Citation Nr: 0812808 Decision Date: 04/17/08 Archive Date: 05/01/08 DOCKET NO. 05-07 021 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a bilateral leg disorder manifested by pain. 2. Entitlement to service connection for a right knee disorder. 3. Entitlement to service connection for bilateral foot disorder to include flat feet. 4. What rating is warranted since January 2, 2004, for residuals of a left thumb fracture? 5. What rating is warranted since January 2, 2004, for mild left knee instability? ATTORNEY FOR THE BOARD W.T. Snyder, Counsel INTRODUCTION The veteran had active service from February 1967 to November 1970 and January 1975 to July 1991. This appeal to the Board of Veterans' Appeals (Board) arose from a May 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The veteran indicated on his September Substantive Appeal (VA Form 9) that he desired a local hearing before an RO Decision Review Officer, which was in fact scheduled for February 7, 2006. In a subsequent letter, however, which is also dated in February 2006, he opted for an Informal Conference in lieu of a hearing. A report of the conference is associated with the claims file. In August 2007, the Board remanded the case to the RO, via the Appeals Management Center (AMC), in Washington, DC, for issuance of a Supplemental Statement of the Case. The RO issued the Supplemental Statement of the Case as directed, continued to deny the claims, and returned the case to the Board for further appellate review. FINDINGS OF FACT 1. The preponderance of the probative evidence indicates that bilateral leg pain is not associated with a specifically diagnosed disorder. 2. The preponderance of the probative evidence indicates that a right knee disorder, including retropatellar pain syndrome, is not related to an in-service disease or injury, or a service-connected disability. 3. The preponderance of the probative evidence indicates that a bilateral foot disorder, including flat feet, is not related to an in-service disease or injury, or a service- connected disability. 4. Since January 2, 2004, left thumb fracture residuals have not manifested with a gap of more than 2 inches (5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 5. Since January 2, 2004, the left knee has not manifested with slight lateral instability, subluxation, or limitation of motion causally related to his active service or service- connected disability. CONCLUSIONS OF LAW 1. Bilateral leg pain is not associated with a specifically diagnosed disability which was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 and Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2007). 2. A right knee disorder, including retropatellar pain syndrome, was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. A bilateral foot disorder, including flat feet, was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1111, 1131, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(b), 3.306(a). 4. The requirements are not met for a rating in excess of 10 percent for left thumb fracture residuals. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5228. 5. The requirements are not met for a compensable rating for left knee lateral instability. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5228. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of the VCAA, Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126, have been met. There is no issue as to providing an appropriate application form or completeness of the application. For an increased-compensation claim, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Further, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. VA notified the veteran in February 2004 prior to the initial decision, and in November 2004, of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain. VA informed the veteran of the need to submit all pertinent evidence in his possession and, in a March 2006 letter, provided adequate notice of how disability ratings and effective dates are assigned. Although the March 2006 letter did not reiterate the rating criteria under which the veteran's service-connected disabilities are rated, the Statement of the Case and the Supplemental Statements of the Case fully apprised him of that information. Further, the October 2007 Supplemental Statement of the Case readjudicated his claims after issuance of the March 2006 letter. While the veteran may not have received full notice prior to the initial decision, after notice was provided, he was afforded a meaningful opportunity to participate in the adjudication of the claims. VA has fulfilled its duty to assist the veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. He was provided the opportunity to present pertinent evidence and testimony. In sum, there is no evidence of any VA error in notifying or assisting the veteran that reasonably affects the fairness of this adjudication. Finally, the Board has reviewed all the evidence in the veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Service Connection The veteran asserts that flat feet were noted on his examination at Induction, and that he has leg pain as a result of the disorder, and that his right leg pain is causally related to treatment he received during his active service. As discussed below, the Board finds the preponderance of the evidence is against the claims. Governing Law and Regulation Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000. Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status do not constitute competent medical evidence. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Analysis Bilateral Leg and Right Knee Disorders. Service medical records note the veteran reported he banged his right knee against a truck in May 1978. The examiner noted a contusion. No other complaints, findings, or treatment is noted. Reports Of Periodic Medical Examinations of May 1980 and October 1986 note the veteran's lower extremities were assessed as normal. The veteran did not indicate any history of right knee complaints on his October 1986 or March 1991 Report of Medical History. The March 1991 Report Of Medical Examination For Retirement note no pathology or abnormality associated with the veteran's right knee. The only notation involved his now service-connected left knee. April 2004 X-rays of the right knee were read as showing a negative study. The February 2006 VA examination report notes the examiner reviewed the claims file, and that the veteran told him that he experienced bilateral knee and leg pain. The knee pain was in the anterior aspect, and it was aggravated by getting up and down stairs and out of a chair. He denied having undergone any surgeries. Physical examination revealed slight limitation of motion on flexion. The examiner diagnosed retropatellar pain syndrome. The examiner opined that the veteran's symptoms were not caused by or the result of his active service, as the service medical records documented a knee contusion, and he did not find the veteran's current complaints at the anterior knee pain and patellofemoral pain were the result of a contusion. Perhaps the most fundamental requirement for establishing entitlement to service connection is proof of the condition claimed. See Brammer v. Derwinski, 3 Vet. App. 233, 225 (1992) (Service connection presupposes a current diagnosis of the claimed disability). There must be evidence of an underlying disorder. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) ("[P]ain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted"). Thus, to the extent that the veteran's complaint is solely one of bilateral leg pain, that is not subject to service connection. Further, in light of the examiner's opinion that the veteran's in-service right knee contusion was an acute and transitory event which resolved completely without any chronic residuals, the diagnosed retropatellar pain syndrome is not causally linked with that event. All that is left are bare complaints of pain, which is not a specific disease or disorder. 38 C.F.R. § 3.303. The benefit sought on appeal is denied. Flat feet. In addition to the legal requirements for service connection noted above, a veteran is presumed to have been in sound condition when enrolled for service, except for any disease or injury noted at the time of enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before enrollment and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. If a pre- existing disorder is "noted" on entering service, the veteran has the burden of showing an increase in disability during service. If the veteran meets that burden and shows that an increase in disability occurred, the burden then shifts to the government to show that any increase was due to the natural progress of the disease. Wagner, 370 F.3d at 1096. There is no aggravation of a preexisting disease or injury if the condition underwent no increase in severity during service on the basis of the evidence of record pertinent to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). Also, intermittent or temporary flare-ups during service of a preexisting injury or disease do not constitute aggravation; rather, the underlying condition, as contrasted with symptoms, must have worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Accordingly, "a lasting worsening of the condition" - that is, a worsening that existed not only at the time of separation but one that still exists currently is required. Routen v. Brown, 10 Vet. App. 183, 189 (1997). The Board notes the service medical records of the veteran's initial tour of active service from 1967 to 1970 are not part of the claims file. Interestingly, the veteran submitted a copy of the January 1967 Report Of Medical Examination For Induction, which in fact notes asymptomatic pes planus (flat feet). The Board discerns no reason to question the authenticity of the copy. Nonetheless, there is no subsequent record of a confirmed diagnoses of flat feet noted in the extant records in the claims file. None of the Reports Of Medical Examinations related to the veteran's subsequent active service note flat feet or any complaints associated with the disorder. The veteran joined the Army National Guard after his initial period of active service. The February 1974 Report Of Medical Examination For Enlistment in the Guard notes the feet were assessed as normal. Contrary to the 1967 Induction examination, the National Guard deemed the veteran physically fit for service with a Profile of all 1. The active service Reports Of Periodic Examinations of May 1980 and October 1986 note the veteran's feet were assessed as normal. Further, the veteran indicated no history of foot complaints or problems on his medical history. An undated Podiatry Consult Request notes the veteran's complaints of a two-year history of left foot pain in the arch region when running. The physician's assistant examiner noted "pes planus otherwise normal." The April 1989 Podiatry consult notes the veteran complained of low back pain in addition to left knee and left arch pain. The podiatrist noted that the veteran's lower extremities appeared good, and examination revealed a mild right hallux abducto valgus deformity (bunion). The diagnosis was left runner's knee syndrome. There is no reference or notation of pes planus or flat feet. On his March 1991 Report Of Medical History for his retirement examination, the veteran denied any history of foot trouble. The March 1991 Report Of Medical Examination For Retirement notes his feet were assessed as normal. The February 2006 Report Of Medical Examination notes the veteran told the examiner that, while in service, he was told he had flat feet. The examiner noted the 1989 podiatry consult but also noted that it provided no details on a flat foot condition. Further, the veteran said his feet did not bother him, and he denied any treatment or current pain, weakness, or fatiguability. Physical examination revealed no corns, calluses, or edema. Toes, nails, and pulses, were normal. Foot posture was normal when standing and on normal gait. There was no tenderness on Achilles manipulation, and his heel swung nicely into varus and reconstituted a good medial arch. The examiner noted the absence of foot pain and opined that the veteran's claimed bilateral leg pain was not caused by the pes planus noted in the service medical records. His diagnoses did not include flat feet or other foot pathology. In the absence of a diagnosed current foot disorder, there is nothing to service connect, be it on a direct basis or on the basis of aggravation of a pre-existing disorder. Thus, the Board finds the preponderance of the evidence is against the claims. 38 C.F.R. § 3.303. The benefit sought on appeal is denied. In reaching this decision the Board considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the veteran's service connection claims, however, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Claims Governing Law and Regulation Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40; see also 38 C.F.R. § 4.45. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath, 1 Vet. App. at 594. Where an increase in the level of a service- connected disability is at issue, however, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nonetheless, 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). The analysis in this decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Analysis Historically, the veteran sustained a Bennett fracture of his left thumb in 1975 and underwent an open reduction and internal fixation as treatment. The retirement examination noted a loose left anterior cruciate ligament. An April 1992 rating decision granted service connection for the thumb fracture residuals with a 10 percent rating, and for the left knee instability, which was rated non-compensable. Parenthetically, as noted by the examiner at the February 2004 examination, the rating decision erroneously references the right thumb, when it was in fact the left thumb. Left thumb. Finger or digit pathology is rated under Diagnostic Code 5228. It provides that evidence of a gap of more than two inches (5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, is necessary for the grant of a 20 percent rating. 38 C.F.R. § 4.71a. The rating is the same for the major and the minor (non-dominant) hand. The February 2004 VA examination report notes the veteran is right-hand dominant, which means his left thumb is on his non-dominant hand. Physical examination of the left thumb revealed a well-healed incision and mild prominence over the radial aspect of the carpal metacarpal joint. There was no focal tenderness to palpation, the veteran was able to oppose the tip of his thumb to each of his digits, and he was able to make a full fist. Diagnosis was post-traumatic arthritis of the carpal metacarpal joint. At the February 2006 examination, the veteran told the examiner that his main limitation was that he had some difficulty with grip and opening a lid. Otherwise, it did not cause any other functional impairment, as it did not affect the use of his hand in any activities. He reported some daily aching, but no stiffness, swelling, heat, or redness, and it did not impact his daily occupation, living, or recreational activity. Examination revealed a well-healed incision at the base of the thumb. He had symmetric range of motion with palmar abduction, opposition, adduction, thumb extension, and flexion, as compared to the right side. Carpometacarpal grind test was negative, and the left hand manifested excellent strength compared to the right hand. The left hand was well perfused, and sensation to light touch was intact. Some slight prominence over the area of the incision was noted, but it was well healed. Diagnosis was left thumb Bennett's fracture, post-open reduction and internal fixation. The examiner noted that the veteran did not have any functional limitation or impairment. The findings on examination at both examinations show the veteran's left thumb to more nearly approximate his assigned 10 percent rating, as his thumb manifested no functional impairment or inability to touch or oppose the fingers. Further, the examination revealed no symptoms that would approximate a compensable rating under the rating criteria for scars. See 38 C.F.R. § 4.118. Thus, the benefit sought on appeal is denied. 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5228. Left knee. The April 1992 rating decision also granted service connection for the left knee and assigned the non-compensable rating under Diagnostic Code 5257, which rates instability. Slight recurrent instability is rated at 10 percent; moderate, 20 percent, and severe, 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5257. At the February 2004 examination, the veteran told the examiner he experienced an ache in his left knee that radiated up and down the left knee, but he denied any swelling or popping, and he also noted that he did not use any assistive device for ambulation or wear special shoes. On a scale of 1 to 10, he assessed the intensity of his pain as 5/10, and he occasionally took aspirin for relief. He was not working at the time of the examination, but he told the examiner he had difficulty doing prolonged walking and rising from a seated position. Physical examination of the left knee revealed no effusion or patellar apprehension. There was mild anterior joint line tenderness, but range of motion was full-0 to 140 degrees. See 38 C.F.R. § 4.71a, Plate II. There was no instability of the ligaments, and the veteran's gait was mildly antalgic on the left. The examiner rendered a diagnosis of left knee arthritis. VA outpatient treatment records note April 2004 X-rays of the left knee which were interpreted as showing a negative study. Further, a November 2004 entry notes the veteran was non- compliant with taking his prescribed Naprosyn for his left knee symptoms. The February 2006 examination report notes the veteran told the examiner he had difficulty using stairs and getting out of a chair. Those were the only movements that caused him difficulty or aching. He denied having experienced any stiffness, swelling, heat, redness, instability, or locking. The veteran noted he worked full time, but his knee did not impact his employment, as he could sit whenever it deemed the need to do so. It impacted his recreational activity in that he noted he used a golf cart when golfing, instead of walking the course as he once did. Examination revealed range of motion of 0 to 130 degrees. There was no further loss of range of motion on repetitive use. There was no instability of the knee or patellofemoral crepitus. The examiner diagnosed patellofemoral pain syndrome. In the absence of any clinical finding of left knee instability or functional impairment at either examination or noted in the veteran's outpatient records, there is no factual basis for a compensable rating for his left knee instability. 38 C.F.R. §§ 4.1, 4.7. The Board notes the diagnosis of arthritis at the 2004 examination, and that separate ratings for arthritis and instability are appropriate where indicated by clinical findings. See VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63,604 (1997). Diagnostic Code 5003 provides that degenerative arthritis established by X-ray is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the joint involved. Further, if the limitation of motion of the joint involved is noncompensable, a rating of 10 percent is applicable. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, but with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and occasional incapacitating exacerbations, a 20 percent evaluation is assigned. With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, a 10 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5003. With any form of arthritis, painful motion is an important factor. It is the intention of the rating schedule to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. A compensable evaluation under Diagnostic Code 5003 and 38 C.F.R. § 4.59 (for painful motion) is in order where arthritis is established by X-ray findings and no actual limitation of motion of the affected joint is demonstrated. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Where compensable limitation of motion is demonstrated in the joint, the Lichtenfels rule is not applicable. Limitation of flexion of the leg to 60 degrees warrants a noncompensable evaluation. Limitation of flexion of the leg to 45 degrees warrants a 10 percent rating. A 20 percent evaluation requires that flexion be limited to 30 degrees. A 30 percent evaluation requires that flexion be limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of either leg to 5 degrees warrants a noncompensable evaluation. A 10 percent evaluation requires that extension be limited to 10 degrees. A 20 percent evaluation requires that extension be limited to 15 degrees. A 30 percent evaluation requires that extension be limited to 20 degrees. A 40 percent evaluation requires that extension be limited to 30 degrees. A 50 percent evaluation requires that extension be limited to 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Consistent with the Lichtenfels decision, the General Counsel, VA, has opined that the limitation of motion need not be to a compensable degree to warrant a separate rating, if the other criteria are met. See VAOPGCPREC No. 9-98 (September 8, 1998), 61 Fed. Reg. 66,749 (1996). The Board finds, however, that the probative medical evidence does not support a separate rating for arthritis. While the examiner diagnosed arthritis at the 2004 examination, the April 2004 X-ray was not interpreted as having shown arthritis. Further, the examiner at the 2006 examination did not diagnose arthritis, even though the veteran's left knee manifested limitation of motion 10 degrees less than normal. See 38 C.F.R. § 4.71a, Plate II. Thus, in the absence of confirmation by X-ray and diagnosis of arthritis at the 2006 examination, the Board finds the preponderance of the evidence is against a separate rating for limitation of motion based on arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Thus, the veteran's left knee instability more nearly approximates a non-compensable rating. 38 C.F.R. § 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. The benefit sought on appeal is denied. In reaching this decision the Board considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the veteran's claims for a higher rating, however, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a bilateral leg disorder manifested by pain is denied. Entitlement to service connection for a right knee disorder is denied. Entitlement to service connection for bilateral foot disorder to include flat feet is denied. Entitlement to rating higher than 10 percent for residuals of a left thumb fracture is denied. Entitlement to a compensable rating for left knee instability is denied. ____________________________________________ MARY GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs