Citation Nr: 1322433 Decision Date: 07/15/13 Archive Date: 07/24/13 DOCKET NO. 09-39 464 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for sleep apnea. 2. Entitlement to service connection for vertigo. 3. Entitlement to service connection for chronic fatigue syndrome. 4. Entitlement to service connection for pes planus. 5. Entitlement to service connection for bilateral leg varicose veins. 6. Entitlement to service connection for residuals of a traumatic brain injury (TBI). 7. Entitlement to service connection for hemorrhoids. 8. Entitlement to an initial rating in excess of 30 percent for insomnia. 9. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease of the right knee. 10. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease of the left knee. 11. Entitlement to an initial rating in excess of 0 percent for onychomycosis of all nails. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from May 1971 to May 1974, from September 1990 to April 1991, and from August 2001 to December 2007. The Veteran had additional inactive service from May 1974 to August 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office in St. Petersburg, Florida (RO). The issues of entitlement to service connection for residuals of a TBI, bilateral leg varicose veins, and hemorrhoids are REMANDED to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. The preponderance of the evidence of record shows that the Veteran has never had a diagnosis of sleep apnea. 2. The preponderance of the evidence of record shows that the Veteran has never had a diagnosis of a disability related to vertigo since his separation from service. 3. The medical evidence of record does not show that the Veteran has a current diagnosis of a any chronic fatigue disability or chronic fatigue syndrome for VA purposes. 4. The preponderance of the evidence of record shows that the Veteran has never had a diagnosis of pes planus since separation from service. 5. The evidence of record shows that the Veteran's insomnia has been consistently manifested by sleep impairment, depression, mild memory impairment, obsessive or ritualistic behavior, and irritability. 6. The medical evidence of record shows that the Veteran's right knee disability is manifested by pain, stiffness, crepitus, and limitation of motion to, at most, 90 degrees of flexion and 0 degrees of extension. 7. The medical evidence of record shows that the Veteran's left knee disability is manifested by pain, stiffness, crepitus, and limitation of motion to, at most, 105 degrees of flexion and 0 degrees of extension. 8. The medical evidence of record shows that the Veteran's onychomycosis has been manifested by, at most, thickened nails of all toes on both feet affecting 0 percent of the Veteran's exposed areas and less than 5 percent of his total body area, with topical treatment. CONCLUSIONS OF LAW 1. Sleep apnea was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. Vertigo was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 3. A chronic fatigue syndrome was not incurred in or aggravated by service, to include as due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). 4. Pes planus was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 5. The criteria for an initial rating in excess of 30 percent for insomnia have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9421 (2012). 6. The criteria for an initial rating in excess of 10 percent for degenerative joint disease of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). 7. The criteria for an initial rating in excess of 10 percent for degenerative joint disease of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). 8. The criteria for an initial rating in excess of 0 percent for onychomycosis of all nails have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7813 (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 July 2006, November 2007, August 2008, and November 2008. 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 determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and his representative 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 Veteran's service medical records from his first period of active service, from May 1971 to May 1974, 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 for the Veteran and has notified him of the records which are unavailable. In a letter dated in January 2009, VA notified the Veteran that his records were unavailable, informed him of the actions taken in the attempt to locate the records, and asked the Veteran that he submit any service medical records in his possession. The Veteran has also received a statement of the case in October 2009 which commented on the Veteran's missing service records. 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 obtainable, 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). 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). Sleep Apnea The Veteran's service medical records include numerous reports of sleep impairment. The vast majority of the reports were noted on medical records documenting the Veteran's complaints of back pain. In a September 2006 VA pre-discharge mental disorders examination report, the Veteran complained of sleep disturbances. After psychiatric examination, the Axis I diagnoses were nicotine dependence in early full remission and adjustment disorder with mood disturbance, mild. A September 2006 VA pre-discharge general medical examination report stated that there was no evidence in the medical record to support complaint, diagnosis, or treatment for a sleep disorder. The Veteran reported that he had side effects of a sleep disorder secondary to medications he took for chronic pain. The Veteran did not complain of a sleep disorder and stated that he slept too much because of medication. After physical examination, the diagnosis was no sleep disorder. A January 2007 service medical report gave an assessment of insomnia. The Veteran reported that since lumbar spine surgery he had been unable to sleep for more than three hours. He was given prescription sleep medication. A September 2007 service medical report stated that the Veteran needed a referral for a sleep apnea test. A November 2007 polysomnogram report stated that the Veteran had a history of excessive daytime sleepiness, snoring, and sleep apnea. After sleep study examination, the interpretation was moderately loud snoring, normal apnea-hypoapnea index after three hours, no significant obstructions, and no periodic leg movements. After separation from service, in a May 2008 VA mental disorders examination report, the Veteran reported that after a 2007 sleep study he was told he was a "noise nuisance" and woke himself up four to five times per night due to snoring. He reported experiencing frequent insomnia with an average of four hours of sleep per night. The Veteran stated that he had experienced this sleep disturbance since November 2005, when he fell in the shower. After psychiatric examination, the Axis I diagnosis was insomnia. The report stated that the Veteran had primary insomnia and that a sleep study ruled out sleep apnea as per the Veteran's report, though his snoring was loud enough to wake him up from sleep. In a May 2008 VA general medical examination report, the Veteran reported that he had undergone a sleep study and was told that he had heavy snoring but no history or evidence of sleep apnea, though he reported that he snored loudly enough to wake himself up. After physical examination, the impression was sleep disorder secondary to snoring. A January 2010 VA mental disorders examination report stated that the Veteran was prescribed a medication which had a side-effect of drowsiness. The Veteran reported that he continued to have moderate insomnia. After mental status examination, the relevant Axis I diagnoses were primary insomnia and sleep disorder due to chronic pain, insomnia type. The Board finds that the preponderance of the evidence of record shows that the Veteran has never had a diagnosis of sleep apnea. The Veteran's service medical records are negative for any diagnosis of sleep apnea. While the current medical evidence includes diagnoses of insomnia, no diagnosis of sleep apnea has been rendered. The Veteran was found to not have sleep apnea following a sleep study in November 2007. The Board notes that the Veteran has been found to have sleep impairment and insomnia on multiple occasions. However, service connection has already been granted for insomnia. Accordingly, any sleep impairment symptoms that the Veteran experiences secondary to his insomnia are not for consideration in conjunction with the sleep apnea claim on appeal. 38 C.F.R. § 4.14 (2012) Under certain circumstances, 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, lay 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 is competent to report that he experiences sleep impairment. However, as he is not a medical professional, the Veteran's statements are not competent to demonstrate that the sleep impairment he experiences is related to sleep apnea, rather than his service-connected insomnia. 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). The Board finds that the preponderance of the competent evidence of record shows that that the Veteran has never had a diagnosis of sleep apnea, and his sleep disorders are attributed to known medical causation and thus are not symptoms of an undiagnosed illness. Thus, the Board finds that service connection for sleep apnea is not warranted. Therefore, the preponderance of the evidence is against the claim and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Vertigo The Veteran's service medical records include multiple reports of dizziness, but no diagnosis of a related disability. In a September 2006 VA pre-discharge audiological examination report, the Veteran complained of intermittent vertigo with spinning and light headedness which lasted from seconds to minutes. After audiological examination, the diagnosis was mild high frequency sensorineural hearing loss, bilaterally. After separation from service, in a May 2008 VA general medical examination report, the Veteran reported that he had been diagnosed with an episode of labyrinthitis approximately 13 years before, but that the symptoms of vertigo abated after four days. He stated that he was presently asymptomatic with no symptoms of vertigo. He denied being on any current treatment for vertigo and had no flare-ups or incapacitations due to vertigo. After physical examination, the impression was vertigo with no clinical evidence of disease. In a May 2008 VA audiological report, the Veteran reported that he had experienced dizziness in the 1990s which was medically treated and had since resolved. After audiological and otoscopy examination, the diagnosis was bilateral hearing loss. The Board finds that the preponderance of the evidence of record shows that the Veteran has never had a diagnosis of a disability related to vertigo since his separation from service. The Veteran's service and post-service medical records are negative for any diagnosis of a vertigo disability. While the Veteran has reported that he experienced a bout of labyrinthitis in approximately 1995, he stated that the disorder resolved after four days and denied any post-service recurrence. Under certain circumstances, 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, lay 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 is competent to report that he experiences vertigo. However, the Veteran has actively denied experiencing a vertigo disorder since separation from service. Accordingly, there is no evidence of record that the Veteran has ever had a diagnosis of a vertigo disability at any point during the pendency of this claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). In addition, there is no evidence to support a finding that any vertigo is due to an undiagnosed illness because no vertigo is claimed or shown during or contemporary to the claim on appeal. 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). The Board finds that the preponderance of the competent evidence of record shows that that the Veteran has never had a diagnosis of a vertigo disability at any point during or contemporary to the pendency of this claim. Therefore, the preponderance of the evidence is against the claim and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Chronic Fatigue Syndrome Initially, the Board notes that fatigue may be considered a manifestation 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). 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). The Veteran's service personnel records show that he had one month and 11 days of foreign service between August 30, 2001, and July 8, 2005, and an additional five months and 29 days of foreign service between July 9, 2005, and December 26, 2007. While the Veteran's service personnel records do not clearly state where and when this foreign service was conducted, the Veteran's service medical records repeatedly state that he fell in the shower in Baghdad, Iraq in November 2005. Accordingly, the evidence of record shows that the Veteran served in the Southwest Asia theater of operations for at least some period between August 2001 and December 2007, including in November 2005. The Veteran's service medical records include numerous reports of fatigue, but no diagnosis of a related disability. A September 2006 VA pre-discharge general medical examination report stated that there was no evidence in the medical record to support complaint, diagnosis, or treatment for chronic fatigue. The Veteran reported that he had side effects of fatigue secondary to medications he took for chronic pain. The Veteran did not complain of chronic fatigue syndrome and stated that he slept too much because of medication. After physical examination, the diagnosis was no chronic fatigue syndrome. After separation from service, in a May 2008 VA general medical examination report, the Veteran denied experiencing chronic fatigue, but he noted that he occasionally fell asleep during the day. A January 2010 VA mental disorders examination report stated that the Veteran was prescribed a medication which had a side-effect of fatigue. After mental status examination, the relevant Axis I diagnoses were primary insomnia and sleep disorder due to chronic pain, insomnia type. The examiner stated that the Veteran noted some slowness of mentation functions due to daytime fatigue associated with insomnia, and sleep and pain medication. The medical evidence of record does not show that the Veteran has a current diagnosis of a chronic fatigue disorder for VA purposes. While the medical evidence of record consistently shows complaints of fatigue, the preponderance of the medical evidence of record shows that it is a symptom of the Veteran's service-connected insomnia and medication prescribed for other disabilities, and not a separate disability in and of itself. There is no medical evidence of record that states that the Veteran has ever experienced a fatigue disorder that is not simply a symptom of another disability. Accordingly, the preponderance of the medical evidence of record shows that the Veteran does not have a current diagnosis of a chronic fatigue disorder for VA purposes. The Board has also reviewed the Veteran's claim as being related to an undiagnosed illness that occurred due to his service in the Persian Gulf. An undiagnosed disorder requires the existence of symptoms and abnormalities, but which cannot be attributed to a known disease or injury. However, the preponderance of the medical evidence of record shows that the Veteran's fatigue symptoms are caused by other disabilities or the medication for those disabilities, and thus are due to a known medical causation. Accordingly, the Veteran's fatigue can be attributed to a known disease or injury. As such, it does not meet the criteria for the symptom of an undiagnosed illness. 38 C.F.R. § 3.317 (2012). Accordingly, the preponderance of the medical evidence of record does not show that the Veteran has a current diagnosis of a chronic fatigue disorder separate from his other disabilities, or that it is the symptom of an undiagnosed illness. Under certain circumstances, 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, lay 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 is competent to report that he experiences fatigue. However, as he is not a medical professional, the Veteran's statements are not competent to demonstrate that the fatigue he experiences is a separate disorder independent of his other disabilities, including insomnia, or that it is the symptom of an undiagnosed illness. 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). The Board finds that the preponderance of the competent evidence of record shows that that the Veteran has never had a diagnosis of a chronic fatigue disorder for VA purposes. Therefore, the preponderance of the evidence is against the claim and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Pes Planus The Veteran's service medical reports include multiple medical reports which gave assessments of congenital pes planus, including an April 2006 service medical report which found bilateral pes planus on physical examination. A September 2006 VA pre-discharge general medical examination report stated that there was no medical evidence to support any complaints, diagnosis, or treatment of pes planus. The Veteran reported that he had no complaints of flat foot and had gotten a second opinion from a podiatrist who stated that he did not have evidence of flat feet. After physical examination, the diagnosis was no evidence of flat feet. In a May 2008 VA general medical examination report, the Veteran stated that he was told he had pes planus one year earlier by an orthopedic specialist. He denied experiencing any foot pain other than that related to his lumbar spine radiculopathy. On physical examination of the Veteran's feet, there was no evidence of abnormal weightbearing, scars, edema, weakness, deformity, or instability. There were no functional limitations on walking or standing, and the Veteran's toe range of motion was within normal limits. There was no hallux valgus deformity and no pes planus. X-ray examination of the Veteran's bilateral feet was negative for any abnormalities. The impression was pes planus with no clinical evidence of disease. The Board finds that the preponderance of the evidence of record shows that the Veteran has never had a diagnosis of pes planus since his separation from service. The Board notes that the Veteran's service medical records include diagnoses of pes planus, with a finding of pes planus on physical examination in April 2006. However, the preponderance of the evidence of record demonstrates that these were misdiagnoses, and that the Veteran has never had pes planus. Specifically, the September 2006 VA pre-discharge general medical examination report and the May 2008 VA general medical examination report both stated that the Veteran did not have pes planus after examination, including radiographic examination in May 2008. Furthermore, the Veteran himself stated that, following the in-service diagnosis of pes planus, he obtained a second opinion from a podiatrist who stated that he did not have evidence of flat feet. There is no medical evidence of record that pes planus has been diagnosed at any point since the Veteran's separation from service. Under certain circumstances, 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, lay 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 is competent to report that he experiences foot pain. However, the Veteran has actively denied experiencing symptoms of flat foot since separation from service. In addition, as he is not a medical professional, the Veteran's statements are not competent to demonstrate that any foot pain he experiences is caused by pes planus and is not related to his service-connected right lower extremity radiculopathy and left lower extremity peripheral neuropathy. Accordingly, there is no evidence of record that the Veteran has ever had a diagnosis of pes planus at any point during or contemporary to the pendency of this claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). 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). The Board finds that the preponderance of the competent evidence of record shows that that the Veteran has never had a diagnosis of pes planus at any point during the pendency of this claim. Therefore, the preponderance of the evidence is against the claim and the claim 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 this factual issue, the Board may only consider the specific factors as are 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 compensate 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 left knee, right knee, onychomycosis, and insomnia claims is based on the assignment of initial ratings following initial awards of service connection for those disabilities. Therefore, evidence contemporaneous with the claims and the initial rating decisions are most probative of the degree of disability existing when the initial ratings were assigned and should be the evidence used to decide whether an original rating on appeal 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). Right and Left Knee Disabilities Service connection for degenerative joint disease of the right and left knees was granted by a January 2009 rating decision and 10 percent ratings were assigned for each knee under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260, effective December 27, 2007. 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. 38 C.F.R. § 4.27 (2012). The hyphenated diagnostic code in this case indicates that traumatic arthritis, under Diagnostic Code 5010, was the service-connected disorder, and limitation of flexion of the leg, under Diagnostic Code 5260, was a residual condition. A September 2006 VA pre-discharge general medical examination report did not include any complaints of a knee disorder. No knee abnormalities were noted on physical examination. After separation from service, in a May 2008 VA general medical examination report, the Veteran reported that he had developed bilateral knee pain approximately five to six months earlier, which was about one month after separation from service. He reported that he was seen by a local doctor in February 2008, at which time he was diagnosed with degenerative joint disease of both knees. He denied experiencing chronic pain, locking, buckling, or swelling, and had no history of knee aspirations. The Veteran reported that he experienced pain with prolonged walking, but did not receive treatment, did not use assistive devices, had no occupational effects, his daily activities were not affected, and he did not experience flare-ups or incapacitation. On physical examination, the Veteran's knees were negative for McMurray's and petallar grind testing. There was no crepitus, deformity, erythema, effusion, or instability, though there was lateral tenderness to palpation, bilaterally. The Veteran had right knee range of motion to 120 degrees of flexion, with pain at 90 degrees, and 0 degrees of extension without any noted pain. He had left knee range of motion to 135 degrees of flexion, with pain at 105 degrees, and 0 degrees of extension without any noted pain. The examiner stated that there was no additional range of motion lost due to pain, weakness, incoordination, lack of endurance or fatigue, following repetitive motion. On x-ray examination, the Veteran's bilateral knees were negative for any abnormalities. The impression was bilateral knee sprain. In a July 2008 VA orthopedics consultation report, the Veteran complained of bilateral knee pain, greater in the right than the left. On observation, the Veteran lacked the last 20 degrees of flexion, bilaterally. He had bilateral mild effusion and was positive for medial joint line tenderness, but he was negative for hyperemia and alignment abnormalities. The Veteran was positive for patellar apprehension, but his knees were stable in all degrees. The impression was moderate traumatic arthritis of the knees. In a January 2009 VA joints examination report, Veteran reported that his bilateral knee degenerative joint disease was manifested by pain which was stable since onset and which was treated with right knee injections and daily pain medication. The Veteran denied experiencing deformity, giving way, instability, weakness, incoordination, decreased speed of joint motion, dislocation, subluxation, locking, or inflammation. He reported experiencing pain, stiffness, and effected motion. The Veteran reported experiencing moderate weekly flare-ups which lasted for hours. He reported that he experienced an additional 20 percent disability during a flare-up. The Veteran did not have any constitutional symptoms or incapacitating episodes of arthritis. He reported being able to stand for 15 to 30 minutes and walk one quarter mile. The Veteran stated that he used a cane occasionally. On physical examination, the Veteran's gait was normal, there was no evidence of abnormal weight bearing, there was no loss of a bone or part of a bone, and there was no inflammatory arthritis. Veteran's bilateral knees were positive for crepitus, but negative for bumps consistent with Osgood-Schlatter's disease, mass behind the knee, grinding, instability, patellar abnormality, meniscus abnormality, abnormal tendons, abnormal bursae, or other knee abnormalities. The Veteran had right knee range of motion to 100 degrees of flexion and 0 degrees of extension, and left knee range of motion to 115 degrees of flexion and 0 degrees of extension. There was objective pain with active motion, bilaterally, including following repetitive motion, but there were no additional limitations after three repetitions. There was no ankylosis. The examiner noted that the Veteran's ranges of motion were reduced from the levels noted in May 2008 because he was experiencing a flare-up during the examination. On x-ray examination of the right knee there was probably minimal cartilaginous degeneration and medial joint compartment space. On x-ray examination of the left knee, there was probable minimal medial joint compartment space narrowing. The diagnosis was degenerative joint disease of the knees, bilaterally. The examiner stated that the disabilities had no effect on the Veteran's feeding, bathing, dressing, toileting, and grooming; a mild effect on shopping, traveling, and driving; and a moderate effect on chores, exercise, sports, and recreation. Limitation of motion of knee joints is rated under Diagnostic Code 5260 for flexion, and Diagnostic Code 5261 for extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). Under Diagnostic Code 5260, flexion that is limited to 60 degrees warrants a 0 percent rating; flexion that is limited to 45 degrees warrants a 10 percent rating; and flexion that is limited to 30 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Under Diagnostic Code 5261, extension that is limited to 5 degrees warrants a 0 percent rating; extension that is limited to 10 degrees warrants a 10 percent rating; and extension that is limited to 15 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Normal motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2012). Recurrent subluxation or lateral instability of the knee warrants a 10 percent rating when it is slight and a 20 percent rating when it is moderate. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). The medical evidence of record shows that the Veteran's right knee disability is manifested by pain, stiffness, crepitus, and limitation of motion to, at most, 90 degrees of flexion and 0 degrees of extension. The medical evidence of record shows that the Veteran's left knee disability is manifested by pain, stiffness, crepitus, and limitation of motion to, at most, 105 degrees of flexion and 0 degrees of extension. Accordingly, the Board finds that a rating in excess of 10 percent is not warranted for either the right or left knees under either Diagnostic Codes 5260 or 5261. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). In addition, separate ratings for limitation of flexion and extension are not warranted in either knee, as the record does not show that the Veteran's right and left knee ranges of motion have ever been limited to a compensable degree in either flexion or extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012); VAOPGCPREC 9-04 (2004), 69 Fed. Reg. 59990 (2004). The Veteran has reported bilateral knee pain on use, a contention which is substantiated by the medical evidence of record. However, the May 2008 VA general medical examination report specifically measured the Veteran's painless range of motion, while the January 2009 VA joints examination report stated that the Veteran did not have additional limitations after three repetitions despite his reports of pain and that he was experiencing a flare-up at the time of the January 2009 examination. There is no evidence of record which indicates that the Veteran's right or left knee pain ever limited either knee range of motion to 45 degrees of flexion or 10 degrees of extension. 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 right or left knee disorders. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). As for other provisions under the Schedule, the Veteran's right and left knees have never been ankylosed, there was no malunion or nonunion of either tibia and fibula, and there were no symptoms from the removal or dislocation of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262 (2012); VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). The record shows that the Veteran has received a diagnosis of right and left knee arthritis, and his current ratings are assigned on this basis. However, those findings, combined with the limitation of motion elicited, would warrant no more than a 10 percent rating under 38 C.F.R §§ 4.45, 4.71a, Diagnostic Codes 5003, 5010 (2012). Accordingly, an initial rating in excess of 10 percent is not warranted for either knee under those diagnostic codes. Furthermore, a separate rating for instability is not warranted for the right or left knee, as the medical evidence of record does not show recurrent subluxation or lateral instability. Not only has no subluxation or instability been found on examination, the Veteran does not report experiencing such symptoms. Therefore, the Board finds that the preponderance of the evidence of record demonstrates that any subluxation or lateral instability the Veteran experiences is sufficiently rare as to not warrant characterization as recurrent. Accordingly, a separate rating for instability is not warranted for either the Veteran's right or left knee disorders. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). These claims have also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's right and left knee symptoms, the evidence shows no distinct periods of time when his symptoms have varied to such an extent that ratings in excess of the currently assigned ratings would be warranted for either knee 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 and left knee disabilities inadequate. The Veteran's right and left knee disabilities were rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261, the criteria of which are found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's right knee disability is manifested by pain, stiffness, crepitus, and limitation of motion to, at most, 90 degrees of flexion and 0 degrees of extension, while his left knee disability is manifested by pain, stiffness, crepitus, and limitation of motion to, at most, 105 degrees of flexion and 0 degrees of extension. When comparing those disability pictures 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 and left knee disorders. Ratings in excess of the currently assigned rating are provided for certain manifestations of knee 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 and left knee disorder 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. The evidence shows that the Veteran is employed and that his right and left knees do not cause an impact on his occupational abilities beyond that contemplated by the currently assigned ratings. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's degenerative joint disease of the right and left knees does not meet the criteria for ratings in excess of 10 percent. Therefore, the claims are denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Onychomycosis Service connection for onychomycosis of all nails was granted by a January 2009 rating decision and a 0 percent rating was assigned under 38 C.F.R. § 4.118, Diagnostic Code 7813, effective December 27, 2007. A September 2006 VA pre-discharge general medical examination report did not include any complaints of a toenail disorder. On physical examination, the Veteran was found to have onychomycosis of the toenails of each foot. The diagnosis was onychomycosis of both feet. After separation from service, in a January 2009 VA skin diseases examination report, the Veteran complained of constant thickened toenails and itching between his toes. He reported that he treated the disorder with a topical antifungal solution, daily. On physical examination, the disorder affected 0 percent of the Veteran's exposed areas and less than 5 percent of his total body area. The disorder was manifested by thickened nails on the bilateral great toes, right second toe, and right third toe. The diagnosis was onychomycosis of the bilateral feet. In a January 2010 VA skin diseases examination report, the Veteran complained of constant thickened bilateral great toenails. He reported that he treated the disorder with a daily topical antifungal solution. On physical examination, the disorder affected 0 percent of the Veteran's exposed areas and less than 5 percent of his total body area. The disorder was manifested by thickened nails on the bilateral great toes. The diagnosis was onychomycosis of the bilateral great toenails. Diagnostic Code 7813 provides ratings for dermatophytosis (or ringworm) in various locations on the body, including the body (tinea corporis), the head (tinea capitis), the feet (tinea pedis), the beard (tinea barbae), the nails (tinea unguium), and the inguinal area, also known as jock itch (tinea cruris). Diagnostic Code 7813 provides that dermatophysosis is to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800), scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending upon the predominant disability. 38 C.F.R. § 4.118 (2012). The medical evidence of record shows that the Veteran's onychomycosis has been manifested by, at most, thickened nails of all toes on both feet affecting 0 percent of the Veteran's exposed areas and less than 5 percent of his total body area, with topical treatment. The medical evidence of record shows that the Veteran's onychomycosis has never been present on the Veteran's head, face, or neck. As a result, Diagnostic Code 7800 is not applicable. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2012). In addition, the evidence of record does not show that the Veteran's onychomycosis has ever covered an area of 144 square inches or more, involved underlying soft tissue damage, been unstable, or been painful. As a result, the remaining diagnostic codes pertaining to scars are not applicable. 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7804, 7805. (2012). Under Diagnostic Code 7806, a 0 percent rating is warranted for dermatitis or eczema that involves less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the previous 12 month period. A 10 percent rating is warranted for dermatitis or eczema that involves at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the previous 12 month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2012). The medical evidence of record does not show that the Veteran's onychomycosis has ever affected at least 5 percent of his entire body or exposed areas, or that it has ever required systemic therapy. The January 2009 and January 2010 VA skin diseases examination reports both measured the areas of the Veteran's body affected by his onychomycosis and both found that this area constituted 0 percent of his exposed areas and less than 5 percent of his total body area. In addition, both of these reports stated that the Veteran's onychomycosis was treated with topical therapy. There is no medical evidence of record that the Veteran's onychomycosis has ever affected at least 5 percent of his entire body, affected at least 5 percent of his exposed areas, or required systemic therapy. Accordingly, a rating in excess of 0 percent is not warranted under Diagnostic Code 7806. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2012). This claim has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's onychomycosis 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 rating would be warranted 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 rating for onychomycosis inadequate. The Veteran's onychomycosis was rated under 38 C.F.R. § 4.118, Diagnostic Code 7813, the criteria of which are found by the Board to be analogous to the Veteran's level of disability and symptomatology. The Veteran's onychomycosis is manifested by, at most, thickened nails of all toes on both feet affecting 0 percent of the Veteran's exposed areas and less than 5 percent of his total body area, with topical treatment. 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 rating currently assigned for his onychomycosis. Ratings in excess of the currently assigned rating are provided for certain manifestations of nail disorders, but the medical evidence does not show that those manifestations are present. The Board finds that the criteria for the currently assigned rating for the Veteran's onychomycosis reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular rating is adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization or marked interference with employment. The evidence shows that the Veteran is employed and that his onychomycosis does not cause an impact on his occupational abilities beyond that contemplated by the currently assigned rating. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.118, Diagnostic Code 7813 (2012). In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's onychomycosis does not meet the criteria for a rating in excess of 0 percent. Therefore, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). Insomnia Service connection for insomnia was granted by a June 2008 rating decision and a 10 percent rating was assigned under 38 C.F.R. § 4.130, Diagnostic Code 9499-9421, effective December 27, 2007. Unlisted disabilities requiring rating by analogy will be coded by the first two numbers of the most closely related body part and 99. 38 C.F.R. § 4.27 (2012). The hyphenated diagnostic code indicates that an unlisted mental disorder, under Diagnostic Code 9499, was the service-connected disorder, and a somatization disorder, under Diagnostic Code 9421, was a residual condition. Subsequently, a January 2010 rating decision assigned a 30 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9499-9421, effective December 27, 2007. In a September 2006 VA pre-discharge psychiatric examination report, the Veteran reported that he experienced mild psychiatric symptoms which were variable and increased with social stressors and resolved with dissipation of social stressors. The examiner stated that the Veteran did not have any social impairment. On objective examination, the Veteran's mental status was within normal limits. He did not have any impairment of thought process or communication, did not experience delusions or hallucinations, and did not display inappropriate behavior. The Veteran did not have any suicidal or homicidal thoughts, plans, or intent. He was able to maintain minimal personal hygiene and perform basic activities of daily living. The Veteran was oriented to person, time, and place; there was no indication of memory loss impairment; and he did not have obsessive or ritualistic behavior which interfered with routine activities. His speech was of normal rate and flow without irrelevant, illogical, or obscure speech patterns. The Veteran did not experience panic attacks and did not have impaired impulse control. However, the Veteran did report some mild depression and sleep impairment, with additional mild cognitive dulling secondary to pain medication, without evidence on examination. The Axis I diagnoses were nicotine dependence in early full remission and adjustment disorder with mood disturbance, mild. The examiner assigned a Global Assessment of Functioning (GAF) score of 75 which contemplates transient and expectable reactions to psychosocial stressors, such as difficulty concentrating after family argument, or no more than slight impairment in social, occupational, or school functioning, such as temporarily falling behind in school work. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). After separation from service, in a May 2008 VA mental disorders examination report, the Veteran reported that he had been with his current partner for 12 years and had a good relationship with her. He reported that he had children from a prior relationship, but was not close with them. The Veteran's social relationships were described as adequate, and he had a number of activities and leisure pursuits. The Veteran denied a history of suicide attempts, violence, or assaultiveness. He reported experiencing frequent insomnia, but denied any depressive or dysthymic symptoms. On psychiatric examination, the Veteran was clean, neatly groomed, and appropriately dressed. His psychomotor activity and speech were unremarkable, his attitude was cooperative, his affect was normal, and his mood was good. The Veteran's attention and orientation were intact, while his thought process and content were unremarkable. The Veteran did not have any delusions or hallucinations, he understood the outcome of behavior, and had insight into his problem. He did experience sleep impairment, but did not have inappropriate behavior, obsessive/ritualistic behavior, or panic attacks. The Veteran did not have homicidal or suicidal thoughts, his impulse control was good, and he had no episodes of violence. The Veteran was able to maintain minimum personal hygiene, he had no problems with activities of daily living, and his memory was normal. The Axis I diagnosis was insomnia. The examiner assigned a GAF score of 80 which contemplates transient and expectable reactions to psychosocial stressors. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The examiner stated that the Veteran did not meet the criteria for a diagnosis of dysthymic disorder or depression. The examiner stated that the Veteran did not experience total occupational and social impairment, nor did he have deficiencies in judgment, thinking, family relations, work, mood, or school. The Veteran also did not have reduced reliability and productivity due to mental disorder symptoms, nor did he have an occasional decrease in work efficiency with intermittent period of an inability to perform occupational tasks due to mental disorder signs and symptoms, but with a generally satisfactory level of functioning. Finally, the Veteran did not have mental disorder signs and symptoms that were transient or mild and decreased work efficiency and ability to perform occupational tasks only during period of significant stress. The examiner further stated that the Veteran's symptoms were not severe enough to interfere with occupational and social functioning. In a January 2010 VA mental disorders examination report, the Veteran reported that he was receiving treatment for insomnia and was taking anti-depressant medication. On psychiatric examination, the Veteran was clean, neatly groomed, and appropriately dressed. His psychomotor activity was restless and fatigued and his speech was spontaneous, hesitant, clear, and coherent. His attitude was cooperative, attentive and guarded, and his affect was full with a good mood. The Veteran's attention and orientation were intact, while his thought process and content were unremarkable. The Veteran did not have any delusions or hallucinations, understood the outcome of behavior, and had insight into his problem. He did experience sleep impairment, but did not have inappropriate behavior or panic attacks and interpreted proverbs appropriately. The Veteran did have obsessive or ritualistic behavior, in that he preferred routines and organization, in part due to his military and work habits and in part so that he did not forget things. The Veteran did not have homicidal or suicidal thoughts, his impulse control was good, and he had no episodes of violence, though his fiancé noted that he had been more irritable since his return from Iraq. The Veteran was able to maintain minimum personal hygiene, but he had slight problems with household chores, shopping, sports, exercise, driving, and recreational activities due to fatigue. His remote memory was normal, but his recent and immediate memory were mildly impaired. The examiner stated that the Veteran's recent and recall memory functions were grossly intact, with slight fine impairments in retention. The Axis I diagnoses were primary insomnia; sleep disorder due to chronic pain, insomnia type; and cognitive disorder, not otherwise specified. The examiner assigned a GAF score of 61, which contemplates some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, such as occasional truancy or theft within the household, but generally functioning pretty well with some meaningful interpersonal relationships. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV). The examiner stated that the Veteran did not experience total occupational and social impairment, nor did he have deficiencies in judgment or mood, though he did have deficiencies in thinking, family relations, and work. These deficiencies were specifically listed, with those of thought resulting from slowness of mentation due to fatigue and memory problems from a cognitive disorder. The deficiencies of thought were limited to increased irritability and impatience, while his deficiencies of work were listed as falling asleep at work for brief periods, without any impairment of his ability to complete assigned duties within timeframes. The examiner also stated that the Veteran had reduced reliability and productivity due to mental disorder symptoms, but then noted that the Veteran was pretty happy except for his physical problems, attempted to maintain a positive attitude, and engaged in normal activates as much as possible. The Schedule provides that assignment of a 30 percent rating is warranted for somatization disorders with occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation, due to such symptoms as: depressed mood, anxiety, suspiciousness, weekly or less often panic attacks, chronic sleep impairment, mild memory loss, such as forgetting names, directions, recent events. 38 C.F.R. § 4.130, Diagnostic Code 9421 (2012). A 50 percent rating is warranted for somatization disorders with occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory such as, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9421 (2012). A 70 percent rating is warranted for somatization disorders with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9421 (2012). A 100 percent rating is warranted for somatization disorders with total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9421 (2012). The evidence of record shows that the Veteran's insomnia has been consistently manifested by sleep impairment, depression, mild memory impairment, obsessive or ritualistic behavior, and irritability. The Board finds that these symptoms do not meet the criteria for a disability rating of 50 percent. 38 C.F.R. § 4.130, Diagnostic Code 9421 (2012). The evidence of record does not show that the Veteran has exhibited circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impaired judgment; impaired abstract thinking; or difficulty in establishing and maintaining effective work and social relationships. The Board notes that the Veteran was found to have memory impairment in the January 2010 VA mental disorders examination report. However, this memory impairment was specifically noted to be mild, consisting only of slight fine impairments in retention. The Board finds that this level of memory impairment is most analogous to that contemplated by a 30 percent rating, which contemplates forgetting names, directions, and recent events, rather than that contemplated by a 50 percent rating, which contemplates retention of only highly learned material and forgetting to complete tasks. Indeed, of all the exemplary symptomatology listed under 38 C.F.R. § 4.130, the only symptom that the Veteran has exhibited that is not contemplated by a rating 30 percent is obsessive or ritualistic behavior. Obsessive rituals which interfere with routine activities is one of the symptoms contemplated by a 70 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9421 (2012). However, the evidence of record does not show that the Veteran's obsessional rituals interfere with routine activities. They were specifically found to not do so in the May 2008 VA mental disorders examination report. While the January 2010 VA mental disorders examination report found that such behavior existed, not only was it not reported to interfere with routine activities, the Veteran reported that it actively assisted him with his memory impairment. Accordingly, the Board finds that the Veteran's obsessive or ritualistic behavior is not analogous to the symptomatology contemplated by a rating in excess of 30 percent. Accordingly, the Veteran's demonstrable psychiatric symptomatology is most closely analogous to that contemplated by a 30 percent rating under 38 C.F.R. § 4.130. The Board finds that the symptomatology most nearly approximates occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation. The Board notes that the January 2010 VA mental disorders examination report stated that the Veteran experienced deficiencies in thinking, family relations, and work, and reduced reliability and productivity due to mental disorder symptoms. Those statements are references to the dominant criteria for 70 and 50 percent ratings, respectively. However, the examiner then added significant detail to those statements, explaining which symptoms caused them. The symptoms listed were the same as those discussed above, which the Board has already found are contemplated by his currently assigned 30 percent rating. In addition, the Board notes that the examiner also assigned a GAF score of 61, which contemplates some mild symptoms, and specifically stated that the Veteran's symptoms did not impact his ability to complete his work in a timely manner. Accordingly, the Board finds that the general statements made at the end of the January 2010 VA mental disorders examination report do not demonstrate that the Veteran's symptoms were sufficiently severe to warrant a rating in excess of 30 percent. This claim has also been reviewed with consideration of whether staged ratings would be warranted. While there may have been occasional fluctuations of the Veteran's insomnia 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 rating would be warranted 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 rating for insomnia inadequate. The Veteran's insomnia was rated under 38 C.F.R. § 4.130, Diagnostic Code 9421, the criteria of which are found by the Board to be analogous to the Veteran's level of disability and symptomatology. The Veteran's insomnia is manifested by sleep impairment, depression, mild memory impairment, obsessive or ritualistic behavior, and irritability. 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 rating currently assigned for his insomnia. Ratings in excess of the currently assigned rating are provided for certain manifestations of psychiatric disorders, but the medical evidence does not show that those manifestations are present. The Board finds that the criteria for the currently assigned rating for the Veteran's insomnia reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular rating is adequate and no referral is required. The Board finds that the evidence does not show frequent hospitalization or marked interference with employment. The evidence shows that the Veteran is employed and that his insomnia does not cause an impact on his occupational abilities beyond that contemplated by the currently assigned rating. VAOGCPREC 06-96 (1996), 61 Fed. Reg. 66749 (1996); 38 C.F.R. § 4.130, Diagnostic Code 9421 (2012). In reaching this decision, the Board finds that the preponderance of the evidence of record shows that the Veteran's insomnia does not meet the criteria for a rating in excess of 30 percent. Therefore, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Massey v. Brown, 7 Vet. App. 204 (1994). ORDER Service connection for sleep apnea is denied. Service connection for vertigo is denied. Service connection for chronic fatigue syndrome is denied. Service connection for pes planus is denied. An initial rating in excess of 30 percent for insomnia is denied. An initial rating in excess of 10 percent for degenerative joint disease of the right knee is denied. An initial rating in excess of 10 percent for degenerative joint disease of the left knee is denied. An initial rating in excess of 0 percent for onychomycosis of all nails is denied. REMAND With respect to the Veteran's residuals of a TBI claim, the Veteran's service medical records are negative for any reports of a traumatic brain injury. In an August 1993 service report of medical history, the Veteran reported that he was being treated for whiplash due to an automobile accident in July 1993. However, the Veteran denied ever having a head injury and only reported experiencing recurrent back pain. The Veteran's service medical records further show that he reported never having experienced a head injury in all of his service reports of medical history, including in May 2001. A February 2006 service medical report stated that the Veteran had fallen in the shower in November 2005. However, the Veteran only reported experiencing pain in his low back and buttocks region, with no complaints of any head injury. A June 2008 VA TBI screening report stated that the Veteran had not been diagnosed as having a TBI during deployment. The Veteran reported that he had fallen during his deployment and stated that fall resulted in loss of consciousness and not remembering the event. He reported that he subsequently experienced memory impairment, irritability, headaches, and sleep problems, and presently experienced memory impairment and sleep problems. On that basis, the TBI screen was found to be positive and the Veteran was referred for a TBI consultation. A July 23, 2008, VA orthopedic consultation report stated that the Veteran had been seen the same day in the TBI clinic, but no documentation from the TBI clinic was included in the report. Subsequently, a January 2010 VA mental disorders examination report stated that the Veteran had a confirmed diagnosis of a cognitive disorder, not otherwise specified, and stated that the diagnosis had been made by a VA medical center in July 2008. There is no documentation of this diagnosis in the claims file. Therefore, there is evidence of record that the Veteran was found to be positive on a screening for a TBI examination. The Veteran was subsequently scheduled for a TBI examination in July 2008, and medical evidence of record shows that a cognitive disorder was diagnosed in July 2008 by the same VA medical center. However, there are no records of that TBI examination, nor any indication as to whether the Veteran was found to have any residuals of a TBI at that time. The Board notes that, in July 2008, the Veteran's representative specifically notified VA of the existence of this examination and that relevant medical records would be generated therein. Accordingly, an attempt must be made to obtain those records and any other relevant medical records that are not currently associated with the claims file. 38 C.F.R. § 3.159(c)(2) (2012). With respect to the Veteran's bilateral leg varicose veins, a September 2006 VA pre-discharge general medical examination report stated that, on physical examination, the Veteran had varicose veins in the right and left lower extremities. The diagnosis was varicose veins in both lower extremities. However, after separation from service, a May 2008 VA general medical examination report did not mention varicose veins at all, including no complaints from the Veteran, no citation of varicose veins included in his problem list, no notations of varicose veins on physical exam, and no diagnosis of varicose veins. The exam found no abnormalities on examination of the Veteran's feet and lower extremities, without specifically saying that there were no varicose veins. While that medical examination did not show any current findings of varicose veins, the report also did not specifically state that the Veteran did not have varicose veins. The fact remains that the Veteran was specifically found to have varicose veins by a VA examination conducted prior to his discharge, and there is no medical evidence of record that the disorder was successfully treated and resolved. Accordingly, an additional examination is needed to determine whether the Veteran has a current diagnosis of varicose veins. 38 C.F.R. §§ 3.159(c)(4), 3.327 (2012). With respect to the Veteran's hemorrhoids, the Veteran's service medical records state that he underwent hemorrhoid removal surgery on May 15, 1990. A September 1998 service medical examination stated that, on clinical evaluation, the Veteran had no hemorrhoids and his rectal area was within normal limits. On a May 2001 active duty service report of medical history, the Veteran reported that he had a hemorrhoid removed in 1988 without sequelae. On clinical evaluation, the Veteran's anus and rectum were normal. However, a September 2002 service colonoscopy operative report stated that initial rectal examination was unremarkable, but a small hemorrhoid was noted on exit. Subsequently, in a September 2006 VA pre-discharge examination report, the Veteran reported experiencing occasional blood in his stool and stated that he was unsure if he had hemorrhoids again. The diagnoses included hemorrhoids, but the examiner did not conduct a rectal examination. After separation from service, in a May 2008 VA general medical examination report the Veteran reported experiencing intermittent rectal bleeding approximately once every two years, typically lasting for two days. On rectal examination, there were no hemorrhoids, fissures, or evidence of bleeding. The impression was status post hemorrhoidectomy with no current clinical evidence of disease. Accordingly, the evidence of record clearly demonstrates that the Veteran had hemorrhoids which pre-existed his second and third periods of active service, from September 1990 to April 1991, and from August 2001 to December 2007. The evidence of record also shows that the pre-existing hemorrhoids were surgically removed prior to these periods of service. However, a hemorrhoid was specifically found on an in-service colonoscopy in September 2002. This constitutes evidence that the Veteran's hemorrhoids may have recurred during active service. While no hemorrhoids were found on physical examination in May 2008, the Veteran has reported experiencing intermittent rectal bleeding in September 2006 and May 2008. Therefore, there is evidence suggesting an increase in symptomatology of the Veteran's pre-existing hemorrhoids during a subsequent period of active service, and evidence of current rectal symptomatology. Neither the September 2006 VA pre-discharge examination report or the May 2008 VA general medical examination report provided an opinion as to whether the Veteran's pre-existing hemorrhoids were aggravated by active service. Accordingly, an additional examination is needed to determine whether the Veteran's pre-existing hemorrhoids were aggravated by active service. 38 C.F.R. §§ 3.159(c)(4), 3.327 (2012). Accordingly, the case is REMANDED for the following actions: 1. Contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated or examined him for a TBI. An attempt must be made to obtain, with any necessary authorization from the Veteran, copies of any pertinent medical records identified which have not been previously secured, to specifically include all July 2008 medical records from the Bay Pines VA Medical Center. The Veteran may also submit the records himself. If, after making reasonable efforts to obtain these records, the records are not obtained, notify the Veteran and identify the specific records unable to be obtained; briefly explain the efforts made to obtain those records; describe any further action to be taken with respect to the claim; and inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 2. Schedule the Veteran for a VA examination to ascertain the existence and etiology of any residuals of a TBI found. The examiner must review the claim file and should note that review in the report. Based upon review of the service and post-service medical records, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any residuals of a TBI found were incurred in or aggravated during any of the Veteran's periods of active service. The examiner must also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any residuals of a TBI found are otherwise related to the Veteran's service in any way, to include as secondary to any service-connected disability. If any residuals of a TBI found are attributable to factors unrelated to the Veteran's service or service-connected disabilities, the examiner should specifically so state. A complete rationale for the opinions must be provided. 3. Schedule the Veteran for a VA examination to ascertain the existence and etiology of any varicose vein disability found. The examiner must review the claim file and should note that review in the report. Based upon review of the service and post-service medical records, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any varicose vein disability found was incurred in or aggravated during any of the Veteran's periods of active service. The examiner must also provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any varicose vein disability found is otherwise related to the Veteran's service in any way, to include as secondary to any service-connected disability. If any varicose vein disability found is attributable to factors unrelated to the Veteran's service or service-connected disabilities, the examiner should specifically so state. A complete rationale for the opinions must be provided. 4. Schedule the Veteran for a VA examination to ascertain the existence and etiology of any hemorrhoids, or residuals of hemorrhoids, found. The examiner must review the claim file and should note that review in the report. Based upon review of the service and post-service medical records, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's pre-existing hemorrhoids underwent a permanent increase in severity during active service. If so, was any permanent increase in severity the natural progress of the disorder? The examiner should also opine whether there is clear and unmistakable evidence that hemorrhoids were not aggravated during active service. If any hemorrhoids or hemorrhoid residuals found are attributable to factors unrelated to the Veteran's service, the examiner should specifically so state. A complete rationale for the opinions must be provided. 5. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs