Citation Nr: 1312423 Decision Date: 04/15/13 Archive Date: 05/02/13 DOCKET NO. 08-22 206 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for degenerative joint disease of the left knee, also claimed as residuals of medial meniscal tear repair. 2. Entitlement to an initial disability rating in excess of 10 percent for degenerative joint disease of the right ankle. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD David Gratz, Counsel INTRODUCTION The Veteran served on active duty from July 1979 to December 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The claim was subsequently transferred to the RO in St. Petersburg, Florida. The appellant testified before a now-retired Veterans Law Judge (VLJ) sitting at the St. Petersburg, Florida, RO in August 2010. A transcript of the hearing is associated with the claims file. In March 2013, the Veteran informed VA that she does not want another hearing before the Board, notwithstanding the fact that the Veterans Law Judge before whom she testified in August 2010 is no longer employed by the Board. 38 C.F.R. § 20.707. In March 2011 and July 2012, the Board remanded this case for further development. The case has returned to the Board for appellate review. FINDINGS OF FACT 1. Throughout the entire appeal period, the Veteran's left knee disability has been productive of pain with extension to 0 degrees and flexion to no less than 90 degrees including on repetition, without clinical evidence of ankylosis. 2. Throughout the entire appeal period, the Veteran's left knee disability has been characterized by slight lateral instability. 3. Throughout the entire appeal period, the Veteran's left knee disability has been characterized by dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 4. Throughout the entire appeal period, the Veteran's right ankle disability has been characterized by moderate limitation of motion. CONCLUSIONS OF LAW 1. The criteria for an initial 10 percent disability evaluation, and no higher, for left knee slight lateral instability have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.71a Diagnostic Code (DC) 5257 (2012). 2. The criteria for an initial 20 percent disability evaluation, and no higher, for left knee dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.71a Diagnostic Code (DC) 5258 (2012). 3. The criteria for an initial disability rating in excess of 10 percent rating for degenerative joint disease of the right ankle have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5271 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). These claims arise from a disagreement with the initial disability ratings that were assigned following the grants of service connection. Courts have held that once service connection is granted 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). VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issues has been obtained. The Veteran's available service, private, and military hospital treatment records have been obtained. The Veteran testified that she has not sought treatment at the VA. See August 2010 transcript, p. 12. The Board remanded the claims in March 2011 and July 2012. There has been substantial, if not full, compliance with the remand directives insofar as VA has obtained additional treatment records and provided the Veteran with new examinations in April 2011 and August 2012. As to the remand directive to the Agency of Original Jurisdiction (AOJ) to contact her private physician, Dr. Oza, to obtain treatment records dated since 2005, the Board finds that the AOJ took all appropriate steps to comply with that remand directive. Specifically, the AOJ sent her a letter in July 2012 requesting that she fill out a new authorization (VA Form 21-4142); this was necessary because her prior authorization, dated April 2011, had expired within 180 days, leaving the AOJ without the authority to request his medical records from Dr. Oza after the Board's July 2012 remand. She did not respond to the AOJ's July 2012 letter requesting another authorization of the request for her records from Dr. Oza. Thus, the AOJ was unable to make another request to Dr. Oza. The Board finds that the AOJ's July 2012 letter to the Veteran, combined with her non-response thereto, warrants the conclusion that the AOJ substantially complied with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998); see also Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (finding that the duty to assist is not a one-way street). The Veteran has been provided with adequate VA examinations in connection with her present claims, including in October 2006, April 2009, April 2011, and August 2012. She has not indicated there are any additional records that VA should seek to obtain on her behalf. Therefore, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claims, and no further assistance to develop evidence is required. The Veteran has been afforded a hearing before a VLJ in which she presented oral argument in support of her claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the since-retired VLJ did not note the bases of the prior determinations or the elements that were lacking to substantiate the Veteran's claims. The now-retired VLJ asked specific questions, however, directed at identifying whether the Veteran had symptoms meeting the schedular criteria for a higher rating. The since-retired VLJ did not specifically seek to identify any pertinent evidence not currently associated with the claims. This was not necessary, however, because the Veteran volunteered her treatment history and symptoms since service. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, neither the Veteran nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has she identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate her claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Analysis Disability ratings are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity in civil occupations. 38 U.S.C.A. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. Where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged ratings" is required. Fenderson v. West 12 Vet. App. 119, 126 (1999). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Finally, the Board notes that the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as the veteran's relevant medical history, his current diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Left Knee The Veteran contends in her August 2007 notice of disagreement that: I do experience recurrent locking of my [left] knee with clicking pain and constant effusion. The effusion is always there and exacerbates with activities of daily living. The effusion and pain is limiting after less than four hours of activity. Additionally, it is painful after prolonged sitting (greater than 20 minutes). After sitting, I have difficulty taking steps. I cannot climb stairs without significant pain in my left knee. I actually have to do most of the weight bearing for stair climbing by supporting myself using the hand rail. I have had several steroid injections into the left knee joint over the past two years with minimal relief of symptoms. I have persistent pain even at rest and at time of sleep. The pain disturbs my sleep after a busy day of activity. My service medical record has examinations noting the locking, clicking and effusion as well as the limit of endurance for activity despite the steroid injections. In her July 2008 substantive appeal (which was accidentally dated July 2007), the Veteran reported that her "[left] knee is constantly swollen, painful, limited range of motion. I am unable to go up or down stairs without relieving weight bearing by using handrails and one[-]stepping stairs." At the August 2010 hearing before a since-retired VLJ, the Veteran testified that she served for 281/2 years as a Registered Nurse. See transcript, p. 3. She further testified that she had undergone a partial meniscectomy of her left knee in service. Id., p. 4. The Veteran described her left knee as being very knobby and very painful to move. Id., p. 4. She stated that she has left knee pain all the time, which gets worse when ambulating. Id., p. 17. She noted that she has to "click it into place" before standing from a sitting position, and has to weight-bear on handrails or use a "baby step" in order to navigate stairs. Id., pp. 4-5, 18. She explained that her left knee does "not literally [lock] like an athlete locks his knee, but it will click through a lock when I go to stand up and I have to...move it." Id., p. 5. The Veteran also described feeling her knee bones grind when walking without her knee brace. Id., pp. 6-7. She reported that her left knee swells on days of greater use. Id., p. 17. She also reported that her left knee disability limits her cleaning the house, shopping, and vacuuming. Id., p. 18. The Veteran reported that her left knee feels more painful than usual for about a week once every three months. Id., p. 20. Under 38 C.F.R. § 4.71a, there are several diagnostic codes that may potentially be employed to evaluate impairment resulting from service-connected knee disorders. Diagnostic Codes (DCs) 5003 and 5010, for evaluation of degenerative and traumatic arthritic changes, are applicable to the knee. 38 C.F.R. § 4.71a, DCs 5003, 5010. Diagnostic Code (DC) 5010 applies to traumatic arthritis and provides that such is evaluated under the criteria for 38 C.F.R. § 4.71a, DC 5003. Diagnostic Code 5003 provides that degenerative arthritis is to be rated on the basis of limitation of motion of the affected joint under the appropriate diagnostic code for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint group or minor joint group affected by limitation of motion. In the absence of limitation of motion, a 20 percent evaluation is provided where there is X-ray evidence of involvement of two or more major joints, or two of more minor joint groups with occasional incapacitating exacerbations. A 10 percent evaluation is provided where there is X-ray evidence of involvement of two or more major joints, or two of more minor joint groups without exacerbations. Knee impairment with recurrent subluxation or lateral instability warrants a 10 percent evaluation if it is slight; a 20 percent evaluation if it is moderate; or, a 30 percent evaluation if it is severe. 38 C.F.R. § 4.71a, DC 5257. Limitation of flexion of a leg warrants a noncompensable evaluation when flexion is limited to 60 degrees. A 10 percent evaluation is appropriate if flexion is limited to 45 degrees and a 20 percent evaluation is assigned if flexion is limited to 30 degrees. Flexion that is limited to 15 degrees is evaluated as 30 percent disabling. 38 C.F.R. § 4.71a, DC 5260. Limitation of extension of a leg is noncompensable when extension is limited to 5 degrees. A 10 percent evaluation is warranted with extension limited to 10 degrees and a 20 percent evaluation when it is limited to 15 degrees. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, DC 5261. Additional rating criteria are found under DCs 5256 (ankylosis of the knee), DC 5258 (which provides for a 20 percent rating for dislocated, semilunar cartilage with frequent episodes of locking, pain and effusion into the joint), 5259 (which provides for a 10 percent rating for symptomatic removal of the semilunar cartilage), and 5262 (impairment of the tibia and fibula). VA's General Counsel has clarified that for a knee disability rated under DC 5257 or DC 5259 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable, but must at least meet the criteria for a zero-percent rating under those codes. A separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59 and DC 5003. VAOPGCPREC 9-98 (1998). VA's General Counsel has more recently held that separate ratings are also available for limitation of flexion and limitation of extension under DCs 5260 and 5261. VAOPGCPREC 9-2004 (2004). For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. The knee is considered a major joint. 38 C.F.R. § 4.45(f) (2012). The RO has evaluated the left knee degenerative joint disease as 10 percent disabling under 38 C.F.R. § 4.71a, DC 5260-5259, effective January 1, 2007. The hyphenated code is intended to show that the Veteran's left knee disabilities include symptoms of limitation of flexion of the leg (DC 5260) and removal of symptomatic semilunar cartilage (DC 5259). An October 2006 in-service examiner noted that the Veteran described her left knee symptoms as painful but not incapacitating. The examiner found no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement or guarding of movement. The examiner found crepitus. The Veteran had flexion to 120 degrees, with pain at 90 degrees. The Veteran had extension to 0 degrees, with pain at 0 degrees. Left knee joint function was additionally limited by 0 degrees by pain and fatigue after repetitive use. Stability and meniscus tests of the left knee were within normal limits. The examiner diagnosed the Veteran with degenerative joint disease of the left knee joints with a moderate degree of degenerative osteoarthritis involving the medial compartment of the left knee. The examiner found that the effect was difficulty with walking and prolonged standing. In August 2008, the Veteran's private treating physician, Dr. M. Oza, found tenderness, synovitis, and a Baker's cyst, and diagnosed her with degenerative joint disease of the left knee. Also in August 2008, a private clinician, R. Lucas, performed a magnetic resonance imaging (MRI) test on the Veteran's left knee, and found (1) severe degenerative osteoarthritis with joint space narrowing, osteophytosis, subcondral cysts and small osteochondral defects not excluded; (2) large ossific and calcific densities posterior which does not appear to be within the joint space; (3) a linear tear in the posterior horn of the medial meniscus and an apparent fragment off the lateral meniscus; and (4) a slight irregularity and signal in the tibial portion of the ACL which could represent a partial tear or strain. In November 2008, January 2009, and March 2009, another private clinician, Dr. M. Leslie, found tenderness and chronic synovial changes in the Veteran's left knee and diagnosed her with degenerative joint disease. An April 2009 VA examiner noted that the Veteran reported having constant and daily left knee pain, as well as difficulty with complete extension; she also reported giving way, instability, stiffness, weakness, decreased speed of joint motion, clicking, locking, swelling, and flare-ups that, when present, cut her daily activity to at least half of normal. The VA examiner found crepitus, tenderness, guarding of movement, and clicks or snaps. The VA examiner found no grinding, instability, or patellar or meniscus abnormality. The Veteran had flexion to 120 degrees and extension to 0 degrees, with pain throughout all motion. Additionally, the examiner heard a click just prior to complete extension of the left knee. The examiner diagnosed the Veteran with left knee degenerative joint disease. The examiner found that the Veteran's left knee disability causes decreased mobility, problems with lifting and carrying, and pain, as well as moderate and severe effects on usual daily activities. In August 2009, a military hospital clinician took x-rays of the Veteran's left knee and found moderate-to-severe tricompartmental degenerative change most pronounced in the medial compartment. Loose bodies in the posterior joint space were stable, and there was no evidence of any acute fracture or effusion. In September 2010, another military hospital clinician noted that the Veteran uses a medial unloading brace for her left knee because of meniscal degeneration and eburnation that causes significant pain and reflex weakness secondary to pain. The Veteran had flexion to 100 degrees, and full extension. The clinician diagnosed the Veteran with osteoarthritis of the left knee with severe degeneration of the meniscus. An April 2011 VA examiner noted that the Veteran stated that she had left knee deformity, instability, pain, stiffness, weakness, decreased speed of joint motion, inflammation, and moderate flare-ups for 3 to 7 days every 3 to 4 months. The VA examiner found a popliteal/Baker's cyst, a mass behind the knee, clicks or snaps, and grinding. The VA examiner found no crepitation, instability, or patellar or meniscus abnormality. The Veteran had flexion to 120 degrees and extension to 0 degrees, with objective evidence of pain starting at 100 degrees of flexion. Repetitive motion elicited pain but no additional limitations of motion. The examiner diagnosed the Veteran with left knee degenerative joint disease. The examiner found that the Veteran's left knee disability causes decreased mobility and pain, as well as moderate, severe, and preventative effects on usual daily activities. After reviewing all of the clinical evidence and subjective complaints since the effective date of service connection, the Board finds that a 10 percent rating for left knee slight lateral instability under 38 C.F.R. § 4.71a, DC 5257, and an additional 20 percent rating for left knee dislocated semilunar cartilage under 38 C.F.R. § 4.71a, DC 5258 is warranted throughout the appellate period. By contrast, for the reasons discussed below, ratings under DCs 5259 and 5260 are not warranted. A separate rating for arthritis (DC 5003, 5010) based on X-ray findings and limitation of motion, in addition to the Veteran's rating under DC 5259, is not warranted because the Veteran's flexion and extension do not meet the criteria for a zero-percent rating under DC 5260 or DC 5261. See VAOPGCPREC 9-98, Comment 1 (1998). Specifically, her most restricted range of flexion was to 90 degrees, and her extension is consistently to 0 degrees, while a zero-percent rating for flexion applies at 60 degrees or less, and a zero-percent rating for extension applies at 5 degrees or more. Additionally, the Board finds that the April 2011 VA examiner's determination that there is no objective evidence of "psoriatic arthritis" of the left knee is most probative based on the examiner's expertise and objective findings. No evidence of left knee ankylosis is of record, so a rating under DC 5256 is not warranted. The Board finds that a rating of 10 percent is warranted for the Veteran's left knee slight lateral instability. See DC 5257. As an initial matter, the Board finds that the evidence does not show recurrent subluxation. With respect to lateral instability, the Board notes that the Veteran was a nurse for many years, and is competent to both observe and diagnose instability. While the Board notes that all three VA examiners-in October 2006, April 2009, and April 2011-found that the Veteran's left knee had no instability during their examinations, the Board finds that the Veteran's competent and credible findings of instability are entitled to equal probative weight based on her medical knowledge and the fact that she is able to observe instability in all circumstances, rather than only at the time of three isolated examinations over the course of approximately five years. Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999) (where conflicting competent opinions are of record, the Board can ascribe greater probative weight to one opinion over another, provided that a rational basis is given); 38 C.F.R. § 4.3. With respect to severity, the Board finds that the Veteran has not provided evidence that her lateral instability is more than slight. Moreover, the evidence does not reflect frequent falling or other symptomatology consistent with moderate or severe lateral instability of the left knee. Therefore, a disability rating of 10 percent, but no greater, under DC 5257 is warranted. The Board finds that an additional rating of 20 percent-the maximum schedular rating available-is warranted for the Veteran's dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. See DC 5258. Specifically, in August 2008 R. Lucas found MRI evidence of an apparent fragment off the lateral meniscus. Similarly, in August 2009 a military hospital clinician found x-ray evidence of loose bodies in the posterior joint space. Although the Board recognizes that both the August 2009 military hospital x-ray clinician and the October 2006 examiner found that the Veteran does not have effusion, she explained in her August 2007 notice of disagreement that the effusion is exacerbated by activities of daily living, and, in light of this fact and the Veteran's medical expertise as a nurse for 281/2 years, the Board finds that the evidence of effusion is in equipoise, warranting a finding in the Veteran's favor. 38 C.F.R. § 4.3. Moreover, the April 2009 and April 2011 VA examiners found evidence of pain and clicking, consistent with the Veteran's testimony that her left knee would "click through a lock when I go to stand up." See transcript, p. 5. As such, an additional 20 percent rating under DC 5258 is warranted. An additional rating is not warranted under DC 5259 because the symptoms of the Veteran's left knee cartilage disorder are more nearly approximated by the 20 percent rating under DC 5258. Although the Veteran did undergo left knee surgery during service, the August 2008 MRI evidence of an apparent fragment off the lateral meniscus and the August 2009 x-ray evidence of loose bodies in the posterior joint space conclusively demonstrate that the Veteran's symptomatic semilunar cartilage was not removed. Moreover, the Veteran continues to have frequent episodes of locking, pain, and effusion into the joint. Thus, the higher 20 percent rating under DC 5258 is assigned, and a separate 10 percent rating under DC 5259 is not assigned because it is not warranted due to the presence of symptomatic semilunar cartilage, and would constitute impermissible pyramiding. 38 C.F.R. § 4.14. No compensable rating is available for the Veteran's limitation of flexion or extension because her lowest flexion is to 90 degrees, and her extension is consistently to 0 degrees-both of which are less severe than the zero percent schedular ratings for flexion and extension. See DCs 5260, 5261. The Board has also considered the Veteran's reports of pain throughout her range of motion, but finds that her overall level of functional impairment-including her ability to attain a noncompensable level of flexion and normal extension-results in no higher rating being warranted. See VAOPGCPREC 9-98, Comment 1 (1998). In reaching this determination, the Board acknowledges that pain on motion must be taken into account when rating a disability based on limitation of motion, even where there is compensable loss as a result of limitation of motion. DeLuca v. Brown, 8 Vet. App. at 205-06. To receive disability compensation, however, for painful motion, that pain must result in functional loss, i.e., limitation in the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination or endurance." See 38 C.F.R. § 4.40; see also Mitchell, 25 Vet. App. at 38. In other words, "although pain may cause functional loss, pain itself does not constitute functional loss" that is compensable for VA benefit purposes. Mitchell, 25 Vet. App. at 37. Here, given the Veteran's ability to perform occupational tasks and her overall range of motion, the Boards finds that the preponderance of the evidence is against entitlement to a higher initial rating for her left knee based on limitation of motion. Moreover, the Veteran's left knee pain is expressly compensated via her 20 percent rating under DC 5258, which specifically contemplates pain; as such, the assignment of an additional rating for pain, whether or not due to arthritis, would constitute impermissible pyramiding. See 38 C.F.R. § 4.14; cf. Burton v. Shinseki, 25 Vet. App. 1 (2011). Therefore, a separate rating under DC 5003, 5260 or DC 5261 is not warranted. No evidence of nonunion or malunion of the tibia and fibula is of record. Thus, a rating under DC 5262 is not warranted. Additionally, no evidence of genu recurvatum is of record. Therefore, a rating under DC 5263 is not warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the applicable rating criteria adequately contemplate the manifestations of the Veteran's left knee disabilities, which include dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint, as well as removal of symptomatic semilunar cartilage. The rating criteria are therefore adequate to evaluate the left knee disabilities and referral for consideration of an extraschedular rating is not warranted. Moreover, even if the established schedular criteria are found to be inadequate to describe the severity and symptoms of the Veteran's disabilities, the case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, the Veteran reported at her April 2011 VA examination that she is currently employed on a fulltime basis and has lost less than one week of work in the past 12 months due to her left knee, for physicians' appointments. The Board finds that the manifestation of the Veteran's symptoms, including less than one week of lost time due to her left knee disability, does not qualify as an exceptional or unusual disability picture. Finally, the Court of Appeals for Veterans Claims has held that a total disability rating based on individual unemployability (TDIU) is a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2001) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The Veteran is gainfully employed and thus, TDIU is not raised by the record. Right Ankle The Veteran contends in her August 2007 notice of disagreement that she has had an "auto-fusion of the joint that has occurred over the years resulting in severe decrease in the range of motion." The Veteran also reported having been prescribed a soft splint to limit the side-to-side grinding of the joint and increase tolerance of activity. The Veteran stated that she has a "frozen joint" which "actually affect[s] the way th[at] I drive my car, requiring whole leg action [with] toe pointing to accelerate or brake the car. Pain is constantly present....My activity endurance is limited to less than 2 hours of walking and no running." In her July 2008 substantive appeal (which was accidentally dated July 2007), the Veteran reported that her "right ankle has extreme limited range of motion as evidenced by inability to point foot and xray demonstrating autofusion (locked). I have constant pain, swelling, and inability to walk long periods." (Emphasis and parentheses in original.) At the August 2010 hearing before a since-retired VLJ, the Veteran testified that she has bone-on-bone grinding in her right ankle. See transcript, pp. 22-23. She also stated that, during her service, she was told that the tibia talus margin, where the ankle connects to the leg bone, had locked or auto-fused. Id., p. 22. The Veteran also asserted that "when [examiners] talk about the range of motion that I can perform with the ankle, it's really curious because the rest of the ankle bones have flexion in them, but that one doesn't, and so they'll be able to point my toes some and call that a flexion or extension, but it's really not that joint moving at all." Id., p. 22. The Veteran also reported that her right ankle causes pain and limits her activities of daily living. Id., pp. 22, 24. Under 38 C.F.R. § 4.71a, there are several diagnostic codes that may potentially be employed to evaluate impairment resulting from service-connected ankle disorders. Diagnostic Codes 5003 and 5010, for evaluation of degenerative and traumatic arthritic changes, are applicable to the ankle. 38 C.F.R. § 4.71a, DCs 5003, 5010. DC 5010 applies to traumatic arthritis and provides that such is evaluated under the criteria for 38 C.F.R. § 4.71a, DC 5003. Diagnostic Code 5003 provides that degenerative arthritis is to be rated on the basis of limitation of motion of the affected joint under the appropriate diagnostic code for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint group or minor joint group affected by limitation of motion. In the absence of limitation of motion, a 20 percent evaluation is provided where there is X-ray evidence of involvement of two or more major joints, or two of more minor joint groups with occasional incapacitating exacerbations. A 10 percent evaluation is provided where there is X-ray evidence of involvement of two or more major joints, or two of more minor joint groups without exacerbations. 38 C.F.R. § 4.71a, DCs 5003, 5010 (2012). Under DC 5270, ankylosis of the ankle in plantar flexion less than 30 degrees warrants a 20 percent rating. Ankylosis of the ankle in plantar flexion between 30 degrees and 40 degrees, or in dorsiflexion between 0 and 10 degrees warrants 30 percent rating. Ankylosis of the ankle in plantar flexion at more than 40 degrees; or in dorsiflexion at more than 10 degrees; or with abduction, adduction, inversion or eversion deformity warrants a 40 percent rating. Under DC 5271, moderate limited motion of the ankle warrants a 10 percent rating. Marked limited motion of the ankle warrants a 20 percent rating. Under DC 5272, ankylosis of the subastragalar or tarsal joint in good weight-bearing position warrants a 10 percent rating. Ankylosis of the subastragalar or tarsal joint in poor weight-bearing position warrants a 20 percent rating. Under DC 5273, a malunion of the os calcis or astragalus with moderate deformity warrants a 10 percent rating. A malunion of the os calcis or astragalus with marked deformity warrants a 20 percent rating. Under DC 5274, an astragalectomy warrants a 20 percent rating. For rating purposes, normal range of motion in an ankle joint is plantar flexion to 45 degrees and dorsiflexion to 20 degrees. 38 C.F.R. § 4.71, Plate II. The ankle is considered a major joint. 38 C.F.R. § 4.45(f) (2012). The RO has evaluated the right ankle degenerative joint disease as 10 percent disabling under 38 C.F.R. § 4.71a, DC 5003-5271, effective January 1, 2007. The hyphenated code is intended to show that the Veteran's right ankle disabilities include symptoms of degenerative arthritis (DC 5003) and limited motion of the ankle (DC 5271). In September 2006, a private physician, D. Pevarski, M.D., took x-rays of the Veteran's right ankle and diagnosed her with severe degenerative changes in the right ankle with essentially obliteration of the tibiotalar joint space and marked increased sclerosis and irregularity of the superior aspect of the talus, representing either severe degenerative changes or underlying osteonecrosis. An October 2006 in-service examiner noted that the Veteran described her right ankle as having pain, stiffness, and swelling, including soft-tissue swelling. The Veteran stated that her condition does not cause incapacitation, but does prevent running and other active activities of daily life. The examiner found no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement or guarding of movement, or any deformity. The Veteran had dorsiflexion to 20 degrees, with pain at 0 degrees, and plantar flexion to 45 degrees, with pain at 20 degrees. After repetitive use, the right ankle was additionally limited by 0 degrees by pain, but was not additionally limited by fatigue, weakness, lack of endurance, or incoordination. The examiner diagnosed the Veteran with degenerative joint disease of the right ankle joints based on x-ray evidence. The examiner also found severe degenerative changes in the right ankle with essentially obliteration of the tibiotalar joint space and marked increased sclerosis and irregularity of the superior aspect of the talus, representing either severe degenerative changes or underlying osteonecrosis. In July 2008, a military hospital clinician took x-rays of the Veteran's right ankle and found severe degenerative change at the tibiotalar joint with joint space obliteration, sclerosis, osteophytosis, and deformity of the talus. There was no evidence of acute fracture or effusion. In August 2008 and October 2010, Dr. Oza diagnosed the Veteran with degenerative joint disease of the right ankle. In November 2008, January 2009, and March 2009, Dr. Leslie also diagnosed the Veteran with degenerative joint disease of the right ankle. An April 2009 VA examiner noted that the Veteran reported having giving way, instability, pain, stiffness, weakness, incoordination, decreased speed of joint motion, and swelling in her right ankle. She reported that she could stand for between 15 and 30 minutes, and could walk more than 1/4 mile but less than 1 mile. The VA examiner found abnormal motion and guarding of movement, but no instability or tendon abnormality. The Veteran had right ankle dorsiflexion to 15 degrees, and plantar flexion to 30 degrees; there was no objective evidence of pain following repetitive motion, no additional limitations after three repetitions of range of motion, and no ankylosis. The VA examiner diagnosed the Veteran with right ankle degenerative joint disease. The examiner found that the Veteran's right ankle disability causes decreased mobility, problems with lifting and carrying, and pain, as well as moderate and severe effects on usual daily activities. In September 2010, a military hospital clinician found that the Veteran's "right ankle is completely fused and she has absolutely no motion." A clinician found that the fusion was secondary to diffuse osteoarthritis. An April 2011 VA examiner noted that the Veteran stated that she had right ankle deformity, instability, pain, stiffness, weakness, decreased speed of joint motion, locking, inflammation, and flare-ups lasting for 3 to 7 days every 1 to 2 months. The VA examiner found bony joint enlargement around both malleoli. The VA examiner found no ankle instability or tendon abnormality. The Veteran had dorsiflexion to 15 degrees, and plantar flexion to 35 degrees, both with objective evidence of pain throughout initial and repetitive motion. There were no additional limitations after three repetitions of range of motion. There was no joint ankylosis. The VA examiner diagnosed the Veteran with degenerative joint disease of the right ankle. The examiner found that the Veteran's right ankle disability causes decreased mobility and pain, as well as moderate, severe, and preventative effects on usual daily activities. In response to a July 2012 remand from the Board, the RO provided the Veteran with a new examination in August 2012 in order to resolve the conflicting evidence as to whether her right ankle is fused or ankylosed, and, if so, in what position. The August 2012 VA examiner noted that the Veteran reported having low-level right ankle pain, worse with weight bearing. The Veteran also reported having flare-ups lasting 4 days, 4 times per year. The Veteran had plantar flexion to 25 degrees, with pain at 25 degrees, and dorsiflexion to 15 degrees, with pain at 15 degrees. The Veteran had no additional limitation of motion following repetitive-use testing. The examiner found no functional loss or functional impairment of the right ankle. The Veteran did have localized tenderness or pain on palpation on the right side. The examiner found that the Veteran does not have ankylosis of the ankle, subtalar, or tarsal joint. The examiner further found that the Veteran does not have, and never had, shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or a talectomy (astragalectomy). The examiner diagnosed the Veteran with degenerative or traumatic arthritis. The examiner found that the Veteran's right ankle condition impacts her work in that her right ankle pain bothers her and makes her careful of how and how much she moves, although her work is mostly a desk job. After reviewing all of the clinical evidence and subjective complaints since the effective date of service connection, the Board finds that an initial disability evaluation in excess of 10 percent for the Veteran's degenerative joint disease of the right ankle is not warranted for the entirety of the appeal period. In this regard, the Board finds that the right ankle degenerative arthritis is manifested by moderate limitation of motion, insofar as her plantar flexion reaches 25 out of a normal 45 degrees, and her dorsiflexion reaches 15 out of a normal 20 degrees. The ankle is a single major joint; hence a higher rating under DCs 5010, 5003 is not warranted. See 38 C.F.R. § 4.45(f); 4.71, DC 5003 (2012). The Board has also considered the Veteran's reports of pain throughout her range of motion, but finds that her overall level of functional impairment-including her ability to attain moderate limitation of motion of the right ankle, and her ability to retain a full-time occupation with less than one week of lost work in the 12 months prior to April 2011-results in no higher rating being warranted. In reaching this determination, the Board acknowledges that pain on motion must be taken into account when rating a disability based on limitation of motion, even where there is compensable loss as a result of limitation of motion. DeLuca v. Brown, 8 Vet. App. at 205-06. To receive disability compensation, however, for painful motion, that pain must result in functional loss, i.e., limitation in the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination or endurance." See 38 C.F.R. § 4.40; see also Mitchell, 25 Vet. App. at 38. In other words, "although pain may cause functional loss, pain itself does not constitute functional loss" that is compensable for VA benefit purposes. Mitchell, 25 Vet. App. at 37. Here, given the Veteran's ability to perform occupational tasks and her overall range of motion, the Boards finds that the preponderance of the evidence is against entitlement to an evaluation in excess of 10 percent for her right ankle disability based on limitation of motion. Additionally, the Board finds that the April 2011 VA examiner's determination that there is no objective evidence of "psoriatic arthritis" of the right ankle is most probative based on the examiner's expertise and objective findings. A separate rating for ankylosis is also not warranted because the most probative evidence shows that the Veteran does not have ankylosis of the right ankle or the subastragalar or tarsal joint. While the Board has considered the statements by the Veteran and the September 2010 military hospital clinician, the Board finds that they are outweighed by the more probative evidence from the April 2009 VA examiner, April 2011 VA examiner, August 2012 VA examiner, finding that the Veteran does not have ankylosis. The Board finds the VA examiners' conclusions regarding the absence of right ankle ankylosis more probative because they specifically measured the Veteran's ankle movement, and because of their duty to provide truthful opinions. Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999). Therefore, a rating under DC 5270 or DC 5272 is not warranted. No evidence of malunion of the os calcis or astragalus is of record. Therefore, a rating under DC 5273 is not warranted. Additionally, no evidence of an Astragalectomy is of record. Therefore, a rating under DC 5274 is not warranted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the applicable rating criteria adequately contemplate the manifestations of the Veteran's right ankle disabilities, which include marked limitation of motion. The rating criteria are therefore adequate to evaluate the right ankle disability and referral for consideration of an extraschedular rating is not warranted. Moreover, even if the established schedular criteria are found to be inadequate to describe the severity and symptoms of the Veteran's disability, the case does not present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization. Specifically, the Veteran reported at her April 2011 VA examination that she is currently employed on a fulltime basis and has lost less than one week of work in the past 12 months due to her right ankle, for physicians' appointments. The Board finds that the manifestation of the Veteran's symptoms, including less than one week of lost time due to her right ankle disability, does not qualify as an exceptional or unusual disability picture. Finally, the Court of Appeals for Veterans Claims has held that a total disability rating based on individual unemployability (TDIU) is a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2001) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The Veteran is gainfully employed and thus, TDIU is not raised by the record. ORDER A 10 percent disability rating for slight lateral instability of the left knee is granted, subject to the applicable criteria governing the payment of monetary benefits. A 20 percent disability rating for left knee dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint is granted, subject to the applicable criteria governing the payment of monetary benefits. An initial evaluation in excess of 10 percent for degenerative joint disease of the right ankle is denied. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs