Citation Nr: 1312203 Decision Date: 04/12/13 Archive Date: 04/19/13 DOCKET NO. 96-23 820 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for residuals of Grade I compound fracture of the tibia and fibula. 2. Entitlement to an initial compensable evaluation for loss of sensation of the left foot, associated with residuals of Grade I compound fracture of the tibia and fibula. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD A.G. Alderman, Counsel INTRODUCTION The Veteran served on active duty from July 1971 to July 1974, from November 1990 to June 1991, from October 2004 to December 2005, and from December 2009 to September 2010. He also has periods of active duty for training with the Army National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 1995 rating decision by the Department of Veterans Affairs (VA) Regional Office in Detroit, Michigan (RO). The issues of entitlement to service connection for posttraumatic stress disorder and to an increased rating for the Veteran's service connected degenerative disc disease of the lumbosacral spine with disc herniation back disability have been raised by the record, but have not been adjudicated by the RO. Therefore, the Board does not have jurisdiction over them, and they are referred to the RO for appropriate action. FINDINGS OF FACT 1. Manifestations of the Veteran's service-connected Grade I compound fracture of the tibia and fibula include malunion of the tibia and fibula, with mild impairment of the knee prior to October 4, 2007. 2. Manifestations of the Veteran's service-connected Grade I compound fracture of the tibia and fibula include malunion of the tibia and fibula, with moderate impairment of the knee beginning on October 4, 2007. 3. Manifestations of the Veteran's service-connected tibia and fibula fracture residuals include mild nerve damage of the left lower extremity resulting in loss of sensation in the left foot. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for Grade I compound fracture of the tibia and fibula prior to October 4, 2007, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2012). 2. The criteria for a 20 percent rating for Grade I compound fracture of the tibia and fibula from October 4, 2007, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2012). 3. The criteria for an initial compensable rating for loss of sensation in the left foot, associated with Grade I compound fracture of the tibia and fibula, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Code 8699-8623 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran filed his initial claim for service connection in August 1995, before the current notice and assist provisions were implemented. Service connection was granted and he appealed the initial rating. Once service connection is granted and the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Further, the Board finds that the Veteran had constructive notice of how to substantiate his appeal for increased and separate ratings as his arguments have specifically cited applicable diagnostic codes and he has argued for specific levels of compensation. Therefore, even though notice of how to substantiate increased ratings was not issued prior to the initial assignment of the rating, the Board finds that the Veteran was aware of the requirements for increased and separate ratings and that he has not been prejudiced by the lack of prior notice on this matter. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records, as well as identified private and VA medical treatment records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In April 1998, the Board remanded this matter for additional development, to include obtaining records from Ireland Army Hospital and for the scheduling of a VA examination. The RO made several requests to obtain medical records, including requesting records from the National Guard, but was unsuccessful. VA neurological and orthopedic examinations were conducted in July 1998. The examiner conducting the neurological examination reviewed the claims file but the orthopedic examiner did not. In February 2000, the Board remanded this matter because prior remand orders were not completed and the VA examinations were not adequate for rating purposes. Specifically, the July 1998 VA examiner did not take new x-rays of the knee and the RO did not request medical records as directed by the Remand. The Board also found that a VA examination should be conducted during a flare-up to determine the full extent of his left lower extremity dysfunction. In October 2005, the Board remanded this matter again, finding that while multiple attempts had been made to obtain medical records, since a negative response had not been received, additional attempts needed to be made. The Board also found that VA examinations had not been conducted and ordered that the appointments be made. After numerous requests, records from Ireland Army Hospital and for the Veteran's period of National Guard service were received in August 2007. A VA examination of the joints was conducted in September 2008. In March 2010, the Board remanded this matter for new VA examinations because the September 2008 VA examination did not assess neurologic symptoms or consider functional loss during periods of flare-up. VA examinations were conducted; however, the Board remanded the matter again in January 2012 to obtain updated VA treatment records and to associate the October 2007 VA examination with the claims file. All records have been received and associated with the claims file. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. 38 C.F.R. § Part 4 (2012). Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). 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 (2012). Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not 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, 595 (1991). The Veteran seeks a rating in excess of 10 percent for Grade I compound fracture of the tibia and fibula, which is currently evaluated as malunion of the tibia and fibula, with mild knee or ankle disability. 38 C.F.R. § 4.71a, Diagnostic Code 5262. A 20 percent rating is warranted for malunion of the tibia and fibula, with moderate knee or ankle disability. Id. A 30 percent rating is provided for malunion with marked knee or ankle disability. Id. A 40 percent rating is provided for nonunion of the tibia and fibula with loose motion, requiring a brace. Id. Intertwined with the above, is the claim seeking a compensable rating for peripheral nerve damage of the left lower extremity, which is associated with the service-connected Grade I compound fracture of the tibia and fibula, and results in loss of sensation of the left foot. This disorder is rated as analogous to incomplete paralysis of the anterior tibial nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8699-8623. When an unlisted residual condition is encountered which requires an analogous rating, the first two digits of the diagnostic code present that part of the rating schedule most closely identifying the bodily part or system involved, with a "99" assigned as the last two digits representing all unlisted conditions. 38 C.F.R. § 4.27 (2012). The separate, noncompensable rating for this residual was granted in a rating decision dated in October 2007, effective October 4, 2007, and represents mild incomplete paralysis of the anterior tibial nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8623. A 10 percent rating is provided for moderate incomplete paralysis, while a 20 percent rating is provided for severe incomplete paralysis. Id. A 30 percent rating is warranted for complete paralysis where the dorsal flexion of the foot is lost. Id. The term "incomplete paralysis" with peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves, at Note. Normal range of motion of the knee is to zero degrees extension and 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II (2012). A 10 percent rating is warranted for flexion of the leg limited to 45 degrees, a 20 percent rating is warranted for flexion limited to 30 degrees, and a 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). February 1995 treatment records from the Ireland Army Hospital show the Veteran's left leg had minimal tenderness at the fracture site. X-rays showed a well healed fracture. He was put on profile and was permitted to run at his own pace and distance. He was limited to lifting a maximum of 40 pounds. At his November 1995 VA examination, the Veteran reported chronic daily pain aggravated by weight bearing activities. His gait was abnormal. Functional effects on the left knee included crepitation and flexion to 128 degrees with extension to 0 degrees. Leg length and calve circumference were equal in both legs. There was decreased sensory testing to pinprick on the left second through fifth toes. Give-way of strength was found in the left great toe. The examiner noted progressive severe left knee arthralgias secondary to the tibial rod, status post hardware removal, chronic residual arthralgias, and post traumatic degenerative joint disease aggravated with weight bearing activities. X-rays showed healed fractures of the mid shaft. Lucent defects were identified in the proximal tibia, noted as most likely representing screw holes. A January 1996 treatment record shows a well-healed incision, crepitus with extension, and left knee flexion to 120 degrees. The Veteran reported knee pain. During an August 1996 hearing before the Decision Review Officer, the Veteran stated that since having the rod removed from his leg, he had had no feeling in the little toes of his left foot and that he had permanent loss of feeling in his lower leg. The Veteran testified that doctors told him he had nerve damage due to crushing in the ankle and fasciotomy on the calf. He was employed as a welder but stated he had to stop and elevate his leg during flare-ups, and had been reprimanded three times for lack of production. He also reported cartilage problems, which doctors attributed to the fracture, pain, and stiffness of the knee. Pain was at the fracture site and in the knee. In August 1996, the Veteran had a VA examination of the peripheral nerves. The examination report shows complaints of numbness to the second through fifth toes, paresthesias of the left foot and calf, and pain in the left mid-tibial region and left knee. The examiner observed intact cranial nerves and a limp, as well as decreased sensory modalities in the distribution of the left superficial peroneal and sural nerves. The diagnosis was neuropathy, sensory partial left superficial peroneal nerve and left sural nerve mild, secondary to the fracture of the left tibia and fibula. During the August 1996 VA examination of the bones, the Veteran reported numbness of the toes and calf as well as pain, swelling, stiffness and soreness. He could not engage in heavy activity due to left knee pain. The examiner observed a normal gait. The left calf was half an inch larger in circumference than the right. Both legs were equal in length. The left knee flexed to 140 degrees and extended to 0 degrees. Ligaments were stable. X-rays showed a normal left knee and satisfactory alignment of the tibia and fibula. No arthritic condition was observed. The examiner found no relationship between the left knee complaint and fracture of the tibia and fibula. No rationale was provided. A September 1996 physical for the National Guard shows mild abnormal gait, with the left leg 1 centimeter (cm.) shorter than the right. Also noted was pes planus of the left foot and mild genu valgus of the left foot. A February 1998 letter from his supervisor noted the Veteran's decline in production and the three verbal warnings issued. The Veteran said the decline in production was due to his inability to stay on his feet to sustain proper production level for any extended period of time. The company was making adjustments to increase his production but if not successful, the company was going to move the Veteran to a less labor intensive job, which would substantially reduce wages and likely eliminate overtime. In a February 1998 statement, the Veteran reported left knee and calf pain. He said his knee was stiff, swelled and at times, and would give out. He limped due to pain. The left calf would swell and was painful when placing heavy weight on it. The left ankle, foot, and toes were numb. The Veteran reported that at work, carrying heavy items caused left knee pain. He could not stand for more than 20 to 30 minutes without his calf and knee swelling, which required him to sit and elevate the leg. The Veteran reported that his service-connected condition impacted his ability to do things at home, prevented participation in sports, and caused a strain in his marriage. A February 1998 statement from a provider at Ireland Army Hospital noted the Veteran's history and that the injury caused a 1 inch atrophy of the quadriceps and a half inch shortening of the left leg. Knee range of motion was within normal limits, with no laxity. There was decreased strength of the peroneal nerve. In July 1998, the Veteran had a VA examination for neurological disorders. He reported mild motor weakness and swelling in the left leg, as well as pain in the left leg and knee. The sensory examination revealed decreased sensation in the left lateral calf and dorsum of the left foot in the distribution of the left superficial peroneal nerve and partially in the left sural nerve distribution. The diagnosis was neuropathy, partial sensory of the left superficial peroneal nerve and left sural nerve. The examiner stated that an electromyography (EMG) report supported mild superficial sensory neuropathy which would not affect the knee, leg, foot, or toe functions. The examiner could not comment further without examining the Veteran during a flare-up. The July 1998 VA examination report for examination of the bones shows report of numbness and coldness of the left little toe. The bottom of the foot and side of the leg had no feeling, while he had pain in the mid-leg when walking. He reported left hip pain and continued interference with work. When working hard he would have to sit, and ice and elevate the leg. Lifting was occasionally difficult. The examiner observed a slight limp. Measurements showed a five-eighth of an inch shortening of the left leg, and a three-quarter of an inch increase in the left calf. Left knee flexion was to 135 degrees, while extension was to zero degrees. The Veteran complained of left knee soreness of the back of the knee joint. The EMG showed normal left peroneal motor conduction and sural sensory study. The superficial peroneal sensory responses were unobtainable, bilaterally, including an asymptomatic site. X-rays were normal. No evidence of degenerative disease was observed. The diagnosis was status post healed fracture of the left tibia and fibula, with mild shortening of the left leg and normal left knee. The examiner opined that the Veteran had recovered well, with only shortening, with limping gait. The Veteran had a VA examination in October 2007. The examiner did not have the claims file for review but reviewed medical records. The examiner observed a scar on the left lateral knee measuring 21 by 1 cm. The scar was linear with keloid. There was no tenderness or skin breakdown. Another scar of the left knee measured 11 by 0.5 cm. The scar was linear and tender but had no skin breakdown. The examiner observed a bone deformity in the left knee with limited motion. Range of motion measured from 0 degrees extension to 115 degrees flexion, with no pain on movement, but with stiffness. The examiner observed a 5 degree loss of flexion with repetitive motion. The left foot was tender on the lateral arch. There was a large thick callous on the medial great toe and small calluses on the pads of the second thru fourth toes. The examiner observed loss of sensation to monofilament to lateral foot from the fifth toe to the ankle. The Veteran reported missing a week of work due to physical problems, including residuals of the left tibia and fibula fracture. He did not believe he would be able to pass the required physical exam to stay in the National Guard and noted that he was already waived from running due to his leg condition. The examiner found the fracture residuals had significant effects on the Veteran's occupation due to reduced mobility. As a result, he was assigned different duties and waived for physical training requirements. The condition mildly impacted his ability to perform chores, recreational activities, and travel; moderately impacted his ability to exercise; and severely impacted his ability to participate in sports. The examiner said the Veteran had limited range of motion of his left knee, with expressed tightness in the joint. He had some fatigue with repetitive movement. The examiner also observed that the left leg was 1 cm. shorter than the right, resulting in antalgic gait. Excessive calluses on the right foot were noted as likely secondary to the gait caused by his left knee condition. Subsequent x-rays show normal left knee joints. The Veteran had a VA examination in September 2008. The examiner reviewed the claims file. The Veteran said that in the past five years he had experienced pain, leg swelling, and giving way of the left knee. He continued to report numbness in his small toes, fatigue, and toe cramping due to his limp. He could stand for one hour and walk a quarter mile. Symptoms included deformity of the left knee, giving way, instability, pain, stiffness, weakness, and dislocation or subluxation on a daily or more basis. Noted were severe flare-ups of the left knee that occurred weekly which caused immobility and swelling. He treated the condition with Ibuprofen. The examiner observed an antalgic gait, abnormal shoe pattern, and pain of the left knee. Range of motion of the left knee measured from 0 degrees extension to 120 degrees flexion, with pain starting at 100 degrees. No additional loss of motion was observed with repetitive use. Crepitation and clicking or snapping of the knee was also observed. The left leg measured one inch shorter than the right, while the left calf measured in inch larger than the right. He walked with a significant limp on the left. Strength of the left leg was slightly less than the right. October 2007 x-rays of the left knee were normal. September 2008 x-rays showed normal knee and ankle. The examiner indicated that the Veteran's condition had significant effects on occupational activities, including increased absenteeism. The Veteran's job required a lot of walking which exacerbated the pain. The condition caused mild impairment with dressing, moderate impairment with recreation, travelling, exercise, shopping and chores. The Veteran could no longer participate in sports and paid someone to do yard work. In an addendum, the examiner said the Veteran had a significant limp and had a leg length discrepancy of 1 inch. He also had swelling of the left calf of 1 inch. The Veteran had mild weakness on the left side. X-rays showed defects in the proximal tibia from previous pinning screw holes and a healed fracture of the mid shaft of the tibia and fibula. The knee appeared normal. In November 2010, the Veteran reported left leg pain, aching, and throbbing with prolonged activity. He indicated pain was a 5 on the pain scale. The provider observed no swelling, asymmetry, muscle atrophy, or ecchymosis and equal strength and normal range of motion of the upper and lower extremities, bilaterally. The Veteran was noted as limping due to a right knee injury, plantar reflexes were down, and deep tendon reflexes were abnormal, bilaterally, at the patella and bicipital. A January 2011 VA treatment record notes arthritis of the left leg as an active problem. X-rays were not provided. The Veteran had a VA examination in January 2011. The examiner reviewed the claims file. The Veteran reported left knee pain and severe weekly flare-ups that could last hours. He stated he had increased pain when working all day, particularly when there was extensive ambulation. Flare-ups caused limited mobility and a limited desire to be active after working all day. The Veteran treated the condition with Ibuprofen. He indicated that he could stand for 15 to 30 minutes and walk 1 to 3 miles. The Veteran's gait was normal, however, the examiner observed abnormal motion of the left knee. Range of motion was from 0 degrees extension to 120 degrees flexion, with no evidence of pain. No additional limitations were noted after repetitive motion. The left leg was one inch shorter than the right leg. Strength in the left leg was greater than the right due to the recent meniscal/anterior cruciate ligament injury to the right knee. December 2010 x-rays showed no significant degenerative changes, post surgical changes in the left tibia, and old fracture deformities of the left fibular diaphysis. The examiner noted significant effects on occupation, including a profile with the National Guard so that the Veteran could walk instead of run for physical training. The condition prevented sports, and moderately impacted chores, exercise, and traveling. It had mild impact on shopping. The Veteran had not lost time from work in the past year due to this condition. The examiner said the Veteran had limited motion of his left knee, likely due to the fracture site of the tibia and fibula, as he required rod placement with entrance over the patellar area. The examiner observed no flare ups of pain with repetitive movement or further limitation of motion. Radiographs showed no joint disease and a preservation of joint space. No instability or joint disease was found. A January 2011 VA nerve examination report shows numbness of the left calf, laterally, extending to the lateral toes. Testing of the peroneal nerve of the left lower extremity was abnormal. Vibration sense was absent in the lateral toes and malleolus, pain, and pinprick sense were absent in the lateral toes and calf, and light touch sense was absent in the lateral toes and calf. There was no dysesthesias. The motor exam showed active movement against resistance of the left knee, ankle dorsiflexion and plantar flexion, and great toe extension. The examiner noted antalgic gait but said it was likely due to recent right knee internal derangement. The Veteran cancelled his EMG appointment and did not reschedule. The Veteran said he had not lost time from work in the past year due to this condition. The diagnosis was peripheral neuropathy of the left lower extremity. The examiner found no effects on employment due to this condition. Due to the unavailability of EMG testing, the examiner was unable to address specific nerves involved and the level involvement. The Veteran had another VA examination in July 2011. The examiner reviewed the claims file and summarized the Veteran's in-service injury. The Veteran reported recent right knee surgery and that he was putting more weight on the left leg. He was no longer taking Ibuprofen. The Veteran reported tingling and numbness in the third through fifth toes, tingling in the lateral side of the dorsum of the foot, and numbness in the lateral calf. He did not have much feeling in the lateral side of the foot or the third through fifth toes, and had no feeling on the lateral side of the lower leg beginning below the knee down to above the ankle. Examination revealed hypoactive ankle jerk on the left. The left lower leg had decreased vibration sense in the area surrounding the surgical scar on the left lateral calf and third through fifth toes. There was a slightly decreased pinprick sensation on the lateral side of the calf and third through fifth toes and decreased light touch sense of the lateral calf close to the scar tissue and third through fifth toes. The motor examination showed a slight decrease in strength, with left great toe extension. The examiner did not observe muscle atrophy, imbalance or tremor, fasciculation's, or any joint affected by the nerve disorder. The examiner said the gait abnormality was due to the right knee surgery. The examiner noted mild neuropathy of the left superficial peroneal nerve and left sural nerve secondary to the tibial fracture. The examiner incorporated the August 2011 EMG testing in to the examination report. The examiner noted that the lower left leg was slightly bulkier than the right. Sensory was decreased on the left lateral lower leg and lateral aspect of the dorsum of the left foot. He had a mild limp on the right side due to recent right anterior cruciate ligament repair. Testing indicated that the motor nerve velocities of the left common peroneal and left posterior tibial nerves were borderline, slightly decreased when compared to the right side, but the amplitude of the motor evoked potentials within normal limits. Also noted were intact bilateral sural sensorius which were comparable; absent left superficial sensory; normal needle EMG of the left gastrocs, left anterior tibialis and left peroneus longue; and increased amplitude and increased duration motor unit potentials in the left extensor digitorum brevis muscle, with slightly decreased recruitment. The examiner said the study was abnormal and diagnosed sensory neuropathy of the left superficial nerve. The examiner could not rule out mild involvement of the distal left common peroneal and left posterior tibial nerves, but noted that motor conduction was intact. The diagnosis was residual mild peripheral neuropathy related to the fracture. Nerve dysfunction caused a mild decrease in sensation in the area of the fracture. The examiner identified neuritis and said this disorder made the Veteran more careful and cautious with his usual occupation and limited heavy activities, such as snow skiing and soft ball, and caused him to take longer when inspecting items. The Veteran no longer worked underneath vehicles as a mechanic. In December 2011, the Veteran submitted a statement indicating that he was fired as a welder in September 2000, after 25 years, due to his condition. He had to find work that did not require lifting, turning, and standing on a cement floor for extended periods of time. Initially, he missed 20 months of work due to the injury and had to use vacation time for follow-up appointments. Since September 2000, he had served as an inspector. He indicated that he had missed work and said climbing on and off and underneath equipment was difficult. He reported symptoms of pain, which fluctuated from a 6 to 9 on the pain scale. In recent years, pain had been on the higher end of the scale, depending on his activity level. Numbness in the outer part of his leg and foot interfered with sleep. The condition caused his leg to fatigue much faster than previously, which was evident when reviewing his declining physical training scores. The Veteran said that a continued decline in performance would cause non-retention and terminate his employment. As for weakness, he did not trust the strength in his left leg and said the pain around the area of the break increased quickly as the leg grew weaker. Overall, the Veteran indicated that the injury prevented promotion in service, accrual of retirement points, and accrual of leave. A February 2012 VA treatment record shows complaints of worsening left knee pain. The active problems list included arthritis of the left leg. Military records dated February 2012 show that the Veteran's neck, back, and bilateral knee disabilities prevented him from evading direct and indirect fire; prevented him from riding in a military vehicle and wearing body armor and load bearing equipment for at least 12 hours per day; prevented him from wearing a protective mask and "MOPP 4" for at least two continuous hours per day; prevented him from moving 40 pounds while wearing usual protective gear at least 100 yards; and prevented him from living in an austere environment without worsening his medical condition. He could not perform the timed 2 mile run, sit ups, timed 2.5 mile walk, or Army physical fitness test bike. Records indicate that he needed a right knee brace. Treatment records show that in July 2012, the Veteran reported that he was going to be released from the Guard and released from his job with the Guard. The Board has reviewed all of the evidence, to include medical records, service records, personal statements, and argument submitted by the Veteran's representative, and has considered it in the light most favorable to the Veteran. Based on the foregoing, the Board finds that a separate rating is not warranted for any period during the pendency of the claim for traumatic arthritis of the left knee. While February 2012 VA treatment records indicate left knee arthritis as an active problem, arthritis has not been confirmed by any x-rays during the pendency of the claim, which is required for a compensable rating. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2010). A separate rating is not warranted for any period during the pendency of the claim for limitation of flexion or extension of the knee. For a compensable rating for limitation of range of motion, flexion must be limited to 45 degrees or extension to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. In this case, at its worst, the Veteran's flexion was limited to 100 degrees, with repetitive motion and consideration of pain. Extension was not been limited. Even with consideration of complaints of pain, stiffness, swelling, fatigue, and other symptoms, his limitation of motion is not of the severity to warrant separate compensable ratings under either Diagnostic Code 5260 or 5261. The Board finds that staged ratings are warranted under Diagnostic Code 5262. 38 C.F.R. § 4.71a. First, the Board finds that the initial 10 percent rating assigned for mild impairment of the knee and ankle is appropriate. Between the date of claim and August 1996, the range of motion of the left knee was limited to 120 degrees flexion, with crepitus and antalgic gait; however, his leg lengths and calf circumferences were equal and x-rays were normal. Thus, the Board finds that the 10 percent rating for mild knee and ankle disability currently assigned is proper based on the limitation of flexion and abnormal gait, as well as his complaints of pain and swelling. From August 1996 to October 2007, left knee range of motion improved, with flexion measuring between 135 degrees and full flexion. Antalgic gait continued to be noted. While knee range of motion improved, the evidence shows onset of shortening of the lower extremity and increase in the left calf circumference when compared to the right. However, considering the relatively normal range of motion of the knee, abnormal lower leg measurements do not support the finding of moderate knee and ankle disability. Even considering complaints of pain, swelling, stiffness, and soreness, the Board finds that the symptoms are mild in degree when observing range of motion and impact on the knee and ankle. X-rays of the knee were normal during this period. Therefore, the Board finds that an initial rating in excess of 10 percent for residuals of the left tibia and fibula fracture is not warranted from August 1996 to October 2007. 38 C.F.R. § 4.71a, Diagnostic Code 5262. However, the Board finds that a 20 percent rating is warranted for moderate residuals of his tibia and fibula fracture from October 4, 2007. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Evidence shows the left knee range of motion worsened, measuring anywhere from 100 to 120 degrees flexion, with repetitive use and objective evidence of pain, tightness of the joint, fatigue, and mild weakness in left leg strength. See 38 C.F.R. §§ 4.40, 4.45 (2012). The Veteran continued to have leg length disparity and calf circumference abnormalities when compared to the right leg, as well as an antalgic gait. X-rays continued to show normal left knee. The evidence does not show ankylosis, any disability of semilunar cartilage of the knee, or genu recurvatum; therefore, a rating in excess of those assigned are not warranted. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5263 (2012). While the Veteran has complained of his left knee giving way, objective testing has not revealed recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). In conjunction with the Veteran's claim, the RO granted a separate, noncompensable rating for loss of sensation in the left foot, rating it as analogous to neuritis of the anterior tibial nerve (deep peroneal). 38 C.F.R. § 4.124a, Diagnostic Code 8699-8623. Mild impairment, rated by analogy under Diagnostic Code 8699-8623, is rated as noncompensable. Because the evidence has not shown moderate incomplete paralysis at any time during the pendency of the claim, a compensable rating cannot be granted. Id. The Board has also considered whether referral for extraschedular ratings is warranted. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). 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, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the assigned ratings inadequate. The Veteran's residuals of his tibia and fibula fracture have been rated under numerous diagnostic codes to ensure that all symptomatology, including symptomatology of the joints, nerves, and skin, have been accounted for. Manifestations of the Veteran's service-connected Grade I compound fracture of the tibia and fibula include malunion of the tibia and fibula, with mild impairment of the knee prior to October 4, 2007, with moderate impairment first shown on October 4, 2007. Manifestations of the Veteran's service-connected tibia and fibula fracture residuals also include loss of sensation in the left foot. Each of the diagnostic codes discussed above provide for ratings in excess of those assigned; however, the Veteran's symptomatology is not of the severity to warrant ratings in excess of those assigned herein. Accordingly, the Board finds that this disability picture is contemplated by the assigned evaluations. As such, the Board is not required to refer this matter to the RO for extra-schedular consideration. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected left leg disorder, the evidence shows no distinct periods of time during the appeal period when the Veteran's service-connected left leg symptoms varied to such an extent that a rating greater or less than what has been assigned herein would be warranted. Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). In reaching these decisions, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an initial evaluation in excess of 10 percent for residuals of Grade I compound fracture of the tibia and fibula prior to October 4, 2007, and a rating in excess of 20 percent from October 4, 2007, as well as an initial compensable evaluation for loss of sensation in the left foot, associated with Grade I compound fracture of the tibia and fibula, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An initial rating in excess of 10 percent prior to October 4, 2007 for residuals of Grade I compound fracture of the tibia and fibula left tibia and fibula fracture, is denied. A 20 percent rating from October 4, 2007 for residuals of Grade I compound fracture of the tibia and fibula is granted, subject to the applicable regulations concerning the payment of monetary benefits. An initial compensable rating for loss of sensation in the left foot, associated with Grade I compound fracture of the tibia and fibula, is denied. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs