance of the evidence shows that the Veteran does not experience a neurologic abnormality due to his lower back disability. C. Bilateral Knee Disabilities The general rating schedules for limitation of motion of the knee are 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees; and a 30 percent disability rating is assigned for flexion limited to 15 degrees. Under Diagnostic Code 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5257 provides for the assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability of a knee; a 20 percent rating when there is moderate recurrent subluxation or lateral instability; and a 30 percent evaluation for severe knee impairment with recurrent subluxation or lateral instability. Id. Subluxation of the patella is "incomplete or partial dislocation of the knee cap." Rykhus v. Brown, 6 Vet. App. 354, 358 (1993) (citing Dorland's Illustrated Medical Dictionary at 1241, 1599 (27th edition 1988)). The Board observes that the words "slight," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). The VA General Counsel has held that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. See VAOPGCPREC 23-97 (1997); VAOPGCPREC 9-98 (1998). In VAOPGCPREC 9-98, the VA General Counsel further explained that when a Veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on X-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. 64 Fed. Reg. 52,376 (1999). A separate rating for arthritis (in addition to Diagnostic Code 5257) could instead be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a (2011). When, however, limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is generally for application. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Service connection was originally granted for right and left knee disabilities in August 2007. This decision established a noncompensable disability rating, effective August 1, 2006 (the day following the Veteran's discharge from active duty). The Veteran requested increased ratings within one year of that decision, and he has pursued the claim continuously since that time. In August 2009, the RO granted an increased 10 percent rating for each knee, effective November 24, 2008. On VA fee-basis compensation and pension examination in May 2007, the Veteran described stiffness and a constant aching pain that rated a 5 on a 1 (low) to 10 (high) pain scale. He said that he did not receive any treatment for his knees, and his knee condition did not cause incapacitation. The examiner found no recurrent subluxation, locking pain, joint effusion, or crepitus of either knee. Both knees were tender. Flexion of both knees was to 140 degrees, and extension was to 0 degrees. All ranges of motion were not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The anterior and posterior cruciate ligament stability test was within normal limits for both knees. The medial and lateral collateral ligament stability test was within normal limits for both knees. The medial and lateral meniscus test was within normal limits for both knees. X-rays of both knees were within normal limits. On VA examination in November 2008, the Veteran reported weakness, stiffness, and giving way. He reported pain that rated from a 3 to an 8 on a 1 (low) to 10 (high) pain scale. The examiner found no signs of edema, effusion, weakness, redness, heat, subluxation, or guarding of movement of either knee. There was also no locking pain, genu recurvatum, or crepitus of either knee. Flexion of the right knee was to 90 degrees with pain, and extension was to 0 degrees. Flexion of the left knee was to 110 degrees, and extension was to 0 degrees. There was no additional limitation of motion of either knee after repetitive use. The anterior and posterior cruciate ligament stability test was within normal limits for both knees. The medial and lateral collateral ligament stability test was within normal limits for both knees. The medial and lateral meniscus test was within normal limits for both knees. X-rays of both knees were within normal limits. At his March 2009 hearing before a DRO, the Veteran said that he experienced pain that rated a 5 on a 1 (low) to 10 (high) pain scale in both of his knees. He related that he experienced episodes of fatigue and buckling. Upon careful review of the evidence of record, the Board finds that the Veteran is not entitled to a compensable rating prior to November 24, 2008, or a rating in excess of 10 percent thereafter, for either knee. In other words, the objective evidence of record does not support a higher rating of the Veteran's bilateral knee disabilities. In this regard, the Board notes that VA must consider all the evidence of record to determine when an ascertainable increase occurred in the rated disability. See Hazan v. Gober, 10 Vet. App. 511 (1997); see also Swanson v. West, 12 Vet. App. 442 (1999). As an initial matter, the Board observes that X-rays studies undertaken in conjunction with the May 2007 and November 2008 VA examinations both reveal normal findings. As there are no X-ray findings of arthritis, a compensable evaluation under Diagnostic Code 5003 is not warranted at anytime during the course of the appeal. Nevertheless, as noted above, the Veteran has objective evidence of painful motion of both knees. Although the Veteran claims that he is entitled to higher ratings due to the subjective complaints of chronic knee pain, as discussed above, the evidence of record reflects painful motion (at its worst) beginning at 140 degrees of flexion with no loss of extension for the time period prior to November 24, 2008. As the evidence does not show limitation of flexion to 45 degrees or less, an increased rating of 10 percent (or higher) is not applicable under Diagnostic Code 5260 prior to November 24, 2008 for either knee. 38 C.F.R. § 4.71, Plate II. Similarly, for the period from November 24, 2008, the evidence of record reflects painful motion (at its worst) beginning at 70 degrees of flexion with no loss of extension for the time period prior to November 24, 2008. As the evidence does not show limitation of flexion to 30 degrees or less, an increased rating of 20 percent (or higher) is not applicable under Diagnostic Code 5260 from to November 24, 2008 for either knee. 38 C.F.R. § 4.71, Plate II. As the record does not show extension limited to 10 degrees or greater at any time during the period of appeal, a separate compensable evaluation based on limitation of extension under Diagnostic Code 5261 is not warranted for either knee. The Board has also considered the Veteran's subjective complaints of weakness and giving way, and the Board recognizes that he is competent to describe his symptoms. Such symptoms could be contemplated under Diagnostic Code 5257. However, as to an increased rating, the Board finds the results of physical examination by multiple competent health care specialists showing no evidence of significant instability to be more persuasive. In that regard, the Board notes that records and examinations during the timeframe on appeal showed no instability, even upon specific instability testing. See May 2007 and November 2008 VA examination reports. As the consistent medical findings of no laxity and no objective evidence of subluxation outweigh the Veteran's subjective complaints, the Board concludes that a separate disability rating under Diagnostic Code 5257 is not warranted for either knee. In addition, no higher or alternative rating under a different Diagnostic Code can be applied. The Board notes that there are other Diagnostic Codes relating to knee disorders, such as Diagnostic Code 5256 (ankylosis of the knee), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (removal of semilunar cartilage, symptomatic), Diagnostic code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (for genu recurvatum). The Veteran's bilateral knee disabilities are not manifested by nonunion or malunion of the tibia and fibula, or genu recurvatum. Ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). The Veteran is able to move both of his knees, albeit with some limitation of motion, so they are clearly not ankylosed. There are no reports or evidence of dislocated or removed semilunar cartilage. As such, he cannot receive a higher rating under Diagnostic Code 5258 or 5259. The Board notes that the Veteran's functional loss was considered, as the medical evidence shows that the Veteran has consistently complained of pain in both knees. 38 C.F.R. §§ 4.40, 4.45. However, the limitation of motion documented in the medical records as resulting from pain is already contemplated in the disability ratings currently assigned. Moreover, although the Veteran had pain on repetitive motion that pain did not result in limitation of flexion or extension to the level that a separate or higher rating would be warranted. Nor is there objective evidence of calculable decreased motion on repetition due to fatigue, weakness, incoordination, or lack of endurance. Although the Veteran has reported weakness and decreased endurance, objective medical evaluation has found no evidence of such. Indeed, the Board finds it extremely significant that multiple examination and treatment records have noted normal lower extremity strength, as well as normal stance and gait. Thus, despite the Veteran's reported problems associated with his knees, he clearly is able to use both knees in close to a normal manner, to include duration of use, and, in fact, does so. There is otherwise no evidence of significant impairment of motor skills, muscle function, or strength attributable to the Veteran's knee disabilities. Consequently, the Board finds that a higher disability rating based on functional loss is not warranted for either knee. D. Bilateral Ankle Disabilities Diagnostic Code 5271 provides a 10 percent rating for moderate limitation of ankle motion, and a 20 percent rating for marked limitation of motion. Full range of ankle dorsiflexion is from zero to 20 degrees, and full range of ankle plantar flexion is from zero to 45 degrees. 38 C.F.R. § 4.71, plate II (2012). The Board observes that the words "mild," "moderate," and "severe," are not defined in the 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." 38 C.F.R. § 4.6 (2012). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). Service connection was originally granted for right and left ankle strain without loss of motion in August 2007. This decision established a noncompensable percent disability rating, effective August 1, 2006 (the day following the Veteran's discharge from active duty). The Veteran requested an increased rating within one year of that decision, and he has pursued the claim continuously since that time. On VA fee-basis compensation and pension examination in May 2007, the Veteran complained of constant bilateral ankle pain that rated a 5 on a 1 (low) to 10 (high) pain scale. It was noted that the Veteran was not receiving any treatment for his condition, and his condition did not cause incapacitation. The examiner noted that both ankles were tender, but there was no deformity. Dorsiflexion of both ankles was to 20 degrees. Plantar flexion of both ankles was to 45 degrees. Joint function of both ankles was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. X-rays of both ankles were within normal limits. On VA examination in November 2008, the Veteran reported bilateral ankle pain that rated a 7 on a 1 (low) to 10 (high) pain scale. The Veteran said that he was not receiving any treatment for his ankles. He reported weakness, stiffness, and lack of endurance. No swelling, heat, redness, giving way, locking, fatigability, or dislocation was found by the examiner. Dorsiflexion of both ankles was to 20 degrees. Plantar flexion of both ankles was to 45 degrees. Joint function of both ankles was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. X-rays of the ankles were within normal limits. A January 2009 VA treatment record contains the Veteran's report of left ankle pain. At his March 2009 DRO hearing, the Veteran said that he experienced bilateral ankle pain that rated a 6 on a 1 (low) to 10 (high) pain scale. He treated his pain with over-the-counter medication. Applying the pertinent rating criteria to the facts in the instant case, the Board finds that the preponderance of the evidence is against granting a compensable rating for the Veteran's bilateral ankle disabilities at any time during the appeal. The Veteran's bilateral ankle disability picture is clearly not productive of "moderate" disability, much less "marked," so as to entitle him to a compensable disability rating under Diagnostic Code 5271. As shown above, both the May 2007 and November 2008 VA examination reports reflect that, the Veteran had a full range of motion (i.e., 20 degrees of dorsiflexion, and 45 degrees of plantar flexion) of both ankles. Neither report indicates that any range of motion of the ankles was limited, and walking ability, standing ability, and distance tolerance were also not limited. The Board notes that the Veteran is not entitled to a higher evaluation under any provisions of the code pertaining to the ankle. Diagnostic Codes 5270 and 5272 are not for application, because ankylosis of either ankle is not shown in the medical evidence of record. Likewise, Diagnostic Code 5273 is not for application because malunion of the os calcis or astragalus is not shown, and Diagnostic Code 5274 is not for application because the Veteran has not undergone an astragalectomy. With regard to assigning a higher disability rating according to 38 C.F.R. § 4.40 and 4.45, the Board acknowledges the Veteran's reported complaints of pain and painful motion. However, as noted above, there is no objective evidence of record reflecting that the Veteran experiences additional functional loss or limitation of motion due to symptoms such as pain, weakness, weakened movement, excess fatigability, or incoordination. Even with consideration of pain, the Veteran has full range of motion of both ankles. Therefore, the Board concludes that the greater weight of evidence is against assigning a compensable disability rating for either ankle as contemplated by the holding in Deluca. E. Migraine Headaches Headaches are evaluated under Diagnostic Code 8100. Migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability are rated 50 percent disabling. Migraine headaches with characteristic prostrating attacks occurring on an average once a month over last several months are rated 30 percent disabling. Migraine headaches with characteristic prostrating attacks averaging one in 2 months over the last several months are rated 10 percent disabling. Migraine headaches with less frequent attacks are rated noncompensably disabling. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The rating criteria do not define "prostrating," nor has the United States Court of Appeals for Veterans Claims (Court). See Fenderson v. West, 12 Vet. App. 119 (1999), in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack. By way of reference, the Board notes that according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." Service connection was originally granted for migraine headaches in August 2007. This decision established a noncompensable percent disability rating, effective August 1, 2006 (the day following the Veteran's discharge from active duty). The Veteran requested an increased rating within one year of that decision, and he has pursued the claim continuously since that time. On VA fee-basis compensation and pension examination in May 2007, the Veteran reported experiencing recurring headaches. He said that when the headaches occurred, he was able to go to work, but required medication. The headache attacks averaged one time per week and would last for two hours. The examiner noted that the ability to perform daily functions during flare-ups was not affected, and the Veteran was not receiving any treatment for his headaches. The examiner indicated that there was no functional impairment resulting from the Veteran's headaches. Examination of the cranial nerves revealed normal findings. On VA examination in November 2008, the Veteran reported that when he experienced headaches, he was able to take care of some household chores, but he was unable to go to work. He experienced headaches on the average of five times per month, and each headache would last for one-and-a-half days. The Veteran was not receiving any treatment for his headaches. Examination of the cranial nerves revealed normal findings. The examiner specified that there were no abnormal findings, and the Veteran's condition was stable. During his March 2009 DRO hearing, the Veteran remarked that he experienced incapacitating episodes of headaches once or twice a week. He said that he took both over-the-counter and prescribed medications for his headaches. A May 2009 VA treatment record reflects that the Veteran experienced a migraine headache and took no medication for it other than piroxicam. Based on this evidence, the Board finds that a compensable rating for headaches is not warranted at any time during the period of appeal. Specifically, while the Veteran reported headaches, the evidence does not reflect that the headaches were prostrating in nature. By the Veteran's own account to the May 2007 and November 2008 VA examiners, even when he was experiencing his migraine headaches, he was still able to perform chores around the house. Although the Veteran stated during his March 2009 DRO hearing that his headaches resulted in "incapacitating episodes," the balance of the transcript clarifies that the asserted "incapacitating episodes" did not rise to the severity of a prostrating attack. At no time during the period of appeal does the evidence reflect that the Veteran's migraine headaches resulted in utter physical exhaustion or helplessness, extreme exhaustion, or powerlessness. All compensable disability ratings contain criteria that include the Veteran experiencing prostrating attacks of his migraine headaches. In this case, the weight of the evidence contains no indication that the Veteran experiences such attacks. Therefore, the criteria for a compensable evaluation for headaches are not shown, and the claim must be denied. F. Pseudofolliculitis Barbae with Keloid on Back of Scalp The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Veteran's skin disability is currently rated under 38 C.F.R. § 4.118, Diagnostic Code 7813-7800. Diagnostic Code 7813 pertains to dermatophytosis (ringworm: of body, tinea corporis; of heat, tinea capitis; of feet, tinea pedis; of beard area, tinea barbae; of nails, tinea unguium; of inguinal area (jock itch), tinea cruris), and specifies that the disability is to be rated as disfigurement of the head, face, or neck (DC 7800), scars (DC's 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the predominant disability. In examining the prior RO rating decisions, it is clear that although Diagnostic Code 7800 (for disfigurement of the head, face, or neck) is referenced, the RO actually rated the disability using the criteria of Diagnostic Code 7806 (for dermatitis or eczema). Diagnostic Code 7806 is deemed by the Board to be the most appropriate code, primarily because it pertains specifically to the disability at issue [pseudofolliculitis barbae], but also because it provides specific guidance as to how symptoms of this disability are to be evaluated. The Board can identify nothing in the evidence to suggest that a diagnostic code other than 7806 would be more appropriate, and the Veteran has not requested that another diagnostic code should be used. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 7806. The applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118 were amended effective August 30, 2002 and again in October 2008. The October 2008 revisions are applicable to application for benefits received by the VA on or after October 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). In this case, the Veteran filed his original claim in August 2006. Therefore, only the 2002 changes to 38 C.F.R. § 4.118 are applicable. (Parenthetically, the Board notes that Diagnostic Code 7806 remained under the same under the criteria effective October 23, 2008.) Diagnostic Code 7806 provides for the following levels of disability: A noncompensable rating is appropriate where less than 5 percent of the entire body or less than 5 percent of exposed areas are affected, and; no more than topical therapy is required during the past 12-month period. A 10 percent rating is warranted when at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than 6 weeks during the past 12-month period. A 30 percent disability rating is appropriate where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12 month period. A 60 percent disability rating is appropriate where more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. See 38 C.F.R. § 4.118, Diagnostic Code 7806, as amended by 67 Fed. Reg. 49596 (July 31, 2002). On VA fee-basis examination in May 2007, the Veteran reported experiencing itching, crusting, and bumps. He related that he had not received any treatment for his skin condition. The examiner noted that the Veteran's keloid had not resulted in any exudation, ulcer formation, itching, shedding, or crusting. Specifically, the examiner indicated that the skin condition located on the face and neck resulted in exfoliation, crusting, and abnormal texture of less than six inches. The keloid on the posterior scalp resulted in abnormal texture of less than six square inches. Neither area had ulceration, tissue loss, induration, inflexibility, hypopigmentation, hyperpigmentation, or limitation of motion. The skin lesion coverage of the exposed area was less than one percent. The skin lesion coverage relative to the whole body was less than one percent. The skin lesions were not noted to be associated with systemic disease. On VA examination in November 2008, the Veteran reported experiencing itching. There was no exudation, ulcer formation, shedding, or crusting. However, the keloid on the back of the head had ulcer formation and shedding. The Veteran reported that he had not undergone any treatment for the previous 12 months, to include intensive light therapy. The examiner remarked that the Veteran had no scar present. The examiner remarked that the Veteran's keloid measured 5 cm by 2 cm. The report reflects that the Veteran's skin condition resulted in hyperpigmentation of less than six square inches and abnormal texture of less than six square inches. The examiner observed no ulceration, exfoliation, crusting, tissues loss, induration, inflexibility, hypopigmentation, or limitation of motion. The skin lesions were not noted to be associated with systemic disease. The skin lesion coverage of the exposed area was 20 percent. The skin lesion coverage relative to the whole body was 5 percent. A VA dermatology consult note from February 2009 reflects that the Veteran had no treatment for the previous two years. The Veteran complained of itching and occasional bleeding, but the other symptoms were deemed to be minimal. The examiner remarked that there was no growth or real inflammatory activity over the previous two years. The examiner observed one 5 cm lineal bulbous plaque on the Veteran's scalp. During the Veteran's March 2009 DRO hearing, the Veteran said that he tried not to shave, because shaving irritated his skin. He said he experienced outbreaks two to three days after shaving. He related that the keloid on his head was always there. He said he experienced itching and bleeding. For the period prior to November 24, 2008, a compensable evaluation under DC 7806 is not warranted because the affected area of the Veteran's skin is not at least 5 percent of his entire body, and he has not been shown to require corticosteroids or other immunosuppressive drugs. As noted above, the May 2007 VA examiner indicated that the Veteran's skin lesion coverage of the both his exposed areas and his whole body was less than one percent. Additionally, the Veteran has not required systemic therapy such as therapeutic doses of corticosteroids, immunosuppressive retinoids, PUVA or UVB treatments, or electron beam therapy. For the period from November 24, 2008, a rating in excess of 30 percent is not warranted. As noted above, a rating in excess of 30 percent requires more than 40 percent of the entire body or more than 40 percent of exposed areas be affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs to be required for a total duration of less than six weeks during the past 12-month period. The evidence during the period on appeal does not rise to this level. As noted above, the November 2008 VA examiner indicated that the skin lesion coverage of the exposed area was only 20 percent, and the skin lesion coverage relative to the whole body was only 5 percent. As such, the clinical evidence does not show that the Veteran's service-connected skin disorder affected at least 40 percent of his exposed or entire body. The Board acknowledges the Veteran's belief that his symptoms are of such severity as to warrant a higher rating for his skin disorder. However, while competent to report on his symptomatology such as reporting that he experiences rashes or itching, he is not competent to provide medical opinions such as quantifying the percentage of his body affected by his service-connected skin disorder. The Board places greater probative value on the physical examination findings completed during the current appeal which have provided sufficient objective findings with which to rate adequately the service-connected skin disorder. In this regard, the Board notes that the physical examination reports were prepared by trained, objective medical professionals impartially recording their observations. Based on the foregoing, the Board concludes that the preponderance of the evidence does not establish that the Veteran's skin disorder affects at least 5 percent of his entire body or exposed body prior to November 24, 2008, or at least 40 percent of his entire body or exposed body thereafter. Furthermore, the evidence does not show that the Veteran requires the use of intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs at any time; therefore, increased ratings are not appropriate. G. Other Considerations In addition, the Board has considered whether the Veteran is entitled to greater levels of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). 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, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the lower back, bilateral knee, bilateral ankle, migraine headache, or skin disabilities is inadequate. A comparison between the levels of severity and symptomatology of the considered disabilities with the established criteria shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology. The Board further observes that, even if the available schedular evaluation for the disabilities is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The Board finds that the evidence does not demonstrate an exceptional or unusual clinical picture beyond that contemplated by the rating criteria. In short, there is nothing in the record to indicate that the service-connected disabilities on appeal cause impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not warranted. ORDER Entitlement to an initial rating in excess of 10 percent for a lumbar spine disability is denied. Entitlement to an initial compensable rating for a right knee disability prior to November 24, 2008, and in excess of 10 percent thereafter, is denied. Entitlement to an initial compensable rating for a left knee disability prior to November 24, 2008, and in excess of 10 percent thereafter, is denied. Entitlement to an initial compensable rating for a right ankle disability is denied. Entitlement to an initial compensable rating for a left ankle disability is denied. Entitlement to an initial compensable rating for migraine headaches is denied. Entitlement to an initial compensable rating for pseudofolliculitis barbae, to include keloid on back of scalp, prior to November 24, 2008, and in excess of 30 percent thereafter, is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs