Citation Nr: 1321295 Decision Date: 07/02/13 Archive Date: 07/12/13 DOCKET NO. 09-27 503 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for an eye disability, claimed as macular degeneration, refractive error, incipient senile cataracts, and crowded optic nerve. 2. Entitlement to service connection for sleep disturbance. 3. Entitlement to service connection for fatigue. 4. Entitlement to service connection for joint pain. 5. Entitlement to an initial rating in excess of 10 percent for a lumbar spine disability, effective November 1, 2007; 20 percent, effective November 10, 2009; and 40 percent, effective April 27, 2012. 6. Entitlement to an initial rating in excess of 10 percent for a cervical spine disability, effective March 6, 2008, and 20 percent, effective November 10, 2009. 7. Entitlement to an initial compensable rating for a right elbow disability, effective November 1, 2007, and 10 percent, effective November 10, 2009. 8. Entitlement to an initial compensable rating for right third trigger finger. ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from January 1968 to May 1968, from April 1991 to July 1991, from February 2003 to July 2004, and from February 2006 to October 2007. The Veteran also had additional inactive service in the Army National Guard of Puerto Rico. This matter comes properly before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office in San Juan, the Commonwealth of Puerto Rico (RO). This case was remanded by the Board in March 2012 for additional development. FINDINGS OF FACT 1. The Veteran's hypermetropia, astigmatism, and presbyopia are refractive errors of the eyes. 2. The preponderance of the evidence of record shows that the Veteran's senile cataracts, pinguecula, and blepharitis are not related to service. 3. The preponderance of the evidence of record shows that the Veteran's crowded optic nerves clearly and unmistakably pre-existed active service and were not aggravated by service. 4. The preponderance of the medical evidence of record demonstrates that the Veteran's macular degeneration is related to active service. 5. The preponderance of the evidence of record shows that the Veteran's currently diagnosed sleep apnea has been aggravated by a service-connected disability. 6. The preponderance of the evidence of record shows that the Veteran does not have a current diagnosis of fatigue for VA purposes which is related to service. 7. The preponderance of the evidence of record shows that the Veteran does not have a current diagnosis of joint pain for VA purposes which is related to service. 8. The medical evidence of record shows that from November 1, 2007, to November 9, 2009, the Veteran's lumbar spine disability was manifested by pain, spasm, and limitation of motion to, at most, 65 degrees of flexion, 5 degrees of extension, 25 degrees of right lateral flexion, 20 degrees of left lateral flexion, 25 degrees of right rotation, and 10 degrees of left rotation. 9. The medical evidence of record shows that from November 10, 2009, to April 26, 2012, the Veteran's lumbar spine disability was manifested by pain, spasm, and limitation of motion to, at most, 35 degrees of flexion, 10 degrees of extension, 10 degrees of right lateral flexion, 15 degrees of left lateral flexion, 20 degrees of right rotation, and 25 degrees of left rotation. 10. The medical evidence of record shows that on and after April 27, 2012, the Veteran's lumbar spine disability was manifested by pain, spasm, and limitation of motion to, at most, 20 degrees of flexion, 10 degrees of extension, 15 degrees of right lateral flexion, 15 degrees of left lateral flexion, 15 degrees of right rotation, and 15 degrees of left rotation. 11. The medical evidence of record shows that prior to November 10, 2009, the Veteran's cervical spine disability was manifested by pain and limitation of motion to 35 degrees of flexion, 35 degrees of extension, 30 degrees of left lateral flexion, 35 degrees of right lateral flexion, 70 degrees of left lateral rotation, and 70 degrees of right lateral rotation. 12. The medical evidence of record shows that on and after November 10, 2009, the Veteran's cervical spine disability was manifested by pain, spasm, and limitation of motion to, at most, 35 degrees of flexion, 10 degrees of extension, 10 degrees of right lateral flexion, 15 degrees of left lateral flexion, 20 degrees of right rotation, and 25 degrees of left rotation. 13. The medical evidence of record shows that, for the entire period on appeal, the Veteran's right elbow disability is manifested by pain, weakness, and limitation of motion to 110 degrees of flexion and 0 degrees of extension. 14. The medical evidence of record shows that prior to April 27, 2012, the Veteran's right middle finger disability was manifested by pain, weakness, and limitation of motion with a gap of less than one inch between the fingertip and the proximal transverse crease of the palm. 15. The medical evidence of record shows that on and after April 27, 2012, the Veteran's right middle finger disability was manifested by pain, weakness, and limitation of motion with a gap of one inch or more between the fingertip and the proximal transverse crease of the palm. CONCLUSIONS OF LAW 1. Hypermetropia, astigmatism, presbyopia, senile cataracts, crowded optic nerves, pinguecula, and blepharitis were not incurred in, or aggravated by, active service. 38 U.S.C.A. §§ 1110, 1131, 1153, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.306, 4.9 (2012). 2. Macular degeneration was incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 3. Sleep apnea was aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 4. A disability claimed as fatigue was not incurred in, or aggravated by, active service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 5. A disability claimed as joint pain was not incurred in, or aggravated by, active service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 4.14 (2012). 6. The criteria for an initial rating in excess of 10 percent for a lumbar spine disability, effective November 1, 2007; 20 percent, effective November 10, 2009; and 40 percent, effective April 27, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). 7. The criteria for an initial rating in excess of 10 percent for a cervical spine disability, effective March 6, 2008, and 20 percent, effective November 10, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). 8. The criteria for initial compensable rating for a right elbow disability, effective November 1, 2007, and 10 percent, effective November 10, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207 (2012). 9. The criteria for initial compensable rating for right third trigger finger, prior to April 27, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2012). 10. The criteria for a rating of 10 percent, but not higher, for right third trigger finger, as of April 27, 2012, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claims with an adjudication of the claims by the RO subsequent to receipt of the required notice. The record does not show prejudice to the Veteran, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in January 2008, March 2008, September 2008, April 2010, April 2012, and July 2012. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls on party attacking agency decision); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran suggest actual knowledge of the elements necessary to substantiate the claims. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the adjudication in the supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The evidence of record shows that the Veteran's service medical records from his periods of service in 1968 and 1991 have been found to be unavailable. The Board is satisfied that the evidence of record shows that VA has made sufficient efforts to secure any additional service records and has notified the Veteran of the records which are unavailable. The evidence of record shows that the Veteran was informed that these records could not be obtained in a July 2012 letter and asked to submit any records that he had in his possession. The Veteran acknowledged that these records were missing in an August 2012 statement. The Board concludes that further development and additional efforts to assist or notify the Veteran in accordance with 38 C.F.R. § 3.159(e) (2012) would serve no useful purpose. Soyini v. Derwinski, 1 Vet. App. 540 (1991). In cases where the Veteran's service medical records are not available, there is a heightened obligation to explain findings and to carefully consider the resolution of reasonable doubt in favor of the claimant. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). The Veteran has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Generally, service connection may be granted for a disability resulting from disease 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(a) (2012). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a) (2012). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by a service connected disability or aggravated by a service connected disability. 38 C.F.R. § 3.310(a) (2012); Allen v. Brown, 7 Vet. App. 439 (1995). The determination as to whether the requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999). When no preexisting condition is noted upon entry into service, the Veteran is presumed to have been sound upon entry. 38 U.S.C.A. § 1111 (West 2002). The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306(a) (2012). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. §§ 3.304 , 3.306(b) (2012). A preexisting disease or injury will be presumed to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity. The occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a) (2012). Aggravation for purposes of entitlement to VA compensation benefits requires more than that a preexisting disability become intermittently symptomatic during service; rather, there must be permanent advancement of the underlying pathology. Aggravation is characterized by an increase in the severity of a disability during service, and a finding of aggravation is not appropriate in cases where the evidence specifically shows that the increase is due to the natural progress of the disease. Furthermore, temporary or intermittent flare-ups of a preexisting disease during service are not sufficient to be considered aggravation of the disease unless the underlying condition, as contrasted to symptoms, is worsened. Jensen v. Brown, 4 Vet. App. 304 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991); Verdon v. Brown, 8 Vet. App. 529 (1996). Eye Disability In a November 1989 service report of medical history, the Veteran reported that he did not wear glasses, had vision in both eyes, and denied having, or ever having had, eye trouble. On examination, the Veteran's eyes were normal. In a December 1993 service report of medical history, the Veteran reported that he wore glasses and had vision in both eyes, and denied having, or ever having had, eye trouble. On examination, the Veteran's eyes were normal, though it was noted that he had decreased uncorrected vision in both eyes. In a January 1996 service report of medical history, the Veteran reported that he wore glasses and had vision in both eyes, and denied having, or ever having had, eye trouble. On examination, the Veteran's eyes were normal, though it was noted that he had decreased uncorrected vision in both eyes. In an April 2001 service report of medical history, the Veteran reported that he wore corrective lenses, but denied having, or ever having had, eye surgery to correct vision, lack of vision in either eye, or eye trouble. On examination, the Veteran's eyes were normal, though it was noted that he had decreased uncorrected vision in both eyes. In a March 2002 service report of medical history, the Veteran reported that he wore contact lenses or glasses, but denied having, or ever having had, an eye disability, eye trouble, loss of vision in either eye, or surgery to correct vision. On examination, the Veteran's eyes were normal, though it was noted that he had decreased uncorrected vision in both eyes. Multiple May 2003 service treatment reports gave diagnoses of congenital hyperemic disc in the right eye. In a June 2003 service treatment record, the Veteran complained of pressure and pain in his right eye for the previous two to three months. The examiner noted that the Veteran's vision was corrected by a prescription. Following thorough optic examination and testing throughout June 2003, the diagnosis was impending central retinal vein occlusion in the right eye. In a February 2006 service report of medical history, the Veteran reported that he wore contact lenses or glasses, but denied having, or ever having had, an eye disability, eye trouble, loss of vision in either eye, or surgery to correct vision. On examination, the Veteran's eyes, pupils, and ocular motility were normal. In a June 2007 service medical report, the Veteran requested an updated corrective lenses prescription due to a noticeable decrease in visual acuity in both eyes. He noted that he had been told that he had an abnormality in the right eye in 2003. After physical and diagnostic examination, the assessments were macular degeneration in both eyes, optic nerve hypoplasia in the right eye, and presbyopia. A July 2007 service medical report gave an assessment of refractive error. In a March 2008 VA eyes examination report, the Veteran complained of occasional right eye pain since 2003. After physical and diagnostic examination, the diagnoses were refractive errors, namely hypermetropia, astigmatism, and presbyopia; bilateral incipient senile cataracts; and small optic nerves, not hypoplasia, with crowded optic nerve in the right eye. The examiner opined that the Veteran's small optic nerves were most likely an anatomic variation which was most likely not related to his symptoms. The examiner also opined that the Veteran's loss of vision was caused by his refractive error and his right eye crowded optic nerve was not related to service. An opinion could not be given with regard to the Veteran's symptoms without resort to mere speculation, and further testing was recommended. A May 2012 VA eye conditions examination report gave diagnoses of dry age related macular degeneration, senile cataracts in both eyes, crowded optic nerve in both eyes, pinguecula in both eyes, and blepharitis. The examiner reviewed the Veteran's reported history and claims file and conducted thorough physical and diagnostic testing. The examiner then opined that the Veteran's loss of vision in both eyes was due to incipient senile cataracts and refractive errors. His dry eyes and red eyes were due to mild blepharitis and pinguecula. He also had macular changes which were suggestive of dry age related macular degeneration, but which were presently not causing a decrease in visual acuity or metamorphopsia. He also had an anatomical variant of the optic nerves, called crowded optic nerves, but without any visual field defect to suggest optic nerve pathology or a papillary defect. The Veteran's optic nerve condition had remained stable since it was initially observed in 2003. The examiner stated that the Veteran's hypermetropia, astigmatism, and presbyopia were refractive errors and had not increased beyond their natural progress during service. The examiner opined that the Veteran's incipient senile cataracts were age-related changes which were not related to macular degeneration, optic nerve hypoplasia, or presbyopia. The Veteran's dry age related macular degeneration was stated to not be congenital nor a refractive error. The Veteran's crowded optic nerves were stated to be a congenital anatomical variation that was stable from when it was previously examined. His right eye optic nerve condition was not causing any decrease in visual acuity or visual field defect and had not increased in severity beyond its natural progress during service. The Veteran's pinguecula and blepharitis were not related to macular degeneration, optic nerve hypoplasia, or presbyopia. The medical evidence of record shows that the Veteran has several separately diagnosed eye disabilities, namely hypermetropia, astigmatism, presbyopia, dry age related macular degeneration, senile cataracts, crowded optic nerves, pinguecula, and blepharitis. With respect to the Veteran's hypermetropia, astigmatism, and presbyopia, those diagnosed disorders are refractive errors of the eyes and thus service connection for those disabilities cannot be granted as they do not constitute disabilities for VA purposes, for which service connection can be granted. 38 C.F.R. §§ 3.303(c), 4.9 (2012). With respect to senile cataracts, pinguecula, and blepharitis, the preponderance of the evidence of record shows that those disabilities are not related to service. None of the disabilities were found on examination during the Veteran's periods of active service. The Board finds such a lack of in-service evidence to be highly probative, as the evidence of record shows that the Veteran underwent extensive optical examination and testing during his final period of active service, including retinal photographs taken in June 2007. As cataracts, pinguecula, and blepharitis were not diagnosed at that time, the Board considers that to be highly probative evidence that the disabilities did not exist at that time. There is no medical evidence of record that cataracts were diagnosed prior to March 2008, or that pinguecula and blepharitis were diagnosed prior to May 2012. In addition, there is no medical evidence of record that relates the Veteran's cataracts, pinguecula, or blepharitis to service. With respect to the Veteran's crowded optic nerves, the Board finds that the evidence of record shows that disability clearly and unmistakably pre-existed active service and was not aggravated by service. The Veteran served on active duty during four separate periods. There is no medical evidence of record that the Veteran's crowded optic nerves were diagnosed during the first two periods, from January 1968 to May 1968 and from April 1991 to July 1991. While there is no evidence that crowded optic nerves were diagnosed on the Veteran's entrance into his third period of active service, in February 2003, the medical evidence of record unanimously states that the disability is congenital in nature. Accordingly, the Board finds that the evidence of record clearly and unmistakably shows that the Veteran's crowded optic nerves began prior to any of his periods of active service, and thus pre-existed all four periods of active service. Therefore, he is not entitled to a presumption of soundness for those periods of service. 38 U.S.C.A. § 1111 (West 2002). Having shown that the Veteran is not entitled to a presumption of soundness, the next step of the inquiry is to determine whether the Veteran's pre-existing crowded optic nerves were aggravated by his periods of active service. A lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the pre-existing condition. 38 C.F.R. § 3.306 (b) (2012). The Board finds that the preponderance of the evidence of record clearly and unmistakably shows that the Veteran's preexisting crowded optic nerves were not aggravated by any of his periods of active service. 38 U.S.C.A. § 1111 (West 2002). While the Veteran's crowded optic nerves were first noted in May 2003, the evidence of record shows that they have been stable since that time and have never increased in severity. The Board finds that the preponderance of the evidence of record shows that the Veteran's crowded optic nerves have been asymptomatic since his separation from his fourth period of service. The March 2008 VA examiner specifically stated that the Veteran's small optic nerves were most likely not related to his eye symptoms, while the May 2012 VA examiner opined that the Veteran's crowded optic nerves had remained stable since initial observation in 2003. Under certain circumstance, lay evidence can be competent and sufficient to establish the etiology or diagnosis of a condition. Davidson v. Shinseki, 581 F.3d 1313 (2009). However, such etiological evidence is only competent to the extent that it relies on observable symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In this case, while the Veteran is capable of observing eye symptomatology, he is not capable of observing which of his various eye disabilities are the cause of that symptomatology. Accordingly, the Veteran's lay statements are not competent to demonstrate that his preexisting crowded optic nerves were permanently aggravated beyond the natural progress of the disease, or that any of his other in-service eye symptoms were related to disabilities other than refractive errors. His statements are not competent to diagnose any eye disability or relate that eye disability to service. Therefore, the Board finds that the preponderance of the evidence of record shows that the Veteran's currently diagnosed hypermetropia, astigmatism, presbyopia, senile cataracts, crowded optic nerves, pinguecula, and blepharitis are not related to service, and that the evidence shows that crowded optic nerves were not aggravated during active service. The Board finds that the preponderance of the evidence is against a finding that hypermetropia, astigmatism, presbyopia, senile cataracts, crowded optic nerves, pinguecula, and blepharitis were incurred in or aggravated during the Veteran's periods of active service. The Board further finds that the evidence of record clearly and unmistakably shows that the Veteran's crowded optic nerves preexisted his periods of active service and clearly and unmistakably did not undergo a permanent increase in the underlying severity during those periods of service. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the claim is denied with respect to the diagnoses of hypermetropia, astigmatism, presbyopia, senile cataracts, crowded optic nerves, pinguecula, and blepharitis. With respect to the Veteran's macular degeneration, the medical evidence of record demonstrates that disability is related to active service. The disability was first diagnosed in June 2007, during the Veteran's final period of active service. This diagnosis was continued by the May 2012 VA eye conditions examination report, thus confirming that the in-service diagnosis was accurate. Furthermore, the May 2012 report stated that the Veteran's dry age related macular degeneration was not congenital nor a refractive error. There is no medical evidence of record that states that the Veteran's macular degeneration is not related to service. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran's macular degeneration is related to active service. Therefore, service connection for macular degeneration is granted. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Sleep Disturbance The Veteran's service medical records are negative for any complaints or diagnosis of sleep disturbance. An April 2010 VA sleep study gave a diagnosis of mild to moderate obstructive sleep apnea. An April 2012 VA mental disorders examination report noted that there was no medical evidence of record that the Veteran's sleep disturbance had ever been related to a psychiatric problem. The Veteran reported that his sleep disturbances had resolved with the use of a respiratory mask, and reported that he had been told they were related to sleep apnea. The examiner opined that was evidently not a psychiatric case and the Veteran had a specific medical/clinical diagnosis that explained his sleep disturbance. A July 2012 VA sleep apnea examination report gave a diagnosis of obstructive sleep apnea. The Veteran reported that his wife complained that he snored loudly and was concerned with periods of choking during his sleep after he returned from Afghanistan. He reported that he was subsequently diagnosed with sleep apnea, and his symptoms had improved with use of a continuous positive airway pressure machine. After a review of the Veteran's medical records, the examiner opined that the Veteran's obstructive sleep apnea was less likely as not related to service in Afghanistan. However, the report also stated that the Veteran's obstructive sleep apnea was aggravated by his rhinitis. The rationale was that it had been documented in medical literature that rhinitis had been associated with an increase in prevalence of obstructive sleep apnea, and contributed to microarousal and sleep fragmentation. The preponderance of the evidence of record shows that the Veteran's currently diagnosed sleep apnea has been aggravated by a service-connected disability. The Veteran has a current diagnosis of sleep apnea. There is only one medical report of record which provides an etiology opinion with regard to the Veteran's sleep apnea. That report is the July 2012 VA sleep apnea examination report, which stated that the Veteran's obstructive sleep apnea was aggravated by his rhinitis. Service connection was granted for allergic rhinitis by a January 2013 rating decision. Therefore, the evidence of record shows that the Veteran's currently diagnosed sleep apnea has been aggravated by a service-connected disability. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran's sleep apnea is aggravated by a service-connected disability. Therefore, service connection for sleep apnea is granted. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Fatigue and Joint Pain Initially, the Board notes that fatigue and joint pain could be considered manifestations of an undiagnosed illness or a chronic multi-symptom illness. VA is authorized to compensate any Persian Gulf Veteran with a chronic disability resulting from an undiagnosed illness, or combination of undiagnosed illnesses, which became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more within a presumptive period following service in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C.A. § 1117 (West 2002). The law currently defines a qualifying chronic disability as that which results from an undiagnosed illness, a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome), or any diagnosed illness that VA determines in regulations warrants a presumption of service connection. 38 U.S.C.A. § 1117 (West 2002). This statute also provides that signs or symptoms that may be manifestations of an undiagnosed illness or a chronic multi-symptom illness include: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurological signs and symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the upper or lower respiratory system; (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 U.S.C.A. § 1117 (West 2002). VA regulations provide that for a disability to be presumed to have been incurred in service, the disability must have become manifest either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016; and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (2012). In this case, the evidence of record shows that the Veteran has never served in the Southwest Asia theater of operations. The Veteran's service personnel records show that his only period of foreign service occurred from June 6, 2006, to May 23, 2007, during which time he served in Afghanistan. The Southwest Asia theater of operations refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2) (2012). While active military, naval, or air service on or after September 19, 2001, in Afghanistan, qualifies as service in the Southwest Asia theater of operations for the purposes of presumptive service connection for certain infectious diseases, the medical evidence of record does not show that the Veteran's fatigue or joint pain have ever been related to any of the qualifying infectious diseases. 38 C.F.R. § 3.317(c) (2012). Therefore, the Board finds that 38 C.F.R. § 3.317 is not applicable to the Veteran's claims. The Veteran's service medical records are negative for any complaints or diagnosis of fatigue or generalized joint pain. In a June 2004 service post-deployment health assessment, the Veteran denied having, presently or during the deployment, swollen, stiff, or painful joints. In a February 2005 VA outpatient medical report, the Veteran denied experiencing fatigue and joint pain. In a May 2005 VA outpatient medical report, the Veteran denied experiencing fatigue and joint pain. In a February 2006 service report of medical history, the Veteran denied having, or ever having had, painful joints. In a June 2007 service medical report, the Veteran stated that in the past month he had not experienced any body aches and pains with no known physical cause. In a February 2008 VA joints examination report, the Veteran complained of right elbow, right middle finger, and left foot pain. After physical examination, the diagnoses were right tennis elbow with weakness of wrist extensors, right trigger finger with residual weakness in hand grip strength, and left foot trauma. In a November 2009 VA joints examination report, the Veteran complained of right elbow pain. After physical and diagnostic examination, the diagnosis was right elbow pain. In a February 2012 VA chronic fatigue syndrome examination, the Veteran complained of generalized myalgia after mild exercise for approximately one year. After physical and diagnostic examination, the examiner opined that the criteria for chronic fatigue syndrome were not met. The preponderance of the evidence of record shows that the Veteran does not have a current diagnosis of a disability manifested by fatigue or joint pain for VA purposes which is related to service. With respect to the Veteran's fatigue, there is no medical evidence of record that the Veteran has ever been diagnosed with a fatigue disorder of any kind. The February 2012 VA chronic fatigue syndrome examination specifically found that the criteria for a diagnosis of chronic fatigue syndrome were not met. In addition, there is no medical evidence of record that the Veteran experiences generalized joint pain other than in his low back, neck, right arm, right hand, right leg, and left foot. While the medical evidence of record shows that the Veteran experiences joint pain in those locations, that pain has been related to specific service-connected lumbar spine, cervical spine, right hand, and left foot disabilities. Accordingly, the Veteran is already receiving compensation for that joint pain, and granting separate rating for those same symptoms would result in pyramiding. 38 C.F.R. § 4.14 (2012). To the extent that the Veteran continues to claim that he experiences generalized fatigue and pain, those symptoms alone, without a diagnosed or identifiable underlying malady or condition, do not in and of themselves constitute disabilities for which service connection may be granted. Sanchez-Benitez v. Brown, 13 Vet. App. 282 (1999). Under certain circumstance, lay evidence can be competent and sufficient to establish the etiology or diagnosis of a condition. Davidson v. Shinseki, 581 F.3d 1313 (2009). However, that etiological evidence is only competent to the extent that it relies on observable symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). In this case, the Veteran does not claim that he has experienced fatigue or joint pain in areas other than his low back, neck, right arm, right hand, right leg, and left foot on a continuous basis since separation from service, nor does he claim to have the medical expertise to diagnose underlying disabilities. Accordingly, the Veteran's lay statements are not competent evidence that he has a current diagnosis of a fatigue or joint pain disability for VA purposes which is related to service. The preponderance of the evidence of record shows that the Veteran has not been diagnosed with a disability for VA purposes which is related to his claims of entitlement to service connection for fatigue and joint pain. The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F. 3d 1328 (1997); Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Here, the preponderance of the evidence shows the Veteran does not currently have a diagnosis of a disability related to fatigue or joint pain for VA purposes. Therefore, service connection for fatigue and joint pain is not warranted. In reaching this decision, the Board finds that the preponderance of the evidence is against the Veteran's claims, and the claims must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Initial Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). The Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). In resolving the factual issue, the Board may only consider the specific factors enumerated in the applicable rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). The appeal of the Veteran's lumbar spine, cervical spine, right elbow, and right third finger claims are based on the assignment of initial ratings following awards of service connection for those disabilities. Therefore, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence used to decide whether an original rating was erroneous. Fenderson v. West, 12 Vet. App. 119 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson v. West, 12 Vet. App. 119 (1999). Lumbar Spine Service connection for L4-L5 degenerative disc and L3-L4 and L4-L5 facet degenerative joint disease was granted by a June 2008 rating decision and a 10 percent rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5243, effective November 1, 2007. Subsequently, a December 2009 rating decision assigned a 20 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5237, effective November 10, 2009. Finally, a January 2013 rating decision assigned a 40 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5237, effective April 27, 2012. An August 2007 service medical report stated that, on physical examination of the Veteran's back, there was tenderness on palpation and muscle spasm in multiple areas. A second August 2007 service medical report stated that, on observation, the Veteran had a full back range of motion with pain at the end of the ranges of motion. A September 2007 service medical report stated that, on observation, the Veteran had decreased back flexion due to pain. There was also pain and muscle spasms on palpation. A second September 2007 service medical report stated that, on physical examination of the Veteran's back, there was no tenderness on palpation but there was muscle spasm. A March 2008 VA general medical examination report stated that, on physical examination, the Veteran's posture and gait were adequate without any mechanical aids. There was tenderness in the thoracolumbar spine and pain was elicited without functional loss. The Veteran had thoracolumbar spine range of motion on flexion to 80 degrees, with pain at 65 degrees; extension to 15 degrees, with pain at 5 degrees; left lateral flexion to 25 degrees, with pain at 20 degrees; right lateral flexion to 30 degrees, with pain at 25 degrees; left lateral rotation to 20 degrees, with pain at 10 degrees; and right lateral rotation to 30 degrees, with pain at 25 degrees. In a November 2009 VA spine examination report, the Veteran reported that he had difficulty stranding for prolonged periods of time and walking long distances. He denied a history of urinary or bowel dysfunction, though he reported numbness, paresthesias, and leg or foot weakness. He denied a history of fatigue, but reported decreased motion, stiffness, weakness, spasms, and pain. The Veteran reported that he experienced severe flare-ups on a weekly basis, with each flare-up lasting hours. During a flare-up, he experienced limitation in back movement which caused difficulty in his daily activities. The report stated that the Veteran had experienced incapacitating episodes of thoracolumbar spine disease almost weekly over the previous year, but had to go to work. On physical examination, the Veteran's posture, head position, and gait were normal. No abnormal spinal curvatures were noted other than lumbar flattening. The Veteran had spasm, pain with motion, and tenderness, but no atrophy, guarding, or weakness. The muscle spasm and tenderness was severe enough to be responsible for abnormal gait or abnormal spinal contour. Nerve abnormalities were noted corresponding to the right L4, L5, and S1 areas. The Veteran had thoracolumbar spine range of motion on flexion to 35 degrees, extension to 10 degrees, left lateral flexion to 15 degrees, left lateral rotation to 25 degrees, right lateral flexion to 10 degrees, and right lateral rotation to 20 degrees. There was objective evidence of pain on active motion and repetitive motion, but there were no additional limitations after three repetitions. On x-ray examination, the impression was mild lumbar spondylosis. On magnetic resonance imaging examination, the impression was straightening of the lumbar lordosis and multilevel degenerative changes. The relevant diagnoses were lumbar strain/myositis/spasm, lumbar L2-L5 degenerative disc disease, lumbar spondylosis, lumbar canal stenosis L4-5, lumbar facet joint disease L3-L4 and L4-L5, and right sciatica. The examiner stated that the disorders had no effect on the Veteran's feeding; a mild effect on grooming; a moderate effect on shopping, recreation, dressing, and toileting; a severe effect on chores, traveling, and bathing; and prevented exercise and sports. An April 2012 VA thoracolumbar spine conditions examination report gave diagnoses of spondylosis of the lumbar spine, degenerative disc disease of the lumbar spine, and lumbar myositis. The Veteran complained of constant low back pain with right leg cramping and numbness, but denied experiencing flare-ups. On physical examination, the Veteran had thoracolumbar spine range of motion on flexion to 20 degrees, with pain at 20 degrees; extension to 10 degrees, with pain at 10 degrees; left lateral flexion to 15 degrees, with pain at 15 degrees; right lateral flexion to 15 degrees, with pain at 15 degrees; left lateral rotation to 15 degrees, with pain at 15 degrees; and right lateral rotation to 15 degrees, with pain at 15 degrees. After repetitive motion, the Veteran's ranges of motions remained the same. The Veteran's thoracolumbar spine functional loss consisted of less movement than normal, pain on movement, disturbance of location, and interference with sitting, standing, and/or weight-bearing. There was localized tenderness to palpation at the bilateral lumbosacral paraspinal muscles, greater on the right than the left, and there was guarding or muscle spasm severe enough to result in an abnormal gait. No muscle or reflex abnormalities were noted, though the Veteran had decreased sensation on light touch in the right thigh/knee, lower leg/ankle, and foot/toes. The examiner stated that the Veteran had mild right radiculopathy but no left radiculopathy. Straight leg raise testing was negative. The Veteran was found to have intervertebral disc syndrome for which the total duration of all incapacitating episodes over the previous 12 months was less than one week. He used a cane, brace, and shoe orthotics. The report stated that the Veteran did not have thoracolumbar spine arthritis or vertebral fracture. The examiner stated that the Veteran could work on a semi-sedentary type of job with duty restrictions such as working on an ergonomic workstation and avoiding lifting, carrying, or pulling heavy objects. The Veteran's service-connected lumbar spine disability is rated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5237. Diagnostic Code 5237 provides that lumbosacral strain is to be rated under the General Rating Formula for Diseases and Injuries of the Spine. The General Rating Formula states that a 10 percent rating is warranted 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 rating is warranted 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 rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula (2012). Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are rated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula (2012). From November 1, 2007 to November 9, 2009 The medical evidence of record shows that from November 1, 2007, to November 9, 2009, the Veteran's lumbar spine disability was manifested by pain, spasm, and limitation of motion to, at most, 65 degrees of flexion, 5 degrees of extension, 25 degrees of right lateral flexion, 20 degrees of left lateral flexion, 25 degrees of right rotation, and 10 degrees of left rotation. There is no medical evidence of record that, for the period from November 1, 2007, to November 9, 2009, the Veteran's thoracolumbar spine was limited to 60 degrees or less of forward flexion, had a combined range of motion not greater than 120 degrees, or had muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. While muscle spasm was noted on physical examination prior to November 10, 2009, the March 2008 VA general medical examination report stated that the Veteran's posture and gait were adequate. The Veteran has reported back pain on use, a contention which is substantiated by the medical evidence of record. However, the March 2008 VA general medical examination report specifically measured the Veteran's functional loss. There is no evidence of record which indicates that the Veteran's back pain ever limited his thoracolumbar spine range of motion to 60 degrees of forward flexion or less or a combined range of motion not greater than 120 degrees during the period from November 1, 2007, to November 9, 2009. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the preponderance of the medical evidence of record does not demonstrate that the Veteran experienced pain or other symptoms which caused additional limitations sufficient to warrant a rating in excess of 10 percent for the Veteran's lumbar spine disability from November 1, 2007, to November 9, 2009. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Accordingly, a rating in excess of 10 percent is not warranted under the General Rating Formula for the orthopedic manifestations of the Veteran's service-connected back disability for the period from November 1, 2007, to November 9, 2009. 38 C.F.R. § 4.71a, General Rating Formula, Diagnostic Code 5237 (2012). From November 10, 2009, to April 26, 2012 The medical evidence of record shows that from November 10, 2009, to April 26, 2012, the Veteran's lumbar spine disability was manifested by pain, spasm, and limitation of motion to, at most, 35 degrees of flexion, 10 degrees of extension, 10 degrees of right lateral flexion, 15 degrees of left lateral flexion, 20 degrees of right rotation, and 25 degrees of left rotation. There is no medical evidence of record that, for the period from November 10, 2009, to April 26, 2012, the Veteran's thoracolumbar spine was ankylosed or limited to 30 degrees or less of forward flexion. The Veteran has reported back pain on use, a contention which is substantiated by the medical evidence of record. However, the November 2009 VA spine examination report specifically measured the Veteran's pain free range of motion. There is no evidence of record which indicates that the Veteran's back pain ever limited his thoracolumbar spine range of motion to 30 degrees of forward flexion or less or resulted in ankylosis for the period from November 10, 2009, to April 26, 2012. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the preponderance of the medical evidence of record does not demonstrate that the Veteran experienced pain or other symptoms which caused additional limitations sufficient to warrant a rating in excess of 20 percent for the Veteran's lumbar spine disability for the period from November 10, 2009, to April 26, 2012. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Accordingly, a rating in excess of 20 percent is not warranted under the General Rating Formula for the orthopedic manifestations of the Veteran's service-connected back disability for the period from November 10, 2009, to April 26, 2012. 38 C.F.R. § 4.71a, General Rating Formula, Diagnostic Code 5237 (2012). On and After April 27, 2012 The medical evidence of record shows that, for the period on and after April 27, 2012, the Veteran's lumbar spine disability was manifested by pain, spasm, and limitation of motion to, at most, 20 degrees of flexion, 10 degrees of extension, 15 degrees of right lateral flexion, 15 degrees of left lateral flexion, 15 degrees of right rotation, and 15 degrees of left rotation. There is no medical evidence of record that, for the period on and after April 27, 2012, the Veteran's thoracolumbar spine was unfavorably ankylosed. The Veteran has reported back pain on use, a contention which is substantiated by the medical evidence of record. However, the April 2012 VA thoracolumbar spine conditions examination report specifically measured the Veteran's pain free range of motion. There is no evidence of record which indicates that the Veteran's back pain ever resulted in unfavorable ankylosis of his thoracolumbar spine during the period on and after April 27, 2012. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the preponderance of the medical evidence of record does not demonstrate that the Veteran experienced pain or other symptoms which caused additional limitations sufficient to warrant a rating in excess of 40 percent for the Veteran's lumbar spine disability for the period on and after April 27, 2012. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Accordingly, a rating in excess of 40 percent is not warranted under the General Rating Formula for the orthopedic manifestations of the Veteran's service-connected back disability for the period on and after April 27, 2012. 38 C.F.R. § 4.71a, General Rating Formula, Diagnostic Code 5237 (2012). For All Periods With regard to the neurologic manifestations of the Veteran's back disability, the evidence shows that the Veteran has repeatedly complained of various neurological symptoms secondary to his service-connected back disability. The medical evidence of record shows that right leg radiculopathy has been diagnosed. However, service connection for radiculopathy of the right lower extremity was granted by a January 2013 rating decision. The Veteran has not perfected an appeal as to the rating or effective date assigned for this radiculopathy. Accordingly, the Board does not have jurisdiction over the rating assigned for the Veteran's right leg radiculopathy. 38 C.F.R. § 20.200 (2012). In addition, the preponderance of the medical evidence of record demonstrates that the Veteran does not have left leg radiculopathy and there is no evidence of record that the Veteran has ever experienced bowel or bladder impairment secondary to his service-connected back disability. Therefore, additional separate ratings for neurologic manifestations of the Veteran's back disability are not warranted. 38 C.F.R. § 4.71a, General Rating Formula (2012). The Board has also considered rating the Veteran's back disability under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, during all periods on appeal. Under the Formula for Rating Intervertebral Disc Syndrome, a 10 percent rating is warranted for 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 is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome (2012). For the purposes of ratings 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. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (2012). The evidence of record does not show that the Veteran has ever experienced symptoms requiring bed rest prescribed by a physician at any point during any of the periods on appeal. The Board notes that the November 2009 VA spine examination report stated that the Veteran had experienced incapacitating episodes of thoracolumbar spine disease almost weekly over the previous year. However, the contemporaneous medical evidence does not show that the Veteran was prescribed bed rest by a physician, let alone on an almost weekly basis. Furthermore, the Veteran himself report that, when he was incapacitated, he stated that he still had to go to work. The Board notes that the fact that the Veteran was capable of going to work weighs heavily against a finding that he was incapacitated for VA purposes at that point in time. In addition, despite the fact that the Veteran's back disability had increased in severity between November 2009 and April 2012, the April 2012 VA thoracolumbar spine conditions examination report stated that the total duration of all of the Veteran's incapacitating episodes over the previous 12 months was less than one week. Accordingly, the medical evidence of record does not show that the Veteran has been prescribed bed rest by a physician for a period of at least two weeks in any one year period. Therefore, a rating in excess of those already assigned is not warranted at any point during the periods on appeal under the Formula for Rating Intervertebral Disc Syndrome. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome (2012). This claim has also been reviewed with consideration of whether further staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's back symptoms, the evidence shows no distinct periods of time when his symptoms have varied to such an extent that a rating in excess of the currently assigned ratings would be warranted for under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). Generally, rating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008); Fisher v. Principi, 4 Vet. App. 57 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular rating is adequate, and no referral is required. When service-connected disability affects employment in ways not contemplated by the rating schedule, 38 C.F.R. § 3.321(b)(1) is applicable. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities ratings for his back disability inadequate. The Veteran's back disability was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012), the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's back disability is manifested by the symptoms listed above. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability ratings currently assigned for his back disability. Ratings in excess of the currently assigned ratings are provided for certain manifestations of back disabilities, but the medical evidence does not show that those manifestations are present. The Board finds that the criteria for the currently assigned ratings for the Veteran's back disability reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular ratings are adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization or marked interference with employment. While the evidence shows that the Veteran's back disability impacts his employment, the evidence shows that the Veteran is employed and there is no evidence of record that the Veteran's occupational abilities are impacted beyond the level which is already contemplated by the ratings assigned for his back disability. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). The Board finds that the preponderance of the evidence is against the claim for increased ratings for a thoracolumbar spine disability. Therefore, the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Cervical Spine Service connection for cervical spine spondylosis was granted by a November 2008 rating decision and a 10 percent rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5237, effective March 6, 2008. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. Unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and 99. 38 C.F.R. § 4.27 (2012). The hyphenated diagnostic code in this case indicates that an unlisted musculoskeletal disability, under Diagnostic Code 5299, was the service-connected disability, and cervical strain, under Diagnostic Code 5237, was a residual condition. Subsequently, a December 2009 rating decision assigned a 20 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5237, effective November 10, 2009. In a March 2008 VA general medical examination report, the Veteran complained of cervical pain for the previous six months. On physical examination, there was tenderness in the cervical spine and pain was elicited on flexion. The Veteran had cervical spine range of motion on flexion to 35 degrees, with pain at 25 degrees; extension to 35 degrees, with pain at 25 degrees; left lateral flexion to 30 degrees, with pain at 20 degrees; right lateral flexion to 35 degrees, with pain at 30 degrees; left lateral rotation to 70 degrees, with pain at 65 degrees; and right lateral rotation to 70 degrees, with pain at 60 degrees. In a November 2009 VA spine examination report, the Veteran denied a history of urinary or bowel dysfunction, though he reported numbness, paresthesias, and leg or foot weakness. He denied a history of fatigue, but reported decreased motion, stiffness, weakness, spasms, and pain. The Veteran reported that he experienced severe flare-ups on a weekly basis, with each flare-up lasting hours. During a flare-up, he experienced limitation in neck movement which caused difficulty in his daily activities. The report stated that the Veteran had experienced incapacitating episodes of thoracolumbar spine disease almost weekly over the previous year, but had to go to work. The Veteran had spasm, pain with motion, and tenderness, but no atrophy, guarding, or weakness. No upper extremity nerve abnormalities were noted. There was cervical spine range of motion to 30 degrees of flexion, 20 degrees of extension 15 degrees of left lateral flexion, 50 degrees of left lateral rotation, 15 degrees of right lateral flexion, and 40 degrees of right lateral rotation. There was objective evidence of pain on active motion and repetitive motion, but there were no additional limitations after three repetitions. On x-ray examination, the impression was mild C3-C7 degenerative disc intervertebral osteochondrosis with associated spondylosis deformans. The relevant diagnoses were cervical strain/myositis/spasm, cervical C3-C7 degenerative disc disease, and cervical spondylosis. The examiner stated that the disorders had no effect on the Veteran's feeding; a mild effect on grooming; a moderate effect on shopping, recreation, dressing, and toileting; a severe effect on chores, traveling, and bathing; and prevented exercise and sports. An April 2012 VA cervical spine conditions examination report gave diagnoses of spondylosis of the cervical spine, degenerative disc disease of the cervical spine, and cervical myositis. The Veteran complained of constant neck pain with right shoulder radiation. He reported that he experienced flare-ups of neck pain which caused him to leave work earlier and sometimes call in sick. On physical examination, the Veteran had cervical spine range of motion on flexion to 40 degrees, with pain at 40 degrees; extension to 15 degrees, with pain at 15 degrees; left lateral flexion to 20 degrees, with pain at 20 degrees; right lateral flexion to 20 degrees, with pain at 20 degrees; left lateral rotation to 25 degrees, with pain at 25 degrees; and right lateral rotation to 20 degrees, with pain at 20 degrees. After repetitive motion, the Veteran's ranges of motions remained the same. The Veteran's cervical spine functional loss consisted of less movement than normal, pain on movement, and interference with sitting, standing, and/or weight-bearing. There was localized tenderness to palpation of the cervical spine and there was guarding or muscle spasm severe enough to result in an abnormal gait. No muscle or reflex abnormalities were noted, though the Veteran had decreased sensation on light touch in the right shoulder, inner/outer forearm, and hand/fingers. The examiner stated that the Veteran had mild right radiculopathy but no left radiculopathy. The Veteran was found to have intervertebral disc syndrome for which the total duration of all incapacitating episodes over the previous 12 months was less than one week. He used a cane, brace, and shoe orthotics. The report stated that the Veteran did not have cervical spine arthritis or vertebral fracture. The examiner stated that the Veteran could work on a semi-sedentary type of job with duty restrictions such as working on an ergonomic workstation and avoiding lifting, carrying, or pulling heavy objects. Under the General Rating Formula for Diseases or Injuries of the Spine (General Rating Formula), a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 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 rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 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 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a, General Rating Formula (2012). Prior to November 10, 2009 The medical evidence of record shows that prior to November 10, 2009, the Veteran's cervical spine disability was manifested by pain and limitation of motion to 35 degrees of flexion, 35 degrees of extension, 30 degrees of left lateral flexion, 35 degrees of right lateral flexion, 70 degrees of left lateral rotation, and 70 degrees of right lateral rotation. There is no medical evidence of record that prior to November 10, 2009, the Veteran's cervical spine was limited to 30 degrees or less of forward flexion, or had muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. The March 2008 VA general medical examination report stated that the Veteran experienced pain in the last 10 degrees of forward flexion, indicating a pain-free range of motion of 25 degrees. However, the examiner also specifically said that the Veteran only had 10 degrees of functional loss, which corresponds to the noted 35 degrees of forward flexion. 38 C.F.R. § 4.71a, Plate V (2012). Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the Board finds that the Veteran's pain at 25 degrees of forward flexion is not sufficient to warrant a rating in excess of 10 percent prior to November 10, 2009. The Veteran has reported neck pain on use, a contention which is substantiated by the medical evidence of record. However, the March 2008 VA general medical examination report specifically measured the Veteran's cervical spine functional loss. There is no evidence of record which indicates that the Veteran's neck pain ever limited his cervical spine range of motion to 30 degrees of forward flexion or less for the period prior to November 10, 2009. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the preponderance of the medical evidence of record does not demonstrate that the Veteran experienced pain or other symptoms which caused additional limitations sufficient to warrant a rating in excess of 10 percent for the Veteran's cervical spine disability for the period prior to November 10, 2009. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Accordingly, a rating in excess of 10 percent is not warranted under the General Rating Formula for the orthopedic manifestations of the Veteran's service-connected neck disability for the period prior to November 10, 2009. 38 C.F.R. § 4.71a, General Rating Formula, Diagnostic Code 5237 (2012). On and After November 10, 2009 The medical evidence of record shows that on and after November 10, 2009, the Veteran's cervical spine disability was manifested by pain, spasm, and limitation of motion to, at most, 35 degrees of flexion, 10 degrees of extension, 10 degrees of right lateral flexion, 15 degrees of left lateral flexion, 20 degrees of right rotation, and 25 degrees of left rotation. There is no medical evidence of record that, for the period on and after November 10, 2009, the Veteran's cervical spine was ankylosed or limited to 15 degrees or less of forward flexion. The Veteran has reported neck pain on use, a contention which is substantiated by the medical evidence of record. However, the November 2009 VA spine examination report and the April 2012 VA cervical spine conditions examination report both specifically measured the Veteran's pain free range of motion. There is no evidence of record which indicates that the Veteran's neck pain ever limited his cervical spine range of motion to 15 degrees of forward flexion or less or resulted in ankylosis for the period on and after November 10, 2009. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the preponderance of the medical evidence of record does not demonstrate that the Veteran experienced pain or other symptoms which caused additional limitations sufficient to warrant a rating in excess of 20 percent for the Veteran's cervical spine disability for the period on and after November 10, 2009. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Accordingly, a rating in excess of 20 percent is not warranted under the General Rating Formula for the orthopedic manifestations of the Veteran's service-connected neck disability for the period on and after November 10, 2009. 38 C.F.R. § 4.71a, General Rating Formula, Diagnostic Code 5237 (2012). For All Periods With regard to the neurologic manifestations of the Veteran's neck disability, the evidence shows that the Veteran has repeatedly complained of various neurological symptoms secondary to his service-connected neck disability. The medical evidence of record shows that right arm radiculopathy has been diagnosed. However, service connection for radiculopathy of the right upper extremity was granted by a January 2013 rating decision. The Veteran has not perfected an appeal as to the rating or effective date assigned for this radiculopathy. Accordingly, the Board does not have jurisdiction over the rating assigned for the Veteran's right arm radiculopathy. 38 C.F.R. § 20.200 (2012). In addition, the preponderance of the medical evidence of record demonstrates that the Veteran does not have left arm radiculopathy and there is no evidence of record that the Veteran has ever experienced bowel or bladder impairment secondary to his service-connected neck disability. Therefore, additional separate ratings for neurologic manifestations of the Veteran's neck disability are not warranted. 38 C.F.R. § 4.71a, General Rating Formula (2012). The Board has also considered evaluating the Veteran's neck disability under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, during all periods on appeal. The evidence of record does not show that the Veteran has ever experienced symptoms requiring bed rest prescribed by a physician at any point during any of the periods on appeal. Accordingly, the medical evidence of record does not show that the Veteran has ever been prescribed bed rest by a physician for a period of at least two weeks in any one year period. Therefore, a rating in excess of those already assigned is not warranted at any point during the periods on appeal under the Formula for Rating Intervertebral Disc Syndrome. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome (2012). This claim has also been reviewed with consideration of whether further staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's neck symptoms, the evidence shows no distinct periods of time when his symptoms have varied to such an extent that a rating in excess of the currently assigned ratings would be warranted for under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities ratings for his neck disability inadequate. The Veteran's neck disability was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012), the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's neck disability is manifested by the symptoms listed above. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability ratings currently assigned for his neck disability. Ratings in excess of the currently assigned ratings are provided for certain manifestations of neck disabilities, but the medical evidence does not show that those manifestations are present. The Board finds that the criteria for the currently assigned ratings for the Veteran's neck disability reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular ratings are adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization or marked interference with employment. While the evidence shows that the Veteran's neck disability impacts his employment, the evidence shows that the Veteran is employed and there is no evidence of record that the Veteran's occupational abilities are impacted beyond the level which is already contemplated by the ratings assigned for his neck disability. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). The Board finds that the preponderance of the evidence is against the claim for increased ratings for a cervical spine disability. Therefore, the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Right Elbow Service connection for right elbow epicondylitis was granted by a June 2008 rating decision and a 0 percent rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5200, effective November 1, 2007. Subsequently, a December 2009 rating decision assigned a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5206, effective November 10, 2009. A February 2007 service medical report stated that, on physical examination, the Veteran's right elbow had a full range of motion without pain, though there was tenderness to palpation over the medial and lateral epicondyle, as well as pain on pronation and supination against resistance. In a February 2008 VA joints examination report, the Veteran complained of right elbow pain. He reported experiencing flare-ups in pain once a month, for two to three hours per flare-up. On examination, the Veteran repeatedly flexed and extended his right elbow without resistance, at which time pain was elicited in the lateral epicondyle without weakness or fatigue. There was no edema, redness, or erythema. The Veteran had right elbow flexion to 145 degrees, with pain at 115 degrees, and extension to 0 degrees, with pain at 20 degrees. There was no functional loss. The Veteran had forearm supination to 80 degrees, with pain at 65 degrees, and no functional loss. He also had full forearm pronation without pain or functional loss. On x-ray examination, the Veteran's right elbow was normal. The diagnosis was right tennis elbow with weakness of wrist extensors. In a November 2009 VA joints examination report, the Veteran complained of increased pain and weakness in his right elbow. He reported experiencing right elbow giving way, pain, stiffness, and decreased speed of joint motion, but no deformity, instability, stiffness, incoordination, episodes of dislocation or subluxation, locking episodes, or effusions. The Veteran reported that he experienced frequent flare-ups. On physical examination, there was right elbow tenderness in the lateral and medial epicondyle areas, as well as weakness with pain exacerbated while grabbing, lifting, or shaking hands with resisted movements. The Veteran had right elbow flexion to 145 degrees, extension to 0 degrees, pronation to 80 degrees, and supination to 85 degrees. There was objective evidence of pain on motion and following repetitive motion, but there were no additional limitations after three repetitions. The Veteran did not have right elbow ankylosis. On x-ray examination, the Veteran's right elbow was normal. The diagnosis was right lateral and medial epicondylitis. The examiner stated that the disability had no effect on the Veteran's feeding, bathing, dressing, toileting, and grooming; a mild effect on recreation; a moderate effect on chores, shopping, traveling, and driving; and prevented exercise and sports. An April 2012 VA elbow and forearm conditions examination report gave a diagnosis of right medial epicondylitis. The Veteran stated that his right elbow pain was stable, intermittent, and increased when he was supporting himself using a cane or lifting heavy objects. He also reported occasional right arm weakness, but denied experiencing any flare-ups that impacted the function of his elbow or forearm. The Veteran had right elbow flexion to 110 degrees, with pain at 90 degrees, and extension to 0 degrees, without pain. After repetitive motion, the Veteran's ranges of motions remained the same. The Veteran's right elbow functional loss consisted of less movement than normal and pain on movement. He had full muscle strength and there was no right elbow ankylosis, flail joint, joint fracture, or impairment of supination or pronation. The Veteran had not had any right elbow surgery and there was no degenerative or traumatic arthritis. The examiner stated that the Veteran could work on a semi-sedentary type of job with duty restrictions such as working on an ergonomic workstation and avoiding lifting, carrying, or pulling heavy objects. Under Diagnostic Code 5206, a 0 percent rating is warranted for limitation of flexion of the major forearm to 110 degrees. A 10 percent rating is warranted for limitation of flexion of the major forearm to 100 degrees. A 20 percent rating is warranted for limitation of flexion of the major forearm to 90 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5206 (2012). Under Diagnostic Code 5207, a 10 percent rating is warranted for limitation of extension of the major forearm to 60 degrees. A 20 percent rating is warranted for limitation of extension of the major forearm to 75 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5207 (2012). The evidence of record shows that the Veteran is right-handed. Therefore, for rating purposes, his right arm is considered his major or dominant extremity and his left arm is considered his minor or non-dominant extremity. 38 C.F.R. § 4.69 (2012). The medical evidence of record shows that, for the entire period on appeal, the Veteran's right elbow disability is manifested by pain, weakness, and limitation of motion to 110 degrees of flexion and 0 degrees of extension. There is no evidence of record that the Veteran's right elbow has ever been limited to 45 degrees of extension or less. While the Veteran was found to have only 90 degrees of pain-free range of right elbow motion in April 2012, the examiner specifically stated that the Veteran retained 110 degrees of total flexion and that his range of motion did not decrease following repetitive motion. Therefore, the evidence shows that the Veteran experienced pain, but no limitation of flexion in the range from 90 to 110 degrees. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the preponderance of the medical evidence of record does not demonstrate that the Veteran experienced pain or other symptoms which caused additional limitations sufficient to warrant a compensable rating for the Veteran's right elbow disability under either Diagnostic Code 5206 or 5207 at any point during the period on appeal. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Accordingly, a rating in excess of 10 percent is not warranted under Diagnostic Codes 5206 and 5207 for the Veteran's right elbow disability at any point during the period on appeal. 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207 (2012). As for other provisions under the Schedule, the Veteran's right elbow disability has never been manifested by ankylosis, flail joint, joint fracture, nonunion of the radius and ulna, impairment of the ulna, impairment of the radius, limitation of pronation beyond the last quarter of the arc, or limitation of supination to 30 degrees or less. 38 C.F.R. § 4.71a, Diagnostic Codes 5205, 5208, 5209, 5210, 5211, 5212, 5213 (2012). Accordingly, an initial rating in excess of 0 percent, prior to November 10, 2009, and in excess of 10 percent, on and after November 10, 2009, is not warranted under these diagnostic codes. This claim has also been reviewed with consideration of whether further staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's right elbow symptoms, the evidence shows no distinct periods of time when his symptoms have varied to such an extent that a rating in excess of the currently assigned ratings would be warranted for under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities ratings for his right elbow disability inadequate. The Veteran's right elbow disability was rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207 (2012), the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's right elbow disability is manifested by pain, weakness, and limitation of motion to 110 degrees of flexion and 0 degrees of extension. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability ratings currently assigned for his right elbow disability. Ratings in excess of the currently assigned ratings are provided for certain manifestations of elbow disabilities, but the medical evidence does not show that those manifestations are present. The Board finds that the criteria for the currently assigned ratings for the Veteran's right elbow disability reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular ratings are adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization or marked interference with employment. While the evidence shows that the Veteran's right elbow disability impacts his employment, the evidence shows that the Veteran is employed and there is no evidence of record that the Veteran's occupational abilities are impacted beyond the level which is already contemplated by the ratings assigned for his right elbow disability. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Codes 5206, 5207 (2012). The Board finds that the preponderance of the evidence is against the claim for increased ratings for a right elbow disability. Therefore, the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Right Third Trigger Finger Service connection for trigger finger of the right third finger, was granted by a June 2008 rating decision and a 0 percent rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5229, effective November 1, 2007. In a February 2007 service medical report, the Veteran complained of snapping and locking in his right middle finger. On physical examination, the Veteran's right middle finger had pain at the A1 pulley and a palpable clinking was felt on motion, but the finger did not lock. The assessment was trigger finger of right middle finger. In a February 2008 VA joints examination report, the Veteran complained of right middle finger pain and stiffness. The examiner noted that the Veteran had undergone right middle finger pulley surgery in 2007. On examination, the Veteran repeatedly opened and closed his right hand without resistance, at which time pain was elicited in the right middle finger without weakness or fatigue. There was no edema, redness, or erythema. The Veteran had a full range of motion in all his digits without functional loss or deficits, though there was reduced grip strength in the right hand compared to the left. The diagnosis was right trigger finger, status post pulley release, with residual weakness in hand grip strength. In a March 2008 private medical report, the Veteran complained of a hypertense region in his right third finger. The Veteran was given several physical therapy exercises to perform. A little pain was noted on the grasping exercises. An April 2008 private medical report stated that the Veteran had improved markedly in right third finger extension with physical therapy. On observation, there was no atrophy but there was mild third finger swelling. There was tenderness at the right third finger proximal interphalangeal joint, but the Veteran's range of motion was essentially normal. The Veteran had reduced muscle strength in the right hand. The assessment was right third trigger finger status post release with hand pain and stiffness. In a November 2009 VA hand, thumb, and fingers examination report, the Veteran complained of pain and difficulty grabbing objects. He reported decreased right hand strength, but no decreased dexterity, other symptoms, or flare-ups. On physical examination, there was objective evidence of pain on motion, but the Veteran's extension was normal in all right third finger joints. The gap between his long finger and the proximal transverse crease of his hand on maximum flexion of the finger was less than one inch. After repetitive motion, there was objective evidence of pain but no additional limitation of motion. On x-ray examination, there were no acute fractures but there was a deformity of the capitates bone which was most likely due to prior trauma. The diagnosis was residual of right third trigger finger tendon surgery. The examiner stated that the disability had a mild effect on the Veteran's recreation, feeding, bathing, dressing, toileting, and grooming; a moderate effect on chores, shopping, and traveling; and prevented exercise and sports. An April 2012 VA hand and finger conditions examination report gave a diagnosis of residual of right small palmar fasciectomy and recurrent right hand trigger finger. The Veteran reported that his right middle finger condition was stable status post surgery in September 2008. The Veteran reported that the trigger finger was resolved, but reported having a weak grip and experiencing right middle finger pain with complete flexion. He denied experience any flare-ups that impacted the function of his hand. There was evidence of limitation of motion or painful motion for the right middle finger. There was a gap between the thumb and the right third finger of less than one inch, and pain began at the gap of less than one inch. There was a gap between the right third fingertip and the proximal transverse crease of the palm of one inch or more, and pain began at the gap of one inch or more. There was no limitation of extension or evidence of painful motion for the right third finger. After repetitive motion, the Veteran's ranges of motions remained the same. The Veteran had scars related to treatment of his right third finger disability, but there was no degenerative or traumatic arthritis. The examiner stated that the Veteran's right third finger disability did not impact his ability to work. Under Diagnostic Code 5229, a 0 percent rating is warranted for limitation of motion of the major index or long finger with a gap of less than one inch between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. A 10 percent rating is warranted for limitation of motion of the major index or long finger with a gap of one inch or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; extension limited by more than 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2012). The evidence of record shows that the Veteran is right-handed. Therefore, for rating purposes, his right hand is considered his major or dominant extremity and his left hand is considered his minor or non-dominant extremity. 38 C.F.R. § 4.69 (2012). The medical evidence of record shows that, for the period prior to April 27, 2012, the Veteran's right middle finger disability was manifested by pain, weakness, and limitation of motion with a gap of less than one inch between the fingertip and the proximal transverse crease of the palm. There is no evidence of record that the Veteran's right middle finger was ever limited in motion with a gap of one inch or more between the fingertip and the proximal transverse crease of the palm, for the period prior to April 27, 2012. The Veteran has reported right middle finger pain on use, a contention which is substantiated by the medical evidence of record. However, the February 2008 VA joints examination report and the November 2009 VA hand, thumb, and fingers examination report specifically measured the Veteran's right middle finger functional loss. There is no evidence of record which indicates that the Veteran's right middle finger was ever limited in motion with a gap of one inch or more between the fingertip and the proximal transverse crease of the palm prior to April 27, 2012. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the preponderance of the medical evidence of record does not demonstrate that the Veteran experienced pain or other symptoms which caused additional limitations sufficient to warrant a rating in excess of 0 percent for the Veteran's right middle finger disability for the period prior to April 27, 2012. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Accordingly, a rating in excess of 10 percent is not warranted under Diagnostic Code 5229 for the Veteran's service-connected right middle finger disability prior to April 27, 2012. 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2012). However, the medical evidence of record shows that, for the period on and after April 27, 2012, the Veteran's right middle finger disability was manifested by pain, weakness, and limitation of motion with a gap of one inch or more between the fingertip and the proximal transverse crease of the palm. That level of limitation of motion was specifically found by the April 2012 VA hand and finger conditions examination report. Therefore, a 10 percent rating is warranted for the Veteran's right middle finger disability as of April 27, 2012. 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2012). A 10 percent rating is the highest rating available under Diagnostic Code 5229. Accordingly, a rating in excess of 10 percent is not warranted under Diagnostic Code 5229. A rating of 20 percent is warranted for amputation of the major long finger with metacarpal resection. 38 C.F.R. § 4.71a, Diagnostic Code 5154 (2012). However, as the Veteran retains a significant range of motion in his right middle finger, the Board finds that his symptoms are not analogous to amputation. Accordingly, a rating in excess of 10 percent is not warranted under Diagnostic Code 5154. The medical evidence of record shows that the Veteran also has surgical scars which are related to his right middle finger disability. However, service connection for scars, status post surgical release and fasciectomy, right middle trigger finger, was granted by a November 2008 rating decision. The Veteran has not perfected an appeal as to the rating or effective date assigned for these scars. Accordingly, the Board does not have jurisdiction over the rating assigned for the Veteran's right middle finger scars. 38 C.F.R. § 20.200 (2012). This claim has also been reviewed with consideration of whether further staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's right middle finger symptoms, the evidence shows no distinct periods of time when his symptoms have varied to such an extent that a rating in excess of the ratings assigned herein would be warranted for under any diagnostic code. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.344 (2012); Fenderson v. West, 12 Vet. App. 119 (1999). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render his disabilities ratings for his right middle finger disability inadequate. The Veteran's right middle finger disability was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2012), the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's right middle finger disability is manifested by the symptoms listed above. When comparing that disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are adequately contemplated by the disability ratings assigned herein for his right middle finger disability. Ratings in excess of the currently assigned ratings are provided for certain manifestations of long finger disabilities, but the medical evidence does not show that those manifestations are present. The Board finds that the criteria for the ratings assigned herein for the Veteran's right middle finger disability reasonably describe the Veteran's disability level and symptomatology and, therefore, the schedular ratings assigned herein are adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization or marked interference with employment. The evidence does not show that the Veteran's right middle finger disability impacts his employment. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Code 5229 (2012). The Board finds that the preponderance of the evidence is against the claim for increased ratings for a right middle finger disability in excess of those assigned herein. Therefore, to that extent, the claim is denied. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). (CONTINUED ON NEXT PAGE) ORDER Service connection for hypermetropia, astigmatism, presbyopia, senile cataracts, crowded optic nerves, pinguecula, and blepharitis is denied. Service connection for macular degeneration is granted. Service connection for sleep apnea, which has been aggravated by a service-connected disability, is granted. Service connection for fatigue is denied. Service connection for joint pain is denied. An initial rating in excess of 10 percent for a lumbar spine disability, effective November 1, 2007; 20 percent, effective November 10, 2009; and 40 percent, effective April 27, 2012, is denied. An initial rating in excess of 10 percent for a cervical spine disability, effective March 6, 2008, and 20 percent, effective November 10, 2009, is denied. An initial compensable rating for a right elbow disability, effective November 1, 2007, and 10 percent, effective November 10, 2009, is denied. An initial rating in excess of 0 percent for right third trigger finger, prior to April 27, 2012, is denied. A rating of 10 percent, but not higher, for right third trigger finger, as of April 27, 2012, is granted. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs