Citation Nr: 1329664 Decision Date: 09/16/13 Archive Date: 09/20/13 DOCKET NO. 11-03 960 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for right ankle sprain with swelling (hereinafter "right ankle disorder"). 2. Entitlement to a disability evaluation in excess of 10 percent for osteoarthritis of the right hip (hereinafter "right hip disability"). 3. Entitlement to a disability evaluation in excess of 10 percent for osteoarthritis of the left hip (hereinafter "left hip disability"). 4. Entitlement to a disability evaluation in excess of 20 percent for degenerative joint disease of the lumbar spine with low back strain (hereinafter "lumbar spine disability"). 5. Entitlement to a disability evaluation in excess of 30 percent for generalized anxiety disorder (hereinafter "GAD"). 6. Entitlement to a total rating based on individual unemployability due to service-connected disability (hereinafter "TDIU"). REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESSES AT HEARING ON APPEAL The Veteran and E. S. ATTORNEY FOR THE BOARD A. Nigam, Counsel INTRODUCTION The Veteran served on active duty from February 1953 to April 1966. This matter initially came to the Board of Veterans' Appeals (hereinafter "Board") on appeal from a February 2010 rating decision of the Atlanta, Georgia Department of Veterans Affairs (hereinafter "VA") Regional Office (hereinafter "RO") wherein the RO denied an increased disability rating for the Veteran's service-connected GAD. Also on appeal is a rating decision, dated in September 2010, which denied entitlement to service connection for right ankle sprain with swelling, and entitlement to a disability evaluation in excess of 10 percent for the right hip disability; a disability evaluation in excess of 10 percent for the left hip disability; and a disability evaluation in excess of 20 percent for the lumbar spine disability. In September 2011 the Board remanded the issue of entitlement to a disability evaluation in excess of 30 percent for GAD to the RO via the Appeals Management Center (hereinafter "AMC") in Washington, D.C. for additional development of the record, including scheduling the Veteran for a videoconference hearing. The Veteran testified at a videoconference hearing before the undersigned Veterans' Law Judge (hereinafter "VLJ") in November 2011 on the issue of entitlement to a higher rating for service-connected GAD. A transcript of that hearing has been associated with the claims file. In February 2012, the Board again remanded the case to the RO via the AMC for additional development of the record, to include requesting VA examination and medical opinion, and issuing a statement of the case (hereinafter "SOC") as to the issues of entitlement to service connection for right ankle sprain with swelling; a disability evaluation in excess of 10 percent for the right hip disability; a disability evaluation in excess of 10 percent for the left hip disability; and a disability evaluation in excess of 20 percent for the lumbar spine disability, as required by 38 C.F.R. § 20.101(d) (2012); Manlincon v. West, 12 Vet. App. 238 (1999). The record shows substantial compliance with the February 2012 Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). In evaluating this case, the Board has not only reviewed the physical claims file, but has also reviewed the eFolder on Virtual VA (hereinafter "Virtual VA") to ensure a complete assessment of the evidence, but no additional documents pertinent to the present appeal were revealed. In March 2013, a supplemental SOC (hereinafter "SSOC") was issued, along with a March 2013 SOC. As such, the Board will proceed to consider the appeal on the merits. See 38 C.F.R. § 20.1304(c) (2012). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). Unfortunately, the matters of entitlement to a disability evaluation in excess of 30 percent for GAD and entitlement to a TDIU rating must again be REMANDED to the RO via the AMC. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the matters on appeal have been accomplished. 2. The Veteran's right ankle disorder did not have its onset in service and was not caused or permanently aggravated by his active military service. 3. For the entire period of the appeal, the Veteran's right hip disability has been productive of no more than painful or limited motion of a major joint. 4. For the entire period of the appeal, the Veteran's left hip disability has been productive of no more than painful or limited motion of a major joint. 5. For the entire period of the appeal, the Veteran's lumbar spine disability has not been manifested by forward flexion of the thoracolumbar spine 30 degrees or less; or, any ankylosis of the entire thoracolumbar spine; or, any intervertebral disc syndrome with incapacitating episodes requiring physician prescribed bed rest within the past 12 months; or, by any symptoms involving the cervical spine. CONCLUSIONS OF LAW 1. Service connection for a right ankle disorder is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2012). 2. The criteria for the assignment of a disability rating in excess of 10 percent for the service-connected right hip disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes (hereinafter "DCs") 5003-5010, 5250-5255 (2012). 3. The criteria for the assignment of a disability rating in excess of 10 percent for the service-connected left hip disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, DCs 5003-5010, 5250-5255 (2012). 4. The criteria for the assignment of a disability rating in excess of 20 percent for the service-connected lumbar spine disability has not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§3.102, 3.159, 3.321, 4.1-4.14, 4.71, 4.71a including DCs 5235 to 5243 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code (hereinafter "38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations (hereinafter "38 C.F.R.") and the precedential rulings of the United States Court of Appeals for the Federal Circuit (hereinafter "Federal Circuit") (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (hereinafter "Court") (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issues under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. A Veteran bears the "'evidentiary burden' to establish all elements of a claim, including the nexus requirement." Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). The Board's duty is to first determine the probative value of all pertinent medical and lay evidence of record based on its credibility and competency, and then weigh the probative value of the evidence regarding all material elements of a claim. See 38 U.S.C.A. § 7104(d); Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). A "veteran is given the 'benefit of the doubt' 'regarding any issue material' to the veteran's claim 'when there is an approximate balance of positive and negative evidence.'" Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). Thus, if there is conflicting medical evidence, the Board may not ignore or disregard any medical professional's opinion, but may assign greater probative to one medical opinion over by providing an adequate statement of reasons or bases for doing so. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Willis v. Derwinski, 1 Vet. App. 66, 70 (1991). A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In making all determinations, the Board must also fully weigh the probative value of the lay evidence of record against the remaining evidence of record. See King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). If credible, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana, 24 Vet. App. at 438; Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). Moreover, lay evidence must not be categorically dismissed as incompetent evidence of medical causation merely because it is lay evidence. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Rather, lay evidence may be competent and sufficient evidence of a diagnosis or nexus if (1) the particular condition at issue is the type of condition that is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 433, n.4. The Board must determine on a case- by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Jandreau, 492 F.3d 1367-77; see also Kahana, 24 Vet. App. at 438, J. Lance dissenting; Robinson v. Shinseki, 312 Fed. Appx. 336, 339 (Fed. Cir. 2009) (nonprecedential). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Duties to Notify and Assist The Veterans Claims Assistance Act (hereinafter "VCAA") describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1). In a freestanding claim for an increased evaluation, the VCAA requirement is generic notice: the type of evidence needed to substantiate the claim, which consists of evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VCAA letters dated in January 2010 and April 2010, collectively explained the evidence necessary to substantiate the claims for increased ratings and for service connection, and informed the Veteran of his and VA's respective duties for obtaining evidence. The Veteran was also advised of the type of evidence needed to substantiate the claims for increased ratings, which consists of evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned, in compliance with Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The letters explained how a disability rating is determined for a service-connected disorder and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-491 (2006). As noted, the claims were readjudicated in the March 2013 SSOC. Accordingly, prejudicial error in the timing or content of VCAA notice has not been established and any error is not outcome determinative. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency). Further, if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome by the following: (1) based on the communications sent to the Veteran over the course of this appeal, he clearly has actual knowledge of the evidence he is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to him by VA, it is reasonable to expect that he understands what is needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). VA has a duty to assist veterans in obtaining evidence necessary to substantiate their claims. The claims file contains post-service medical treatment records, and reports of VA examinations (also known in the record as Disability Benefits Questionnaires or "DBQs") (June 2010 and May 2012). With respect to the VA examinations, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examination reports generally reflect review of the claims file, examination of the Veteran, and description and evaluation of his disabilities in accordance with the criteria for rating the hip and spine disabilities. They also contain discussion of the likelihood of a relationship between the Veteran's claimed right ankle disorder and his military service. In particular, these examination findings are sufficient for proper application of the relevant rating criteria and are adequate for the purpose of adjudication of the right and left hip, and lumbar spine disabilities. These examination reports also contain an opinion as to the etiology of the Veteran's right ankle disorder. As stated above, in February 2012, the Board remanded the case for additional development of the record, to include providing the Agency of Original Jurisdiction (hereinafter "AOJ") with the opportunity to review the newly submitted evidence, and as noted, the RO has issued the March 2013 SOC, as required by 38 C.F.R. § 20.101(d) (2012); Manlincon v. West, 12 Vet. App. 238 (1999). As such, the Board finds that the development directed in the prior remand has been substantially completed. Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran also was provided an opportunity to set forth his contentions during the November 2011 hearing before the undersigned; he has not requested a personal hearing on the remaining issues that are now on appeal. The Court has held that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board and that a VLJ has a duty to explain fully the issues and a duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The record reflects that at the November 2011 hearing the undersigned set forth the issue to be discussed at the hearing, focused on the elements necessary to substantiate the claim, and sought to identify any further development that was required to help substantiate the claim. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing The Veteran has not made the RO, the AMC or the Board aware of any additional evidence that must be obtained in order to fairly decide the claims on appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of these issues have been obtained and the case is ready for appellate review. The Board additionally finds that general due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). The Merits of the Claim-Entitlement to Service Connection Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999). The determination as to whether these 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); 38 C.F.R. § 3.303(a). "Congress specifically limits entitlement to service- connected disease or injury where such cases have resulted in a disability. In the absence of a proof of present disability there can be no claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal; service connection may be awarded even though the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Certain chronic diseases, which are listed in 38 C.F.R. § 3.309(a) may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Id. If chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 3.309(a)." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also 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). The Veteran generally contends that he injured his right leg in service, and appears to assert that his right ankle disorder is related to that injury. Notably, in a statement received in May 2010, the Veteran reported that in March 1967 or April 1967 he was hospitalized with a severe swollen and infected right leg, and that since then he had many recurrences. He noted that in April 2010 he was treated in the emergency room and later hospitalized for this problem. He indicated that he was told by doctors in 1967 that this problem would never go away or improve with time. In his VA Form 9, Appeal to the Board of Veterans' Appeals, received in April 2013, the Veteran reported that he had never had any physical problems until 1958, but that for several years doctors have diagnosed him with degenerative joint problems, and in 1965 he was diagnosed with arthritis. The Board finds, after careful consideration of all relevant evidence, that the preponderance of the more probative evidence weighs against the claim for service connection for a right ankle disorder, for the following reasons. Initially, the Board finds that the following facts are not in dispute. The service treatment records are generally without findings of any complaint, treatment or diagnosis related to a right ankle disorder. However, a November 1964 service treatment record reflects that the Veteran had a 1000 pound case fall onto him which resulted in acute low back pain and pain down past his legs to his heels. He was diagnosed with acute low back strain at that time. Immediately following his separation from service, in May 1966 the Veteran underwent a VA examination, during which he complained of pain in the legs and spine, stiffness of the elbows and knees, and dermatitis of the feet, among other things. However, he failed to report any right ankle symptoms at that time, and on physical examination his ankle jerks were observed to be normal. In an April 1968 VA social service report, the Veteran reported that he experienced back and leg pain since his separation from service, but again failed to report any right ankle symptoms at that time. Also, a May 1971 VA outpatient clinic examination revealed normal findings for the right ankle. The Board finds the May 1966, April 1968 and May 1971 VA treatment record and examination reports, showing normal physical findings for the right ankle within a few years of separation from service, to be highly credible as they were generated with a view towards ascertaining the Veteran's then-state of physical fitness and are akin to statements of diagnoses or treatment. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); see also LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). Thus, the Board finds the probative evidence of record weighs against a finding of continuity of a chronic right ankle disorder since service. The post-service clinical record shows treatment for edema of the ankles, a single instance of decreased range of motion in the ankles, warm extremities and a general history of arthritic pain and diagnosis of rheumatoid arthritis, starting in 2007. There is also a more recent diagnosis of right ankle sprain. Accordingly, the record demonstrates evidence of a current disability, which meets the first element of a service connection claim. Hickson, 12 Vet. App. at 253. Most critically, however, the second and third elements of a service connection claim, that is medical or lay evidence of in-service incurrence or aggravation of a disease or injury; and medical or lay evidence of a nexus between the claimed in-service disease or injury and the present disability, have not been satisfied. Hickson, 12 Vet. App. at 253. Weighing in favor of the claim are lay statements from the Veteran, which indicate observations that after his separation from service he experienced symptoms of right ankle pain and swelling that he believed were related to his military service. The Board finds that these lay statements are competent evidence that the Veteran experienced post- service right ankle problems, as the Veteran is deemed competent to report observable symptoms for the right ankle, including pain and swelling. Washington, 19 Vet. App. at 368; Layno, 6 Vet. App. at 469. See also 38 C.F.R. § 3.159(a)(2). However, the Board notes that these statements generally indicate that the Veteran did not experience a continuous right ankle disorder since his separation from service. Also, the Board finds that the question of whether the Veteran currently experiences a right ankle disorder that is related to his military service is a complex medical question outside the competence of a layperson. The Veteran has not been shown to have the diagnostic capabilities to determine that the right ankle problems he claims to have experienced in service were not resolved in service, and that the current right ankle disorder developed as the result of post-service employment or injury. His opinion is therefore not competent evidence of a diagnosis or etiology. See Kahana, 24 Vet. App. at 433, n.4; Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. On VA examination, dated in June 2010, the Veteran reported a history of a right ankle disorder with swelling since November 1964, but could not explain how it occurred. He complained of symptoms of weakness, stiffness, swelling, redness, lack of endurance, tenderness and pain. He denied heat, giving way, locking fatigability, deformity, drainage, effusion, subluxation and dislocation. The Veteran denied ever being hospitalized or undergoing any surgery to treat his right ankle, and noted that in the past 12 months he had not experienced incapacitation. On physical examination, the Veteran's posture, gait and tandem gait were characterized as normal. Walking was observed to be steady, and examination of the feet did not reveal any signs of abnormal weight bearing or breakdown. The Veteran did not require any assistive device for ambulation, or have any callosities or unusual shoe wear pattern. Examination of the ankle included observations of right ankle edema and tenderness, without any instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, drainage, or subluxation. The examiner noted there was no deformity or ankylosis in the right ankle. Moreover, the Veteran's ranges of motion in the right ankle were within normal limits, repetitive ranges of motion were possible and within normal limits, and there was no additional degree of limitation. Additionally, right ankle X-ray findings were within normal limits, there was no indication of a malunion to the os calcis on the right, and there was no indication of malunion of the astralgus on the right. The Veteran was diagnosed with a right ankle sprain with swelling. The examiner opined that it was less likely that the current diagnosis of right ankle condition with swelling/right ankle sprain was related to military service. The examiner explained that there was no available pertinent medical evidence referencing an ankle condition, and that although there was documentation of complaints of arthritis involving the knees and hands, there was no specific mention of an ankle condition in the records provided. The examiner noted that evidence of a right ankle disorder was not documented until many years post-service. Therefore, the Board finds that the June 2010 VA examiner's opinion that the Veteran's right ankle disorder was not incurred in or aggravated by service is highly persuasive because it provides a clear opinion supported by an accurate factual foundation and a thorough explanation. It is clear that the examiner delved into the in-service and post- service clinical record, as it was noted that the Veteran reported that he did not know the cause of his right ankle disorder. Although the examiner's opinion does not expressly discuss the Veteran's reports of observations of his right ankle symptoms after service, this omission is nonconsequential for several reasons. First, as a general matter, a medical examiner is not required to comment on every favorable piece of evidence in a claims file. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012). Second, for the reasons discussed above and to the extent that there is any suggestion of systemic or rheumatoid arthritis that may affect the right ankle, the lay statements fail to indicate credible observations of a continuity of symptoms, especially in light of absence of right ankle symptoms in 1966 and 1968 records, and the normal right ankle findings on examination in 1971. Notably, x-rays in June 2010 are negative for right ankle pathology. Further, such lay statements and are found not competent evidence to relate the Veteran's current right ankle symptoms to any in-service right ankle symptoms. Any deficiency in the VA examiner's factual foundation or explanation is consequently immaterial. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (a VA examination report "must be read as a whole" to determine an examiner's rationale); Acevedo v. Shinseki, 25 Vet. App. 286, 293- 942012); see also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Accordingly, the probative value of the VA examiner's opinion is not materially diminished in this respect. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board finds that the June 2010 VA examination is the most probative evidence of record as it consists of clear conclusions based on a thorough examination of the clinical record and consideration of the Veteran's assertions. Moreover, it directly addresses the central question of causation in this case. There are no related findings in the Veteran's service treatment records. The Veteran's right ankle disorder was acknowledged, but the examiner ultimately concluded that the Veteran's right ankle pathology was not incurred in or aggravated by service. Such a medical opinion, which is factually accurate, fully articulated, and based on sound reasoning, carries significant weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board, in its own lay capacity (as with the Veteran), is not otherwise qualified to call into question the VA examiner's medical judgment, nor does the Board find any reason to do so. See, e.g., Monzingo, 26 Vet. App. 97, 106 (2012). Accordingly, the Board finds that the June 2010 VA examiner's opinion, which represents the most probative evidence on this question, establishes that it is less likely than not that a causal relationship ("nexus") between any present bilateral ankle disorder and the Veteran's military service. Moreover, as noted, the record shows the Veteran was first treated for an ankle-related problem in 2007, more than four decades after his separation from service. In fact, he did not even file a claim for service connection for a right ankle disorder until April 2010. The passage of so many years between his service separation and the medical documentation of the current right ankle disorder is evidence against the claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board finds the evidence against the claim to be more probative than the evidence in favor of the claim. Therefore, the Veteran's claim for service connection for a right ankle disorder must be denied. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine in not applicable where, as here, the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107(b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The Merits of the Claim-Entitlement to Increased Ratings Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.20 (2012). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In evaluating the severity of a particular disability it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where, as in this case, entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim, if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Ratings shall be based, as far as practicable, upon the average impairments of earning capacity. However, from time to time, VA will readjust this schedule of ratings in accordance with experience. To accord justice in an exceptional case in which the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service- connected disability or disabilities. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). All potential applicable diagnostic codes, whether or not raised by a claimant, must be considered. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the Veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Furthermore, when it is not possible to separate the effects of the service-connected disability from a nonservice- connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). However, "disability ratings are assigned based on a 'condition,' rather than on any symptoms of a particular condition." Cullen v. Shinseki, 24 Vet. App. 74, 80-81, 84 (2010). Thus, separate disability ratings under the same diagnostic code are not assignable "for different symptoms of an underlying spinal condition, such as pain, ankylosis, or muscle spasms." Id. In other words, "within a particular diagnostic code, a claimant is not entitled to more than one disability rating for a single disability unless the regulation expressly provides otherwise." Id. However, separate ratings may be assignable under different diagnostic codes where a disability involves distinct conditions. Id. It is important to note generally that the joining of schedular criteria by the conjunctive "and" in a diagnostic code does not always require all criteria to be met, except in the case of diagnostic codes that use successive rating criteria, where assignment of a higher rating requires that elements from the lower rating are met. Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). See also Tatum v. Shinseki, 23 Vet. App. 152 (2009) (indicating the joining of criteria by the conjunctive "and" in a diagnostic code does not always require all criteria to be met, except in the case of a diagnostic code that uses successive rating criteria, where assignment of a higher rating requires that elements from the lower rating are met.) Right and Left Hip Disabilities The Veteran's service-connected right hip disability and left hip disabilities are currently rated pursuant to 38 C.F.R. § 4.71a, under the General Rating Formula for Diseases and Injuries of the Hip and Thigh (DCs 5250-5255). Normal hip flexion is from zero to 125 degrees, and normal hip abduction is from zero to 45 degrees. 38 C.F.R. § 4.71, Plate II. He has been assigned 10 percent disability ratings for each hip based on findings of painful or limited motion of a major joint, under the diagnostic codes for rating traumatic and degenerative arthritis, 38 C.F.R. § 4.71a, DCs 5003 and 5010. When an evaluation of a disability is based on limitation of motion, VA must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Although pain may cause a functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). With any form of arthritis, painful motion is an important factor of disability. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59. Diagnostic Code 5010 provides that traumatic arthritis is to be rated as degenerative arthritis. Diagnostic Code 5003 in turn provides that degenerative arthritis (that is established by X-ray findings) will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 pct and 10 pct ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Diagnostic Code 5250 provides a 90 percent rating will be assigned for extremely unfavorable ankylosis of the hip, the foot not reaching the ground, crutches necessitated; a 70 percent rating will be assigned for intermediate hip ankylosis; and a 60 percent rating will be assigned for favorable ankylosis of the hip in flexion at an angle between 20 degrees and 40 degrees, and slight adduction or abduction. See 38 C.F.R. § 4.71a, DC 5250 (2012). Diagnostic Code 5251 provides a 10 percent rating will be assigned for limitation of extension of the thigh to 5 degrees. See 38 C.F.R. § 4.71a, DC 5251 (2012). Diagnostic Code 5252 provides a 40 percent rating will be assigned for limitation of flexion of the thigh to 10 degrees; a 30 percent rating will be assigned for limitation of flexion of the thigh to 20 degrees; a 20 percent rating will be assigned for limitation of flexion of the thigh to 30 degrees; and a 10 percent rating will be assigned for limitation of flexion of the thigh to 45 degrees. See 38 C.F.R. § 4.71a, DC 5252 (2012). Diagnostic Code 5253 provides a 20 percent rating will be assigned for thigh impairment with limitation of abduction of the thigh with motion lost beyond 10 degrees; a 10 percent rating will be assigned for limitation of adduction, cannot cross legs, or for limitation of rotation, cannot toe-out more than 15 degrees, affected leg. See 38 C.F.R. § 4.71a, DC 5253 (2012). Diagnostic Code 5254 provides an 80 percent rating will be assigned for hip flail joint. See 38 C.F.R. § 4.71a, DC 5254 (2012). Diagnostic Code 5255 provides an 80 percent rating will be assigned for impairment of femur, fracture shaft or anatomical neck, with nonunion, with loose motion (spiral or oblique fracture); a 60 percent rating will be assigned for impairment of femur with nonunion, without loose motion, weight bearing preserved with aid of brace, or for fracture of surgical neck of the femur with false joint; a 30 percent rating will be assigned for malunion of the femur with marked knee or hip disability; a 20 percent rating will be assigned for malunion of the femur with moderate knee or hip disability; and a 10 percent rating will be assigned for malunion of the femur with slight knee or hip disability. See 38 C.F.R. § 4.71a, DC 5255 (2012). In June 2010, the Veteran underwent a VA general examination, during which he reported a history of being diagnosed with osteoarthritis of the bilateral hip, which had existed since November 1964. Specifically, he reported the original injury occurred in 1964 due to injury moving equipment. Since then, the Veteran had experienced symptoms of weakness, stiffness, swelling, redness, lack of endurance, tenderness and pain. He denied experiencing symptoms of heat, giving way, locking, fatigability, deformity, drainage, effusion, subluxation and dislocation. He indicated that he experienced flare-ups of functional impairment, including difficulty lifting, jumping, standing and walking. He noted that these flare-ups occurred as often as once a day, lasting for 3 hours at a time, occurring spontaneously, and alleviated spontaneously and by acetaminophen 500 milligrams. The Veteran denied ever being hospitalized or undergoing surgery for his disability, and reported that his condition had not resulted in any incapacitation over the previous 12 months. He also denied undergoing joint replacement surgery, and noted that his overall functional impairment was that "at times it was impossible to perform." On physical examination of the musculoskeletal system, the Veteran's posture, gait and tandem gait were characterized as normal, his walk was steady, his leg length from the anterior superior iliac spine to the medial malleolus was 87 centimeters on the right and 87 centimeters on the left. Examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, nor did it reveal any callosities or unusual shoe wear pattern. The Veteran did not require any assistive device for ambulation. On examination of the hips, right and left hip tenderness was observed, without any signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, drainage, or subluxation. Notably, there was no ankylosis in either hip. Range of motion testing was within normal limits on both the right and left sides, with repetitive range of motion possible and within normal limits, and without any additional degree of limitation. The examiner indicated that joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use on either side. The Veteran was diagnosed with osteoarthritis of the right hip and the left hip associated with degenerative joint disease, lumbar spine with low back strain. The Veteran's disabilities were described as active, with subjective factors of pain and objective factors of right and left hip tenderness. In May 2012, the Veteran underwent a second VA examination, during which he reported experiencing symptoms of constant pain rated as 5 out of 10, with swelling, stiffness and sharp pain to 10 out of 10 with standing over 5 minutes and walking over 200 yards. He described daily flare-ups that impacted the function of his hips whenever he stood for over 5 minutes, walked for over 200 yards, or sat for more than 30 minutes. Range of motion testing included right hip and left hip flexion to 90 degrees, with painful motion beginning at 90 degrees; right hip extension greater than 5 degrees with painful motion beginning at 5 degrees; no abduction lost beyond 10 degrees; no adduction limited such that the Veteran could not cross his legs; and no rotation limited such that the Veteran could not toe-out more than 15 degrees. The examiner noted that the Veteran's range of motion was normal and explained that he had orthopnea, dyspnea and abdominal engorgement secondary to nonservice- connected heart failure and chronic obstructive pulmonary disease; therefore he was unable to tolerate the supine position, thus the examination was performed in the upright position. The examiner indicated that the Veteran was able to perform repetitive-use testing with post-test flexion for the right hip limited to 100 degrees, extension to 5 degrees or greater, and no abduction, adduction, or rotation limitations observed. The post-test flexion for the left hip was to 90 degrees, extension to 5 degrees or greater, and no abduction, adduction, or rotation limitations observed. The examiner opined that the Veteran did not have additional limitation in ranges of motion of the hip and thigh following repetitive-use testing; however, there was functional loss and/or functional impairment of the hip and thigh. Specifically, the Veteran was observed to have pain on movement in both hips, along with localized tenderness or pain to palpation for both hips. The examiner reported findings of normal muscle strength testing and no ankylosis in either hip. Also, there was no malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran did not have a total hip joint replacement, or arthroscopic or other hip surgery, although he was observed to have antalgic gait, and to ambulate with a "Nanny walker" on a constant basis for a variety of joint issues. The examiner indicated that due to the Veteran's hip disabilities, there was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Diagnostic testing revealed findings of degenerative or traumatic arthritis in both hips, and he was diagnosed with mild degenerative joint disease of the left hip. The Veteran was diagnosed with osteoarthritis of the right hip and the left hip since 1964. The examiner noted that the Veteran's hip disabilities impaired his ability to work insofar as they caused him to have difficulty with prolonged walking over half a mile, prolonged sitting over half an hour at a time, and lifting over 30 pounds. A VA treatment record, dated in March 2013, shows findings of chronic left hip pain, for which the Veteran was prescribed hydrocodone for pain control. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to disability evaluations in excess of 10 percent, respectively, for either service-connected hip disability. There is no evidence showing that he has more than painful or limited motion of a major joint. A 20 percent evaluation is not warranted unless there is evidence of malunion of the femur with moderate knee or hip disability; limitation of abduction of motion lost in the thigh beyond 10 degrees; or flexion limited to 30 degrees. In this case, the Veteran is competent to report his bilateral hip symptoms, such as constant hip pain, which impairs his ability to work, walk and sit. His complaints are credible to the extent that they reflect pain and other functional limitation as described above. However, the Veteran's complaints fail to establish that he has any further limitation of flexion or abduction, or malunion of the femur, which would entitle him to a 20 percent evaluation in either hip. The Board also considered whether the functional loss due to pain could result in higher schedular evaluations for the right and left hip disabilities. While pain alone does not constitute functional loss, the Court has clearly indicated that the Board must consider the effects of pain, particularly as to any adverse impact on the normal working movements of the body. See 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). In this case, the Veteran has described significant right and left hip pain, which he has treated with medication. As noted, he is currently being rated for painful or limited motion of a major joint group. Moreover, even considering the effects of pain, there is nothing in the record that suggests the pain resulted in a functional loss akin to flexion limited to 30 degrees or more, a flail hip joint, impairment of the femur, limitation of abduction of motion of the thigh lost beyond 10 degrees, or any ankylosis. The evidence clearly demonstrates the Veteran has continued to retain motion in his hips. As described above, even considering the effects of pain, the Veteran retained near normal ranges of motion during this period. 38 C.F.R. § 4.45, 4.71a, DCs 5250 to 5255; DeLuca, 8 Vet. App. at 202; Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Accordingly, the Board is unable to grant increased schedular evaluations based upon pain. Based upon the guidance of the Court in Hart v. Mansfield, 21 Vet. App. 505 (2007), the Board has also considered whether staged ratings are appropriate for either hip disability at any point during the appeal. In the present case, the Board finds the symptoms have been relatively constant throughout the appeal period, and thus, increased evaluations are not warranted at any time. Accordingly, the preponderance of the evidence is against the Veteran's claims, and increased schedular evaluations are not warranted for the entire period of the appeal. 38 C.F.R. § 4.3. As the preponderance of the evidence is against the increased rating claims for the right and left hip disabilities denied above, the benefit-of-the-doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Lumbar Spine Disability The Veteran seeks an increased rating for his service- connected lumbar spine disability, which was rated as 20 percent disabling, under 38 C.F.R. § 4.71a, DCs 5235 to 5243 (2012). Under the General Rating Formula for Diseases and Injuries of the Spine, 38 C.F.R. § 4.71a, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 evaluation is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent evaluation is warranted for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code; Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habits, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 5235 Vertebral fracture or dislocation, 5236 Sacroiliac injury and weakness, 5237 Lumbosacral or cervical strain, 5238 Spinal stenosis, 5239 Spondylolisthesis or segmental instability, 5240 Ankylosing spondylitis, 5241 Spinal fusion, 5242, Degenerative arthritis of the spine (see also diagnostic code 5003). See 38 C.F.R. § 4.71a, DCs 5235 to 5242 (2012). Evaluate intervertebral disc syndrome (preoperatively or postoperatively) either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under section 4.25. A 10 percent evaluation is entitled for intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent evaluation is entitled for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is entitled for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is entitled for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1): For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. See 38 C.F.R. § 4.71a, DC 5243 (2012). Normal ranges of motion of the thoracolumbar spine are to 30 degrees in extension, to 90 degrees in flexion, to 30 degrees in lateral flexion, and to 30 degrees in rotation. 38 C.F.R. § 4.71, Plate V (2012). In June 2010 the Veteran underwent a VA general examination in which the severity of his lumbar spine was evaluated. Here, the Veteran reported being diagnosed with degenerative joint disease of the lumbar spine with low back sprain since November 1964, stemming from an injury in which a steam cabinet fell on top of him. He complained of limitation in walking due to his spine disability, and claimed that on average he could only walk 200 yards and that it took him 15 minutes to do so. He also reported experiencing falls due to his spine disability, along with symptoms of stiffness, fatigue, decreased motion and numbness; however, he denied experiencing spasms and paresthesia. He also complained of weakness of the spine, leg and foot, but denied having any bowel problems, bladder problems or erectile dysfunction related to the spine. He indicated that he began to experience severe, spontaneously occurring pain in the lower back that occurred constantly since the 1964 injury; however, he could function with medication and had been taking Acetaminophen 500 milligrams with benefit. During flare-ups the Veteran noted experiencing functional impairment which was described as "not able to lift items, walking, standing," and limitation of motion of the joint was described as "not able to lift items, walking, standing." He reported being hospitalized for his back because of his injury in 1964, and described the residuals of pain. The Veteran denied experiencing any incapacitating episodes related to his spine disability over the previous 12 months, and described his overall functional impairment as "not able to lift items, walking, standing." On physical examination of the thoracolumbar spine, the examiner observed that there was no evidence of radiating pain on movement and muscle spasm was absent, but there was tenderness in the lumbar region. The spinal contour was described as "preserved" although there was tenderness. There was no guarding of movement noted, and the examination did not reveal any weakness. Muscle tone and musculature were characterized as normal. There was negative straight leg raising in both legs, Lasegue's sign was negative, there was no atrophy present in the limbs, and there was no ankylosis of the thoracolumbar spine. Range of motion testing was within normal limits, repetitive ranges of motion were possible and within normal limits, and there was no additional degree of limitation. The examiner noted that the joint function of the spine was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The inspection of the spine revealed normal head position with symmetry in appearance, and there was symmetry of spinal motion with normal curves of the spine. Neurological examination of the lumbar spine revealed no sensory deficits from L1 to L5, and examination of the sacral spine revealed no sensory deficits of S1. The examiner noted that the modalities used to test sensory function was a pin prick and a feather. There was no lumbosacral motor weakness, and the lower extremity reflexes revealed +2 knee and ankle jerks bilaterally. The examiner observed the lower extremities showed no signs of pathologic reflexes, as well as normal cutaneous reflexes. The examiner noted there were no signs of lumbar intervertebral disc syndrome with chronic and permanent nerve root involvement, and there were no non-organic physical signs. The Veteran was diagnosed with degenerative joint disease of the lumbar spine with low back strain. His subjective factors were pain, and his objective factor was lumbar tenderness. In May 2012, the Veteran underwent a second VA examination, during which he complained of symptoms of constant dull pain rated as 5 out of 10 with occasional sharp pain about prolonged sitting in one position for over 10 minutes, walking over 200 yards, and lifting over 15 pounds, as well as stiffness and swelling. He reported daily flare-ups with prolonged sitting in one position over 10 minutes, walking over 200 yards, and lifting over 15 pounds. Range of motion testing with a goniometer revealed findings of forward flexion to 65 degrees with painful motion beginning at 60 degrees; extension to 25 degrees with painful motion beginning at 20 degrees; right and left lateral flexion to 25 degrees, respectively, with painful motion beginning at 20 degrees; and right and left lateral rotation to 25 degrees, respectively, with painful motion beginning at 15 degrees. The Veteran was able to perform repetitive-use testing with three repetitions, with post-test forward flexion ending at 65 degrees; post-test extension ending at 25 degrees; and post-test right and left lateral rotation and flexion ending at 25 degrees. The examiner observed the Veteran did not have additional limitation in range of motion of the thoracolumbar spine following repetitive-use testing; however, he did have functional loss in the form of less movement than normal and pain on movement, after repetitive use. The examiner noted there was localized tenderness and pain to palpation for the soft tissue of the thoracolumbar spine, as well as guarding and muscle spasm of the spine resulting in abnormal gait, but not in abnormal spinal contour, such as scoliosis, reversed lordosis or abnormal kyphosis. Moreover, there was no guarding and/or muscle spasm present. The examiner noted the Veteran did not experience any muscle atrophy, had normal reflex and sensory examinations, and had negative straight leg testing. He did not have any radicular pain or signs or symptoms of radiculopathy, nor did he have any other neurologic abnormalities or findings related to the spine disability. The Veteran did not have findings of intervertebral disc syndrome, but was observed to use a walker for multiple joint disabilities. Diagnostic testing revealed findings of arthritis and vertebral fracture, with 10 percent of loss of vertebral body. The Veteran was diagnosed on X-ray study with an impression of straightening of the normal lumbar lordosis, which could reflect muscle spasm; with osteopenia and mild compression fracture of T12; with degenerate spondylosis from L2 to L3 and L5 to S1; with mild facet arthropathy in the lower lumbar spine; with transitional thoracolumbar anatomy; and aortoiliac calcified atherosclerosis. The Veteran was diagnosed with degenerative joint disease of the lumbar spine with lower back strain since 1964, with mild compression fracture of T12 since 2012, and with degenerate spondylosis from L2 to L3 and from L5 to S1 since 2012. The examiner opined that the Veteran's back disability impacted his ability to work insofar as the Veteran experienced worsened pain with prolonged sitting, standing or walking. A VA treatment record, dated in March 2013, shows the Veteran's degenerative joint disease of the spine was described as "stable" and his pain was controlled with hydrocodone-acetaminophen. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to a disability evaluation in excess of 20 percent for the service-connected lumbar spine disability. There is no evidence showing that his lumbar spine has been manifested by forward flexion of the thoracolumbar spine 30 degrees or less; or, any ankylosis of the entire thoracolumbar spine; or, any intervertebral disc syndrome with incapacitating episodes requiring physician prescribed bed rest within the past 12 months; or, by any symptoms involving the cervical spine. The Veteran is competent to report his lumbar spine symptoms, such as constant pain, which impairs his ability to work, walk and sit. His complaints are credible to the extent that they reflect pain and other functional limitation as described above. However, the Veteran's complaints fail to establish that he has any further limitation of flexion in the thoracolumbar spine, any ankylosis, or any intervertebral disc syndrome, which would warrant a higher evaluation. The Board notes that ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)); Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (Ankylosis is "stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint," citing Stedman's Medical Dictionary 87 (25th ed. 1990)). The aforementioned range of motion findings do not demonstrate that the Veteran's lumbar spine is immobile or fixed in place, nor does the Veteran contend that his spine is stiff and fixed causing immobility due his disability. Based upon the guidance of the Court in Hart v. Mansfield, 21 Vet. App. 505 (2007), the Board has also considered whether staged ratings are appropriate for the lumbar spine disability at any point during the appeal. In the present case, the Board finds the symptoms have been relatively constant throughout the appeal period, and thus, increased evaluations are not warranted at any time. Accordingly, the preponderance of the evidence is against the Veteran's claim, and an increased schedular evaluation is not warranted for the entire period of the appeal. 38 C.F.R. § 4.3. As the preponderance of the evidence is against the increased rating claim for the lumbar spine disability denied above, the benefit-of-the-doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Additional Considerations Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Schedular ratings are based primarily upon the average impairment in earning capacity, that is, upon the economic or industrial handicap which must be overcome and not from individual success in overcoming it. 38 C.F.R. § 4.15. As noted, to afford justice in exceptional situations, however, an extraschedular rating may also be assignable. 38 C.F.R. § 3.321(b). The Board may not, in the first instance, assign an increased rating on an extraschedular basis, but may determine whether referral for extraschedular consideration is warranted, provided that it articulates the reasons or bases for that determination. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). This determination follows a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, the level of severity and symptomatology of a veteran's service-connected disability must be compared with the established criteria found in the rating schedule for that disability. Id. If the rating criteria reasonably describe a veteran's disability level and symptomatology, the disability picture is contemplated by the rating schedule. Therefore, the assigned schedular evaluation is adequate and no referral is required. Id. If the schedular evaluation does not contemplate the level of disability and symptomatology, and is found inadequate, the second step of the inquiry requires the Board to determine whether the exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-16. The first two steps should be undertaken by comparing the disability picture of each service-connected disability with the criteria in the rating schedule for that disability. The Board should compare the service-connected disability picture with the criteria in the rating schedule for that disability. Johnson v. Shinseki, No. 10-1785, slip op. at 10 (Vet. App. Mar. 27, 2013) (en banc). Extraschedular consideration is undertaken on the basis of each individual service-connected disability. Based on this disability-by- disability approach, the Board is not required to consider whether a veteran is entitled to referral for extraschedular consideration of his service-connected disabilities on a collective basis. Id. If analysis of the first two steps shows that the rating schedule is inadequate to evaluate the disability picture and that picture shows the related factors discussed above, the final step requires that the disability be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. 111. Here, the rating criteria reasonably describe the Veteran's right and left hip, and lumbar spine disability levels and symptomatology, and provide for consideration of greater disability and symptoms than currently shown by the evidence. It is noted that the symptoms listed in the rating criteria are demonstrative and not exhaustive; thus, the rating criteria actually consider many other orthopedic symptoms. See Mauerhan, 16 Vet. App. 436; see also 38 C.F.R. § 4.71a. Overall, the occupational and social impairment caused by the Veteran's right and left hip, and lumbar spine disabilities and associated residuals, as described above, are accounted for by the rating criteria. Thus, the assigned schedular evaluation is adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. (Continued on the next page) ORDER Service connection for a right ankle disorder is denied. A disability evaluation in excess of 10 percent for a right hip disability is denied. A disability evaluation in excess of 10 percent for a left hip disability is denied. A disability evaluation in excess of 20 percent for a lumbar spine disability is denied. REMAND A May 2012 VA mental disorders examination report shows the Veteran reported undergoing treatment at the Atlanta VA Medical Center (hereinafter "VAMC") with psychologist "Dr. L.M.M." in November 2011. The VA examiner commented on the content of the report, and on Dr. L.M.M.'s findings; however, the record does not contain this treatment record. As this record appears to be relevant to the Veteran's increased rating claim, as it speaks to the current level of severity of the Veteran's psychiatric disability, complete VA treatment records from the Atlanta VAMC must be obtained and associated with the claims file. VA's duty to assist includes obtaining records of relevant VA medical treatment. 38 U.S.C.A. § 5103A(c)(2); 38 C.F.R. § 3.159(c)(2), (c)(3). See also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA is charged with constructive, if not actual, knowledge of evidence generated by VA). Also, the Board finds that a final appellate decision on the claim for TDIU must again be deferred pending resolution of the preliminary claim for entitlement to a disability evaluation in excess of 30 percent for GAD, as this matter is inextricably intertwined with the TDIU claim, in light of contentions that the severity of the psychiatric disability impacts the Veteran's employability. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO/AMC must request the Veteran to identify all records of VA and non-VA health care providers who have treated his psychiatric disability. The RO/AMC must take appropriate steps to obtain copies of any outstanding treatment records, to include any treatment records from the Atlanta VAMC, to specifically include the November 2011 report of psychiatric treatment by Dr. L.M.M. The RO/AMC must follow the procedures set forth in 38 C.F.R. § 3.159(c) as regards requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Thereafter, the RO/AMC must consider all of the evidence of record and readjudicate the claim for an increased rating. Only after readjudication of the claim for an increased rating for GAD, should the RO/AMC readjudicate the claim for a TDIU. If the benefits sought on appeal are not granted, the Veteran and his representative should be furnished with an SSOC and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs