Citation Nr: 1300293 Decision Date: 01/04/13 Archive Date: 01/11/13 DOCKET NO. 10-12 979 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to a rating in excess of 10 percent for chondromalacia patella of the left knee prior to July 17, 2010. 2. Entitlement to a rating in excess of 10 percent for chondromalacia patella of the left knee since July 17, 2010. 3. Entitlement to a rating in excess of 10 percent for right ankle instability prior to July 17, 2010. 4. Entitlement to a rating in excess of 10 percent for right ankle instability since July 17, 2010. 5. Entitlement to a rating in excess of 10 percent for flat feet prior to July 17, 2010. 6. Entitlement to a rating in excess of 10 percent for flat feet since July 17, 2010. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and her spouse ATTORNEY FOR THE BOARD J. Smith, Counsel INTRODUCTION The Veteran served on active duty from September 1977 to September 1997. The Veteran's claim comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs' (VA) Regional Office (RO) in Columbia, South Carolina. The Board notes that additional evidence dated from 2011 and 2012 has been associated with the claims file, in both electronic and hardcopy form, without a waiver of RO jurisdiction. Because this portion of appeal is being remanded for other action, on remand, the RO should review the additional evidence and issue a Supplemental Statement of the Case. See 38 C.F.R. § 19.31 (2011). In August 2010 statements from the Veteran and her representative, the issue of entitlement to an increased rating for a low back disability was withdrawn from appeal. As the issue has been properly withdrawn in accord with 38 C.F.R. § 20.204, it will not be addressed in the decision herein. The issue of entitlement to service connection for a right knee disability, to include as secondary to service connected left knee and right ankle disorders, has been raised by the record. This issue, however, has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to ratings in excess of 10 percent for the Veteran's left knee, right ankle, and flat feet disorders since July 17, 2010 are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to July 17, 2010, the preponderance of the evidence shows that left knee flexion was greater than 30 degrees, extension was greater than 15 degrees, and instability was not shown. 2. Prior to July 17, 2010, the Veteran's right ankle disability was not manifested by a marked limitation of motion. 3. Prior to July 17, 2010, the Veteran's flat feet could not be described as "severe" with objective evidence of a marked deformity (pronation, abduction, etc.), an indication of swelling on use, or characteristic callosities. CONCLUSIONS OF LAW 1. Prior to July 17, 2010, the criteria for a rating in excess of 10 percent for chondromalacia patella of the left knee were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2012). 2. Prior to July 17, 2010, the criteria for a rating in excess of 10 percent for right ankle instability were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2011). 3. Prior to July 17, 2010, the criteria for a disability rating in excess of 10 percent for flat feet were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). In this case, the requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in April 2009 correspondence of the information and evidence needed to substantiate and complete her claim of entitlement to increased ratings for her left knee, right ankle, and bilateral foot disabilities, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. The claim was most recently readjudicated in an August 2010 supplemental statement of the case. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording a VA examination. In July 2011, the Veteran testified at a personal hearing before the undersigned. A transcript of the hearing has been associated with the Veteran's claims file. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. Analysis At the outset, the Board observes that in a rating decision of October 1997, service connection was awarded for chondromalacia patella of the left knee, and flat feet. She was assigned noncompensable and 10 percent ratings, respectively. The Veteran did not appeal the decision pertaining to her flat feet. She appealed the rating assigned for her left knee. In August 1999, the Board awarded the Veteran a 10 percent rating for her left knee disability. In an October 1999 rating decision the RO effectuated an August 1999 Board decision granting entitlement to service connection for right ankle instability and a 10 percent rating was assigned. The appellant did not appeal. The Veteran filed the current claim for increased ratings in April 2009. While the Veteran's entire history is reviewed when making a disability determination, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board has reviewed all of the evidence in the Veteran's claims folders and on Virtual VA. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to each claim. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. The assignment of a particular diagnostic code is 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 current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the Veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant 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. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Recently, the Court held that pain alone does not constitute functional loss under VA regulations that evaluate disabilities based upon loss of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Terms such as "slight," "moderate," and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Left Knee The Veteran's left knee disability has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Arthritis due to trauma is evaluated pursuant to Diagnostic Code 5010, which provides that such arthritis should be rated as degenerative arthritis pursuant to Diagnostic Code 5003. See 38 C.F.R. § 4.71a, Diagnostic Code 5010. Under Diagnostic Code 5003, the severity of degenerative arthritis, established by X-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected. When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. VA's rating schedule provides for ratings of 0, 10, or 20 percent where there is limitation of flexion of the leg to 60, 45, or 30 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The rating schedule also provides ratings of 0, 10, and 20 percent for limitation of extension of the leg to 5, 10, or 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. For rating purposes, a normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5257, slight recurrent subluxation or lateral instability, is rated as 10 percent disabling. Moderate recurrent subluxation or lateral instability warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5257. VA's General Counsel has held that a claimant who has arthritis (resulting in limited or painful motion) and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, cautioning that any such separate rating must be based on additional disabling symptomatology. See VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). The VA General Counsel has further held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Considering the pertinent evidence in light of the above rating criteria, the Board finds that prior to July 17, 2010, entitlement to a rating in excess of 10 percent for left knee chondromalacia was not warranted. On VA examination in May 2009, the Veteran complained of constant aching exacerbated by sitting or climbing stairs, occasional locking and instability, and intermittent swelling. She reported that the disability was improved by ice, anti-inflammatory medication, and rest. She reported problems with prolonged walking. She denied the use of assistive devices. On examination, she displayed flexion to 60 degrees without pain, and to 90 degrees with pain. Extension was to zero degrees. The range of left knee motion was not additionally limited following repetitive use. Lachman's test, anterior and posterior drawer tests, and varus and valugus stress tests revealed no abnormalities. McMurray's test was also negative. The knee was nontender to palpation with evidence of mild crepitus. X-rays revealed mild degenerative joint disease of the left knee. In February 2010, a VA treatment provider noted no edema in the knee. The Veteran flexed to only 30 degrees. There was tenderness with palpation of the feet, and McMurray's test could not be conducted due to accuracy concerns. Some swelling and crepitus at the left patella inferiorly was noted. The Veteran's primary complaints were of increased back pain with radiating pain into the legs, and foot swelling. The appellant was noted to be obese, and it is notable that a left knee disorder was not diagnosed, but the appellant did report left leg parathesia that radiated down to the foot. On VA examination in July 2010, the Veteran complained of constant pain aggravated by prolonged standing, bending, and climbing stairs. She complained of locking, instability, and swelling. She reported temporary pain relief with ice. She reported difficulty performing chores. No assistive devices were used. Her job as a custodian was affected by her need for frequent breaks and missed work. She stated that she had one flare up monthly which required that she stay off her feet. On examination, the range of motion of the left knee was from zero degrees of full extension to 40 degrees of flexion with pain at 40 degrees. There was no decrease in motion due to pain or fatigue following repetitive motion. There was no ligamentous laxity in any direction in the left knee. McMurray's test was negative. There was no crepitus, but there was diffuse tenderness to palpation. X-ray showed mild degenerative joint disease. The preponderance of the evidence shows that for this portion of the appeal, flexion has been consistently been greater than 30 degrees, and extension has consistently been greater than 15 degrees. As such, motion of the left knee has not been limited to the degree necessary to assign higher or separate ratings for the Veteran's service-connected disability. 38 C.F.R. § 4.71a. While flexion was limited to 30 degrees in a VA treatment record of February 2010, the Board does not find that this alone justifies a rating in excess of 10 percent prior to July 17, 2010, as the finding is inconsistent with the remainder of the evidence. Moreover, it is unclear from the record whether this limitation was flexion was due to the Veteran's left knee disability alone, or was also caused by problems with her back and bilateral feet. In this regard, it is telling that no left knee disorder was diagnosed in February 2010. It is logical that an examiner will attempt to diagnose the problems responsible for any abnormal symptoms shown, and the fact that a left knee disorder was not diagnosed is strong evidence that a left knee disorder was not responsible for the limitation of flexion. As regards the DeLuca factors, the Board acknowledges the evidence of pain on motion and the Veteran's functional limitations. Despite this, both VA examiners found that repetitive movement did not change the Veteran's range of motion or increase pain. The examiners did not document weakness, decreased endurance, or easy fatigability due to repetitive motion. The evidence shows that no assistive devices were required at any time during this time period, and symptoms were relieved by ice, rest, and medication. Based on this evidence, the Board finds insufficient medical evidence to support that the Veteran's pain, weakness, or fatigability is so disabling as to actually or effectively limit knee motion to such an extent as to warrant assignment of a higher rating under either 38 C.F.R. § 4.71a, Diagnostic Code 5260 or 5261. The evidence also shows that an additional rating for recurrent subluxation or lateral instability of the left knee under 38 C.F.R. § 4.71a, Diagnostic Code 5257 is not warranted prior to July 17, 2010. Records from this time period reflect no objective evidence of instability or subluxation. To the contrary, the May 2009 and July 2010 examiners found no evidence of instability on diagnostic testing. As such, this evidence does not establish that the Veteran is entitled to a higher or separate rating for knee instability. Furthermore, no other diagnostic code provides a basis for assignment of a rating in excess of 20 percent for the left knee. As noted above, disabilities of the knee and leg are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5263; however, many of these diagnostic codes simply do not apply to the Veteran's service-connected knee disability. As it is neither contended nor shown that the Veteran's service-connected knee disability involves ankylosis, a dislocated semilunar cartilage, or malunion or nonunion of the tibia and fibula, there is no basis for assignment of a higher rating under Diagnostic Codes 5256, 5258, or 5262. See 38 C.F.R. § 4.71a. Other diagnostic codes, specifically, Diagnostic Codes 5259 and 5263, are inapplicable because they do not offer ratings in excess of 10 percent. For all the foregoing reasons, the Board finds no basis for the assignment of a higher rating or a staged rating under the applicable rating criteria prior to July 17, 2010. The claim for a higher rating for this time period must be denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet.App. 49 (1990). Right Ankle The Veteran's service-connected right ankle disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271. That code provides a maximum rating of 20 percent where there is evidence of a "marked" ankle disability. According to the rating schedule, normal dorsiflexion of the ankle is to 20 degrees, and normal plantar flexion of the ankle is to 45 degrees. 38 C.F.R. § 4.71, Plate II. In light of these regulations, the Board cannot find that a rating in excess of 10 percent was warranted for the Veteran's right ankle instability prior to July 17, 2010. On VA examination in May 2009, the Veteran complained of constant pain localized along the right lateral malleolus which was exacerbated by prolonged standing or walking. She reported chronic swelling as well, and instability. Treatment included heat, ice, and compression stockings. She denied the use of assistive devices. She stated that her occupation was affected since her position required that she stand for prolonged periods. On examination, she had diffuse swelling and tenderness to palpation overlying the lateral malleolus. She had dorsiflexion to 15 degrees, plantar flexion to 25 degrees, inversion to 20 degrees, and eversion to 10 degrees. She had pain throughout the movements. The range of motion was not additionally limited following repetitive use. Stability on drawer testing and strength testing revealed no abnormalities in the ankle. X-rays revealed chronic soft tissue swelling overlying the lateral malleolus. On VA examination in July 2010, the Veteran complained of constant 8/10 pain that was aggravated by prolonged standing and walking. She also complained of locking and instability. She complained of difficulties with mopping and doing dishes due to the ankle, and a need to take frequent breaks at work. On examination, dorsiflexion was to 15 degrees, plantar flexion was to 30 degrees, and inversion and eversion were each to 10 degrees. There was pain at the ends of range of motion, but no decrease in motion due to pain or fatigue on repetition. There was medial and lateral ankle tenderness to palpation, as well as lateral ankle swelling. Plantar and dorsiflexion strength were to 4+/5. Stability was normal, and weight bearing was normal. Based on this evidence, a rating in excess of 10 percent is not warranted for the Veteran's right ankle disability prior to July 17, 2010. While decreased motion was documented on each VA examination, dorsiflexion was limited by only 5 degrees, and plantar flexion was not reduced to even the halfway point. Strength, stability, and weight bearing were normal. The Veteran did not display any problems with gait or posture. Assistive devices were never required. Given this, the Board cannot find the presence of a "marked" ankle disability for this time period. The Board considered all other diagnostic codes pertaining to the ankle but none provide the basis for an increase in excess of 10 percent prior to July 17, 2010. Diagnostic Code 5003 does not provide the basis for an increased evaluation because the limitation of motion documented on both VA examinations. There is no evidence that the ankle is ankylosed, hence, an increased rating under Diagnostic Code 5272 is not in order. Diagnostic Code 5273 does not apply because it requires evidence of malunion of os calcis or astragalus. There is no evidence of this in the file, including on any x-ray report. Similarly, Diagnostic Code 5274 requires evidence of astragalectomy. There is no objective medical evidence of this procedure, or of any surgery since service, in the claims file. For these reasons, an increased rating is not warranted under any other diagnostic code pertaining to the ankle for this time period. In reaching these determinations, the Board has considered all applicable statutory and regulatory provisions to include 38 C.F.R. §§ 4.40 and 4.59 as well as the holding in DeLuca, regarding functional impairment attributable to pain, particularly in light of the fact that the appellant contends her disability is essentially manifested by pain. Despite this, both VA examiners found that repetitive movement did not change the Veteran's range of motion or increase pain. The examiners did not find any objective evidence of weakness, decreased endurance, or easy fatigability due to repetitive motion. The evidence shows that no assistive devices were required for this time period, and the disorder was responsive to heat, ice, and medication. For all of these reasons, the Board finds that the current rating assigned adequately compensates the Veteran's functional loss, pain, and weakness resulting from her right ankle disorder for this time period. For all the foregoing reasons, the Board finds no basis for the assignment of a higher rating or a staged rating under the applicable rating criteria prior to July 17, 2010. The claim for a higher rating for this time period must be denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert. Flat Feet The Veteran has been assigned the 10 percent evaluation for flat feet pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5276. Under this diagnostic code a 30 percent rating is warranted when the evidence shows severe acquired bilateral flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. Considering the pertinent evidence in light of the above, the Board finds that prior to July 17, 2010, a rating in excess of 10 percent for the Veteran's flat feet was not warranted. On VA examination in May 2009, the Veteran complained of pain localized along the plantar aspects of both feet. Custom-made inserts were effective initially but then less effective. She was waiting to receive new inserts. She reported functional limitations related to prolonged standing or walking. She denied flare-ups. The appellant stated that at her job foot pain began to limit her activities after she had stood for a prolonged term. On examination, she had no corns, calluses, or edema. Neither the feet nor the Achilles tendons were painful on manipulation. Both Achilles tendons were normal in alignment. There was no obvious painful or restricted motion. There was tenderness along the plantar aspects of both feet. The Veteran's gait was antalgic and weightbearing was abnormal. There was no evidence of weakness or instability in the feet. The examiner noted a right second toe hammertoe deformity. X-rays revealed no obvious abnormalities. In a VA treatment record of October 2009, no calcaneal tenderness was noted. There was tenderness to palpation of the proximal 1/3 attachment of the plantar fascia on the left. Active and passive ranges of motion were normal. Accessory inter-talar, metatarsals, and interphalangeals were normal. Muscle testing was normal. There was mild chronic bi-malleolar effusion. In a VA treatment record of November 2009, the Veteran reported doing well and that she had less pain. Mild tenderness to palpation was noted. Active and passive ranges of motion were normal. Muscle testing was normal. There was no swelling. On VA examination in July 2010, the Veteran complained of pain to a level of 8/10 aggravated by prolonged standing and sitting. Ibuprofen and Aleve provided mild, temporary relief. Inserts did not provide significant relief, and physical therapy offered temporary relief. She reported flare-ups occurring twice per month. On examination there were no corns, calluses, or edema of either foot. There was moderate bilateral pes planus with a normally aligned and nontender Achilles tendon bilaterally. Bilateral toe flexion was painful but not restricted. The plantar and dorsal aspects of both feet were tender to palpation. Weight bearing strength and stability were normal bilaterally. Based on this evidence a rating in excess of 10 percent is not warranted for the Veteran's bilateral foot disability prior to July 17, 2010. The evidence demonstrates that the Veteran's foot disability cannot be characterized as severe for this time period. There was no objective evidence of a marked deformity. Calluses were not found. There was no indication of swelling on use. While pain on manipulation was noted, the Board does not find that this alone justifies an increased rating for the Veteran's condition in the absence of the other criteria contemplated by Diagnostic Code 5276. The Board has also considered the DeLuca factors, particularly in light of the fact that the appellant contends her disability is essentially manifested by pain. However, no functional loss caused by pain has been documented. In fact, loss of motion has not been documented by any provider for this portion of the appeal period; indeed, the May 2009 examiner found no obvious painful or restricted motion. For these reasons the Board finds that the 10 percent disability rating assigned for the Veteran's bilateral flat feet appropriately reflects her level of disability, and there is no basis for a higher rating for this time frame. The Board also considered whether any alternate diagnostic code provision affords the Veteran a disability rating in excess of 10 percent for her bilateral flat feet. As it is neither contended nor shown that the Veteran's service-connected bilateral foot disability involves claw foot or the malunion or nonunion of the tarsal or metatarsal bones, there is no basis for assignment of a higher rating under Diagnostic Codes 5278 or 5283. Diagnostic Codes 5277, 5279, 5280, 5281, and 5282 do not offer ratings in excess of 10 percent. The Board finds that the only other diagnostic code of potential application here is Diagnostic Code 5284, which affords a 20 percent evaluation for "moderately severe" injuries of the foot. However, based on the competent evidence as discussed above, the Veteran's flat foot disability is not found to more nearly approximate a 20 percent evaluation under Diagnostic Code 5284. Aside from the Veteran's pain, the medical evidence shows little to no other objective abnormalities. For all the foregoing reasons, the Board finds no basis for the assignment of a higher rating or a staged rating under the applicable rating criteria prior to July 17, 2010. The claim for a higher rating for this time period must be denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert All Claims In assessing the severity of the Veteran's disabilities, the Board has considered the Veteran's own assertions regarding her symptoms, which she is certainly competent to provide. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the criteria needed to support higher ratings for each disability require medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the Veteran's assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support higher ratings than those presently assigned. The Board has also considered whether the Veteran's disabilities present an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). In this case there are no exceptional or unusual factors with regard to the appellant's left knee, right ankle, or feet disorders. The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluation for that service-connected disability is inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical.") Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology, and provide for consideration of greater disability and symptoms than currently shown by the evidence. Thus, her disability pictures are contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extra-schedular consideration is not warranted. ORDER Entitlement to a rating in excess of 10 percent for chondromalacia patella of the left knee prior to July 17, 2010 is denied. Entitlement to a rating in excess of 10 percent for right ankle instability prior to July 17, 2010 is denied. Entitlement to a rating in excess of 10 percent for bilateral flat feet prior to July 17, 2010 is denied. REMAND The Board's review of the claims file reveals that further development is necessary before the claims remaining on appeal can be properly adjudicated. A remand is required in order to afford the Veteran a current VA examination for her left knee, right ankle, and bilateral foot disabilities. At the July 2011 hearing and in January 2011 written correspondence, the Veteran specifically alleged that each of her conditions has worsened since the most recent VA examination of July 16, 2010. See Hearing Transcript, p. 14. The United States Court of Appeals for Veterans Claims (Court) has held that when a Veteran alleges that his service-connected disability has worsened since he was previously examined, a new examination may be required to evaluate the current degree of impairment. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). As such, the Board finds that a current VA examination is necessary to ascertain the current severity of the Veteran's disabilities since July 17, 2010. On remand, the RO should also obtain and associate with the claims file all updated treatment records. At the hearing, the Veteran testified that she received recent treatment at the VA Medical Center in Columbia, South Carolina, as well as at Fort Jackson Moncrief Army Community Hospital. An attempt should be made to obtain all updated treatment records. Finally, the claims file shows that since the last supplemental statement of the case was issued, additional relevant VA medical records were added to the Veteran's Virtual VA claims file, and the Veteran additionally submitted a September 2011 private medical report. The record does not contain a waiver of RO jurisdiction with regard to these records and on remand, all evidence received since the August 2010 supplemental statement of the case must be considered. See 38 C.F.R. §§ 19.37, 20.1304 (2011). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should obtain all outstanding pertinent treatment records from the VA Medical Center in Columbia, South Carolina, and Fort Jackson Moncrief Army Community Hospital. All records and/or responses received should be associated with the claims file. If the RO/AMC cannot locate such records, it must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO/AMC must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. Thereafter, the Veteran must be afforded a VA orthopedic examination to assess the current severity of her left knee, right ankle, and flat feet disorders. The examiner is to be provided access to the claims folder, a copy of this remand, and Virtual VA. The examiner must specify in the report that the claims file and Virtual VA records have been reviewed. In accordance with the latest worksheets for rating chondromalacia of the knee, ankle instability, and pes planus the examiner is to provide a detailed review of the Veteran's pertinent medical history current complaints and the nature and extent of each and every left knee, right ankle, and bilateral foot disability. The examiner must differentiate any pathology caused by a disorder other than left knee chondromalacia, right ankle instability and flat feet. The impact of each of these disorders on the appellant's ability to work must be addressed. A complete rationale for any opinion expressed must be provided. 3. The Veteran is to be notified that it is her responsibility to report for the examination 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 (2012). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 4. After the development requested has been completed, the RO should review the examination report to ensure that it is in complete compliance with the directives of this REMAND. The AMC/RO must ensure that the examiner documents his/her consideration of Virtual VA. If the report is deficient in any manner, the RO must implement corrective procedures at once. 5. After completion of any action deemed appropriate in addition to that requested above, the appellant's claims should be readjudicated. All applicable laws and regulations, and all evidence received since the August 2010 supplemental statement of the case, to include in the electronic claims file, should be considered. If any benefit sought remains denied, the appellant should be provided a supplemental statement of the case and given the opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs