Citation Nr: 1330461 Decision Date: 09/23/13 Archive Date: 09/30/13 DOCKET NO. 06-30 842 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased initial rating for sinusitis, currently rated as 10 percent disabling. 2. Entitlement to an increased initial rating for gastroenteritis, currently rated as 10 percent disabling. 3. Entitlement to an increased rating for a low back disability, currently rated as 10 percent disabling. 4. Entitlement to an increased rating for a left knee disability, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from November 1990 to May 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2005, October 2005, and December 2005 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The July 2005 rating decision continued a 10 percent rating for a low back disability. The October 2005 rating decision granted service connection for sinusitis and assigned a 10 percent rating, effective January 4, 1999, and granted service connection for gastroenteritis and assigned a 0 percent rating, effective January 4, 1999. The December 2005 rating decision continued a 0 percent rating for a left knee disability. A December 2006 rating decision increased the disability rating for gastroenteritis from 0 percent to 10 percent, effective January 4, 1999, and increased the disability rating for a left knee disability from 0 percent to 10 percent, effective January 4, 1999. However, as these grants do not represent total grants of benefits sought on appeal, the claims for increase remain before the Board. AB v. Brown, 6 Vet. App. 35 (1993). Additionally, in an April 2009 rating decision, the RO assigned a temporary total evaluation for the left knee disability, effective February 3, 2009, and continued the 10 percent rating thereafter, effective May 1, 2009. Therefore, the Board's analysis for increased rating for a left knee disability will not include the period of temporary total evaluation. In December 2010, the Veteran testified at a travel board hearing before a Veterans Law Judge regarding the issues on appeal. A transcript of the hearing is associated with the claims file. The Veteran was notified by letter dated in July 2012 that the Veterans Law Judge who conducted the aforementioned hearing is no longer employed by the Board. He was told that the Board could make a decision on the appellate record as it stood, but he had the right to testify at another hearing. 38 C.F.R. § 20.717 (2012). However, he indicated that he did not wish to appear at another hearing and wanted the case considered on the evidence of record. The Board remanded these claims for additional development in February 2011. The Board notes that a claim for total disability based on individual unemployability (TDIU) is part of an increased rating claim when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the issue of entitlement to a TDIU rating has been raised by the record. However, during the pendency of the appeal, the Veteran filed a claim for entitlement to TDIU in May 2008, and the RO denied the claim in a December 2008 rating decision. The Veteran did not appeal this decision, and therefore, the issue of entitlement to a TDIU is not before the Board at this time. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. The Veteran's sinusitis has not been manifested by three or more incapacitating episodes per year of requiring prolonged antibiotic treatment, or more than six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting. 2. The Veteran's gastroenteritis has been manifested by persistently recurrent epigastric distress with regurgitation and scapular pain. However, the clinical evidence does not show that the disease was productive of considerable impairment of health, anemia, or malnutrition. 3. The Veteran's low back disability has been manifested by pain, with full forward flexion and combined range of motion limited to 230 degrees at worst, without muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour; there are no objective findings of a compensable neurological disability and there have been no incapacitating episodes in the past 12 months as defined by VA regulation. 4. The Veteran's left knee disability has been manifested by full extension and flexion limited at most to 110 degrees. There is no subluxation or ankylosis. There is x-ray evidence of arthritis. The Veteran also has left knee instability that is no more than mild in severity. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for sinusitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.97, Diagnostic Code 6513 (2012). 2. The criteria for an initial rating in excess of 10 percent for gastroenteritis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.114, Diagnostic Code 7399-7346 (2012). 3. The criteria for a rating in excess of 10 percent for a low back disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). 4. The criteria for a rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.71a, Diagnostic Code 5003, 5010, 5024, 5260, 5261 (2012). 5. The criteria for a rating of 10 percent, but not higher, for left knee instability have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. Regarding the Veteran's claim for increased rating for a low back disability, in a May 2005 letter issued prior to the decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim for a higher rating, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. With respect to the claim for increased rating for a left knee disability and the claims for service connection for sinusitis and gastroenteritis, in an August 2005 letter, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claims for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. Additionally, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim for a higher rating, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The May 2005 and August 2005 letters also advised the Veteran of the necessity of providing medical or lay evidence demonstrating the level of disability and the effect that the disability has on his employment. The notice also provided examples of pertinent medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) relevant to establishing entitlement to a disability evaluation. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be "veteran specific"). An August 2006 letter issued with the August 2006 statement of the case further advised the Veteran of how effective dates are assigned, and the type of evidence which impacts those determinations. Although the August 2006 notification was issued after the adjudication on appeal, the Veteran's case was subsequently readjudicated in the December 2006, November 2008, February 2009, and May 2012 supplemental statements of the case. The Veteran also had the opportunity to submit additional argument and evidence. Therefore, the content timing error did not affect the essential fairness of the adjudication of the claims. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis). Additionally, regarding the issues of increased initial ratings for sinusitis and gastroenteritis, the appeal arises from the initial awards of service connection. In Dingess, the Court held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see also 38 C.F.R. § 3.159(b)(3)(i) (2012). Thus, because the notice that was provided before service connection was granted was sufficient, VA's duty to notify in this case has been satisfied. See generally Turk v. Peake, 21 Vet. App. 565 (2008) (where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating); see also Shipwash v. Brown, 8 Vet. App. 218, 225 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999) (establishing that initial appeals of a disability rating for a service-connected disability fall under the category of "original claims"). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA and private medical records, VA examination reports, and the Veteran's statements. The Board notes that the Veteran is in receipt of Social Security Administration (SSA) disability benefits. The RO attempted to obtain the Veteran's SSA records, but they were unavailable. In August 2008, the RO made a Formal Finding of Unavailability of the Veteran's SSA records. Therefore, the Board finds that no additional development is needed regarding the obtaining of the Veteran's SSA records. The Veteran has been afforded a hearing before a Veterans Law Judge (VLJ) in which he presented oral argument in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c) (2) (2012) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ did not specifically note the bases of the prior determinations or the elements that were lacking to substantiate the Veteran's increased rating claim. The VLJ asked specific questions, however, directed at identifying whether the Veteran had symptoms meeting the schedular criteria for higher ratings. The VLJ also specifically sought to identify any pertinent evidence not currently associated with the claims. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that no further action pursuant to Bryant is necessary. Additionally, the prior remand instructions were substantially complied with. Instructions pertinent to the claims being decided included re-sending the February 2009 supplemental statement of the case to the Veteran's updated address and scheduling the Veteran for current VA examinations. In response, the Veteran received a copy of the most recent supplemental statement of the case, and the RO/AMC scheduled the Veteran for April 2011 VA examinations for his disabilities. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by providing evidence and argument, including testifying at a hearing. Thus, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in 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, 38 C.F.R. § 4.2 (2012); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2012); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2012); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods based on the facts found - a practice known as "staged" ratings. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Sinusitis Service connection for sinusitis was granted by the October 2005 rating decision, with a 10 percent rating assigned under 38 C.F.R. § 4.97, Diagnostic Code 6513, effective January 4, 1999. Diagnostic Code 6513 pertains to chronic maxillary sinusitis. Diagnostic Codes 6510 through 6514 pertain to various types of sinusitis, each of which is rated pursuant to a General Formula for Sinusitis set forth in the rating schedule following Diagnostic Code 6514. This general rating formula for sinusitis applies in all circumstances in which VA is to rate the severity of sinusitis, no matter the particular diagnosis. Under the General Rating Formula for Sinusitis, a 0 percent rating is warranted for sinusitis detected by x-ray only. A 10 percent rating is awarded for sinusitis manifested by one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or by three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is awarded for sinusitis manifested by three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or by more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is awarded for sinusitis following radical surgery with chronic osteomyelitis, or manifested by near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 38 C.F.R. §§ 4.97, Diagnostic Code 6513 (2012). An incapacitating episode of sinusitis is specifically defined in the regulations as one requiring bed rest and treatment by a physician. 38 C.F.R. § 4.97 (2012). VA medical records dated from June 2007 to March 2012 show that the Veteran received intermittent treatment for sinusitis. He suffered from such symptoms as breath odor, sinus congestion, nasal and ethmoid sinus pressure, and post nasal gestational trophoblastic tumor. On VA examination in August 2005, the Veteran reported using over-the-counter medication for his sinus infections about one to two times a week. He denied any side effects from the medications, history of injury to the sinuses, or the use of any type of oxygen respirator. He complained of stuffy nose, watery eyes, and occasional sinus pressure and headaches. He indicated that he had occasional interference with breathing through the nose, but denied any purulent discharge or dyspnea at rest or on exertion, speech impairment, or injury affecting the soft palate. The sinuses involved were those of the maxillary and left frontal area. He stated that his sinus attacks/infections occurred approximately once a month with pain being a 7-8/10 in severity. He maintained that he was normal between his sinus attacks and that he occasionally had a sore throat with his sinus problems. He reported no fever or ear infection with his sinus problems and was not incapacitated during his sinus infections. Examination revealed no nasal polyps. The left nare was 70 percent obstructed, and the right nare had no obstruction. There was no evidence of tenderness on palpation of the maxillary or frontal sinuses, purulent discharge, or crusting. The examiner found that the Veteran's sinusitis was mildly disabling. At a December 2008 VA examination, the Veteran complained of an increase in nasal congestion and had been taking oral medication on a daily basis in the past month. The examiner noted that the current level of severity of the Veteran's sinus condition was mild because the Veteran had only noticed an increase of symptoms in the past month. The Veteran reported current rhinitis symptoms of excess nasal mucous, watery eyes, and sneezing. He had occasional breathing difficulty. Examination revealed no evidence of sinus disease or soft palate abnormality. There was 50 percent left nasal obstruction and 50 percent right nasal obstruction. The Veteran had no nasal polyps, septal deviation, permanent hypertrophy of turbinates from bacterial rhinitis, rhinoscleroma, Wegener's granulomatosis or granulomatous infection, or tissue loss, scarring, or deformity of the nose. The Veteran testified before the Board at a travel board hearing in December 2010. Testimony revealed, in pertinent part, that the Veteran suffered from constant draining of the nose, itchy and watery eyes, headaches, and sinus infections. The Veteran testified that his runny nose caused him a lot of daily aggravation and that he tended to not like being around a lot of people because of it. He did not report any bed rest for his sinusitis and stated that he was only taking medication for his condition. He indicated that at his last job, he had missed a lot of days because of his sinus infections and colds, and that this had caused him to lose his job. He maintained that his condition worsened depending on the weather. He also testified that he had been on antibiotic treatment for his sinusitis about 2 or 3 times in the past year, and that each course of antibiotics had lasted about 10 to 14 days. He reported having a lot of constant crusting and drainage. He stated that his sinus headaches occurred probably once or twice a week. On VA examination in April 2011, the Veteran reported that he had experienced a severe sinus infection about 3 years ago that had required antibiotic treatment. He complained of some occasional mucous with nasal drip. He denied a history of incapacitating episodes, but described his non-incapacitating episodes as being characterized by headaches, fever, purulent drainage, and sinus pain. He stated that his sinus episodes occurred 3 times a year and lasted 3 or 4 days. The Veteran's current rhinitis symptoms included nasal congestion, excess nasal mucous, itchy nose, watery eyes, and sneezing. His current sinus symptoms included sinus pain and frequent difficulty with breathing. Examination revealed no evidence of sinus disease or soft palate abnormality. There was 0 percent left nasal obstruction and 70 percent right nasal obstruction. The Veteran had no nasal polyps, septal deviation, permanent hypertrophy of turbinates from bacterial rhinitis, rhinoscleroma, Wegener's granulomatosis or granulomatous infection, or tissue loss, scarring, or deformity of the nose. The Veteran was diagnosed with rhinitis. The examiner found that the Veteran's current nasal/sinus condition had no significant effects on his usual occupation and would not affect his employability. There were also no effects on the Veteran's usual daily activities. Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, the Board finds that the Veteran's sinusitis is appropriately evaluated as 10 percent disabling for all periods under consideration. The evidence shows that the Veteran has not had any incapacitating episodes of sinusitis. Indeed, at his August 2005 and April 2011 VA examinations and at his December 2010 hearing, the Veteran has denied having any incapacitating episodes of sinusitis where he required bed rest. The Board acknowledges that during one year, the Veteran required 2 to 3 courses of antibiotic treatment for his sinusitis. However, the antibiotic treatment was not prolonged (lasting 4 to 6 weeks), as each course of treatment lasted only 10 to 14 days. Additionally, although the Veteran suffers from non-incapacitating episodes of sinusitis that are characterized by headaches, pain, and purulent discharge or crusting, the evidence does not show that he experiences more than 6 of these episodes per year. The August 2005 and December 2008 VA examiners found that the Veteran's sinusitis was only mildly disabling. Despite reporting monthly sinus attacks at his August 2005 VA examination, these episodes were not all characterized by headaches, pain, and purulent discharge or crusting, as the Veteran indicated that he had only occasional sinus pressure and headaches and denied having any purulent discharge. Moreover, during his December 2010 hearing, while the Veteran reported having constant sinus infections with headaches and crusting or drainage, he did not indicate that he experienced any pain with these episodes. The criteria under Diagnostic Code 6513 are conjunctive, not disjunctive; thus all criteria must be 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). Finally, at his most recent VA examination in April 2011, the Veteran maintained that he had 3 non-incapacitating episodes of sinusitis a year that were characterized by headaches, fever, purulent drainage, and sinus pain. While the evidence shows that the Veteran continues to seek treatment for sinusitis, his condition is not shown to have increased in severity to the extent that a higher rating is warranted. Thus, the Board finds that the Veteran does not meet or nearly approximate the criteria for an initial rating in excess of 10 percent under Diagnostic Code 6513. 38 C.F.R. § 4.97. The evidence of record also reveals that the Veteran suffers from symptoms of allergic rhinitis. However, as the Veteran is not service-connected for allergic rhinitis, the Board need not consider the Veteran's sinus disability under the diagnostic criteria for allergic rhinitis. See 38 C.F.R. § 4.97, Diagnostic Code 6522 (2012). Gastroenteritis The Veteran has been diagnosed with gastroenteritis. Gastroenteritis is an unlisted disorder that has been rated by analogy under Diagnostic Code 7399-7346. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2012). Diagnostic Code 7399 refers to an unlisted disability of the digestive system. Diagnostic Code 7346 pertains to hiatal hernia. The Board acknowledges that the Veteran has also been diagnosed with fatty liver disease, which would be rated under Diagnostic Code 7345 as chronic liver disease without cirrhosis. See 38 C.F.R. § 4.114, Diagnostic Code 7345 (2012). However, because of the overall nature of the Veteran's disability, the Board finds that the rating criteria applied by the RO (i.e. Diagnostic Code 7346) are appropriate. Pernorio v. Derwinski, 2 Vet. App. 625 (1992); 38 C.F.R. §§ 4.20, 4.21 (2012). The Board can identify no more appropriate diagnostic codes and the Veteran has not identified any. Butts v. Brown, 5 Vet. App. 532 (1993). Accordingly, the Board will proceed with an analysis of the Veteran's disability under Diagnostic Code 7346. Under Diagnostic Code 7346, if the condition is manifested by symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or by other symptom combinations productive of severe impairment of health, a 60 percent rating is warranted. If the condition is manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, and is productive of considerable impairment of health, a 30 percent rating is warranted. A 10 percent rating is warranted where two or more of the symptoms for a 30 percent rating are present and of less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346 (2012). For purposes of evaluating conditions in 38 C.F.R. § 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer. 38 C.F.R. § 4.112 (2012). The term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. Id. Under governing law, ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, are not be combined with one another. 38 C.F.R. §§ 4.14, 4.113, 4.114 (2012). Rather, a single evaluation is to be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such evaluation. 38 C.F.R. § 4.114 (2012). VA and private medical records dated from October 2001 to July 2010 show that the Veteran received intermittent treatment for gastrointestinal disabilities. He suffered from such symptoms as heartburn when he ate the wrong/spicy foods, dyspepsia, chest pain, lower abdominal cramping, diarrhea, and emesis. The Veteran was hospitalized in October 2009 for severe gastritis, grade I esophageal varices, and gas in the portal vein. He had upper abdominal distress and fever and was treated with antibiotics. A CT scan of the stomach showed pneumatosis with portal venous gas. The Veteran underwent an esophagogastroduodenoscopy in June 2010. In July 2010, the Veteran was diagnosed with nonalcoholic fatty liver disease. On VA examination in August 2005, the Veteran complained of occasional cramps in the upper epigastric area that did not radiate and usually occurred after eating. He reported that the cramps were associated with some reflux and occasional nausea. He also stated that that he would get abdominal cramps after ingesting milk products. He denied a history of pyrosis, hematemesis, melena, vomiting, anemia, weight gain or loss, loss of appetite, circulatory disturbances after meals, or hypoglycemic reactions. He indicated that he had been taking daily over-the-counter medication for the last two months with some relief of his symptoms. He maintained that he did get diarrhea once every two weeks with loose stools that might come twice a day with no associated blood. He reported that the severity of his abdominal pain was a 5-7/10 and denied any nausea, vomiting, colic, or distension associated with his pain. Examination revealed decreased bowel sounds. Abdomen was soft and nontender. There was no guarding, rebound tenderness, or organomegaly. The examiner found that the Veteran's gastritis and gastroenteritis was mild in severity. At a December 2008 VA examination, the Veteran complained of an increase in intermittent epigastric pain during the past year. He stated that this was sometimes associated with foods like bananas, cabbage, and ice cream. He reported that his pain occurred twice a month and lasted for several hours. The examiner noted that the current level of severity of the Veteran's gastrointestinal condition was mild because the Veteran had only noticed an increase of symptoms in the past year, and that he took Prilosec several times a week with relief of symptoms. The Veteran indicated that he had a history of weekly, episodic diarrhea that occurred more than 12 times a week and lasted 1 day or less. He also stated that he experienced belching symptoms. Examination revealed no signs of significant weight loss, malnutrition, or anemia. The Veteran weighed 225 pounds and was noted to have no weight change. The examiner found that the Veteran's gastroenteritis had moderate effects on recreation and feeding. The Veteran testified before the Board at a travel board hearing in December 2010. Testimony revealed, in pertinent part, that the Veteran experienced diarrhea about once or twice a week, regurgitation, a constant burning sensation in his chest and lower part of the stomach, and difficulty swallowing. The Veteran testified that the burning sensation could occur after he ate certain things or prior to a bowel movement, and that sometimes it was accompanied by acid reflux in his upper chest area. He reported that he had informed his doctor about chest pain about 6 to 8 months ago, but that his doctor had not been sure the chest pain had anything to do with his gastrointestinal disability. He stated that he had been hospitalized for a week in October 2009 for severe gastritis and that he had suffered lower abdominal pain and fever. He indicated that since that hospitalization, his constant abdominal pain had worsened, and he had to take daily medication prior to eating. He maintained that he would be affected occupationally by his disability because he had to go to the bathroom more frequently than before. He also testified that his doctor had prescribed a restricted diet for him and that he had been taking Omeprazole since October 2009. He reported that even with the medication, he would still experience regurgitation and vomiting about once or twice a week. He stated that he also suffered from stomach cramps and hemorrhoid-type bleeding with his stools. On VA examination in April 2011, the examiner noted the Veteran's October 2009 hospitalization for severe gastritis. The Veteran reported that since October 2009, his gastroenteritis was intermittent with remissions. His treatments included proton pump inhibitors and Omeprazole. He complained of having one black stool that morning and stated that he had taken Maalox the night before and eaten more red meat than usual. Examination revealed that the Veteran was 240 pounds and that there had been no weight change. There were no signs of significant weight loss, malnutrition, or anemia. Abdominal examination was normal. The Veteran was diagnosed with a normal stomach examination with a past history of gastritis. The examiner found that the Veteran's current stomach condition had no significant effects on his usual occupation and would not affect his employability. There were also no effects on the Veteran's usual daily activities. Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, the Board finds that the Veteran's gastroenteritis is appropriately evaluated as 10 percent disabling for all periods under consideration. The record reflects that the manifestations of the Veteran's disability included epigastric pain, reflux, heartburn, and regurgitation of stomach contents. However, the Veteran's symptoms have not been accompanied by substernal or arm or shoulder pain. Indeed, the Veteran has never indicated that he had experienced arm or shoulder pain with his gastrointestinal symptoms. Moreover, although the Veteran had reported chest pain to his doctor, the chest pain had not been found to be related to his gastrointestinal disability. The criteria under Diagnostic Code 7346 are conjunctive, not disjunctive; thus all criteria must be met. See Melson v. Derwinski, 1 Vet. App. 334 (June 1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). Indeed, the criteria for the 10 percent rating require two or more symptoms for a 30 percent rating, but of less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346 (emphasis added). Such indicates that the same symptoms are contemplated in both the 10 percent and 30 percent criteria, but that the distinguishing factor for the higher criteria is the requirement that the symptoms result in considerable impairment of health. Here, in addition to the lack of substernal or arm or shoulder pain, the competent and credible evidence does not show that the Veteran's gastroenteritis was productive of considerable impairment of health. In this regard, although the Veteran was hospitalized for a week in October 2009 due to severe gastritis, he was overall shown to have good nutritional health. The VA examinations consistently revealed that the Veteran had no significant weight loss, malnutrition, or anemia. The August 2005 and December 2008 VA examiners found that the Veteran's disability was mild in severity, and the April 2011 VA examiner found that the Veteran's current stomach condition had no significant effects on his usual occupation or daily activities. The April 2011 VA examiner also found that the Veteran had a normal stomach examination. While the Veteran experienced gastrointestinal symptoms, his disability was able to be somewhat mitigated by medication and restricted diet. As the Veteran's disability does not result in considerable impairment of health to warrant a 30 percent rating, it therefore follows that his disability does not result in severe impairment of health. Thus, an evaluation higher than 10 percent is not warranted at any time during the course of the appeal. Low Back Disability 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. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2012); see also 38 C.F.R. §§ 4.45, 4.59 (2012). The Veteran contends that he is entitled to a higher disability rating for his low back disability. Such disability has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237, as 10 percent disabling. The General Rating Formula for Diseases and Injuries of the Spine provides that, 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, the following ratings will apply. A 10 percent evaluation requires evidence of forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation requires evidence of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation requires evidence of forward flexion of the thoracolumbar spine to 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. 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). Any associated objective neurologic abnormalities should be evaluated separately, under an appropriate diagnostic code. Id. at Note 1. VA medical records dated from August 2004 to May 2009 show that the Veteran received intermittent treatment for his low back disability. He experienced nonradiating back pain that was aggravated by bending. He denied any paresthesias or incontinence. On VA examination in May 2005, the Veteran complained of low back pain in the center of his back and increasing stiffness in the center of his back. He reported that he had flare-ups about once a year and that the pain would become so severe that he was unable to walk or move for a significant amount of time. He stated that he did have occasional flare-ups of mild worsening approximately one to two times per week. He denied any numbness, tingling, or bladder or bowel problems. He indicated that if he was up working for long periods of time, he would occasionally feel some weakness and stiffness in the legs. He maintained that he had had to switch jobs to more sedentary-type activity because he could not do a heavy amount of lifting like he had at his previous job. Examination revealed normal stride length and walking without painful gait. Range of motion testing showed 90 degrees flexion, 30 degrees extension, and 30 degrees lateral flexion and rotation bilaterally. Upon repetitive motion, there was no additional limitation of motion. The bilateral lower extremities were neurovascularly intact with normal reflexes, pulses, and sensation. An x-ray indicated mild degenerative changes with the possibility of some degree of spinal stenosis. The examiner diagnosed the Veteran with chronic low back pain with evidence of degenerative disc disease by x-ray report. The major functional limitation was noted to be pain and decreased range of motion within the lumbar spine. At a December 2008 VA examination, the Veteran complained that his low back pain and stiffness had worsened. He reported a history of weakness and denied any incapacitating episodes of spine disease. He used a cane as an assistive device and was unable to walk more than a few yards. He also stated that he had episodes where he could not get out of bed for hours. Examination revealed normal spinal posture, spinal head appearance, spinal symmetry in appearance, and gait. There were no abnormal spinal curvatures or objective abnormalities of the thoracic sacrospinalis. There was also no muscle spasm, localized tenderness, or guarding that was severe enough to be responsible for abnormal gait or spinal contour. Muscle tone was normal, and there was no muscle atrophy. Motor and sensory examinations of the lower extremities were normal. Reflexes of the bilateral lower extremities were normal. Range of motion testing showed 90 degrees flexion, 30 degrees extension, and 30 degrees lateral flexion and rotation bilaterally. Upon repetitive motion, there was no objective evidence of pain or additional limitations. Lasegue's sign was negative. An x-ray indicated that the Veteran had mild degenerative joint disease of the lumbar spine. The Veteran's mild degenerative joint disease of the lumbar spine was found to have no significant effects on usual occupation or daily activities. The Veteran testified before the Board at a travel board hearing in December 2010. Testimony revealed, in pertinent part, that the Veteran's low back pain had prevented him from playing with his children as much because he could not bend over and lift them. The Veteran testified that he had also had problems being intimate with his wife. He reported that his back pain caused him to have to take anywhere from 30 minutes to an hour to get motivated to start his day and that it took him 30 to 45 minutes to relax at night. He stated that he took 2 to 3 medications for his back. He indicated that at his most recent place of employment, he had been unable to lift things when doing inventory. He maintained that his back pain was agonizing, and that although he had not had a back spasm within the last 4 or 5 months, the last time he had experienced one, he had been forced to lay down on the floor for 30 to 40 minutes before he could get up. He also testified that he thought that he had received physician-prescribed bed rest a couple of times. On VA examination in April 2011, the Veteran complained of low back pain and occasional tightening of the back. He reported a history of fatigue and constant lumbar spine pain that was achy and mild in nature and occurred daily. He denied any radiation of pain, incapacitating episodes of spine disease, or assistive devices/aids. He stated that he was able to walk 1 to 3 miles. Examination revealed normal gait, spinal posture, spinal head position, and spinal symmetry in appearance. There were no abnormal spinal curvatures or objective abnormalities of the thoracic sacrospinalis. There was also no muscle spasm, localized tenderness, or guarding that was severe enough to be responsible for abnormal gait or spinal contour. Range of motion testing showed 90 degrees flexion, 20 degrees extension, and 30 degrees lateral flexion and rotation bilaterally. There was no objective evidence of pain on motion. Upon repetitive motion, there was no objective evidence of pain or additional limitations. Muscle tone was normal, and there was no muscle atrophy. Motor and sensory examinations of the lower extremities were normal. Reflexes of the bilateral lower extremities were hypoactive bilaterally. An x-ray indicated that there were mild degenerative changes of the lumbar spine with the possibility of some degree of spinal stenosis. The Veteran's degenerative joint disease of the lumbar spine was found to have a mild effect on his employability, as he had been assigned different duties due to his lumbar spine disability and had problems with lifting, carrying, and pain. The Veteran's usual daily activities were also noted to be affected by pain. Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, the Board finds that the Veteran's low back disability is appropriately evaluated as 10 percent disabling for all periods under consideration. The objective findings of record do not reflect evidence of forward flexion of the thoracolumbar spine to 60 degrees or less; combined range of motion of the thoracolumbar spine to 120 degrees or less; 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. 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). During this period, the Veteran's forward flexion of the thoracolumbar spine was consistently normal at 90 degrees, and his combined range of motion was shown to be 230 degrees at worst on VA examination in April 2011. The May 2005, December 2008, and April 2011 VA examiners noted that the range of motion was not additionally limited by pain, fatigue, weakness, incoordination, or lack of endurance after three repetitions. Thus, even considering the Veteran's subjective complaints of pain, the medical evidence of record does not support any additional limitation of motion in response to repetitive motion that would support an evaluation in excess of the 10 percent assigned. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2012); see also 38 C.F.R. §§ 4.45, 4.59 (2012). The Veteran has alleged at his December 2010 hearing that when he experienced a back spasm, he was forced to lay down on the floor for 30 to 40 minutes before he could get up. He also testified that he thought that he had received physician-prescribed bed rest a couple of times. However, the objective medical evidence of record does not show that the Veteran ever received any physician-prescribed bed rest. An "incapacitating episode" for purposes of Diagnostic Code 5243 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. Although the Veteran has reported having to lie down and rest during back spasms, he has not had incapacitating episodes as defined by VA regulation. Accordingly, evaluation of his disability pursuant to Diagnostic Code 5243 based on incapacitating episodes is not warranted. See 38 C.F.R. § 4.71a. With regard to Note (1) of the General Rating Formula for Diseases and Injuries of the Spine, the Veteran has not reported any neurological symptomatology related to his low back disability. The Board acknowledges that the Veteran's reflexes of the bilateral lower extremities were 1+ bilaterally on VA examination in April 2011. However, the Veteran had no other objective neurological findings or symptoms at his May 2005, December 2008, and April 2011 VA examinations other than the hypoactive reflexes at the April 2011 VA examination. Specifically, at all of the Veteran's VA examinations, his lumbar spine had no sensory or motor deficits, and there was no muscle atrophy or abnormal muscle tone. As the medical evidence fails to show any objective neurological symptomatology other than hypoactive reflexes, the Board finds that the Veteran would not meet the criteria for a compensable rating under 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2012), and therefore, a separate compensable rating for the neurological manifestations of the Veteran's low back disability is not warranted at this time. 38 C.F.R. §§ 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1), 4.124a, Diagnostic Code 8520 (2012). Left Knee Disability Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2012). Raters must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. 38 C.F.R. § 4.14 (2012). The guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. However, the Board notes that the provisions of 38 C.F.R. § 4.40 (2012) and 38 C.F.R. § 4.45 (2012) should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). In addition, the Board notes that the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2011). For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (2012). The standardized description of joint measurements is provided in Plate II under 38 C.F.R. § 4.71a (2012). For VA purposes, normal extension and flexion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71a, Plate II (2012). Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (degenerative arthritis) and 5010 (traumatic arthritis). Diagnostic Code 5010 (traumatic arthritis) directs that the evaluation of arthritis be conducted under Diagnostic Code 5003, which states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5010. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5010. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010, Note 1. A claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Code 5003 and Diagnostic Code 5257, and rating a knee disability under both of those codes does not amount to pyramiding under 38 C.F.R. § 4.14 (2012). VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63604 (1997); Esteban v. Brown, 6 Vet. App. 259 (1994). However, a separate rating must be based on additional compensable disability. Separate ratings may also be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a Veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). The Veteran contends that he is entitled to a higher disability rating for his left knee disability. Such disability has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5024, as 10 percent disabling. Diagnostic Code 5024 is used for rating tenosynovitis, which is to be rated on limitation of motion of affected parts, as arthritis, degenerative. See 38 C.F.R. § 4.71a, Diagnostic Code 5024 (2012). Degenerative arthritis is addressed in Diagnostic Code 5003. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion of the leg is addressed in Diagnostic Code 5260, which pertains to limitation of flexion of the leg; and Diagnostic Code 5261, which contemplates limitation of extension of the leg. Other potentially applicable diagnostic codes include Diagnostic Code 5257, which contemplates recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260, 5261 (2012). VA medical records dated from May 2008 to March 2012 show that the Veteran received intermittent treatment for his left knee disability. He complained of such symptoms as left knee pain, swelling, and popping. In May 2008, the Veteran received a wrap around hinge brace for his left knee. He reported that his left knee had been giving way more frequently in the last 3 months when he bent his knee or while walking. A November 2008 VA medical report shows that the Veteran had 130 degrees flexion and 0 degrees extension in the left knee. His gait was antalgic, and he was ambulating with a cane. McMurray's and valgus stress test were positive. He was diagnosed with left knee arthralgia. In January 2009, the Veteran was diagnosed with internal derangement of the left knee, probable torn medial meniscus. He was prepared to undergo arthroscopic debridement. In February 2011, the Veteran received a corticosteroid injection in his left knee. A March 2012 MRI of the left knee showed patellar tendinosis "jumper's knee" and thinning of the cartilage in the patellofemoral compartment. On VA examination in November 2005, the Veteran complained of a slow, steady increase in left knee flare-ups. He described having 1 to 2 episodes a month in which the knee became slightly painful and felt unstable, causing him to experience severe pain for about 1 to 2 hours. He reported that otherwise, his left knee caused minor discomfort only with strenuous or heavy activities. He denied stiffness, swelling, heat, redness, the use of assistive devices, and history of dislocation or recurrent subluxation. He stated that he had occasional locking in the knee. He indicated that his left knee would occasionally bother him at work only when he had to perform some strenuous lifting, bending, squatting, heavy lifting, or prolonged standing. Examination revealed normal gait without evidence of pain. There was no redness or effusion. The left knee had full range of motion with no pain upon repetitive motion. Medial and lateral collateral ligaments were stable to varus and valgus stress anteriorly and posteriorly. Cruciate ligaments were intact with negative anterior and posterior drawer signs. McMurray's test and Lachman were negative. The left lower extremity was also found to be neurovascularly intact. An x-ray of the left knee indicated that there were some very minimal degenerative type changes. The Veteran was diagnosed with left knee pain with increase in frequency of flare-ups. At a December 2008 VA examination, the Veteran complained of progressively worsening left knee pain. He reported daily locking episodes as well as swelling and tenderness in the left knee. He stated that he was unable to stand for more than a few minutes and unable to walk more than a few yards. He indicated that he always used a cane. Examination revealed that the left knee had tenderness to the medial joint line, crepitus, effusion, tenderness, pain at rest, weakness, guarding of movement, and clicks or snaps. A meniscus abnormality was noted, and the examiner found evidence of locking and effusion. There was evidence of a tear, as McMurray's test was positive, but there was no dislocation. Range of motion testing showed 110 degrees flexion and 0 degrees extension. There was objective evidence of pain on motion and following repetitive motion. The examiner was unable to test whether there were additional limitations after three repetitions due to pain. An x-ray indicated that there was left knee degenerative joint disease. The Veteran was diagnosed with left knee degenerative joint disease with possible meniscal tear. His left knee pain was found to have significant effects on his occupational and daily activities. The examiner noted that the current severity of the left knee disability was moderate to severe and indicated that the Veteran was a surgical candidate for an arthroscopy. The Veteran testified before the Board at a travel board hearing in December 2010. Testimony revealed, in pertinent part, that the Veteran was experiencing increased left knee pain, cracking, and popping. He wore a left knee brace and used a cane about two or three times a week when he left the house to walk. He reported that as long as he had his left knee brace on, his knee felt sturdy, but that without the knee brace, his left knee would give way and buckle. He indicated that his knee would start to lock up if he walked or stood for too long. He maintained that his knee would lock up straight and that he unlocked it by moving it around until it popped back into place. On VA examination in April 2011, the Veteran complained of left knee pain, giving way, popping, and swelling. He reported that he was able to stand for 15 to 30 minutes and walk for 1 to 3 miles. He used a knee brace intermittently, but frequently. Examination revealed normal gait. There was evidence of left knee crepitus and clicks or snaps. Range of motion testing showed 130 degrees flexion and 0 degrees extension. There was no objective evidence of pain with motion. Upon repetitive motion, there was no additional pain or limitations. An x-ray of the left knee indicated that there was no evidence of arthritis or joint effusion. The Veteran was diagnosed with left knee degenerative joint disease. His left knee pain was found to have a mild effect on his employability as well as on his chores, shopping, and recreation. For VA purposes, normal extension and flexion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71a, Plate II. On the above examinations, the Veteran's left knee had flexion limited, at worst, to 110 degrees. The flexion of the Veteran's left knee must be limited to 30 degrees in order to warrant an increased rating of 20 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Diagnostic Code 5260 therefore cannot serve as a basis for an increased rating in this case. Similarly, an increased rating is not warranted under Diagnostic Code 5261. The Veteran had full extension on all of the above examinations. The Veteran's left knee extension would have to be limited to 15 degrees in order to warrant an increased rating of 20 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Because there is no evidence that the Veteran's left knee extension was limited to 15 degrees, Diagnostic Code 5261 cannot serve as a basis for an increased rating for the Veteran's left knee disability. The Board also finds that the Veteran is not entitled to an increased rating due to functional impairment as a result of pain on repetitive use. The Board notes that although the Veteran had pain on motion at his December 2008 VA examination, at no time did the Veteran have additional functional limitation or loss of motion due to pain, weakness, stiffness, fatigability, or incoordination with repetitive use. There was no evidence which suggests, that, on repetitive use, the left knee would be restricted by pain or other factors to only 30 degrees flexion or 15 degrees extension, the criteria for a 20 percent rating, or restricted such that any separate compensable ratings for flexion or extension would be warranted. Thus, even considering the effects of pain on use, the evidence does not show that the left knee is limited in motion to 15 degrees extension or 30 degrees flexion, and thus the requirements for an increased rating are not met. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). Furthermore, the Board finds that the evidence does not show that any additional functional limitation would result in the Veteran warranting any separate compensable ratings for limitation of extension or flexion. Diagnostic Code 5257 provides a 10 percent rating for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). In this case, the medical evidence does not show any recurrent subluxation, nor does the Veteran report any subluxation. With respect to instability, the Veteran has consistently reported episodes of his knee giving way. Specifically, in May 2008, the Veteran indicated that his left knee had been giving way more frequently in the last 3 months when he bent his knee or while walking, and he consequently received a wrap around hinge brace for his left knee. At his December 2010 hearing, the Veteran also reported that as long as he had his left knee brace on, his knee felt sturdy, but that without the knee brace, his left knee would give way and buckle. Despite the Veteran's reports of continued instability, the objective medical evidence of record does not show that the Veteran had left knee instability on examination. However, the Board does not find that the Veteran's lay statements lack credibility merely because they are unaccompanied by contemporaneous medical evidence. See Davidson v. Shinseki, 2009 WL 2914339 (Fed. Cir.), quoting Buchanon, 451 F.3d at 1337 ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). The Board finds the Veteran to be credible in his reports of his left knee continuing to give way since May 2008. The Veteran reported suffering from his left knee giving way, but there was no objective evidence of any instability at the VA examinations dated in November 2005, December 2008, and April 2011. The evidence seems to suggest that prior to being prescribed a knee brace to aid in ambulation, the Veteran had experienced more frequent episodes of knee buckling, as noted by the May 2008 VA physician. However, after the Veteran was prescribed a knee brace to aid in ambulation and instability, he experienced much less frequent episodes of instability. The Board thus finds that taken together, the overall evidence indicates that the Veteran's instability was no more than mild. Therefore, resolving all reasonable doubt in favor of the Veteran, a 10 percent rating, but not higher, for left knee instability is warranted under Diagnostic Code 5257. The Board notes that there is x-ray evidence of left knee arthritis. The Veteran currently has a 10 percent rating under Diagnostic Code 5010 because although he has noncompensable left knee limitation of flexion, there is still at least some limitation of motion. 38 C.F.R. §§ 4.71a, Diagnostic Codes 5003, 5010. However, a higher 20 percent rating is only warranted if there is x-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations. In this case, there is no evidence that more than one joint group is involved or that the Veteran has occasional incapacitating exacerbations. Therefore, the Board finds that an increased rating is not warranted for the Veteran's left knee disability under Diagnostic Code 5010. Other Considerations The Board concludes that the medical findings on examinations are of greater probative value than the Veteran's allegations regarding the severity of his sinusitis, gastroenteritis, low back disability, and left knee disability. The symptomatology noted in the medical and lay evidence has been adequately addressed by the evaluations assigned and do not more nearly approximate the criteria for higher evaluations at any time during all relevant periods on appeal. See 38 C.F.R. §§ 4.71a, Diagnostic Codes 5003, 5010, 5024, 5237, 5257, 5260, and 5261; 4.97, Diagnostic Code 6513; 4.114, Diagnostic Code 7346 (2012); see also Fenderson, supra. The Board has also considered whether the Veteran's sinusitis, gastroenteritis, low back disability, and left knee disability present exceptional or unusual disability pictures as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). 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. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology, and provide for higher ratings for additional or more severe symptomatology than is shown by the evidence. With respect to sinusitis, the Veteran's 10 percent rating contemplates his functional impairment as well as his subjective complaints of headaches, sinus pain, and purulent discharge or crusting. The Veteran exhibited approximately 3 non-incapacitating episodes of sinusitis per year that were characterized by headaches, sinus pain, and purulent discharge or crusting. He did not have any incapacitating episodes of sinusitis that required prolonged antibiotic treatment lasting 4 to 6 weeks. The April 2011 VA examiner also found that the Veteran's current nasal/sinus condition had no significant effects on his usual occupation and would not affect his employability. Therefore, the Veteran's subjective complaints were included in the 10 percent rating. Regarding gastroenteritis, the Veteran's 10 percent rating contemplates his functional impairment as well as his subjective complaints of epigastric pain, reflux, heartburn, regurgitation of stomach contents, diarrhea, and vomiting. The Veteran's symptoms were not accompanied by substernal or arm or shoulder pain, nor were they productive of considerable impairment of health. The April 2011 VA examiner also found that the Veteran's current stomach condition had no significant effects on his usual occupation and would not affect his employability. Therefore, the Veteran's subjective complaints were included in the 10 percent rating. With respect to low back disability, the Veteran's 10 percent rating contemplates his functional impairment as well as his subjective complaints of back pain, spasms, tightening, stiffness, and weakness. Other than one finding of 20 degrees extension at his April 2011 VA examination, the Veteran had full range of motion of the lumbar spine without pain on motion or additional limitation following repetitive use. There were no compensable neurological manifestations or any other objective manifestations. Indeed, the Veteran had not had any incapacitating episodes of his spine disability as defined by VA regulation. The April 2011 VA examiner also found that the Veteran's current back condition had only mild effects on his employability. Therefore, the Veteran's subjective complaints were included in the 10 percent rating. Regarding left knee disability, the Veteran's 10 percent rating for his left knee disability based on limitation of motion contemplated his functional impairment, as well as his subjective complaints of pain, swelling, popping, locking, and cracking. There was no evidence that his left knee disability was manifested by compensable limitation of motion, subluxation, or ankylosis. Therefore, the Veteran's subjective complaints were included in the 10 percent rating. The Veteran's 10 percent rating for his left knee instability also contemplated his subjective complaints of his left knee giving way, as well as his functional impairment. The Veteran was prescribed a knee brace, which helped to lessen the frequency of his episodes of instability, and he was not found to have any objective evidence of instability at any of his VA examinations. The April 2011 VA examiner also found that the Veteran's current left knee disability had only mild effects on his employability. Therefore, the Veteran's subjective complaints were included in the 10 percent ratings. Thus, the Veteran's disability pictures are contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, appropriate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. The Board finds that the evidence shows that the Veteran's left knee disability warranted a separate 10 percent rating for instability. However, as the preponderance of the evidence is against the rest of the Veteran's claims, that doctrine is not applicable to those issues. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER An initial rating in excess of 10 percent for sinusitis is denied. An initial rating in excess of 10 percent for gastroenteritis is denied. A rating in excess of 10 percent for a low back disability is denied. A rating in excess of 10 percent for a left knee disability due to limitation of motion is denied. A 10 percent rating, but not higher, for left knee instability is granted, subject to the law and regulations governing the payment of monetary benefits. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs