Citation Nr: 1312970 Decision Date: 04/18/13 Archive Date: 05/02/13 DOCKET NO. 07-37 791 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for a right knee disability, to include as secondary to a service-connected right tibia injury. 2. Entitlement to an increased rating for service-connected residuals of right tibia disability, rated 0 percent prior to January 25, 2007, and 10 percent thereafter. 3. Entitlement to an increased rating for service-connected residuals of left tibia disability, rated 0 percent prior to January 25, 2007, and 10 percent thereafter. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran had active service from April 1981 to December 1983. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from the July 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which denied a compensable rating for right and left tibia injuries, and denied service connection for a bilateral knee condition. The Veteran appealed, and in May 2011, the Board denied the claim for a left knee disability, and remanded the other claims for additional development. In September 2011, the Appeals Management Center assigned separate 10 percent ratings for the right, and left, tibia injuries, effective date of January 25, 2007. However, as those increases do not represent a total grant of benefits sought on appeal, the claims for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. The Veteran does not have a right knee disability that was caused by his service, or that was caused or aggravated by any service-connected disability. 2. Prior to January 25, 2007, the Veteran's left leg shin splints were shown to be productive of complaints of pain, but not a malunion of the tibia and fibula, with slight knee or ankle disability. 3. Prior to January 25, 2007, the Veteran's right leg shin splints were shown to be productive of complaints of, but not a malunion of the tibia and fibula, with a slight knee or ankle disability. 4. As of January 25, 2007, the Veteran's left leg shin splints are shown to be productive of complaints of pain, but not a malunion of the tibia and fibula, with a moderate knee or ankle disability. 5. As of January 25, 2007, the Veteran's right leg shin splints are shown to be productive of complaints of pain, but not a malunion of the tibia and fibula, with a moderate knee or ankle disability. CONCLUSIONS OF LAW 1. The Veteran does not have a right knee disability that was caused by his service, or that was caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. Prior to January 25, 2007, the criteria for a compensable rating for left leg shin splints were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102 , 3.159, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5257, 5260, 5261, 5262 (2012). 3. Prior to January 25, 2007, the criteria for a compensable rating for right leg shin splints were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5262 (2012). 4. As of January 25, 2007, the criteria for a rating in excess of 10 percent for left leg shin splints are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5262 (2012). 5. As of January 25, 2007, the criteria for a rating in excess of 10 percent for right leg shin splints are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40. 4.45, 4.71a, Diagnostic Code 5262 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection The Veteran contends that he currently has a right knee condition that was incurred in service, or that was caused or aggravated by his service-connected residuals of the right and left tibia injuries. He has argued that his service-connected disabilities resulted in an altered gait, which caused or aggravated a right knee disability, such as in the representative's March 2013 brief. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection may also be granted for arthritis, when manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted, on a secondary basis, for a disability, which is proximately due to, the result of, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310 (2012). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000); Mercado-Martinez v. West, 11 Vet. App. 415 (1998); Cuevas v. Principi, 3 Vet. App. 542 (1992). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran's service treatment reports show that beginning in May 1981, he was treated for complaints of symptoms in his right leg, or bilateral legs, on multiple occasions. The May 1981 assessment, based on complaints of right shin pain, was strain. An October 1982 report shows that the Veteran complained of right leg pain. He denied trauma, although he may have bumped his calf that morning. He stated that he had no feeling from his knee to his foot. A report, dated in February 1983, specifically mentioned the knees and noted that the pain was at the tibial tuberosity. Subsequently dated reports show that the Veteran was repeatedly noted to have bilateral stress fractures, sometimes characterized as tibial stress fractures. A May 1983 X-ray report notes bilateral stress fractures of the mid-shaft of the tibias. A May 1983 report indicates that the Veteran underwent a bone scan of his knees, and that the results were positive for a stress fracture at about the right tibial plateau that was consistent with DJD (degenerative joint disease). The Veteran's separation examination report, dated in December 1983, shows that his lower extremities were clinically evaluated as normal, and that he had a physical profile of L-1 at the time of this examination. Odiorne v. Principi, 3 Vet. App. 456 (1992) (PULHES profile reflects the overall physical and psychiatric condition of the Veteran on a scale of 1, a high level of fitness, to 4, medical condition or physical defect below the level of medical fitness for retention in service). In an associated report of medical history, the Veteran denied having a history of a trick or locked knee. The evidence after service includes VA medical reports dated between 1985 and 2011. That evidence includes a June 1985 VA examination report which shows that the Veteran complained of bilateral calf symptoms. He reported a history of bilateral fractures at the bones near his calves. On examination, the knees were normal. The diagnosis was residuals, following injury to both tibiae with history of hairline fracture. An associated X-ray report for the tibiae notes that no fractures or dislocations were seen. A May 1993 VA examination report notes complaints of bilateral leg pain below the knee, particularly when walking, standing for a period of time, or running. He also reported swelling. On examination, there was bony overgrowth of the right tibia in the mid-portion. The diagnosis was residuals of stress fractures of the right and left tibia. VA progress notes, dated from 1994 to 2011, show that in September 2000, the Veteran was treated for right knee symptoms and noted to have swelling across the superior aspect of his knee. The assessment was right knee effusion. An associated X-ray report contains diagnoses of osteochondritis dissecans medical femoral condyle with in situ sequestrum, and small joint effusion. A July 2002 report notes that the Veteran underwent a left Achilles tendon repair after a basketball injury. His leg was casted and he used a walker through October 2002. A May 2007 report notes that the Veteran had undergone surgery following a right trimalleolar fracture. The report also indicates that he had sustained a torn right Achilles tendon. A July 2007 report notes a history of a torn right Achilles tendon about seven months before, and a displaced bimalleolar fracture in April 2007. He was casted for eight weeks. Following an MRI (magnetic resonance imaging) study, the medial malleolus appeared as if it might go into non-union, and the bimalleolus fracture looked slightly displaced. There were fracture fragments that were somewhat separated with no, or little, callus formation. An August 2007 report shows that the Veteran complained of right knee pain. On examination, the right knee was mildly swollen. An X-ray was noted to show osteochondritis dissecans with free in situ bone fragment, medial femoral condyle (as described in the September 2000 X-ray report), mild medical compartmental osteoarthritis, and probable small joint effusion. In October 2007, the Veteran reported that he had no significant right ankle pain. He had a barely perceptible limp. The examiner concluded that the Veteran should be allowed to walk on his ankle. In January 2008, the Veteran complained of mild right knee pain. He stated that he was doing well as far as his right ankle was concerned, and that he was walking without any special shoes and had no pain. In October 2008, the Veteran stated that he played football, so he could handle pain. In March 2009, he was treated for head trauma after wrestling with his brother. In April 2009, he was treated for pain and swelling of the right knee and ankle for the past several years. He was prescribed Ibuprofen and a brace for his right knee. In September 2009, the Veteran was treated for left knee symptoms. The assessment was left knee pain consistent with patellar bursitis vs. gout. That same month, the Veteran was issued a right knee brace. A June 2007 VA examination report shows that the examination was performed to evaluate the Veteran's service-connected bilateral shin splints. The examiner stated that the Veteran's claims file was not available for review. The report notes a history that included left Achilles tendon repair in 2002, a tear of the right Achilles tendon, a twisted right ankle in November 2006, with X-rays showing a nondisplaced bilmalleolar fracture, and an additional right ankle injury the day of the examination. The Veteran reported a history of inservice bilateral pain over the mid- and distal thirds of his tibiae. Inservice X-rays were noted to show stress fractures at the junction of the mid- and distal thirds of each tibia. On examination, the knees had a full range of motion. There was no relevant diagnosis. An examination report by A.G.F., M.D., of the University of Cincinnati, Division of Occupational Medicine, dated in June 2011, shows that Dr. F stated that the Veteran's claims file had been reviewed. The Veteran complained of right knee pain, and mild weakness with lack of endurance. It was noted that the Veteran used bilateral knee braces, but no spinal braces, shoe inserts, corrective shoes, cane, crutches, or walker. Dr. F summarized the Veteran's history, to include his history of right ankle and left knee disorders. Dr. F noted that during service, the Veteran was treated for shin splints and right knee pain, that he had no history of right knee surgery. He had a right ankle bimalleolar fracture in 2004. On examination, the Veteran had decreased weight-bearing on the right due to knee and ankle pain. The tandem gait was unsteady. He had standing and gait deficits due to right knee osteoarthritis and bilateral ankle Achilles tendon ruptures, and residuals of his right bimalleolar ankle fracture. There were no callosities, breakdown, or abnormal shoe wear patterns that would indicate abnormal weight bearing. Posture was normal. The diagnosis noted a history of bilateral ankle Achilles tendon ruptures, a history of a right ankle trimalleolar fracture, and right knee medial osteochondritis dessicans and osteoarthritis. Dr. F stated that the Veteran had slight ankle and moderate knee disabilities in his lower extremities, and that it was less likely as not (less than a 50/50 probability) caused by or a result of the Veteran's active duty service. Dr. F explained that there was no history of right knee injury, and no history of chronic right knee symptoms in the service medical records. Dr. F. stated, "More importantly, the Veteran did not report any right knee pain, and there was no knee pathology found at the time of his 1983 military exit history and physical." With regard to the possibility of secondary service connection, Dr. F concluded that it was less likely as not (less than a 50/50 probability) that the Veteran's right knee conditions were caused by or aggravated by his service-connected right tibial shin splints as a secondary condition. Dr. F explained the following: the Veteran had no knee complaints upon discharge from service, and that he did not seek treatment for years after he left the military. There was no nexus with which to link the conditions, because there is no objective evidence that his shin splints persisted for more than a few months after he stopped running and marching in the military. Shin splints are not associated with the development of any knee intra-articular joint pathology. Dr. F. concluded that, "In my medical opinion, the Veteran's right knee osteochondritis and osteoarthritis (involving only the distal femur) are completely separate and distinct, and these conditions involve a different bone (femur) from the service-connected (mid-tibial) right shin splints." The Board finds that a preponderance of the evidence is against the claim for service connection for a right knee disability. Although the Veteran complained of knee pain on one or two occasions during service, he appears to have primarily complained of pain in the area of his shins. He was repeatedly diagnosed with stress fractures of his tibiae. He was never diagnosed with any right knee disability, nor are there any inservice findings to show the existence of any chronic right knee pathology. He specifically denied having a trick or locked knee upon separation from service, and his lower extremities were clinically evaluated as normal at that time. The earliest post-service medical evidence of right knee symptoms is found in a VA progress note dated in September 2000, which notes osteochondritis dissecans medical femoral condyle with in situ sequestrum. That was about 17 years after separation from service. The Veteran has not specifically asserted that he has had an ongoing continuity of symptomatolgoy since his service, and that lengthy period weighs against the claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection). In addition, the Board finds that Dr. F's June 2011 opinion is highly probative evidence against the claim. In that opinion, it was essentially concluded that the Veteran's right knee disorder was not caused by or a result of his service, or as a result of or aggravated by any service-connected disability. 38 C.F.R. § 3.303 (2012). Dr. F indicated that the Veteran's claims files had been reviewed, and the opinion is accompanied by a sufficiently detailed rationale. Prejean v. West, 13 Vet. App. 444 (2000); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). There is no evidence to show that right knee arthritis was manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307, 3.309 (2012). Finally, to the extent that the Veteran has presented a claim based on secondary service connection, the only competent opinion is found in the Dr. F's June 2011 examination report, and that opinion weighs against the claim. 38 C.F.R. § 3.310 (2012). The Board finds that opinion is highly probative evidence against the claim and the Veteran has not submitted any competent favorable evidence. In summary, the Board finds that the evidence is insufficient to show that the Veteran has a right knee disability that was manifest in service, or that was caused or aggravated by a service-connected disability, and the Board finds that the preponderance of the evidence is against the claim. Therefore, the claim must be denied. The issue on appeal is based on the contention that the Veteran has a right knee disability due to service, or as secondary to service-connected disability. To the extent that the Veteran may have intended to assert that he began having right knee symptoms at any particular point in time, his statements are competent evidence to show that he experienced those symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). However, the Veteran does not have the requisite skills, knowledge, or training, to be competent to state whether his symptoms were sufficient for a diagnosis of a right knee disability, or whether a right knee disability is related to his service, or to a service-connected disability. Lay persons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, the specific issue in this case falls outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, the Veteran's service medical records do not show findings of any right knee disability, or a diagnosis involving a right knee disability. His post-service medical records do not note right knee symptoms prior to September 2000, which is about 17 years after service. A physician has issued an opinion in which it was determined that the Veteran does not have a right knee disability that is related to his service, or to a service-connected disability. Considering the foregoing, the Board finds that the service treatment reports, and the post-service medical evidence, outweigh the Veteran's contentions that he has a right knee disability that is related to service, or to a service-connected disability. The Board finds that the preponderance of the evidence is against the claim for service connection, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Ratings The Veteran asserts that he is entitlement to increased ratings for his service-connected residuals of right and left tibia injuries, rated as 0 percent prior to January 25, 2007, and as 10 percent thereafter. During service, the Veteran was repeatedly noted to have bilateral stress fractures, sometimes characterized as tibial stress fractures. A May 1983 X-ray report noted bilateral stress fractures of the mid-shaft of the tibias. A May 1983 report indicates that the Veteran underwent a bone scan of his bilateral knees, and that the results were positive for a stress fracture at about the right tibial plateau that was consistent with DJD (degenerative joint disease). Following separation from service, a September 2000 VA X-ray report contained diagnoses of osteochondritis dissecans medial femoral condyle with in situ sequestrum, and small joint effusion. In August 1985, the RO granted service connection for residuals of injuries to the right and left tibia, with each disability assigned a 0 percent rating. There was no appeal, and the RO's decision became final. 38 U.S.C.A. § 7105(c) (West 2002 & Supp. 2012). In January 2007, the Veteran filed claims for increased ratings. In July 2007, the RO denied the claims. The Veteran appealed, and a September 2011 rating decision assigned separate 10 percent ratings for the right and left tibia injuries, effective January 25, 2007. Because this increase did not constitute a full grant of the benefits sought, the increased rating issues remain in appellate status. AB v. Brown, 6 Vet. App. 35 (1993). Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). The RO has rated the Veteran's shin splints under Diagnostic Code 5262 which provides a 10 percent rating for malunion of the tibia and fibula of either lower extremity if there is a slight knee or ankle disability. A 20 percent rating is warranted if there is a moderate knee or ankle disability. 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2012). The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2012). The use of terminology such as severe by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2012). Normal extension and flexion of the knee is from 0 to 140 degrees. Normal dorsiflexion of the ankle is from 0 to 20 degrees. Normal plantar flexion of the ankle is from 0 to 45 degrees. 38 C.F.R. § 4.71, Plate II (2012). The Veteran filed his claim on January 25, 2007. Therefore, the time period on appeal is from January 25, 2006, to the present. 38 C.F.R. § 3.400(o)(2) (2012). Prior to January 25, 2007 The relevant medical evidence consists of VA progress notes, which show that in September 2006, the Veteran was noted not to have any musculoskeletal symptoms. His lower extremities were noted to have no edema, or calf tenderness. The knees and ankles were not inflamed. In January 2007, the Veteran sought treatment for complaints of right ankle and foot pain. On examination, his foot was swollen and there was tenderness over the Achilles heel. The report states that X-rays were negative for fracture, and that there was a possible tendon injury. The Board has determined that the claims must be denied. In this case, there is no evidence of a malunion of the tibia and fibula of either leg, nor are the findings sufficient to show that the Veteran has an associated slight knee or ankle disability. The January 15, 2007 VA progress note shows that the Veteran's right foot was swollen and there was tenderness over the Achilles heel. However, the report indicates that X-rays were negative for a fracture. Although there was a possible tendon injury of the right foot, that was not confirmed during the time period on appeal, nor were there any recorded findings sufficient to establish a slight ankle disability. The Board therefore finds that the criteria for a compensable 10 percent rating under Diagnostic Code 5262 are not shown to have been met for either leg prior to January 25, 2007, and that the claims must be denied. The Board finds that the preponderance of the evidence is against the assignment of any compensable rating for right or left tibia disability, prior to January 25, 2007. Therefore, those claims for increase are denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As of January 25, 2007 VA progress reports show a number of treatments for residuals of injuries to the ankles, and for knee symptoms. A June 2007 VA examination report shows that the examiner stated that the Veteran's claims file was not available for review. The examiner noted a history that included left Achilles tendon repair in 2002, a tear of the right Achilles tendon, a twisted right ankle in November 2006, with X-rays showing a nondisplaced bilmalleolar fracture, and an additional right ankle injury the day of the examination. The Veteran reported a history of inservice bilateral pain over the mid- and distal thirds of his tibiae. Inservice X-rays were noted to show stress fractures at the junction of the mid- and distal thirds of each tibia. On examination, the knees had a full range of motion. He wore an ankle brace on the right ankle. He did not walk with any supports. Gait was normal. The lower extremities had no obvious deformities, malalignments, and no rotatory or angular malalignment. Leg lengths were equal. There was no swelling, soft tissue thickening, boney deformity, or boney prominence over either tibial area. There was no pain, tenderness, or discomfort, over either tibia. The left ankle had a full range of motion. The calves had equal circumference, and there was no atrophy. The right ankle had discomfort, pain, and tenderness, with dorsiflexion to 10 degrees, and plantar flexion to 25 degrees. The left ankle had dorsiflexion to 10 degrees, and plantar flexion to 35 degrees, without pain or discomfort. Sensation to light touch was intact bilaterally. Motor power over the calves, ankles and feet were 5/5. The right Achilles tendon had 4/5 strength upon dorsiflexion. Both tibias were nontender, with no discomfort. The right ankle had soft tissue thickening, and was one inch greater in circumference than the left ankle. X-rays of the tibias were noted not to show any boney abnormalities, bilaterally. The right ankle had a healing fracture of the medial lateral malleolus with some widening of the ankle mortis. The impression notes that the Veteran had essentially normal tibias, with no positive objective findings, a nonservice-connected bilmalleolar fracture of the left ankle in 2006 and 2007, a postoperative repair of an Achilles tendon rupture in 2002 with a satisfactory result, and a chronic rupture of the right Achilles tendon that is not related to the Veteran's service-connected stress fractures. An examination report by Dr. F, dated in June 2011, shows that Dr. F stated that the Veteran's claim file had been reviewed. The Veteran complained of mild right knee weakness with occasional morning stiffness. He denied deformity, instability giving way, or locking of the joints. He also complained of flare-ups occurring about twice a week and lasting about 20 minutes. During flare-ups, and after repetitive use, he complained of an additional limitation of motion due to pain, but no limitation of function, and no weakened movement, excess fatigability, endurance, incoordination, or functional loss. He brought bilateral hinged knee braces to the examination. On examination, there were no signs of inflammation, including joint heat, redness, or drainage. Dr. F stated that the Veteran's current symptoms were persistent mid-tibial pain with walking. The left ankle had dorsiflexion form 0 to 17 degrees, and plantar flexion from 0 to 40 degrees. The right ankle had dorsiflexion form 0 to 18 degrees, and plantar flexion from 0 to 41 degrees. There was no objective evidence for painful joint motion during rest and during active range of motion. There was no joint instability, or objective evidence of weakness. There was no functional limitation on standing. There were standing and gait deficits due to right knee osteoarthritis and bilateral ankle Achilles tendon ruptures and residuals of the bimalleolar ankle fracture. There was no malunion, loose motion, or false joint. There was no malunion of the os calcis or astragalus. Dr. F stated that there was no joint involvement associated with the tibial bone disease. X-rays of the knees showed enlarging osteochondral defect in the anterior weight-bearing surface of the right medial femoral condyle. The left knee was normal. X-rays of the tibias showed a healed bimalleolar fracture on the right, and contour irregularity of the left tibia that may be related to prior fracture or ligamentous injury. No acute abnormality was seen. The impression was possible prior osseous injuries, with no acute abnormality noted. In the diagnosis, Dr. F noted a history of bilateral tibial shin splints while on active duty service with no objective evidence that they are currently active, a history of bilateral ankle Achilles tendon ruptures, a history of a right ankle trimalleolar fracture, and right knee medial osteochondritis dessicans and osteoarthritis. There was no malunion or nonunion, and no loose motion requiring a brace, although the Veteran wore bilateral knee braces for comfort. There were slight ankle and moderate knee disabilities. Dr. F stated that the Veteran's malunion of the distal right tibia has no relationship to any knee disability or left ankle disability, and contributed only slightly to the right ankle disability. The Board has determined that the claims must be denied. In this case, there is no evidence of a malunion of the tibia and fibula of either leg. In June 2007, X-rays of the tibias were noted not to show any boney abnormalities, bilaterally. In June 2011, Dr. F stated that there is no objective evidence that the Veteran's shin splints persisted for more than a few months after he stopped running and marching in the military. Dr. F. also concluded that there was no objective evidence that the Veteran's bilateral tibial shin splints were currently active. The vast majority of the findings and medical evidence pertained to the Veteran's ankle and knee disorders, and not to his bilateral shin splints. However, regulations specifically prohibit rating service-connected disabilities based on symptoms that are not service-connected. 38 C.F.R. § 4.14 (2012). In this case, the Veteran's bilateral ankle and bilateral knee disorders are clearly shown to be due to post-service injuries. With regard to the ankles, following separation from service, the Veteran is shown to have sustained bilateral ankle Achilles tendon ruptures, and a right ankle trimalleolar fracture. The June 2007 VA examiner specifically concluded that the Veteran's chronic rupture of the right Achilles tendon was not related to his service-connected stress fractures. With regard to the knees, in May 2001, the Board determined service connection was not warranted for a left knee disability. The Board has determined that service connection was not warranted for a right knee disability. The Board further notes that Dr. F's June 2011 opinion concluded that the Veteran's malunion of the distal right tibia had no relationship to any knee disability or left ankle disability. Dr F also stated that there was no joint involvement associated with the tibial bone disease. Considering the foregoing, the Veteran's ankle and knee symptoms are sufficiently dissociated from his bilateral tibial injuries, and they may not be considered as a basis for an increased rating. Mittleider v. West, 11 Vet. App. 181 (1998). Finally, the Board has considered Dr. F's statement, that the Veteran's right tibial injury contributed only slightly to the right ankle disability. However, he characterized the right ankle disability itself as slight, and that evidence is insufficient to show that the required criteria have been met. The Board therefore finds that the criteria for a 20 percent rating under Diagnostic Code 5262 are not shown to have been met for either leg, and that the claims must be denied. The Board finds that a higher rating is not warranted for functional loss. 38 C.F.R. §§ 4.40, 4.45 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995); VAGCOPPREC 9-98 (1998), 63 Fed. Reg. 56703 (1998). As an initial matter, the Board has determined that service connection is not warranted for the Veteran's bilateral knee disabilities, and his left ankle disorder is not shown to be related to his service-connected bilateral tibial injuries. Therefore, the service-connected disabilities are not shown to have affected those joints, the ranges of motion for these joints are not relevant to the issues on appeal, and the provisions as to functional loss need not be considered. Johnson v. Brown, 9 Vet. App. 7 (1996) (when a diagnostic code is not predicated on a limited range of motion alone, the provisions of 38 C.F.R. §§ 4.40 and 4.45 do not apply). The June 2007 VA examination report shows that both tibias were nontender, with no discomfort. The impression noted essentially normal tibias, with no positive objective findings. Dr. F's June 2011 opinion shows that he determined that there was no objective evidence that the Veteran's bilateral tibial injuries were currently active. There were standing and gait deficits, but these were due to right knee osteoarthritis and bilateral ankle Achilles tendon ruptures and residuals of the bimalleolar ankle fracture. To the extent that Dr. F indicated that the Veteran's right tibial injury contributed only slightly to the right ankle disability, the right ankle was shown to have a nearly normal range of motion. 38 C.F.R. § 4.71a, Plate II (2012). Dr. F found that there was no objective evidence for painful joint motion during rest and during active range of motion, there was no joint instability, or objective evidence of weakness, and that there was no functional limitation on standing. VA progress notes indicate 5/5 strength (October 2008), and that all joints had a FROM (full range of motion) (March 2012). In summary, the Board finds that there is insufficient evidence of functional loss to warrant a rating in excess of 10 percent for either lower extremity. DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board finds that the preponderance of the evidence is against the assignment of any higher ratings for the right and left tibial disabilities. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board finds that the Veteran's bilateral leg disorders do not warrant referral for extra-schedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extra-schedular rating is made. There is a three-step analysis for determining whether an extra-schedular rating is appropriate. First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as governing norms, including marked interference with employment and frequent periods of hospitalization. If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. 38 C.F.R. § 3.321(b)(1) (2012); Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the Veteran has not expressly raised the matter of entitlement to an extra-schedular rating for his service-connected bilateral leg disorders. The Veteran's contentions have been limited to those discussed above, essentially that his disability is more severe than compensated by the currently assigned ratings. Brannon v. West, 12 Vet. App. 32 (1998) (while Board must interpret a claimant's submissions broadly, Board is not required to conjure up issues not raised by the claimant). There has been no showing that the Veteran's disability picture for his bilateral leg disorders could not be contemplated adequately by the applicable schedular rating criteria discussed above. Those criteria provide for higher ratings in this case, but the currently assigned ratings adequately describe the severity of the Veteran's symptoms. In addition, the evidence does not show that the Veteran's disabilities include such exceptional factors as periods of hospitalization and interference with employment. Referral for consideration of the assignment of a disability rating on an extra-schedular basis is not warranted. 38 C.F.R. § 3.321(b)(1) (2012); Thun v. Peake, 22 Vet. App. 111 (2008); Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Duties to Notify and Assist. The Board finds that the duties to notify have been fulfilled by information provided to the Veteran in letters from the RO dated in March 2007 and May 2011. 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Those letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claims, and identified the Veteran's duties in obtaining information and evidence to substantiate his claims. 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); Mayfield v. Nicholson, 20 Vet. App. 537 (2006); Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The RO also provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service medical reports, and post-service records relevant to the issues on appeal have been obtained and are associated with the Veteran's claims files. The RO has obtained the Veteran's VA medical records. The Veteran has been afforded examinations, and an etiological opinion has been obtained. In May 2011, the Board remanded the claims. The Board essentially directed that notice be issued with regard to the claim for service connection, which discussed the theory of secondary service connection. That same month, a notice was issued that was in compliance with the Board's remand instruction. The Board also directed that the Veteran's treatment records be obtained, dated since October 2007, from the Cincinnati VA Medical Center, and that has been done. Finally, the Board directed that the Veteran be scheduled for appropriate VA examinations to assess the nature and etiology of his claimed right knee disability, and the current severity of his service-connected bilateral tibial injuries. In June 2011, that was done. The Board finds that the examination report obtained is adequate, as it is predicated on a review of the pertinent evidence, consideration of the Veteran's lay statements, and an examination of the Veteran. An etiological opinion was included. Accordingly, the Board finds that VA's duty to assist with respect to obtaining examinations, and opinion with respect to the service connection issue on appeal, has been met. 38 C.F.R. § 3.159(c)(4) (2012). Under the circumstances, the Board finds that there has been substantial compliance with its remand. Dyment v. West, 13 Vet. App. 141 (1999); Sabonis v. Brown, 6 Vet. App. 426 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). The Veteran and his representative have not argued that any error or deficiency in the accomplishment of the duty to notify has prejudiced him in the adjudication of his appeal. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination). In view of the above, the Board finds that the notice requirements pertinent to the issues on appeal have been met. In summary, the Board finds that the available medical evidence is sufficient for an adequate determination of the claims on appeal. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with these claims does not cause any prejudice to the Veteran. ORDER Entitlement to service connection for a right knee disability is denied. Entitlement to an increased rating for service-connected residuals of right tibia disability, rated 0 percent prior to January 25, 2007, and 10 percent thereafter, is denied. Entitlement to an increased rating for service-connected residuals of left tibia disability, rated 0 percent prior to January 25, 2007, and 10 percent thereafter, is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs