Citation Nr: 1302148 Decision Date: 01/18/13 Archive Date: 01/23/13 DOCKET NO. 07-19 358 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Whether new and material evidence has been received to reopen a claim seeking service connection for low back disability. 2. Entitlement to service connection for right leg disability, to include radiculopathy of the right lower extremity, including as secondary to residuals of a right foot injury. 3. What evaluation is warranted for chondromalacia of the right knee from March 21, 2006 to August 3, 2011? 4. What evaluation is warranted for chondromalacia of the right knee since August 4, 2011? 5. Entitlement to a rating in excess of 10 percent for residuals of a right foot injury prior to August 4, 2011. 6. Entitlement to a rating in excess of 10 percent for residuals of a right foot injury since August 4, 2011. REPRESENTATION Appellant represented by: Jan Dils, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from October 1983 to October 1984. These matters are before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision by the Roanoke, Virginia Department of Veterans Affairs (VA) Regional Office (RO). In March 2012, the case was remanded to the RO for further development. In August 2012, a Board hearing was held before the undersigned Veterans' Law Judge. A transcript of the hearing is of record. During the August 2012 Board hearing, the Veteran withdrew her claims for entitlement to service connection for hypothyroidism, Vitamin D and Vitamin B-12 deficiency and cracked teeth. Thus, these claims are no longer on appeal before the Board. 38 U.S.C.A. § 7105. The issues of entitlement to ratings in excess of 10 percent each for right foot and knee disabilities from August 4, 2011 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. In an August 2006 decision, the Board denied entitlement to service connection for low back disability. 2. Evidence associated with the record since the August 2006 Board decision relates to an unestablished fact and raises a reasonable possibility of substantiating the claim of entitlement to service connection for low back disability. 3. The preponderance of the probative evidence is against finding that the Veteran's current low back disability is related to service or to her service-connected foot disability. 4. The preponderance of the evidence is against finding that the Veteran has any right lower extremity disability, other than her already service-connected right foot and right knee disabilities. 5. For the period from March 21, 2006 to August 3, 2011 the Veteran's right knee disability was not manifested by extension limited to 10 degrees or more, flexion limited to 45 degrees or less, lateral instability, subluxation or ankylosis. 6. Prior to August 4, 2011, the preponderance of the evidence is against finding of a moderately service right foot injury. CONCLUSIONS OF LAW 1. The August 2006 Board decision is final. 38 U.S.C.A. § 7104 (West 2002 & Supp. 2012). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for low back disability. 38 U.S.C.A. § 5108 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.156 (2012). 3. A low back disability was not incurred in or aggravated by active service, it was not caused or aggravated by any service-connected disability, and lumbar arthritis may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309(a), 3.310 (2012). 4. A right leg disability, distinct form right knee chondromalacia and residuals of a right foot injury was not incurred in or aggravated by active service and was not caused or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1131, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2012). 5. For the period from March 21, 2006 to August 3, 2011, the criteria for an evaluation greater than 10 percent for right knee chondromalacia are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.951(b), 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5257, 5258, 5260, 5261 (2012). 6. Prior to August 4, 2011, the criteria for an evaluation greater than 10 percent for residuals of a right foot injury are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5283, 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VCAA As service connection, an initial rating, and an effective date have been assigned, the notice requirements of 38 U.S.C.A. § 5103(a) have been met in relation to the claim for an initial rating in excess of 10 percent for right knee chondromalacia. Regarding the other claims decided in this decision, 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 May 2006, May 2008 and March 2010 of the information and evidence needed to substantiate and complete a claim, 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 case was most recently readjudicated in a December 2011 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 VA examinations. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. II. Analysis A. New and Material Claim Generally, when a claim is disallowed by the Board, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C.A. § 7104. Under 38 U.S.C.A. § 5108, however, "If new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim." "New" evidence means existing evidence not previously submitted to agency decision makers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510 (1992). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In order to establish entitlement to service connection for a present disability the Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). A disability which is proximately due to or the result of a service- connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability aggravates a nonservice- connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). 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 appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In August 2006 the Board denied entitlement to service connection for lumbar strain secondary to residuals of a right foot injury. The record showed evidence of a current lumbar strain but did not show that it was manifest in or related to service, or that it was caused or aggravated by a service-connected right foot disability. The August 2006 decision is final based on the evidence then of record. 38 U.S.C.A. § 7104. Evidence of record since the August 2006 decision includes a June 2011 letter from a VA treating physician and a January 2012 letter from a private physician. Both letters include opinions tending to indicate that the Veteran's right foot injury more likely than not resulted in her low back injury. As this evidence has not been previously considered, it is new. Also, because the credibility of this evidence must be presumed, it clearly tends to indicate that a relationship exists between the Veteran's current low back disability and his service-connected foot disability. Consequently, the evidence relates to an unestablished fact and raises a reasonable possibility of substantiating the claim. Thus, the claim is reopened. B. Service connection for right lower extremity radiculopathy, and a low back disability The service treatment records do not show any findings or complaints of low back or right leg pathology. They do show that the Veteran suffered a right foot crush injury in November 1983 for which she received both inpatient and outpatient treatment, including emergency room treatment. At a March 1984 medical evaluation in advance of Medical Board proceedings, the Veteran was found, in pertinent part, to have bilateral foot pathology. At a June 1984 medical examination, the spine was found to be normal and no lower back pathology was noted. In a July 1984 statement, made in conjunction with a Medical Board proceeding, the Veteran indicated that a little more than a month after her initial injury, she was walking down stairs when she accidentally fell and aggravated her right foot injury. She was sent to the emergency room and a soft cast was placed on her foot. The Veteran noted continuing to experience foot problems and receiving treatment and evaluation for the foot up until July 1984. Private medical records from 1999 to 2005 show intermittent treatment and evaluation of low back and right lower extremity problems. In October 1999, the Veteran called her physician and complained, in part, of abdominal and lower back pain. An appointment was offered but the Veteran declined. In February 2001, the Veteran complained of pain in the back of the calf, knee and right buttock. In March 2001, she reported that her door at home hit her lower leg causing pain and discoloration. In August 2001, she complained of low back pain. In August 2002, the Veteran voiced multiple complaints, including shin abrasions and sunburn on the tops of her feet. The pertinent diagnoses were superficially infected shin abrasions, sunburn of the feet, and a possible local reaction to topical antibiotic ointment over the right shin. In January 2003, the Veteran reported falling at home and a chair falling on top of her. As a result, she reported having right sided clavicle and shoulder pain. In March 2004, the Veteran reported injuring her back in November 2003, and now having bilateral leg pain. Physical examination yielded diagnoses of a lumbosacral strain and L5 radiculopathy. In June 2004, the Veteran reported right lower extremity paresthesias. The onset was apparently work-related, occurring in August 2002 when she suffered shin abrasions and sunburn. The diagnostic assessment was peripheral neuropathy (burning paresthesias in the right pretibial region. In an April 2004 statement, the Veteran indicated that about four to five years prior, she tripped due to the loss of sensation in her foot. The fall caused arm problems which ultimately led to undergoing multiple arm surgeries. The Veteran also requested that service connection be granted for her back as secondary to her foot problems. She noted that her physician had documentation related to her back in her medical records. A May 2005 QTC right foot examination report shows a diagnosis of intermittent symptomatic residuals of right foot injury with associative ambulation and bilateral hallux valgus deformities. The Veteran reported radiating pain to the proximal aspect of the leg with intermittent acute onset and acute spontaneous resolution. A separate diagnosis pertaining to the right leg was not rendered. In August 2005, the Veteran complained of right ankle pain. The diagnosis was tendinitis of the right ankle. In May, June and October 2006 statements the Veteran indicated that since the initial injury to her right foot, the disability had steadily gotten worse, causing secondary right knee, leg and lower back problems. She reported that around Thanksgiving 2004, her right foot went numb while sitting and she fell while trying to stand up. As a consequence of this purported fall she allegedly hurt her right arm and lower back when she hit the cement. She indicated that it took several months after the injury to move without pain. In a June 2006 statement, the Veteran reported that approximately 4 to 5 years prior, she started feeling a burning sensation from the ankle to the shin. This burning sensation caused a rash with quite painful itching. Also, wearing socks, nylons or shoes on a daily basis caused her foot, knee and leg to become extremely sore. She asserted that her foot would either tingle or go numb. This in turn allegedly caused her to stumble or fall, which in turn caused bruising to other parts of her body, such as the time she injured her right arm. In an October 2006 statement, the Veteran alleged that a crush injury in service had caused nerve damage going up her leg. She also indicated that she had a large callus on the bottom of the left foot that would not heal, and alleged that this demonstrated that she exhibited abnormal weight-bearing. Private medical records from 2007 show ongoing evaluation and treatment for low back and right leg disabilities. A January 2007 private electromyogram report shows that the sural, superficial, peroneal, medial and lateral plantar nerves were evaluated, along with common peroneal and tibial motor nerves. All values were within normal limits. Needle examination of the right lower extremity showed no abnormal findings. The diagnostic interpretation was normal right lower extremity electromyographic/nerve conduction studies. In October 2007, the Veteran complained of paresthesias in the right lower extremity primarily from the knee to the ankle, and feeling that her leg would give out. She denied a history of trauma or injury. The diuretic she was taking helped with her peripheral edema but her tingling sensation had persisted. Physical examination yielded an assessment of right lower extremity paresthesias. In November 2007, a private nerve conduction study of the right foot/leg showed findings that were within normal limits. Physical examination of the right lower extremity showed no abnormalities. A July 2009 private DEXA scan of the lumbar spine showed that the Veteran had osteopenia of the spine. In a December 2009 medical history, the Veteran alleged that during service she experienced a second foot injury while on profile resulting in the placement of another soft cast. A January 2010 private electromyogram revealed a normal lower extremity with no evidence of neuropathy or radiculopathy. During a January 2010 private medical visit, the Veteran indicated that she had recently felt right leg numbness when standing, that her leg had become weak and that she fell back, striking her head. Physical examination showed that straight leg raising was negative. Reflexes and strength of the lower extremities were equal bilaterally. There was no muscle atrophy. The pertinent diagnostic assessment was right lower extremity paresthesias. A January 2010 private lumbar MRI produced a diagnostic impression of L5-S1 mild disc bulging. During January and February 2010 visits to Dr. S, the physician found that the Veteran's paraspinal musculature was non-tender to palpation, that there were no subluxations present, that range of motion was full and painless in all planes, and that paraspinal muscle strength was within normal limits. He also found that the Veteran had an unusual problem involving numbness in the leg but negative EMG testing and MRI testing. In February 2010 the Veteran again reported that leg and foot numbness resulted in numerous falls and secondary injuries. She noted the prior fall where injured her back on a cement floor. She also reported many other accidents, including cracking a tooth, acquiring several capped teeth due to clenching, and a history of numerous headaches as a result of needing to avoid pain medication. A March 2010 private progress note shows that the Veteran reported a few day history of low back pain, with pain radiating into her hips. She also noted buttock pain. Physical examination yielded a diagnosis of low back pain. A March 2010 VA progress note shows that after receiving joint fluid injection therapy the Veteran reported severe knee pain up into the hip and lower back. She felt as if the injection had caused injury to the L5 nerve. Neurological examination of the lower extremities was unremarkable. The diagnosis was right leg dysfunction. Private physician's notes from May to August 2010 show that the Veteran reported low back pain radiating into the right leg. Physical examination yielded diagnostic assessments of left lumbar pain, sprain/strain of the lumbar spine and mild lumbar L5-S1 disc bulging per MRI. During a June 2011 DRO hearing, the Veteran reported that periodic right foot numbness had resulted in her falling on her back twice, once right after the injury in service and once later on cement. She was also taking the diuretic to try and keep the swelling down in her foot and leg. The tingling and numbness occurred almost daily. She indicated that she thought the nerves in the top of the foot had been damaged during the initial in-service injury. She noted that at the time of her most recent electromyographic study Dr. S indicated that they had put too much stress on her right lower extremity. As a result, he instructed her to remain at home and stay off her leg. In a June 2011 letter, a treating VA physician noted that the Veteran had suffered the severe crush injury in boot camp in 1983. A couple of months later, the right leg went numb and she fell down a flight of stairs and injured her low back. Due to these injuries, she was able to stay in the military only a little less than one year and was medically discharged due to service-connected disability. She continued to complain of right foot and leg numbness. At one point in the 1990s, the numbness caused a fall and a low back injury. The physician noted that although electromyographic/nerve conduction testing of the right leg had been normal in January 2010, the Veteran had experienced severe pain and sensory changes of the right leg and an MRI of the lumbosacral spine had showed some disc bulging of the L5-S1 disc. In summary, the physician found that since the 1983 right foot injury the Veteran had experienced episodes of sudden numbness of the right foot and leg, causing a loss of balance. This in turn allegedly caused the appellant to fall and sustain significant injuries including to the low back. In the physician's opinion, the right foot injury more likely than not resulted in the episodes of the right foot and leg numbness, falls and injuries. At an August 2011 VA physiatrist's examination with electromyographic studies the Veteran reported that she had undergone electromyographic testing in the community in 2010, which was normal. She indicated, however, that after having the needle portion of that study she was unable to walk for about one week. Physical examination of the right lower extremity showed that sensation was intact to light touch, cold and vibration in the right lower extremity. It also showed that the Veteran was able to ambulate and had at least 4/5 resistance of dorsiflexion, plantar flexion and quadriceps. Nerve conduction and electromyographic testing produced a diagnostic impression of normal study. There was no evidence of right lower extremity lumbar radiculopathy and no evidence of peripheral neuropathy affecting either lower extremity. During an August 2011 VA low back examination, the Veteran gave a history of injuring her low back from falls on three occasions, the first one occurring in service in 1983. She reported current stiffness, spasm and pain. Physical examination showed thoracolumbar spasm. Range of motion of the lumbar spine was essentially normal with pain on motion noted. Neurological examination showed decreased sensation to light touch in the right foot. X-rays of the lumbar spine showed diffuse osteopenia and mild degenerative disc disease at L4-5 and L5-S1. The examiner found no evidence of radiculopathy or neuropathy. Physical examination had revealed mild decreased sensation but the nerve conduction testing had been normal. The examiner also found that the Veteran's low back disability was less likely than not due to her foot disability. The examiner found no documentation of a foot injury while in service, only multiple documentations by a primary care physician after separation. X-ray studies of the lumbar spine revealed only osteopenia compatible with the Veteran's age. Thus, it was felt that the back problem was less likely than not affected by the right foot injury. Moreover, the physician did not find that the right foot or knee condition was aggravated by activities lately as the x-rays of the foot and knee did not support a finding of aggravation. In a January 2012 letter, a private physician, Dr. D, noted that the Veteran suffered from a lumbar strain secondary to a lower extremity injury. The Veteran had fallen down stairs in service secondary to the foot injury and had developed low back pain after the fall. Based on the earlier June 2011 letter, the physician opined that it was as likely as not that the Veteran's current back pain was a direct result of the crush injury of the foot she sustained in service. An April 2012 MRI of the lumbar spine produced a diagnostic impression of mild to moderate posterior disc bulging at L4-5 and L5-S1 with no focal posterior disc protrusion or extrusion. There was also no spinal stenosis. April and June 2012 private progress notes from Dr. S show that the Veteran was seen for low back pain. The symptoms reportedly began in early 2012 and had progressed. They reportedly had a sharp quality and they radiated into the right leg in a nonspecific distribution. The pain was in the right leg, back posterior leg and the thigh but not the knee. She did mention some right knee swelling. Physical examination yielded diagnoses of were lumbar spine strain/sprain and mild lumbar L5-S1 bulging disc per MRI. During the August 2012 Board hearing, the Veteran testified that right lower extremity numbness now affected her whole leg. The Veteran's attorney also indicated that Dr. D, an orthopedist had found that it was at least as likely as not that the Veteran's back disability was related to her foot injury because of her antalgic gait. The Veteran reported back pain during activities including when driving and bending over. She also reported a restricted range of motion. She indicated that she had always had back pain, beginning after a fall down the stairs during service. She reported that she was told she had had a small back injury in the military but that her limping due to her foot had made it worse. Low back disability The Veteran contends that her current low back disability is secondary to her service-connected foot disability and/or is directly related to service. As noted above, the Veteran's service treatment records are negative for any clinical reference to low back problems. The record then does not contain any reference to low back pathology until 1999, approximately 15 years after service. A lengthy interval of time between service and initial postservice manifestation of a "disability" for which service connection is sought is, of itself, a factor against a finding that the disability was incurred or aggravated in service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The Veteran has specifically contended that her fall down the stairs in service injured her back. Notably, however, in March 1984 she received a detailed medical work-up in advance of Medical Board proceedings. This evaluation included findings of bilateral foot pathology, mild obstructive airway disease, dental caries and eosinophilia but specifically did not include any findings of low back pathology. Similarly, during a June 1984 medical examination, the spine was found to be normal and no low back pathology was noted. When specifically describing her fall in her July 1984 statement, the Veteran did not report any back injury but simply indicated that the fall aggravated her right foot injury. In an April 2004 postservice statement the Veteran reported falling about 4 to 5 years prior, which caused arm injury and which she attributed to her right foot disability. In this same statement, she claimed service connection for low back disability but did not reference any fall in service or allege that this fall caused any injury to her back. Given the Veteran's contemporaneous in-service account of the fall did not include any suggestion that she injured her back inservice; given that the service treatment records do not show any evidence of an inservice back injury; and given that the Veteran did not report that the in-service fall injured her back when initially claiming service connection, the Board finds her contention that she injured her back in-service not credible. As mentioned above, the June 2011 VA physician found that the Veteran's right foot injury more likely than not resulted in her falls and injuries. In regard to the low back, however, this finding was based on the Veteran's reported history of the low back injury in service, as this is the only low back injury mentioned by the physician. As the underlying history is not credible, the opinion is assigned minimal probative weight. Similarly, as the January 2012 private physician based his opinion on that of the June 2011 VA physician, specifically noting the reported low back injury in service, his opinion is also assigned minimal probative weight. In contrast, the August 2011 VA physician found that a low back disability was less likely than not due to the Veteran's right foot disability and less likely than not affected by her right foot disability. He specifically found no documentation of any low back injury in service. He found that the lumbar spine disability was primarily osteopenia, a disorder that was consistent with the Veteran's age. The examiner's opinion weighs strongly against a finding that the Veteran's low back injury is related to service, especially in light of the lack of any low back injury in service and the affirmative finding of age-related osteopenia. Similarly, the August 2011 opinion weighs strongly against a finding that the Veteran's low back disability was caused or aggravated by the foot injury. This latter conclusion is also based on the lack of evidence of an in-service back injury and the finding of age-related osteopenia. Both of these factors lead the physician to conclude that it was less likely than not that the back disability was caused by the foot disability. The Veteran specifically contends that she more recently suffered one or two falls onto her back due to right foot numbness, the first one occurring around Thanksgiving 2004. The evidence does appear to indicate some history of a low back injury during this time frame. Given that the report that the right foot disability caused the falls is clearly self serving , and given the Veteran's lack of credibility concerning any alleged in-service fall, however, the Board does not find credible her report that a recent injury resulted from falls specifically caused by a right foot disability. Additionally, even if these specific reports were deemed credible, they do not establish that the injuries resulted in any current, chronic low back disability. Once again, the most probative medical opinion of record is that of the August 2011 VA examiner. That provider specifically found that the appellant's low back disability consisted of osteopenia consistent with her age, a finding that weighs against concluding that falls resulted in any current low back disability. Thus, for all the reasons mentioned, the weight of the medical evidence is against a finding that the Veteran's low back disability is related to service or caused or aggravated by her service-connected low back disability. Although the Veteran alleges that such a relationship does exist, as a layperson, her opinion concerning such a medical nexus is minimally probative. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Additionally, to the extent she is alleging continuity of low back pathology since service, the Board does not find this assertion credible, given the non-credible nature of her reported injury in service. In summary, given that that the Veteran's report of low back injury in service is not credible; given that a low back disability was not shown until many, many years after service; and given that the weight of the evidence is against finding a nexus between any low back disability and service, and against finding a nexus between any low back disorder and any right foot disability, the claim must be denied. Right Leg Disability The Veteran is not clinically shown to have any current right leg disability other than the already service-connected right foot and knee disabilities. Throughout the appeal period the Veteran has undergone electromyographic and nerve conduction testing to determine whether there is any right lower extremity neurological impairment. Testing in January 2007, November 2007, January 2010 and August 2011 all produced normal results, thus clearly weighing against diagnoses of radiculopathy or neuropathy. Also, after reviewing the record and examining the Veteran, the August 2011 VA examiner specifically found that no independent right leg disability was present. He did find mild decreased sensation in the leg, and the Veteran has exhibited symptoms of both pain and numbness in the area. He noted, however, that the neurological testing had been negative and that no radiculopathy or neuropathy was present. Dr. S did earlier describe the Veteran's symptomatology as right leg dysfunction, noting leg numbness and bouts of severe pain after objective medical testing. Given the myriad negative objective findings and the August 2011 VA examiner's finding, however, the preponderance of the most probative evidence is against finding an underlying distinct chronic right lower extremity disability, aside from the existing right foot and knee disabilities. The Veteran clearly has some level of right leg symptomatology, including pain and numbness. Such symptoms, however, without an established underlying malady or condition, do not constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). Additionally, while her bouts of pain after testing are reasonably shown to be disabling, the Veteran's own report tends to indicate that these are temporary flare-ups, with the one in 2010 lasting about a week. In the absence of proof of current disability, there can be no valid claim of service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Thus, this claim must be denied. B. Increased Rating Claims Disability ratings are based on average impairment in earning capacity resulting from a particular disability, and are determined by comparing symptoms shown with criteria in VA's Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations, which are potentially applicable, based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations apply, 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. When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202(1995); 38 C.F.R. §§ 4.40, 4.45. When evaluating a loss of motion, consideration is given to the degree of functional loss caused by pain. Id. In DeLuca, the Court explained that, when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40 ) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id. at 206. A. Right knee disability An August 2006 rating decision granted entitlement to service connection for chrondromalacia of the patella, right knee, assigning a 10 percent rating effective March 21, 2006. That decision noted that the Veteran had an arthroscopy and lateral release operation in January 2006. The 10 percent rating was assigned for removal of the semilunar cartilage, which is symptomatic under Diagnostic Code 5259. A 10 percent rating is the highest available under this code. The right knee disability may also potentially be rated under Diagnostic Codes, 5257, 5258, 5260 or 5261. Under Diagnostic Code 5257, where there is slight recurrent subluxation or lateral instability, a 10 percent rating may be assigned. A 20 percent evaluation will be assigned for moderate recurrent subluxation or lateral instability, and a 30 percent rating is assigned for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Diagnostic Code 5258 provides that a 20 percent rating will be assigned when there is dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. A 20 percent rating is the highest disability rating provided by this code. Diagnostic Code 5260 pertains to limitation of flexion of the knee. This code provides that flexion limited to 30 degrees warrants a 20 percent evaluation and flexion limited to 45 degrees warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 pertains to limitation of extension of the knee. This code provides that extension limited to 15 degrees warrants a 20 percent evaluation; and, extension limited to 10 degrees warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5261. VA General Counsel, has held that separate ratings may be assigned in cases where a service-connected knee disorder includes both arthritis and instability, provided, of course, that the degree of disability is compensable under each set of criteria. VAOPGCPREC 23-97; 62 Fed. Reg. 63604 (1997). In VAOGPREC 9-2004 (September 17, 2004) VA General Counsel held that despite motion being in one plane the two motions, flexion (a retrograde motion) in bending the leg and extension (a forward motion) in straightening the leg, serve different functional roles, although both are necessary for normal function, such that they constitute two symptomatologies or manifestations that are not duplicative or overlapping such that separate ratings may be assigned for limitation of knee flexion (Diagnostic Code 5260) and for limitation of knee extension (Diagnostic Code 5261) without violation of the rule against pyramiding, at 38 C.F.R. § 4.14, regardless of whether the limited motions are from the same or different causes. Diagnostic Code 5262 pertains to impairment of the tibia and fibula. This code provides a 20 percent evaluation for moderate disability; and slight knee or ankle disability warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5262. A September 2005 MRI of the right knee produced diagnostic impressions of intact ligaments, no strict MRI criteria for meniscal tear, grade IV patellar chrondromalacia, very small joint effusion and no obvious loose bodies noted. Private progress notes from September 2005 to February 2006 show ongoing treatment and evaluation of right knee disability by Dr. S. In September 2005, the Veteran had discomfort on the inner aspect of the knee at the medial joint line. She had increased Q-angle and the treating physician was concerned with problems with the patella maltracking. A subsequent progress note shows that the MRI was reviewed and the Veteran was noted to be a potential candidate for arthroscopic surgery. In December 2005, the Veteran reported that she was still experiencing discomfort of the knee, which was parapatellar in nature and moderate in severity. Examination showed a good range of motion of both knees and no notable effusion in either knee. The Veteran had increased Q-angle bilaterally and muscular tone was normal. Her gait for short distances was reasonable. With the increased Q-angle, the physician believed that an arthroscopy with proximal lateral release would be reasonable. A January 2006 operative report from Dr. S shows that the Veteran underwent right knee surgery, including arthroscopy, chondroplasty of the patella and lateral retinacular release. Two days after the surgery, there was minimal swelling of the knee and no calf tenderness or pedal edema. In February 2006, the Veteran had 2 to 3+ knee effusion and good flexion and extension. The physician advised her to gradually increase her activity. In a February 28, 2006, notation, Dr. S noted that he did not have any professional experiences, which justified him commenting on medical dilemmas regarding service-connected disabilities. In a February 2006 letter, Dr. S indicated that he had been treating the Veteran's right knee disability. Limping caused by her right foot disability had put increased stress on the right knee, exacerbating an underlying, asymptomatic chrondromalacia. She had increased Q-angle, which put stress on the lateral aspect of the patella. Subsequently, the Veteran had undergone the surgery for this condition. March and April 2006 private progress notes show that the Veteran received physical therapy for the right knee. In March 2006, she reported that she was doing all her assigned exercises at home. She did report some pain. The therapist found that the Veteran tolerated the exercises well, making progress toward achieving the goals of therapy. In April 2006, the Veteran reported that she was doing a little bit too much with activities approximately two to three times per day as she was experiencing increased soreness. She indicated that after so much activity, her knee would just "give out." The therapist found that the Veteran was making somewhat slow progress. She was progressing with her strengthening but she was somewhat hesitant to challenge the knee with further strengthening. The therapist found that overall the Veteran was making progress. In the June 2006 statement, the Veteran reported that over the prior year, she had begun experiencing more knee, leg and foot pain. The pain reportedly made it extremely difficult to climb stairs, drive more than 20 minutes, vacuum, carry things such as groceries, walk down the street, or attend exercise class. She reported having trouble putting her full weight down on her right foot and knee. Progress notes from Dr. S from March 2006 to March 2007 show ongoing treatment and evaluation of the right knee. In March 2006, the Veteran still had some slight limitation of motion but was making progress. Flexion was limited to about 90 degrees. She had minimal swelling. In May 2006, the Veteran was noted to have been overstressing the knee resulting in increased discomfort. She had good flexion/extension. In June 2006, the Veteran was noted to be making progress. She reported that the knee would still "go out." She also noted some continued discomfort. Physical examination showed full flexion/extension with no notable effusion. In October 2006, the Veteran reported that the knee still popped and clicked occasionally. Clinically the knee looked quite good. She did not have significant effusion and had good flexion/extension. Her legs were clinically straight and muscle tone was full and equal. In March 2007, the Veteran reported that she had slipped about 10 days prior and struck the right knee, resulting in some increased discomfort. She also noted some popping and burning in the anterior aspect of the knee. Physical examination showed patellofemoral crepitus with forced extension of the knee. The Veteran noted burning at the inferior pole of the patella and the popping was in the mid patellar region. There was trace effusion. The Veteran had good range of motion. X-rays showed mild degenerative changes lateral and posterior to the patella. During a June 2006 QTC examination, it was noted that the Veteran had been suffering from asymptomatic chrondromalacia. She reported stiffness each morning, swelling by noon, and weakness by early afternoon. The knee, foot and leg reportedly gave way 2 to 3 times per day. She alleged that she had a lack of endurance with various activities, locking, especially trying to squat and fatigability by early afternoon. She reported suffering from pain in the knee every day, approximately 6 hours per day. The pain could be elicited by physical activity and sitting or could come on by itself. At the time of pain she could function without medication and the condition did not cause incapacitation. The current treatment was physical therapy. There was no functional impairment resulting from the condition. Physical examination showed no right knee weakness or tenderness. There was crepitus. Range of motion was 110 degrees flexion with pain at 110 degrees and 5 degrees extension with pain at 5 degrees. Joint function was limited by pain, fatigue, weakness, lack of endurance and incoordination on repetitive use, with pain having the major functional impact. The examiner was unable to determine any additional limitation in degrees following repetitive use without resorting to speculation. X-rays of the right knee showed joint narrowing. The examiner commented that the effect of both the Veteran's right knee and right foot disabilities on occupation and daily activities was the inability to stand, walk, or climb stairs or ladders. In July 2006, the Veteran indicated that for the past several years, she had been unable to wash the kitchen floor, carry laundry up and down stairs or ladders, clean under the beds or clean or get items from the upper cabinets. She reported being unable to scrub a bath tub, take a bath, push a 1/2 filled shopping cart for more than 5 to 10 minutes and vacuum the car. She alleged that she could not wear stockings or nylons because they caused her leg to swell. She described having difficulty getting in or out of a car. She claimed that she could not kneel at church or stand for long periods, could not walk her dogs, could not drive for more than 15 to 20 minutes in traffic, and had not been able to exercise or play with her kids. She averred that she could not shave her legs, cut the lawn or do any camping activities. She maintained that she was limited in the volunteer activities in which she could participate and if she sat down to garden, someone would have to help her up. Additionally, she argued that lifting objects over 10 to 15 pounds caused leg strain, and that she had to use a cane every day. In a December 2009 medical history, the Veteran indicated that she experienced right knee weakness, stiffness, swelling, pain, giving way and drainage. She reported flare-ups 4 to 5 times per week, and that she could not put full weight on the right leg. January 2010 progress notes from Dr. S show complaints of right knee pain, popping and locking. On January 6, 2010, the pain was mild to moderate with an aching quality. It was not localized. The Veteran associated the start of the pain with hitting her head on her washer and falling. She reported discomfort with all activities, and that her symptoms increased with walking. They allegedly were relieved by rest and Tylenol. She also continued to feel discomfort in her right hip and thigh since her most recent electromyogram. Physical examination showed tenderness to palpation in the medial parapatellar with mild effusion. There was also some weakness with forced flexion and extension. McMurray's sign was positive medially. The diagnostic assessment was right knee parapatellar pain. On January 12, 2010, the Veteran complained of parapatellar pain with mild effusion. Examination showed weakness with forced flexion and extension but active flexion and extension was full and painless. On January 21, 2010, physical examination produced similar findings. During a January 2010 QTC examination, the Veteran reported weakness, stiffness, swelling, giving way, drainage and pain. She indicated that she experienced flare-ups as often as four times per week and each time this would last for two days. During flare-ups she experienced tingling, numbness, burning, swelling and limitation of motion of the joint. She reported difficulty with standing/walking, and that she could not drive for more than 20 minutes as her knee and lower leg started to swell, throb and get numb. She reported being unable to sit for long periods as she needed to get up and stretch her leg. She was taking a diuretic to relieve water retention and was taking Tylenol for pain. She reported that in the last 12 months the condition had not resulted in any incapacitation. Physical examination showed that the Veteran leaned on a cane. She required the cane but did not require a brace, crutches, corrective shoes, a wheelchair, prosthesis or a walker. Examination of the right knee showed guarding of movement and crepitus. There was no subluxation or ankylosis. The right knee showed extension to 0 degrees and 120 degrees of flexion with pain at 10 degrees of extension and 90 degrees of flexion. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination on repetitive use. Medial/lateral/collateral ligaments stability test, anterior/posterior cruciate ligaments stability test and medial/lateral meniscus stability test were all within normal limits for the right knee. Right knee X-rays showed degenerative arthritic changes. The diagnosis was Grade IV chrondromalacia patella, right knee and status post arthroscopic surgery with scar and degenerative joint disease. The effect on the Veteran's daily activity was right knee pain after prolonged standing and walking. February 2010 progress notes from Dr. S shows that the Veteran was seen for a follow-up evaluation of her complaints of right knee pain, popping and locking. Physical examinations again showed tenderness to palpation of the medial parapatella with mild effusion. Range of motion was full and painless and crepitance was present. There was still weakness with forced flexion and extension. An antalgic gait was noted. The diagnostic assessments were chondromalacia patella and knee pain. A February 2010 private MRI of the right knee showed intact ligaments. There was no MRI evidence of a meniscal tear. There was mild grade IV patellar chrondromalacia, unchanged, and small joint effusion, unchanged. In her February 2010 Form 9, the Veteran reported that when her right knee would swell up she had more difficulty with bending and her flexibility lessened. This occurred more often in cold and/or rainy weather than in warm weather. A March 2010 VA progress note shows that the Veteran complained of pain in the right knee. Periodic swelling of the knee had been helped by taking the diuretic. During a June 2011 RO hearing, the Veteran reported that at home, she avoided going upstairs until going to bed because going downstairs was hard on her knee. She reported that she would take her children when she went shopping so that they could carry heavy items. She claimed that she was not allowed to carry more than five pounds, and that she could not push a shopping cart by herself as her knee would swell. Regarding chores, her sons and husband did the vacuuming and she had to wash the floor by hand in a seated position. She avoided using ladders. She noted that she could not scuba dive, bowl, ski, camp or hike. She also alleged that she could not put all her weight on her right leg when in the shower. The appellant reported experiencing throbbing knee pain. If she remembered to limit her activities the knee would not swell up too badly but it was worse in the winter and the swelling would limit motion. She would avoid bending down or squatting. She testified that several times a week she experienced flare-ups where she no longer could bend her knee. The flare-ups arguably could last up to several days unless she took enough of the diuretic to bring the swelling down. She noted that Dr. S had ordered bedrest on several occasions; the last time was after the EMG testing made her whole leg numb. The longest she had been told her to say off the knee was a week or two. She noted that when she would go down the stairs, her knee would feel as if it was going to buckle. At an August 2011 VA right knee examination, the Veteran reported that she still experienced swelling now and then with grinding and was told she might eventually need a knee replacement. She was taking a diuretic to help with the swelling. The Veteran's reported that her symptoms included giving way, pain, stiffness, weakness, decreased speed of joint motion, swelling and tenderness. She indicated that she was able to stand for one hour and walk a quarter mile. She described using a cane frequently. Physical examination showed an antalgic gait. Examination of the right knee showed bony joint enlargement and grinding. There was some mild weakness. Examination of the right ankle was unremarkable. Right knee motion studies showed full extension to 0 degrees, and full flexion to 140 degrees. There was objective evidence of pain on motion but there was no additional limitation after three repetitions of range of motion. An X-ray of the right knee was unremarkable. The examiner diagnosed a right knee strain. The examiner found no pathology on the day of examination. The examiner found that the right knee disorder had no significant effects on the Veteran's usual occupation or daily activities. From March 21, 2006 to August 4, 2011, the preponderance of the evidence is against finding that the Veteran has right knee flexion limited to 45 degrees or less, or that right knee extension has been limited to 10 degrees or more. Instead, flexion has not been shown to be limited to less than 90 degrees and extension has not been shown to be limited to less than 5 degrees. Thus, a compensable rating is not warranted under either Diagnostic Code 5260 or 5261. Similarly, neither objective evidence of right knee instability or recurrent subluxation has been shown. There are no objective findings of record of instability or subluxation and the January 2010 QTC examiner specifically found that the right knee medial/lateral/collateral ligaments stability test, anterior/posterior cruciate ligaments stability test and medial/lateral meniscus stability test were all within normal limits and that the Veteran did not have any subluxation. The Veteran has reported problems with the right knee "giving way" at times, but given the fact that neither objective evidence of instability nor objective evidence of subluxation was shown during any of the examinations or medical visits of record prior to August 4, 2011, the weight of the evidence is against a finding that such symptomatology is present. Indeed, such repeated objective findings raise grave doubts as to the credibility of the appellant's assertions. Thus, a compensable rating is also not warranted under Diagnostic Code 5257. A dislocation of the semilunar cartilage with frequent episodes of locking, pain and effusion into the joint has never been shown. Consequently, a higher 20 percent rating is not warranted under Diagnostic Code 5258. The Board has considered whether a higher rating could be awarded under any other Diagnostic Codes. As neither ankylosis nor nonunion of the tibia and fibula are shown assigning a rating under these Codes is not warranted. The Board also notes that the Veteran's right knee disability could be rated by analogy under the criteria pertaining to degenerative arthritis of the knee under Diagnostic Code 5003. As the maximum rating for one joint such as the knee is 10 percent, however, application of this Code would not allow for assignment of increased compensation. Additionally, assignment of a separate 10 percent rating under this Code would amount to impermissible pyramiding. Additional factors that could provide a basis for an increase have also been considered; however the evidence does not show that the Veteran has functional loss beyond that currently compensated. 38 C.F.R. §§4.40, 4.45, Deluca. The June 2006 QTC examiner was not able to determine the presence of any additional loss of motion on repetitive use without resort to speculation, the January 2010 QTC examiner specifically found that joint function was not additionally limited by pain fatigue, weakness, lack of endurance or incoordination on repetitive use and the August 2011 VA examiner found that although there was objective evidence of pain on motion, there was no additional range of motion limitation after three repetitions. The June 2006 QTC examiner did conclude that the effect of both the Veteran's right knee and foot disabilities on her occupation and daily activities was an inability to stand, walk, or climb stairs or ladders. The Board assigns no probative weight to this finding, however, as earlier in the examination the examiner found that the Veteran had no limitation standing or walking. Indeed, at worst the Veteran has argued that she has limitations standing and walking, not that she is unable to do so. Accordingly, this conclusion is not supported. The Veteran has reported that knee swelling limits knee motion, even to the point where she cannot bend it. The objective evidence of record preponderates against finding such a severe limitation. While the Veteran was found to have mild right knee effusion in January 2010 with weakness with forced flexion and extension, active flexion and extension were full and painless. Given this specific finding and the lack of any other objective findings during the rating period indicating a loss of motion due to swelling, the Board does not find credible the Veteran's account of regular, severe swelling to the point that she cannot bend her knee. Additionally, the more mild level of functional loss from swelling that has been shown is appropriately compensated by the existing 10 percent rating. Also, the Veteran has described significant overall limitations in her daily activities, the record indicates that these described limitations are due to the combination of the Veteran's numerous disabilities, including of the knee, foot, and nonservice connected leg and back disorders. Thus, given the consistent objective findings pertaining only to the knee, the Board finds that the existing 10 percent rating provides appropriate compensation for the Veteran's functional loss. B. Right foot disability The Veteran's service treatment records show that she injured her right foot in November 1983 when a trash can was accidentally dropped on it during basic training. Physical examination three weeks later showed tenderness over the dorsal right foot and increased pain over the metatarsophalangeal joint. There was no swelling or discoloration, full range of motion and a normal gait. The diagnostic assessment was metatarsalgia. In March 1984, she was evaluated on an inpatient basis. The orthopedic surgery department found that Veteran had a congenital abnormality of both feet (1st metatarsal cuneiform joint). Separation from service was recommended due to pain, which prohibited the wearing of combat service boots. A Medical Board convened in June 1984 determined that the Veteran had a congenital abnormality of the first metatarsal cuneiform joint that had been aggravated by service. This precluded her from participating in initial training and the wearing of normal military footgear. As a result, she was discharged from service in October 1984. In a June 1985 rating decision VA found that the Veteran had sustained a right foot injury in November 1983. VA also found that the Veteran had a congenital deformity of both feet but that it was not aggravated by service. Service connection for residuals of the right foot injury, however, was granted and a noncompensable rating was assigned effective October 1984. In a July 2005 rating decision, the rating was increased to 10 percent effective April 22, 2004, based on a finding that the disability resulted in moderate symptoms. The existing 10 percent rating has been assigned under Diagnostic Code 5284 for other injuries of the foot. Under this Code, foot injuries that are moderate warrant a 10 percent disability rating. If moderately severe, a 20 percent disability rating is appropriate. If the foot injury is severe, a maximum 30 percent disability rating is warranted. 38 C.F.R. § 4.71a , Diagnostic Code 5284. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, no added under diagnostic code 5003. After considering the evidence of record under the laws and regulations as set forth above, the Board concludes that not more than a moderate foot disability is present in the right foot. As such the Veteran is not entitled to an evaluation in excess of 10 percent. During a June 2006 QTC examination, the Veteran reported that she suffered pain located on the underside of the foot approximately four times per week with each episode lasting approximately two hours. The pain was throbbing and she indicated that it would travel up the leg to the lower back. The pain could be elicited by physical activity or could come on by itself. At the time of pain, she could function with or without medication. She reported that weakness and swelling at rest. When standing or walking she reported having weakness, swelling and fatigue. She had received water therapy in 2002. She alleged that functional impairment prevented extensive walking, climbing, standing and physical activity. Physical examination showed no tenderness, weakness, edema, atrophy or disturbed circulation. Pes planus was present and there was no forefoot/midfoot malalignment. Palpation of the right foot plantar surface revealed slight tenderness. The right Achilles tendon was in good alignment. The Veteran had claw feet. There was moderate contraction and shortening of the plantar fascia on the right. Dorsiflexion of all the toes on the right did not produce pain. Palpation of the metatarsal heads of the toes on the right produced slight tenderness. The Veteran did not have any limitation with standing and walking. She did not require any type of support with her shoes. Right foot x-rays showed a bunion deformity. The examiner diagnosed residuals of a right foot injury, also claimed as loss of sensation, weakness and throbbing in the foot, with bunions, pes planus and plantar fasciitis. The examiner commented that the effect of both the right knee and foot disabilities on the Veteran's occupation and daily activities was an inability to stand, walk, or climb stairs or ladders. The examiner commented that the right foot pes planus, plantar fasciitis and hallux valgus were related to her service-connected right foot disability. The above noted July 2006 statement is incorporated by reference to this claim. In an October 2006 statement, the Veteran noted that Dr. S had found that she did not have pes planus and pes cavus simultaneously, which would be impossible. Moreover, Dr. S had found that the Veteran's small bunion did not cause right leg or foot swelling, burning or tingling sensation. He further found that the Veteran did not have claw feet. During the January 2010 QTC examination, the Veteran denied having right foot pain. She described having occasional right foot/leg swelling and numbness. At rest she reported having weakness, swelling and fatigue but no pain or stiffness. She indicated that due to her knee and foot pain, she had to use a cane every day. Physical examination showed that the Veteran leaned on a cane. Examination of the feet revealed no signs of abnormal weight-bearing, breakdown, callosities or any unusual shoe wear pattern. She required the cane but did not require a brace, crutches, corrective shoes, a wheelchair, prosthesis or a walker. Examination of the right ankle revealed no abnormality and range of motion was within normal limits. Joint function was not additionally limited after repetitive use. Examination of the right foot revealed no tenderness, painful motion, weakness, edema, heat, redness, instability, atrophy or disturbed circulation. There was active motion in the metatarsophalangeal joint of the right great toe. Palpation of the plantar surface of the right foot revealed no tenderness. Alignment of the Achilles tendon was normal. Pes planus, pes cavus and Morton's metatarsalgia were not present. Hallux valgus of the right foot was present. The degree of angulation was slight with no resection of the metatarsal head present. The Veteran did not have any limitation with standing and walking. She did not require any type of shoe support. Right foot X-rays showed degenerative joint disease and a bunion. The examiner noted that the bunion on X-ray was asymptomatic and not related to the service-connected injury. The diagnosis was status post crush injury to the right foot with degenerative joint disease. The examiner opined that the residuals of the right foot injury were occasional pain and swelling. The effect of the condition on the Veteran's usual occupation was unknown. The effect on the Veteran's daily activity was right foot pain post prolonged standing and walking. On her February 2010 Form 9, the Veteran reported that there were days that her foot swelled up so much that she could not wear a shoe or walk without pain or weakness of some sort. In addition to the symptoms and limitations previously discussed, during her June 2011 DRO hearing, the Veteran reported continuing to take a diuretic to keep right leg and foot swelling down. She reported having daily swelling, that tingling and numbness occurred almost daily, and that she used a cane between 60 and 70 percent of the time. She testified that she had to frequently put her foot up to keep swelling down. She alleged that half of the time she would drive without shoes or walk to her daughter's school without shoes because her foot was so swollen. At an August 2011 VA foot examination, the Veteran reported having daily right foot pain. She reported being able to walk a quarter mile and stand for one hour. She was currently not seeing a foot doctor or taking any medication. She described suffering from swelling, stiffness, fatigability, weakness and lack of endurance. She used a cane. Physical examination showed slightly decreased sensation in the right foot. The Veteran walked with a cane and limped on the right foot. X-rays showed mild bilateral hallux valgus. There was no fracture or dislocation and the joint spaces were preserved. The diagnosis was right foot strain with no pathology on the day of the examination, and mild bilateral hallux valgus. The examiner opined that the right foot disorder had no significant effect on the Veteran's usual occupation or daily activities. The examiner noted that the appellant was employed fulltime as a legal assistant. In the present case, the medical evidence of record shows that the Veteran's right foot disability is not more than moderately disabling. The January 2010 QTC examiner specifically found no limitation with standing or walking and that the Veteran did not require any type of support with her shoes. She also found that the residuals of the right foot injury were occasional pain and swelling and that the effect on the Veteran's daily activity was right foot pain after prolonged standing and walking. Similarly, the August 2011 VA examiner found only slightly decreased sensation on physical examination and diagnosed the Veteran with right foot strain with no pathology on the day of the examination. The August 2011 examiner also found that the right foot disorder had no significant effect on the Veteran's daily activities. The earlier June 2006 QTC examiner did find that the effect of both the Veteran's right knee and foot disabilities on occupation and daily activities was an inability to stand, walk, or climb stairs or ladders. The Board, however, assigns no probative weight to this finding, however, as earlier in that June 2006 examination, the examiner had found that the Veteran did not have any limitation with standing and walking. Additionally, the Veteran has not affirmatively reported that she is unable to stand and walk, only that she has limitations in doing so. Accordingly, the Board finds this conclusion non-probative. Once again, the Veteran has described a long list of limitations in her daily activities due to her foot disorder. The objective record demonstrates, however, that her limitations are due to the combination of her numerous disabilities, including of the knee, foot, and nonservice connected leg and back disorders. Given that objective findings pertaining to the foot from the January 2010 and August 2011 VA examinations do not show more than a mild level of impairment, and given that the most probative objective findings of record pertaining to the right foot are indicative of no more than a moderate level of impairment, the weight of the evidence is in favor of assignment of no more than a 10 percent rating for moderate disability of the foot. As the Veteran has been diagnosed with right foot degenerative arthritis, the Board considered whether a higher rating is warranted under Diagnostic Code 5003. As the appellant is already in receipt of a compensable rating, without a showing of greater objective limitations of foot motion there is no basis for assigning a rating in excess of 10 percent under this Code. Additionally, the Board has considered the applicability of other codes for rating the foot. The June 2006 VA examiner diagnosed claw foot (pes cavus), flatfoot (pes planus), plantar fasciitis and hallux valgus found that the right foot pes planus, plantar fasciitis and hallux valgus were related to the service-connected right foot disability. The January 2010 QTC examiner specifically found that the Veteran did not have pes cavus or pes planus and did not diagnose plantar fasciitis, however. Also, the August 2011 VA examiner did not diagnose pes planus, pes cavus or plantar fasciitis. Additionally, although both examiners diagnosed hallux valgus, the January 2010 QTC examiner specifically found that hallux valgus was not related to the service-connected foot disability. Given that the June 2006 QTC examiner's findings have already been called in to question by the analysis above, the Board attaches significantly greater weight to the diagnostic impressions of the January 2010 QTC examiner and the August 2011 VA examiner. Thus, as the Veteran is not shown to have service related pes cavus, pes planus or plantar fasciitis, and as hallux valgus is not shown to be service-related, rating codes pertaining to these conditions are not for application. Additionally, malunion or nonunion of the tarsal bones is not present. Moreover, the maximum rating assignable for metatarsalgia is 10 percent and assignment of a separate rating under this Code would violate the doctrine against pyramiding. 38 C.F.R. § 4.14. Thus, there is no basis for assigning a rating in excess of 10 percent under these other rating Codes. 38 C.F.R. § 4.71a, Diagnostic Codes 5276, 5278, 5279, 5280, 5283. Additional factors that could provide a basis for an increase have been considered; however the evidence preponderates against finding that the Veteran has functional loss beyond that currently compensated. 38 C.F.R. §§4.40, 4.45. The objective medical findings of record preponderate against finding a level of functional loss that is more than moderate. Indeed, the evidence tends to indicate that any service connected right foot functional loss is not more than mild. Also, there are no other objective findings of record indicating that the service-connected right foot disability, in and of itself, produces more than a moderate level of functional loss. The Veteran has subjectively described significant overall limitations in her daily activities, the objective evidence indicates, however, that her described limitations are due to the combination of the Veteran's numerous disabilities, including of the knee, foot, and nonservice connected leg and back disorders. Given the consistent objective findings from the January 2010 and August 2011 VA examinations pertaining only to the foot, the Board finds that the existing 10 percent rating provides appropriate compensation for the Veteran's functional loss. C. Extraschedular Consideration The Board has also considered whether the Veteran's claims for increased ratings or right knee and foot disabilities should be referred for consideration of an extraschedular evaluation. The Board concludes that no such referral is warranted for any time frame in question. As explained above, the Veteran's right knee symptomatology, including pain, swelling and stiffness, is fully contemplated by the pertinent diagnostic criteria. Similarly, the Veteran's right foot symptomatology, including pain and swelling, is fully contemplated by the pertinent diagnostic criteria. There is nothing in the record to suggest that her disability picture is so exceptional or unusual as to render impractical the application of the regular schedular standards. See, e.g., Thun v. Peake, 22 Vet. App. 111 (2008). ORDER New and material evidence having been received, the claim of entitlement to service connection for low back disability is reopened. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a right leg disability, to include right lower extremity radiculopathy, including as secondary to residuals of a right foot injury, is denied. Entitlement to a rating in excess of 10 percent for chondromalacia of the right knee from March 21, 2006 is denied. Entitlement to a rating in excess of 10 percent for residuals of a right foot injury is denied. REMAND During the August 2012 Board hearing, the Veteran testified that both her foot and knee disability had gotten worse since the August 2011 VA examination. She testified that she had lost some time from work due to these disorders, including 64 hours of vacation time over the past year, along with time for medical appointments. Given these allegations, a VA examination to assess the current severity of the Veteran's foot and knee disabilities is warranted. Prior to arranging for the VA examination, the AMC/RO should obtain all VA records of treatment or evaluation for right foot and knee disability since August 2011. The AMC/RO should also ask the Veteran to identify all additional sources of treatment or evaluation she has received for her right knee and foot disorders since August 2011. Thereafter, the AMC/RO should secure copies of complete records of the treatment or evaluation from all sources appropriately identified. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should obtain all VA records of treatment or evaluation for right knee and foot disability since August 2011. The AMC/RO should also ask the Veteran to identify all additional sources of treatment or evaluation she has received for her right knee and foot disability since August 2011 and secure copies of complete records of the treatment or evaluation from all sources appropriately identified. For any records the AMC/RO cannot locate, it must specifically document the attempts that were made, and explain in writing why further attempts to locate them would be futile. The AMC/RO 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 should be afforded a VA orthopedic examination to assess the current severity of her right knee and foot disabilities. 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 knee and foot disabilities, the examiner is to provide a detailed review of the Veteran's pertinent medical history, current complaints and the nature and extent of any disability due chondromalacia of the right knee and due to residuals or right foot injury. If other right knee or right foot disorders are diagnosed, the examiner must carefully differentiate other pathology. The examiner should attempt to distinguish objective pathology from any functional pathology. 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 AMC/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 examiners document their consideration of Virtual VA. If the report is deficient in any manner, the RO must implement corrective procedures at once. 5. After the completion of any action deemed appropriate in addition to that requested above, the appellant's claim must be readjudicated. All applicable laws and regulations, and all pertinent evidence received, 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