Citation Nr: 1333420 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 09-37 592 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for sleep apnea. 2. Entitlement to service connection for a right ankle disorder. 3. Entitlement to service connection for a left ankle disorder. 4. Entitlement to a compensable disability rating (evaluation) for service-connected right long finger, status post fracture of the distal tuft of the distal phalanx with strain (right long finger disability). 5. Entitlement to a compensable disability rating (evaluation) for service-connected hemorrhoids. 6. Entitlement to an initial disability rating (evaluation) in excess of 10 percent for service-connected osteoarthritis of the right knee, status post arthroscopic surgery times two and autograph transplant, medial femoral condyle defect (right knee disability). 7. Entitlement to an initial disability rating (evaluation) in excess of 10 percent for service-connected osteoarthritis of the left knee (left knee disability). 8. Entitlement to an initial compensable disability rating (evaluation) for service-connected migraine headaches. WITNESS AT HEARING ON APPEAL Appellant (Veteran) ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from December 1979 to March 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2007 and August 2011 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. This appeal was processed using the Virtual VA paperless claims processing system. In April 2011, the Veteran testified at a local RO hearing before a hearing officer. A transcript of the hearing is of record. Although the Veteran indicated that he wanted a Board hearing on the undated VA Form 9 received in September 2009, on the September 2009 Appeals Election Form, which included the various options for a Board hearing, he clarified that he wanted to have a local RO hearing. On the subsequent VA Form 9 filed in August 2013, the Veteran indicated that he did not want a Board hearing. For these reasons, the Board finds that there is no pending request for a Board hearing in this case. FINDINGS OF FACT 1. Symptoms of snoring, choking, and halted breathing began during service and were later attributed to a diagnosis of sleep apnea by a medical professional. 2. The Veteran had treatment for right ankle problems during service but does not have a currently diagnosed right ankle disorder. 3. The Veteran was treated for left ankle problems during service but does not have a currently diagnosed left ankle disorder. 4. Throughout the rating period, the Veteran's right long finger disability has been manifested by pain, decreased strength, decreased flexibility, locking, stiffness, and swelling, and a 2 centimeter (cm) gap between the palm and the middle finger with motion at the transverse crease of the palm. 5. Throughout the rating period, the Veteran's hemorrhoids have been manifested by persistent bleeding and secondary anemia, with intermittent fissures and are so severe that they require surgical treatment. 6. Throughout the rating period, the Veteran's right knee disability more closely approximates right knee flexion limited to 15 degrees. 7. Throughout the rating period, the Veteran's left knee disability more closely approximates left knee flexion limited to 15 degrees. 8. Throughout the rating period, the Veteran's migraine headaches are manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. Giving the benefit of the doubt to the Veteran, the criteria for service connection of sleep apnea are met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 2. The criteria for service connection of a right ankle disorder are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 3. The criteria for service connection of a left ankle disorder are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 4. The criteria for a compensable rating for the right long finger disability have not been met or approximated for the rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.27, 4.71a, Diagnostic Code (DC) 5299-5229 (2013). 5. Giving the benefit of the doubt to the Veteran, the criteria for a 20 percent rating for hemorrhoids have been approximated for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.114, DC 7336 (2013). 6. Giving the benefit of the doubt to the Veteran, the criteria for a 30 percent rating for the right knee disability have been approximated for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5003-5260 (2013). 7. Giving the benefit of the doubt to the Veteran, the criteria for a 30 percent rating for the left knee disability have been approximated for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5003-5260 (2013). 8. Giving the benefit of the doubt to the Veteran, the criteria for a 50 percent rating for migraine headaches have been approximated for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.27, 4.124a, DC 8100 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims 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, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA must inform the claimant 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. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, 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). If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a statement of the case (SOC) or supplemental statement of the case (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Collectively, in multiple notice letters sent from November 2010 to December 2011, the RO advised the Veteran of what the evidence must show to substantiate the claims, and described the types of information and evidence that the Veteran should submit in support of the claims. The RO also explained what evidence VA was responsible for obtaining or would assist in obtaining on the Veteran's behalf in support of the claims. The RO further explained how VA determines the disability rating and the effective date. Although the notice letters were not sent prior to the initial denial of the claims, the claims were readjudicated after issuance of proper notice; therefore, the timing defect was cured. Upon review, the Board finds that VCAA notice requirements were fully satisfied. In consideration of the foregoing, the Board concludes that the requirements of the notice provisions of the VCAA have been met, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Regarding the initial rating appeals, the Veteran is challenging the initial disability ratings assigned following the grant of service connection. The Court has held that, where 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 in fact been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess v. Nicholson, 19 Vet. App. 473, 490-91; Dunlap v. Nicholson, 21 Vet. App. 112, 117 (2007). Furthermore, under 38 C.F.R. § 3.159(b)(3)(i), there was no duty to provide the Veteran with VCAA notice upon receipt of a Notice of Disagreement, such as in this case. For these reasons, the Board finds that no further notice, beyond that afforded in the context of the original claims for service connection, is needed under the VCAA. Regarding VA's duty to assist in claims development, the RO afforded the Veteran with QTC medical examinations in connection with the claims in November 2006 (pre-discharge) and May 2011. Collectively, the medical examination reports include all relevant findings and medical opinions needed to evaluate fairly the Veteran's claims. The VA examiners considered the history of the claimed disabilities, as well as the Veteran's subjective complaints as it related to his current symptomatology and its effects on his daily life and performed a thorough physical evaluation of the Veteran, to include x-rays; therefore, the VA medical examiners had adequate facts and data regarding the history and condition of the Veteran's claimed disabilities when providing the medical opinions. See VAOPGCPREC 20-95 (interpreting that in some cases an accurate history by a veteran may be a valid basis for an examination report rather than claims file review); see also Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). There has been no allegation or indication that there has been a material change in condition of the Veteran's disabilities since the last QTC examinations. For these reasons, the Board finds that the medical examination reports are adequate for rating purposes, and there is no need for further medical examination. Also, post-service treatment records adequately identified as relevant to the Veteran's appeals have been obtained or otherwise submitted and are associated with the record. The service treatment records are complete and included in the record. The Veteran has not made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal, and no further development is required to comply with the duty to assist in developing the facts pertinent to the claims decided herein. In view of the foregoing, the Board will proceed with appellate review. Service Connection Legal Criteria It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). The Board has thoroughly reviewed all the evidence in this case. The analysis below focuses on the most relevant evidence and on what this evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). As will be explained below, the Veteran is not currently diagnosed with a left or right ankle disorder. The Veteran's currently diagnosed sleep apnea is not a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are not applicable. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service Connection for Sleep Apnea Analysis The Veteran contends that symptoms of sleep apnea began during service. Specifically, on the December 2010 VA Form 21-4138, the Veteran wrote that he has had sleep apnea since the Saudi War but did not know what it was. The Veteran further noted that some of the symptoms that he had originally attributed to posttraumatic stress disorder (PTSD) were later attributed to a diagnosis of sleep apnea by his medical provider. After review of the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether symptoms of the Veteran's currently diagnosed sleep apnea had their onset during service. On the one hand, the service treatment records do not show a diagnosis or treatment for sleep apnea, and the first diagnosis of sleep apnea is not shown until 2009, approximately two years after service retirement. See December 2009 health record; see also January 2010 diagnostic polysomnography report. On the other hand, the Veteran, on a service report of medical history, specifically checked "Yes" when asked if he then had or had ever had frequent trouble sleeping. The Veteran's wife wrote, in a December 2010 statement, that she had observed the Veteran's sleep problems during service, which included snoring, choking, and halted breathing. The Veteran's wife is considered competent to report the symptoms she observed, and there is no indication that the account is not credible. Furthermore, the post-service treatment records show that, in December 2008, the Veteran told a treating medical provider that he had had difficulty sleeping "for years" for three to four hours per night, and the treating medical provider noted an assessment of a breathing-related sleep disorder with consideration of ordering a sleep study pending further discussion with the Veteran. A breathing-related sleep disorder was subsequently included in the Veteran's active problems list until the diagnosis of sleep apnea was made in December 2009, and the presence of obstructive sleep apnea was confirmed by the January 2010 polysomnography report. Lay evidence can be competent to describe symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this case, the Veteran's wife reported that she observed the Veteran's snoring, choking, and halted breathing during service, and the Veteran reported having had difficulty sleeping on a service report of medical history completed during service. Also, when the Veteran presented for medical treatment in December 2008, he told his treating medical provider that he had had difficulty sleeping for years for three to four hours per night, which is consistent with the account that symptoms of sleep apnea began during service and deemed credible. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy). After considering the Veteran's complaints of difficulty sleeping, the medical provider initially assessed a breathing-related sleep disorder and attributed the sleep-related complaints to the noted assessment. The breathing-related sleep disorder was later diagnosed as sleep apnea. See, e.g., the January 2010 polysomnography report. In consideration of the foregoing, resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for sleep apnea is warranted. Service Connection for Left and Right Ankle Disorders Analysis The Veteran contends that he currently suffers from left and right ankle disorders due to injuries he sustained during service. See the December 2010 VA Form 21-4138 (wherein the Veteran wrote that he broke the left and right ankles while serving in Iraq). After review of the lay and medical evidence of record, the Board notes that there is evidence of treatment for problems related to the left and right ankles during service. Indeed, the service treatment records show that the Veteran was treated for left ankle problems at various times from November 1983 to June 2005, and was once treated for right ankle pain in January 1981. The weight of the evidence, however, is against finding that the Veteran currently suffers from a left or right ankle disorder, to include any chronic residuals of in-service ankle injury. When the Veteran underwent a VA medical examination in November 2006 in connection with the appeal, he reported weakness, stiffness, some fatigability, and intermittent pain in his ankles one to two times per day. However, on physical examination, the VA medical examiner noted that the ankles were normal in appearance with no edema, effusion, weakness, tenderness, redness, heat, abnormal movement, guarding movement, or subluxation noted. The VA medical examiner also wrote that there was no dorsiflexion, plantar flexion, inversion, or eversion deformity, and there was no ankylosis. The VA medical examiner additionally noted that the range of motion bilaterally was dorsiflexion of 20 degrees (normal is 20 degrees), and plantar flexion of 45 degrees (normal is 45 degrees), without additional limitation by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. X-rays of the bilateral ankles were normal. The VA medical examiner then wrote that he found no pathology to render a diagnosis for either or left or right ankle disorder. Review of the Veteran's treatment records also shows no diagnosis of a current left or right ankle disorder. While the Veteran has complained of pain, weakness, stiffness, and fatigability associated with the ankles, and he is competent to report any symptoms that come to him through the senses, those are symptoms, not a diagnosed disability. The Veteran lacks the requisite medical expertise to diagnose an ankle disorder or attribute any of the symptoms he experiences to a diagnosed disability involving the ankles. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). Therefore, the Veteran's opinion that he currently suffers from a bilateral ankle disorder is afforded less probative value than the medical evidence showing no bilateral ankle disorder, to include any chronic residuals from in-service ankle injury. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997). The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claims process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, where, as here, the evidence of record does not support a diagnosis of the claimed disability during the claims process, that holding is of no advantage; therefore, the preponderance of the evidence is against the claims, and service connection is not warranted for a right or left ankle disorder. In reaching the conclusion, the Board notes that under the provisions of 38 U.S.C.A. § 5107(b), 38 C.F.R. § 3.102, a reasonable doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. However, because the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable. Disability Rating Legal Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the 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 on 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 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. 38 C.F.R. §§ 4.40. The factors involved in evaluating, and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. In DeLuca v. Brown, 8 Vet. App. 202, 205 (1995), the Court held that, for disabilities evaluated on the basis of limitation of motion, VA was required to apply the provisions of 38 C.F.R. §§ 4.40, and 4.45, pertaining to functional impairment. The Court instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination. Such inquiry was not to be limited to muscles or nerves. These determinations were, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. Under 38 C.F.R. § 4.59, with any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. 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. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. Although pain may cause a functional loss, pain itself does not constitute functional loss. 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. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of a veteran's condition. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). An appeal from the initial assignment of a disability rating requires consideration of the entire time period involved and contemplates staged ratings where warranted. Fenderson v. West, 12 Vet. App. 119 (1999). Disability Rating Analysis for the Right Long Finger Disability For the entire rating period, the right long finger disability has been rated at 0 percent (i.e., noncompensable) under 38 C.F.R. § 4.71a, DC 5299-5229. Under DC 5229 (for limitation of motion of the long finger), a 0 percent rating is warranted when there is limitation of motion with evidence of a gap of less than one inch (2.5 cm) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. A 10 percent rating is warranted when there is limitation of motion with evidence of a gap of one inch (2.5 cm) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. After review of the lay and medical evidence of record, the Board finds that the weight of the evidence is against a higher rating for the right long finger disability under DC 5229. At the November 2006 QTC medical examination, the Veteran demonstrated proximal interphalangeal joint (PIP) flexion of 90 degrees (110 degrees is normal), metacarpal phalangeal joint (MP) flexion of 90 degrees (90 degrees is normal), and distal interphalangeal joint (DIP) flexion of 50 degrees (70 degrees is normal). The QTC examiner noted that there was no increasing pain, fatigue, weakness, lack of endurance, incoordination, or any additional limitation with repetitive motion. The QTC examiner also noted that there was no ankylosis with repetitive motion. The examiner indicated that the tips of all fingers can approximate the transverse crease of the palm for all fingers except the right long finger which takes 2 cm. X-rays of the right long finger showed an old healed fracture of the distal tuft of the distal phalanx of the third right finger, with an otherwise normal finger. This evidence, which does not show that the Veteran's right long finger disability results in a gap of one inch (2.5 cm) or more between the fingertip and the proximal transverse crease of the palm, or extension limited by more than 30 degrees, weighs against the assignment of a 10 percent rating under DC 5229. Also, at the May 2011 QTC examination, the Veteran reported pain, decreased strength in pulling, pushing, and twisting, decreased flexibility, locking, stiffness, and swelling. On physical examination, the QTC examiner noted that the Veteran demonstrated a 2 cm gap between the palm and the middle finger with motion at the transverse crease of the palm. This degree of a gap between the palm and middle finger is contemplated in the schedular criteria for the current 0 percent rating, not a 10 percent rating, under DC 5229. Also, on range of motion testing, the right long finger PIP flexion was 60 degrees, right long finger MP flexion was 90 degrees, and right long finger DIP flexion was 50 degrees. Thus, the range of motion findings were within normal limits, and there was no additional limitation on repetitive use. The radiological report of the right hand showed an "old heal[ed] fracture of the tuft of the third distal phalanx, otherwise normal." This evidence also weighs against finding that a higher rating is warranted under DC 5229. Furthermore, the treatment records relevant to the rating period include complaints of pain and limited motion of the right finger at various times; however, the records do not show that the Veteran's right long finger has limited motion to the extent required for a compensable rating under DC 5229. Although the Board has considered the Veteran's complaints of pain, decreased strength, decreased flexibility, locking, stiffness, and swelling in the hand due to the right long finger disability, and there is no indication that the report of such symptoms is not credible, none of the symptoms are shown to have resulted in limitation of motion to the extent required for a compensable rating under DC 5229. The degree of limited motion and resulting functional impairment is contemplated by the current 0 percent schedular rating. For these reasons, the Board finds that a compensable rating under DC 5229 is not warranted for the entire rating period. The Board has considered whether a higher rating is available under DC 5226 for ankylosis of the long finger. In this case, the evidence does not show that the right long finger disability is manifested by ankylosis at any time during the rating period; therefore, a higher rating under the diagnostic code is not warranted. The Board has further considered whether the increased rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the Board does not find any symptoms or functional impairment that is not already encompassed by the current schedular 0 percent rating under 5229. As discussed above, the Veteran's right long finger disability is manifested by pain, decreased strength, decreased flexibility, locking, stiffness, and swelling, and some limitation of motion. The schedular criteria under DC 5229 specifically contemplate right long finger limitation of motion, to include any resulting functional impairment and factors such as pain, swelling, weakness, and locking. The Veteran is in receipt of a 0 percent disability rating for the symptoms and functional impairment associated with the right long finger disability. The rating schedule, which was designed as a guide for evaluating the average impairment in earning capacity as a result of disability, provides for no more than a 0 percent rating for the degree of limitation of motion of the right long finger demonstrated by the Veteran. Thus, the symptoms and functional impairment related to the Veteran's right long finger disability are adequately compensated by the 0 percent disability rating under DC 5229. In consideration of the foregoing, the Board finds that manifestations of the Veteran's disability are fully contemplated in the currently assigned noncompensable rating under DC 5229. For these reasons, the Board finds that the schedular criteria are not inadequate to rate the Veteran's right long finger disability, and referral for consideration of extraschedular rating is not necessary. Disability Rating Analysis for Hemorrhoids For the entire rating period, the Veteran is rated at 0 percent for hemorrhoids pursuant to 38 C.F.R. § 4.114, DC 7336 (external or internal hemorrhoids). Under DC 7336, a noncompensable rating is warranted for mild or moderate external or internal hemorrhoids. A 10 percent rating is warranted for large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating is warranted when there are hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. See 38 C.F.R. § 4.114, DC 7336. After a review of the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether the Veteran's hemorrhoids more closely approximate the criteria for the maximum 20 percent disability rating under DC 7336. On the one hand, the November 2006 QTC examination report noted no evidence of fistula, and the May 2011 QTC medical examination report reveals that the Veteran demonstrated normal rectal tone with no fistulas, no evidence of bleeding, and no ulcerations. The May 2011 QTC examiner also noted that there was no evidence of thrombosis or redundant tissue. This evidence tends to weigh against finding that a compensable rating for hemorrhoids under DC 7336 is warranted. On the other hand, the November 2006 QTC examiner noted that the hemorrhoids caused significant anemia, which is a symptom contemplated in the schedular criteria for a 20 percent rating. Also, on the August 2013 VA Form 9, the Veteran wrote that the hemorrhoids were manifested by bleeding, among other symptoms such as ulcerations that were irreducible and thrombotic and fistulas, and noted that he was waiting to be scheduled for hemorrhoid surgery. The Veteran's statement is consistent with other medical evidence of record and is deemed credible. For example, an April 2013 private treatment record notes a pre-operative diagnosis of rectal bleeding and post-operative diagnoses that include external hemorrhoid, and the August 2013 prescription note from a digestive clinic reads that the Veteran needed to see a surgeon for hemorrhoids. The Board has also considered the Veteran's report at the May 2011 QTC examination that the hemorrhoids symptoms were "near constant," as well as notation by the May 2011 QTC examiner that there was evidence of external hemorrhoids that were not reducible at the examination. Thus, when viewing the totality of the evidence, the Board finds that the evidence shows that the Veteran's hemorrhoids are manifested by persistent bleeding and secondary anemia, are thrombotic and irreducible with frequent recurrences, and are of such a severity so as to require surgical treatment throughout the rating period. For these reasons, resolving reasonable doubt in favor of the Veteran, the Board finds that an increased rating of 20 percent for the hemorrhoids under DC 7336 is warranted for the entire rating period. The Board has considered whether the increased rating appeal for the hemorrhoids warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. The schedular criteria for rating hemorrhoids reasonably describe all symptoms and functional impairment associated with the disability. The Veteran's hemorrhoids have been manifested by persistent bleeding and secondary anemia, ulcerations that are thrombotic and irreducible with frequent recurrences, and are of such a severity so as to require surgical treatment. The 20 percent schedular rating under DC 7336 specifically contemplates such symptomatology and resulting functional impairment. The 20 percent rating is based on the persistent bleeding with secondary anemia and intermittent fissures associated with the hemorrhoids. In consideration of the foregoing, the Board finds, after comparing the functional impairment and symptoms manifested by the Veteran to the schedular criteria for the current rating, that the Veteran's hemorrhoids symptoms and related functional impairment are fully contemplated in the current 20 percent schedular rating; therefore, because the schedular rating criteria are adequate to rate the Veteran's service-connected hemorrhoids, no extraschedular referral is warranted in this case. Disability Rating Analysis for the Right Knee Disability For the entire rating period, the right knee disability has been rated at 10 percent under 38 C.F.R. § 4.71a, DC 5003 for degenerative arthritis of the knee based on painful motion. Under Diagnostic Code 5003, 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 joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. 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. DC 5260 provides for a 0 percent rating when there is flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent evaluation is warranted for flexion limited to 30 degrees. 38 C.F.R. § 4.71a. DC 5261 provides for assignment of a 0 percent rating for extension limited to 5 degrees, a 10 percent rating for extension limited to 10 degrees, a 20 percent rating for extension limited to 15 degrees, a 30 percent rating for extension limited to 20 degrees, a 40 percent rating for extension limited to 30 degrees, and a 50 percent rating for extension limited to 45 degrees. 38 C.F.R. § 4.71a. Normal range of motion for the knee is from 140 degrees flexion to 0 degrees extension. 38 C.F.R. § 4.71, Plate II (2013). After review of the lay and medical evidence in this case, the Board finds that the evidence is in equipoise on the question of whether the maximum 30 percent schedular rating under DC 5260 for limitation of leg flexion is warranted for the rating period. In order for the Veteran to receive a 30 percent rating under DC 5260 (limitation of leg flexion), the evidence must show that the service-connected right knee disability is manifested by flexion limited to 30 degrees. At the November 2006 QTC medical examination, right knee flexion was 90 degrees, with pain throughout (i.e., starting at 0 degrees). On repetitive movement, the right knee showed increasing pain, fatigue, weakness, lack of endurance, or incoordination and, ultimately, the Veteran was unable to perform range of motion with repetitive motion after a short period of time. In consideration thereof, resolving reasonable doubt in favor of the Veteran, the Board finds that the schedular criteria for a 30 percent rating under DC 5260 have been approximated for the entire appeal period. The Board will next consider whether the criteria for a separate rating under DC 5261 for limitation of leg extension have been met. Separate ratings may be assigned under DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg). VAOPGCPREC 9-04, published at 69 Fed. Reg. 59,990 (2004). Specifically, where a veteran has both a limitation of flexion and a 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. Id. However, because the evidence in this case does not demonstrate compensable limitation of extension under the schedular criteria, as will be explained below, the Board finds that VAOPGCPREC 9-04 is inapplicable in the instant case. After review of the lay and medical evidence of record relevant to the rating period, the Board finds that the weight of the evidence is against finding that a separate compensable disability rating for the right knee disability is warranted for any period under DC 5261. In order for the Veteran to receive a separate disability rating under DC 5261 (limitation of leg extension), the evidence must show that the service-connected right knee disability is manifested by extension limited to 10 degrees or greater. However, the evidence does not show such a disability picture. At the November 2006 QTC medical examination, right knee extension was 0 degrees, without pain. Although the Veteran was eventually unable to perform range of motion testing of the right knee with repetitive movement, there is no indication that he had limitation of right knee extension to the degree required for a compensable rating under DC 5261. Review of the Veteran's treatment records relevant to the rating period similarly does not show that the right knee extension has been limited to 10 degrees or greater. Thus, in consideration of the foregoing, the Board finds that a separate rating for limitation of right knee extension is not warranted under DC 5261 for the entire rating period. At the November 2006 QTC examination, the QTC examiner considered the Veteran's complaints of pain, stiffness, fatigue, weakness, lack of endurance, incoordination, and giving way associated with the right knee disability. The QTC examiner specifically noted that the knee showed increased pain, fatigue, weakness, lack of endurance, or incoordination with repetitive movement to the point that he was unable to perform range of motion testing after a short period of time. The Board has considered such symptoms and functional impairment when awarding the 30 percent schedular rating under DC 5260 for the entire period. DeLuca, 8 Vet. App. at 206-07 (holding that functional loss, supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion, is recognized as resulting in disability); 38 C.F.R. §§ 4.10, 4.40, 4.45 (2013). The Board further recognizes that a separate rating may be assigned for instability of the knee under 38 C.F.R. § 4.71a, DC 5257 if (1) a veteran also has limitation of knee motion which at least meets the criteria for a noncompensable disability rating under 38 C.F.R. § 4.71a, Diagnostic Code 5260 and/or 5261, or (2) if the veteran is in receipt of a 10 percent rating on the basis of X-ray evidence of arthritis and evidence of painful motion. VAOPGCPREC 23-97, published at 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, published at 63 Fed. Reg. 56,704 (1998); 38 C.F.R. § 4.59. In this case, the Veteran has degenerative arthritis and is in receipt of a 30 percent disability rating based on limitation of knee flexion under DC 5003-5260. Diagnostic Code 5257 provides for a 10 percent rating when there is evidence of slight impairment of the knee manifested by recurrent subluxation or lateral instability, a 20 percent rating for moderate impairment of the knee manifested by recurrent subluxation or lateral instability, and a 30 percent rating for severe impairment of the knee manifested by recurrent subluxation or lateral instability. 38 U.S.C.A. § 4.71a. After review of the lay and medical evidence, the Board finds that the evidence weighs against the assignment of a separate rating for instability because the Veteran has had a stable right knee throughout the rating period. At the November 2006 QTC examination, the Veteran demonstrated a stable right knee on all stability tests. Treatment records relevant to the rating period do not show an unstable right knee, and the Veteran has not alleged that he has right knee instability; therefore, a separate rating based on instability of the right knee under DC 5257 is not warranted for the rating period. Furthermore, no other diagnostic codes pertaining to the knee provide a basis to assign a higher or separate schedular evaluation for the Veteran's right knee disability for the rating period. The Veteran has already been awarded a 30 percent schedular rating under DC 5260 for the entire rating period for the inability to perform range of motion testing after repetitive movement during the QTC examination. In order for the Veteran to receive a higher rating under DC 5256 for a condition analogous to knee ankylosis, the evidence must additionally show that the right knee was in flexion between 10 to 20 degrees, flexion between 20 degrees and 45 degrees, or in flexion at an angle of 45 or more. The fact that the Veteran was initially able to flex to 90 degrees and extend to 0 degrees weighs against finding that the right knee is limited to a particular range of flexion for a schedular rating higher than 30 percent under DC 5256. Because the Veteran's inability to perform range of motion testing is already contemplated in the current 30 percent rating under DC 5260, the same symptoms may not also be compensated in a separate rating under DC 5256. 38 C.F.R. § 4.14. In consideration of the foregoing, a higher rating under DC 5256 is not warranted. Also, the evidence does not show that there is impairment of the tibia and fibula; therefore, a higher rating under DC 5262 is not warranted for the entire rating period. In addition, the Veteran is not shown to have genu recurvatum, and the maximum disability rating under DC 5263 is 10 percent; therefore, a higher rating under DC 5263 is not warranted for the entire rating period. Furthermore, the evidence does not show that there has been removal of semilunar cartilage with continued symptoms, or that there is semilunar dislocated cartilage with frequent episodes of locking, pain, and effusion into the joint; therefore, a higher or separate rating under either DC 5258 or DC 5259 is not warranted for the rating period. Moreover, because the three right knee scars were described as not tender, disfiguring, and without ulceration, adherence, and tissue loss, and are not shown to cause functional limitation, no compensable residuals have been shown during the rating period; therefore, a separate compensable rating for the Veteran's residual right knee scars is not warranted. The Veteran is already in receipt of a zero percent rating for the scars. Disability Rating Analysis for the Left Knee Disability For the entire rating period, the left knee disability has been rated at 10 percent under 38 C.F.R. § 4.71a, DC 5003 for degenerative arthritis of the knee based on painful motion. After review of the lay and medical evidence in this case, the Board finds that it is in equipoise on the question of whether the maximum 30 percent schedular rating under DC 5260 for limitation of leg flexion is warranted for the rating period. In order for the Veteran to receive a 30 percent rating under DC 5260 (limitation of leg flexion), the evidence must show that the service-connected left knee disability is manifested by flexion limited to 30 degrees. At the November 2006 QTC medical examination, left knee flexion was 100 degrees, with pain throughout (i.e., starting at 0 degrees). On repetitive movement, the left knee showed increasing pain, fatigue, weakness, lack of endurance, or incoordination, and the Veteran was eventually unable to perform range of motion with repetitive motion after a short period of time. In consideration thereof, resolving reasonable doubt in favor of the Veteran, the Board finds that the evidence approximates limitation of left knee flexion to 15 degrees; therefore, a 30 percent rating under DC 5260 is warranted for the entire appeal period. The Board will next consider whether the criteria for a separate rating under DC 5261 for limitation of leg extension have been met. Separate ratings may be assigned under DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg). VAOPGCPREC 9-04, published at 69 Fed. Reg. 59,990 (2004). Specifically, where a veteran has both a limitation of flexion and a 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. Id. However, because the evidence in this case does not demonstrate compensable limitation of extension under the schedular criteria, as will be explained below, the Board finds that VAOPGCPREC 9-04 is inapplicable in the instant case. After review of the lay and medical evidence of record relevant to the rating period, the Board finds that the weight of the evidence is against finding that a separate compensable disability rating for the left knee disability is warranted for any period under DC 5261. In order for the Veteran to receive a separate disability rating under DC 5261 (limitation of leg extension), the evidence must show that the service-connected left knee disability is manifested by extension limited to 10 degrees or greater. However, the evidence does not show such a disability picture. At the November 2006 QTC medical examination, left knee extension was 0 degrees, without pain. Although the Veteran was eventually unable to move the left knee with repetitive movement, there is no indication that he had limitation of left knee extension to the degree required for a compensable rating under DC 5261. Review of the Veteran's treatment records relevant to the rating period similarly does not show that the left knee extension has been limited to 10 degrees or greater. Thus, in consideration of the foregoing, the Board finds that a separate rating for limitation of left knee extension is not warranted under DC 5261 for the entire rating period. While performing range of motion testing at the November 2006 QTC examination, the examiner considered the Veteran's complaints of pain, stiffness, fatigue, weakness, lack of endurance, incoordination, and giving way associated with the left knee disability. The Board has considered such symptoms and the Veteran's inability to perform range of motion testing after a short time on repetitive movement when awarding the 30 percent schedular rating under DC 5260 for the entire period. DeLuca, 8 Vet. App. at 206-07 (holding that functional loss, supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion, is recognized as resulting in disability); 38 C.F.R. §§ 4.10, 4.40, 4.45 (2013). The Board further recognizes that a separate rating may be assigned for instability of the knee under 38 C.F.R. § 4.71a, DC 5257 if (1) a veteran also has limitation of knee motion which at least meets the criteria for a noncompensable disability rating under 38 C.F.R. § 4.71a, Diagnostic Code 5260 and/or 5261, or (2) if the veteran is in receipt of a 10 percent rating on the basis of X-ray evidence of arthritis and evidence of painful motion. VAOPGCPREC 23-97, published at 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, published at 63 Fed. Reg. 56,704 (1998); 38 C.F.R. § 4.59. In this case, the Veteran has degenerative arthritis and is in receipt of a 30 percent disability rating based on limitation of knee flexion under DC 5003-5260. Diagnostic Code 5257 provides for a 10 percent rating when there is evidence of slight impairment of the knee manifested by recurrent subluxation or lateral instability, a 20 percent rating for moderate impairment of the knee manifested by recurrent subluxation or lateral instability, and a 30 percent rating for severe impairment of the knee manifested by recurrent subluxation or lateral instability. 38 U.S.C.A. § 4.71a. After review of the lay and medical evidence, the Board finds that the evidence weighs against the assignment of a separate rating for instability because the Veteran has had a stable left knee throughout the rating period. At the November 2006 QTC examination, the Veteran demonstrated a stable left knee on all stability tests. Treatment records relevant to the rating period do not show an unstable left knee, and the Veteran has not alleged that he has instability of the left knee; therefore, a separate rating based on instability of the left knee under DC 5257 is not warranted for the rating period. Furthermore, no other diagnostic codes pertaining to the knee provide a basis to assign a higher or separate schedular evaluation for the Veteran's knee disability for the rating period. The Veteran has already been awarded a 30 percent schedular rating under DC 5260 for the entire rating period for the inability to perform range of motion testing after repetitive movement during the QTC examination. In order for the Veteran to receive a higher rating under DC 5256 for a condition analogous to knee ankylosis, the evidence must additionally show that the left knee was in flexion between 10 to 20 degrees, flexion between 20 degrees and 45 degrees, or in flexion at an angle of 45 or more. The fact that the Veteran was initially able to flex to 100 degrees and extend to 0 degrees weighs against finding that the left knee is limited to a particular range of flexion for a schedular rating higher than 30 percent under DC 5256. Because the Veteran's inability to perform range of motion testing is already contemplated in the current 30 percent rating under DC 5003-5260, the same symptoms may not also be compensated in a separate rating under DC 5256. 38 C.F.R. § 4.14. In consideration of the foregoing, a higher rating under DC 5256 is not warranted. Also, the evidence does not show that there is impairment of the tibia and fibula; therefore, a higher rating under DC 5262 is not warranted for the entire rating period. Additionally, the Veteran is not shown to have genu recurvatum, and the maximum disability rating under DC 5263 is 10 percent; therefore, a higher rating under DC 5263 is not warranted for the entire rating period. Furthermore, the evidence does not show that there has been removal of semilunar cartilage with continued symptoms, or that there is semilunar dislocated cartilage with frequent episodes of locking , pain, and effusion into the joint; therefore, a higher or separate rating under either DC 5258 or DC 5259 is not warranted for the rating period. Moreover, because the three left knee scars were described as not tender, not disfiguring, and without ulceration, adherence, and tissue loss, and are not shown to cause functional limitation, no compensable residuals are shown during the rating period; therefore, a separate compensable rating for the Veteran's residual left knee scars is not warranted. The Veteran is already in receipt of a zero percent rating for the scars. The Board has further considered whether the initial rating appeals for the knee disabilities warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008). The schedular criteria for rating disabilities of the knee reasonably describe all symptoms and functional impairment associated with the Veteran's knee disabilities. The Veteran's left and right knee disabilities have been manifested by degenerative arthritis with painful limitation of motion on flexion to the point that the Veteran was unable to perform range of motion testing on repetitive movement after a short time. The 30 percent schedular ratings under DC 5003-5260 specifically contemplate such symptomatology and resulting functional impairment. The schedular rating criteria specifically provide ratings for limitation of motion due to painful arthritis (Diagnostic Codes 5003, 38 C.F.R. § 4.59), and contemplate ratings based on limitation of motion (Diagnostic Codes 5256, 5260, 5261), including motion limited by factors such as pain, weakness, and stiffness (38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca). The 30 percent ratings are based on limited flexion and consider functional impairment, to include as due to Deluca factors. In consideration of the foregoing, the Board finds, after comparing the functional impairment and symptoms manifested by the Veteran to the schedular criteria for the current ratings, that the Veteran's right and left knee symptoms and related functional impairment are fully contemplated in the current 30 percent schedular ratings; therefore, because the schedular rating criteria are adequate to rate the Veteran's service-connected knee disabilities, no extraschedular referral is warranted in this case. Disability Rating Analysis for Migraine Headaches For the entire rating period, the Veteran has been rated at 0 percent under 38 C.F.R. § 4.124a, DC 8100 for migraine headaches. Under DC 8100, which addresses migraines, a noncompensable evaluation is assigned with less frequent attacks. A 10 percent rating is assigned with characteristic prostrating attacks averaging one in two months, over the last several months. A 30 percent rating is assigned with characteristic prostrating attacks occurring on an average of once a month of the last several months. Finally, a 50 percent rating is assigned when there are migraines with very frequent, completely prostrating and prolonged attacks that are productive of severe economic inadaptability. Id. After review of the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether the Veteran's migraine headaches are of the frequency and severity to warrant a 50 percent rating under DC 8100. In order for the Veteran to receive a 50 percent disability rating of 10 percent for the migraine headaches under DC 8100, the disability picture must more closely approximate headaches with very frequent, completely prostrating and prolonged attacks that are productive of severe economic inadaptability. At the November 2006 QTC examination, the Veteran reported that he had recurrent migraine headaches, which were intense, throbbing, and caused vomiting and pain. He reported that he sometimes had to stay in bed and was unable to do anything when he had migraine headaches. He also reported that they occurred one to two times per month and lasted about two days. Prostration is defined as extreme exhaustion or powerlessness. Dorland's Illustrated Medical Dictionary 1523 (30th ed. 2003). The severity of the headaches as described by the Veteran at the QTC medical examination indicates that they are, indeed, characterized by prostrating attacks. At the November 2006 QTC medical examination, the Veteran stated that the headaches were intense, caused vomiting and pain, and were sometimes so severe that he had to stay in bed. There is no indication in the record that the Veteran's report of symptoms associated with the migraine headaches is not credible. Also, there is both favorable and unfavorable evidence of record to show that the Veteran has very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. On the one hand, the Veteran has typically reported that migraine headaches occur approximately once or twice per month, which more closely approximates the criteria for a 30 percent rating. See November 2006 QTC medical examination report; see also September 2009 VA Form 9 (wherein the Veteran notes that the migraine headaches occur a minimum of twice per month). However, at the 2011 RO hearing, the Veteran testified that he had migraine headaches at least three to four times per month, and often had to call into work and take sick leave due to migraine symptoms. See hearing transcript, page 6. The Veteran also testified that he had to change his work schedule due to the migraine headaches. On the December 2010 statement, the Veteran wrote that he had been counseled for missing work due to the headaches. There is no indication that the account is not credible. Thus, resolving reasonable doubt in favor of the Veteran, the evidence shows that migraine headaches have been manifested by very frequent completely prostrating and prolonged attacks that are productive of severe economic inadaptability during the rating period so as to warrant a 50 percent rating under DC 8100. This is the maximum rating for migraine headaches under DC 8100. The Board has considered whether the initial rating appeal for the migraine headaches warrants referral for consideration of an extraschedular rating. The schedular criteria for rating the migraine headaches encompass all symptoms and functional impairment associated with the Veteran's migraines. As stated above, the 50 percent rating contemplates migraine headaches manifested by very frequent completely prostrating and prolonged attacks that are productive of severe economic inadaptability. The Veteran's migraine headaches are manifested by such symptomatology and are fully contemplated by the 50 percent rating. In consideration of the foregoing, the Board finds, after comparing the functional impairment and symptoms manifested by the Veteran to the schedular criteria for the current rating, that the Veteran's symptoms and related functional impairment are fully contemplated in the current 50 percent schedular rating; therefore, because the schedular rating criteria are adequate to rate the Veteran's service-connected migraine headaches, no extraschedular referral is warranted in this case. Consideration of a Total Disability Rating Based on Individual Unemployability The Board has further found that the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) has not been raised by the Veteran or the record in this case. Rice v. Shinseki, 22 Vet. App. 447 (2009). On the December 2010 VA Form 21-4138, the Veteran wrote that he was able to work and provide for his family. At the 2011 RO hearing, the Veteran stated that he worked at a boiler plant. See hearing transcript, page 3. The Veteran has not alleged, and the record does not indicate, that the Veteran is rendered unemployable due to the service-connected disabilities. Therefore, a TDIU is not raised, and is not part of the rating appeal. ORDER Service connection for sleep apnea is granted. Service connection for a right ankle disorder is denied. Service connection for a left ankle disorder is denied. An increased (compensable) rating for the right long finger disability is denied. An increased rating of 20 percent rating for hemorrhoids is granted. An initial rating of 30 percent rating for the right knee disability is granted. An initial rating of 30 percent rating for the left knee disability is granted. An initial rating of 50 percent rating for the migraine headaches is granted. ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs