Citation Nr: 1603413 Decision Date: 02/02/16 Archive Date: 02/11/16 DOCKET NO. 09-15 164 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an initial disability evaluation in excess of 10 percent for residuals of right ankle fracture. 2. Entitlement to an initial disability evaluation in excess of 10 percent for status post fracture of the thoracic spine. 3. Entitlement to an initial disability evaluation in excess of 20 percent for status post fracture of the cervical spine with degenerative changes. 4. Entitlement to an initial disability evaluation in excess of 20 percent for left shoulder myofascial pain syndrome. 5. Entitlement to an initial disability evaluation in excess of 10 percent for plantar fasciitis and degenerative changes of the bilateral feet. 6. Entitlement to service connection for fibromyalgia, to include as the result of an undiagnosed illness. 7. Entitlement to service connection for an upper respiratory or allergic disorder, to include as the result of an undiagnosed illness and/or as aggravated by exposure to hazardous chemicals. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Yvette Hawkins, Counsel INTRODUCTION The Veteran served with the Colorado Army National Guard on active duty for training from October 1965 to November 1971, April 1972 to October 1974, June 1981 to January 1991, and June 1991 to January 2002. He served on active duty from January 1991 to June 1991, in the Southwest Asia Theater of Operations, during the First Persian Gulf War. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The RO, inter alia, denied service connection for fibromyalgia; service connection for an upper respiratory or allergic disorder, and service connection for status post-concussion with memory loss. It granted service connection for residuals of right ankle fracture, assigning an initial disability rating of 10 percent; status post fracture of the cervical spine and status post fracture of the thoracic spine, assigning an initial disability rating of 10 percent each; left shoulder myofascial pain syndrome, assigning a noncompensable disability rating; and plantar fasciitis and degenerative changes of the bilateral feet, assigning a noncompensable disability rating. The effective date for each rating was September 8, 2006. In a February 2009 rating decision, the Cheyenne, Wyoming, RO increased the disability ratings for the cervical spine and left shoulder disorders to 20 percent each, and assigned a separate disability rating of 10 percent for the thoracic spine disorder. Despite the assignment of an increased disability evaluation for these disorders, the issues remain in appellate status because the Veteran has continued to express disagreement with the assigned ratings. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Jurisdiction for the claims was returned to the Denver EO, In December 2011, the Veteran testified before the undersigned Veterans Law Judge (VLJ) during a Board video conference hearing. A transcript of the hearing has been associated with the claims folder. In April 2012, the Board remanded the issues to the Agency of Original Jurisdiction (AOJ) for further development, to include affording the Veteran additional VA examinations. As there has been substantial compliance with the Board's remand directives, the Board finds there is sufficient evidence to adjudicate the claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In a May 2013 rating decision, the AOJ increased the disability rating for the Veteran's bilateral foot disorder to 10 percent; as the Veteran has continued to express disagreement with the rating, it remains on appeal. See AB, supra. The AOJ also granted service connection for traumatic brain injury (previously status-post concussion with memory loss). As the Veteran has not appealed the rating or effective date assigned to this disability, the claim is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). This appeal was partly processed using the Veterans Benefits Management (VBMS) and Virtual VA paperless claims processing systems. FINDINGS OF FACT 1. Throughout the course of the appeal, the Veteran's residuals of right ankle fracture have been shown to be no greater than degenerative arthritis and mild pain with motion, without marked limitation of motion or involvement of two or more minor joint groups, with or without occasional incapacitating exacerbations. 2. Throughout the course of the appeal, the Veteran's status post fracture of the thoracic spine has been shown to be no greater than forward flexion to 90 degrees, extension to 25 degrees, left lateral flexion to 20 degrees, right lateral flexion to 25 degrees and bilateral rotation to 25 degrees, with a combined range of motion of 210 degrees. 3. Throughout the course of the appeal, the Veteran's status post fracture of the cervical spine with degenerative changes has been shown to be no greater than forward flexion to 45 degrees, extension to 38 degrees, right lateral flexion to 22 degrees with pain at endpoint, left lateral flexion to 18 degrees with pain at endpoint, right lateral rotation to 40 degrees with pain at endpoint, left lateral rotation to 40 degrees, and mild straightening of the upper cervical lordosis. 4. Throughout the course of the appeal, the Veteran's left shoulder myofascial pain syndrome has been shown to be no greater than forward flexion to 180 degrees, abduction to 110 with pain, internal rotation to 80 degrees, and external rotation to 90 degrees. 5. Throughout the course of the appeal, the Veteran's plantar fasciitis and degenerative changes of the bilateral feet has been shown to be no greater than very mild degenerative joint disease and mild pain bilaterally, without callosities, abnormal weight-bearing or inward bowing of the tendo achilles. 6. The preponderance of the evidence is against a showing that the Veteran has a current diagnosis of fibromyalgia. 7. The Veteran is not shown by the probative and competent evidence of record to have a current upper respiratory, and rhinitis, to include as the result of an undiagnosed illness and/or as aggravated by exposure to hazardous chemicals, was neither caused, nor aggravated by service. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for residuals of right ankle fracture have not been met. 38 U.S.C.A. §§ 1110, 1111, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.71a, Diagnostic Codes 5003, 5010, 5271 (2015). 2. The criteria for an initial rating in excess of 10 percent for status post fracture of the thoracic spine have not been met. 38 U.S.C.A. §§ 1110, 1111, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.71a, Diagnostic Codes 5003, 5010, 5242 (2015). 3. The criteria for an initial rating in excess of 20 percent for status post fracture of the cervical spine with degenerative changes have not been met. 38 U.S.C.A. §§ 1110, 1111, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.71a, Diagnostic Code 5235 (2015). 4. The criteria for an initial rating in excess of 20 percent for left shoulder myofascial pain syndrome have not been met. Diagnostic Codes 5299-5201 (2015). 5. The criteria for an initial rating in excess of 10 percent for plantar fasciitis and degenerative changes of the bilateral feet have not been met. 38 U.S.C.A. §§ 1110, 1111, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.71a, Diagnostic Codes 5010, 5276 (2015). 6. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C.A. §§ 1110, 1111, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2015). 7. The criteria for service connection for an upper respiratory or allergic disorder, to include as the result of an undiagnosed illness, and/or as aggravated by exposure to hazardous chemicals, have not been met. 38 U.S.C.A. §§ 1110, 1111, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015). The Veterans Claims Assistance Act of 2000 (VCAA) notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Of particular importance, in Dingess/Hartman, the Court of Appeals for Veterans Claims (Court) held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection is awarded. VA satisfied the notification requirements of the VCAA by means of a September 2006 letter, which advised the veteran of the types of evidence needed in order to substantiate his service connection claims, including evidence needed for Gulf War undiagnosed illnesses, the division of responsibility between himself and VA for obtaining the required evidence, and asked him to provide any information or evidence in his possession that pertained to such claims. 38 U.S.C.A. §5103(a); 38 C.F.R. § 3.159(b). The letter also provided him with notice of how VA assigns the disability rating and effective date elements of the claim, thus satisfying Dingess. Regarding the initial rating claims, that portion of the appeal arises from disagreement with the initial disability ratings assigned following the grant of service connection. Once service connection is granted, the claim is substantiated and additional VCAA notice is not required; any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board notes that a VCAA letter advising the Veteran of the evidence necessary to substantiate his increased initial ratings claims was not provided. However, the case was readjudicated in a February 2009 Statement of the Case (SOC), which provided the Veteran with the complete rating criteria upon which his initial disability ratings were based, and a detailed explanation as to why the claims were denied. Additionally, during the December 2011 Board video conference hearing, and significantly, in June and December 2015 post-remand briefs, the Veteran's representative clearly demonstrated an actual knowledge of the information necessary to prevail on the issues of service connection and increased disability ratings. VA's duty to assist has also been satisfied. The claims file contains the Veteran's service treatment records and post-service treatment records. The claims file also contains VA examination reports dated February 2007 (feet), August 2007 (ankle), November 2007 (left shoulder, spine) and June 2012 (back, neck, shoulder, ankle, foot, pes planus, fibromyalgia, respiratory and sinusitis/rhinitis). Additionally, the claims file contains the Veteran's statements and testimony in support of his claims. The Veteran has not referenced any outstanding, available records that he wanted VA to obtain that have not already been obtained and associated with the record. The VA examinations are adequate upon which to base decisions in these matters. The examiners reviewed the Veteran's treatment records, obtained a history of symptomatology and treatment from the Veteran, performed comprehensive examinations, along with reviews of available diagnostic test results, provided the diagnostic criteria necessary to evaluate the severity of the Veteran's disabilities, and provided sound reasons and basis for their conclusions. As noted above, in December 2011, the Veteran testified at a Board hearing before the undersigned VLJ. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The hearing was held in compliance with the provisions of Bryant. Further, there has been no assertion by the Veteran or his service organization representative that VA or the VLJ failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any other prejudice in the conduct of the Board hearing. Moreover, the Veteran's statements, as well as those of his representative, demonstrate actual knowledge of the elements and evidence necessary to substantiate the claims because the statements focused on such evidence and elements. The representative subsequently provided two post-remand briefs, in which he set forth the specific rating criteria for each of the Veteran's service-connected disabilities, as well the criteria for an award of service connection. The Board thus finds that the VLJ complied with the duties set forth in Bryant and the claims may be adjudicated based on the current record. VA also has a duty to obtain records from the Social Security Administration (SSA) when relevant. In Tetro v. Gober, 14 Vet. App. 110 (2000), the Court held that VA has the duty to request information and pertinent records from other Federal agencies when on notice that such information exists. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). During the course of the appeal, the Veteran informed VA healthcare providers that he was receiving SSA benefits. Although the AOJ requested records from the SSA in April 2012, SSA replied that the medical records did not exist and further attempts to find them would be futile. Accordingly, no further notice or assistance to the Veteran is required to fulfill VA's duties to notify and assist him in the development of his claims. See 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). Analysis Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, and by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries, and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). Separate Diagnostic Codes (DC) identify the various disabilities and the criteria for specific ratings. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2015). The veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2015). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it is possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2009). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2015). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). Orthopedic Disabilities Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40 (2015). It is essential that the examination on which ratings are based adequately portray the anatomical damage and functional loss with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. Id. With regard to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: less movement than normal; more movement than normal; weakened movement; excess fatigability; incoordination; impaired ability to execute skilled movements smoothly; and pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2015). Painful, unstable, or malaligned joints, due to healed injury are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59 (2015). The Court has held that when evaluating loss in range of motion, consideration is given to the degree of functional loss caused by pain. DeLuca v. Brown, 8 Vet. App. 202 (1995) (evaluation of musculoskeletal disorders rated on the basis of limitation of motion requires consideration of functional losses due to pain). In DeLuca, the Court explained that, when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40 ) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id. at 206. The fact that the revised criteria include symptoms such as pain, stiffness, aching, etc., if present, means that evaluations based on pain alone are not appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the neurologic sections of the rating schedule. See 68 Fed. Reg. 51,455 (Aug. 27, 2003). The words "slight," "moderate" and "severe," as used in the various diagnostic codes, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, so that its decisions are "equitable and just." 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C.A. § 7104 (West 2014); 38 C.F.R. §§ 4.2, 4.6 (2015). A. Entitlement to initial disability rating in excess of 10 percent for residuals of right ankle fracture. The Veteran's residuals of right ankle fracture is evaluated under DC 5010. Under this diagnostic code, arthritis due to trauma, substantiated by x-ray findings, is rated as degenerative arthritis under DC 5003. Pursuant to DC 5003, degenerative arthritis (hypertrophic or osteoarthritis), established by x-ray findings, will be evaluated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. A 10 percent rating is warranted with x-ray evidence of involvement of 2 or more major joints, or 2 or more minor joint groups. A 20 percent rating is warranted for x-ray evidence of involvement of 2 or more major joints, or 2 or more minor joint groups, with occasional incapacitating exacerbations. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by such findings as swelling, muscle spasm or satisfactory evidence of painful motion. See 38 C.F.R. § 4.59; Hicks v. Brown, 8 Vet. App. 417, 420 (1995) ((citing Litchenfels v. Derwinski, 1 Vet. App. 484, 488 (1991)). The normal range of motion of the ankle is from zero to 20 degrees of dorsiflexion, and from zero to 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II (2015). The Veteran was afforded a VA ankle examination in August 2007. He reported that he had soreness and achiness in his right ankle every day. However, the VA examiner noted that the ankle did not cause pain with motion, was not tender, and there was no swelling. Plantar flexion was zero to 30 degrees and dorsiflexion was zero to 10 degrees. VA Medical Center (VAMC) reports show that the Veteran had an x-ray of the bilateral ankles in October 2011 (as well as x-rays of other parts of the body), which showed a remote, healed fracture and mild degenerative changes of the right ankle. However, there are no VA or private treatment records showing treatment for the right ankle during the appeal period. In June 2012, during a second VA ankle examination, the Veteran reported occasional pain, twice a week, lasting two hours. He rated the pain 5 out of 10, with 10 being the worse; he said he used over-the-counter analgesics for pain. He said the ankle was not unstable and did not swell. He said he had not been treated for his ankle since 1991. Range of motion testing showed plantar flexion zero to 45 degrees without pain, and dorsiflexion zero to 10 degrees without pain. After repetitive motion, the ranges of motion were the same. There was no pain on palpation. Muscle strength testing revealed normal strength in both plantar flexion and dorsiflexion. There was no instability or ankylosis. The Veteran reported that he regularly used over-the-counter shoe inserts. An x-ray revealed degenerative arthritis. The examiner said that the condition did not affect the Veteran's ability to work. The competent and probative evidence is against the Veteran's claim of entitlement to a disability rating in excess of 10 percent for residuals of right ankle fracture under DC 5010 at any time during the appeal period. During the course of the appeal, there was no objective evidence of limitation of motion or pain. There were also no additional symptoms that could constitute a functional loss, including no evidence of swelling, ankylosis or instability. Moreover, during both examinations, there were no findings of fatigue, lack of endurance, weakness, lack of coordination or decrease in degrees of range of motion upon repetitive motion, which, if present, could possibly warrant a higher disability rating. See Deluca, supra. The Board has also considered whether other diagnostic codes are applicable to the Veteran's right ankle disability. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (en banc) (the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case."). Under DC 5271, moderate limitation of motion of the ankle warrants a 10 percent disability rating, and marked limitation of motion of the ankle warrants a 20 percent disability rating; a 20 percent evaluation represents the maximum rating available under DC 5271. In order to obtain a higher rating under DC 5270, there must be a finding of ankylosis. Ankylosis in plantar flexion, between 30 and 40 degrees, or in dorsiflexion, between 0 and 10 degrees, warrants a 30 percent rating. Ankylosis in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity warrants a 40 percent rating. There are no other applicable diagnostic codes that would warrant a higher rating. DC 5270 provides for a disability rating for ankylosis of the ankle, and DC 5272 provides for ankylosis of the subastragalar or talar joint. However, the Veteran has never been shown to have ankylosis. Moreover, although higher disability evaluations are available under DC 5273 for malunion of os calcis (calcaneus) or astragalus (talus), and DC 5274 for astragalectomy, neither of these conditions was diagnosed during the course of the appeal. With regard to assigning a higher disability rating based on functional loss, as contemplated by the Court's holding under Deluca v. Brown, supra., the Court has repeatedly held that veterans are competent to report symptoms that are readily recognizable to those without medical training. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). During the Board hearing in December 2011, the Veteran reported that his right ankle had no residual problems other than occasional twinges. Accordingly, the Veteran does not meet or nearly approximate the criteria for a rating in excess of 10 percent for residuals of right ankle fracture under any of the potentially applicable diagnostic codes during any portion of the appeal period. Staged ratings are not applicable. See Fenderson v. West, supra. B. Entitlement to initial disability rating in excess of 10 percent for status post fracture of the thoracic spine, and an initial disability rating in excess of 20 percent for status post fracture of the cervical spine with degenerative changes. VA regulations provide a General Rating Formula for Diseases and Injuries of the Spine (for DCs 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes) with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease as follows: For unfavorable ankylosis of the entire spine (100 percent); For unfavorable ankylosis of the entire thoracolumbar spine (50 percent); For unfavorable ankylosis of the entire cervical spine, or forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine (40 percent); For forward flexion of the cervical spine to 15 degrees or less, or favorable ankylosis of the entire cervical spine (30 percent); For forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or the combined range of motion of the cervical spine not greater than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent); and For forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50 percent or more of the height (10 percent). 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, entire thoracolumbar spine, or entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 68 Fed. Reg. 51,443, Note (5) (Aug. 27, 2003). Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, disability is evaluated as follows: With incapacitating episodes having a total duration of at least 6 weeks during the past 12 months, assignment of a 60 percent evaluation is warranted. With incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months, assignment of a 40 percent evaluation is warranted. With incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months, assignment of a 20 percent evaluation is warranted. With incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months, assignment of a 10 percent evaluation is warranted. The notes for rating intervertebral disc syndrome under this regulation state as follows: Note (1): an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2): if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. When evaluating diseases and injuries of the spine, any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are evaluated separately, under an appropriate diagnostic code. Id., Note (1). The Veteran's thoracic spine disability is evaluated under DC 5010-5242, degenerative arthritis of the spine. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after the hyphen. Regulations provide that when a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely-related disease or injury, in which both the functions affected and the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2015). Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The Veteran's cervical spine disorder is evaluated under DC 5235, vertebral fracture or dislocation. For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees; extension is zero to 45 degrees; left and right lateral flexion are zero to 45 degrees; and left and right lateral rotation are zero to 80 degrees. Id., Note (2); see 38 C.F.R. § 4.71a, Plate V. The normal combined range of motion of the cervical spine is 340 degrees. Id. The Veteran's first VA spine examination was in November 2007. He reported having constant pain in the neck and upper back. He said he had stiffness, creaking and decreased range of motion of the cervical spine. He also said that he experienced numbness into the bilateral upper extremities. He denied any incapacitating episodes over the previous 12 months, and did not endorse flare-ups. Upon physical examination, the cervical spine was manifested by tenderness and mild spasm. Forward flexion was zero to 50 degrees with pain at endpoint, extension 0 to 38 degrees, right lateral flexion zero to 22 degrees with pain at endpoint, left lateral flexion zero to 18 degrees with pain at endpoint, right lateral rotation zero to 40 degrees with pain at endpoint, left lateral rotation zero to 40 degrees and mild straightening of the upper cervical lordosis. The thoracic spine showed no tenderness and no spasms. Range of motion in forward flexion was zero to 90 degrees, extension zero to 25 degrees, left lateral flexion zero to 20 degrees, right lateral flexion zero to 25 degrees and bilateral rotation zero to 25 degrees; the combined range of motion was 210 degrees. There was no loss of range of motion after repetitions on active range of motion. There was no fatigue, no lack of endurance and no weakness. VAMC reports show that in October 2011, an x-ray of the cervical spine revealed degenerative change. However, there are no VAMC reports during the course of the appeal period to show that the Veteran sought or was treated for upper back or neck problems. The Veteran later reported that he had not been treated for his spine since 2007. There are no treatment reports of record for that period. During a June 2012 spine examination, the Veteran's cervical spine was manifested by mild degenerative change with forward flexion zero to 45 degrees, extension zero to 45 degrees, right lateral flexion zero to 45 degrees, left lateral flexion zero to 45 degrees with pain at endpoint, right lateral rotation zero to 80 degrees and left lateral rotation zero to 60 degrees with pain at endpoint. The thoracic spine was manifested by full range of motion with pain on repetitions. There were no findings of fatigue, lack of endurance, weakness, lack of coordination or decrease in degrees of range of motion upon repetitive motion. The Veteran did not report any periods of incapacitation over the previous 12 months or flare-ups of his spinal disorders. Although the Veteran had reported radiation into his upper extremities during the November 2007 examination, there were no neurological findings at this time. Additionally, a VAMC neurological consultation in September 2011 found no neuropathy resulting from the Veteran's cervical or thoracic disabilities. The probative and competent evidence is against the Veteran's claims of entitlement to an initial disability evaluation in excess of 10 percent for status post fracture of the thoracic spine, and an initial disability evaluation in excess of 20 percent for status post fracture of the cervical spine under the General Rating Formula for Diseases and Injuries of the Spine. As shown by the VA examination results, there has been no evidence during the appeal period that the Veteran had forward flexion of the cervical spine to 15 degrees or less, or favorable ankylosis of the entire cervical spine to warrant a higher 30 percent rating for his cervical spine disability. There is also no evidence that the Veteran had forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis, to warrant a 20 percent rating for the thoracic spine. There was also no evidence of ankylosis in either the cervical or thoracolumbar spine, or forward flexion of the thoracolumbar spine to 30 degrees or less, to warrant any higher rating. In addition, there was no evidence that the Veteran had a diagnosis of intervertebral disc syndrome or had any incapacitation episodes during the course of the appeal to warrant a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Moreover, although the Veteran continued to report neck and back pain, the criteria under the General Rating Formula for Diseases and Injuries of the Spine include symptoms such as pain, stiffness, aching, etc. There is also no objective evidence that the Veteran has any associated neurological abnormalities, including radiculopathy. While the Veteran reported numbness in the upper extremities during the November 2007 examination, a September 2011 VA neurological consultation report revealed no evidence of neuropathy caused by the Veteran's neck or back disorders. The June 2012 examination was also negative for a neurological disorder. As such, a separate disability rating for upper extremity radiculopathy is not warranted. With regard to assigning a higher disability rating based on functional loss as contemplated by the Court's holding under DeLuca v. Brown for either the Veteran's cervical or thoracic spine disabilities, although the Veteran reported pain in the cervical and thoracic spine, he did not demonstrate additional limitation with repetitive testing, did not report flare-ups and did not have significant weakness or tenderness. There are no other relevant diagnostic codes that would be applicable to the Veteran's cervical or thoracic spine disabilities. The Board has also considered whether the Veteran is entitled to "staged" ratings for his service-connected spine disabilities. Fenderson v. West, supra. However, based upon the record, at no time during the claims period have the disabilities on appeal been more disabling than the current ratings contemplate. C. Entitlement to an initial disability evaluation in excess of 20 percent for left shoulder myofascial pain syndrome. The Veteran's left shoulder myofascial pain syndrome is rated under 38 C.F.R. § 4.71a, DC 5299-5201, for limitation of motion of the arm. The rating criteria provide different ratings for the minor arm and the major arm. As the Veteran is right-handed, his left arm is his minor arm. Under 38 C.F.R. § 4.69, handedness, for the purpose of a dominant rating, will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand of an ambidextrous individual will be considered the dominant hand for rating purposes. Under DC 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor arm; limitation of motion midway between side and shoulder level warrants a 30 percent rating for the major arm and 20 percent for the minor arm; limitation of motion to 25 degrees from the side warrants a 40 percent rating for the major arm and 30 percent for the minor arm. As noted above, DC 5003 for degenerative arthritis, a 10 percent rating is warranted for x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is applicable with x-ray evidence of involvement of 2 or more major joints, or 2 or more minor joint groups, with occasional incapacitating episodes. The Veteran was afforded a VA arm/shoulder examination in November 2007. He reported constant left shoulder pain rated 6-7 out of 10, some stiffness and tightness. He denied fatigue, swelling, locking and instability. He reported using over-the-counter medications for pain. He said his activities of daily living were not affected by the disorder. On physical examination, there was some tenderness over the left trapezius muscle and between the shoulder blades. Forward elevation was zero to 180 degrees (normal is to 180 degrees), abduction zero to 140 degrees (normal is to 180 degrees) with discomfort, internal rotation zero to 80 degrees (normal is to 90 degrees) with pain at endpoint and external rotation zero to 90 degrees (normal is to 90 degrees) with pain at endpoint. There was no evidence of ankylosis. Following repetitions with a 5-pound weight, the Veteran evidenced painful range of motion and demonstrated pain on abduction from 110 to 140 degrees. However, range of motion remained the same. The examiner said that he was adding 30 degrees for loss of abduction due to painful motion following repetitions, and acute flares with no fatigue or weakness. This resulted in abduction limited to zero to 110 degrees. During a VA examination in June 2012, the Veteran reported having a constant pain, rated 4-7 out of 10, in the anterior and posterior joint lines of the left shoulder. There was tenderness or pain on palpation. Forward flexion was zero to 180 degrees and abduction was zero to 180, each without objective evidence of pain. After repetitions, there was no loss of range of motion, but he evidenced pain. There was no ankylosis. Imaging studies revealed degenerative changes and mild degenerative joint disease of the glenohumeral joint. There are no VA or private treatment records showing that the Veteran sought or received treatment for his left shoulder at any time during the appeal period. During the June 2012 examination, he reported that he had not been treated for his left shoulder since 2007. There are no treatment reports of record for that period. Based on the evidence of record, the Board concludes that the probative and competent evidence is against the Veteran's claim of entitlement to an initial rating in excess of 20 percent for left shoulder myofascial pain syndrome under diagnostic codes 5299-5201. As discussed above, under this diagnostic code, a 30 percent rating is warranted when the limitation of motion for the minor arm is limited to 25 degrees from the side; that is the maximum rating available for the minor arm. Because the Veteran is not left-handed, a 30 percent evaluation for limitation of motion midway between the side and shoulder level is not applicable. Similarly, a 40 percent evaluation for limitation of motion 25 degrees from the side for the major arm is not applicable. Further, as noted above, the maximum available rating under DC 5003, degenerative arthritis, is 20 percent. The Board has also considered whether a higher disability rating based on functional loss, as contemplated by the Court's holding in DeLuca, is warranted. Although the Veteran was found to have left shoulder pain with range of motion and on repetitions, he did not demonstrate additional limitation with repetitive testing, did not report flare-ups and did not have significant weakness or tenderness. In considering whether a higher disability rating is warranted for the Veteran's left shoulder disability under any other diagnostic code, during the period on appeal, he was never diagnosed with scapulohumeral articulation ankylosis (DC 5200), impairment or malunion of the humerus (DC 5202), or impairment, dislocation, nonunion or malunion of the clavicle or scapula (DC 5203). Therefore, a higher disability rating under another diagnostic code is not for application. "Staged" ratings for left shoulder myofascial pain syndrome are not applicable, as there was no evidence during the appeal period that the Veteran's should disorder was ever more disabling than the current rating contemplates. Fenderson v. West, supra. D. Entitlement to an initial disability evaluation in excess of 10 percent for plantar fasciitis and degenerative changes of the bilateral feet. The Veteran contends that his plantar fasciitis and degenerative changes of the bilateral feet are more disabling that the current 10 percent rating contemplates. The disability is rated under 38 C.F.R. § 4.71a, DC 5010-5276 for degenerative arthritis and flatfoot, acquired. As previously discussed, under DC 5010, arthritis due to trauma, substantiated by x-ray findings, is rated as degenerative arthritis under DC 5003, based on limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is applicable for limitation of motion of each such major joint or group of minor joints. Under DC 5276, mild flatfoot with symptoms relieved by built-up shoe or arch support, is rated as noncompensable (zero percent). Moderate flatfoot with weight-bearing line over or medial to the great toe, inward bowing of the atendo achillis, pain on manipulation and use of the feet, bilateral or unilateral, is rated 10 percent disabling. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, is rated 20 percent disabling for unilateral disability, and 30 percent disabling for bilateral disability. Pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achilles on manipulation, that is not improved by orthopedic shoes or appliances, is rated 30 percent disabling for unilateral disability, and is rated 50 percent disabling for bilateral disability. 38 C.F.R. § 4.71a. During the February 2007 VA feet examination, the examiner noted mild tenderness to palpation bilaterally at the plantar fascia origin of the oscalsis. There was no evidence of callosities or abnormal weight-bearing and no bunions or lesser toe deformities. There was normal strength testing in inversion and eversion on repetition, and there was no easy fatigability or incoordination in motion. There was no increase in symptomology with repetitions. X-rays showed very mild degenerative joint disease bilaterally. The diagnosis was mild plantar fasciitis with mild degenerative joint disease bilaterally. During the June 2012 examination, the Veteran reported burning in his heels twice per month for a few days, rated 5 out of 10. He said he experienced pain only on weight-bearing and said he took no medications for the condition. It was noted, during the ankle examination, that he used over-the-counter shoe inserts. X-rays revealed degenerative arthritis. The diagnosis was bilateral mild hallus valgus, bunion and stiffness of the big toe, moderate degenerative joint disease of the first metatarsal, and mild pes planus. The examiner opined that the Veteran's foot disorder did not affect his ability to work. Neither VA, nor private treatment records, show evidence that the Veteran sought or received treatment for his bilateral foot disability at any time during the appeal period. Accordingly, the Board concludes that the probative and competent evidence is against the Veteran's claim of entitlement to an initial rating in excess of 10 percent plantar fasciitis and degenerative arthritis of the bilateral feet under diagnostic codes 5010-5276. Throughout the course of the appeal, there was no evidence that his feet demonstrated objective evidence of marked deformity (pronation, abduction, etc.) pain on manipulation and use accentuated, indication of swelling with use, and characteristic callosities to warrant a 30 percent rating for disability of both feet, or a 20 percent rating for disability of one foot. There was also no evidence of manifested marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achilles, on manipulation, not improved by orthopedic shoes or appliances, to warrant a 50 percent rating for disability of the bilateral feet, or a 30 percent rating for disability of one foot. Also, there were no additional symptoms that could constitute a functional loss, including no evidence of swelling, ankylosis or instability. Moreover, during both examinations, there were no findings of fatigue, lack of endurance, weakness, lack of coordination or decrease in degrees of range of motion upon repetitive motion, which, if present, could possibly warrant a higher disability rating. See Deluca, supra. The Board has also considered whether other diagnostic codes are applicable to the Veteran's bilateral foot disability. See Butts v. Brown, supra. However, at no time during the period on appeal was the Veteran diagnosed with weak foot (DC 5277), claw foot (DC 5278), anterior metatarsalgia (DC 5279), hallus rigidus (DC 5281), or malunion or nonunion of the tarsal or metatarsal bones (DC 5283). Moreover, although he was found to have mild hallux valgus (DC 5280) during the June 2012 examination, the highest rating under that diagnostic code is 10 percent. In addition, an increased rating under the diagnosis code for other foot injuries (DC 5284) is not applicable, as a 20 percent rating is awarded for moderately severe injuries, and 30 percent is awarded for severe foot injuries. However, there is no evidence at any time during the appeal period to suggest that the Veteran's bilateral plantar fasciitis with degenerative changes has been any worse than mild. Extraschedular Considerations The Board has also considered whether any of the Veteran's disabilities may be rated on an extraschedular basis. Ordinarily, the VA Schedule for Rating Disabilities will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2015). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. Id. The diagnostic codes used to evaluate the Veteran's disabilities consider the symptoms reported and objectively demonstrated. In other words, there are no symptoms that are unusual or different from those contemplated by the schedular criteria. The Veteran does not demonstrate exceptional or unusual disability; he merely disagrees with the assigned evaluation for his level of impairment. Furthermore, there is no evidence that the Veteran has undergone repeated hospitalizations or multiple surgical procedures for any of his service-connected disabilities during the period on appeal. As such, the record does not demonstrate hospitalizations of such frequency or length as to warrant extraschedular consideration. Moreover, the evidence does not establish that his disabilities markedly interfere with his employment or employability beyond that contemplated by the Schedule for Rating Disabilities. Therefore, referral for assignment of an extra-schedular evaluation is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). E. Entitlement to service connection for fibromyalgia, to include as the result of an undiagnosed illness. The Veteran claims that he has fibromyalgia, to include as a result of an undiagnosed illness resulting from active duty service in the Persian Gulf. In order to establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) the 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 or aggravated during service"- the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Alternatively, under 38 C.F.R. § 3.303(b), service connection may be awarded for a "chronic" condition when (1) a chronic disease manifests itself and is identified as such in service, or within the presumptive period under 38 C.F.R. § 3.307, and the veteran presently has the same condition; or (2) a disease manifests itself during service, or during the presumptive period, but is not identified until later, and there is a showing of continuity of related symptomatology after discharge, and medical evidence relates that symptomatology to the Veteran's present condition. Savage v. Gober, 10 Vet. App. 488, 495-98 (1997). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Under 38 U.S.C.A. § 1117(a)(1) (West 2014), compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the VA Secretary. Effective December 18, 2006, VA extended the presumptive period in 38 C.F.R. § 3.317(a)(1)(i) through December 31, 2011 (for qualifying chronic disabilities that become manifest to a degree of 10 percent or more after active duty in the Southwest Asia theater of operations). See 71 Fed. Reg. 75669 (2006). The definition of "qualifying chronic disability" was expanded to include (a) an undiagnosed illness, (b) a medically-unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. See 38 C.F.R. § 3.317(a)(2) (2015). Significantly, the chronic disability must not be attributed to any known clinical disease by history, physical examination or laboratory tests. See 38 U.S.C.A. § 1117 (West 2014); 38 C.F.R. § 3.317(a), (b) (2015). The Veteran served in the Persian Gulf War during Operation Desert Storm/Desert Shield. Service treatment records, including periodic examination reports, however, contain no diagnosis of fibromyalgia. While these reports contain multiple complaints, clinical findings and treatment of neck and back pain, these are disorders already service-connected. Profiles in May 1993 and May 1995 reported chronic neck strain/myofascial pain syndrome. A February 1997 profile indicated myofascial pain syndrome. The last periodic examination report of record, dated in April 1996, shows complaints of chronic neck and back pain, which the examiner attributed to probable arthritis. However, the physical examination revealed normal findings for the musculoskeletal system, and the Veteran reported that he was "in good health." In a December 1997 letter, a physician wrote that the Veteran had a history of neck and dorsal spine pain resulting from a fall in 1984 while parachuting; this is the same injury, resulting in cervical and thoracic spine fractures, for which he is service-connected. In a March 1998 annual medical certificate, the Veteran said that he had "continued pain [and] movement problems due to past neck [and] back fractures." In an April 1999 annual medical certificate, he reported continued back and neck pain. The only service treatment report of record that mentions fibromyalgia is a November 1998 report showing that the Veteran was placed on permanent profile for fibromyalgia, fracture and degenerative joint disease of the thoracic spine, and degenerative joint disease of the cervical spine. However, there are no records showing a diagnosis of, or treatment for, fibromyalgia. Rather, the records show treatment for his service-connected cervical and thoracic spine fractures, and myofascial pain syndrome, a known clinical disorder. A June 1994 treatment report showed that the Veteran was assessed with chronic, left worse than right, paracervical and shoulder girdle myofascial pain syndrome. There are no records showing that he had any signs or symptoms of a medically-unexplained, chronic multi-symptom illness. Post-service treatment records contain no diagnosis of, or treatment for, fibromyalgia. While a March 2010 private treatment report cites fibromyalgia among the Veteran's list of medical problems, this appears to have been based on a report from the Veteran himself, as there are no treatment records for the condition. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (the mere transcription of medical history does not transform the information into competent medical evidence merely because the transcriber happens to be a medical professional). In June 2012, the Veteran was afforded a VA fibromyalgia examination, in which the examiner opined that he did not meet the criteria for a diagnosis of fibromyalgia, and had never been diagnosed with the disorder. Instead, she explained that, at the time of his November 1998 physical profile, he had symptoms of pain in his upper left shoulder, thoracic and cervical spine, and soft tissue of the right shoulder. She noted that she could not find any prior mention or original diagnosis of fibromyalgia in his service treatment records. The examiner noted that the diagnostic criteria for fibromyalgia includes widespread pain above and below the waist, which the Veteran did not have. She also said that he reported that neither took medication, nor was being treated for fibromyalgia. In finding that he had no clinical findings, signs or symptoms attributable to fibromyalgia, she said that, while the Veteran reported bilateral tenderness on palpation of the suboccipital muscle, mid upper trapezius and supraspinatus, he was not tender at other trigger pints. She said that he manifested only six out of 18 for positive trigger point tenderness, and did not meet the usual criteria for a fibromyalgia diagnosis of at least 11 of 18 positive trigger points. The Board concludes that the probative and competent evidence of record is against the Veteran's claim of entitlement to service connection for fibromyalgia, to include as the result of an undiagnosed illness. As noted above, the threshold requirement for service connection to be granted is competent medical evidence of the current existence of the claimed disorder. See Degmetich, Brammer, supra. Here, there is no medical evidence demonstrating that the Veteran has a current diagnosis of fibromyalgia, or was ever diagnosed with the condition during the pendency of the appeal. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (service connection may be granted if a disability existed at the time a claim for VA disability compensation was filed or at any time during the pendency of the claim, even if the disability resolves prior to the adjudication of the claim). In addition to the medical evidence, the Board has also considered the statements of the Veteran concerning his claimed disability. The Court has repeatedly held that laypersons, such as the Veteran, are competent to describe symptoms of which they have first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, there is no evidence that the Veteran has the medical knowledge or training that would permit him to determine the etiology of a complex disorder, such as fibromyalgia. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, his statements in that regard are not competent. The Board finds the most probative evidence to be the findings of the June 2012 VA examiner, who provided sound reasons and bases for her opinion that the Veteran did not have fibromyalgia. Accordingly, the Board concludes that the most probative evidence of record weighs against the claim for service connection for fibromyalgia. The "benefit-of-the-doubt" rule, enunciated in 38 U.S.C.A. § 5107(b), does not apply in this case, as there is not an approximate balance of probative evidence. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Therefore, the claim for service connection for fibromyalgia, to include as the result of an undiagnosed illness, is denied. F. Entitlement to service connection for an upper respiratory or allergic disorder, to include as the result of an undiagnosed illness and/or as aggravated by exposure to hazardous chemicals. The Veteran alleges that he has a chronic upper respiratory or allergic disorder, to include as a result of an undiagnosed illness and/or exposure to hazardous chemicals during his service in the Persian Gulf. Alternatively, he contends that an allergic or respiratory disorder existed prior to active duty service and was permanently aggravated. Every veteran who served in the active military, naval, or air service after December 31, 1946 is taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment, and was not aggravated by such service. 38 U.S.C.A. §§ 1111, 1137 (West 2014). Only those conditions recorded in examination reports can be considered as "noted," 38 C.F.R. § 3.304(b) (2014), and a history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions. Id. § 3.304(b)(1). Determination of the existence of a pre-existing condition may be supported by contemporaneous evidence, or recorded history in the record, which provides a sufficient factual predicate to support a medical opinion (see Miller v. West, 11 Vet. App. 345, 348 (1998), or a later medical opinion based upon statements made by the Veteran about the pre-service history of his/her condition. Harris v. West, 203 F.3d. 1347 (Fed. Cir. 2000). To rebut the presumption of soundness for conditions not noted at entrance into service, VA must show by both clear and unmistakable (obvious and manifest) evidence that the disease or injury existed prior to service, and that the disease or injury was not aggravated by service. VAOPGCPREC 3-03 (July 16, 2003), 70 Fed. Reg. 23027 (May 4, 2005); Wagner v. Principi¸ 379 F.3d 1089, 1096 (Fed. Cir. 2004). A preexisting injury or disease will be presumed to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 2014); 38 C.F.R. § 3.306 (2014). Temporary or intermittent flare-ups of a pre-existing injury or disease during service are not sufficient to be considered aggravation in service unless the underlying disability, as opposed to the symptoms of that disability, has worsened. See Hunt v. Derwinski, 1 Vet. App. 292 (1991), Beverly v. Brown, 9 Vet. App. 402 (1996). If the presumption of soundness is not rebutted, "the Veteran's claim is one for service connection." Wagner, 370 F.3d at 1096. That is to say, no deduction will be made for the degree of disability existing at the time of the Veteran's entry into service. Id. The term "active military, naval, or air service" includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty, or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C.A. § 101(21), (24) (West 2014); 38 C.F.R. § 3.6(a), (d) (2015); Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). ACDUTRA is, generally, full-time duty in the Armed Forces performed by reserves for training purposes. 38 C.F.R. § 3.6(c)(1) (2015). The Court has held that regulations concerning presumptive service connection, the presumption of soundness, and the presumption of aggravation are inapplicable to claims based upon ACDUTRA and INACDUTRA service. See Smith v. Shinseki, 24 Vet. App. 40 (2010). If "veteran" status has been established through a prior period of active duty and an entrance examination was performed prior to the period of ACDUTRA, the presumption of soundness only, will apply to a period of ACDUTRA. Id. As noted above, the Veteran served several periods of ACDUTRA prior to his active duty service from January 1991 to June 1991. Although his October 1965 enlistment examination report is not of record, a December 1965 periodic examination report showed normal findings for the nose, sinuses, mouth, throat, lungs and chest. In the accompanying medical history report, the Veteran endorsed hay fever, but denied ever having ear, nose or throat trouble, sinusitis, asthma, chronic cough or shortness of breath. In his summary, the physician stated that his hay fever was mild and seasonal. A March 1967 examination report also revealed normal findings for the respiratory system. Again, the Veteran reported that he had hay fever, and the clinician wrote "hay fever seasonal - mild - responds to med[ication]s." The clinician also noted that the Veteran had undergone a submucous resection when he was 14 years old. Subsequent examination reports during ACDUTRA service also revealed normal findings for the respiratory system. The first examination report of record for the Veteran's period of active duty service, dated in March 1991, revealed that although the Veteran endorsed hay fever, and treatment records prior to his period of active duty service included complaints of coughing and cold symptoms (i.e., runny nose, sneezing, cough),respiratory findings were normal with no evidence or diagnosis of a respiratory disorder. Treatment records for the Veteran's period of ACDUTRA service after his period of active duty service include several periodic examination reports showing no diagnosis of a respiratory disorder. Treatment records after his last period of ACDUTRA service include a 2002 treatment report stating that the Veteran had undergone allergy testing, which showed that he reacted to cat and dog dander, although he owned a dog at the time. A January 2006 treatment report shows that the Veteran was evaluated by Dr. C for upper respiratory infections. He reported that he had had a cough since 1991, after exposure to the oil fires in Kuwait. Sinus x-rays were within normal limits. In a June 2006 treatment report, Dr. C opined that Veteran's cough was related to postnasal drip due to his chronic allergic rhinitis, which he did not relate to service. Treatment reports from December 2009 show that the Veteran sought treatment for complaints of a constant dry cough, nasal drip and congestion of about four weeks duration, without sore throat, headache or runny nose. However, the examinations showed that his ears, mouth, nose, sinus and throat were of normal appearance. The oral mucosa was unremarkable with a non-inflamed posterior pharynx. There was normal respiratory effort, normal to auscultation bilaterally. At various times during the month, he was diagnosed with esophageal reflux (the physician opined that he suspected sinus issues may be at the root of cough/chronic inflammation) and acute bronchitis. Although the Veteran's Gulf War service was noted in his history, the clinician did not opine that his symptoms were the result of, or had been aggravated by, such service. In June 2012, the Veteran was afforded VA sinusitis and respiratory disorder examinations. He reported that he had had allergic rhinitis due to hay fever since childhood and had undergone nasal surgery for the disorder at that time. He said that, during service in the Persian Gulf, he had spent five months stationed 20 kilometers away from the burning oil wells, where he was exposed to smoke from the fires. He said that he currently experienced a dry cough once per week. Upon examination, his pulmonary function test (PFT) results were normal. The clinician diagnosed the Veteran with rhinitis; she opined that there was insufficient evidence to diagnose a respiratory disorder. She found that his solitary pulmonary nodules were common, incidental findings of his rhinitis that were usually not of clinical significance, and were less likely than not to cause any symptoms of a dry cough. She further opined that his chronic cough was due to postnasal drip from his allergic rhinitis, a common symptom of the disorder. She said that his rhinitis had existed since childhood and there had been a natural progression of the disorder without aggravation during service. The Board concludes that the competent and probative evidence is against the Veteran's claim of entitlement to service connection for an upper respiratory or allergic disorder, to include as the result of an undiagnosed illness and/or as aggravated by exposure to hazardous chemicals. As noted above, the June 2012 VA examiner, after reviewing the complete claims folder, including the Veteran's ACDUTRA and active duty service treatment records, as well as his post-service treatment reports, concluded that rhinitis was not the result of service. Moreover, because the Veteran was diagnosed with a disorder attributed to a known clinical disease, service connection as the result of an undiagnosed illness is not for application. Regarding the Veteran's claim for service connection for aggravation of his rhinitis, as discussed above, treatment records prior to his period of active duty service in January 1991 contained no diagnosis of rhinitis. There was also no diagnosis of a respiratory disorder during his March 1991 active duty service examination. Although the Veteran now claims that he has had allergic rhinitis since childhood, there is no medical evidence to support that claim. Furthermore, even if allergic rhinitis had been found to pre-exist active duty service, there has been no probative evidence indicating that the disorder was permanently aggravated. As discussed above, temporary or intermittent flare-ups of a pre-existing injury or disease during service are not sufficient to be considered aggravation in service unless the underlying disability, as opposed to the symptoms of that disability, has worsened. See Hunt, Beverly, supra. The Board has also considered the statements and assertions from the Veteran concerning the etiology of his allergic rhinitis. The Veteran is competent to report what he experiences with his own senses. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). However, there is no competent medical evidence or opinion relating his current disorder to service and the Veteran's opinions are insufficient to provide the requisite nexus between an in-service injury or event and any current disability because, as a lay person, he is not competent to establish a medical etiology merely by his own assertions; such matters require medical expertise. See 38 C.F.R. § 3.159(a)(1); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). Accordingly, the Board concludes that the competent and probative evidence of record weighs against the claim for service connection for an upper respiratory or allergic disorder, to include as the result of an undiagnosed illness and/or as aggravated by exposure to hazardous chemicals. The "benefit-of-the-doubt" rule enunciated in 38 U.S.C.A. § 5107(b) does not apply in this case, as there is not an approximate balance of probative evidence. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Ortiz v. Principi; Gilbert v. Derwinski, supra. Therefore, the claim for is denied. (ORDER ON NEXT PAGE) ORDER An initial disability rating in excess of 10 percent for residuals of fracture right ankle is denied. An initial disability evaluation in excess of 10 percent for status post fracture of the thoracic spine is denied. An initial disability evaluation in excess of 20 percent for status post fracture of the cervical spine with degenerative changes is denied. An initial disability evaluation in excess of 20 percent for left shoulder myofascial pain syndrome is denied. An initial disability evaluation in excess of 10 percent for plantar fasciitis and degenerative changes of the bilateral feet is denied. Service connection for fibromyalgia, to include as the result of an undiagnosed illness is denied. Service connection for an upper respiratory or allergic disorder, to include as the result of an undiagnosed illness and/or as aggravated by exposure to hazardous chemicals, is denied. ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs