Citation Nr: 1628242 Decision Date: 07/14/16 Archive Date: 07/28/16 DOCKET NO. 10-27 288A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a rating in excess of 20 percent for a left ankle disability. 2. Entitlement to a rating in excess of 10 percent for a left knee disability. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Harold A. Beach, Counsel INTRODUCTION The Veteran served on active duty from December 1978 to December 1998. This case was previously before the Board of Veterans' Appeals (Board) on appeal from a decision of a Department of Veterans Affairs (VA) Regional Office (RO) in September 2015, when it was remanded for further development. FINDINGS OF FACT 1. The Veteran's left ankle disability is productive of marked limitation of motion. 2. The Veteran's left knee disability is manifested primarily by complaints of pain, tenderness to palpation, crepitus, and flexion to 90 degrees. CONCLUSIONS OF LAW 1. The criteria have not been met for a rating in excess of 20 percent for tuberculosis of the left ankle. 38 U.S.C.A. § 1155, 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71, Diagnostic Codes 5010, 5271 (2015). 2. The criteria have not been met for a rating in excess of 10 percent for arthritis of the left knee. 38 U.S.C.A. § 1155, 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.71, Diagnostic Codes 5010, 5256-5262 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Prior to consideration of the merits of an appeal, the Board must ensure that VA has met the duty to notify the Veteran of the information and evidence necessary to substantiate his claim and to assist him in obtaining relevant evidence. 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA's duty to notify the Veteran as to the information and evidence necessary to substantiate the claims was satisfied by a letter in December 2007. The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and the VA has notified the Veteran of any evidence that could not be obtained. Indeed, the Veteran has not referred to any unobtained, relevant, available evidence. Furthermore, the VA has obtained adequate examinations for his claims. Thus, the Board finds that VA has satisfied the duty to assist. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Veteran contends that the ratings for service-connected left ankle and left knee disabilities do not adequately compensate the level of severity caused by those disabilities. Therefore, he maintains that increased ratings are warranted. However, after carefully considering the claim in light of the record and the applicable law, the Board is of the opinion that the preponderance of the evidence is against those claims. Disability ratings are determined by comparing the manifestations of a particular disability with the criteria set forth in the Diagnostic Codes of the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155, 38 C.F.R. Part 4 (2015). The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity in civilian occupations resulting from service-connected disability. 38 C.F.R. § 4.1 (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). In order to rate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant evidence of record consists of reports of VA examinations in December 2006, January 2008, October 2008, April 2011, July 2012, and February 2016; records of the Veteran's treatment at the St. Francis Orthopaedic Institute from July 2007 to June 2008; statements from H. T., a long-time friend of the Veteran in and after service, R. L., the Veteran's supervisor; and J. R. S., a co-worker; records of the Veteran's VA treatment from December 2006 to August 2015; and the transcript of a May 2015 hearing before the undersigned Veterans Law Judge. VA treatment records, dated from December 2006 through August 2015, show that occasionally, the Veteran reported pain in the left lower extremity. In August 2015, it was noted that three times a week, he walked two to three miles on a treadmill. During an August 2006 VA examination, the Veteran complained of a constant achy left knee and left ankle. The left knee pain was increased with prolonged walking, prolonged sitting with his knees flexed, any increased awkward activity, and climbing up stairs. The left ankle pain was increased by prolonged standing or walking. The Veteran took over-the-counter Tylenol, which helped relieve his pain. He stated he wore knee and ankle braces and walked with a cane which was also helpful. He noted that he had to watch where he walked or how he placed his foot, because any awkward movement caused increased pain. He denied any swelling of the knees and stated that he had no flare-ups that he considered incapacitating. He stated that his left knee condition did not interfere with his employment or daily activities but the pain becoming more aggravating. He reported that he drove a city waste management truck and that he did not miss work because of his ankle or knees. On examination, it was noted that the Veteran ambulated with a very awkward unsteady gait. He used a cane and had a left ankle brace on. He had increased difficulty rising on his toes and his heels and shifted his weight to the right while doing so, minimizing the pressure on that left lower leg. The Veteran had significant muscle wasting of that left lower leg consistent with the decreased use of weight bearing of the leg. He also had decreased strength of the left lower leg. Grade 4/5 on the left and 5/5 on the right. He had no constitutional symptoms or active infections of the left lower leg bone. There was no swelling of the left lower leg. He had a moderate amount of tenderness over the left knee with manipulation. He was able to extend the left knee fully with minimal limitation due to pain. He flexed the left knee to 120 degrees with moderate limitation due to pain. He had increased weakness in that left knee with repetitive range of motion. He had no increased pain and no additional loss in degrees of range of motion as a result of repetition. No left knee instability was appreciated. X rays of the left knee revealed changes consistent with arthritis manifested by joint space narrowing. On further examination, the Veteran demonstrated extreme guarding of the left ankle. He had a moderate amount of tenderness with manipulation of the left ankle. Dorsiflexion of the left ankle was from 0 degrees to 10 degrees with moderate limitation due to pain. Plantar flexion of the left ankle was from 0 degrees to 30 degrees with moderate limitation due to pain. The Veteran was unable to invert or evert that left ankle at all or make any mediolateral movements of the left ankle. There were no varus or valgus angulations of the os calcis. He had increased weakness and guarding with repetitive range of motion of the left ankle but no additional limitation of motion. An X-ray of the left ankle was normal. From July 2007 through June 2008, during treatment at the St. Francis Orthopaedic Institute, the Veteran had no difficulty with his left ankle. X-rays showed no significant abnormality of the left ankle. The neurologic status of the lower extremities was normal. Muscle testing revealed all muscle groups to be functioning and intact. The Veteran had a full range of non-painless motion in the knee and ankle. In August 2007, the Veteran demonstrated muscle weakness in the left quadriceps associated with a low back disability. In October 2007, there was no laxity or subluxation of any joints, and no masses, effusions, misalignment, crepitus, or tenderness in any major joints. There was hypoesthesia in left medial ankle distribution. The reflexes were normal at the knee and ankle, bilaterally, and Babinski's test was negative. The Veteran's coordination was normal, and his muscle strength was full at 5/5 in all major muscle groups. His gait was antalgic. During a January 2008 VA examination, the Veteran reported increasing left knee pain, swelling, popping, and locking. It was noted that he was being treated by a private physician and used Aleve for left knee pain. The Veteran stated he had flare ups twice a day lasting a few minutes. They reportedly produced a shocking sensation but were the result of no particular cause. The Veteran stated that he experienced minimal physical impairment but could not run or drive a truck because of the knee pain while using the clutch. The Veteran also continued to report left ankle pain. He stated that he had moderate impairment of the left ankle due to numbness in the ankle and left leg with prolonged standing. He walked at a slow pace with a limp and reported that he could not run. It was noted that the Veteran took Aleve for pain. He stated that he had weekly flare-ups which were associated with increased activity and lasted about one or two days. The Veteran complained of weakness as a constitutional symptom of arthritis but no incapacitating episodes. He stated that he was unable to stand for more than 15 to 30 minutes. He was able to walk one to three miles. He reported that he occasionally used a brace, and he walked with an antalgic gait. There was no evidence of abnormal weight bearing. In addition, there was no loss of a bone or part of a bone and no joint ankylosis. X-rays of the left knee and left ankle were normal. The examiner noted that the Veteran experienced no occupational effects from the left knee or left ankle disability, as he was not employed. However, those disabilities affected his daily activities. They prevented his participation in sports and severely impaired his ability to perform chores, go shopping, or exercise. They moderately impaired his ability to travel, bathe, dress, groom himself, or use the toilet. They did not impair his ability to feed himself. In a July 2008 addendum, the VA examiner reported that the Veteran had active left knee flexion against gravity from 0 degrees to 100 degrees with pain beginning at 90 degrees. Active left knee flexion against gravity was accomplished to 0 degrees with pain. Active left ankle plantar flexion against gravity was from 0 degrees to 10 degrees with pain beginning at 10 degrees. Active dorsiflexion against gravity was from 0 degrees to 20 degrees with pain beginning at 20 degrees. There was no additional limitation of motion on repetitive use of either the left knee or ankle. During an October 2008 VA examination, the Veteran reported constant left ankle pain, and some stiffness and swelling. He stated that his left leg and foot went numb and that he had to shake it in order to get feeling in it. He reported that he could not walk at a fast pace and sometimes used a cane. He described sharp left knee pain many times a day which lasted for about 30 seconds. At night he reported that he had to lie on his side, so that his whole left leg did not go to sleep. The Veteran denied any history of swelling of the knee. Aggravating factors were prolonged standing and yard work. He continued to take Aleve for the pain. He also described stiffness if he sat for prolonged periods of time. He reported that he had been driving an 18-wheeler but that he switched to smaller trucks. He noted that during the previous 12 months, he reported that he probably missed about two days of work because of knee and ankle disability. Examination of the left knee found some tenderness medially and some effusion. The patellar compression test produced no pain. The Veteran's range of left knee motion was guarded. He was able to flex the knee to about 120 degrees and to extend it completely to 0 degrees. There was no crepitus and no instability. The Veteran was unable to perform deep knee bends especially on the left knee. The Veteran walked with an antalgic gait favoring his left ankle and left knee. There were several well-healed surgical scars which were very tender with slight keloid formation and slight contracture of the scar of the medial malleolar area. The VA examiner stated that the range of left ankle motion was moderately to severely decreased. Dorsiflexion was accomplished to about 10 degrees and plantar flexion was accomplished to about 15 degrees. Inversion and eversion were also significantly limited. X rays of the left ankle done in December of 2006 and January of 2008 were reviewed and interpreted as above. Following the VA examination, the diagnoses included status post treatment for tuberculosis of the left ankle with incision and drainage of the left ankle swelling several times in 1989 and 1990. Functional loss due to pain and functional impairment of the left ankle was characterized as moderately severe. Also diagnosed was status post treatment for recurrent effusion of left knee in 1979 with minimal arthritic changes. Functional loss due to left knee pain was characterized as moderate. October and November 2008 lay statements from H. T., R. L., and J. R. S. indicate that the Veteran walked with a left-sided limp and that he could not stand for long, because his left leg went numb. It was also noted that the Veteran's ankle and knee made a popping sound when he walked. At times, the left knee reportedly locked and gave way. The laymen noted that sometimes the Veteran missed work due to his medical problems. The laymen are competent to report their observations of the Veteran. Layno v. Brown, 6 Vet. App. 465 (1994). However, there is no evidence to suggest that any of them are competent by training or experience to diagnose any pathology causing the Veteran's difficulties. During an April 2011 VA examination, it was noted that in service, the Veteran sustained a left knee injury while performing field exercises. The joint was aspirated at that time and since then had required medication on occasion. The Veteran stated that he experienced intermittent, throbbing, aching pain in the left knee with flare-ups once a week which lasted up to two hours. Running and prolonged walking increased the pain, and he stated that he was taking Motrin and, occasionally, hydrocodone for pain relief. He was able to walk on a treadmill for approximately 10 minutes. It was noted that since service, he had worked as a truck driver. He reportedly had no problem with activities of daily living and required no assistive aids for ambulation. It was also noted that he had not had any incapacitating episodes during the previous 12 months. With respect to the left ankle, the Veteran sustained a baseball injury in service to the left ankle and was treated with Motrin and a profile. Thereafter, while in service, his joint swelled and he subsequently required incision and drainage and two additional operative procedures. Following a biopsy, a diagnosis was made that the patient had tuberculosis of the left ankle. The Veteran stated that since that time, he had had constant, aching, throbbing pain in the left ankle with weekly flare-ups. Mowing the lawn and walking seemed to increase the pain, and it was noted that he took Motrin and hydrocodone for pain relief. On examination, the Veteran walked in a rhythmic and symmetric fashion. He was able to extend the knee fully to 0 degrees and to flex it to 130 degrees. There appeared to be no increased loss of function with repetitive motion due to pain, fatigue, weakness, lack of endurance, or incoordination. The Veteran demonstrated no medio-lateral or antero-posterior instability. There was mild tenderness medially and to a lesser degree laterally. There was no joint swelling, heat, or redness noted. There was no scarring, crepitus, or patella femoral compression pain elicited. On examination of the left ankle, the Veteran was able to dorsiflex to -15 degrees and plantar flex 50 degrees. Inversion was accomplished to 5 degrees and eversion to 0 degrees. Subtalar motion was absent. There appeared to be no increased loss of function with repetitive motion due to pain, fatigue, weakness, lack of endurance or incoordination. There appeared to be no antero-posterior or medio-lateral instability. There was no joint tenderness, swelling, heat, or redness. The patient had a 6 centimeter well-healed operative scar medially and a 2.5 centimeters operative scar antero-laterally. There was no joint crepitus present. X-rays of the left ankle showed normal joint space with the articular surfaces being even. There appeared to be no evidence of recent or old trauma. X-rays of the left knee revealed a superior patellar spur. There was otherwise normal joint spaces medially and laterally. No soft tissue abnormalities were noted. The examining VA physician opined that the Veteran was experiencing a mild disability from left knee strain and a moderate to moderately severe disability from a left ankle infection, primarily due to loss of motion. During a July 2012 VA examination of the thoracolumbar spine, the Veteran demonstrated active left knee extension and active left ankle plantar flexion and dorsiflexion, each against some resistance (4/5). There was no muscle atrophy. Deep tendon reflexes and sensation were normal. There was radiculopathy from the lumbar spine to the left lower extremity. During a May 2015 hearing before the undersigned Veterans Law Judge, the Veteran testified that the knee was weak and that he experienced sharp pain with left knee motion. He also stated that the knee gave way and that he had to stop driving large trucks, because he was unable to adequately operate the clutch. At a February 2016 VA examination, the diagnosis was arthritis of the left knee with history of injury. The Veteran advised that his left knee locked and that he had sharp pains out of nowhere in the left knee. He further advised that he could not run or climb stairs any more. He stated that he could hardly put pressure on the left side because of the ankle and knee. The Veteran related having left knee arthroscopy in service and that he was diagnosed with degenerative arthritis at the time. He stated that he was not currently getting any treatment for the left knee pain and aching. The Veteran reported that when he walked up stairs, it seemed like his knee was pulling or stretching. He denied having had any steroid injections or hospitalizations for treatment of the left knee. On examination, there was no ankylosis. Left knee extension was to 0 degrees, and left knee flexion was to 120 degrees. The Veteran had crepitus in the knee and pain on weight bearing. Repetitive testing caused no additional functional loss of motion. The Veteran was examined immediately after repetitive use over time. The examiner reported that the Veteran did not have pain, weakness, fatigability, or incoordination which would significantly limit his functional ability with repeated use over a period of time. The examiner stated that the Veteran's left knee pain was responsible for functional loss and decreased motion during flare-ups of 0 degrees to 120 degrees. His muscle strength was full at 5/5 for flexion and extension, and there was no atrophy of any associated muscles. On further examination, there was no history of effusion, recurrent subluxation, lateral instability, or anterior, posterior, or medial instability of the left knee. It was noted that the Veteran did not then have nor had he ever had a meniscus or semilunar cartilage condition. The Veteran reportedly used a brace and cane constantly. It was also noted that the Veteran's service-connected left knee disability impacted his ability to perform any type of occupational task due to associated difficulty with prolonged standing or walking. X-rays of the Veteran's left knee showed spurring of the bilateral tibial spines and left anterior superior patella. There were also tiny marginal osteophytes of the posterior left patella. At a February 2016 VA examination, the diagnosis was tuberculosis of the left ankle with degenerative changes. The Veteran reported that his left ankle ached and swelled after walking a half mile or so. He advised that he had constant left ankle pain. The Veteran also advised that he had had five surgeries on the left ankle, with the last ankle occurring in 1990 in service. The Veteran denied current treatment for the left ankle. He stated that he walked with a cane at all times, and wore a brace. The Veteran denied steroid injections, hospitalizations, or physical therapy. He reported that he had been on INR therapy for tuberculosis in service from 1990-1992. He denied any tuberculosis treatment since that time. He acknowledged taking over-the counter Aleve/Tylenol for pain daily, with minimal relief. On examination, there was no evidence of ankylosis. Dorsiflexion was from 0 to 10 degrees. Plantar flexion was from 0 degrees to 25 degrees. All motion was limited by pain. There was no crepitus or tenderness to palpation. The Veteran was examined immediately after repetitive use over time, but weakness, fatigability or incoordination did not significantly limit his functional ability. The Veteran's left ankle strength was normal at 5/5, with no atrophy, no instability, and no dislocation. He reported the constant use of a brace and cane. The Veteran's left ankle disability impacted the ability to perform any type of occupational task due to difficulty with prolonged standing or walking. X-rays of the left ankle showed dorsal marginal osteophyte formation of the talonavicular joint. The Veteran has surgical scars on the left ankle which separately rated and are not at issue in this case. In February 2016, the Veteran was also examined by the VA to determine the severity of tuberculosis of the left ankle. It was noted that the Veteran did not now have, nor had he ever had, active pulmonary tuberculosis. The Veteran's tuberculosis was found to be skeletal in nature at the left ankle. It was noted to be inactive. Left Ankle Disability The Veteran's tuberculosis of the left ankle is rated on the basis of limitation of left ankle motion. 38 C.F.R. § 4.71a, Diagnostic Code 5001-5271 (2015). A 20 percent rating is warranted for severe limitation of motion and is the highest schedular rating under those Diagnostic Codes. A higher schedular rating could be considered under 38 C.F.R. § 4.71a, Diagnostic Code 5270. However, the Veteran does not have the requisite ankylosis and a higher rating requires ankylosis. Accordingly, the Board finds that a schedular rating in excess of 20 percent is not warranted. The preponderance of the evidence is against the assignment of a higher rating for a left ankle disability, and that 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). Left Knee Disability Traumatic arthritis, confirmed by X-ray findings, is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2015). Degenerative arthritis is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2015). When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Diagnostic Code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2015). For the purpose of rating disability from arthritis, the knee, and ankle are considered major joints. 38 C.F.R. § 4.45 (f) (2015). Ratings for arthritis cannot be combined with ratings based on limitation of motion of the same joint. 38 C.F.R. §§ 4.14, 4.71a, Diagnostic Code 5003 (2015). Limitation of motion of knee is rated using Diagnostic Codes 5260 and 5261. A 10 percent rating is warranted when flexion is limited to 45 degrees or when extension is limited to 10 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees or when extension is limited to 15 degrees. A 30 percent rating is warranted when flexion is limited to 15 degrees or when extension is limited to 20 degrees. 38 C.F.R. §§ 4.71a, Diagnostic Codes 5260, 5261 (2015). Separate ratings can be assigned for limitation of flexion and limitation of extension only where the criteria for a compensable rating are met under both the limitation of flexion and limitation of extension criteria. Also applicable in rating the Veteran's left knee disability is 38 C.F.R. §§ 4.71a, Diagnostic Code 5257, the Diagnostic Code used to rate knee impairment associated with recurrent subluxation or lateral instability. A 10 percent rating is warranted for slight impairment, manifested by recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate impairment, manifested by recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe impairment, manifested by recurrent subluxation or lateral instability. 38 C.F.R. §§ 4.71a, Diagnostic Code 5257 (2015). Separate ratings can be assigned under Diagnostic Code 5257 and for limitation of motion, but only where the criteria are met for compensable ratings under each set of criteria. In determining the adequacy of assigned disability ratings, consideration is given to factors affecting functional loss, to include a lack of normal endurance and functional loss due to pain and pain on use, specifically limitation of motion due to pain on use including that experienced during flare ups. 38 C.F.R. § 4.40 (2015); DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability, and incoordination, as well as the effects of the disability on the veteran's ordinary activity. 38 C.F.R. § 4.10, 4.45 (2015). With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, or the like on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2015). A review of the evidence shows that the Veteran's left knee arthritis is manifested primarily by complaints of pain, tenderness to palpation, crepitus, and limitation of flexion. He walks with an antalgic gait and uses a knee brace and cane. However, he has full extension of the knee to 0 degrees and pain free flexion up to 90 degrees. Moreover, there are no deficits in left knee reflexes or sensation, and the lower extremity strength is, generally, full. The earlier VA examinations, such as those performed in December 2006 and January 2008, show that the Veteran had moderate limitation of left knee function due primarily to pain. While the December 2006 examination showed muscle wasting in the left lower extremity, the evidence showed that he retained active left knee motion against some resistance. He was able to fully extend the knee and to flex the knee to 120 degrees. He did not demonstrate associated symptomatology such as instability or recurrent dislocation or subluxation of the patella. Although the Veteran continues to report chronic left knee pain, which increases with repetitive testing, there is no objective evidence that it is productive of additional limitation of motion, fatigue, incoordination, or lack of endurance. Therefore, the Board finds that pain was contemplated by the 10 percent rating. 38 C.F.R. § 4.59 (2015); Spurgeon v. Brown, 10 Vet. App. 194 (1997) (the rating schedule does not require a separate rating for pain alone). While the report of the most recent VA examination shows that Veteran's left knee disability impacts his ability to perform any type of occupational task due to difficulty with prolonged standing or walking, recent VA treatment records show that three times a week, he walks two to three miles on a treadmill. Moreover, the February 2016 VA examination report shows that the left lower extremity is strong without evidence of muscle atrophy, skin changes, or the like which could be expected with a little used part of the musculoskeletal system. 38 C.F.R. § 4.40 (2015). In addition, there is no objective evidence of ankylosis, fixed deformity, malaligned joints, muscle spasm, heat, abnormal coloration, or swelling to suggest that the Veteran's left knee symptoms meet or more nearly approximate the criteria for the next higher rating. The Board finds that the range of motion findings do not support any separate or higher rating. The evidence does not show that there is instability which could be assigned any separate rating. The evidence does not show ankylosis, semilunar cartilage pathology, impairment of the tibia or fibula, or genu recurvatum that could be assigned any separate or higher rating. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an increased rating for a left knee disability. Therefore, 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). Extraschedular Considerations In arriving at the foregoing decisions, the Board has considered the possibility of referring this case to the Director of the VA Compensation and Pension Service for possible approval of an extraschedular rating for the service-connected left knee arthritis and left ankle tuberculosis. 38 C.F.R. § 3.321 (2015). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but would still be adequate to address the average impairment in earning capacity caused by a particular disability. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321 (2015). There is a three-step inquiry for determining whether a claimant 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. In this regard, the Board must compare the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular rating is adequate and no referral is required. Second, if the schedular rating is found to be inadequate, the Board must determine whether the Veteran'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 claimant's disability picture with such related factors 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, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321 (2015). The Veteran's service-connected left knee arthritis is manifested by manifested primarily by complaints of pain, tenderness to palpation, crepitus, and limitation of flexion. 38 C.F.R. § 4.71a, Diagnostic Code 5003-5260 (2015). The Veteran's left ankle disability is manifested primarily by marked limitation of left ankle motion. 38 C.F.R. § 4.71a, Diagnostic Code 5001-5271 (2015). For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by decreased or abnormal excursion, speed, coordination, or endurance. 38 C.F.R. § 4.40 (2015); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as excess fatigability and pain on movement. 38 C.F.R. §§ 4.45, 4.59 (2015); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Because the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability pictures. In short, there is nothing exceptional or unusual about the Veteran's arthritis of the left knee or the tuberculosis of the left ankle, either separately or in combination, because the rating criteria reasonably describe his disability level and symptomatology. Therefore, he does not meet the criteria for referral to the Director of the VA Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321 (2015). ORDER Entitlement to a rating in excess of 20 percent for a left ankle disability is denied. Entitlement to a rating in excess of 10 percent for a left knee disability is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs