Citation Nr: 1237266 Decision Date: 10/26/12 Archive Date: 11/09/12 DOCKET NO. 09-26 130 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a left ankle disability, to include as secondary to the service-connected pes planus. 2. Entitlement to a disability rating in excess of 10 percent for the service-connected left knee chondromalacia. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD L.B. Cryan, Counsel INTRODUCTION The Veteran had active military service from October 1989 to October 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In a February 2011 decision, the Board reopened a previously denied claim of service connection for pes planus and a left ankle condition, and remanded those issues, along with the issue of entitlement to a rating in excess of 10 percent for left knee chondromalacia, back to the RO for additional development of the record. Before the case was returned to the Board on appeal, the RO issued a rating decision in April 2012 in which service connection for bilateral pes planus was granted, with an initial disability of 50 percent assigned. As this represents a complete grant of benefits on appeal with respect to that issue, the issue of entitlement to service connection for pes planus is no longer before the Board or on appeal at this time. In September 2012, the RO issued a Supplemental Statement of the Case which only addressed the issue of entitlement to an increased rating for the service-connected chondromalacia, rated as 10 percent disabling. However, the issue of service connection for a left ankle disability was not readjudicated at the RO before the case was re-certified to the Board on appeal in October 2012. The issue of entitlement to service-connection for a left ankle disability was not included in the September 2012 Supplemental Statement of the Case, and a review of the claims file and the Veteran's virtual VA folder does not show that this disability was granted in any rating decision to date. Although the issue of entitlement to service connection for a left ankle disability was, at one time, included with the issue of entitlement to service connection for pes planus, the grant of service connection for pes planus does not automatically subsume the issue of entitlement to service connection for a left ankle disability. This is a separate issue, and it remains in appellate status, despite the grant of service connection for pes planus. It is apparent that the RO also considered the issue separately given that the RO scheduled the Veteran for an examination of the left ankle in August 2012, after they issued the April 2012 rating decision which granted service connection for pes planus. It is unclear why the issue of entitlement to service connection was not addressed after the August 2012 VA examination, either in a subsequent rating decision, or in the September 2012 SSOC. That notwithstanding, the Board is granting service connection for a left ankle disability in this decision; and, as such, the lack of the RO's inclusion of the issue on the September 2012 SSOC results in harmless error. FINDINGS OF FACT 1. The competent medical evidence of record establishes that the Veteran's left ankle disability is at least as likely as not caused by his service-connected pes planus. 2. The service-connected left knee chondromalacia is manifested by pain, with flexion of the knee limited to, at most, 100 degrees with pain, and extension at 0; neither ankylosis nor instability and/or subluxation of the left knee is demonstrated. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left ankle disability have been met. 38 U.S.C.A. § § 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2011). 2. The criteria for the assignment of a disability rating in excess of 10 percent for the service-connected left knee disability have not been met at any time during the appeal period. 38 U.S.C.A. § 1155, 5103, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 4.1-4 .14, 4.71a, Diagnostic Codes 5260, 5003 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Despite any defect in the notice provided to the Veteran regarding the service connection claim, that claim is being granted in full pursuant to this decision; thus, any defect in this regard results in harmless error. With regard to the increased rating claim, the RO provided the appellant pre-adjudication notice by letter dated in August 2007. This notification letter complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. The letter also notified the Veteran about degrees of disability and effective dates. After these issues were remanded for additional development of the record in February 2011, the RO issued another duty-to-assist letter to the Veteran which once again notified the claimant of the information and evidence not of record that is necessary to substantiate the claims, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notices provided to the Veteran over the course of the appeal provided all information necessary for a reasonable person to understand what evidence and/or information was necessary to substantiate his claims. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). VA has obtained service treatment records, assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations, and afforded the Veteran the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. At the most recent VA examination in August 2012, the VA examiner refers to a July 2012 x-ray of the left knee that was negative. The actual x-ray report is not of record, but the lack of this evidence does not have any impact on this claim. Even if the x-ray report were of record, and assuming, arguendo, that the report did, in fact, show arthritis of the left knee, the outcome in this case would be the same. The Veteran's service-connected disability is already being rated based on limitation of motion with pain, the same basis upon which arthritis is rated. As discussed in more detail below, the outcome of this case is not dependent on whether the Veteran has arthritis of the knee. Pursuant to the Veteran's requests throughout the course of the appeal, the Veteran's pertinent VA treatment records from the New York City VA Medical Center were obtained, and the Veteran has been diligent in identifying and providing pertinent private records to the RO and Board. The Veteran's knee has been examined on three different occasions during the course of the appeal to assess the severity of his disability. There has also been substantial compliance with the Board's remand as the RO obtained VA treatment records dating from June 2007 and provided examinations to the Veteran which are adequate. In light of the foregoing, VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. II. Service Connection The Veteran seeks service connection for a left ankle disability. The Veteran asserts that his service-connected pes planus has either caused or aggravated his left ankle disability. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where there is a chronic disease shown as such in service or within the presumptive period under § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however, remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). This rule does not mean that any manifestations in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease entity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Additionally, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). See Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. See 38 C.F.R. § 3.310(a), (b), as amended effective October 10, 2006. In this case, the Veteran's claim for service connection was filed in June 2007. The credibility and weight of all the evidence, including the medical evidence, should be assessed to determine its probative value, and the evidence found to be persuasive or unpersuasive should be accounted for, and reasons should be provided for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). VA medical records show complaints of ankle pain. A November 2004 VA outpatient treatment record notes that the Veteran presented with left ankle pain, which he had been experiencing for the prior two weeks. He reported no history of injury, fracture or sprain. According to the Veteran, his ankle "just started hurting." Left ankle pain was the assessment, and the Veteran was referred to podiatry for further examination. A December 2004 VA podiatry consultation record notes an assessment of pes planus causing ankle pain. Objective findings included five degrees equinus of the ankles. At February 2006 and May 2006 VA podiatry outpatient follow-up appointments, the Veteran reported that he continued to have pain in the ankle joint, despite a cortisone injection and the use of a brace. The examiner noted a significant pes planus deformity. There was some pain along the peroneal tendon region or posterolateral ankle joint. The assessment was left posterolateral ankle arthralgia; possible left peroneal tendonitis; flat foot deformity. A June 2006 radiology report of the foot revealed no fractures, dislocations, or bony abnormalities. The soft tissues were unremarkable and joint spaces were preserved without arthritic change. The impression was normal views of the left foot. In November 2006, the Veteran was diagnosed with flat foot deformity and subtalar joint arthralgia. A January 2007 radiology report of the left foot revealed skeletal structures, joint spaces, and soft tissues to be within normal limits. The impression was normal left foot radiographs. January 2007, May 2007, August 2007 and February 2008 VA podiatry notes indicated that the Veteran's ankle condition essentially remained unchanged, and the assessment was pain in the foot, flat foot deformity, and subtalar joint arthralgia. In June 2008, the Veteran underwent a surgical procedure to repair his Achilles tendon. VA outpatient treatment records dated through February 2011 indicate that the Veteran continued to seek treatment for left ankle pain. At a VA examination of the feet and ankles in April 2011, the Veteran reported foot and ankle pain, with pain mainly in the left ankle. There was mild edema noted in the left ankle. The diagnosis was residuals of left Achilles tendon lengthening. At a VA examination of the feet and ankles in June 2012, the examiner noted a diagnosis of ankle arthralgia of the left ankle. On examination, there was pain to palpation of the left ankle. The examiner did not provide an opinion as to the likely etiology of the left ankle arthralgia. In an August 2012 VA examination report, the examiner opined that the Veteran's left ankle condition was at least as likely as not caused by the service-connected flat feet. The examiner noted that the Veteran was a well-established podiatry patient at the VAMC podiatry clinic suffering with flatfoot related symptoms of the left foot to include subtalar joint arthritis, peroneal tendonitis, ankle/leg equinas, as well as left ankle arthritis. The examiner reasoned that it is well-accepted that in many advanced cases of flatfeet, the end result may include rear foot and ankle arthritis and in some cases arthrosis. His condition has been aggravated by his bilateral equinas deformity which he had surgically addressed but only with minimal temporary success. The examiner further noted that the Veteran continued to suffer with chronic pain and it was reasonable to suggest that it would continue to be progressive in nature. His left ankle arthralgia condition, the examiner opined, should be regarded as likely caused by his service-connected flatfeet condition. As the VA podiatrist is specifically medically trained to provide such an opinion as to the biomechanics of weight bearing on flat feet, or the consequences thereof, just by the very nature of his specialty, the VA podiatrist's opinion is given great weight in this case. Moreover, there is no contradictory evidence which would weigh against the claim. The VA opinion linking the Veteran's left ankle disability to his service-connected flat foot provides the necessary criteria to grant this claim. To the extent that the left ankle disability is at times diagnosed as arthralgia, the Board notes that he also has an identifiable underlying malady as he has functional loss in the form of limitation of ankle motion as shown on examination. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (the Court held that "pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted."). For the foregoing reasons, all doubt is resolved in the Veteran's favor, and it is at least as likely as not that the Veteran's left ankle disability was caused by the service-connected flat foot. The Veteran is therefore entitled to the benefit of the doubt. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly service connection for a left ankle disability is warranted. II. Increased Rating The Veteran seeks an increased disability rating (higher than 10 percent) for the service-connected left knee chondromalacia. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity resulting from a disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4. When there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Additionally, in all increased rating cases, it is appropriate to consider whether separate ratings should be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3 (2006). Regarding orthopedic disabilities, in determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, if flexion of the knee is limited to 45 degrees a 10 percent rating is in order. If flexion of the knee is limited to 30 degrees a 20 percent rating is in order. If flexion of the knee is limited to 15 degrees a 30 percent rating is in order. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, if extension of the knee is limited to 10 degrees a 10 percent rating is in order. If extension of the knee is limited to 15 degrees a 20 percent rating is in order. If extension of the knee is limited to 20 degrees a 30 percent rating is in order. If extension of the knee is limited to 30 degrees a 40 percent rating is in order. Full range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2011). Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent is assigned for each such major joint or group of minor joints, with occasional incapacitating exacerbations, affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Other rating criteria pertinent to the knee are potentially applicable in this case. Under 38 C.F.R. § 4.71a , Diagnostic Code 5256, ankylosis at a favorable angle in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent rating; ankylosis with flexion between 10 degrees and 20 degrees warrants a 40 rating; ankylosis with flexion between 20 degrees and 45 degrees warrants a 50 rating; and extremely unfavorable ankylosis (flexion at an angle of 45 degrees or more) warrants a 60 percent rating. Under 38 C.F.R. § 4.71a , Diagnostic Code 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling. Moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling. And, severe recurrent subluxation or lateral instability warrants a 30 percent rating. The terms "mild," "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Under 38 C.F.R. § 4.71a, Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint warrants a 20 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5259, removal of the semilunar cartilage when symptomatic warrants a 10 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5262, impairment of the tibia and fibula with slight knee or ankle disability warrants a 10 percent rating; with moderate knee or ankle disability warrants a 20 percent rating; with marked knee or ankle disability warrants a 30 percent rating; and with nonunion (loose motion requiring brace) warrants a 40 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5263, Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) warrants a 10 percent rating. In Esteban v. Brown, 6 Vet. App. 259, 261 (1994), that Court held that in cases where the record reflects that the appellant has multiple problems due to service-connected disability, it is possible for an appellant to have "separate and distinct manifestations" from the same injury, permitting separate disability ratings. The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with the symptomatology of the other conditions. Id. In this regard, VA General Counsel has also held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260, and a compensable limitation of extension under Diagnostic Code 5261 provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). The basis for the opinion was a finding that a limitation in planes of movement were each compensable. Id. VA General Counsel has also held that separate ratings may be assigned in cases where the service-connected knee disability includes both arthritis and instability, provided of course, that the degree of disability is compensable under each set of criteria. VAOPGCPREC 23-97 (July 1, 1997). Historically, service connection for a left knee condition was established by way of a June 1999 rating decision. An initial 10 percent rating was assigned, effective from October 19, 1998, the day after the Veteran's discharge from service. The 10 percent rating was confirmed and continued in rating decisions dated in March 2004, August 2004, November 2004, and June 2005. In June 2007, the RO received the Veteran's most recent claim for increase. The RO denied the claim in an October 2007 rating decision and this appeal ensued. After the Veteran filed his June 2007 claim for increase, he was afforded a VA examination to assess the severity of the service-connected left knee chondromalacia. At an August 2007 VA examination, the Veteran reported pain, swelling and popping of the left knee. The pain was increased with walking half a mile. The Veteran reported flares of pain every other day, with a level of 8/10. The Veteran reported that the left knee disability interfered with his job because he had to take a lot of breaks to sit down. Physical examination revealed a smooth steady gait. Crepitus was noted with respect to the knee. There was no increased heat or redness and no edema. There was no effusion. Extension was 0 degrees and flexion was 0 to 140 degrees. No pain was indicated with range of motion. There was no evidence of weakness, lack of endurance, fatigue or incoordination with repetition of three. The knee was stable. X-rays of the left knee revealed no evidence of acute skeletal injury; and a subtle area of exostosis, medial femoral condyle. The diagnosis was chondromalacia, left knee with exostosis. In statements submitted to the RO in May 2008 and July 2009, the Veteran reported that the pain in his left knee was getting worse. The Veteran's left knee was examined again in March 2011. The examiner noted that the Veteran had no physical therapy or orthopedic follow up since his last VA examination in August 2007. The Veteran reported flare-ups of knee pain daily that last for four hours, during which time the pain increases from a 5/10 to a 7/10. The Veteran reportedly used 15 sick days because of knee pain. Although he was not in danger of losing his job, he worked two jobs full time, both of which required constant walking and standing. The Veteran reported pain, weakness, stiffness, instability or giving way, locking, lack of endurance in the left knee. The Veteran reported occasional swelling. He did not use any assistive devices for his knee. There were no constitutional symptoms of inflammatory arthritis. On examination, the Veteran ambulated six yards with a wide-based gait and significant out-toeing noted bilaterally. There was no tenderness to palpation of the left knee. The examiner indicated that normal range of motion secondary to the Veteran's size would be 0-120. The Veteran could flex the left knee from 0 to 100, but pain began at 70 degrees. Extension was 0 degrees. The knee was stable. Medial and lateral collateral ligament testing was negative. Lachman was negative and McMurray was negative. Three repetitions of motion showed no change in the range of motion. Crepitus was noted throughout the motion. The examiner's impression was chondromalacia left knee with noted physical and x-ray findings. The examiner indicated there was "no noted Deluca criteria." The examiner also specifically noted that there was no lateral instability or recurrent subluxation. At another VA examination of the left knee in August 2012, the objective findings were similar to those on examination of March 2011. The Veteran had no subluxation or lateral instability, based on normal joint stability testing (Lachman, Posterior drawer, and valgus/varus pressure. He could flex the left knee from 0 to 100 degrees, with pain beginning at 90 degrees. Extension was 0 degrees. The Veteran could perform repetitive testing with 3 repetitions without losing any additional motion. Again, normal range of motion due to body habitus was noted to be 0 to 120 degrees. The Veteran's functional loss included pain on motion and less movement than normal, as noted above. There were no other conditions of the knee noted, and no ankylosis and no meniscal tear. The examiner indicated that imaging studies of the knee had been performed and the results, which were available, did not document degenerative or traumatic arthritis. In addition, the examiner noted no patellar subluxation on x-ray. Finally, the Veteran reported that he lost 30 to 40 days of work at his second job, and was going to leave this job due to pain with walking. The Veteran also noted that he was not in danger of losing his job. Based on the above, the criteria for the assignment of a rating in excess of 10 percent are not met under any of the Diagnostic Codes pertaining to the knee as noted above. The Veteran does not have compensable limitation of motion or compensation limitation of extension such that a compensable rating under Diagnostic Code 5260 or 5261 would apply in this case. Similarly, a higher rating under Diagnostic Code 5256 is not applicable here because no ankylosis is shown. At no time during the period of the claim has either subluxation or instability of the left knee been demonstrated. While the Veteran has reported that he experiences instability or giving way, multiple medical examination reports indicate that the Veteran does not have instability. The August 2007 examiner found the knee was stable, the March 2011 examiner found no evidence of lateral instability and the March 2012 examiner reported the anterior instability test (Lachman test) was normal, the posterior instability (posterior drawer test) was normal, and that medial-lateral instability testing was normal. The Veteran's statements have been considered and they are entitled to a finding of credibility, competence and probative weight as he is reporting a symptom that is capable of observation. However, the medical evidence outweighs the Veteran's reports that he has lateral instability as a result of his service-connected knee disability. Testing was accomplished specifically to determine whether there was lateral instability and none was found. Accordingly, as medical professionals trained to assess disabilities of the knee, conducted physical examinations and appropriate testing and determined that there was no instability, the Board finds that the medical evidence is entitled to greater probative weight and outweighs the Veteran's report of instability. As such, a separate rating under Diagnostic Code 5257 is not for application in this case. The Veteran does not have dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint, nor does he have removed semilunar cartilage. On examination, the Veteran was found not to have any abnormality of the meniscus nor has his cartilage been surgically removed. While the Veteran reported on one occasion that he experienced locking, medical professionals have not found a meniscal abnormality nor has his meniscus been removed. The medical evidence is entitled to greater weight, because while the Veteran is competent to report that he experienced locking, he is not competent to diagnose a meniscal abnormality as this is not subject to lay observation. Thus, the criteria pertaining to Diagnostic Codes 5258 and 5259 are not applicable here. Likewise, as there is no impairment of the tibia or fibula, a rating under 38 C.F.R. § 4.71a, Diagnostic Code 5262, is not warranted. Finally, a rating under 5263 for genu recurvatum is likewise not warranted because this condition is not shown. It is noted that the Veteran has been rated under Diagnostic Codes 5099-5014, meaning that his disability is rated analogous to osteomalacia, beginning with the rating decision on appeal. Prior to this rating decision, the Veteran was also rated pursuant to Diagnostic Codes 5257, other impairment of the knee manifested by recurrent subluxation or lateral instability, and 5019, bursitis. Diseases rated under Diagnostic Codes 5014 and 5019 are rated based on limitation of motion as degenerative arthritis. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the RO explained in the rating decision on appeal that the knee was being rated analogously to Diagnostic Code 5014 based on the functions affected. It was noted that the knee was stable but there was a history of painful motion. Based on the predominant findings of limitation of motion on flexion with evidence of pain, the Board finds that the disability is ultimately most appropriately rated pursuant to Diagnostic Code 5260. Moreover, even if the disability were rated analogous to Diagnostic Code 5014 or 5019, the disability would still ultimately be rated under Diagnostic Code 5260, once Diagnostic Code 5003 is applied, because the predominant findings are limitation of motion on flexion. In this case, the Veteran has been assigned a 10 percent disability rating based on non-compensable limitation of motion due to pain. The evidence of record during the entire appeal period demonstrates that the Veteran's flexion has been limited to, at most, 100 degrees with consideration of pain; and, extension is normal. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. As noted above, the VA examination in August 2012 created some confusion as to whether the Veteran actually has arthritis of his knee. In this case, however, the Veteran's left knee disability is already being rated as if the Veteran did have arthritis of the knee. Under Diagnostic Code 5003, arthritis is assigned a 10 percent rating when the joint involved exhibits noncompensable limitation of motion, as is the case here. In other words, the outcome would not be different regardless of whether the Veteran had a diagnosis of arthritis supported by x-ray evidence, because he is already being compensated as if he did have such a diagnosis. A confirmation of an arthritis diagnosis would not allow for a higher rating in this case. The Veteran's current rating is based on non-compensable painful motion, and a rating based on arthritis would be based on the same symptoms or manifestations in this case. The Veteran has pain on left knee motion, which is compensated by the 10 percent disability rating currently assigned. Although his left knee pain may have worsened over the years, the overall disability picture does not more nearly approximate the criteria for a rating in excess of 10 percent at any time during the appeal period under any of the knee codes as explained above. Pain has been considered when addressing limitation of motion; and, there is no additional limitation, weakness, fatigue, or lack of endurance after repetitive use, as shown on examination. Even taking into consideration that the Veteran's normal range of motion on flexion based on body habitus has been reported to be 120 degrees, his flexion is not shown to approximate 30 degrees and, accordingly, a higher evaluation is not warranted. Moreover, the medical evidence does not show any additional limitation of motion on use and while the Veteran reports increased pain during flare-ups, he does not report any additional functional limitations. The Board has considered whether staged ratings are warranted, but finds that the criteria for a higher evaluation are not met during any period of time that is covered by this claim. In addition, the VA examination reports are adequate for evaluating the level of disability as they were based on physical examinations and as sufficient information was provided to allow the Board to render an informed determination. The issue of an extra-schedular rating was also considered in this case under 38 C.F.R. § 3.321(b)(1). There are three analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App 111, 115-16 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The level of severity and symptomatology of the Veteran's service-connected left knee chondromalacia is carefully compared with the established criteria found in the rating schedule. The Veteran reported missing up to 40 days of work due to knee pain, but that was at a second job, and he indicated that he was not in danger of losing his job. In this case, the criteria in the general rating formula specifically contemplate the Veteran's symptoms, which include pain, stiffness, lack of endurance, swelling, and weakness, which ultimately result in limited motion. Thus, the Veteran's left knee symptoms and objective manifestations are addressed by the rating criteria under which such disabilities are rated. The Veteran's pain on motion has been considered in assigning the current rating. The Veteran also reported on one occasion that he has locking and these criteria are contemplated by the diagnostic criteria applicable to meniscal abnormality and removal. However, the medical evidence is against finding that he has such disabilities. In sum, there are no additional manifestations of his left knee disability that are not addressed by the rating schedule. The rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disability and are adequate. Consequently, referral of this case for consideration of an extra-schedular rating is not warranted. Thun v. Peake, 22 Vet. App 111, 115-16 (2008). Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). TDIU may be a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran is currently employed and has not alleged that he was unemployable during the course of the appeal due to the service-connected disability. Thus, a TDIU claim is not raised. ORDER Service connection for a left ankle disability is granted. An increased rating for the service-connected left knee disability, currently rated as 10 percent disabling, is denied. ____________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs