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