Citation Nr: 1310060 Decision Date: 03/25/13 Archive Date: 04/02/13 DOCKET NO. 09-40 297 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the left knee (left knee disability). 2. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the right knee (right knee disability). 3. Entitlement to an increased rating for the left ankle disability rated as 10 percent from February 9, 2004 and 20 percent from August 31, 2012. REPRESENTATION Appellant represented by: American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Chapman, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1966 to July 1969, August 1970 to August 1973, and from February 1975 to February 1979. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston Salem, North Carolina. In May 2012, the Veteran testified during a Travel Board hearing before the undersigned; a transcript of the hearing is of record. The issues on appeal were previously remanded by the Board in July 2012 for additional development. While the case was in remand status, the RO assigned separate 10 percent ratings for the Veteran's right and left knees due to moderate recurrent instability. The Veteran did not file a notice of disagreement regarding knee instability, so this specific issue is not on appeal. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Since February 22, 2008, the Veteran's degenerative joint disease (DJD) of both knees has worsened, reflecting moderate degenerative changes manifested by chronic pain, periodic swelling, stiffness, locking episodes, bilateral knee crepitus, effusion, and x-ray findings consistent with significant medial compartment narrowing. 2. Prior to August 31, 2012, the Veteran's left ankle disability is more nearly approximated by moderate limitation of motion. 3. From August 31, 2012, the Veteran's left ankle disability is manifested by ankylosis with dorsiflexion between 0 and 10 degrees. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for 20 percent ratings for left knee disability and for right knee disability (but no higher), effective February 22, 2008, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.71a, Diagnostic Code (DC) 5258 (2012). 2. The criteria for a rating in excess of 10 percent for left ankle disability prior to August 31, 2012 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.59, 4.7, 4.71a, DC 5270-5274 (2012). 3. The criteria for a 30 percent rating for left ankle disability from August 31, 2012 have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.59, 4.7, 4.71a, DC 5270 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 defined VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) and that the claimant is expected to provide. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In this case, letters satisfying the notice requirements of 38 C.F.R. § 3.159(b)(1) were sent to the Veteran in May 2008, June 2008, and January 2009. This letter informed him of the evidence required to substantiate his claim and of his and VA's respective responsibilities in obtaining supporting evidence. The Veteran does not contend, nor does the evidence show, any notification deficiencies with respect to content that have resulted in prejudice. See Shinseki v. Sanders / Simmons, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA also fulfilled its duty to assist the Veteran by obtaining all relevant evidence in support of his claim that is obtainable, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). The RO obtained his service treatment records (STRs) and lay statements in support of his claim. In addition, the RO arranged for a VA compensation examination to assess the severity of his bilateral knee and left ankle disabilities, which are now the determinative downstream issues since his appeal is for higher ratings for these disabilities. See McLendon v. Nicholson, 20 Vet. App. 79 (2006), citing 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). See also Caffrey v. Brown, 6 Vet. App. 377 (1994). The report of that evaluation contains all findings needed to properly evaluate his disabilities. 38 C.F.R. § 4.2. The examiner adequately addressed all relevant aspects of the claim, to include whether there was impaired function due to pain or on repeated movements. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. Legal Criteria The Board has reviewed all of the evidence in the Veteran's claims file and in the "Virtual VA" electronic records storage system. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence of record. See Gonzales v. West, 218 F. 3d 1378, 1380-81 (Fed. Cir. 2009). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows or fails to show as to the claim. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher one 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 reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When VA grants a claim for an increased rating, it may assign an effective date up to one year before the date the claimant's application for increase was received, provided it is factually ascertainable that an increase in disability occurred within that time frame. 38 U.S.C.A. § 5110(b)(2); Hart, 21 Vet. App. 505, 509 (2007). Here, the relevant evidentiary window begins November 2006 (one year before the Veteran filed his claim for an increased rating), and continues to the present time. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). An extraschedular evaluation will be assigned if the case presents an unusual or exceptional disability picture with such related factors as marked interference with employment or frequent periods of hospitalization such as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). Left and Right Knee Disability At the outset, the Board points out, as explained in more detail below, that the Veteran's left and right knee disabilities are rated, in part, on the basis of limitation of motion. In this regard, the Board notes that, when evaluating such 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). See also Johnson v. Brown, 9 Vet. App. 7 (1996). The Veteran was granted service connection for DJD of the right and left knee by the RO in June 2004, effective February 9, 2004. The Veteran's bilateral knee disability is rated 10 percent for each knee under DC 5010. Under DC 5010, traumatic arthritis is rated as degenerative arthritis (established by x-ray) under DC 5003, which in turn is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200, etc.). 38 C.F.R. § 4.71a, DCs 5003 and 5010. 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, not added, under DC 5003. The 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, DC 5003. Under DC 5260, limitation of flexion of either leg to 60 degrees warrants a noncompensable (0 percent) rating. A 10 percent rating requires flexion to 45 degrees. A 20 percent rating requires flexion limited to 30 degrees. A maximum 30 percent rating requires flexion limited to 15 degrees. See 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, limitation of extension of either leg to 5 degrees warrants a noncompensable (0 percent) rating. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating requires extension limited to 15 degrees. A 30 percent rating requires extension limited to 20 degrees. A 40 percent rating requires extension limited to 30 degrees. A maximum 50 percent rating requires extension limited to 45 degrees. See 38 C.F.R. § 4.71a, DC 5261. For rating purposes, normal range of motion in a knee joint is from 0 degrees (extension) to 140 degrees (flexion). 38 C.F.R. § 4.71, Plate II. Under DC 5258, cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint, is rated as 20 percent. See 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5257, other impairment of the knee, such as recurrent subluxation or lateral instability, is rated as 10 percent when slight, 20 percent when moderate and 30 percent when severe. See 38 C.F.R. § 4.71a, DC 5257. The terms "slight," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just" as contemplated by the requirements of the law. 38 C.F.R. § 4.6 (2010). Separate, compensable evaluations may be afforded for distinct disabilities resulting from the same injury as long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994); VAOPGPREC 23-27 (July 1, 1997; revised July 24, 1997). Considering the pertinent evidence in light of the governing legal authority, the Board finds that 20 percent ratings are warranted for the Veteran's DJD of the left and right knee from February 22, 2008. In February 2008, the Veteran was afforded a VA examination. The examiner noted deformity of the left knee, giving way, instability, constant pain, stiffness, locking episodes, and limitation of motion in both knees. In addition, the examiner noted flare-ups in the left knee occurring 6 times in 12 months, as well as swelling and heat. Walking was limited to 15 minutes, with standing limited to 15-20 minutes. No inflammatory arthritis was noted. Right knee findings included no deformity, tender around the patella, and no instability. Left knee findings included a deformed and swollen knee, tender over medial ligament and joint surface, and crepitation. Right knee range of motion studies revealed flexion to 140 degrees with pain beginning at 135 degrees and no additional limitation on repetitive use; extension was to 0 degrees with no additional limitation on repetitive use. Left knee range of motion studies revealed flexion to 130 degrees with pain beginning at 120 degrees and no additional limitation on repetitive use; extension was to 0 degrees with no additional limitation on repetitive use. Diagnostic testing revealed mild osteoarthritis of the right knee and moderately severe osteoarthritis of the left knee. The bony structures of both knees were presently intact with no evidence of fracture or dislocation; also no evidence of joint effusion or associated soft tissue abnormalities. The Veteran again received a VA examination in September 2008. The examiner noted the Veteran's frequent, intermittent use of a case and knee brace, standing limitations of 10 minutes, and walking limitations of 30-50 yards. Symptoms of the Veteran's knees included giving way, instability, pain, stiffness, weakness, locking episodes daily or more often, effusion, limitation of motion, weekly flare-ups, and inflammation. Left knee range of motion studies revealed flexion to 120 degrees, with pain beginning at 105 degrees and with limitation on repetitive use to 100 degrees with pain; extension to 0 degrees with no additional limitation on repetitive use. Right knee range of motion studies revealed flexion to 120 degrees with pain beginning at 100 degrees and with a limitation on repetitive use to 105 degrees with pain; extension was to 0 degrees with no limitation on repetitive use. The examiner noted no ankylosis, inflammatory arthritis, or bone loss. After an examination, the examiner stated that the Veteran's knee condition was manifested by bony joint enlargement, crepitus, tenderness, painful movement, and guarding of movement. Diagnostic imaging revealed mild DJD of the right knee and osteoarthritis of both knees. A diagnosis of DJD was provided for both knees. After a July 2012 Board remand, the Veteran was afforded another VA examination in August 2012. The examiner noted diagnoses of traumatic arthritis of both the right and left knee since 2008. The Veteran reported that daily flare-ups impact the function of his knee, and that while the pain is continuous, it increases in severity after standing or walking for any period of time. Right knee range of motion studies revealed flexion to 80 degrees with painful motion beginning at 70 degrees; extension was to 0 degrees with no objective evidence of painful motion. Left knee range of motion studies revealed flexion to 70 degrees with painful motion beginning at 70 degrees; extension was to 0 degrees with no objective evidence of painful motion. There was no additional limitation of range of motion after repetitive-use testing. Functional loss of the knees was characterized by less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, instability of station, disturbance of locomotion, and interference with sitting, standing and weight-bearing. Pain on palpation was present for both knees; muscle strength was 4/5. The examiner also noted that the Veteran uses braces occasionally and uses a cane regularly. Diagnostic testing of the knees revealed degenerative or traumatic arthritis of both knees. X-rays did not show patellar subluxation or any other significant findings. Moderate degenerative changes of both knees were noted with significant medial compartment narrowing and no acute bony abnormality of either knee. The examiner opined that the Veteran has signs and symptoms of worsening bilateral knee DJD and with his history, it is likely that his condition will continue to get worse. Additionally, VA treatment records, including records located on Virtual VA, during this period reflect continued left and right knee complaints, including swelling, chronic pain, and bilateral knee crepitus. The Board has also considered the Veteran's lay statements, in addition to a statement from his wife. In the Veteran's May 2008 statement in support of his claim for an increased rating, he stated that he lives with severe pain daily, and it was becoming difficult for him to do his job. In his wife's January 2008 statement, she reported that the Veteran's daily activities are affected by the pain in his knees, in addition to his job as it has become difficult for him to get in and out of the truck he drives. During the May 2012 hearing, the Veteran testified that he experiences stiffness, constant pain, popping and cracking in his knees, which leads to difficulty walking. He stated that he uses a cane and knee braces. Since the Veteran's February 2008 VA examination, the left and right knee range of motion, shown by medical evidence, does not reflect limitation of motion to a compensable degree. However, the February 2008 VA examiner noted giving way, instability, constant pain, stiffness, and locking episodes. The left knee was also characterized by flare-ups, swelling, and crepitation. Although the examiner noted that there was no joint effusion and that the bony structures of both knees were intact, a physical examination from June 2008 noted bilateral knee crepitus. Further, a September 2008 VA examiner similarly noted knee symptoms including giving way, instability, pain, stiffness, weakness, locking episodes daily or more often, effusion, limitation of motion, weekly flare-ups and inflammation. Here, the examiner noted bony joint enlargement, crepitus, tenderness, painful movement, and guarding of movement. The most recent VA examination in August 2012 showed lessening range of motion, and functional loss of the knees manifested by less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, pain on palpation, swelling, instability, disturbance of locomotion, and interference with sitting, standing and weight-bearing. And while this examiner found no acute bony abnormalities in the knees, he did note moderate degenerative changes in both knees with significant medial compartment narrowing and worsening of the Veteran's bilateral knee DJD. Consistent with these findings, the Veteran has complained and testified about chronic pain, stiffness, locking, and swelling. These symptoms have continued since 2008 when the Veteran first received a VA examination. This symptomatology closely resembles the disability picture in DC 5258. Thus, resolving all doubt in the Veteran's favor, a 20 percent rating for the Veteran's left knee disability and a 20 percent rating for the Veteran's right knee disability is warranted pursuant to 38 C.F.R. § 4.71a, DC 5258, effective from February 22, 2008 (the date of the VA examination). See 38 C.F.R. § 3.400(o)(2). As 20 percent is the highest possible rating under Diagnostic Code 5258, a rating higher than 20 percent is not warranted. This rating is assigned instead of the 10 percent rating, which the RO previously assigned under the DC pertaining to arthritis. The Board finds that separate compensable ratings may not be assigned under both DCs under the particular facts of the present case. In the present case, the pain on motion is being considered as a basis for the rating under 5258, and cannot also provide a basis for assigning a separate rating under the DC for arthritis. Separate, compensable evaluations may only be afforded for distinct disabilities where the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994); VAOPGPREC 23-27 (July 1, 1997; revised July 24, 1997). The Board further finds that no other DC provides a basis for the assignment of a higher rating for left knee and right knee disabilities at any time. Disabilities of the knee and leg are rated under 38 C.F.R. § 4.71a, DCs 5256 to 5263; however, many of these diagnostic codes are simply not applicable to the Veteran's service-connected left knee and right knee disabilities. It is neither contended nor shown that the Veteran's service-connected left knee and right knee disability involves ankylosis, symptomatic removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. As such, evaluation of the Veteran's left knee and right knee disabilities under DC 5256, 5259, 5262, or 5263, respectively, is not warranted. The Board again notes that the Veteran has already received a separate rating for both knees based on instability. Left Ankle Disability The Veteran contends that his service-connected left ankle disability is worse than the current evaluations contemplate. In a January 2013 rating decision, the RO increased the Veteran's 10 percent rating for left ankle disability to 20 percent, effective August 31, 2012, based on evidence received from an August 2012 VA examination report. The Veteran's left ankle disability is rated 20 percent disabling under DC 5271 pertaining to limitation of motion of the ankle. This Code provides for a maximum 20 percent rating for marked limitation of motion of the ankle. 38 C.F.R. § 4.71a, DC 5271. As the Veteran is already in receipt of a 20 percent rating under this diagnostic code, this DC cannot serve as a basis for an increased rating. However, the Board finds that DC 5270, which pertains to ankylosis of the ankle joint, is applicable in this case and under this DC, a 30 percent rating is warranted. On August 2012 VA examination, the examiner noted a diagnosis of DJD of the left ankle since 1990. The Veteran reported no flare-ups. Range of motion studies revealed left ankle plantar flexion to 15 degrees, with evidence of painful motion at 10 degrees; plantar dorsiflexion was to 5 degrees with evidence of painful motion at 5 degrees. Repetitive use testing did not result in an additional limitation of motion. Functional loss of the ankle by characterized by less movement than normal, weakened movement, excess fatigability, pain on movement, swelling, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. There was pain on palpation, muscle strength was 4/5, and the Talar tilt test showed laxity compared with the opposite side. Significantly, the examiner noted that ankylosis was present, with plantar flexion at less than 30 degrees and dorsiflexion between 0 and 10 degrees. See question 10 of the examination report. Diagnostic imaging of the ankle was reviewed, showing moderate degenerative changes, most prominent in the syndesmosis. No radiopague foreign bodies were identified in addition to no displacement or dislocation. The examiner opined that the Veteran's left ankle disability has at least as likely as not worsened and it is likely that his condition will continue to get worse. The Board has noted that the findings of the examination are somewhat conflicting, as the examiner appeared to state that the Veteran retains some range of motion, yet also concluded that ankylosis is present. Resolving all reasonable doubt in the Veteran's favor, because the findings from this examination show that the Veteran had ankylosis in dorsiflexion between 0 and 10 degrees, a 30 percent rating from the time of this examination, August 31, 2012, is warranted. A 40 percent rating under DC 5270 is not warranted because the Veteran's left ankle disability is not manifested by ankle ankylosis of plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. Additionally, the Board has also considered whether other DCs would provide a higher rating; however, there are no other ankle DCs which provide a rating higher than 30 percent. Next, while the Veteran has been diagnosed with DJD of the left ankle, because he is in receipt of a compensable rating under a DC predicated upon limitation of motion (5271), he is not entitled to a separate 10 percent rating under either DC 5003 or 5010. 38 C.F.R. § 4.71a, DC 5010, Note 1. And, as discussed above regarding the knee disabilities, the pain on motion is being considered as a basis for the rating under DC 5270, and cannot also provide a basis for assigning a separate rating under the DC for arthritis. While the Board finds that a 30 percent rating is warranted from August 31, 2012, the Board also finds that an increased rating prior to this date is not warranted. Prior to August 31, 2012, the Veteran received two VA examinations. On February 2008 VA examination, the examiner noted left ankle symptoms including deformity, instability, pain, and flare-ups 6 times in the past 12 months. The Veteran also reported that sometimes his left ankle curls over. Range of motion studies revealed plantar flexion to 15 degrees with pain beginning between 10-15 degrees; dorsiflexion to 30 degrees with pain beginning at 20-30 degrees; inversion to 20 degrees with pain beginning between 10-20 degrees; and eversion to 12 degrees with pain beginning between 8-12 degrees. The examiner noted no bone loss, no inflammatory arthritis, no joint ankylosis, and no indication of unequal leg length. Diagnostic imaging of the left ankle revealed old trauma noted of the medial and lateral malleolus; unremarkable ankle mortise; a large posterior calcaneal spur, and some bilateral soft tissue swelling. On September 2008 VA examination, the examiner noted DJD of the left ankle, characterized by giving way, instability, pain, stiffness, weakness, effusion, and inflammation. The Veteran had an antalgic gait. Range of motion studies revealed dorsiflexion to 15 degrees, with pain beginning at 15 degrees and no additional limitation on repetitive use; plantar flexion to 30 degrees with pain beginning at 30 degrees and no additional limitation on repetitive use; and flexion to 120 degrees with pain beginning at 105 degrees and a limitation to 100 degrees after repetitive use due to pain. In addition, the Board has considered VA treatment records, including those on Virtual VA, which noted continued complaints of left ankle pain and swelling, in addition to statements made by the Veteran and his wife, alleging a worsening of the Veteran's left ankle condition. However, the Board finds that the evidence prior to August 31, 2012 more nearly approximates moderate limitation of motion, and does not allow for a rating in excess of 10 percent. Under DC 5271, a 10 percent rating indicates moderate limitation of motion. Thus, a 10 percent rating, which he is currently assigned for the period prior to August 31, 2012, is appropriate. This rating also takes into account the Veteran's complaints of chronic left ankle pain. See Deluca, 8 Vet. App. at 204-7. Extraschedular The Board has also considered whether the Veteran's knee and ankle 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 extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2010); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). In this case, there are no exceptional or unusual factors with regard to the Veteran's disabilities on appeal. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. 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 his disability level and symptomatology and provides for more severe symptoms than shown by the evidence during the period in question; thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Hence, referral for extraschedular consideration is not warranted. Further, there is no evidence to indicate that the Veteran is unable to maintain full time employment. While the Veteran has stated that his disabilities made working as a truck driver difficult (having to get in and out of the 18-wheeler truck), he also stated that he is currently retired, in part due to his disabilities, but also due to suffering from cancer. Thus, the issue of entitlement to total disability based upon individual unemployability (TDIU) is not for present consideration. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In reaching the above determinations, the Board has also considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). While the Board has resolved reasonable doubt in the Veteran's favor by assigning a 20 percent rating for each knee from February 22, 2008, in addition to assigning a 30 percent rating for the left ankle from August 31, 2012, the Board also finds that the preponderance of the evidence is against assignment of any higher or separate rating. ORDER 1. A 20 percent rating for DJD of left knee is granted, effective February 22, 2008. To this extent only, the appeal is granted. 2. A 20 percent rating for DJD of right knee is granted, effective February 22, 2008. To this extent only, the appeal is granted. 3. A 30 percent rating for ankylosis of the left ankle is granted effective August 31, 2012. To this extent only, the appeal is granted. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs