Citation Nr: 1339110 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 10-21 983 ) DATE ) ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for erectile dysfunction, including as due to a qualifying chronic disability to include undiagnosed illness. 2. Entitlement to service connection for irritable bowel syndrome, including as due to a qualifying chronic disability to include undiagnosed illness. 3. Entitlement to service connection for chronic fatigue syndrome, including as due to a qualifying chronic disability to include undiagnosed illness. 4. Entitlement to service connection for a left upper extremity disability (claimed as traumatic arthritis) (hereinafter "left arm disability"), to include as secondary to the service-connected right knee disability. 5. Entitlement to service connection for a right upper extremity disability (claimed as traumatic arthritis) (hereinafter "right arm disability"), to include as secondary to the service-connected right knee disability. 6. Entitlement to an increased rating (or evaluation) in excess of 20 percent for left leg varicose veins with history of ligation/stripping (hereinafter "left leg varicose veins"). 7. Entitlement to an increased rating (or evaluation) in excess of 10 percent for right knee retropatellar pain syndrome and history of ligament strain and traumatic arthritis (hereinafter "right knee disability"). REPRESENTATION Veteran represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from September 1984 to March 1996 including service in the Southwest Asian Theater from December 1990 to April 1991. This appeal comes to the Board of Veterans' Appeals (Board) from a June 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied service connection for erectile dysfunction, irritable bowel syndrome, chronic fatigue syndrome, traumatic arthritis of the right upper extremity and traumatic arthritis of the left upper extremity; increased the evaluation for left leg varicose veins to 20 percent disabling; and, denied a disability rating in excess of 10 percent for the right knee disability. The Veteran filed a notice of disagreement with regard to these issues in November 2009. In a July 2010 rating decision during the appeal, in an April 2010 decision, the RO continued denial of a rating in excess of 20 percent for left leg varicose veins and a rating in excess of 10 percent for the right knee disability. In a May 2010 Substantive Appeal (VA Form 9) for the claims for service connection, the Veteran requested a Board hearing to be held by live videoconference. In a written statement received May 2011, the Veteran subsequently withdrew the hearing request. In a December 2012 Substantive Appeal (VA Form 9) for the increased rating claims, the Veteran requested a Board hearing to be held at the RO (Travel Board hearing). In a written statement received March 2013, the Veteran subsequently withdrew the hearing request. The hearing requests are withdrawn. 38 C.F.R. § 20.704 (2013). In reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. The issue of entitlement to service connection for bilateral weak foot secondary to service-connected right and left knee disabilities has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). (See January 2012 Veteran's Supplemental Claim for Compensation). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran served in the Southwest Asian Theater during the Persian Gulf War. 2. The Veteran does not have current diagnosed disabilities of erectile dysfunction, chronic fatigue syndrome, or irritable bowel syndrome. 3. The Veteran does not have a qualifying chronic disability characterized by symptoms of erectile dysfunction, including resulting from an undiagnosed illness. 4. The Veteran does not have a qualifying chronic disability characterized by symptoms of chronic fatigue, including resulting from an undiagnosed illness. 5. The Veteran does not have a qualifying chronic disability characterized by symptoms of irritable bowel syndrome, including resulting from an undiagnosed illness. 6. The Veteran sustained a right arm injury in service. 7. The Veteran right arm disability has been medically attributed to diagnosed disorders of chronic cubital tunnel syndrome and lateral epicondylitis, which first manifested many years after service separation, and is not causally or etiologically related to active military service or to the service-connected right knee disability. 8. The Veteran's left arm disability has been medically attributed to diagnosed disorders of chronic cubital tunnel syndrome and medial epicondylitis; the Veteran did not sustain a disease, injury, or event related to his left arm in service; and, the left arm disability is not caused or permanently worsened by the service-connected right knee disability. 9. For the entire rating period, the Veteran's left leg varicose veins have been manifested by symptoms of persistent edema that are relieved by elevation of the extremity and compression hosiery; some statis pigmentation; mild eczema; and, aching, fatigue, and abnormal sensations in the left leg at rest or after prolonged standing or walking 10. For the entire rating period, the Veteran's left leg varicose veins have not been manifested by persistent edema and persistent ulceration or massive board-like edema with constant pain at rest. 11. For the entire rating period, the Veteran's right knee disability has been manifested by arthritis, noncompensable limitation of motion, including due to pain, fatigue, weakness, lack of endurance, incoordination, painful motion, edema, tenderness, and abnormal gait that resulted in noncompensable limitation of motion. 12. For the entire rating period, the Veteran's right knee disability has not been manifested by ankylosis, recurrent subluxation or lateral instability, dislocated or removal of semilunar cartilage, malunion or non-union of the tibia and fibula with loose motion requiring a brace, or genu recurvatum. CONCLUSIONS OF LAW 1. Erectile dysfunction, including as due to a qualifying chronic disability including an undiagnosed illness, was not incurred in active service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1112, 1117 1131, 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2013). 2. Chronic fatigue syndrome, including as due to a qualifying chronic disability including an undiagnosed illness, was not incurred in active service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1112, 1117 1131, 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2013). 3. Irritable bowel syndrome, including as due to a qualifying chronic disability including an undiagnosed illness, was not incurred in active service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1112, 1117 1131, 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2013). 4. A right arm disability was not incurred in active service, and may not be presumed to have been incurred therein, nor is it secondary to the service-connected right knee disability. 38 U.S.C.A. §§ 1110, 1112, 1131, 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2013). 5. A left arm disability was not incurred in active service, and may not be presumed to have been incurred therein, nor is it secondary to the service-connected right knee disability. 38 U.S.C.A. §§ 1110, 1112, 1131, 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2013). 6. The criteria for an increased rating in excess of 20 percent for left leg varicose veins have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7120 (2013). 7. The criteria for an increased rating in excess of 10 percent for right knee disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263 (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 & Supp. 2013); 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, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for an increased rating, the VCAA requires only generic notice as to 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). Regarding the Veteran's claims for entitlement to service connection for erectile dysfunction, irritable bowel syndrome, chronic fatigue syndrome, a right arm disability, and a left arm disability, the RO provided notice to the Veteran in August 2008, prior to the initial adjudication of the claims in June 2009. The Veteran was notified of the evidence not of record that was necessary to substantiate the claims, as well as of VA and the Veteran's respective duties for obtaining evidence. Although the notice provided did not address either the rating criteria or effective date provisions that are pertinent to the Veteran's claim, such error was harmless given that service connection is being denied for all the claims on appeal; hence, no rating or effective date will be assigned with respect to these claimed condition. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Regarding the Veteran's claims for increased rating for left leg varicose veins and right knee disability, the RO provided notice to the Veteran in May 2008 for the right knee disability and in July 2008 for the left leg varicose veins, prior to the initial adjudication of the claims in June 2009. The Veteran was notified of the evidence not of record that was necessary to substantiate the claims, as well as of VA and the Veteran's respective duties for obtaining evidence. The May 2008 and July 2008 notice letters also informed the Veteran how disability ratings and effective dates are assigned. Thus, the Board concludes that VA satisfied its duties to notify the Veteran. VA satisfied its duty to assist the Veteran in the development of his claims. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA treatment records, VA examination reports, private treatment records, and lay statements. The Veteran has contended that he underwent a Gulf War Registry examination at the VA Medical Center (VAMC) St. Louis; however, the RO could not find any indication that examination was performed. The RO asked the Veteran in a May 2010 statement of the case to provide the date of the claimed Gulf War examination, but the Veteran did not respond. Second, VA satisfied its duty obtain a medical opinion when required. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). In disability compensation claims, VA's duty to assist includes providing a medical examination if the information and evidence of record does not contain sufficient competent evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 83-86 (noting that the third prong may be satisfied by lay evidence of continuity or equivocal or non-specific medical evidence). With regard to the Veteran's claims for increased ratings for left leg varicose veins and right knee disability, the Veteran was provided with VA examinations (the reports of which have been associated with the claims file) in April 2009, June 2010, and March 2013. The Board finds the VA examinations were thorough and adequate and provide a sound basis upon which to base a decision with regard to the Veteran's claims. The VA examiners personally interviewed and examined the Veteran, fully reviewed all medical evidence of record, and specifically addressed the symptoms listed in the relevant criteria in the potentially applicable diagnostic codes. Additionally, neither the Veteran nor his representative has questioned the adequacy of any examination. As will be discussed below, because the weight of the evidence demonstrates that the Veteran had no in-service injury, disease, or event related to his left arm, there is no duty to provide a VA medical examination. Furthermore, the Veteran himself has not endorsed in-service symptoms, but rather has stated his belief that his left arm disability is secondary to his service-connected right knee disability. Absent some evidence of a recognizable in-service injury, disease, or event to which a competent medical opinion could relate the claimed disability, there is no reasonable possibility that a VA examination or opinion could aid in substantiating the current claims for service connection. See 38 U.S.C.A. § 5103A(d)(2) (West 2002); 38 C.F.R. § 3.159(d); see also Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (holding that where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). Additionally, the competent evidence of record indicates that the claimed left arm disability is not causally related to the service-connected right knee disability. With regard to the Veteran's claim for service connection for a right arm disability, there is no duty to provide a VA medical examination because the evidence of record does not indicate that the claimed disability may be associated with the in-service injury or the Veteran's service-connected right knee disability. Rather, as will be discussed below, the competent, probative evidence of record indicates that the claimed right arm disability is not associated with the in-service right arm injury and rather is causally related to the Veteran's post-service employment. Additionally, the competent evidence of record indicates that the claimed right arm disability is not causally related to the service-connected right knee disability. With regard to the Veteran's claims for service connection for erectile dysfunction, chronic fatigue syndrome, and irritable bowel syndrome, there is no duty to provide a VA examination because there is no competent evidence in the record of diagnoses of the claimed disabilities, symptoms of the claimed disabilities, or even assertions by the Veteran of symptoms related to his claimed disabilities. See 38 C.F.R. § 3.159(c)(4) The Veteran was offered the opportunity to testify at a hearing before the Board, but withdrew his hearing request in written statements received May 2011 and March 2013. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Service Connection Laws and Regulations Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a) (2013). Generally, service connection for a disability requires evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Additionally, none of the conditions at issue, erectile dysfunction, chronic fatigue syndrome, irritable bowel syndrome, right arm disability, and left arm disability, is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. §§ 3.303(b) and 3.309(a) do not apply to these non-chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With regard to the claims for service connection for right and left arm disabilities, the Veteran asserted that he has traumatic arthritis in these extremities; however, the Board finds that the weight of the evidence is against a finding that the Veteran has arthritis in either extremity. For this reason, the presumptive provisions of 38 C.F.R. §§ 3.303(b) and 3.309(a) do not apply. Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see 38 C.F.R. § 3.159(a)(2). As a lay person, the Veteran is competent to relate some symptoms that may be associated with arthritis, such as pain and joint stiffness, but he does not have the requisite medical knowledge, training, or experience to be able to diagnose the medically complex disorder of degenerative joint disease (arthritis). See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that requires a medical opinion to diagnose and to relate to service or differentiate from in-service symptoms and diagnosis). Arthritis is also a medically complex disease process because of its multiple etiologies, requires specialized testing required to diagnose, and manifests even observable symptomatology that overlaps with other disorders. Woehlaert, 21 Vet. App. at 462 (holding that rheumatic fever is not a condition capable of lay diagnosis). The Veteran is not shown to have such knowledge, training, or experience. Arthritis is diagnosed primarily on clinical findings such as X-rays or specialized testing such as MRI that the Veteran is not competent to conduct or interpret. See 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5003 (degenerative arthritis established by X-ray findings), DC 5010 (traumatic arthritis established by X-ray findings), DC 5002 (rheumatoid arthritis must be "objectively confirmed by findings" that show limitation of motion). Cf. 38 C.F.R. § 4.66 (indicating the usual way to diagnose arthritis is by X-ray, which is also required to see arthritic changes). A December 2007 private treatment record notes that X-ray results of the left and right arms reveal some postoperative changes at the lateral epicondyle, but note no other significant bone or joint abnormalities. The evidence of record is negative for any diagnosis of arthritis in either of the upper extremities. Therefore, the Board finds the presumptive provisions of 38 C.F.R. §§ 3.303(b) and 3.309(a) do not apply to the claims for entitlement to service connection for right and left arm disabilities. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). In addition, presumptive service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. A Persian Gulf veteran is defined as a veteran who served on active duty in the Armed Forces in the Southwest Asia Theater of operations during the Persian Gulf War. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(d)(1). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(d)(2). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). An undiagnosed illness is defined as a condition that, by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). A medically unexplained chronic multi-symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome and fibromyalgia as well as functional gastrointestinal disorders. A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2). Additionally, effective September 29, 2010, presumptive service connection is warranted with the manifestation of the following infectious diseases: (i) brucellosis, (ii) campylobacter jejuni, (iii) Coxiella burnetii (Q fever), (iv) malaria, (v) mycobacterium tuberculosis, (vi) nontyphoid salmonella, (vii) shigella, (viii) visceral leishmaniasis, and (ix) West Nile virus. 38 C.F.R. § 3.317. In the present appeal, the Veteran is not claiming service connection for any of those diseases. Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability shall be considered service connected for purposes of all laws of the United States. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(4). In rendering a decision on appeal, the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Service Connection for Erectile Dysfunction, Chronic Fatigue Syndrome, and Irritable Bowel Syndrome In a July 2008 claim, the Veteran requested service connection for erectile dysfunction, chronic fatigue syndrome, and irritable bowel syndrome associated with his Persian Gulf War service. Beyond his July 2008 claim, the Veteran has not made any specific contentions with regard to these claims. The Veteran's DD Form 214 reflects that he had service in Southwest Asia from December 1990 through April 1991 and is in receipt of the Kuwait Liberation Medal (K), Kuwait Liberation Medal (SA), and the Southwest Asia Service Medal with 3 bronze service star (BSS). Therefore, he is a "Persian Gulf veteran" (i.e., had active military service in the Southwest Asian Theater of operations during the Gulf War) as defined by 38 C.F.R. § 3.317. Service treatment records are negative for any complaints, finding or diagnosis of erectile dysfunction, chronic fatigue syndrome, or irritable bowel syndrome. An October 1993 physical examination noted the Veteran was circumcised but found no other genito-urinary tract abnormalities. The Veteran's abdomen was also noted as clinically normal. The evidence of record, which includes VA treatment records dated from January 1997 through present, is also silent for any post-service diagnosis or treatment of the claimed conditions. A May 2010 problem list from a VAMC indicates that the Veteran has been treated for knee pain, foot pain, varicose veins, smoking, and dizziness. A June 2012 VA treatment record notes the Veteran has a medical history of knee pain, foot pain, varicose veins, smoking, dizziness, hypertension, obesity, and a vitamin D deficiency. The evidence of record does not reflect objective indications of a qualifying chronic fatigue, gastrointestinal, or erectile dysfunction disorder in this case to a compensable (10 percent or higher) degree. The Veteran has not asserted the presence of such symptoms in service and there is no in-service history, complaints, findings, or treatment for such symptoms during service. Although a qualifying chronic disability of an undiagnosed illness or a medically unexplained chronic multi-symptom illness includes neurological and/or neuropsychological signs or symptoms, 38 C.F.R. § 3.317 makes clear that there must be at least some objective evidence perceptible to an examining physician and other, non-medical factors that are capable of independent verification. The provisions of 38 C.F.R. § 4.88b, Diagnostic Code (DC) 6354, provide ratings for chronic fatigue syndrome. This diagnostic code provides that chronic fatigue syndrome includes debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms. A compensable (10 percent) rating is assigned for signs and symptoms of chronic fatigue syndrome that wax and wane but result in periods of incapacitation of at least one but less than two weeks total duration per year or the symptoms are controlled by continuous medication. There is no evidence of record, or assertions by the Veteran, that he experiences symptoms of debilitating fatigue, cognitive impairments, or a combination of other signs and symptoms that result in periods of incapacitation of at least one but less than two weeks total duration per year or that he is, or has ever, taken medication to control said symptoms. The provisions of 38 C.F.R. § 4.114, Diagnostic Code 7319, provide ratings for irritable colon syndrome. A compensable (10 percent) rating is assigned for signs and symptoms of irritable colon syndrome for moderate symptoms based on frequent episodes of bowel disturbance with abdominal distress. There is no evidence of record, or assertions by the Veteran, that he experiences frequent episodes of bowel disturbance with abdominal distress. Conversely, an October 2002 VA treatment record notes that the Veteran had no changes in appetite or weight, nausea, vomiting, abdominal pain, or diarrhea. A June 2012 VA treatment record notes that the Veteran's appetite is good; no bloating, constipation, or diarrhea; and, that the Veteran denied nausea and vomiting. The provisions of 38 C.F.R. § 4.115b, Diagnostic Code 7522, provide for a single 20 percent rating where the evidence shows deformity of the penis with loss of erectile power. There is no evidence of record, or assertions by the Veteran, that he suffers from penile deformity or that he experiences loss of erectile power. Based on this evidence, the Board finds that the competent and probative evidence of record does not show that the Veteran has a disability manifested by chronic fatigue, a functional gastrointestinal condition including irritable bowels, or erectile dysfunction to a compensable degree. Without a showing that the disability is manifested to a compensable degree, the veteran's claims for presumptive service connection for erectile dysfunction, chronic fatigue syndrome, and irritable bowel syndrome under the provisions of 38 C.F.R. § 3.317 must be denied. Service connection for erectile dysfunction, chronic fatigue syndrome and irritable bowel syndrome are also not warranted on a direct service connection basis. The Veteran has not contended that the claimed disorders are directly related to an injury, event, or disease in service or that any were incurred during service. Service treatment records are negative for any complaints or findings of erectile dysfunction, chronic fatigue syndrome, or irritable bowel syndrome. An October 1993 physical examination noted the Veteran was circumcised but found no other genito-urinary track abnormalities. The Veteran's abdomen was also noted as clinically normal. Furthermore, there is no evidence of record that the Veteran has a current diagnosis of erectile dysfunction, chronic fatigue syndrome, or irritable bowel syndrome or that the Veteran has ever sought or received treatment for the claimed conditions. Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. §§ 1110, 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection can also be warranted if there was a disability present at any point during the claim period, even if it is not currently present. McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board is also cognizant of the holding of the U.S. Court of Appeals for Veterans Claims (Court) in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). In Romanowsky, the Court held that, when the record contains a recent diagnosis of disability prior to a veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. In a footnote, the Court noted that a determination that a diagnosis is "sufficiently proximate to the filing of a claim so as to constitute evidence of a 'current diagnosis' is a factual finding to be made by the Board in the first instance." However, the evidence in this case does not demonstrate erectile dysfunction, chronic fatigue syndrome, or irritable bowel syndrome at any point during the claim period or even recent diagnoses prior to the filing of the claim for service connection. For the reasons discussed above, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a qualifying chronic disability, including undiagnosed illness, characterized by erectile dysfunction, chronic fatigue syndrome or irritable bowel syndrome, including resulting from an undiagnosed illness nor does he have current diagnoses of the claimed conditions; therefore, the claims for service connection for erectile dysfunction, chronic fatigue syndrome, and irritable bowel syndrome, including qualifying chronic disabilities, must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Right Arm Disability In this case, the Veteran seeks service connection for a right arm disability, to include as secondary to the service-connected right knee disability. Specifically claiming that he had traumatic arthritis of the right arm is causally related to his right knee traumatic arthritis. After reviewing all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the currently diagnosed right arm disability was not incurred in service nor is it secondary to (caused or aggravated by) the Veteran's service-connected right knee disability. The Board finds that the Veteran has currently diagnosed chronic cubital tunnel syndrome and lateral epicondylitis in his right arm as evidenced by private treatment records. Private treatment records reflect that the Veteran was seen for right lateral elbow pain in January 2006. The Veteran underwent operations for right lateral epicondylitis in February and November 2006 and for right cubital tunnel syndrome in July 2008. A November 2008 private treatment record notes that the Veteran has a partial permanent disability at the level of the right elbow. Initially, the Board finds that, inasmuch as the Veteran's right arm disability has been attributed to clinically diagnosed cubital tunnel syndrome, the provisions of 38 C.F.R. § 3.317 are not for application. The Veteran has not contended otherwise. Next, the Board notes an in-service incurrence of an injury to the right arm but not chronic symptoms after the injury in service. Specifically, service treatment records reflect that the Veteran was treated for a right elbow injury in July 1992. An October 1993 physical examination notes that the Veteran's upper extremities were found clinically normal. Therefore, service treatment records reflect an in-service right arm injury and the element has been met; however, the Board finds that the weight of the competent evidence does not attribute the current right arm disability to active duty. In a January 2006 private new patient questionnaire, the Veteran reported first noticing symptoms of continuous tendinitis in his right elbow going to fingers three months prior. As detailed in a December 2007 private treatment record in connection with the Veteran's left lateral epicondylectomy, the Veteran reported that he works as a telephone repairman, describing a fairly arm intensive type of job where he cuts and splices cables, digs, and climbs poles and ladders throughout the day. The December 2007 private physician, Dr. D.B., stated that the Veteran had not reported any other activities outside of work that would put him at risk for medial epicondylitis, and opined that the Veteran's civilian work in combination with the lack of any outside activities or medical problems would be considered the prevailing cause of his need for treatment for his medial epicondylitis. In a June 2008 private treatment record, Dr. D.B. opined that the Veteran's current employment would be considered the prevailing cause of the Veteran's need for evaluation for a possible peripheral compression neuropathy of the right upper extremity. Dr. D.B. stated that the Veteran's job, combined with his lack of other medical problems, put him at risk for either medial epicondylitis or a peripheral compression neuropathy. When the Veteran sought to establish medical care with the private physician for his right arm pain in January 2006, he did not report the onset of right arm pain during or soon after service or even indicate that the symptoms were of long-standing duration. Rather the Veteran stated he had been experiencing right arm pain for three months prior to January 2006, i.e., since approximately October 2005. Such histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories of right arm symptoms during or soon after service given for VA disability compensation purposes. 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 because the declarant has a strong motive to tell the truth in order to receive proper care. Additionally, the Board finds the June 2008 private medical opinion that the prevailing cause of the Veteran's right arm disability is his post-service civilian employment, combined with his lack of other medical problems, to be highly probative. There is no indication that the private physician was not aware of the Veteran's past medical history or that he misstated any relevant fact. Moreover, the examiner has the requisite medical expertise to render a medical opinion regarding the etiology of the disorder and had sufficient facts and data on which to base the conclusion. Further, there is no contradicting medical evidence of record. The Board is not obligated to accept medical opinions premised on a veteran's recitation of inaccurate medical history. See Godfrey v. Brown, 8 Vet. App. 113 (1995). Reliance on a veteran's statements renders a medical report incredible only if the Board rejects the statements of the veteran. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005) (citing Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992) for the proposition that Board may not disregard a medical opinion solely on the rationale that the medical opinion was based on a history given by the veteran). In this case, while the private medical examiner did not have access to the Veteran's claims file, the Board finds that the Veteran's recitation of his medical history regarding his right arm was credible; thus, the Board finds the private medical opinion highly probative. The Board has weighed the Veteran's statements as to a nexus and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous statements made for treatment purposes and the private medical opinion. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of a nexus between his current claim and service. The Veteran has also filed a claim for service connection for a right arm disability as secondary to his service-connected right knee disability, specifically claiming that he had traumatic arthritis of the right arm that was causally related to his right knee traumatic arthritis. As noted above, the Board finds that the weight of the evidence is against a finding that the Veteran currently has arthritis in his upper right extremity. After reviewing all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the currently diagnosed right arm disability is not secondary to the Veteran's service-connected right knee disability. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau, 492 F.3d 1372; see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical disorders require specialized training for a determination as to diagnosis and causation; therefore, such issues are not susceptible of lay opinions on etiology, and a veteran's statements therein cannot be accepted as competent medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (stating that it "is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert, at 462 (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). As a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorders such as arthritis, chronic cubital tunnel syndrome, or lateral epicondylitis. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). The etiology of the Veteran's current right arm disability is a complex medical etiological question involving internal and unseen system processes unobservable by the Veteran. The Board does not find the Veteran competent to provide evidence of an etiological nexus between his service-connected right knee disability and his non-service connected right arm disability, as the complex relationship between an orthopedic disability in the right knee and another orthopedic disability in a different anatomical location of the right arm is not susceptible to lay observation. As such, there is no competent evidence of record even suggesting a causal relationship between the Veteran's right arm disability and his service-connected right knee disability. For the reasons discussed above, the Board finds that the weight of the evidence demonstrates that the Veteran's right arm disability was not incurred in or aggravated by active service, including as secondary to the service-connected right knee disability, and may not be presumed to have been incurred therein. Therefore, the claim for service connection for a right arm disability must be denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Left Arm Disability In this case, the Veteran seeks service connection for a left arm disability, to include as secondary to the service-connected right knee disability. Specifically claiming that he had traumatic arthritis of the left arm that is causally related to his right knee traumatic arthritis. After reviewing all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the currently diagnosed left arm disability was not incurred in or aggravated by service nor is it secondary to the Veteran's service-connected right knee disability. The Board finds that the Veteran has currently diagnosed chronic cubital tunnel syndrome and medial epicondylitis in his left arm. Private treatment records reflect the Veteran underwent operations for left lateral epicondylectomy in November 2006 and for left cubital tunnel syndrome in May 2008. A November 2008 private treatment record notes that the Veteran has a partial permanent disability at the level of the left elbow. Initially, the Board finds that, inasmuch as the Veteran's left arm disability has been attributed to clinically diagnosed cubital tunnel syndrome and medial epicondylitis, the provisions of 38 C.F.R. § 3.317 are not for application. Nor has the Veteran contended otherwise. The weight of the evidence demonstrates that the Veteran did not sustain an injury or disease of the left arm in service, nor did he exhibit symptoms of a left arm disability in service. The Veteran has not reported the presence of any left arm symptoms in service, and service treatment records do not reflect any complaints related to the Veteran's left arm in service. An October 1993 physical examination notes that the Veteran's upper extremities were found clinically normal. A July 2006 private treatment record is the first notation of record that Veteran has a diagnosis of left lateral epicondylitis. All of the Veteran's left arm complaints, treatment, and diagnoses as shown by the record were made after the July 2006 complaint of left lateral elbow pain, over 10 years since service separation. The Board finds that such absence of complaints, findings, or treatment during service or post-service until left lateral epicondylitis was diagnosed in July 2006 is highly probative, contemporaneous evidence, along with other factors, showing that a left arm disability did not manifest in service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Buchanan, 451 F.3d at 1337. As noted above, the Board finds that the weight of the evidence is against a finding that the Veteran currently has arthritis in his upper left extremity. After reviewing all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the currently diagnosed left arm disability is not either caused or aggravated by the Veteran's service-connected right knee disability. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau, 492 F.3d 1372; see also Buchanan at 1331 (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical disorders require specialized training for a determination as to diagnosis and causation; therefore, such issues are not susceptible of lay opinions on etiology, and a veteran's statements therein cannot be accepted as competent medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (stating that it "is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert at 462 (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau at n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). As a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorders such as arthritis, chronic cubital tunnel syndrome, or lateral epicondylitis. See Kahana, 24 Vet. App. at 437 (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). The etiology of the Veteran's current left arm disability is a complex medical etiological question involving internal and unseen system processes unobservable by the Veteran. The Board does not find the Veteran competent to provide an etiological nexus between his service-connected right knee disability and his non-service connected left arm disability, as the complex relationship between an orthopedic disability in the right knee and another orthopedic disability in a different anatomical location of the right arm is not susceptible to lay observation. As such, there is no competent evidence of record even suggesting a causal relationship between the Veteran's left arm disability and his service-connected right knee disability. For the reasons discussed above, the Board finds that the weight of the evidence demonstrates that the left arm disability was not incurred in service nor is it caused or aggravated by the service-connected right knee disability; therefore the claim for service connection for a left arm disability must be denied. As the preponderance of the evidence is against the claim for service connection for a left arm disability, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Disability Rating Criteria Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2013). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1 (2013). Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2013). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Where, as here, entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern, including the appropriateness of staged ratings whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The Board has considered whether a staged rating is warranted; however, as the Board will discuss in more detail below, neither the Veteran's left leg varicose veins or right knee disability has increased in severity over the course of the appeal, such that would warrant different ratings. Increased Rating for Left Leg Varicose Veins The Veteran is in receipt of a 20 percent disability rating for left leg varicose veins under Diagnostic Code (DC) 7120. A 20 percent rating is assigned for varicose veins, with persistent edema, incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema. A 40 percent rating is assigned for varicose veins, with persistent edema and stasis pigmentation or eczema, with or without intermittent ulcerations. A 60 percent rating is assigned for varicose veins with persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. These evaluations are for involvement of a single extremity. If more than one extremity is involved, each extremity is to be evaluated separately and combined. 38 C.F.R. § 4.104, Diagnostic Code (DC) 7120. The Veteran contends that he is entitled to a higher disability rating for his service-connected left leg varicose veins. He has reported symptoms or impairment of leg of pain after walking long distances, pain in his legs while resting, and aching, fatigue, abnormal sensations in the left leg at rest or after prolonged standing or walking, and that the left leg varicose veins prevent him from exercise and exertion. After a review of all the evidence, lay and medical, the Board finds that, for the entire appeal period, the Veteran's is not entitled to a disability rating in excess of 20 percent for his service-connected left leg, varicose veins under Diagnostic Code 7120. 38 C.F.R. § 4.104. For the entire appeal period, the Veteran's left leg varicose veins have been manifested by symptoms of persistent edema that is relieved by elevation of the extremity and compression hosiery; some statis pigmentation; mild eczema; and, aching, fatigue, and abnormal sensations in the left leg at rest or after prolonged standing or walking. The Board finds that these symptoms more nearly approximate the 20 percent rating. DC 7120. Having reviewed the evidence of record, the Board finds that the criteria for an increased rating greater than 20 percent for the Veteran's left leg varicose veins has not been met or more nearly approximated for the entire rating period. In April 2009, the Veteran underwent a VA examination for his left leg varicose veins. The Veteran reported that the left leg varicose veins prevented him from exercise and exertion. The Veteran reported suffering from claudication, i.e., leg pain after walking long distances that begins soon after starting to walk on level ground. The Veteran reported pain in his legs while resting. The Veteran reported aching, fatigue, and abnormal sensations in his left leg at rest or after prolonged standing or walking. The Veteran reported symptoms of edema were relieved by elevation of the extremity. The Veteran stated he was not currently receiving any treatment for his left leg varicose veins. The April 2009 VA examiner noted visible and palpable varicose veins of the bilateral lower extremities. The VA examiner noted mild, persistent edema that was not boardlike. The VA examination report notes that the Veteran had stasis pigmentation, but that ulcers and eczema were absent. The VA examiner diagnosed the Veteran with superficial and deep varicosities of the bilateral lower extremities with venous insufficiency with statis dermatitis. The VA examination report notes that the Veteran's activities are limited due to constant pain and swelling. In June 2010, the Veteran underwent another VA examination. The Veteran reported that the left leg varicose veins prevented him from exercise and exertion. The Veteran endorsed burning/numbing pain in his left leg, but denied claudication. The Veteran reported aching, fatigue, and abnormal sensations in his left leg at rest or after prolonged standing or walking. The Veteran reported symptoms of edema were relieved by evaluation of the extremity and compression hosiery. The Veteran stated he was not currently receiving any treatment for his left leg varicose veins. The June 2010 VA examiner noted the worst varicosities are in the Veteran's left thigh area with visible and palpable varicose veins. The VA examiner noted mild, persistent edema in the lower left extremity that was not boardlike. The VA examiner noted no statis pigmentation. Mild eczema was also noted in the Veteran's lower left extremity. The VA examination report notes that the Veteran's activities are limited due to pain from the left leg varicose veins. The Board finds that the Veteran's left leg varicose veins symptoms described above more nearly approximate the criteria for a 20 percent disability rating under Diagnostic Code 7120. See 38 C.F.R. § 4.104. Persistent edema, relieved by elevation of the extremity, as noted on both the April 2009 and June 2010 VA examinations, is contemplated by the 20 percent rating. At the April 2009 VA examination, the Veteran had statis pigmentation, but ulcers and eczema were absent. At the June 2010 VA examination, mild eczema, but no ulcers or statis pigmentation, was noted on the Veteran's lower left extremity. The Board notes that persistent edema and statis pigmentation or eczema is required for a 40 percent rating; however, because the edema is relieved by elevation of the extremity, the Board finds that the Veteran's left leg varicose veins are more closely approximated by the 20 percent rating criteria. Id. Based on the above evidence, the Board finds that a disability rating in excess of 20 percent is not warranted for the Veteran's service-connected left leg varicose veins for the entire rating period. Assignment of staged ratings has been considered, but found not to be applicable in this case. The Board has also considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert, 1 Vet. App. 49. Accordingly, entitlement to a rating in excess of 20 percent for the Veteran's left leg varicose veins for any period must be denied. 38 C.F.R. §§ 4.3, 4.7. Increased Rating for Right Knee Disability The Veteran is in receipt of a 10 percent disability rating for his right knee disability. The RO indicated the 10 percent rating was being granted under the criteria found at 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260, although the actual findings regarding limitation of flexion to 45 degrees to meet the criteria for a 10 percent rating under Diagnostic Code 5260 were not supported by the record. Diagnostic Code 5260 provides for ratings based on limitation of flexion of the leg. 38 C.F.R. §§ 4.71a. The assigned 10 percent initial disability rating is consistent with the 10 percent rating provided under Diagnostic Codes 5010-5003 for arthritis with painful motion that manifests to a noncompensable (less than 10 percent) degree, which the evidence in this case supports. Diagnostic Code 5010 represents arthritis due to trauma, substantiated by x-ray findings, which in turn is to be rated under Diagnostic Code 5003 as degenerative arthritis (hypertrophic or osteoarthritis). 38 C.F.R. §§ 4.71a. Degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating 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, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Id., Diagnostic Code 5003. Notes (1) and (2) under Diagnostic Code 5003 provides the following: Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Notes (1) and (2). The Diagnostic Codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 and 5261. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a noncompensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. Id. For disabilities of the musculoskeletal system, the Board also considers whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 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). The Veteran contends that his right knee disability has worsened, making the 10 percent disability rating assigned too low. He has reported that he has pain, swelling, instability, fatigability, weakness, heat, giving way, stiffness, and lack of endurance in the right knee. The Veteran's representative has asserted that the Veteran claimed his leg is greatly swollen, that flexion of the knee cap to the lower part of his leg has affected his walk and gait, and that the right leg could only flex 25 to 30 degrees. Having reviewed the evidence of record, both lay and medical, the Board finds that the criteria for an increased rating greater than 10 percent for the Veteran's right knee disability has not been met or more nearly approximated for the entire rating period. For the entire rating period, the Veteran's right knee disability has not been manifested by ankylosis, recurrent subluxation or lateral instability, dislocated or removal of semilunar cartilage, malunion or non-union of the tibia and fibula with loose motion requiring a brace, or genu recurvatum. In April 2009, the Veteran underwent a VA joints examination. The Veteran reported pain, swelling, instability, fatigability, weakness, heat, giving way, stiffness, and lack of endurance in the right knee. The Veteran denied any periods of flare up, the use of any ambulatory aids, any episodes of dislocation, or recurrent subluxation. The VA examiner noted that the Veteran was right side dominant. The VA examination report notes that there was no ankylosis of the knee joints. Objective range of motion testing found decreased range of motion in the Veteran's right knee with flexion to 110 degree and extension to 0 degrees, with degree pain begins and ends listed as "present." The VA examination report notes that pain and weakness were present following initial range of motion testing, but not fatigue, lack of endurance, or incoordination. Following initial range of motion testing, no objective evidence of edema, effusion, instability, tenderness, redness, heat, abnormal movement, or guarding of movement was noted. While the VA examiner indicated that there was painful motion and weakness in the left knee, the evidence of record makes it clear that he was actually referring to the right knee. Upon repetition, objective range of motion testing found no additional loss in degree in either flexion or extension. While the VA examiner indicated that there was painful motion and weakness in the left knee, the evidence of record makes it clear that he was actually referring to the right knee. No fatigue, lack of endurance or incoordination was noted upon repetition. The VA examiner noted that the Veteran's gait was normal, there were no functional limitations on standing and walking and there was no sign of abnormal weight bearing. In June 2010, the Veteran underwent another VA examination. The Veteran reported pain, weakness, stiffness, swelling, redness, giving way, "locking," fatigability, and lack of endurance with his right knee, but did not endorse heat or instability. The Veteran denied any periods of flare-ups, the use of ambulatory aids, or episodes of dislocation. The Veteran endorsed experiencing abnormal movement of the bone (recurrent subluxation), reporting that, at times, the right patella felt as if it was going out. The VA examiner noted that the Veteran's gait was abnormal with slow, painful movement and that there were functional limitations on standing and walking with reduced tolerance for both. The VA examiner indicated that the Veteran is right side dominant. The VA examination report notes that there was no ankylosis of the knee joints. Objective range of motion testing found decreased range of motion in the Veteran's right knee with flexion to 110 degree and extension to 0 degrees. The VA examiner noted that pain, fatigue, weakness, lack of endurance, and incoordination were present after the initial range of motion test. Objective evidence of painful motion, edema, and tenderness was noted, but there was no effusion, instability, weakness, redness, heat, or guarding of movement observed. Though the Veteran endorsed abnormal movement, the VA examination found no evidence of abnormal movement. Upon repetition, range of motion testing found decreased range of motion in the Veteran's right knee with flexion to 105 degrees and extension to 0 degrees, representing a 5 degree additional loss in motion in extension. The VA examiner noted that pain, fatigue, weakness, lack of endurance, and incoordination were present after repetitive range of motion testing. The VA examiner noted that pain, fatigue, weakness, lack of endurance, and incoordination were present. The VA examination report notes that no instability was found upon examination. In the December 2010 Notice of Disagreement, the Veteran's representative stated that the Veteran claimed his leg is greatly swollen and the flexion of the knee cap to the lower part of his leg has affected his walk and gait. Through his representative, the Veteran reported that his right leg could only flex 25 to 30 degrees at most. In March 2012, the Veteran underwent another VA examination regarding a separate claim for service connection or right hip and lumbar spine conditions. Objective range of motion testing of the Veteran's right knee noted flexion from 0 to 130 degrees. The report notes that range of motion remained the same upon repetition. The VA examiner noted pain, fatigability, weaknees, and lack of endurance was minimally present in the right knee with no incoordination. The VA examination report notes that there was no crepitus, i.e., popping, during range of motion testing of the right knee. Based on the above, the evidence of record does not establish that the Veteran's right knee disability warrants an evaluation in excess of 10 percent disability for any period on appeal. The Board has considered application of 38 C.F.R. §§ 4.40 and 4.45 and DeLuca, supra for the entire appeal period, specifically the additional limitations of motion due to pain, in reaching its finding that the Veteran has limitation of motion to a noncompensable degree. Although the April 2009, June 2010 and March 2012 VA examinations reports note that the Veteran experienced pain, such findings do not provide for a higher disability rating than 10 percent in this case. While the VA examination reports indicated pain upon motion, even considering the additional motion limitation upon repetition to 105 degrees of flexion evidence at the June 2010 VA examination, the degree of impairment does not warrant a higher evaluation based on limitation of motion. In this regard, as noted above, the Veteran had near full range of motion during the appeal period even with consideration of pain that limits motion. The range of motion for extension has been consistently 0 degrees in all three VA examinations, which does not warrant a compensable rating based on extension. See 38 C.F.R. § 4.71a, DC 5261. The range of motion for flexion was 110 degrees, both initially and upon repetition, at the April 2009 VA examination; 110 degrees initially and 105 degrees upon repetition at the June 2010 VA examination; and 130 degrees, both initially and upon repetition at the March 2012 VA examination. None of the range of motion measures warrants a compensable rating based on flexion. See id., DC 5260. The Veteran, through his representative, in the December 2010 Notice of Disagreement, has alleged that the Veteran has limited of flexion of 25 to 30 degrees, which would warrant a rating in excess of 10 percent. The Veteran is competent to give evidence about what he experiences, e.g., limitation of flexion of the right knee. Layno, 6 Vet. App. at 469. However, the Board finds that the multiple range of motion tests, including the March 2012 range of motion findings subsequent to the Veteran's December 2010 Notice of Disagreement, as more probative evidence that the Veteran has not experienced limitation of flexion to such a marked degree. During the entire appeal period, the limitation of motion did not reveal extension limited to 15 degrees or more, or flexion limited to 30 degrees or less as needed for a 20 percent evaluation, even with consideration of the additional limitation due to pain. The evidence also does not show compensable limitation of motion of extension (10 degrees) and limitation of motion of flexion (45 degrees) to warrant separate compensable ratings for both limitation of extension and limitation of flexion. See VAOPGCPREC 09-04 (separate ratings may be awarded for compensable limitation of flexion and limitation of extension of the same knee joint). Therefore, a higher disability rating in excess of 10 percent is not warranted under Diagnostic Codes 5260 or 5261 for limitation of extension and flextion. 38 C.F.R. § 4.71a. The Board finds that no higher or separate schedular rating is warranted under any of the other codes pertaining to the knee. For point of explanation, ankylosis is "[s]tiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint." Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (quoting from Stedman's Medical Dictionary 87 (25th ed. 1990)). There is no lay or medical evidence of ankylosis, recurrent subluxation or lateral instability, semilunar, dislocated cartilage with frequent episodes of "locking," pain, and effusion into the joint, impairment of the tibia and fibula by malunion or nonunion, genu recurvatum, or history of removal of semilunar cartilage. Both the April 2009 and June 2010 VA examination reports specifically note that no instability was present in the right knee. Therefore, the criteria of Diagnostic Codes 5256, 5257, 5258, 5259, 5262 and 5263 do not apply. 38 C.F.R. § 4.71a. Based on the above evidence, the Board finds that a disability rating in excess of 10 percent is not warranted for the Veteran's service-connected right knee disability for the entire rating period. Assignment of staged ratings has been considered, but found not to be applicable in this case. The Board has also considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against this claim, the doctrine is not for application. 38 C.F.R. §§ 4.3, 4.7. Accordingly, entitlement to a rating in excess of 10 percent for the Veteran's right knee disability for the entire period must be denied. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted for the left leg varicose veins or the right knee disability. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's left leg varicose veins are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 7120, specifically provide for disability ratings based on persistent edema, incompletely relieved by elevation of extremity; statis pigmentation; eczema; and arching or fatigue in leg after prolonged standing and walking. These manifestations are part of the schedular rating criteria. The Board also finds that the symptomatology and impairment caused by the Veteran's right knee disability are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's right knee disability has been manifested by arthritis, limitation of motion, including due to pain, fatigue, weakness, lack of endurance, incoordination, painful motion, edema, tenderness, and abnormal gait. The schedular rating criteria specifically provides ratings for such noncompensable limitation of motion due to painful arthritis (DC 5003, 38 C.F.R. § 4.59), and contemplate ratings based on limitation of motion (DC 5251, 5252, 5253), including motion limited to orthopedic factors such as pain, weakness, and guarding (38 C.F.R. §§ 4.40, 4.45, DeLuca). In this case, comparing the Veteran's disability level and symptomatology of the right knee disability to the rating schedule, the degree of disability of each throughout the entire period under consideration is contemplated by the rating schedule and the assigned ratings are, therefore, adequate. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the left leg varicose veins or right knee disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is part of an increased rating claim when such claim is expressly raised by a veteran or reasonably raised by the record. At the March 2012 VA examination, the Veteran stated that he is employed full time as a telephone repairman. Thus, the Board finds that Rice is inapplicable since there is no evidence of unemployability due to the Veteran's service-connected right knee disability or left leg varicose veins. ORDER Service connection for erectile dysfunction, including as due to a qualifying chronic disability to include undiagnosed illness, is denied. Service connection for chronic fatigue syndrome, including as due to a qualifying chronic disability to include undiagnosed illness, is denied. Service connection for irritable bowel syndrome, including as due to a qualifying chronic disability to include undiagnosed illness, is denied. Service connection for a left upper extremity disability is denied. Service connection for a right upper extremity disability is denied. An increased disability rating in excess of 20 percent for the left leg varicose veins with history of ligation/stripping is denied. An increased disability rating in excess of 10 percent for the right knee retropatellar pain syndrome and history of ligament strain and traumatic arthritis is denied. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs