Citation Nr: 1009167 Decision Date: 03/11/10 Archive Date: 03/17/10 DOCKET NO. 06-13 234 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1 Entitlement to service connection for sciatic pain and leg swelling, claimed as secondary to a service-connected bilateral knee condition. 2. Entitlement to a disability rating in excess of 10 percent for bilateral pes planus. 3. Entitlement to a disability rating in excess of 10 percent for the left knee, status post total synovectomy. 4. Entitlement to an initial compensable disability rating for right knee strain, secondary to service-connected left knee, status post total synovectomy, for the period of May 6, 2005 to June 12, 2007. 5. Entitlement to an initial disability rating in excess of 10 percent for right knee strain, secondary to service- connected left knee, status post total synovectomy, for the period of June 13, 2007 to the present. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1982 to March 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which denied service connection for sciatic pain and leg swelling, secondary to a service-connected bilateral knee condition; continued 10 percent disability evaluations for the left knee, status post total synovectomy, and bilateral pes planus; and granted service connection for right knee strain, secondary to service-connected left knee, status post total synovectomy, assigning a noncompensable evaluation, effective May 6, 2005. In December 2005, the Veteran submitted a notice of disagreement and subsequently perfected his appeal in March 2006. In a March 2009 rating decision, the RO increased the Veteran's disability rating for right knee strain, secondary to service-connected left knee, status post total synovectomy, to 10 percent, effective June 13, 2007. Because the RO did not assign the maximum disability rating possible, the appeal for a higher evaluation remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement 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). As the Veteran perfected his appeal from the October 2005 assignment of an initial noncompensable disability rating, the Board will address whether he was entitled to a compensable disability rating prior to June 13, 2007, as well as whether he is entitled to a disability rating higher than 10 percent from June 13, 2007. Therefore, the issues on appeal have been rephrased as shown above. The Veteran is not prejudiced by such recharacterization of the issues. In October 2009, the Veteran presented sworn testimony during a video conference hearing in Cleveland, Ohio, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's claims file. FINDINGS OF FACT 1. The competent medical evidence of record does not indicate that sciatic pain and bilateral leg swelling are the result of a disease or injury in active duty service or secondary to a service-connected disability. 2. The Veteran's service-connected bilateral pes planus is manifested by mild to moderate pronation and a medial interphalangeal joint (IPJ) callosity on the right foot. 3. The Veteran's service-connected left knee disability is manifested by flexion limited to 105 degrees with pain throughout the entire range of motion, use of a knee brace, and no objective signs of instability. 4. From May 6, 2005 to June 12, 2007, the Veteran's service- connected right knee disability was manifested by flexion limited to 135 degrees with pain over the last 30 degrees of flexion. 5. As of June 13, 2007, the Veteran's service-connected right knee disability is manifested by flexion limited to 114 degrees with pain throughout the entire range of motion. CONCLUSIONS OF LAW 1. Sciatic pain and bilateral leg swelling were not incurred in or aggravated by service, and are not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2009). 2. The criteria for a disability rating in excess of 10 percent for service-connected bilateral pes planus have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.71a, Diagnostic Code 5276 (2009). 3. The criteria for a disability rating in excess of 10 percent for service-connected left knee, status post total synovectomy, have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.71a, Diagnostic Codes 5003, 5257 (2009). 4. The criteria for the assignment of an initial disability rating of 10 percent, but no higher, for service-connected right knee strain, secondary to service-connected left knee, status post total synovectomy, from May 6, 2005 to June 12, 2007, have been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.59, 4.71a, Diagnostic Code 5260 (2009). 5. The criteria for an initial disability rating in excess of 10 percent for service-connected right knee strain, secondary to service-connected left knee, status post total synovectomy, from June 13, 2007 to the present, have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.59, 4.71a, Diagnostic Code 5260 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2009). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2009); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA 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. Prior to initial adjudication of the Veteran's claims, a letter dated in June 2005 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2009); Quartuccio at 187. Further, a March 2006 letter informed the Veteran of how VA determines the appropriate disability rating and effective date to be assigned when a claim is granted, consistent with the holding in Dingess/Hartman v. Nicholson. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records, VA treatment records, Social Security Administration records, and all obtainable private treatment records are in the file. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The record indicates that the Veteran underwent VA examinations for his knees, feet, and back in August 2005 and June 2007, and the results from those examinations have been included in the claims file for review. The examinations involved a thorough examination of the Veteran and an opinion that was supported by sufficient rationale. Therefore, the Board finds that the examinations are adequate for deciding the issues on appeal. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Additionally, with regard to the Veteran's left knee disability, bilateral pes planus, and right knee disability, there is no evidence indicating that there has been a material change in severity since he was last examined in June 2007. See 38 C.F.R. § 3.327(a) (2009). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. The Board finds that the VA examinations of record are adequate to decide the claims and that a new VA examination is not necessary at this time. Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claims. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds. II. Merits of the Claims A. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. See 38 U.S.C.A. § 1131 (West 2002). However, that an injury or disease occurred in service is not enough; there must also be a chronic disability resulting from that injury or disease. If there is no showing of the chronic disability during service, then a showing of continuous symptoms after service is required to support a finding of chronicity. See 38 C.F.R. § 3.303(b) (2009). 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. See 38 C.F.R. § 3.303(d) (2009). In order to establish service connection for a disability, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in- service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in- service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310(a) (2009). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 39 C.F.R. § 3.310(b) (2009); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. Sciatic Pain and Bilateral Leg Swelling The Veteran has not alleged that his sciatic pain and leg swelling are directly related to service. The service treatment records do not contain any reference to treatment or diagnosis of sciatic pain or leg swelling. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002). No competent medical evidence has directly related the Veteran's sciatic pain and bilateral leg swelling to military service. Accordingly, the basis for a grant of service connection on a direct basis is not presented. A review of the medical evidence of record shows that the Veteran has a current disability. Specifically, the May 2005 VA examiner noted the Veteran's reported symptoms with regard to his legs and sciatic pain and diagnosed him with intermittent claudication. Thus, the first element of Wallin is met. Additionally, a review of the claims file indicates that the Veteran is service connected for a right knee disability, a left knee disability, and bilateral pes planus. Thus, the second element of Wallin is met. The remaining question is whether a medical nexus exists between the Veteran's current intermittent claudication and his service-connected disabilities. As referenced above, the Veteran was afforded a VA examination in August 2005. At that time, the examiner reviewed the claims file and noted the Veteran's complaints of tingling in his legs. He observed poor balance, mildly decreased sensation in the Veteran's feet, and absent ankle reflexes. He diagnosed the Veteran with intermittent claudication and concluded that it was likely due to acquired lumbar stenosis, secondary to degenerative disc disease. He did not indicate that there was a medical nexus between the Veteran's intermittent claudication and his service-connected disabilities. The only other clinical evidence of record that discusses a possible etiology for the Veteran's bilateral leg and sciatic pain is a May 2007 VA treatment record. That treatment record indicates that the Veteran's chronic low back pain is secondary to obesity and lack of exercise, not his service- connected disabilities. There is simply no medical evidence of record indicating a link between the Veteran's current complaints of sciatic pain and bilateral leg swelling and his service-connected disabilities. As such, the medical nexus element of Wallin is not met. In this case, the only evidence which purports to relate the Veteran's sciatic pain and bilateral leg swelling to his service-connected disabilities consists of the statements of the Veteran and his representative. However, it is now well established that laypersons, such as the Veteran and his representative, without medical training are not competent to relate those symptoms to a specific etiology. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992); see also 38 C.F.R. § 3.159 (a)(1) (2009) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran can describe what he experiences, he is not able to provide competent evidence as to the etiology of his left knee disability. His assertions are accorded less weight than the competent medical evidence, the August 2005 VA examiner's opinion and the May 2007 VA treatment record, that is against his claim. Competent evidence linking the Veteran's sciatic pain and bilateral leg swelling to a service-connected disability is lacking in this case. Accordingly, the Board finds that the claim of entitlement to service connection for sciatic pain and bilateral leg swelling, secondary to service-connected bilateral knee disabilities, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of- the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to service connection, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2009); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). B. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2009). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2009). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2009). The veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2009). Where the veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. See 38 C.F.R. § 4.14 (2009). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Bilateral Pes Planus The Veteran's service-connected bilateral pes planus has been evaluated as 10 percent disabling under Diagnostic Code 5276. He seeks a higher rating. Under Diagnostic Code 5276, a 10 percent evaluation is assigned for unilateral or bilateral moderate acquired flatfeet with weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet. A 20 percent evaluation is assigned for unilateral severe acquired flatfoot with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent evaluation is assigned for bilateral severe acquired flatfeet with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities; or for unilateral pronounced acquired flatfoot with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. Finally, a 50 percent evaluation is assigned for bilateral pronounced acquired flatfoot with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. See 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2009). The Veteran most recently underwent a VA examination for his bilateral pes planus in June 2007. At that time, the examiner noted that the Veteran reported daily pain, weakness, fatigue, stiffness, swelling, heat, and redness. The Veteran reported an increase in symptoms with weight- bearing, standing. He indicated that the maximum amount of time he could spend on his feet was 5 minutes and that he did not use corrective shoes or inserts. The examiner observed bilateral, semi-flexible decreased arches with no open lesions or preulcerative lesions. He had full range of motion and an achilles insertion medially that was reducible without pain. There was no additional limitation of motion or function with repetitive use. The examiner did not observe any painful motion, edema, instability, weakness, or tenderness on examination. A medial IPJ callos was observed. X-rays showed mild hallux valgus and mild pes planus bilaterally. The examiner diagnosed the Veteran with minimally symptomatic bilateral pes planus. The Veteran previously underwent a VA examination in August 2005. At that time, the examiner noted the Veteran's complaints of bilateral foot pain, aches, soreness, and tenderness. The Veteran reported using a cane for support and shoe inserts, which he said helped. The examiner observed mild to moderate pronation of both feet with no callosities. There was no valgus or deformity in the achilles or other toe abnormalities. The Veteran reported increased pain with repetitive use, but the examiner did not observe any symptomatic changes. The examiner diagnosed the Veteran with bilateral pes planus. The medical evidence of record does not establish that the Veteran's service-connected bilateral pes planus warrants more than a 10 percent disability rating. There is no evidence of severe flatfeet, such as objective evidence of marked deformity, accentuated pain on manipulation and use, or indication of swelling on use to warrant a 30 percent rating. As such, a rating in excess of 10 percent for bilateral pes planus cannot be granted. The Board has reviewed the remaining diagnostic codes relating to foot disabilities and finds that they are not applicable. As such, an increased rating cannot be assigned under Diagnostic Codes 5277-5284. See 38 C.F.R. § 4.71a, Diagnostic Codes 5277-5284 (2009). Additionally, there is no indication in the medical evidence of record that the Veteran's symptomatology warranted other than the currently assigned 10 percent disability rating throughout the appeal period. As such, assignment of staged ratings is not warranted. See Hart, supra. In reaching the above-stated conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an increased rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2009); see also Ortiz, supra. Knees The Veteran's service-connected left knee, status post total synovectomy, has been evaluated as 10 percent disabling under Diagnostic Code 5257. His service-connected right knee strain, secondary to service-connected left knee, status post total synovectomy, has been assigned a noncompensable disability evaluation from May 6, 2005 to June 12, 2007, and a 10 percent disability evaluation from June 13, 2007 to the present, under Diagnostic Code 5260. He seeks higher ratings. Under Diagnostic Code 5257, a 10 percent evaluation is assigned for slight recurrent subluxation or lateral instability of the knee. A 20 percent evaluation is assigned for moderate recurrent subluxation or lateral instability of the knee, and a 30 percent evaluation is assigned for severe recurrent subluxation or lateral instability of the knee. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2009). Diagnostic Codes 5260 and 5261 provide the criteria for rating limitation of motion of the knees. Normal range of motion for the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II (2009). Under Diagnostic Code 5260, a noncompensable rating is assigned for flexion of the leg limited to 60 degrees. A 10 percent rating is assigned for flexion of the leg limited to 45 degrees. A 20 percent rating is assigned for flexion of the leg limited to 30 degrees. And a 30 percent rating is assigned for flexion of the leg limited to 15 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2009). Under Diagnostic Code 5261, a noncompensable rating is assigned for extension of the leg limited to 5 degrees. A 10 percent rating is assigned for extension of the leg limited to 10 degrees. A 20 percent rating is assigned for extension of the leg limited to 15 degrees. A 30 percent rating is assigned for extension of the leg limited to 20 degrees. A 40 percent rating is assigned for extension of the leg limited to 30 degrees. And a 50 percent rating is assigned for extension of the leg limited to 45 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2009). Additionally, the evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, under Diagnostic Code 5003, 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, 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. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2009). The General Counsel for VA, in a precedent opinion dated July 1, 1997, (VAOPGCPREC 23-97) held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. General Counsel stated that when a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion which at least meets the criteria for a 0 percent rating under Diagnostic Code 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more) in order to obtain a separate rating for arthritis. General Counsel subsequently held in VAOPGCPREC 9-98 that a separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. See also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). Where additional disability is shown, a veteran rated under Diagnostic Code 5257 can also be compensated under Diagnostic Code 5003 and vice versa. Left Knee As referenced above, the Veteran most recently underwent a VA examination in June 2007. At that time, the examiner noted that the Veteran experienced bilateral knee pain, aching, soreness, and tenderness. The Veteran reported that his symptoms were exacerbated by prolonged standing and walking and repetitive use. The examiner recorded range of motion measurements of 0 to 105 degrees of flexion with pain throughout the entire range of motion. Repetitive use caused increased aching, pain, soreness, tenderness, and fatigability, but no change in the range of motion measurements. He also indicated that the Veteran used braces on his knees and a cane, but that his knees were stable to medial and lateral and anterior and posterior testing. The examiner diagnosed the Veteran with postoperative residuals of injury of the left knee, including arthritis. The Veteran also underwent a VA examination in August 2005. At that time, the examiner noted the Veteran's complaints of aches, pains, soreness, tenderness, and occasional swelling. The Veteran reported increased symptoms with prolonged standing and walking, repetitive use, and weather changes. The examiner observed slight crepitation, and recorded range of motion measurements of 0 to 135 degrees of flexion with pain of the last 30 degrees of flexion. Repetitive use caused increased aches, pains, soreness, tenderness, and fatigability, but no observed change in range of motion. The examiner did not observe any subluxation or signs of instability, and the Veteran's left knee was stable to medial and lateral and anterior and posterior testing. He diagnosed the Veteran with postop synovectomy of the left knee. Additionally, the evidence includes range of motion measurements from the Bureau of Disability, dated May 2003. Those records show flexion of the left leg to 120 degrees and extension of the left leg to 0 degrees. The medical evidence of record does not establish that the Veteran's service-connected left knee disability warrants more than a 10 percent disability rating. There is no indication that he experiences moderate recurrent subluxation or lateral instability to warrant a 20 percent rating under his currently assigned Diagnostic Code 5257. Indeed, both VA examiners found that the Veteran's left knee showed no signs of instability. As such, a rating in excess of 10 percent for instability of the left knee cannot be granted. Additionally, there is no indication that the Veteran's limitation of motion of the left knee reaches a compensable level to warrant a higher rating under Diagnostic Codes 5260 or 5261. The medical evidence contains no indication that flexion of his left leg has been limited to 60 degrees or less or that his extension of his left leg has been limited to 0 degrees or greater. Thus, a separate compensable rating under Diagnostic Codes 5260 or 5261 is not warranted. There is also no indication that the Veteran experiences any functional loss due to pain, weakness, fatigability, incoordination or pain on movement of a joint to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45 (2009); see also DeLuca, supra. Significantly, while both the August 2005 and June 2007 VA examiners noted the Veteran's complaints of increased pain and other symptoms with repetitive use, they indicated that this did not result in an observable change in his range of motion measurements. Further, the June 2007 examiner indicated that the Veteran was able to perform his daily activities without interference from his knees. Thus, an increased rating under DeLuca is not warranted. Further, an additional 10 percent rating for arthritis is not warranted. As discussed above, General Counsel has held that a veteran rated under Diagnostic Code 5257 may also be granted an additional 10 percent rating for arthritis with limitation of motion. However, the additional 10 percent is limited to cases where the Veteran's limitation of motion meets at minimum the noncompensable rating criteria. See VAOPGCPREC 23-97. In this case, the Veteran's most limited range of motion measurements showed flexion of the knee to 105 degrees. This fails to meet the noncompensable rating criteria for limitation of flexion (flexion limited to 60 degrees or less). As such, an additional 10 percent rating is not warranted under Diagnostic Codes 5003. The Board has reviewed the remaining diagnostic codes relating to knee disabilities. However, the claims folder contains no medical evidence indicating that the Veteran's left knee disability is manifested by ankylosis, removal of cartilage, impairment of the tibia and fibula, or symptoms other than those discussed above. As such, an increased rating cannot be assigned under Diagnostic Codes 5256, 5258- 5259, or 5262-5263. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258-5259, 5262-5263 (2009). Further, the Board notes that there is no indication in the medical evidence of record that the Veteran's symptomatology warranted other than the currently assigned 10 percent disability rating throughout the appeal period. As such, assignment of staged ratings is not warranted. See Hart, supra. In reaching the above-stated conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an increased rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2009); see also Ortiz, supra. Right Knee As noted above, the Veteran most recently underwent a VA examination of his right knee in June 2007. At that time, the Veteran reported pain, aching, soreness, and tenderness in his right knee, which was worsened with prolonged standing or walking and repetitive use. He also reported experiencing flare-ups of increased pain with repetitive use. The examiner recorded range of motion measurements of flexion from 0 to 114 degrees, with pain throughout the range of motion. He noted that repetitive use caused increased aching, pain, soreness, tenderness, and fatigability, but that there was no observable change in the range of motion measurements as a result. The examiner diagnosed the Veteran with right knee strain and noted that previous x-rays showed a normal right knee. The Veteran also underwent a VA examination for his right knee in May 2005. At that time, the examiner noted the Veteran's complaints of occasional aches, stiffness, and soreness in his right knee. He did not observe any crepitation, effusion, or tenderness, and indicated that the Veteran's knee was stable to medial and lateral and anterior and posterior testing. He reported that the Veteran had flexion of the right knee from 0 to 135 degrees. X-rays showed no significant bone pathology. The examiner diagnosed the Veteran with right knee strain. Additionally, May 2003 range of motion measurements from the Bureau of Disability Determinations show flexion of the right knee to 130 degrees and extension of the right knee to 0 degrees. With regard to the period of May 6, 2005 to June 12, 2007, with resolution of reasonable doubt in the Veteran's favor, the Board finds that the Veteran's right knee disability has resulted in pain and fatigability upon repetitive use. Specifically, although this has not resulted in change in the range of motion measurements, it does appear to limit the Veteran's ability to stand or walk for prolonged periods of time. Accordingly, the Board finds that his symptoms more closely approximate a 10 percent rating for right knee strain throughout this period. See 38 C.F.R. §§ 4.40, 4.45 (2009); see also DeLuca, supra. However, although a higher initial rating is warranted, the evidence of record does not reflect symptomatology of right knee strain that would meet the criteria for a rating in excess of 10 percent during this period of time. While the evidence of record demonstrates painful motion and limitations on standing and walking, it does not reflect compensable limitation of motion or more severe functional loss. As such, a higher rating under Diagnostic Code 5260 is not warranted for the time period of May 6, 2005 to June 12, 2007. With regard to the period of June 13, 2007 to the present, the medical evidence of record does not establish that the Veteran's service-connected right knee strain warrants a disability rating in excess of 10 percent. There is no indication that he experiences limitation of flexion of the leg 30 degrees or less or that his right knee strain results in more severe functional loss than limitations on standing and walking to warrant a higher rating under Diagnostic Code 5260. As such, the Board finds that an evaluation in excess of 10 percent for right knee strain from June 13, 2007 to the present is not warranted. Further, there is no indication that the Veteran's right knee disability warrants an increased rating under any other diagnostic code relating to the knees. The claims folder contains no medical evidence indicating that the Veteran's right knee disability is manifested by arthritis, ankylosis, removal of cartilage, impairment of the tibia and fibula, limitation of extension, or symptoms other than those discussed above. As such, an increased rating cannot be assigned under Diagnostic Codes 5003, 5256, 5258-5259, 5261- 5263. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5256, 5258-5259, 5261-5263 (2009). Additionally, there is no evidence indicating that the severity of the Veteran's right knee strain has fluctuated throughout the appeals period to warrant staged ratings. Thus, the assignment of staged ratings is not appropriate. See Fenderson, supra. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to a rating in excess of 10 percent for any time during the appeals period, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2009); see also Ortiz, supra. Extraschedular Consideration The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2009); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court set forth a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, 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 Veteran's disability picture requires the assignment of an extraschedular rating. The evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The Veteran's complaints of instability and painful motion of his bilateral knees, as well as pain from flat feet, are adequately contemplated by the rating schedule. As the Veteran's disability picture is contemplated by the rating schedule, the threshold issue under Thun is not met and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that the Veteran's service-connected disabilities present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2009). Thus, referral of these issues to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. ORDER Entitlement to service connection for sciatic pain and leg swelling, claimed as secondary to a service-connected bilateral knee condition, is denied. Entitlement to a disability rating in excess of 10 percent for bilateral pes planus is denied. Entitlement to a disability rating in excess of 10 percent for the left knee, status post total synovectomy, is denied. Entitlement to an initial disability rating of 10 percent for right knee strain, secondary to service-connected left knee, status post total synovectomy, is granted from May 6, 2005 to June 12, 2007, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a disability rating in excess of 10 percent for right knee strain, secondary to service-connected left knee, status post total synovectomy, from June 13, 2007 to the present, is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs