Citation Nr: 0810258 Decision Date: 03/28/08 Archive Date: 04/09/08 DOCKET NO. 03-29 689 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for onychomycosis of the bilateral feet. 2. Entitlement to service connection for bilateral calluses of the 5th toes. 3. Entitlement to service connection for puntate keratosis of the bilateral hands. 4. Entitlement to an initial compensable rating for service- connected tension headaches. 5. Entitlement to an increased initial rating for service- connected degenerative changes of the right ankle, currently evaluated as 20 percent disabling and evaluated as 10 percent disabling prior to May 1, 2007. 6. Entitlement to an increased initial rating for service- connected left knee degenerative joint disease (DJD) with meniscal tear, currently evaluated as 20 percent disabling and evaluated as noncompensable prior to May 1, 2007. 7. Entitlement to an increased initial rating for service- connected right knee patellofemoral syndrome, currently rated as 10 percent disabling and rated as noncompensable prior to May 1, 2007. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Vella Camilleri, Associate Counsel INTRODUCTION The veteran served on active duty from November 1984 to June 2001. He also had a prior unverified period of active service. See DD 214. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which denied service connection for onychomycosis of the toenails of both feet, calluses of the 5th toes, and punctate keratosis of the bilateral hands. Service connection was granted for degenerative changes of the right ankle, tension headaches, and patellofemoral chondromalacia of the bilateral knees; a 10 percent evaluation was assigned for the right ankle and noncompensable evaluations were assigned for the bilateral knee disabilities and headaches, effective July 1, 2001. In a July 2007 rating decision, the RO in Montgomery, Alabama, which currently has jurisdiction of the appeal, granted increased ratings for service-connected left knee DJD with meniscal tear, right knee patellofemoral syndrome, and degenerative changes of the right ankle. A 10 percent rating was assigned for the right knee disability and 20 percent ratings were assigned for the left knee and right ankle disabilities, effective May 1, 2007. Despite the increased ratings granted by the RO, and for the reasons to be discussed more fully below, the veteran's appeal concerning these disabilities remains before the Board. Cf. AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement (NOD) as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). FINDINGS OF FACT 1. The evidence of record does not show that the veteran's onychomycosis of the bilateral feet is etiologically related to active service. 2. The evidence of record does not show that the veteran's bilateral calluses of the 5th toes are etiologically related to active service. 3. The evidence of record does not show that the veteran's puntate keratosis of the bilateral hands is etiologically related to active service. 4. The veteran's tension headaches are not manifested by characteristic prostrating attacks averaging one in two months over the last several months. 5. Prior to May 1, 2007, the veteran's right ankle exhibited marked limitation of motion; there is no evidence showing ankylosis of the veteran's right ankle. 6. A November 2002 magnetic resonance imaging (MRI) of the veteran's left knee revealed a small radial tear in the discoid lateral meniscus. 7. The veteran's left knee is not manifested by ankylosis, severe recurrent subluxation or lateral instability, flexion limited to 15 degrees, or extension limited to 20 degrees or more. 8. Prior to May 1, 2007, the veteran's right knee did not exhibit recurrent subluxation or lateral instability, flexion limited to 45 degrees or less, or extension limited to 10 degrees or more. 9. As of May 1, 2007, there is no evidence showing right knee ankylosis, moderate or severe recurrent subluxation or lateral instability, flexion limited to 30 degrees or less, or extension limited to 15 degrees or more. CONCLUSIONS OF LAW 1. The criteria for service connection for onychomycosis of the bilateral feet have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). 2. The criteria for service connection for bilateral calluses of the 5th toes have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). 3. The criteria for service connection for puntate keratosis of the bilateral hands have not been met. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). 4. The criteria for an initial compensable rating for service-connected tension headaches have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2007). 5. The criteria for an initial evaluation of 20 percent, and no higher, for service-connected degenerative changes of the right ankle have been met prior to May 1, 2007. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5271 (2007). 6. The criteria for an initial evaluation greater than 20 percent for service-connected degenerative changes of the right ankle have not been met as of May 1, 2007. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5271 (2007). 7. The criteria for an initial evaluation of 20 percent, and no higher, for service-connected left knee DJD with meniscal tear have been met prior to May 1, 2007. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5258, 5260 (2007). 8. The criteria for an initial rating greater than 20 percent for service-connected left knee DJD with meniscal tear have not been met as of May 1, 2007. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5258, 5260 (2007). 9. The criteria for an initial compensable evaluation for service-connected right knee patellofemoral syndrome have not been met prior to May 1, 2007. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260 (2007). 10. The criteria for an initial rating greater than 10 percent for service-connected right knee patellofemoral syndrome have not been met as of May 1, 2007. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service connection claims To establish service connection for a claimed disability, the evidence must demonstrate that a disease or injury resulting in current disability was incurred during active service or, if pre-existing, was aggravated therein. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2007). Service connection may also be granted for any injury or disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2007). The veteran contends that he has onychomycosis of the bilateral feet, bilateral calluses of the 5th toes, and puntate keratosis of the bilateral hands as a result of active service. See July 2003 NOD. He asserts that these conditions were not present upon his entrance into service so that it only stands to reason that they originated from various training events, to include field exercises, forced marches, and physical fitness. The veteran indicates that there are no records related to treatment for these conditions in his medical record because these conditions were treated by over-the-counter products. See September 2003 VA Form 9. The veteran's service medical records reveal that he was treated for lacerations to the third and fourth digits of his left hand in December 1981. See medical record. There is no reference to complaint of, or treatment for, problems with the skin of his hands, and each time the veteran reported skin diseases on examination, he was noted to have tinea versicolor. See November 2000 report of medical history; August 1984 report of medical history; see also June 1980 report of medical examination and December 1983 health record. Nor is there any reference to complaint of, or treatment for, onychomycosis of the bilateral feet or bilateral calluses of the 5th toes, though bilateral chronic plantar scaling was noted on one occasion in August 1994 and the veteran reported foot trouble in November 2000 (ultimately noted to be bilateral ankle pain). See August 1994 report of medical examination; November 2000 report of medical history. During an undated separation examination, there is no reference to problems involving the veteran's hands, feet or skin, though his tattoos were reported. See report of medical examination. The veteran underwent a VA compensation and pension (C&P) general medical examination in March 2002, at which time the VA examiner noted that there were no outpatient records for review. The veteran did not report any problems with onychomycosis of the bilateral feet, bilateral calluses of the 5th toes, or puntate keratosis of the bilateral hands, though he did report problems with tinea versicolor. In pertinent part, physical examination revealed scattered hyperpigmented plaques of the skin, callous formation of the metatarsal heads of the fifth toe of the bilateral feet, thickened, dry skin of the bilateral heels, discolored and dystrophic nails of the bilateral feet, one through five, and increased moisture and maceration of the web space between the fourth and fifth toes of the bilateral feet. The veteran was diagnosed with tinea versicolor, bilateral tinea pedis and bilateral onychomycosis (both presently untreated) and punctate keratosis of the bilateral hands. No opinion on etiology was provided. Post-service medical evidence does not indicate the veteran has received treatment for onychomycosis, bilateral calluses of the 5th toes, or punctate keratosis of the bilateral hands. See VA treatment records. At this juncture, the Board notes that onychomycosis is defined as tinea unguium, which in turn is defined as tinea involving the nails in which the invasion is restricted to white patches or pits on the nail surface or the lateral or distal edges of the nails are first involved, followed by establishment of the infection beneath the nail plate. Tinea versicolor is defined as a common, chronic, non-inflammatory and usually symptom-less disorder, characterized only by occurrence of multiple macular patches, of all sizes and shapes, varying from whitish in pigmented skin to fawn- colored or brown in pale skin. See Dorland's Illustrated Medical Dictionary 1178, 1714 (28th ed. 1994). The Board notes that service connection for tinea versicolor was denied by the RO in the September 2002 rating decision, but the veteran did not initiate an appeal of this denial. See July 2003 NOD. The evidence of record does not support the veteran's claims for service connection. As an initial matter, the Board does not find the veteran's statement regarding the presence of onychomycosis, calluses, and keratosis during service to be credible. He has not described suffering from any specific symptoms during service. Rather, he stated only that he did not seek treatment for these conditions during service because he was treating these conditions with over-the- counter medication. The service medical records reveal, however, that he sought treatment for a myriad of other problems during service, to include treatment for tinea versicolor. Given the fact that the veteran sought treatment for other skin ailments, it strains credibility that he would not have sought treatment for or mentioned onychomycosis, calluses, and keratosis. Of note, on separation examination in November 2000, clinical evaluation of the skin, feet, and upper extremities was normal. The veteran gave a history of skin diseases, but this was described as tinea versicolor. Moreover, barring the issue of service connection for versicolor, the veteran's claim for service connection did not include any reference to problems with his skin or toenails, and there is no reference to problems with his feet or hands. See September 2001 VA Form 21-526. Rather, the veteran was found to have onychomycosis, calluses and keratosis at the time of the March 2002 VA examination and the RO adjudicated claims for these conditions. As the veteran was not noted to have any problems involving his hands, feet or skin at the time of his discharge from service, and in light of the fact that the veteran did not assert a claim for any of these conditions when he filed for service connection, the Board finds that the veteran's report that these conditions were present in service to be incredible. In addition to the lack of credible in-service evidence that the veteran was treated for onychomycosis, calluses and/or keratosis, there is no competent medical evidence of record to establish that any of these conditions, first noted in March 2002, are etiologically related to service. Nor has the veteran described suffering from any continuity of symptoms since service. In the absence of such evidence, service connection is not warranted and the claims must be denied. See 38 C.F.R. § 3.303 (2007). II. Increased rating claims Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2007). Separate rating codes identify various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. See generally 38 C.F.R. §§ 4.1, 4.2 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2007). Where the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). In this case, staged ratings have been assigned for service-connected degenerative changes of the right ankle, left knee DJD with meniscal tear, and right knee patellofemoral syndrome, as will be discussed below. When evaluating disabilities of the musculoskeletal system, an evaluation of the extent of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2007); DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). In other words, when rated for limitation of motion, a higher rating may be assigned if there is additional limitation of motion from pain or limited motion on repeated use of the joint. A finding of functional loss due to pain must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." 38 C.F.R. § 4.40 (2007). Service connection for tension headaches was granted by analogy pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100. Service connection for right and left knee patellofemoral chondromalacia was also granted by analogy pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5260. Noncompensable evaluations were assigned for each of these disabilities effective July 1, 2001. See September 2002 rating decision. Evaluation of a service-connected disability in accordance with schedular criteria that closely pertain to an analogous disease in terms of functions affected, anatomical localization, and symptomatology, is permitted. 38 C.F.R. § 4.20 (2007). The September 2002 rating decision also granted service connection for degenerative changes of the right ankle, and a 10 percent evaluation was assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5010, effective July 1, 2001. As noted above, the RO subsequently granted increased rating for the veteran's bilateral knee and right ankle disabilities. A 20 percent evaluation was assigned for degenerative changes of the right ankle pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5271. The veteran's left knee disability was recharacterized as DJD with meniscal tear and a 20 percent evaluation was assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5258. The right knee disability was recharacterized as patellofemoral syndrome and a 10 percent evaluation was assigned by analogy under 38 C.F.R. § 4.71a, Diagnostic Code 5257. The effective date assigned for each was May 1, 2007. See July 2007 rating decision. The Board notes that in granting the increased ratings for the veteran's right ankle and left knee, the RO found that the veteran's appeal had been satisfied. The rationale employed by the RO was that it had assigned the maximum rating possible under diagnostic codes 5010 and 5271 (right ankle) and 5003 and 5258 (left knee). The Board must determine, however, whether the veteran is entitled to an increased rating for the time period prior to May 1, 2007, and must also consider the other diagnostic criteria related to the ankle and knee to determine whether an increased rating is warranted as of May 1, 2007. In light of the foregoing, the Board will determine whether the veteran is entitled to ratings in excess of those initially assigned between July 1, 2001 and April 30, 2007, and increased ratings in excess of those currently assigned as of May 1, 2007. During the March 2002 VA C&P general medical examination, the veteran reported that he was not seen for headaches during service but would have them at various intervals during that time and that he would take Motrin or Aleve to relieve the symptoms. He indicated that he believed his headaches were related to the sunlight; with exposure to bright light, a headache would often develop in the forehead area lasting a minimum of 15 minutes, with relief with rest and medication. The veteran indicated that he was having more frequent headaches due to the increased stress of his job. He reported that the last headache occurred two weeks prior, lasted about 15 minutes, and resolved after lying down. The veteran reported light sensitivity but denied nausea, vomiting and noise sensitivity. The veteran also reported doing a lot of running in the military with constant motion, which would often result in popping of the knees with slight, usually dull, pain. He denied any swelling, giving way, or a locking sensation. The veteran denied using a cane or crutch but reported buying a brace. The veteran also reported a loss of mobility of his right ankle as a result of running. He noted swelling in the right ankle but was unsure if he had a fracture, though he stated it was determined that he possibly had a healed fracture and it was arthritis of the ankle. The veteran pointed to the anterior malleolus area and indicated tenderness there at intervals and swelling with prolonged standing. Physical examination revealed negative straight leg raises, full extension of the bilateral knees, flexion to 120 degrees, bilaterally, and audible crepitance with range of motion of the knees. Neurological examination revealed that the veteran was ambulatory with a slight limp performing heel raises. The veteran indicated slight discomfort in the right ankle but was able to do toe raises and tandem walking. Strength testing was 5/5 for the lower extremities. X-rays showed no interval change or evidence of degenerative change, bone destruction, narrowing of the joint space, or joint effusion in the bilateral knees and no evidence of degenerative change, bone destruction, narrowing of the joint space, or soft tissue abnormality in the right ankle. The veteran was diagnosed with tension headache, patellar femoral syndrome of the bilateral knees, and multiple right ankle sprains. The examiner noted that the veteran's headaches persist at intervals and that he takes over-the-counter medication with minimal relief reported, that the veteran's knee conditions are unresolved with crepitance with range of motion, and that the veteran reported intermittent pain of the ankle area at intervals with intermittent edema. The veteran also underwent a VA C&P joints examination in March 2002 specific to his knees and ankle. The veteran denied injections or surgical interventions on the bilateral knees. He reported that the pain in the right knee was greater than in the left, mainly with running, on long walks, or going up and down stairs. The veteran indicated that the pain is mainly anterior in nature, especially in the morning and with occasional cracking, popping and swelling, but no giving way. The veteran reported that his left knee pain was more posterior in nature. He also indicated that his ankle hurt and was swollen about 95 percent of the time. The veteran reported multiple twisting injuries to both ankles and no specific trauma. He also reported some dull pain in the medial and posterior aspects of his foot. Physical examination revealed palpable pop and grind on the anterior aspect of the veteran's right knee, which recreated his discomfort. The veteran had no medial or lateral joint line and no significant swelling. His anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and radial collateral ligament (RCL) were all intact and McMurray's sign was negative. The right knee had full range of motion from zero to 145 degrees; left knee range of motion was also zero to 145 degrees with mild pop and crepitance but no swelling on mediocollateral or lateral collateral. Left knee ACL and PCL were intact and McMurray's sign was negative. The examiner noted moderate effusion of the right ankle. The examiner further noted mainly anterior pain with palpation, which is where most of the swelling was, though global in nature. Range of motion was limited with dorsiflexion of five degrees, plantar flexion of 35 degrees, inversion of 10 to 15 degrees and eversion of five to 10 degrees. Pain was maximum on dorsiflexion, there was a negative drawer sign, and the veteran was distally intact neurovascularly. X-rays of the bilateral knees showed no specific abnormalities or degenerative arthritis. His right ankle had some anterior osteophytic changes present but no significant degenerative changes in regards to loss of ankle joint height space. The veteran was diagnosed with right moderate patellofemoral chondromalacia, left mild anterior knee pain consistent with patelloformal chondromalacia, and right ankle pain with loss of range of motion with x-ray changes of anterior osteophytes of the distal tibial region. The examiner further indicated that the veteran was left with moderate swelling of his right ankle. VA treatment records reveal that the veteran was seen for the first time in October 2001 with complaint of off and on knee and ankle pain. Extremity examination showed mild bilateral crepitus of the knees and slight swelling of the right ankle. Range of motion appeared normal, there was no edema or cyanosis, and peripheral pulsations were good. The examining physician prescribed ibuprophen for the veteran's knees and scheduled him for x-rays; he indicated that the veteran would continue taking Advil and ibuprophen for his right ankle pain. In March 2003, the veteran was seen for a routine follow-up appointment. He reported continuing pain and swelling in his right ankle and left knee pain, both gradually getting worse. The veteran indicated that he continued to take over-the-counter medication for pain control and seemed satisfied with it (Advil and Aleve). Physical examination revealed no swelling in the left knee but some tenderness on the lateral aspect. Range of motion seemed normal. The right ankle had moderate swelling. The veteran was assessed with arthritis but advised to continue exercises, especially low impact type such as riding a stationary bike or swimming. See group practice notes. In May 2003, the veteran reported right ankle pain, treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and injection. He indicated that the injections lasted two to three weeks, that the NSAIDs only occasionally helped, and that the pain was worse with increased standing or motion. Physical examination revealed mild swelling over the medial aspect of the right ankle over the tibiotalar joint, tenderness with extreme dorsiflexion, anteriorly, and pain to palpation about the anterior ankle joint (negative pain with subtalar motion). The veteran was neurovascularly intact distally. X-ray examination revealed mild tibiotalar arthritis with anterior spurring. The veteran was set up for a right ankle arthroscopy, which was subsequently cancelled. See May 2003 and June 2003 orthopedic surgery notes. The Board notes that there are no VA records related to treatment for headaches. The veteran underwent another VA C&P joints examination in May 2007. He reported an increasing sharp pain in his right ankle with swelling and over the last couple of years. The veteran indicated that his current treatment included medication (NSAIDs) and bracing. More specifically, the veteran reported taking Aleve with partial relief and indicated that the brace helps with instability but not pain or swelling. The veteran also reported a stabbing pain in the left knee and more stiffness bilaterally over the last few years. As with his ankle, the veteran reported current treatment in the form of medication (NSAIDs) and a brace. He indicated taking Aleve with partial results and occasionally wearing a brace on the left knee with limited results. The veteran denied hospitalization or surgery, trauma to the joints, neoplasm, and the need of assistive aids for walking. He reported functional limitations on standing because he is unable to stand for more than a few minutes, and functional limitations on walking because he is only able to walk one quarter of a mile. The veteran also reported that his left knee and right ankle will give way and are unstable and also indicated that he has pain, stiffness and weakness in his knees and right ankle. He denied episodes of dislocation, subluxation and locking, but reported repeated effusion, swelling and tenderness of his ankle and knees. The veteran indicated that the condition did not affect motion but that he had severe, weekly flare-ups of joint disease, which cause 75 percent further impairment in function, last less than one hour, and occur a couple of times per week. The veteran's gait was described as antalgic but there was no evidence of abnormal weight bearing. Range of motion testing revealed active and passive range of motion of the right knee from zero to 105 degrees with pain beginning at 105 degrees; active and passive range of motion of the left knee from zero to 110 degrees with pain beginning at 110 degrees; active and passive dorsiflexion of the right ankle from zero to five degrees with pain beginning at five degrees; and passive and active plantar flexion of the right ankle from zero to 30 degrees with pain beginning at 30 degrees. There was no loss of a bone or part of a bone or joint ankylosis. The examiner noted crepitus and painful movement of the bilateral knees but no mass behind the knee, clicks or snaps, grinding, instability, patellar or meniscus abnormality, other tendon or bursa, or other knee abnormality. The examiner also noted edema and painful movement of the right ankle but no instability, tendon abnormality or angulation. The examiner reported that a November 2002 MRI of the veteran's left knee contained an impression of discoid lateral meniscus with small radial tear; fluid seen under the iliotibial tendon (may be seen in the setting of iliotibial band syndrome, but is nonspecific); small Baker's cyst; and small tibial enchondroma. A November 2002 MRI of the right ankle contained an impression of pseudoarticulation within the posterolateral aspect of the talus extending into the posterior facet of the subtalar joint, compatible with an accessory ossicle or old fracture; and marked associated degenerative changes, which abut both the pseudoarticulation and the posterior facet. X-rays taken in May 2007 showed irregular sclerosis in the talar neck of the right ankle, suggestive of prior trauma, and linear sclerosis in the talar dome, may represent mild osteonecrosis. The joint spaces were well-preserved and the impression made was evidence of remote trauma to the right ankle. X-rays of the bilateral knees showed normal joint spaces, no osteophytes, and no joint effusion. The impression was no significant abnormality. The veteran was diagnosed with right ankle DJD and the examiner noted significant effects on occupational activities in that the veteran has decreased mobility and problems with lifting and carrying, and severe effects on exercise and sports. The left knee diagnosis was meniscal tear and DJD with significant effects on occupation due to decreased mobility, problems with lifting and carrying, and pain, and severe effect on exercise and sports. The veteran was also diagnosed with right knee patellofemoral syndrome, which also had significant effects on the veteran's occupation due to decreased mobility and problems with lifting and carrying. There was only moderate effect on exercise and sports. The veteran underwent a miscellaneous neurological disorders examination in May 2007. He reported intermittent, sharp headaches that can be frontal or occipital, photosensitivity, and occasional nausea, but denied vomiting, syncope or seizures. The veteran indicated no current treatment for this condition and denied a history of hospitalization, surgery or trauma to the central nervous system (CNS). The veteran indicated that during the past 12 months, he had headaches two to three times per month, but denied being treated with continuous medication. He reported that less than half of the attacks are prostrating and indicated that the usual duration of a headache is hours. Motor examination revealed normal strength, muscle tone and muscle bulk. Sensory examination revealed normal light touch, pin prick and position sense. Mental status, fundoscopic and cerebellar examination were normal, all cranial nerves were intact, reflexes were normal, there was no evidence of chorea, and no carotid bruits. The veteran was diagnosed with tension headaches and the examiner indicated they have significant effect on the veteran's usually occupation due to pain, but no effects on usual daily activities. A. Tension headaches As noted above, the veteran's tension headaches are rated by analogy under 38 C.F.R. § 4.124a, Diagnostic Code 8100, which provides the rating criteria for migraines. Pursuant to these diagnostic criteria, migraines with characteristic prostrating attacks averaging one episode in 2 months over the last several months warrant the assignment of a 10 percent evaluation. A 30 percent evaluation is warranted for migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months. The maximum schedular rating of 50 percent is warranted for migraines with very frequent and completely prostrating and prolonged attacks which produce severe economic inadaptability. The evidence of record does not support the assignment of a compensable rating for the veteran's service-connected tension headaches. During the March 2002 VA C&P general medical examination, the veteran's headaches were only noted to persist at intervals, and there was no indication that they resulted in prostrating attacks. The Board acknowledges that during the May 2007 VA examination, the veteran reported headaches two to three times per month, of which less than half were found to be prostrating. The Board acknowledges that the veteran indicated this condition caused significant effects on his usual occupation due to pain and that some of his headaches are prostrating. However, this is not supported by the evidence of record. Specifically, the veteran denied receiving any current treatment for the condition, which is reflected in the absence of medical documentation that he sought treatment, and also denied being treated with continuous medication. In addition, he denied that his headaches have any effect on his usual daily activities. The veteran's description of his headaches as prostrating is not credible. In light of the foregoing, the symptoms associated with the veteran's service-connected tension headaches do not more nearly approximate the criteria for a 10 percent evaluation. Consequently, the claim for increased rating is denied. B. Right ankle As noted above, the veteran's right ankle was initially rated solely under 38 C.F.R. § 4.71a, Diagnostic Code 5010 but is now rated in conjunction with 38 C.F.R. § 4.71a, Diagnostic Code 5271. Diagnostic Code 5010 provides that arthritis due to trauma is to be rated as degenerative arthritis. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010 (2007). The rating criteria provided for limitation of motion of the ankle is found at 38 C.F.R. § 4.71a, Diagnostic Code 5271, which provides a 10 percent evaluation for moderate limitation of motion of the ankle and a 20 percent evaluation for marked limitation of motion of the ankle. Normal range of motion for the ankle is 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. 38 C.F.R. § 4.71a, Plate II (2007). The Board finds that the veteran met the criteria for a 20 percent evaluation for his right ankle prior to May 1, 2007. His right ankle was slightly swollen when he was first treated by VA in October 2001 and again in March 2003, and though range of motion appeared normal during both visits, no measurements were provided. The veteran's ankle was again noted to be swollen in May 2003 and was also found to have tenderness with extreme dorsiflexion, anteriorly. Pain to palpation about the anterior ankle joint was also noted. In addition to these findings, the veteran was only able to reach five degrees of dorsiflexion during the March 2002 VA C&P joints examination. As normal dorsiflexion is to 20 degrees, the limitation of motion exhibited by the veteran constitutes marked limitation of motion. He also exhibited a 10 degree limitation of plantar flexion. For these reasons, the Board finds that the symptoms associated with the veteran's right ankle for the time period prior to May 1, 2007 more nearly approximate the criteria for a 20 percent evaluation. See 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5271 (2007). The evidence of record does not, however, support the assignment of a rating in excess of 20 percent either prior to, or as of, May 1, 2007. The 20 percent evaluation is the maximum rating provided under Diagnostic Code 5271. As such, an increased rating under these diagnostic criteria is impossible. The Board has considered the other rating criteria pertinent to the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5270, which provides the rating criteria for ankylosis of the ankle and is the only diagnostic code that provides ratings in excess of 20 percent, is not applicable to the instant case as there is no evidence showing that the veteran's ankle has ankylosis. See VA treatment records; VA x-ray reports; March 2002 and May 2007 VA C&P examination reports; November 2002 MRI. Consideration has also been given to whether an increased rating is warranted on the basis of functional impairment and pain. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2007); DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). The Board acknowledges the veteran's complaint of right ankle tenderness, swelling, stiffness, aching, numbness and pain. See March 2002 and May 2007 VA C&P examination reports. The Board also acknowledges that the veteran exhibited maximum pain on dorsiflexion during the March 2002 and May 2007 VA C&P joints examination. In this case, however, the assignment of a 20 percent rating contemplates the functional loss exhibited in his right ankle. As such, a rating in excess of 20 percent is not warranted under 38 C.F.R. §§ 4.40 and 4.45 pursuant to the guidelines set forth in DeLuca. Additionally, as mentioned, the veteran is currently at the maximum evaluation under Diagnostic Code 5271 and, even with painful motion and functional impairment, a higher evaluation is not available. See Johnston v. Brown, 10 Vet. App. 80 (1997). C. Bilateral knees The veteran's bilateral knee disabilities were initially rated analogously to 38 C.F.R. § 4.71a, Diagnostic Code 5260, which provides the rating criteria for limitation of flexion of the leg. Flexion of either leg limited to 60 degrees is noncompensable, flexion limited to 45 degrees merits a 10 percent rating, limitation of flexion to 30 degrees warrants a 20 percent evaluation, and a 30 percent evaluation requires that flexion be limited to 15 degrees. The veteran's left knee is now rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5258. His right knee is now rated by analogy under 38 C.F.R. § 4.71, Diagnostic Code 5257. Diagnostic Code 5003 has been discussed in the section above. Diagnostic Code 5258 provides the rating criteria for dislocated semilunar cartilage with frequent episodes of "locking," pain and effusion into the joint, and only provides a 20 percent evaluation. Semilunar cartilage is defined externally as the meniscus lateralis articulationis genus (lateral meniscus) and internally as the meniscus medialis articulationis genus (medial meniscus). See Dorland's Illustrated Medical Dictionary 273 (28th ed. 1994). Diagnostic Code 5257 provides the rating criteria for other impairments of the knee, with 10, 20 and 30 percent evaluations assigned for slight, moderate and severe recurrent subluxation or lateral instability, respectively. The other diagnostic criteria pertinent to the knee are found at 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5261, 5262 and 5263. Several of the diagnostic codes, however, are simply not applicable to the veteran's service-connected knee disabilities as it is neither contended nor shown that his disabilities involve ankylosis of the knees (Diagnostic Code 5256); any impairment of the tibia and fibula (Diagnostic Code 5262); or genu recurvatum (Diagnostic Code 5263). See VA treatment records; VA C&P examination reports. Diagnostic Code 5261 provides ratings of 0 percent for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for extension limited to 15 degrees, 30 percent for extension limited to 20 degrees, 40 percent for extension limited to 30 degrees, and 50 percent for extension limited to 45 degrees. i. Right knee The evidence of record does not support the assignment of a compensable rating for the veteran's service-connected right knee disability prior to May 1, 2007 under Diagnostic Code 5260. First, there was no evidence of degenerative change, bone erosion, narrowing of the joint space, or joint effusion on x-rays taken in October 2001 and March 2002. See VA records. Secondly, the veteran did not exhibit the requisite limitation of flexion during the March 2002 VA C&P examinations so as to meet the criteria for a compensable rating. See general medical examination report (flexion to 120 degrees); joints examination report (flexion to 145 degrees). Nor does the evidence support the assignment of a compensable rating for the right knee disability prior to May 1, 2007 under the other available diagnostic criteria. The veteran consistently denied any giving way and there was no evidence of subluxation, a dislocated or removed right semilunar cartilage, or limitation of extension so as to merit the assignment of a higher and/or separate compensable rating under Diagnostic Codes 5257, 5258, 5259 or 5261. See VA treatment records; VA x-ray reports; VA C&P examination reports (denied giving way and locking; full extension). As such, an increased rating is not warranted for the veteran's right knee disability between July 1, 2001 and April 30, 2007. The evidence of record also does not support the assignment of a rating in excess of 10 percent as of May 1, 2007. As noted above, the RO applied Diagnostic Code 5257 rather than Diagnostic Code 5260 in granting the 10 percent evaluation. See July 2007 rating decision. Also noted above, ratings in excess of 10 percent under this diagnostic code require moderate (20 percent) or severe (30 percent) recurrent subluxation or lateral instability. During the May 2007 VA examination, the veteran did not report any right knee giving way, instability, or episodes of dislocation, subluxation or locking, but indicated that he had pain, stiffness, weakness, effusion and inflammation. In the absence of evidence of moderate recurrent subluxation or lateral instability, a rating in excess of 10 percent is not warranted under Diagnostic Code 5257 as of May 1, 2007. Nor is an increased and/or separate rating warranted under the other applicable diagnostic codes as there is no evidence of dislocated right knee semilunar cartilage (Diagnostic Code 5258) and the veteran has not exhibited the requisite limitation of flexion or extension under Diagnostic Codes 5260 and 5261. See May 2007 VA C&P examination report (right knee active and passive range of motion from 0 to 105 degrees). Consideration has also been given to whether an increased rating is warranted on the basis of functional impairment and pain. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2007); DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). The Board acknowledges the veteran's complaint of right knee cracking, popping and occasional swelling during the March 2002 VA C&P joints examination. The Board also acknowledges his complaint of right knee pain, stiffness, weakness, effusion and inflammation, and his report of an additional 75 percent further impairment in function during flare ups, during the May 2007 VA C&P joints examination. In this case, however, even with consideration of the guidelines set forth in DeLuca, the veteran's right knee disability does not warrant an increased evaluation either prior to, or as of, May 1, 2007 because his right knee range of motion was only slightly limited and there was no additional limitation of motion exhibited on repetitive use. In addition, though the veteran's right knee caused decreased mobility and problems with lifting and carrying, there was only moderate effect on some daily activities. In light of the foregoing, the Board finds that the ratings assigned during the periods in question contemplate the noted functional loss. ii. Left knee The Board finds that the evidence of record supports the assignment of a 20 percent rating for the veteran's service- connected left knee disability prior to May 1, 2007. The November 2002 MRI report discussed above revealed, in pertinent part, a small radial tear in the discoid lateral meniscus. This finding merits the assignment of a 20 percent rating under Diagnostic Code 5258. A rating in excess of 20 percent is not warranted prior to May 1, 2007 pursuant to the remaining applicable criteria as there is no evidence of severe recurrent subluxation or lateral instability (Diagnostic Code 5257), flexion limited to 15 degrees (Diagnostic Code 5260), or extension limited to 20 degrees or more (Diagnostic Code 5261). See VA treatment records; March 2002 VA C&P examination reports (range of motion from 0 to 120 and 0 to 145 degrees). Nor does the evidence of record support the assignment of a rating in excess of 20 percent for the veteran's left knee disability as of May 1, 2007. Though the veteran reported left knee giving way, instability, pain, stiffness, weakness and inflammation, he denied episodes of dislocation, subluxation, or locking and he still does not demonstrate the requisite limitation of motion in this knee. See May 2007 VA C&P examination report (active and passive range of motion from 0 to 110 degrees). Consideration has also been given to whether an increased rating is warranted on the basis of functional impairment and pain. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2007); DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). The Board acknowledges the veteran's report of a 75 percent impairment of function during a left knee flare up. See May 2007 VA C&P examination report. The veteran did not exhibit additional limitation of motion on repetitive use of his left knee, however, and the Board finds that the assignment of a 20 percent rating contemplates the functional loss exhibited in his left knee. As such, a rating in excess of 20 percent is not warranted under 38 C.F.R. §§ 4.40 and 4.45 pursuant to the guidelines set forth in DeLuca. III. Duties to notify and assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2007); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Proper notice must also ask the claimant to provide any evidence in his or her possession that pertains to the claim. Notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Prior to the issuance of the September 2002 rating decision that is the subject of this appeal, the veteran was advised of the evidence necessary to substantiate his claims for service connection for tension headaches, degenerative changes of the right ankle, and patellofemoral chondromalacia of the bilateral knees, and of his and VA's respective duties in obtaining evidence. He was also asked to provide evidence in support of his claims, which would include that in his possession. See February 2002 letter. The Board acknowledges that the veteran was not provided pre- adjudicatory notice concerning his claims for service connection for onychomycosis of the bilateral feet, bilateral calluses of the 5th toes, and puntate keratosis of the bilateral hands. The requisite notice was sent to the veteran, however, in an October 2006 letter. Although this letter was not sent before the initial adjudication, this error was not prejudicial to the veteran because the February 2002 letter previously provided him with the general notice of how to substantiate a claim for service connection, he has been afforded a meaningful opportunity to participate effectively in the processing of his claims, and he has been given ample time to respond. Additionally, the claims were readjudicated in the July 2007 supplemental statement of the case. For these reasons, it is not prejudicial to the veteran for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. With respect to claims for increased rating, "[i]n cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated - it has been proven." Dingess v. Nicholson, 19 Vet. App. 473, 491 (2006). When service connection has been granted and an initial disability rating and effective date have been assigned, section 5103(a) is no longer applicable. Accordingly, the duty to notify has been fulfilled as to these claims. The veteran was also provided notice of the appropriate disability rating and effective date of any grant of service connection, as required by Dingess v. Nicholson, 19 Vet. App. 473 (2006). See March 2006 letter. VA also has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2007). This duty has also been met as the veteran's service medical and VA treatment records were obtained and he was afforded appropriate VA examinations in connection with his claims. Remand for a medical opinion regarding the claims for service connection is not warranted because, as discussed above, the veteran's statements concerning the onset of these condition during service are not credible. The record does not suggest the existence of additional, pertinent evidence that has not been obtained. For the reasons set forth above, the Board finds that no further notification or assistance is necessary, and deciding the appeal is not prejudicial to the veteran. ORDER Service connection for onychomycosis of the bilateral feet is denied. Service connection for bilateral calluses of the 5th toes is denied. Service connection for puntate keratosis of the bilateral hands is denied. An initial compensable rating for service-connected tension headaches is denied. A disability rating of 20 percent, and no higher, for service-connected degenerative changes of the right ankle is granted prior to May 1, 2007. A disability rating in excess of 20 percent for service- connected degenerative changes of the right ankle is denied as of May 1, 2007. A disability rating of 20 percent, and no higher, for service-connected left knee DJD with meniscal tear is granted prior to May 1, 2007. A disability rating in excess of 20 percent for service- connected left knee DJD with meniscal tear is denied as of May 1, 2007. An initial compensable rating for service-connected right knee patellofemoral syndrome is denied prior to May 1, 2007. A disability rating in excess of 10 percent for service- connected right knee patellofemoral syndrome is denied as of May 1, 2007. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs