Citation Nr: 1642405 Decision Date: 11/03/16 Archive Date: 11/18/16 DOCKET NO. 14-15 941A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a left ankle disability. 2. Entitlement to service connection for gastroenteritis. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for sleep apnea. 5. Entitlement to service connection for allergic rhinitis. 6. Entitlement to an initial rating in excess of 30 percent for adjustment disorder with anxiety. 7. Entitlement to an initial rating in excess of 20 percent for lumbar strain. 8. Entitlement to an initial rating in excess of 10 percent for right knee strain. 9. Entitlement to an initial rating in excess of 10 percent for left knee strain. REPRESENTATION Appellant represented by: Ralph J. Bratch, Attorney ATTORNEY FOR THE BOARD R. Casadei, Counsel INTRODUCTION The Veteran served on active duty from August 2007 to January 2012. This case comes on appeal before the Board of Veterans' Appeals (Board) from an October 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. FINDINGS OF FACT 1. The Veteran does not have diagnoses relating to a left ankle disability, gastroenteritis, sleep apnea, allergic rhinitis, or hypertension. 2. For the entire initial rating period on appeal, the Veteran's adjustment disorder with anxiety has been characterized by occupational and social impairment with reduced reliability and productivity manifested by anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impaired abstract thinking, disturbance of motivation and mood, and difficulty adapting to stressful circumstance. 3. For the entire initial rating period on appeal, the Veteran's adjustment disorder with anxiety has not been characterized by occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. 4. For the entire initial rating period on appeal, the Veteran's lumbar spine disability has not manifested forward flexion to 30 degrees or less or unfavorable ankylosis of the entire thoracolumbar spine. 5. For the entire initial rating period on appeal, the Veteran's right knee disability has been manifested by normal extension, with flexion, at worst, to 115 degrees, without lateral instability or recurrent subluxation. 6. For the entire initial rating period on appeal, the Veteran's left knee disability has been manifested by normal extension, with flexion, at worst, to 110 degrees, without lateral instability or recurrent subluxation. CONCLUSIONS OF LAW 1. The criteria for service connection for a left ankle disability have not been met. 38 U.S.C.A. § 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). 2. The criteria for service connection for gastroenteritis have not been met. 38 U.S.C.A. § 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). 3. The criteria for service connection for sleep apnea have not been met. 38 U.S.C.A. § 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). 4. The criteria for service connection for allergic rhinitis have not been met. 38 U.S.C.A. § 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). 5. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. § 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.3.09 (2015). 6. For the entire initial rating period on appeal, the criteria for a rating of 50 percent, but not higher, for adjustment disorder with anxiety have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9413 (2015). 7. For the entire initial rating period on appeal, the criteria for a rating in excess of 20 percent for the lumbar spine disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5237 (2015). 8. For the entire initial rating period on appeal, the criteria for a disability rating in excess of 10 percent for the right knee disability have not been met. 38 C.F.R. §§ 1155, 5103, 5103A, 5107, 7104 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2015). 9. For the entire initial rating period on appeal, the criteria for a disability rating in excess of 10 percent for the left knee disability have not been met. 38 C.F.R. §§ 1155, 5103, 5103A, 5107, 7104 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has duties to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). VA must notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The notice requirements apply to all five elements of a service connection claim. Those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between a service and the disability; (4) degree of disability; and (5) effective date of the disability. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2015); Dingess v. Nicholson, 19 Vet. App. 473 (2006). A February 2012 letter provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, and what information and evidence must be submitted by the Veteran and what evidence VA would obtain. The notice included provisions for disability ratings and effective dates. The Veteran's service medical records, post-service treatment records, and the Veteran's statements are associated with the claims file. The Veteran was also provide VA examinations in connection with the service connection and increased rating claims in October 2012. When VA provides an examination or obtains an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the VA opinion and findings obtained in this case are adequate. The opinions provided considered all the pertinent evidence of record, the Veteran's symptoms, and provided a rationale for the opinions stated. Significantly, the Veteran and representative have not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Therefore, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Service Connection 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 (West 2014); 38 C.F.R. § 3.303(a) (2015). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2015). The condition of hypertensions is a chronic disease listed under 38 C.F.R. § 3.309(a) (2015). Therefore, the provision of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology apply to that claim. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Congress specifically limits entitlement for service-connected disease or injury to cases where the disease or injury has resulted in a disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). In making a decision on appeal the Board must 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 the rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (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 (1997); Layno v. Brown, 6 Vet. App. 465 (1994). Although interest may affect the credibility of testimony, it does not affect competency to testify. Cartright v. Derwinski, 2 Vet. App. 24 (1991). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as thoroughness and degree of detail, and whether there was review of the claims file. Prejean v. West, 13 Vet. App. 444 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, and a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379 (1998); Claiborne v. Nicholson, 19 Vet. App. 181 (2005). A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms, or treatment, including by a Veteran. Harris v. West, 203 F.3d 1347 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171 (2005) (medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by Veteran); Reonal v. Brown, 5 Vet. App. 458 (1993) (Board may reject a medical opinion based on inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015). The Veteran essentially contends that he has a left ankle disability, gastrointestinal disability, hypertension, sleep apnea, and allergic rhinitis that are related to service. The service medical records include a May 2008 record where the Veteran complained of left ankle pain after running. He was diagnosed with tendonitis of the Achilles and told to use heat and perform ankle exercises. In June 2008, an ankle examination found no abnormalities and he had full range of motion in the toes and ankles. In a July 2011 treatment record, the Veteran was noted to have no weakness in the left ankle and his gait was normal. In November 2011 and December 2011 records, it was noted that the Veteran complained of ankle joint pain, but no diagnosis was provided. The service medical records also include a February 2009 note where the Veteran was diagnosed with gastroenteritis. He was prescribed medication and told to rest and increase fluids. In July 2010, the Veteran was again seen for complaints of abdominal pain for 24 hours. He was diagnosed with viral gastroenteritis. The service medical records are negative for diagnoses or treatment for hypertension or allergic rhinitis. Regarding sleep apnea, an October 2011 treatment record indicates that the Veteran was to be referred for a sleep study. However, the subsequent service medical records do not show any sleep study report or any diagnosis of sleep apnea confirmed by a sleep study. In a November 2011 report, the Veteran indicated problems of ankle joint pain, sleep apnea, insomnia, gastroenteritis, and isolated blood pressure was elevated. The evidence also includes VA examinations pertaining to the Veteran's claimed disabilities dated in October 2012. Regarding the left ankle, the examiner indicated that the Veteran had sustained an acute left ankle sprain in November 2011. The Veteran reported a gradual onset of dull, aching pain with no known mechanism of injury. After conducting a physical examination, to include range of motion and muscle strength testing, the examiner noted that the Veteran had a normal bilateral orthopedic ankle examination. X-ray imaging results were negative for any abnormal findings. In regard to a gastrointestinal disability, the examiner indicated that the Veteran had experienced acute gastroenteritis in February 2008 and July 2010(during service. During the evaluation, the Veteran reported a history of two episodes of acute gastroenteritis during active service. However, the Veteran indicated that the symptoms resolved in both instances without residual. After performing a physical examination, the October 2012 VA examiner indicated that the Veteran's condition had resolved without residuals. There was no objective evidence during the examination of a chronic disability related to the in-service acute gastroenteritis. The October 2012 VA examiner examined the Veteran for a claimed hypertension disability. During the evaluation, the Veteran stated that his blood pressure was evaluated several times during service, but he was never diagnosed with hypertension and was not prescribed medication during active service. During the October 2012 VA examination, blood pressure readings were 130/74, 129/65, and 129/72. The examiner indicated that there was no objective evidence of hypertension on examination. The October 2012 VA examiner examined the Veteran regarding the claimed allergic rhinitis disability. The Veteran reported that he had symptoms of stuffy, runny nose, sneezing, postnasal drip, and itchy watery eyes during the summer months. After performing a physical examination, the examiner indicated that there was no objective evidence of allergic rhinitis on examination. Post-service VA treatment records are negative for diagnoses or treatment for a left ankle disability, gastrointestinal disability, hypertension, or allergic rhinitis. Regarding the claimed sleep apnea disability, the Veteran indicated that he was diagnosed with sleep apnea during active service. However, the October 2012 VA examiner noted that the Veteran was not currently receiving any care for sleep apnea through the VA medical system. Although a sleep study was not performed, the examiner indicated that there was no documented sleep disorder in the record. Further, service medical records were silent for a sleep study evaluation. Therefore, the examiner indicated that he was unable to verify a diagnosis of sleep apnea. Further, in a March 2012 VA treatment record, it was noted that the Veteran had unspecified insomnia. However, according the Veteran's report, he had undergone a sleep study that was negative. Further, although the Veteran has been diagnosed with unspecified insomnia, his sleep impairment symptoms have been listed in the rating decisions by the RO that have addressed the Veteran's disability rating for his service-connected adjustment disorder, which was claimed as depression and insomnia. Thus, the Veteran's sleep impairment due to unspecified insomnia has already been considered a symptom associated with a service-connected psychiatric disability. The provisions of 38 C.F.R. § 4.130 indicate that chronic sleep impairment is a manifestation of psychiatric disability for rating purposes. There has not been a separate sleep disability identified, to include sleep apnea, that would overcome the inadmissible practice of pyramiding, or rating the same disability under different diagnoses. 38 C.F.R. § 4.14 (2015). Regarding the Veteran's complaints of seasonal summer symptoms of a runny nose, sneezing, and itchy watery eyes, the Board notes that seasonal and other acute allergic manifestations subsiding on the absence of or removal of the allergen are generally to be regarded as acute diseases, healing without residuals. 38 C.F.R. § 3.380 (2015). As residuals have not been demonstrated, and none were found on objective examination, the Board finds that service connection for seasonal allergic rhinitis is not warranted. The Board has considered the Veteran's statements regarding his belief that he has a left ankle disability, gastrointestinal disability, hypertension, sleep apnea, and allergic rhinitis. As a lay person, the Veteran is competent to relate some symptoms that may be associated with the claimed disorders, but he does not have the requisite medical knowledge, training, or experience to diagnose the claimed disabilities. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Joint disabilities, gastrointestinal disabilities, hypertension, sleep apnea, and allergic rhinitis are medically complex disabilities that usually require specialized testing and medical knowledge to diagnose. They can also manifests symptomatology that may overlap with other disabilities. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, the Board finds that the Veteran is not competent to diagnose the claimed disabilities. To the extent that his statements claim the presence of the claimed disabilities, the Board finds that the opinion of the VA examiner is more persuasive because of the training and expertise of the examiner. Accordingly, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a diagnosed left ankle disability, gastroenteritis, sleep apnea, allergic rhinitis, or hypertension. Therefore, he has not met the threshold to establish a disability, and the claim must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). The Board finds that the preponderance of the evidence is against the claims, and the claims must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). If two ratings are potentially applicable, 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). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2015). In rating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately compensates the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). Here the Board finds that the disabilities has not significantly changed during the rating period under consideration and uniform ratings are warranted. In making a decision on appeal, the Board must 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 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the Board has considered all the evidence of record, lay and medical, as it bears on the issue of rating the disabilities. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation). Adjustment Disorder The Veteran contends that his psychiatric disability, diagnosed as adjustment disorder with anxiety, is more severe than contemplated by the currently assigned 30 percent rating. The Veteran is assigned a 30 percent rating for adjustment disorder under Diagnostic Code 9413 for the entire rating period on appeal. A rating of 30 percent is warranted if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130 (2015). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130 (2015). A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130 (2015). A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the veteran's own occupation or name. 38 C.F.R. § 4.130 (2015). In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, the signs and symptoms shall be attributed to the service-connected disability. 38 C.F.R. § 3.102 (2015); Mittleider v. West, 11 Vet. App. 181 (1998); Mitchem v. Brown, 9 Vet. App. 136 (1996) (Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so). In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV or DSM-5). If the evidence demonstrates that a claimant has symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Within the DSM-IV, Global Assessment Functioning (GAF) scale scores ranging from 1 to 100 indicate psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Carpenter v. Brown, 8 Vet. App. 240 (1995); see also Richard v. Brown, 9 Vet. App. 266 (1996). GAF scores from 71 to 80 indicate transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores from 61 to 70 indicate some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 indicate moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 indicate serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 31 to 40 indicate some impairment in reality testing or communication (e.g., speech which is at times illogical, obscure, or irrelevant) or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood (depressed patient who avoids friends, neglects family, and is unable to do work). Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated DSM-5. As the Veteran's claim was certified to the Board prior to August 4, 2014, the DSM-5 is not applicable to this case. However, according to the DSM-5, clinicians do not typically assess GAF scores. The DSM-5 introduction states that it was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity, such as including symptoms, suicide risk, and disabilities in its descriptors, and questionable psychometrics in routine practice. In reviewing the evidence of record, the Board will consider the assigned GAF score. However, the Board is cognizant that GAF scores are not the dispositive element in rating a disability. Rather, GAF scores must be considered in light of the actual symptoms of the disorder, which provide the primary basis for the rating assigned. 38 C.F.R. § 4.126(a) (2015). Upon review of all the evidence of record, lay and medical, the Board finds that, for the rating period on appeal, the evidence is in equipoise as to whether the Veteran's adjustment disorder and anxiety has been characterized by occupational and social impairment with reduced reliability and productivity manifested by depression, anxiety, suspiciousness, mild memory loss, impaired abstract thinking, disturbance of motivation and mood, and difficulty adapting to stressful circumstance. Post-service VA treatment records include an April 2012 VA mental health consult note where the Veteran was seen for depression. He reported that his wife had noted that he was irritable and angry. The Veteran indicated that he averaged about three hours of sleep each night. On mental status examination, the Veteran's judgment and insight were fair. Affect was restricted and mood was depressed and irritable. A GAF score of 55 was noted, indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. At an October 2012 VA examination, the Veteran reported being married for over four years and he described his marriage in mixed terms. He stated that his wife complained that he did not want to go out and see people. The Veteran also indicated that he had a three year old daughter and their second child was due in three months. He reported that he maintained regular contact with his parents, but denied other significant social contacts or activities. Most of his time was spent watching television, researching on the Internet, playing video games, and working on the car. The Veteran stated that he was presently attending Universal Technical Institute in Orlando for automotive training. Symptoms were noted to include anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impaired abstract thinking, disturbance of motivation and mood, and difficulty adapting to stressful circumstance. A GAF score of 60 was assigned, indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. The examiner indicated that the Veteran's psychiatric disability resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily. On review of all the evidence of record, both lay and medical, the Board finds that the evidence is in equipoise as to whether the Veteran's PTSD disability more nearly approximates a 50 percent rating for the entire initial rating period on appeal. The Board finds that the Veteran's symptoms have remained relatively consistent throughout the appeal period, including ongoing, anxiety, depression, suspiciousness, diminished interest or participation in activities, mild memory loss, impaired abstract thinking, disturbance of motivation and mood, and difficulty adapting to stressful circumstance. Further, the GAF scores during the appeal period were 55 and 60, which indicate moderate symptoms or moderate difficulty in social, occupational, or school functioning. Accordingly, the Board finds that a 50 percent rating for the Veteran's psychiatric disability is warranted for the entire initial rating period on appeal. The Board next finds that, for the entire initial rating period on appeal, the Veteran's adjustment disorder has not more nearly approximated occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; and difficulty in adapting to stressful circumstances. The Board recognizes that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. However, without those examples, differentiating between ratings would be extremely ambiguous. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board finds that the weight of the evidence demonstrates that the Veteran's overall psychiatric disability picture is adequately contemplated by the 50 percent rating currently assigned. The Veteran has sleep impairment, and suspiciousness, but that is specifically contemplated under the criteria for a 30 percent rating, a lower rating than the currently assigned 50 percent rating. The Veteran's disturbance of motivation and mood, depression, and impaired thinking are contemplated in the 50 percent rating criteria. The Veteran has also stated that he is married and has a relationship with family members. That evidence further demonstrates that the Veteran was going to school in efforts to advance his career. That is evidence against a finding of deficiencies in most areas due to mental disorder. Therefore, the Board finds that the preponderance of the evidence is against the assignment of a higher rating. Accordingly, resolving reasonable doubt in the Veteran's favor, the Board finds that a 50 percent rating, but not higher, for adjustment disorder with anxiety is warranted for the entire initial rating period on appeal. However, the Board finds that the preponderance of the evidence is against the assignment of any higher rating. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015). Lumbar Spine Disability The Veteran maintains that his lumbar spine disability warrants a higher rating in excess of 20 percent. The Veteran's lumbar spine disability has been appropriately rated under Diagnostic Code 5237 for lumbosacral strain. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made 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. 38 C.F.R. § 4.71a (2015). The disabilities of the spine that are rated under the General Rating Formula for Diseases and Injuries of the Spine include vertebral fracture or dislocation (Diagnostic Code 5235), sacroiliac injury and weakness (Diagnostic Code 5236), lumbosacral or cervical strain (Diagnostic Code 5237), spinal stenosis (Diagnostic Code 5238), unfavorable or segmental instability (Diagnostic Code 5239), ankylosing spondylitis (Diagnostic Code 5240), spinal fusion (Diagnostic Code 5241), and degenerative arthritis of the spine (Diagnostic Code 5242). Degenerative arthritis of the spine can also be rated using Diagnostic Code 5003. 38 C.F.R. § 4.71a (2015). The General Rating Formula for Diseases and Injuries of the Spine provides a 20 percent rating for 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. 38 C.F.R. § 4.71a (2015). A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, unfavorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a (2015). Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2015). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 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 normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, Plate V, General Rating Formula for Diseases and Injuries of the Spine, Note (2) (2015). The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (4) (2015). In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion. Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (3) (2015). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the 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 (0 degrees) always represents unfavorable ankylosis. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5) (2015). Disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (6) (2015). Diagnostic Code 5243 provides that intervertebral disc syndrome (IVDS) is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (2015). 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. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1) (2015). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated 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. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (2) (2015). On review of all the evidence of record, both lay and medical, the Board finds that, for the entire initial rating period on appeal, the Veteran's lumbar spine disability has not more nearly approximated a rating in excess of 20 percent. At an October 2012 VA spine examination, the Veteran reported a gradual onset of dull, achy lower back pain with no known mechanism of injury. The Veteran stated that he occasionally had pain that radiated into the upper legs. Regarding flare-ups, the Veteran stated that he could still perform all activities normally, but with increased pain. Range of motion testing showed flexion limited to 60 degrees with pain starting at 60 degrees. Extension was limited to 25 degrees with pain at 25 degrees. After repetitive use testing, range of motion was unchanged in both flexion and extension. Muscle spasms were noted from L3 to L5. Sensory examination was normal and radiculopathy was not noted. The examiner also indicated that the Veteran did not have IVDS. The Board finds that a rating in excess of 20 percent for the lumbar spine disability is not warranted. The next higher 40 percent disability rating is assigned when forward flexion of the thoracolumbar spine is 30 degrees or less; or there is unfavorable ankylosis of the entire thoracolumbar spine. The evidence of record demonstrates that the Veteran's lumbar spine has been limited to, at worst, 60 degrees with no evidence of unfavorable ankylosis of the entire thoracolumbar spine. For these reasons, the Board finds that a rating in excess of 20 percent for the lumbar spine disability is not warranted for the entire initial rating period on appeal. Next, the Board finds that the Veteran has not been diagnosed with IVDS of the lumbar spine. Therefore, a higher rating under the IVDS Formula is not proper. Even were those criteria applicable, the evidence does not show incapacitating episodes, with treatment by a physician and bed rest prescribed by a physician, of at least four weeks in a 12-month period. The Board has also considered the Veteran's reported impairment of function, such as back and neck pain, and has considered additional limitations of motion due to pain, incoordination, fatigability, excess motion, weakened motion, or on flare up. Even considering additional limitation of motion or function of the spine due to pain or other symptoms such as weakness, fatigability, pain, or incoordination the evidence still does not show that the lumbar spine disability more nearly approximate the criteria for higher rating. Upon repetitive use testing, range of motion of the spine did not show any additional loss of range of motion of the lumbar spine, and the Veteran stated that he remained able to function during flare up, with only increased pain. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2015); DeLuca v. Brown, 8 Vet. App. at 202 (1995). The factors that may additionally limit motion and function were considered and assessed by the examination report. The VA examiner noted less movement than normal, pain on movement, and interference with sitting, standing, and weight-bearing. The Veteran described flare-ups were manifested by increased pain but continued ability to function. The Board finds that pain and reduced range of motion is fully contemplated in the current 20 percent ratings assigned. The evidence does not show that any additional factors reduce thoracolumbar flexion to 30 degrees or less. Moreover, the Board has considered whether separate rating for neurological disabilities are warranted. Objective neurological abnormalities should be rated separately under an appropriate diagnostic code. In this case, during the October 2012 VA examination the Veteran reported some radiating pain to the lower extremities. Moreover, VA treatment records list lumbar radiculopathy on the Veteran's general problem list. However, after a performing a physical and sensory examination, the October 2012 VA examiner did not indicate any neurological impairment associated with the lumbar spine, including radiculopathy. The remaining medical evidence of record does not show a confirmed diagnosis of lumbar radiculopathy. Therefore, absent clinical evidence of radiculopathy in either lower extremity that is at least mild in nature, the Board concludes that a separate rating is not warranted for either lower extremity under for any period of time on appeal. Accordingly, the Board finds that a rating in excess of 20 percent for the Veteran's lumbar spine disability for the entire rating period on appeal is not warranted. The Board finds that the preponderance of the evidence is against the claim for increase and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015). Right and Left Knee Disabilities The Veteran's knee disabilities are currently rated as 10 percent disabling under Diagnostic Code 5261. 38 C.F.R. § 4.71a (2015). The Veteran contends that higher ratings are warranted. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2015). The Rating Schedule provides for ratings of 0, 10, 20, or 30 percent where there is limitation of flexion of the leg to 60, 45, 30, or 15 degrees, respectively, and for ratings of 0, 10, 20, 30, 40, or 50 percent for limitation of extension of the leg to 5, 10, 15, 20, 30, or 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Diagnostic Code 5257 provides ratings of 10, 20, and 30 percent for recurrent subluxation or lateral instability of the knee which is slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2015). Diagnostic Code 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259 (2015). Separate ratings are available for limitation of flexion and limitation of extension of the same knee under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004), 69 Fed. Reg. 59988 (2004). A Veteran who has limitation of motion and instability in the same knee may receive separate ratings under Diagnostic Code 5003 (or Diagnostic Codes 5260 and 5261) and Diagnostic Code 5257. VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63,604 (1997).. The Separate ratings are only warranted in cases when a Veteran has limitation of motion in the knee to at least meet the criteria for a 10 percent rating under Diagnostic Codes 5260 or 5261, or where there is probative evidence showing the Veteran experiences painful motion attributable to arthritis and a compensable level of recurrent lateral instability or subluxation. 38 C.F.R. §§ 4.45, 4.59 (2015); DeLuca v. Brown, 8 Vet. App. at 202 (1995); VAOPGCPREC 9-98 (1998). At an October 2012 VA knee examination, the Veteran complained of dull, aching pain in both knees of gradual origin with no known mechanism of injury. Flare-ups were noted to include difficulty squatting and kneeling. Range of motion testing showed flexion in the right knee limited to 120 degrees with pain starting at 115 degrees. Left knee flexion was limited to 120 degrees, with pain at 110 degrees. Extension in both knees was to 0 degrees. Repetitive use testing did not manifest additional limitation of motion in either knee. Medial-lateral instability tests were normal in both knees. There was no patellar subluxation or dislocation. There was also no meniscal condition or surgical procedure. Based on the evidence of record, the Board finds that ratings in excess of 10 percent for the right and left knee disabilities are not warranted. Normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2015). In the October 2012 VA examination, the Veteran had full bilateral extension, and did not warrant any rating for limitation of extension. Also, flexion was, at worst, 115 degrees in the right knee and 110 degrees in the left knee, which would not warrant a rating higher than 10 percent. In addition, ratings cannot be assigned for arthritis and limitation of motion in the same joint. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2015). Accordingly, the Board finds that a higher initial rating in excess of 10 percent is not warranted under Diagnostic Codes 5003, 5260, or 5261 for either knee. The Board also finds that a higher or separate rating is not warranted under Diagnostic Code 5257 which provides ratings of 10, 20, and 30 percent for recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2015). The October 2012 VA examiner noted normal medial and later meniscus tests and no instability of either knee. As such, the Board finds that the Veteran does not have instability of either knee and a higher or separate evaluation under Diagnostic Code 5257 is not warranted. The Board has also considered Diagnostic Code 5258 where a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Further consideration has been provided under Diagnostic Code 5259, where a 10 percent rating is warranted for symptomatic removal of a semilunar cartilage or meniscus. In this case, the evidence does not show that the Veteran has a right or left knee meniscal condition. The examiner found no meniscal disability. Therefore, separate ratings under those diagnostic codes is not warranted. The Board has also considered other Diagnostic Codes relating to the knees. However, the Board finds that they are not applicable. The Board finds that the record does not demonstrate evidence of ankylosis of the knee (Diagnostic Code 5256); impairment of the tibia and fibula (Diagnostic Code 5262); or genu recurvatum (Diagnostic Code 5263). 38 C.F.R. § 4.71a (2015). Therefore, the Board finds that higher or separate ratings for each knee are not warranted under any of those Diagnostic Codes. The Board has also considered whether a higher rating is warranted based on additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare-ups. 38 C.F.R. §§ 4.40, 4.45 (2015); DeLuca v. Brown, 8 Vet. App. at 202 (1995). During the October 2012 VA examination, the Veteran complained of difficulty squatting and kneeling when having a flare-up. The examiner indicated that the Veteran was able to perform repetitive-use testing with no additional loss of motion. Even considering the Veteran's reports of pain, bilateral extension was normal and flexion was, at worst, 115 degrees in the right knee and 110 degrees in the left knee. The evidence does not show any additional function loss that would reduce knee limitation of motion such that any higher rating would be warranted. The loss of function due to pain and flare up is considered within the 10 percent ratings already assigned. Accordingly, the Board finds that the weight of the evidence is against the assignment of ratings in excess of 10 percent for either knee. To the extent any higher level of compensation is sought, the Board finds that the preponderance of the evidence is against the claims, and the claims must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015). Extraschedular Consideration The Board also has considered whether referral for extraschedular consideration is warranted. An extraschedular 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 make impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2015); Fanning v. Brown, 4 Vet. App. 225 (1993). 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 ratings for that service-connected disability are inadequate. Second, if the schedular rating 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 rate a Veteran'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 VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. 38 C.F.R. § 3.321(b)(1) (2015); Thun v. Peake, 22 Vet App 111 (2008), The Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. A comparison between the level of severity and symptomatology of the Veteran's symptoms with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the disability and contemplate the Veteran's symptoms, as those criteria rate occupational and social impairment due to all psychiatric symptoms. Specifically, the Veteran's adjustment disorder symptoms has been characterized by anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impaired abstract thinking, disturbance of motivation and mood, and difficulty adapting to stressful circumstance, which are symptoms contemplated by the rating criteria. As for the spine disability, the criteria specifically provide for ratings based on the presence of arthritis, limitation of motion or ankylosis of the spine, including due to pain, and other orthopedic factors and incapacitating episodes. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2015); DeLuca v. Brown, 8 Vet. App. at 202 (1995). The symptomatology and impairment caused by the Veteran's lumbar spine disability is contemplated by the pertinent schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran has reported pain, stiffness, and limitation of motion of the lumbar spine. Those symptoms contemplated by and encompassed by the symptoms listed under the pertinent schedular rating criteria for spine disabilities. The Veteran's right knee disability has been manifested by painful motion of the with normal extension, with flexion, at worst, to 115 degrees, without lateral instability or recurrent subluxation, and no meniscal condition. The Veteran's left knee disability has been manifested by painful motion with normal extension, with flexion, at worst, to 110 degrees, without lateral instability or recurrent subluxation, and without disability of the semilunar cartilage. Ankylosis is not shown. The schedular rating criteria specifically allow for different ratings based on the severity of the limitations of motion of the knees, including due to pain and other orthopedic factors. The Board finds that the schedular rating criteria are adequate to rate the disabilities on appeal, and referral for consideration of an extraschedular rating is not warranted. 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 (West 2014). 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 (2015). In this case, the problems reported by the Veteran regarding the service-connected disabilities are specifically contemplated by the rating criteria, including the effect of the Veteran's symptoms on occupation and daily life. In the absence of exceptional factors associated with the disabilities, 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. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Therefore, the Board finds that the record does not show that the Veteran's disabilities are so exceptional or unusual as to warrant referral for consideration of the assignment of a higher rating on an extra-schedular basis. In the absence of those factors, the Board finds that the requirements for a referral for consideration of the consideration of the assignment of an extraschedular rating for the Veteran's disabilities under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). A veteran may be entitled to consideration under 38 C.F.R. § 3.321(b) for referral for an extraschedular rating based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular ratings. Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the combined effect of multiple service-connected disabilities when the collective impact or compounding negative effects of the service-connected disabilities, when that presents disability not adequately captured by the schedular ratings for the service-connected disabilities. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). In this case, the Veteran has not asserted, and the evidence of record has not suggested, any combined effect or collective impact of multiple service-connected disabilities that creates such an exceptional circumstance to make the schedular rating criteria inadequate. There is neither allegation nor indication that the collective impact or combined effect of the service-connected disabilities presents an exceptional or unusual disability picture to make inadequate the schedular rating criteria. Finally, an inferred claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) has not been raised by the Veteran or the evidence of record. During the October 2012 VA examination, the Veteran reported that he was attending school for automotive training. The Veteran has not maintained that he is unemployable as a result of the service-connected disabilities. Therefore, the Board finds that the issue of entitlement to TDIU has not been reasonably raised by the record or by the Veteran. Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Entitlement to service connection for a left ankle disability is denied. Entitlement to service connection for gastroenteritis is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for allergic rhinitis is denied. For the entire initial rating period on appeal, entitlement to a 50 percent rating, but not higher, for adjustment disorder with anxiety is granted. For the entire initial rating period on appeal, entitlement to a rating in excess of 20 percent for lumbar strain is denied. For the entire initial rating period on appeal, entitlement to an initial rating in excess of 10 percent for right knee strain is denied. For the entire initial rating period on appeal, entitlement to an initial rating in excess of 10 percent for left knee strain is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs