Citation Nr: 1107276 Decision Date: 02/23/11 Archive Date: 03/04/11 DOCKET NO. 06-16 644 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to an initial evaluation in excess of 20 percent for degenerative osteoarthritic changes, thoracolumbar spine. 2. Entitlement to an initial evaluation in excess of 10 percent for cervical spondylosis. 3. Entitlement to an initial evaluation in excess of 10 percent for degenerative osteoarthritic changes, right hand, bilateral knees, bilateral hips, left ankle, and bilateral feet with hammertoe deformity, for the period from October 1, 2004 to August 21, 2009. 4. Entitlement to a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the right knee, beginning August 21, 2009. 5. Entitlement to a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the left knee, beginning August 21, 2009. 6. Entitlement to a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the right hip, beginning August 21, 2009. 7. Entitlement to a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the left hip, beginning August 21, 2009. 8. Entitlement to a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the right hand, beginning August 21, 2009. 9. Entitlement to a separate evaluation in excess of 10 percent for a bilateral foot disability, beginning August 21, 2009. 10. Entitlement to a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the left ankle, beginning August 21, 2009. 11. Entitlement to an effective date earlier than September 4, 2009, for the grant of service connection for a psychiatric disorder, to include posttraumatic stress disorder and anxiety. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran, Veteran's Mother ATTORNEY FOR THE BOARD David S. Ames, Counsel INTRODUCTION The Veteran served on active duty from September 1984 to September 2004. This matter comes properly before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office in Wichita, Kansas (RO). With the exception of the earlier effective date claim, all of the claims on appeal were remanded by the Board in February 2009 for additional development. The issues of entitlement to an initial evaluation in excess of 10 percent for degenerative osteoarthritic changes of the left ankle and entitlement to an effective date earlier than September 4, 2009, for the grant of service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and anxiety are addressed in the Remand portion of the decision below and are remanded to the RO via the Appeals Management Center, in Washington, DC. FINDINGS OF FACT 1. The medical evidence of record shows that the Veteran's thoracolumbar spine disability is manifested by pain and limitation of motion to, at most, 50 degrees of flexion and 15 degrees of extension. 2. The medical evidence of record shows that the Veteran's cervical spine disability is manifested by pain and limitation of motion to, at most, 45 degrees of flexion, 40 degrees of extension, 29 degrees of right lateral flexion, 29 degrees of left lateral flexion, 73 degrees of right rotation, and 70 degrees of left rotation. 3. The medical evidence of record shows that, for the period prior to August 21, 2009, the Veteran's degenerative arthritis of the right hand, bilateral knees, bilateral hips, left ankle, and bilateral feet was manifested by pain and arthritis shown through x-ray examination. 4. The medical evidence of record shows that, for the period on and after August 21, 2009, the Veteran's right knee disability is manifested by pain and limitation of motion to 110 degrees of flexion. 5. The medical evidence of record shows that, for the period on and after August 21, 2009, the Veteran's left knee disability is manifested by pain and limitation of motion to 110 degrees of flexion. 6. The medical evidence of record shows that, for the period on and after August 21, 2009, the Veteran's right hip disorder is manifested by pain and limitation of motion from 9 degrees of extension to 98 degrees of flexion. 7. The medical evidence of record shows that, for the period on and after August 21, 2009, the Veteran's left hip disorder is manifested by pain and limitation of motion from 10 degrees of extension to 99 degrees of flexion. 8. The medical evidence of record shows that, for the period on and after August 21, 2009, the Veteran's right hand disorder is manifested by pain. 9. The medical evidence of record shows that the Veteran's bilateral foot disability is manifested by pain, moderate bilateral flatfoot, hammertoes of all toes, and bilateral hallux valgus that was not equivalent to amputation of the great toes. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for degenerative osteoarthritic changes, thoracolumbar spine, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2010). 2. The criteria for an evaluation in excess of 10 percent for cervical spondylosis have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2010). 3. The criteria for an evaluation in excess of 10 percent for degenerative osteoarthritic changes, right hand, bilateral knees, bilateral hips, left ankle, and bilateral feet with hammertoe deformity, for the period from October 1, 2004 to August 21, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2010). 4. The criteria for a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the right knee, for the period on and after August 21, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2010). 5. The criteria for a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the left knee, for the period on and after August 21, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2010). 6. The criteria for a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the right hip, for the period on and after August 21, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2010). 7. The criteria for a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the left hip, for the period on and after August 21, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2010). 8. The criteria for a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the right hand, for the period on and after August 21, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2010). 9. The criteria for a separate evaluation in excess of 10 percent for degenerative osteoarthritic changes of the feet, bilateral hallux valgus, and bilateral pes planus for the period on and after August 21, 2009, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5276, 5280 (2010). 10. The criteria for a separate evaluation of 10 percent, but no more, for right foot hammertoe have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5282 (2010). 11. The criteria for a separate evaluation of 10 percent, but no more, for left foot hammertoe have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5282 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims, 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 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2010). Prior to initial adjudication, a letter dated in July 2004 satisfied the duty to notify provisions. Additional letters were also provided to the Veteran in August 2005, March 2006, September 2008, and April 2009, after which the claims were readjudicated. See 38 C.F.R. § 3.159(b)(1); Overton v. Nicholson, 20 Vet. App. 427 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006). The Veteran's service treatment records, VA medical treatment records, and indicated private medical records have been obtained. VA examinations sufficient for adjudication purposes were provided to the Veteran in connection with her claims. See McLendon v. Nicholson, 20 Vet. App. 79 (2006), Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). There is no indication in the record that additional evidence relevant to the issues decided herein is available and not part of the claims file. 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, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. 473. Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of her claims, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007) (holding that although Veterans Claims Assistance Act notice errors are presumed prejudicial, reversal is not required if VA can demonstrate that the error did not affect the essential fairness of the adjudication). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2010). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2010). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2010). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Staged ratings are, however, appropriate when the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Thoracolumbar Spine Service connection for degenerative osteoarthritic changes of the bilateral feet, right hand, bilateral knees, bilateral hips, left ankle, and thoracolumbar spine was granted by a July 2005 rating decision and a 10 percent evaluation was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5003, effective October 1, 2004. Subsequently, a December 2006 statement of the case granted a separate 20 percent evaluation for degenerative osteoarthritic changes, thoracolumbar spine, under 38 C.F.R. § 4.71a, Diagnostic Code 5003-5242, effective October 1, 2004. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27 (2010). The hyphenated diagnostic code in this case indicates that degenerative arthritis, under Diagnostic Code 5003, was the service-connected disorder, and degenerative arthritis of the spine, under Diagnostic Code 5242, was a residual condition. A May 2005 VA general medical examination report stated that radiographic examination of the thoracic spine showed degenerative osteoarthritic changes with diffuse demineralization of the thoracic spine and narrowing of the adjoining interspaces of the thoracic vertebral bodies. There was also an S-shape scoliosis of the thoracic spine. The Veteran denied having a traumatic injury but reported scoliosis and constant, aching pain, which she rated as a three on a scale from one to ten. The Veteran reported that she experienced a flare-up of pain approximately once per day for about an hour per occurrence, with pain during the flare-up rated as a nine on a scale from one to ten, with additional radiation to the right hip. The Veteran denied the use of mobility devices, falling, weight changes, bladder dysfunction, bowel dysfunction, and sexual dysfunction. She denied radiation of pain and periods of incapacitation, defined as bed rest prescribed by a physician. On range of motion testing, the Veteran had lumbar flexion to 90 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right rotation to 30 degrees, and left rotation to 30 degrees. There was no pain in any area of motion. The Veteran did not have stiffness, muscle spasm, guarding, or localized tenderness. The impression was degenerative osteoarthritic changes involving the thoracic spine with diffuse demineralization of the thoracic spine and narrowing of the adjoining interspaces of the thoracic vertebral bodies In an April 2006 VA fee-based orthopedic examination report, the Veteran complained of back pain. On physical examination, there was evidence of thoracolumbar scoliosis. In the thoracic area, there was mild discomfort with palpation of the spine and bilateral paravertebral muscles. In the lumbar area, there was discomfort in all areas palpated, including the lumbar spine, bilateral paravertebral muscles, bilateral gluteal areas, and bilateral sacroiliac joints. No muscle spasms were seen. On range of motion testing, the Veteran had lumbar flexion to 50 degrees, extension to 15 degrees, right lateral flexion to 20 degrees, left lateral flexion to 20 degrees, full right rotation, and full left rotation. The Veteran complained of discomfort in the extremes of the ranges of motion. In a February 2007 private medical report, the Veteran complained of increasing back pain which she rated at a level of ten on a scale from one to ten. On physical examination of the thoracolumbar spine, there was scoliosis and tenderness on palpation. The thoracolumbar spine had abnormally limited ranges of motion in all directions. On physical examination of the lumbosacral spine, there was tenderness on palpation. The lumbosacral spine had abnormally limited ranges of motion in all directions, with pain elicited by motion. In an August 2007 private medical report, the Veteran complained of back pain. After radiographic examination, the impression was idiopathic scoliosis, mild triple curve with superimposed degenerative arthritis primarily at L2-3. In a September 2008 private medical report, the Veteran complained of back pain which she rated at a level of eight on a scale from one to ten. An August 2009 VA spine examination report stated that, on physical examination of the lumbar spine, the Veteran had normal toe walk, heel walk, gait, and posture. She had positive straight leg raising on the left. The Veteran had reflexes at "1/4," with negative Babinski's test. On range of motion testing, the Veteran had lumbar flexion to 90 degrees, extension to 31 degrees, right lateral flexion to 23 degrees, left lateral flexion to 25 degrees, right rotation to 21 degrees, and left rotation to 19 degrees. There was pain at the end of the range of motion on all movements and after 10 repetitions. On x-ray examination, there was right concave rotoscoliosis of the lumbar spine. There was no spondylolisthesis or spondylolysis of the lumbar spine. There was a loss of height of the intervertebral disc space at L2-L3, and facet hypertrophic changes at L4-L5 and L5-S1. The impression was concave right rotoscoliosis of the lumbar spine and degenerative changes of the lumbar spine. The Veteran's service-connected thoracolumbar spine disability is rated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5242. Diagnostic Code 5242 provides that degenerative arthritis of the spine is to be rated under either the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or under Diagnostic Code 5003, for degenerative arthritis. The General Rating Formula states that a 20 percent disability rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. See 38 C.F.R. § 4.71a, General Rating Formula. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are rated separately under an appropriate diagnostic code. Id. at Note (1). The medical evidence of record shows that the Veteran's thoracolumbar spine disability is manifested by pain and limitation of motion to, at most, 50 degrees of flexion and 15 degrees of extension. There is no medical evidence of record that the Veteran's thoracolumbar spine has ever been limited to 30 degrees or less of forward flexion or that it has been ankylosed, either favorably or unfavorably. The Veteran has reported low back pain on use, a contention which is substantiated by the evidence of record. However, the medical evidence of record does not show that this results in additional limitation in range of motion due to pain sufficient to limit the Veteran's forward flexion to 30 degrees or less. The April 2006 VA fee-based orthopedic examination report stated that pain occurred at "the extremes" of the range of motion. Similarly, the August 2009 VA spine examination report stated that there was pain "at the end of the range of motion." Accordingly, there is no medical evidence of record that the Veteran currently experiences pain which causes additional limitation of motion sufficient to warrant an evaluation in excess of 20 percent. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2010); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Accordingly, a rating in excess of 20 percent is not warranted under the General Rating Formula for the orthopedic manifestations of the Veteran's service-connected back disability. See 38 C.F.R. § 4.71a, General Rating Formula. With regard to the neurologic manifestations of the Veteran's thoracolumbar spine disability, the medical evidence of record shows that the Veteran experiences pain in the lower extremities. However, there is no medical evidence of record that this pain is neurologic pain which is secondary to the Veteran's thoracolumbar spine disability, nor is there any other medical evidence of record that the Veteran has other neurologic manifestations of the thoracolumbar spine disability, including bowel and bladder impairment. In addition, service connection is already in effect for disabilities of the bilateral hips, bilateral knees, bilateral ankles, and bilateral feet. Accordingly, a separate evaluation for neurologic manifestations of the Veteran's thoracolumbar spine disability is not warranted. The medical evidence of record also shows that the Veteran has narrowing of spinal disc spaces. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (Formula for Rating IVDS), a 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS. For the purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating IVDS, at Note (1). However, the medical evidence of record does not show that the Veteran has ever been prescribed bed rest by a physician for a period of at least four weeks in any one year period. Moreover, as noted above, there is no evidence of neurological manifestations associated with the Veteran's thoracolumbar spine disorder. As such, a rating in excess of 20 percent is not warranted under the Formula for Rating IVDS. See 38 C.F.R. § 4.71a, Formula for Rating IVDS. The record shows that lumbar spine arthritis has been diagnosed, shown through x-ray examination. 38 C.F.R § 4.71a, Diagnostic Code 5003; see also 38 C.F.R. § 4.45. Awarding a separate evaluation under Diagnostic Code 5003 would constitute prohibited pyramiding. 38 C.F.R. § 4.14 (2010); see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Accordingly, an evaluation in excess of 20 percent is not warranted for the Veteran's thoracolumbar spine disability. As this issue deals with the rating assigned following the original claim for service connection, consideration has been given to the question of whether staged ratings would be in order. However, as the assigned evaluation reflects the degree of impairment shown since the date of the grant of service connection for a thoracolumbar spine disability, there is no basis for staged ratings with respect to this claim. Fenderson, 12 Vet. App. at 126. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2010). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2010). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria under the Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Schedule, and the assigned schedular evaluation is adequate, and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996) (when service- connected disability affects employment "in ways not contemplated by the rating schedule[,]" § 3.321(b)(1) is applicable). The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render her disabilities rating for her thoracolumbar spine disability inadequate. The Veteran's thoracolumbar spine disability was evaluated under 38 C.F.R. § 4.71, Diagnostic Code 5242, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. As noted above, the Veteran's thoracolumbar spine disability is manifested by pain and limitation of motion to, at most, 50 degrees of flexion and 15 degrees of extension. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the disabilities rating for her thoracolumbar spine disability. A rating in excess of the currently assigned rating is provided for certain manifestations of back disabilities, but the medical evidence reflects that those manifestations are not present in this case. The criteria for a 20 percent rating for the Veteran's thoracolumbar spine disability more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluation is adequate and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749 (1996); see also 38 C.F.R. § 4.71, Diagnostic Code 5242. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the evidence of record does not show findings that meet the criteria for an evaluation in excess of 20 percent, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Cervical Spine Service connection for cervical spondylosis was granted by a July 2005 rating decision and a noncompensable evaluation was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5242, effective October 1, 2004. The hyphenated diagnostic code in this case indicates that an unlisted musculoskeletal disorder, under Diagnostic Code 5299, was the service-connected disorder, and degenerative arthritis of the spine, under Diagnostic Code 5242, was a residual condition. See 38 C.F.R. § 4.27 (unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and "99"). Subsequently, a December 2006 supplemental statement of the case assigned a 10 percent evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5242, effective October 1, 2004. A May 2005 VA general medical examination report stated that radiographic examination of the cervical spine showed cervical spondylosis. The Veteran complained of intermittent neck pain and stiffness. She characterized the pain at a level of four to seven on a scale from one to ten, with radiation down the left arm which lasted for one to two hours. The Veteran denied loss of work due to pain and denied any incapacitating episodes in the previous 12 months, defined as bed rest prescribed by a physician. She denied experiencing flare-ups. On range of motion testing, the Veteran had cervical forward flexion to 45 degrees, extension to 45 degrees, right lateral flexion to 45 degrees, left lateral flexion to 45 degrees, right rotation to 80 degrees, and left rotation to 80 degrees. There was no pain in any area of motion. The Veteran did not have stiffness, muscle spasm, guarding, or localized tenderness. The impression was cervical spondylosis. In an April 2006 VA fee-based orthopedic examination report, the Veteran complained of neck pain. On physical examination of the Veteran's neck, there was normal position and alignment at rest. There was mild tenderness to palpation of the lower cervical spine, upper thoracic spine, and paravertebral muscle areas. On range of motion testing, the Veteran had full cervical forward flexion, extension to 40 degrees, right lateral flexion to 45 degrees, left lateral flexion to 45 degrees, right rotation to 80 degrees, and left rotation to 70 degrees. There was mild discomfort in the neck at the extremes of the ranges of motion. In an October 2006 private medical report, the Veteran complained of neck pain two days before which lasted for eight hours. She reported that the pain had been at a level of nine on a scale from one to ten, but denied muscle tightness, stiffness, and swollen glands. On physical examination, the cervical spine was normal in appearance without tenderness to palpation. The range of motion was normal and pain was not elicited by motion. In an April 2007 private medical report, the Veteran complained of neck pain which she characterized at a level of four to five on a scale from one to ten. On physical examination, the Veteran had a full range of motion of the neck In an August 2009 VA spine examination report, the Veteran complained of neck and arm pain at a level of three on a scale from one to ten. On physical examination of the cervical spine, there was tenderness in the C6-C7 area of the spinous processes and paraspinal muscle areas. On range of motion testing, the Veteran had cervical forward flexion to 63 degrees, extension to 45 degrees, right lateral flexion to 29 degrees, left lateral flexion to 29 degrees, right rotation to 73 degrees, and left rotation to 73 degrees. The Veteran had pain at the ends of all ranges of motion. There was increased pain in the cervical spine area after 10 repetitions. After x-ray examination of the cervical spine, the impression was degenerative osteoarthritis of the cervical spine; small cervical disc protrusion of C5-6; osteophyte formations with impingement and nerve root compression; and minimal first degree anterolisthesis of C2 over C3. The Veteran's service-connected cervical spine disability is rated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5242. Diagnostic Code 5242 provides that degenerative arthritis of the spine is rated under either the General Rating Formula or under Diagnostic Code 5003, for degenerative arthritis. The General Rating Formula states that a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, the combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent evaluation is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent evaluation is warranted for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. See 38 C.F.R. § 4.71a, General Rating Formula. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are rated separately under an appropriate diagnostic code. Id. at Note (1). The medical evidence of record shows that the Veteran's cervical spine disability is manifested by pain and limitation of motion to, at most, 45 degrees of flexion, 40 degrees of extension, 29 degrees of right lateral flexion, 29 degrees of left lateral flexion, 73 degrees of right rotation, and 70 degrees of left rotation. There is no medical evidence of record that the Veteran's cervical spine has ever been limited to 30 degrees or less of forward flexion or a combined range of motion of the cervical spine of 170 degrees or less. In addition, there is no medical evidence that the Veteran's cervical spine symptoms results in an abnormal gait or abnormal spinal contour. While the Veteran does have scoliosis, it is of the thoracolumbar spine and thus is not for consideration in the evaluation of the Veteran's cervical spine disability. The Veteran has reported neck pain on use, a contention which is substantiated by the evidence of record. However, the medical evidence of record does not show that this results in additional limitation in range of motion due to pain sufficient to limit the Veteran's forward flexion to 30 degrees or less or the combined range of motion of the cervical spine of 170 degrees or less. The April 2006 VA fee-based orthopedic examination report stated that pain occurred at "the extremes" of the range of motion. Similarly, the August 2009 VA spine examination report stated that there was pain "at the end of the range of motion." Accordingly, there is no medical evidence of record that the Veteran currently experiences pain which causes additional limitation of motion sufficient to warrant an evaluation in excess of 10 percent. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206. Accordingly, a rating in excess of 10 percent is not warranted under the General Rating Formula for the orthopedic manifestations of the Veteran's service-connected neck disability. See 38 C.F.R. § 4.71a, General Rating Formula, Diagnostic Code 5242. With regard to the neurologic manifestations of the Veteran's cervical spine disability, the medical evidence of record shows that the Veteran experiences arm pain which she has related to her cervical spine disability. However, there is no medical evidence of record that this pain is neurologic pain which is secondary to the Veteran's cervical spine disability, nor is there any other medical evidence of record that the Veteran has other neurologic manifestations of the cervical spine disability, including bowel and bladder impairment. In addition, service connection is already in effect for arthritis of the left hand and wrist and arthritis of the right hand. Accordingly, a separate evaluation for neurologic manifestations of the Veteran's cervical spine disability is not warranted. The medical evidence of record also shows that the Veteran's cervical spine disability impacts her cervical spine discs. Under the Formula for Rating IVDS, a 10 percent evaluation is warranted for incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months. A 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS. For the purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating IVDS, at Note (1). However, the medical evidence of record does not show that the Veteran has ever been prescribed bed rest by a physician for a period of at least two weeks in any one year period. As such, a rating in excess of 10 percent is not warranted under the Formula for Rating IVDS. See 38 C.F.R. § 4.71a, Formula for Rating IVDS. The record shows that cervical spine arthritis has been diagnosed, shown through x-ray examination. However, such findings, combined with the limitation of motion elicited, would warrant no more than a 10 percent evaluation under 38 C.F.R § 4.71a, Diagnostic Code 5003; see also 38 C.F.R. § 4.45. Additionally, awarding a separate evaluation under Diagnostic Code 5003 would constitute prohibited pyramiding. 38 C.F.R. § 4.14; see also Esteban, 6 Vet. App. at 261-62. Accordingly, an evaluation in excess of 10 percent is not warranted for the Veteran's cervical spine disability. As this issue deals with the rating assigned following the original claim for service connection, consideration has been given to the question of whether staged ratings would be in order. However, as the assigned evaluation reflects the degree of impairment shown since the date of the grant of service connection for a cervical spine disability, there is no basis for staged ratings with respect to this claim. Fenderson, 12 Vet. App. at 126. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render her disabilities rating for her cervical spine disability inadequate. The Veteran's cervical spine disability was evaluated under 38 C.F.R. § 4.71, Diagnostic Code 5242, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. As noted above, the Veteran's cervical spine disability is manifested by pain and limitation of motion to, at most, 45 degrees of flexion, 40 degrees of extension, 29 degrees of right lateral flexion, 29 degrees of left lateral flexion, 73 degrees of right rotation, and 70 degrees of left rotation. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the disabilities rating for her cervical spine disability. A rating in excess of the currently assigned rating is provided for certain manifestations of neck disabilities, but the medical evidence reflects that those manifestations are not present in this case. The criteria for a 10 percent rating for the Veteran's cervical spine disability more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluation is adequate and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749; see also 38 C.F.R. § 4.71, Diagnostic Code 5242. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the evidence of record does not show findings that meet the criteria for an evaluation in excess of 10 percent, the doctrine is not for application. Gilbert, 1 Vet. App. at 54. Right Hand, Bilateral Knees, Bilateral Hips, Left Ankle, and Bilateral Feet Prior to August 21, 2009 Service connection for degenerative osteoarthritis changes of the bilateral feet, right hand, bilateral knees, bilateral hips, left ankle, and thoracolumbar spine, was granted by a July 2005 rating decision and a 10 percent evaluation was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5003, effective October 1, 2004. Subsequently, a December 2006 statement of the case separated out the thoracolumbar spine disability, effective October 1, 2004, and kept the bilateral feet, right hand, bilateral knees, bilateral hips, and left ankle evaluated together. Finally, an August 2010 rating decision granted a separate evaluation for each individual joint, effective August 21, 2009, and discontinued the group evaluation effective the same date. As the Veteran's disabilities were compensated as a single disability prior to August 21, 2009, the Board will also address them as a single disability during that same time period. Diagnostic Code 5003 states that degenerative arthritis which is 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 in noncompensable under the appropriate diagnostic codes, a combined evaluation is assigned under Diagnostic Code 5003. A 10 percent evaluation is warranted with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent evaluation is warranted with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating episodes. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Accordingly, for the purposes of evaluating the Veteran's multiple joint degenerative arthritis disability prior to August 21, 2009, an increased evaluation will only be warranted if the degenerative arthritis caused occasional incapacitating episodes. In addition, separate evaluations will only be warranted prior to August 21, 2009, if the Veteran's degenerative arthritis caused compensable limitation of motion in any of the joints encompassed by the assigned 10 percent evaluation. For the sake of clarity, the Board will thus focus its discussion on these symptoms for the period prior to August 21, 2009. In a December 2004 VA outpatient medical report, the Veteran complained of generalized joint pain. After physical examination, the assessment was degenerative joint diseases. A May 2005 VA general medical examination report stated that radiographic examination gave an impression of degenerative osteoarthritic changes in the left hip, right hip, left knee, right knee, left ankle, right foot, left foot, and right hand. The Veteran reported that there was no effect on her occupation, recreation, or activities of daily living from the symptoms of her right foot and left foot. She reported that her right hand symptoms were "only 'annoying.'" The Veteran denied periods of incapacitation due to the symptoms of her right knee, left knee, right hip, left hip, and left ankle. On physical examination, the Veteran had normal ranges of motion, without pain, in all aspects for the left ankle, right knee, left knee, and right hip. The Veteran also had normal ranges of motion, without pain, in all aspects of the left hip, except for external rotation, which produced pain. The Veteran was able to spread her toes without difficulty or limited motion. She had bilateral hammertoes and flexible flat foot. The impression was degenerative osteoarthritic changes of the right foot and left foot, normal on examination; degenerative osteoarthritic changes of the right knee, left knee, right hip, left hip, and left ankle, all with a full range of motion; and multiple abnormalities of the right hand with a full range of motion. An April 2006 VA feebased examination stated that, on physical examination, the Veteran had a normal range of motion of the right hip and left hip. Her right knee range of motion was from 135 degrees of flexion to 0 degrees of extension. Her left knee range of motion was from 138 degrees of flexion to 0 degrees of extension. The Veteran's left ankle had a normal range of motion. The Veteran's right foot had a mild hammertoe deformity in the second and third toes with slight callus formation. Her left foot had a mild hammertoe deformity in the second and third toes with slight callus formation. No other foot deformities were noted. There was a full range of motion in the Veteran's right wrist and all right fingers. An October 2006 private medical report stated that, on physical examination, the Veteran's right hand and bilateral knees were normal. The report stated that the Veteran's "[h]ips showed full range of motion limited in all directions." The right hip was also noted as "[m]otion was abnormal." The diagnosis was osteoarthritis. A November 2006 private medical report stated that, on physical examination, the Veteran's right hip had full internal and external rotation. A February 2007 private medical report stated that, on physical examination, the Veteran's right hand was normal. The report stated that the Veteran's "[h]ips showed full range of motion limited in all directions." The right hip was also noted as "[m]otion was abnormal." A July 2008 private medical report stated that, on physical examination, the Veteran had normal movement of all extremities. The medical evidence of record shows that, for the period prior to August 21, 2009, the Veteran's degenerative arthritis of the right hand, bilateral knees, bilateral hips, left ankle, and bilateral feet was manifested by pain and arthritis shown through x-ray examination. There is no medical evidence of record that the Veteran's degenerative arthritis caused occasional incapacitating episodes prior to August 21, 2009. Accordingly, an evaluation in excess of 10 percent is not warranted under Diagnostic Code 5003 prior to August 21, 2009. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board has also considered whether separate evaluations are warranted for the Veteran's right hand, right knee, left knee, right hip, left hip, left ankle, right foot, and left foot prior to August 21, 2009. In this regard, the October 2006 and February 2007 private medical reports both stated that the Veteran's "[h]ips showed full range of motion limited in all directions," and that the right hip was noted as "[m]otion was abnormal." Accordingly, the Board does not find these reports probative medical evidence that the Veteran had compensable limitation of motion or laxity of either hip. Accordingly, there is no medical evidence of record that, prior to August 21, 2009, the Veteran experienced limitation of motion or joint laxity that was compensable in degree in the right hand, right knee, left knee, right hip, left hip, or left ankle. 38 C.F.R. § 4.71a, Diagnostic Codes 5214, 5215, 5250, 5251, 5252, 5253, 5256, 5257, 5258, 5260, 5261, 5270, 5271 (2010). Accordingly, the provisions of Diagnostic Code 5003 do now allow for a separate evaluation for those joints prior to August 21, 2009. With respect to the Veteran's feet, there are no diagnostic codes which provide evaluations based on limitation of motion of the foot. However, a separate evaluation is not warranted for either foot, as there is no medical evidence of record that either of the Veteran's feet warranted a compensable evaluation under any diagnostic code prior to August 21, 2009. The medical evidence of record does not show that the Veteran had bilateral weak foot, acquired claw foot, Morton's disease, unilateral hallux valgus, unilateral hallux rigidus, or malunion or nonunion of the tarsal or metatarsal bones. 38 C.F.R. § 4.71a, Diagnostic Codes 5277, 5278, 5279, 5280, 5281, 5283 (2010). While the May 2005 VA medical examination report stated that the Veteran had "flexible flat foot," flatfoot was not found on any other physical examination prior to August 21, 2009. Accordingly, the Board finds that any flatfoot that was present was not more than mild, and thus an initial compensable evaluation is not warranted for flatfoot. 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2010). Furthermore, while the medical evidence of record shows that the Veteran had hammer toes, the condition was limited to the second and third toes of each foot, and thus an initial compensable evaluation is not warranted for hammer toes. 38 C.F.R. § 4.71a, Diagnostic Code 5282 (2010). Finally, due to the general lack of significant foot symptomatology for the period prior to August 21, 2009, the Board finds that the Veteran's bilateral foot disorder was best characterized as being mild. Accordingly, a compensable evaluation is not warranted for other foot injuries. 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2010). For the purposes of all of the separate evaluations considered above, the Board has also considered the Veteran's reports of pain on use. However, the medical evidence of record does not show that, prior to August 21, 2009, the Veteran experienced pain which caused additional limitation of motion sufficient to warrant a compensable evaluation in any of the relevant joints. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206. Consideration has been given to the question of whether staged ratings would be in order. However, as the assigned evaluation reflects the degree of impairment shown since the date of the grant of service connection for degenerative osteoarthritic changes, right hand, bilateral knees, bilateral hips, left ankle, and bilateral feet with hammertoe deformity, there is no basis for staged ratings with respect to this claim. Fenderson, 12 Vet. App. at 126. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render her disabilities rating for her right hand, bilateral knees, bilateral hips, left ankle, and bilateral feet prior to August 21, 2009 inadequate. The Veteran's degenerative arthritis of the relevant joints was evaluated under 38 C.F.R. § 4.71, Diagnostic Code 5003, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. As noted above, prior to August 21, 2009, the Veteran's degenerative arthritis was manifested by pain and arthritis shown through x-ray examination. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the disabilities rating for her degenerative arthritis of the relevant joints. A rating in excess of the currently assigned rating is provided for certain manifestations of degenerative arthritis of the relevant joints, but the medical evidence reflects that those manifestations are not present in this case. The criteria for a 10 percent rating for the Veteran's degenerative arthritis of the relevant joints prior to August 21, 2009 more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluation is adequate and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749; see also 38 C.F.R. § 4.71, Diagnostic Code 5003. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the evidence of record does not show findings that meet the criteria for an evaluation in excess of 10 percent, the doctrine is not for application. Gilbert, 1 Vet. App. 49 (1990). Bilateral Knee Disorder, Subsequent to August 21, 2009 A separate rating for degenerative osteoarthritic changes of the right and left knees was granted by an August 2010 rating decision and a 10 percent evaluation was assigned for each knee under 38 C.F.R. § 4.71a, Diagnostic Code 5003, effective August 21, 2009. In an August 2009 VA joints examination report, the Veteran complained of bilateral knee pain after standing for one hour. She reported that the pain was at a level of six to seven on a scale from one to ten, increasing with cold weather and weather changes. The Veteran reported that the pain caused her to sit while teaching. She reported that she could walk one mile and did not use assistive devices. On physical examination of the bilateral knees, there was no evidence of swelling, erythema, or tenderness. On range of motion testing, the Veteran had flexion to 110 degrees with pain at the end of the range of motion, bilaterally. The knees were stable and there was no additional limitation following repetitive use. On x-ray examination, there were degenerative changes in the left knee, but the right knee was normal. The impression was borderline degenerative changes of the left knee and normal right knee. The examiner opined that the Veteran did not have functional impairment of the knees. Degenerative arthritis is rated on the basis of limitation of motion. However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is warranted for each major joint affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability from arthritis, the knee is considered to be a major joint. 38 C.F.R. § 4.45 (2010). Limitation of motion of knee joints is rated under Diagnostic Code 5260 for flexion, and Diagnostic Code 5261 for extension. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Under Diagnostic Code 5260, flexion that is limited to 60 degrees is noncompensable, flexion that is limited to 45 degrees warrants a 10 percent evaluation, and flexion that is limited to 30 degrees warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, extension that is limited to 5 degrees is noncompensable, extension that is limited to 10 degrees warrants a 10 percent evaluation, and extension that is limited to 15 degrees warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The standard motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2010). Recurrent subluxation or lateral instability of the knee warrants a 10 percent evaluation when it is slight and a 20 percent evaluation when it is moderate. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The medical evidence of record shows that, for the period on and after August 21, 2009, both of the Veteran's knee disabilities are manifested by pain and limitation of motion to 110 degrees of flexion. Limitation of motion on extension has not been shown. Accordingly, a rating in excess of 10 percent is not warranted for either knee under either Diagnostic Codes 5260 or 5261. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. In addition, separate ratings for limitation of flexion and extension are not warranted for either knee, as the record does not show that the Veteran's knee ranges of motion have ever been limited to a compensable degree in either flexion or extension. See Id.; see also VAOPGCPREC 9-04, 69 Fed. Reg. 59990 (2004). The Veteran has reported bilateral knee pain on use, a contention which is substantiated by the medical evidence of record. However, the August 2009 VA joints examination report stated that there was pain "at the end" of the range of motion. Accordingly, there is no medical evidence of record that the Veteran currently experiences pain which causes additional limitation of motion sufficient to warrant an evaluation in excess of 10 percent for either knee. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206. As for other provisions under the Schedule, the Veteran's bilateral knees have never been ankylosed, there was no malunion or nonunion of either the tibia or fibula, and there were no symptoms from the removal or dislocation of semilunar cartilage. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262 (2010); see also VAOPGCPREC 23-97, 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). Accordingly initial evaluations in excess of 10 percent are not warranted under these diagnostic codes. Furthermore, a separate evaluation for instability is not warranted for either knee, as the medical evidence of record does not show recurrent subluxation or lateral instability. Accordingly, a separate evaluation for instability is not warranted for either knee. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render her disabilities rating for degenerative osteoarthritic changes of the right and left knees inadequate. The Veteran's knee disabilities were evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5003, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. As noted above, both of the Veteran's knee disabilities are manifested by pain and limitation of motion to 110 degrees of flexion. When comparing these disability pictures with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the disabilities ratings assigned for her right and left knee disabilities. Ratings in excess of the currently assigned ratings are provided for certain manifestations of knee disorders, but the medical evidence reflects that those manifestations are not present in this case. The criteria for 10 percent ratings for the Veteran's degenerative osteoarthritic changes of the right and left knees more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluations are adequate and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749; see also 38 C.F.R. § 4.71a, Diagnostic Code 5003. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence does not show findings that meet the criteria for ratings in excess of 10 percent at any time subsequent to August 21, 2009, the doctrine is not for application. Gilbert, 1 Vet. App. 56; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). Bilateral Hip Disorder Subsequent to August 21, 2009 Separate ratings for degenerative osteoarthritic changes of the right and left hips was granted by an August 2010 rating decision and a 10 percent evaluation was assigned for each hip under 38 C.F.R. § 4.71a, Diagnostic Code 5003, effective August 21, 2009. In an August 2009 VA joints examination report, the Veteran complained of bilateral hip pain when sitting or standing. She reported that on a scale from one to ten, the pain was at a level of six to seven in the morning, decreased to three, then increased to eight or nine by the end of the day. The Veteran did not use assistive devices and could walk one mile. She reported that she sat at work due to pain and had to rotate from side to side due to her hip pain. The Veteran did not have "true" flare-ups. On physical examination, the hips were symmetrical without evidence of swelling, tenderness, or erythema. The Veteran's right hip range of motion was to 98 degrees of flexion, 9 degrees of extension, 75 degrees of external rotation, and 35 degrees of internal rotation. The Veteran's left hip range of motion was to 99 degrees of flexion, 10 degrees of extension, 70 degrees of external rotation, and 40 degrees of internal rotation. The examiner reported abduction to 25 degrees with pain at the end of motion in the right hip, and abduction to 20 degrees with pain at the end of motion in the left hip. The examiner also reported abduction to 30 degrees with pain at the end of motion in the right hip, and abduction to 21 degrees with pain at the end of motion in the left hip. There were no additional limitations following repetitive use. On x-ray examination, there were degenerative changes in the right hip, but the left hip was normal. The impression was borderline degenerative changes of the right hip and normal left hip. The examiner opined that the Veteran did not have functional impairment of the hips. The medical evidence of record shows that, for the period on and after August 21, 2009, the Veteran's right hip disorder is manifested by pain and limitation of motion from 9 degrees of extension to 98 degrees of flexion and her left hip disorder is manifested by pain and limitation of motion from 10 degrees of extension to 99 degrees of flexion. Degenerative arthritis is rated on the basis of limitation of motion. However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is warranted for each major joint affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability from arthritis, the hip is considered to be a major joint. 38 C.F.R. § 4.45. The Schedule provides that assignment of a 10 percent is warranted for limitation of thigh extension to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5251. A 10 percent evaluation is the maximum rating for this disorder under the provisions of Diagnostic Code 5251. Accordingly, higher ratings are not possible under this diagnostic code. The Schedule provides that assignment of a 10 percent rating is warranted for limitation of thigh flexion to 45 degrees. A 20 percent evaluation is warranted for limitation of thigh flexion to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. The medical evidence of record does not show that the Veteran's range of motion has ever been limited to 30 degrees of flexion in either hip. Accordingly, higher evaluations are not warranted under this diagnostic code. The Schedule provides that assignment of a 10 percent rating for impairment of the thigh is warranted for an inability to cross legs and an inability to toe-out more than 15 degrees. A 20 percent rating is warranted for a limitation of abduction beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. The medical evidence of record does not show that the Veteran's range of motion has ever been limited to 10 degrees of abduction in either hip. Accordingly, higher evaluations are not warranted under this diagnostic code. The Board has considered rating the Veteran's service-connected left hip disorder under all appropriate diagnostic codes. However, the evidence of record does not demonstrate that the Veteran has ankylosis of either hip, flail joint of either hip, fracture of the shaft or anatomical neck of either femur with nonunion, fracture of the surgical neck of either femur with a false joint, or malunion of either femur. See 38 C.F.R. § 4.71a, Diagnostic Codes 5250, 5254, 5255 (2010). Accordingly, ratings in excess of 10 percent are not warranted for the Veteran's service-connected hip disabilities under these diagnostic codes. The Veteran has reported bilateral hip pain on use, a contention which is substantiated by the medical evidence of record. The August 2009 VA joints examination report stated that there was pain "at the end" of the ranges of motion. Accordingly, there is no medical evidence of record that the Veteran currently experiences pain which causes additional limitation of motion sufficient to warrant an evaluation in excess of 10 percent for either hip. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render her disabilities rating for degenerative osteoarthritic changes of the right and left hips inadequate. The Veteran's hip disabilities were evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5003, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. As noted above, the Veteran's right hip disorder is manifested by pain and limitation of motion from 9 degrees of extension to 98 degrees of flexion and her left hip disorder is manifested by pain and limitation of motion from 10 degrees of extension to 99 degrees of flexion. When comparing these disability pictures with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the disabilities ratings assigned for her right and left hip disabilities. Ratings in excess of the currently assigned ratings are provided for certain manifestations of hip disorders, but the medical evidence reflects that those manifestations are not present in this case. The criteria for 10 percent ratings for the Veteran's degenerative osteoarthritic changes of the right and left hips more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluations are adequate and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749; see also 38 C.F.R. § 4.71a, Diagnostic Code 5003. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence does not show findings that meet the criteria for ratings in excess of 10 percent at any time subsequent to August 21, 2009, the doctrine is not for application. Gilbert, 1 Vet. App. 56; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). A Right Hand Disorder Subsequent to August 21, 2009 A separate rating for degenerative osteoarthritic changes of the right hand was granted by an August 2010 rating decision and a 10 percent evaluation was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5003, effective August 21, 2009. In an August 2009 VA hand, thumb, and fingers examination report, the Veteran complained of right hand numbness and pain on awakening which lasted for 30 to 60 minutes. She reported that she experienced continuous pain which she rated on a scale from one to ten, at a level of three, increasing to eight to nine with extended use. The Veteran was left-handed and it was reported that she did not have "true" flare-ups. On physical examination, the Veteran's right hand was cool to touch, but with normal color and capillary filling. There was no evidence of swelling, erythema, or tenderness. The first metacarpal phalangeal joint had flexion to 48 degrees. The first interphalangeal joint had flexion to 77 degrees, with pain at the end. The remaining fingers had flexion of the proximal phalanges to 99 degrees without pain, the middle interphalangeal joints to 85 degrees without pain, and the distal interphalangeal joints to 77 degrees without pain. The right hand showed closure of all the digits to the proximal palmar crease. The thumb was able to touch the fingertips. The Veteran had full strength in her right hand. Extension of the fingers of the right hand was to 9 degrees. The Veteran had right wrist range of motion to 72 degrees of dorsiflexion, 65 degrees of palmar flexion, 35 degrees of radial deviation, and 35 degrees of ulnar deviation without pain. There was no additional limitation following repetitive use. Electromyography and radiographic examinations of the Veteran's right hand were both normal. The impression was normal right hand. The examiner opined that the Veteran did not have functional impairment of the right hand. The medical evidence of record shows that for the period on and after August 21, 2009, the Veteran's right hand disorder is manifested by pain. Degenerative arthritis is rated on the basis of limitation of motion. However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is warranted for each major joint affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability from arthritis, the wrist is considered to be a major joint. 38 C.F.R. § 4.45. The Schedule provides that assignment of a 10 percent evaluation is warranted for limitation of motion of the wrist to less than 15 degrees of dorsiflexion or with palmar flexion limited in line with the forearm. 38 C.F.R. § 4.71a, Diagnostic Code 5215. The medical evidence of record does not show that the Veteran's right wrist range of motion has ever been limited to these ranges of motion. Accordingly, a separate compensable evaluation is not warranted under this diagnostic code. With regard to the Veteran's individual digits, the Schedule provides that assignment of a noncompensable rating is warranted for all limitations of motion of the ring finger and little fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5230. Accordingly, a separate compensable evaluation is not warranted under this diagnostic code. The Schedule provides that assignment of a 10 percent rating is warranted for limitation of motion of the index or long finger with a gap of one inch or more between the fingertip and the proximal transverse crease of the palm, or with extension limited by more than 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5229. There is no medical evidence of record that for the period on and after August 21, 2009, the Veteran experienced limitation of motion of the index or long finger with a gap of one inch or more between the fingertip and the proximal transverse crease of the palm, or extension that was limited by more than 30 degrees. Accordingly, a separate compensable evaluation is not warranted under this diagnostic code. The Schedule provides that assignment of a 10 percent rating is warranted for limitation of motion of the thumb with a gap of one to two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5228. There is no medical evidence of record that for the period on and after August 21, 2009, the Veteran experienced limitation of motion of the thumb with a gap of one to two inches between the thumb pad and the fingers. Accordingly, a separate compensable evaluation is not warranted under this diagnostic code. The Veteran has reported right hand pain on use, a contention which is substantiated by the medical evidence of record. However, the August 2009 VA joints examination report found pain only on a few of the ranges of motion, and even then characterized the pain as being "at the end" of the ranges of motion. This characterization is not consistent with pain that was sufficient to meet the criteria for compensable evaluation for limitation of motion of the wrist or digits. Accordingly, there is no medical evidence of record that the Veteran currently experiences pain which causes additional limitation of motion sufficient to warrant an evaluation in excess of 10 percent for her right hand. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render her disabilities rating for degenerative osteoarthritic changes of the right hand inadequate. The Veteran's right hand disability was evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5003, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. As noted above, the Veteran's right hand disorder is manifested by pain. When comparing this disability picture with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the disabilities ratings assigned for her right hand disability. Ratings in excess of the currently assigned rating are provided for certain manifestations of hand disorders, but the medical evidence reflects that those manifestations are not present in this case. The criteria for 10 percent ratings for the Veteran's degenerative osteoarthritic changes of the right hand more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluation is adequate and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749; see also 38 C.F.R. § 4.71a, Diagnostic Code 5003. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence does not show findings that meet the criteria for a rating in excess of 10 percent at anytime subsequent to August 21, 2009, the doctrine is not for application. Gilbert, 1 Vet. App. 56; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Bilateral Foot Disorder Subsequent to August 21, 2009 A separate evaluation for degenerative osteoarthritic changes of both feet with hammertoe deformity was granted by an August 2010 rating decision and a noncompensable evaluation was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5003, effective August 21, 2009. In an August 2009 VA feet examination report, the Veteran complained of numbness and a burning sensation in her toes, but "not a true pain." The Veteran was able to perform her job and the symptoms did not impact her activities of daily living. The Veteran did not use an assistive device. On physical examination, the feet were symmetrical. There were eight degrees of hallux valgus, bilaterally. The Veteran's toes had proximal interphalangeal joint flexion to 28 degrees in hammertoes position, and metacarpal phalangeal joint flexion to 28 degrees. There was no pain on motion. There was no swelling, erythema, or tenderness in either foot. There was mild to moderate pes planus and a three degree Achilles-calcaneal valgus, bilaterally. The Veteran's ankles had essentially normal stability. On x-ray examination, the Veteran had right foot degenerative osteoarthritis with spur formation on the plantar aspect of the calcaneus. The left foot had minimal degenerative changes of the first metatarsophalangeal joint. The impression was bilateral hammertoes; degenerative osteoarthritis with spur formation, right foot; minimal degenerative changes of the first left metacarpal phalangeal joint; bilateral hallux valgus; mild to moderate pes planus; and Achilles-calcaneal valgus. The examiner opined that the Veteran had minimal functional impairment of the feet due to pain. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21 (2010). The Board is also required to consider all potentially applicable diagnostic codes, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, service connection has been granted for degenerative osteoarthritis of the bilateral feet. This disability is a separate and distinct disability from other foot disabilities, such as flatfoot and hammertoes. However, the Veteran has specifically stated that her flatfoot and hammertoes began during military service, and as discussed above, both flatfoot and hammertoes were found on physical examination in May 2005. That examination was conducted only eight months after the Veteran's separation from a 20 year period of continuous active duty service. Accordingly, the medical evidence of record supports the Veteran's claims that these other foot disabilities began during active military service. As such, the Board will consider all of the Veteran's foot symptoms as part of the adjudication of the bilateral foot claim on appeal. The Veteran's disability is currently evaluated under Diagnostic Code 5003, which stated that degenerative arthritis is rated on the basis of limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, there are no diagnostic codes which provide evaluations based on limitation of motion of the foot. Instead, the medical evidence of record specifically states that the Veteran has flatfoot, hammertoes, and hallux valgus. Of these disabilities, only the diagnostic code for flatfoot contemplates general foot pain, the main symptom for which the Veteran is currently receiving a 10 percent evaluation under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5276. In addition, due to the far greater scope of foot symptomatology contemplated by Diagnostic Code 5276, that diagnostic code is more analogous to the Veteran's bilateral foot disability than Diagnostic Code 5003. As such, the Board finds that the Veteran's bilateral foot symptoms are most analogous to an evaluation under Diagnostic Code 5276, which contemplates acquired flatfoot. 38 C.F.R. § 4.71a, Diagnostic Code 5276; see Butts v. Brown, 5 Vet. App. 532, 538 (1993) (stating that assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case."); Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992) (stating that any change in Diagnostic Code by a VA adjudicator must be specifically explained.) The Schedule provides that assignment of a noncompensable evaluation is warranted for mild acquired flatfoot with symptoms relieved by built up shoe or arch support. A 10 percent evaluation is warranted for acquired flatfoot, both bilateral and unilateral, that is moderate in severity with weight-bearing line over or medial to the great toe, inward bowing of the atendo achillis, pain on manipulation and use of the feet. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, warrants a 20 percent evaluation if it is unilateral and a 30 percent evaluation if it is bilateral. 38 C.F.R. § 4.71a, Diagnostic Code 5276. The medical evidence of record shows that the Veteran's bilateral flatfoot is "mild to moderate" in severity. As such, an evaluation in excess of 10 percent is not warranted under Diagnostic Code 5276, as the medical evidence of record does not demonstrate that the Veteran has severe flatfoot. In addition, the medical evidence of record shows that the Veteran has a current diagnosis of bilateral hammertoes. Under Diagnostic Code 5282, hammertoe warrants a noncompensable evaluation when it impacts single toes, and a 10 percent evaluation when it impacts all toes. 38 C.F.R. § 4.71a, Diagnostic Code 5282. The August 2009 VA feet examination report stated that the Veteran's "toes" were "in hammertoe position." While the report does not specifically say which toes were "in hammertoe position," the phrasing of the sentence indicates that it applied to all toes. As further clarification is not available, the higher of these two evaluations must be assigned. 38 C.F.R. § 4.7 (2010). Accordingly, separate 10 percent evaluations are warranted for the Veteran's left foot hammertoes and right foot hammertoes. With regard to the Veteran's hallux valgus, under Diagnostic Code 5280, unilateral hallux valgus warrants a 10 percent evaluation if it is severe and equivalent to amputation of the great toe, or operated with resection of the metatarsal head. The August 2009 VA feet examination report stated that the Veteran had eight degrees of bilateral hallux valgus. While no specific characterization of the severity of this disorder was made, the Veteran has not reported any significant complaints with regard to her great toes and the examiner who wrote the August 2009 VA feet examination report stated that the Veteran had only "minimal functional impairment" of the feet. Accordingly, the preponderance of the evidence of record does not demonstrate that the Veteran's bilateral hallux valgus is sufficiently severe to be equivalent to amputation of the great toes. As such, separate evaluations for right foot hallux valgus and left foot hallux valgus are not warranted. 38 C.F.R. § 4.31 (2010). The Board has considered rating the Veteran's service-connected bilateral foot disorder under all appropriate diagnostic codes. However, the evidence of record does not demonstrate that the Veteran has weak foot, claw foot, Morton's disease, hallux rigidus, or malunion or nonunion of the tarsal or metatarsal bones. See 38 C.F.R. § 4.71a, Diagnostic Codes 5277, 5278, 5279, 5281, 5283 (2010). In addition, the preponderance of the medical evidence of record does not demonstrate that the Veteran's bilateral foot disability is moderately severe in nature. See 38 C.F.R. § 4.71a, Diagnostic Codes 5284 (2010). Accordingly, ratings in excess of 10 percent are not warranted for the Veteran's service-connected bilateral foot disability under these diagnostic codes. The Veteran has reported bilateral foot pain on use, a contention which is substantiated by the medical evidence of record. However, pain on manipulation and use is explicitly mentioned in the criteria for the evaluation of flatfeet and has thus been specifically considered. 38 C.F.R. § 4.71a, Diagnostic Code 5276. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render her disabilities rating for a bilateral foot disability inadequate. The Veteran's foot disabilities were evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5276, 5280, and 5282, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. As noted above, the Veteran's bilateral foot disability is manifested by pain, moderate bilateral flatfoot, hammertoes of all toes, and bilateral hallux valgus that was not equivalent to amputation of the great toes. When comparing these disability pictures with the symptoms contemplated by the Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the disabilities ratings assigned herein for her bilateral foot disabilities. Ratings in excess of the currently assigned ratings are provided for certain manifestations of foot disorders, but the medical evidence reflects that those manifestations are not present in this case. The criteria for the evaluations assigned herein for the Veteran's bilateral foot disability more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the currently assigned schedular evaluations are adequate and no referral is required. See VAOGCPREC 06-96, 61 Fed. Reg. 66749; see also 38 C.F.R. § 4.71a, Diagnostic Codes 5276, 5280, and 5282. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence does not show findings that meet the criteria for ratings in excess of those assigned herein at anytime subsequent to August 21, 2009, the doctrine is not for application. Gilbert, 1 Vet. App. 56; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). ORDER An evaluation in excess of 20 percent for service-connected degenerative osteoarthritic changes, thoracolumbar spine, is denied. An evaluation in excess of 10 percent for service-connected cervical spondylosis is denied. An evaluation in excess of 10 percent for service-connected degenerative osteoarthritic changes, right hand, bilateral knees, bilateral hips, left ankle, and bilateral feet with hammertoe deformity, for the period from October 1, 2004 to August 21, 2009, is denied. An evaluation in excess of 10 percent for service-connected degenerative osteoarthritic changes, right knee, for the period on and after August 21, 2009, is denied. An evaluation in excess of 10 percent for service-connected degenerative osteoarthritic changes, left knee, for the period on and after August 21, 2009, is denied. An evaluation in excess of 10 percent for service-connected degenerative osteoarthritic changes, right hip, for the period on and after August 21, 2009, is denied. An evaluation in excess of 10 percent for service-connected degenerative osteoarthritic changes, left hip, for the period on and after August 21, 2009, is denied. An evaluation in excess of 10 percent for service-connected degenerative osteoarthritic changes, right hand, for the period on and after August 21, 2009, is denied. An evaluation in excess of 10 percent, for degenerative osteoarthritic changes of the feet, bilateral hallux valgus, and bilateral pes planus for the period on and after August 21, 2009, is denied. A separate evaluation of 10 percent for right foot hammertoe, for the period on and after August 21, 2009, is granted, subject to the laws and regulations governing the payment of monetary benefits. A separate evaluation of 10 percent, but no more, for left foot hammertoe, for the period on and after August 21, 2009, is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND With respect to the Veteran's left ankle claim, an August 2009 VA joints examination report stated that the Veteran had left ankle dorsiflexion to 2 degrees without pain, and plantar flexion to 82 degrees, without pain. However, as the normal range of dorsiflexion of the ankle is to 20 degrees, and normal plantar flexion is to 45 degrees. 38 C.F.R. § 4.71, Plate II. Furthermore, the finding of 2 degrees of motion on dorsiflexion represents a 90 percent loss of range of motion on dorsiflexion, a finding which is not remotely consistent with the other findings described in the August 2009 VA joints examination report. As such, the left ankle claim must be remanded for a new medical examination as the August 2009 VA joints examination report was inadequate. 38 C.F.R. § 3.159(c)(4); Barr, 21 Vet. App. at 311 (noting that if VA provides the Veteran with an examination, the examination must be adequate). In February 2009, the Board remanded the claim of entitlement to service connection for a psychiatric disorder, to include PTSD. Subsequently, an August 2010 rating decision granted service connection for a psychiatric disorder, to include PTSD and anxiety, and assigned a 30 percent evaluation under 38 C.F.R. § 4.130, Diagnostic Code 9411, effective September 4, 2009. In August 2010, the Veteran filed a notice of disagreement with the effective date assigned for the Veteran's psychiatric disorder by the August 2010 rating decision. The filing of a notice of disagreement initiates the appeal process. See Godfrey v. Brown, 7 Vet. App. 398, 408-410 (1995). VA has not yet issued a statement of the case as to the issue of entitlement to an effective date earlier than September 4, 2009, for the grant of service connection for a psychiatric disorder, to include PTSD and anxiety. 38 C.F.R. § 19.26 (2010). The Board is, therefore, obligated to remand this issue. See Manlicon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is remanded for the following actions: 1. The RO must make arrangements with the appropriate VA medical facility for the Veteran to be afforded an orthopedic examination to determine the current severity of her service-connected left ankle disability. The claims folder and a copy of this remand must be made available to the examiner for review in conjunction with the examination. All indicated testing must be conducted, including a thorough orthopedic examination of the left ankle. The examiner must record pertinent complaints, symptoms, and clinical findings, to include whether instability exists, and if so, to what degree. Any pain during range of motion testing must be noted, and the examiner must accurately measure and report where any recorded pain begins when measuring range of motion, with and without repetition. If limitation of motion is found, the examiner must characterize the limitation of motion as mild, moderate, or marked. Then, after reviewing the Veteran's complaints and medical history, the orthopedic examiner must render an opinion as to the extent to which the Veteran experiences functional impairments, such as weakness, excess fatigability, incoordination, or pain due to repeated use or flare-ups, etc. Objective evidence of loss of functional use can include the presence or absence of muscle atrophy and/or the presence or absence of changes in the skin indicative of disuse due to a left ankle disorder. A complete rationale for all opinions must be provided. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and specifically explain why an opinion cannot be provided without resort to speculation. The report must be typed. 2. The RO must notify the Veteran that it is her responsibility to report for the VA examination scheduled, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2010). In the event that the Veteran does not report for the scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. Copies of all documentation notifying the Veteran of any scheduled VA examination must be placed in the Veteran's claims file. 3. The RO must then readjudicate the left ankle claim and, thereafter, if the claim on appeal remains denied, the Veteran and her representative must be provided a supplemental statement of the case. After the Veteran and her representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. 4. The RO must issue a statement of the case and notification of the Veteran's appellate rights on the issue of entitlement to an effective date earlier than September 4, 2009, for the grant of service connection for a psychiatric disorder, to include PTSD and anxiety. See 38 C.F.R. §§ 19.29, 19.30 (2010). The Veteran and her representative are reminded that to vest jurisdiction over this issue with the Board, a timely substantive appeal to the August 2010 rating decision must be filed. 38 C.F.R. § 20.202 (2010). If the Veteran perfects the appeal as to this issue, the case must be returned to the Board for appellate review. No action is required by the Veteran until she receives further notice; however, she may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs