Citation Nr: 1334484 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 08-18 861 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for allergies. 2. Entitlement to service connection for hearing loss. 3. Entitlement to service connection for glaucoma. 4. Entitlement to service connection for rheumatoid arthritis and/or arthritis of the cervical spine, lumbar spine, elbows, wrists, and hips. 5. Entitlement to an initial rating in excess of 20 percent prior to March 27, 2010, and in excess of 40 percent since March 27, 2010, for benign prostatic hypertrophy with erectile dysfunction. 6. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease with hiatal hernia. 7. Entitlement to separate compensable ratings for osteoarthritis of the left knee, right knee, and left shoulder prior to March 27, 2010. 8. Entitlement to an initial rating in excess of 10 percent for osteoarthritis of the left knee since March 27, 2010. 9. Entitlement to an initial rating in excess of 10 percent for osteoarthritis of the right knee since March 27, 2010. 10. Entitlement to an initial rating in excess of 10 percent for osteoarthritis of the left shoulder since March 27, 2010. 11. Entitlement to an initial compensable rating prior to March 6, 2010, and in excess of 10 percent since March 6, 2010, for temporomandibular joint dysfunction. 12. Entitlement to an initial compensable rating prior to November 13, 2007, and in excess of 10 percent since November 13, 2007, for left foot bone spurs and plantar fasciitis. 13. Entitlement to an initial compensable rating for hypertension. 14. Entitlement to an initial compensable rating prior to March 27, 2010, and in excess of 10 percent since March 27, 2010, for left wrist ganglion cyst. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD J. W. Kim, Counsel INTRODUCTION The Veteran had active service from November 1984 to April 2006. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. In the February 2007 rating decision on appeal, the RO granted service connection for osteoarthritis of the left knee, right knee, and left shoulder and evaluated the disabilities as one disability, assigning a combined 10 percent rating effective May 1, 2006. In an October 2012 rating decision, the RO assigned separate 10 percent ratings for each knee and left shoulder, effective March 27, 2010. As the Veteran appeals for separate 10 percent ratings for those disabilities prior to that time, the issue has been characterized as stated on the title page. Also in the October 2012 rating decision, the RO increased the rating for left foot bone spurs and plantar fasciitis to 10 percent effective November 13, 2007; increased the rating for benign prostatic hypertrophy with erectile dysfunction to 40 percent effective March 27, 2010; increased the rating for temporomandibular joint dysfunction to 10 percent effective March 6, 2010; and increased the rating for left wrist ganglion cyst to 10 percent effective March 27, 2010. As those increases did not represent the maximum ratings available, the issues remain in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). In July 2013, the Veteran testified during a Board hearing before the undersigned Acting Veterans Law Judge at the RO. The issue of entitlement to service connection for rheumatoid arthritis and/or arthritis of the cervical spine, elbows, wrists, and hips is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. In February 12, 2013, correspondence, the Veteran requested a withdrawal of his appeal with respect to the claims for service connection for allergies, hearing loss, and glaucoma. 2. On the record during the July 10, 2013, Board hearing, the Veteran requested a withdrawal of his appeal with respect to the claims for an initial rating in excess of 20 percent prior to March 27, 2010, and in excess of 40 percent since March 27, 2010, for benign prostatic hypertrophy with erectile dysfunction; an initial rating in excess of 10 percent for gastroesophageal reflux disease with hiatal hernia; an initial rating in excess of 10 percent for osteoarthritis of the left knee since March 27, 2010; an initial rating in excess of 10 percent for osteoarthritis of the right knee since March 27, 2010; an initial rating in excess of 10 percent for osteoarthritis of the left shoulder since March 27, 2010; an initial rating in excess of 10 percent for temporomandibular joint dysfunction since March 6, 2010; an initial rating in excess of 10 percent for left foot bone spurs and plantar fasciitis since November 13, 2007; and an initial rating in excess of 10 percent for left wrist ganglion cyst since March 27, 2010. 3. The Veteran's spondylosis of the thoracolumbar spine manifested to a compensable degree within one year of separation from active service. 4. Prior to March 27, 2010, the Veteran's osteoarthritis of the left knee, right knee, and left shoulder had each been manifested by degenerative arthritis established by x-ray findings and noncompensable limitation of motion. 5. Prior to March 6, 2010, the Veteran's temporomandibular joint dysfunction had been manifested by painful motion of the jaw, comparable to inter-incisal range from 31 to 40 millimeters or lateral excursion from zero to 4 millimeters. 6. Prior to November 13, 2007, the Veteran's left foot bone spurs and plantar fasciitis had been manifested by disability comparable to moderate foot injuries. 7. The Veteran's hypertension has been manifested by a history of diastolic pressure predominantly 100 or more and requiring continuous medication for control. 8. Prior to March 27, 2010, the Veteran's left wrist ganglion cyst had been manifested by disability comparable to a scar that was superficial and painful on examination. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran with respect to the claims for service connection for allergies, hearing loss, and glaucoma, and for an initial rating in excess of 20 percent prior to March 27, 2010, and in excess of 40 percent since March 27, 2010, for benign prostatic hypertrophy with erectile dysfunction; an initial rating in excess of 10 percent for gastroesophageal reflux disease with hiatal hernia; an initial rating in excess of 10 percent for osteoarthritis of the left knee since March 27, 2010; an initial rating in excess of 10 percent for osteoarthritis of the right knee since March 27, 2010; an initial rating in excess of 10 percent for osteoarthritis of the left shoulder since March 27, 2010; an initial rating in excess of 10 percent for temporomandibular joint dysfunction since March 6, 2010; an initial rating in excess of 10 percent for left foot bone spurs and plantar fasciitis since November 13, 2007; and an initial rating in excess of 10 percent for left wrist ganglion cyst since March 27, 2010, have been met. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2013); 38 C.F.R. § 20.204 (2013). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for spondylosis of the thoracolumbar spine have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.2, 3.303, 3.307, 3.309 (2013). 3. Resolving reasonable doubt in the Veteran's favor, prior to March 27, 2010, the criteria for a separate 10 percent rating, but no higher, for osteoarthritis of the left knee have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321, 4.3, 4.71a, Diagnostic Codes 5003, 5010 (2013). 4. Resolving reasonable doubt in the Veteran's favor, prior to March 27, 2010, the criteria for a separate 10 percent rating, but no higher, for osteoarthritis of the right knee have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321, 4.3, 4.71a, Diagnostic Codes 5003, 5010 (2013). 5. Resolving reasonable doubt in the Veteran's favor, prior to March 27, 2010, the criteria for a separate 10 percent rating, but no higher, for osteoarthritis of the left shoulder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321, 4.3, 4.71a, Diagnostic Codes 5003, 5010 (2013). 6. Resolving reasonable doubt in the Veteran's favor, prior to March 6, 2010, the criteria for a 10 percent rating, but no higher, for temporomandibular joint dysfunction have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321, 4.3, 4.40, 4.45, 4.59, 4.150, Diagnostic Code 9905 (2013). 7. Resolving reasonable doubt in the Veteran's favor, prior to November 13, 2007, the criteria for a 10 percent rating, but no higher, for left foot bone spurs and plantar fasciitis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284 (2013). 8. Resolving reasonable doubt in the Veteran's favor, the criteria for a 10 percent rating, but no higher, for hypertension have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.104, Diagnostic Code 7101 (2013). 9. Prior to March 27, 2010, the criteria for a 10 percent rating, but no higher, for left wrist ganglion cyst have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321, 4.3, 4.118, Diagnostic Code 7804 (effective prior to October 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Withdrawn Claims The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2013). A substantive appeal may be withdrawn on the record during a hearing, and at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204 (2013). Withdrawal may be made by the veteran or by the authorized representative. 38 C.F.R. § 20.204 (2013). In February 12, 2013, correspondence, the Veteran requested a withdrawal of his appeal with respect to the claims for service connection for allergies, hearing loss, and glaucoma. Therefore, there remain no allegations of errors of fact or law for appellate consideration with respect to those claims. Thus, the Board does not have jurisdiction to review the appeal as to those claims, and they must be dismissed. Then, on the record during the February 29, 2013, Board hearing, the Veteran requested a withdrawal of his claims for an initial rating in excess of 20 percent prior to March 27, 2010, and in excess of 40 percent since March 27, 2010, for benign prostatic hypertrophy with erectile dysfunction; and an initial rating in excess of 10 percent for gastroesophageal reflux disease with hiatal hernia. Based on the Veteran's hearing testimony, the Board finds that he also requested a withdrawal of his claims for initial ratings in excess of 10 percent for osteoarthritis of the left knee, osteoarthritis of the right knee, osteoarthritis of the left shoulder, and left wrist ganglion cyst, all since March 27, 2010; an initial rating in excess of 10 percent for temporomandibular joint dysfunction since March 6, 2010; and an initial rating in excess of 10 percent for left foot bone spurs and plantar fasciitis since November 13, 2007. The Veteran indicated that he was satisfied with the current 10 percent ratings but wanted the 10 percent ratings to go back to the effective dates of service connection. See Hearing Transcript, pages 5-8, 26-30. Therefore, there remain no allegations of errors of fact or law for appellate consideration with respect to those claims. Accordingly, the Board does not have jurisdiction to review the appeal as to those claims, and they must be dismissed. Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant and his or her representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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 U.S.C.A. § 5103(a) (West 2002 & Supp. 2013); 38 C.F.R. § 3.159(b) (2013); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Given the favorable decision on the claim for service connection for arthritis of the lumbar spine, no further discussion of the duties to notify and assist is needed. The Veteran's claims for higher and separate ratings arise from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Thus, no further notice is needed. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2013); 38 C.F.R. § 3.159 (2013). In this case, all necessary development has been accomplished and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, and post-service reports of VA and private treatment and examination. The Veteran's statements in support of the claims are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the claims. VA provided the Veteran with examinations in July 2006 to determine the nature and severity of his disabilities. 38 C.F.R. § 3.159(c)(4) (2013). When VA provides an examination or obtains an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds the VA examination reports to be thorough and adequate upon which to base a decision on the claims. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information needed to evaluate the disabilities under the applicable rating criteria. To the extent that the reports are inadequate, given the favorable decisions in this case, the Board finds no prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Also, with respect to the disabilities of the knees, left shoulder, temporomandibular joint, left foot, and left wrist, the rating periods at issue involve an earlier time and thus a current examination would be of little probative value in evaluating the disabilities for that earlier time. The Board finds that no further notice or assistance is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a disorder noted during service is not shown to be chronic, then generally a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b) (2013). Where a veteran served for 90 days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year from the date of separation from service, the disease shall be presumed to have been incurred in service, even though there is no evidence of such disease in service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307, 3.309 (2013). While the disease need not be diagnosed within the presumption period, it must be shown by acceptable lay or medical evidence that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307, 3.309 (2013). The presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307, 3.309 (2013). Service connection requires competent evidence of (1) a current disability; (2) the incurrence or aggravation of a disease or injury during service; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Veteran claims that he has arthritis of the lumbar spine due to active service. The Veteran was afforded a VA examination in July 2006, within three months of separation from active service. X-rays of the chest showed incidental findings of spondylosis of the thoracic spine. The Board observes that spondylosis represents degenerative spinal changes due to osteoarthritis. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY, 1780 (31st ed. 2007). As noted above, the disability was found within one year of separation from active service. The remaining question is whether the disability manifested to a degree of 10 percent within that time. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; 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. 38 C.F.R. § 4.71a (2013). The objective medical evidence of record does not show that the Veteran's back disability manifested in the criteria needed for a 10 percent rating within one year of separation from active service. However, he filed a claim within one month of separation, indicating the presence of pain and some degree of loss of range of motion at that time. The Board notes that he is competent to give evidence about observable symptoms such as pain. Layno v. Brown, 6 Vet. App. 465 (1994). In that regard, the Board observes that pain associated with range of motion generally results in some loss of range of motion and functional impairment. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2013); DeLuca v. Brown, 8 Vet. App. 202 (1995). Resolving reasonable doubt in the Veteran's favor, the Board finds that his spondylosis manifested to a compensable degree within one year of separation from active service. See 38 U.S.C.A. § 5107 (West 2002 & Supp. 2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Thus, spondylosis of the thoracolumbar spine shall be presumed to have been incurred in service and service connection is warranted. Initial Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. § 4.1 (2013). The Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204 (1994). But see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1 (2013); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When the veteran has disagreed with the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged" ratings (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119 (1999). The analysis below is therefore undertaken with consideration of the possibility that different "staged" ratings may be warranted for different time periods. When evaluating joint disabilities rated on the basis of limitation of motion, VA may consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2013); DeLuca v. Brown, 8 Vet. App. 202 (1995). Osteoarthritis of the Left Knee, Right Knee, and Left Shoulder The Veteran seeks separate compensable ratings for osteoarthritis of the left knee, right knee, and left shoulder prior to March 27, 2010. His osteoarthritis of the knees and left shoulder has been assigned a single 10 percent rating under Diagnostic Code 5010. 38 C.F.R. § 4.71a (2013). Under Diagnostic Code 5010, arthritis due to trauma is rated as degenerative arthritis under Diagnostic Code 5003. 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 joint or 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 diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, x-ray evidence of involvement of two or more major joints or two or more minor joint groups warrants a 10 percent rating and x-ray evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations warrants a 20 percent rating. 38 C.F.R. § 4.71a (2013). Under Diagnostic Code 5260, a 10 percent rating requires limitation of flexion to 45 degrees, a 20 percent rating requires limitation of flexion to 30 degrees, and a 30 percent rating requires limitation of flexion to 15 degrees. 38 C.F.R. § 4.71a (2013). Under Diagnostic Code 5261, a 10 percent rating requires limitation of extension to 10 degrees, a 20 percent rating requires limitation of extension to 15 degrees, a 30 percent rating requires limitation of extension to 20 degrees, a 40 percent rating requires limitation of extension to 30 degrees, and a 50 percent rating requires limitation of extension to 45 degrees. 38 C.F.R. § 4.71a (2013). For VA purposes, normal extension and flexion of the knee is from 0 to 140 degrees. Plate II, 38 C.F.R. § 4.71 (2013). Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating. 38 C.F.R. § 4.71a (2013). Separate ratings may be assigned based on limitation of flexion and limitation of extension of the same knee joint under Diagnostic Code 5260 and Diagnostic Code 5261, respectively. VAOPGCPREC 09-04 (September 17, 2004). Separate ratings may be assigned under Diagnostic Code 5257 for other knee impairment or 5258/5259 for cartilage impairment, and Diagnostic Code 5010, where there is x-ray evidence of arthritis in addition to recurrent subluxation, lateral instability, or symptoms of locking, pain, and effusion related to the removal or dislocation of semilunar knee cartilage, but only if there is additional disability due to limitation of motion. See VAOPGCPREC 23-97 (July 1, 1997) and VAOPGCREC 9-98 (August 14, 1998). The Veteran's service treatment records show complaints of bilateral knee and left shoulder pain. In June 2005, he complained of bilateral knee pain and swelling, and was found to have tenderness and edema. In November 2005, he had flexion of each knee to 110 degrees. In January 2006, he was seen for left shoulder pain and had 80 percent of range of motion of the shoulder. He underwent surgery on his left shoulder later that month. In April 2006, he complained of intermittent right knee pain. The service treatment records also show that he had restrictions on his physical profile due to his knees and left shoulder. A July 2006 VA examination report reflects complaints of occasional tightness in the left shoulder and intermittent stiffness in the right knee. He denied any current symptoms in the left knee. He noted that surgery partially resolved the intermittent pain and stiffness in the left shoulder. The examiner stated that range of motion of the left shoulder was not affected by pain, fatigue, weakness, lack of endurance, or incoordination. The examiner stated that there was normal range of motion of both knees, and range of motion was not affected by pain, fatigue, weakness, lack of endurance, or incoordination. The examiner indicated that there was no instability in either knee. X-rays showed early osteoarthritis of each knee and left shoulder. A September 2007 private treatment note shows that pain was elicited on abduction of the left shoulder greater than 90 degrees. During the July 2013 hearing, the Veteran testified that his knee and left shoulder symptoms have remained the same since the July 2006 VA examination. With respect to the Veteran's knee disabilities, even considering the principles set forth in 38 C.F.R. §§ 4.40, 4.45 and 4.59, the Board finds that they do not warrant a compensable rating under Diagnostic Code 5260 or 5261. However, degenerative arthritis of each knee was seen on x-ray during the July 2006 examination. While limitation of motion was not seen at that time, limitation of motion was seen during service and a later March 2010 VA examination, and the Veteran has essentially testified that his symptoms have remained the same since separation from service. Resolving reasonable doubt in his favor, the Board finds that, prior to March 27, 2010, his osteoarthritis of the left and right knees had each been manifested by degenerative arthritis established by x-ray findings and noncompensable limitation of motion. Thus, a 10 percent rating is warranted for each knee, a major joint, under Diagnostic Code 5003. Similarly, even considering the principles of 38 C.F.R. §§ 4.40, 4.45 and 4.59, his left shoulder disability does not warrant a compensable rating under Diagnostic Code 5201. However, degenerative arthritis of the left shoulder was seen on x-ray during the July 2006 examination. While limitation of motion was not seen during that examination, limitation of motion was seen during service, September 2007 treatment, and a later March 2010 VA examination, and he has essentially testified that his symptoms have remained the same since discharge from service. Resolving reasonable doubt in his favor, the Board finds that, prior to March 27, 2010, his osteoarthritis of the left shoulder had been manifested by degenerative arthritis established by x-ray findings and noncompensable limitation of motion. Thus, a 10 percent rating is warranted for the left shoulder under Diagnostic Code 5003. The Board has also considered whether any other applicable rating criteria may enable a higher evaluation. However, the findings do not provide for a higher rating under any other diagnostic code. In conclusion, the Board has applied the benefit-of-the-doubt doctrine in granting separate 10 percent ratings for osteoarthritis of the left knee, right knee, and left shoulder prior to March 27, 2010. As the preponderance of the evidence is against even higher ratings, the benefit-of-the-doubt doctrine is not applicable to that aspect of the claim. See 38 U.S.C.A. § 5107 (West 2002 & Supp. 2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Temporomandibular Joint Dysfunction The Veteran seeks a compensable rating for temporomandibular joint (TMJ) dysfunction prior to March 6, 2010. His TMJ dysfunction has been assigned a 0 percent rating under Diagnostic Code 9999-9905. 38 C.F.R. § 4.150 (2013). Thus, his disability has been rated by analogy under Diagnostic Code 9905 for limited motion of temporomandibular articulation. See 38 C.F.R. §§ 4.20, 4.27 (2013). Under Diagnostic Code 9905, an inter-incisal range from zero to 10 millimeters warrants a maximum 40 percent rating, from 11 to 20 millimeters warrants a 30 percent rating, from 21 to 30 millimeters warrants a 20 percent rating, and from 31 to 40 millimeters warrants a 10 percent rating. Range of lateral excursion from zero to 4 millimeters warrants a maximum 10 percent rating. Ratings for limited inter-incisal movement shall not be combined with ratings for limited lateral excursion. 38 C.F.R. § 4.150 (2013). A July 2006 VA examination report reflects inter-incisal range of 48 millimeters, lateral excursion to the right of 8 millimeters, and lateral excursion to the left of 10 millimeters. There was clicking on the TMJ but no functional impairment or loss of masticatory function, no deviation from the midline on opening and closing, and no tenderness on the left TMJ. X-rays were interpreted as normal. During the July 2013 hearing, the Veteran testified that his TMJ symptoms have remained the same since the July 2006 VA examination. Initially, the Board notes that the RO's assignment of the March 6, 2010, effective date of the 10 percent rating was in error. The correct date of the VA examination report upon which the effective date is based is March 16, 2010. However, given the favorable outcome of this matter, there is no prejudice to the Veteran. The Board notes that the RO assigned the current 10 percent rating based on painful motion of the jaw, pursuant to 38 C.F.R. § 4.59 (2013). The Veteran has testified that his TMJ dysfunction, including the pain on moving his jaw, has remained the same since the July 2006 examination. The July 2006 examiner did not comment on the presence or absence of pain on moving the jaw or the effect of repetitive opening and closing of the jaw. The examiner also only noted that there was no tenderness on the left TMJ, leaving open the possibility that there was tenderness on the right. The Board also notes that the Veteran is competent to give evidence about observable symptoms such as pain. Layno v. Brown, 6 Vet. App. 465 (1994). The Board again observes that pain associated with range of motion generally results in some loss of range of motion and functional impairment. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2013); DeLuca v. Brown, 8 Vet. App. 202 (1995). Resolving reasonable doubt in his favor, the Board finds that, prior to March 6, 2010, his TMJ dysfunction had been manifested by painful motion of the jaw, comparable to inter-incisal range from 31 to 40 millimeters or lateral excursion from zero to 4 millimeters. Thus, a 10 percent rating is warranted under Diagnostic Code 9905. The Board has also considered whether any other applicable rating criteria may enable a higher evaluation. However, the findings do not provide for a higher rating under any other diagnostic code. In conclusion, the Board has applied the benefit-of-the-doubt doctrine in granting an initial 10 percent rating for TMJ dysfunction prior to March 6, 2010. As the preponderance of the evidence is against an even higher rating, the benefit-of-the-doubt doctrine is not applicable to that aspect of the claim. See 38 U.S.C.A. § 5107 (West 2002 & Supp. 2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Foot Bone Spurs and Plantar Fasciitis The Veteran seeks a compensable rating for left foot bone spurs and plantar fasciitis prior to November 13, 2007. His spurs and plantar fasciitis have been assigned a 0 percent rating under Diagnostic Code 5099-5020. 38 C.F.R. § 4.71a (2013). Thus, his disability has been rated by analogy under Diagnostic Code 5020 for synovitis. See 38 C.F.R. §§ 4.20, 4.27 (2013). Synovitis is to be rated on limitation of motion of affected parts, as degenerative arthritis. 38 C.F.R. § 4.71a (2013). Under Diagnostic Code 5284, moderate foot injuries warrant a 10 percent rating. 38 C.F.R. § 4.71a (2013). A July 2006 VA examination report reflects complaints of intermittent pain in the left heel due to the bone spur, usually with prolonged walking or standing. There was no sign of abnormal weight bearing. There was no pain to palpation to the Achilles of the calcaneus or plantar fascia, or the bottom of the foot. The Achilles tendon was considered normal with good alignment. There was no evidence of claw feet, hallux valgus, hallux varus, or hallux rigidus. There was no evidence of limited function for standing or walking. His gait was normal. X-rays showed plantar and posterior calcaneal spurs but the bony alignment was normal, there was no evidence of fracture or other structural abnormalities, and joints spaces were maintained. A September 2007 private treatment note shows complaints left foot pain worse while standing, walking, running, and jumping. There was tenderness to palpation of the ball of the left foot but no swelling or pain on motion. A treatment note dated later that month shows tenderness to palpation of the bottom of the left foot but no swelling, no limited motion, and no pain on motion. However, it was noted that the foot did not demonstrate full range of motion. During the July 2013 hearing, the Veteran testified that his left foot symptoms have remained the same since the July 2006 VA examination. The July 2006 VA examiner did not provide range of motion findings with respect to the left foot. The examiner also did not comment on the presence or absence of pain in the process of moving the foot. The Board again notes that the Veteran is competent to give evidence about observable symptoms such as pain. Layno v. Brown, 6 Vet. App. 465 (1994). While the examiner noted that there was no evidence of limited function for standing or walking, the examiner did not provide any limitation of motion findings, and the Veteran stated that he had pain on prolonged standing or walking, which would account for the negative findings at the examination. Further, a lack of range of motion was noted in September 2007, and the Veteran has essentially testified that his symptoms have remained the same since discharge from service. However, resolving reasonable doubt in his favor, the Board finds that, prior to November 13, 2007, his left foot bone spurs and plantar fasciitis had been manifested by disability comparable to moderate foot injuries. Thus, a 10 percent rating is warranted under Diagnostic Code 5284 pursuant to 38 C.F.R. §§ 4.40, 4.45 and 4.59. The Board has also considered whether any other applicable rating criteria may enable a higher evaluation. However, the findings do not provide for a higher rating under any other diagnostic code. In conclusion, the Board has applied the benefit-of-the-doubt doctrine in granting an initial 10 percent rating for left foot bone spurs and plantar fasciitis prior to November 13, 2007. As the preponderance of the evidence is against an even higher rating, the benefit-of-the-doubt doctrine is not applicable to that aspect of the claim. See 38 U.S.C.A. § 5107 (West 2002 & Supp. 2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hypertension The Veteran seeks a compensable rating for hypertension. His hypertension has been assigned a 0 percent rating under Diagnostic Code 7101. 38 C.F.R. § 4.104 (2013). Under Diagnostic Code 7101, a maximum 60 percent rating is warranted for diastolic pressure predominantly 130 or more; a 40 percent is warranted for diastolic pressure predominantly 120 or more; a 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more; and a 10 percent rating is warranted where diastolic pressure is predominantly 100 or more, systolic pressure is predominantly 160 or more, or where an individual has a history of diastolic pressure predominantly 100 or more and requires continuous medication for control. The Veteran's service treatment records show that an October 1998 screening showed blood pressure readings of 171/86 and 154/84. During a five-day blood pressure check, he had readings of 140/98, 142/106, 134/90, 166/84, and 154/86. In November 1998, he was diagnosed with hypertension and started on an exercise program and a diet. In January 2001, he was started on medications. In March 2002, he had readings of 154/108, 162/108, 160/110, and 140/100. In February 2006, his blood pressure readings were 185/103 and 160/96. In March 2006, his reading was 148/104 and he reported having readings in the 150s/90s. During a July 2006 VA examination, the Veteran reported a history of hypertension, requiring three medications and being asymptomatic. Blood pressure readings were 134/74, 130/70, and 130/70, and the examiner noted that the Veteran's hypertension was under good control. Private medical records show that the Veteran was continuing to take multiple medications for his hypertension. They show a blood pressure reading of 160/99 in September 2007, at which time he reported losing one of his medications. He was provided with a refill. Later that month, his reading was 149/96 and he reported having readings in the 170s/100s. He asked for a prescription for a prior medication that had better controlled his hypertension but was discontinued due to cost. By the end of the month, his blood pressure reading was 136/82. During a December 2012 VA examination, the Veteran's blood pressure was taken three times and the readings were all 136/78. Given the above, and resolving reasonable doubt in the Veteran's favor, the Board finds that his hypertension has been manifested by a history of diastolic pressure predominantly 100 or more and requiring continuous medication for control. Even while on medications, his diastolic pressure has been 100 or more and his systolic pressure has been 160 or more. Thus, an initial 10 percent rating is warranted under Diagnostic Code 7101 since the effective date of service connection. The Board has also considered whether any other applicable rating criteria may enable a higher evaluation. However, the findings do not provide for a higher rating under any other diagnostic code. In conclusion, the Board has applied the benefit-of-the-doubt doctrine in granting an initial 10 percent rating for hypertension. As the preponderance of the evidence is against an even higher rating, the benefit-of-the-doubt doctrine is not applicable to that aspect of the claim. See 38 U.S.C.A. § 5107 (West 2002 & Supp. 2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Wrist Ganglion Cyst The Veteran seeks a compensable rating for a left wrist ganglion cyst prior to March 27, 2010. His ganglion cyst has been assigned a 0 percent rating under Diagnostic Code 7899-7819. Thus, his disability has been rated by analogy under Diagnostic Code 7819 for benign skin neoplasms. See 38 C.F.R. §§ 4.20, 4.27 (2013). Benign skin neoplasms are to be rated as scars or impairment of function. 38 C.F.R. § 4.118 (2013). The rating criteria pertaining to scars were revised effective October 23, 2008. However, those changes only apply to claims filed on or after that date or when the veteran has specifically requested consideration under the new criteria, neither of which applies in this case. Thus, the Board will only consider the rating criteria in effect prior to October 23, 2008. Under Diagnostic Code 7804, scars that are superficial and painful on examination warrant a 10 percent rating. 38 C.F.R. § 4.118 (effective prior to October 23, 2008). A July 2006 VA examination report reflects that the Veteran has had a knot in the left wrist for about 20 years but has never received treatment for it and denied any resultant functional impairment or limitation of motion. The examiner noted that the ganglion cyst was minimally tender to deep palpation and did not enter full range of motion of the left wrist. The wrist was otherwise normal. The examiner stated that there was normal range of motion of the wrist. The examiner further stated that range of motion was not affected by pain, fatigue, weakness, lack of endurance, or incoordination. The examiner noted that the cyst was 1 cm by 1 cm. During the July 2013 hearing, the Veteran testified that his left wrist cyst symptoms have remained the same since the July 2006 VA examination. Given the findings of the VA examination, the Board finds that the Veteran's left wrist ganglion cyst had been manifested by disability comparable to a scar that was superficial and painful on examination. Thus, a 10 percent rating is warranted under Diagnostic Code 7804. The Board has also considered whether any other applicable rating criteria may enable a higher evaluation. As the cyst did not involve an area exceeding 12 square inches (77 sq. cm.), a higher rating is not warranted under Diagnostic Code 7801. Although the July 2006 examiner provided conflicting statements as to whether the cyst resulted in loss of range of motion of the wrist, the Veteran indicated that his symptoms were the same at the time of the later March 2010 examination, which showed normal range of motion of the wrist. Moreover, there was no evidence that the cyst caused ankylosis of the wrist. Thus, a higher rating is not warranted under Diagnostic Code 5214. In conclusion, an initial 10 percent rating for left wrist ganglion cyst prior to March 27, 2010, is warranted. As the preponderance of the evidence is against an even higher rating, the benefit-of-the-doubt doctrine is not applicable to that aspect of the claim. See 38 U.S.C.A. § 5107 (West 2002 & Supp. 2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Additional Considerations The Board must also determine whether the schedular evaluations are inadequate, thus requiring a referral of the claim to the Under Secretary for Benefits or Director of Compensation and Pension Service for consideration of an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disabilities. 38 C.F.R. § 3.321(b)(1) (2013). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the disability. Thun v. Peake, 22 Vet. App. 111 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111 (2008). When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1) (2013); Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the schedular evaluations are adequate. Evaluations in excess of those assigned are provided for certain manifestations of the Veteran's various service-connected disabilities, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the disorders. As the rating schedule is adequate to evaluate the disabilities, referral for extra-schedular consideration is not in order. Even if the Board were to determine that the rating criteria were inadequate to address all of the effects of the Veteran's service-connected disabilities, his disabilities do not present exceptional or unusual circumstances. There is no indication that his disabilities markedly interfered with employment. There is also no indication his disabilities have resulted in frequent hospitalizations. Thus, the Board declines to refer the matters for extraschedular consideration. Finally, although the Veteran has submitted evidence of a medical disability, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable, due to his service-connected disabilities. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). ORDER The appeal with respect to the claim for service connection for allergies is dismissed. The appeal with respect to the claim for service connection for hearing loss is dismissed. The appeal with respect to the claim for service connection for glaucoma is dismissed. The appeal with respect to the claim for an initial rating in excess of 20 percent prior to March 27, 2010, and in excess of 40 percent since March 27, 2010, for benign prostatic hypertrophy with erectile dysfunction is dismissed. The appeal with respect to the claim for an initial rating in excess of 10 percent for gastroesophageal reflux disease with hiatal hernia is dismissed. The appeal with respect to the claim for an initial rating in excess of 10 percent for osteoarthritis of the left knee since March 27, 2010, is dismissed. The appeal with respect to the claim for an initial rating in excess of 10 percent for osteoarthritis of the right knee since March 27, 2010, is dismissed. The appeal with respect to the claim for an initial rating in excess of 10 percent for osteoarthritis of the left shoulder since March 27, 2010, is dismissed. The appeal with respect to the claim for an initial rating in excess of 10 percent for temporomandibular joint dysfunction since March 6, 2010, is dismissed. The appeal with respect to the claim for an initial rating in excess of 10 percent for left foot bone spurs and plantar fasciitis since November 13, 2007, is dismissed. The appeal with respect to the claim for an initial rating in excess of 10 percent for left wrist ganglion cyst since March 27, 2010, is dismissed. Service connection for spondylosis of the thoracolumbar spine is granted. A separate 10 percent rating for osteoarthritis of the left knee prior to March 27, 2010, is granted, subject to the provisions governing the award of monetary benefits. A separate 10 percent rating for osteoarthritis of the right knee prior to March 27, 2010, is granted, subject to the provisions governing the award of monetary benefits. A separate 10 percent rating for osteoarthritis of the left shoulder prior to March 27, 2010, is granted, subject to the provisions governing the award of monetary benefits. An initial 10 percent rating for TMJ dysfunction prior to March 6, 2010, is granted, subject to the provisions governing the award of monetary benefits. An initial 10 percent rating for left foot bone spurs and plantar fasciitis prior to November 13, 2007, is granted, subject to the provisions governing the award of monetary benefits. An initial 10 percent rating for hypertension is granted, subject to the provisions governing the award of monetary benefits is . An initial 10 percent rating for left wrist ganglion cyst prior to March 27, 2010, is granted, subject to the provisions governing the award of monetary benefits. REMAND Although service connection for arthritis of the thoracolumbar spine was deemed warranted, further development is needed on the claim for service connection for rheumatoid arthritis and/or arthritis of the cervical spine, elbows, wrists, and hips. The Veteran contends that he developed rheumatoid arthritis and/or arthritis of the claimed joints during service. During service in January 2006, the Veteran was seen for pain in his shoulders. Examination of the head and neck was unremarkable. The upper extremities were normal except for the left shoulder, which showed muscle atrophy and loss of range of motion. The spine and lower extremities were normal. He was diagnosed with a left shoulder disability, hypertension, and low grade rheumatoid arthritis. However, it is unclear whether the diagnosis of rheumatoid arthritis was specific to the left shoulder or a general diagnosis. It is additionally unclear whether the diagnosis was based on laboratory tests. In that regard, laboratory tests were negative for rheumatoid arthritis in August 1993 and there are no further test results. The Veteran was afforded a VA examination in July 2006. The examiner indicated that examination of the cervical spine, elbows, wrists, and hips was normal and did not order any further diagnostic testing. In a June 2008 statement, the Veteran indicated that he has had chronic fatigue for years with body-wide joint problems and muscle pain. During the July 2013 hearing, the Veteran raised the issue of entitlement to service connection for an undiagnosed disability due to his service in the Persian Gulf. That aspect of the claim has not been developed. Given the above, the Veteran should be afforded a VA examination to determine whether he has rheumatoid arthritis; arthritis of the cervical spine, elbows, wrists, and hips; or an undiagnosed disability manifested by pain in the cervical spine, elbows, wrists, and hips. Prior to the examination, any outstanding medical records should be obtained. Accordingly, the case is REMANDED for the following actions: 1. Ask the Veteran to identify any health care providers who have treated him for his disabilities of the cervical spine, elbows, wrists, and hips. Obtain any records adequately identified. 2. Then, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his claimed disabilities of the cervical spine, elbows, wrists, and hips. All necessary diagnostic tests, including those for rheumatoid arthritis, should be completed. The claims file should be provided to the examiner for review, and the examiner should note that it has been reviewed. The examiner is requested to state whether the Veteran's complaints are attributable to known clinical diagnoses or to disease processes other than known clinical diagnoses. If the examiner cannot identify any known disease or disability that is causing the Veteran's symptoms, the examiner should so state. The examiner should clarify whether the symptoms in question are chronic in nature (e.g., present for 6 months or more). Based on a review of the entire record, including, but not limited to, the Veteran's reported history, the service treatment records and post-service treatment records, the examiner should further opine as to whether it is at least as likely as not (a 50 percent or higher likelihood) that the Veteran's symptoms are part of a medically unexplained chronic multi-symptom illness such as fibromyalgia or chronic fatigue syndrome. If the Veteran's complaints are attributable to known clinical diagnoses, the examiner should render an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that each diagnosed disability is etiologically related to active service or events therein. In providing the above-noted opinions, the examiner may not rely solely on the lack of any in-service or immediate post-service documentary evidence of relevant treatment or complaints, and must instead take into account the Veteran's report of in-service onset and continuing complaints thereafter. The examiner should also provide a complete rationale for any opinions expressed. 3. Then, readjudicate the claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case, allow the appropriate time for response, and then return the claim to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2013). ______________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs