Citation Nr: 1314446 Decision Date: 05/02/13 Archive Date: 05/15/13 DOCKET NO. 10-06 486 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a low back disorder. 2. Entitlement to an initial rating in excess of 10 percent for arthritis of the right hip, effective August 31, 2000 through June 18, 2009. 3. Entitlement to a rating in excess of 20 percent for arthritis of the right hip, effective June 19, 2009. 4. Entitlement to a separate rating for impairment of the right thigh. 5. Entitlement to an initial rating in excess of 10 percent for arthritis of the left hip. 6. Entitlement to a separate rating for impairment of the left thigh. 7. Entitlement to an initial rating in excess of 10 percent for arthritis of the right knee, effective August 31, 2000 through June 18, 2009. 8. Entitlement to a rating in excess of 20 percent for arthritis of the right knee, effective June 19, 2009. 9. Entitlement to an initial compensable rating for arthritis of the left knee, effective August 31, 2000 through May 23, 2007. 10. Entitlement to a rating in excess of 10 percent for arthritis of the left knee, effective May 24, 2007. 11. Entitlement to an initial compensable rating for arthritis of the right ankle, effective August 31, 2000 through May 23, 2007. 12. Entitlement to a rating in excess of 10 percent for arthritis of the right ankle, effective May 24, 2007 through June 18, 2009. 13. Entitlement to a rating in excess of 20 percent for arthritis of the right ankle, effective June 19, 2009. 14. Entitlement to an initial compensable rating for arthritis of the left ankle, effective August 31, 2000 through May 23, 2007. 15. Entitlement to a rating in excess of 10 percent for arthritis of the left ankle, effective May 24, 2007 through June 18, 2009. 16. Entitlement to a rating in excess of 20 percent for arthritis of the left ankle, effective June 19, 2009. 17. Entitlement to special monthly compensation due to loss of use of both feet. 18. Entitlement to special monthly compensation due to loss of use of both buttocks. 19. Entitlement to special monthly compensation due to the need for regular aid and attendance of another person. 20. Entitlement to a compensable rating for arthritis of the right first metatarsophalangeal joint. 21. Entitlement to a compensable rating for arthritis of the left first metatarsophalangeal joint. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Harold A. Beach, Counsel INTRODUCTION The Veteran served on active duty from August 1956 to August 1960. Thereafter, he had multiple periods of Active Duty for Training in the Coast Guard Reserve, including, but not limited to, a period from September 1965 to January 1966. The Veteran is in receipt of a total disability evaluation based on individual unemployability, effective August 31, 2000 - the date of submission of his original claims of service connection. This matter came to the Board of Veterans' Appeals (Board) on appeal from a June 2003 rating decision by the RO. The Board will REMAND to the RO through the Appeals Management Center (AMC) the issues of entitlement to special monthly compensation on the basis of the need for the regular aid and attendance of another person, on the basis of the loss of use of both feet, and/or on the loss of use of both buttocks; and the issues of entitlement to initial compensable ratings for arthritis of the first metatarsal phalangeal joints of each foot. In addition to the foregoing, the Veteran has submitted claims which have not yet been considered by VA. In August 2000, the Veteran submitted a claim of entitlement to service connection for arthritis of the shoulders, wrists, and fingers. In a statement, dated in March 2012, the Veteran raised contentions to the effect that service connection was warranted for fibromyalgia and peripheral neuropathy. Finally, in March 2013, the Veteran, through his representative, claimed that he should have earlier effective dates as follows: an effective date prior to June 19, 2009 for a 20 percent rating for arthritis of the right knee; an effective date prior May 24, 2007 for a 10 percent rating for his service-connected arthritis of the left knee; an effective date prior May 24, 2007 for a 10 percent rating for his service-connected arthritis of the right ankle; an effective date prior to June 19, 2009 for a 20 percent rating for his service-connected arthritis of the right ankle; an effective date prior May 24, 2007 for a 10 percent rating for his service-connected arthritis of the left ankle; an effective date prior to June 19, 2009 for a 20 percent rating for his service-connected arthritis of the left ankle; and an effective date prior to June 19, 2009 for a 20 percent rating for his service-connected arthritis of the left hip. Those claims have not been certified to the Board on appeal nor have they otherwise been developed for appellate purposes. Specifically with regard to the Veteran's contentions regarding earlier effective dates, it appears that the Veteran may be disagreeing with the initially-assigned staged ratings for these service-connected disorders. To this extent, the Board has granted the claims in part in this decision. However, the Board is unable to glean any other theory of entitlement for earlier effective dates of compensation, given that there has been no contention the Veteran filed earlier claims of compensation. Therefore, the Board has no jurisdiction over those claims, and they will not be considered below. 38 U.S.C.A. § 7104(a) (West 2002 and Supp. 2012); 38 C.F.R. § 20.101 (2012). They are, however, referred to the RO for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. A low back disorder is proximately due to the Veteran's service-connected pes planus. 2. From the time service connection became effective August 31, 2000 through June 18, 2009, the Veteran's right hip arthritis was manifested primarily by flexion of the right hip to 90 degrees with pain coming at 70 degrees, abduction of the right hip from at least 0 to 20 degrees. 3. Since June 19, 2009, the Veteran's right hip arthritis was manifested primarily by flexion from 0 to 30 degrees; extension from 0 to 20 degrees; abduction from 0 to 20 degrees. 4. Since June 19, 2009, the Veteran has had right thigh impairment, manifested by an inability to cross his legs and inability to toe out more than 15 degrees. 5. Since service connection became effective August 31, 2000, the Veteran's left hip arthritis has been manifested primarily by complaints of pain, flexion to at least 40 degrees; extension to 0 degrees. 6. Since June 19, 2009, the Veteran has had left thigh impairment, manifested by an inability to cross his legs and inability to toe out more than 15 degrees. 7. From the time service connection became effective August 31, 2000 through June 18, 2009, the Veteran's right knee arthritis was manifested primarily by complaints of pain and weakness; flexion to at least 120 degrees; and extension to at least 0 degrees. 8. Since June 19, 2009, the Veteran's right knee arthritis has been manifested primarily by right knee extension to 0 degrees and post-repetition right knee flexion to 30 degrees. 9. For the period from August 31, 2000 through May 23, 2007, the Veteran's left knee arthritis was manifested primarily by complaints of pain, flexion to 140 degrees; and extension to at least 0 degrees. 10. Since May 24, 2007, the Veteran's left knee arthritis has been manifested primarily by complaints of pain and post-repetitive left knee flexion to 70 degrees. 11. For the period from August 31, 2000 through May 23, 2007, the Veteran's right ankle arthritis was productive of moderate impairment. 12. For the period from May 24, 2007 through June 18, 2009, the Veteran's right ankle arthritis was productive of no more than moderate impairment. 13. Since June 19, 2009, the Veteran's arthritis of the right ankle has been productive of no more than marked impairment. 14. For the period from August 31, 2000 through May 23, 2007, the Veteran's arthritis of the left ankle was productive of moderate impairment. 15. For the period from May 24, 2007 through June 18, 2009, the Veteran's arthritis of the left ankle was productive of no more than moderate impairment. 16. Since June 19, 2009, the Veteran's arthritis of the left ankle has been productive of no more than marked impairment. CONCLUSIONS OF LAW 1. The criteria for secondary service connection for a low back disorder have been approximated. 38 U.S.C.A. §§ 5103, 5103A, 5107(b) (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2012). 2. For the period from effective August 31, 2000 through June 18, 2009, the criteria have not been met for an initial rating in excess of 10 percent for arthritis of the right hip. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5252 (2012). 3. Since June 19, 2009, the criteria have not been met for a rating in excess of 20 percent for arthritis of the right hip. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5252 (2012). 4. Since June 19, 2009, the criteria have been met for a separate 20 percent rating for impairment of the right thigh. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5253 (2012). 5. Since service connection became effective August 31, 2000, the criteria have not been met for an initial rating in excess of 10 percent for arthritis of the left hip. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5252 (2012). 6. Since June 19, 2009, the criteria have been met for a separate 20 percent rating for impairment of the left thigh. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5253 (2012). 7. For the period from August 31, 2000 through June 18, 2009, the right knee arthritis did not meet the criteria for an initial rating in excess of 10 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260 (2012). 8. Since June 19, 2009, the criteria have not been met for a rating in excess of 20 percent for right knee arthritis. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260 (2012). 9. For the period from August 31, 2000 through May 23, 2007, the left knee arthritis did not meet the criteria for an initial compensable rating. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260 (2012). 10. Since May 24, 2007, the left knee arthritis did not meet the criteria for a rating in excess of 10 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260 (2012). 11. For the period from August 31, 2000 through May 23, 2007, the criteria were met for a 10 percent rating for arthritis of the right ankle. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5271 (2012). 12. For the period from May 24, 2007 through June 18, 2009, the criteria for a rating in excess of 10 percent were not met for arthritis of the right ankle. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5271 (2012). 13. Effective June 19, 2009, the criteria for a rating in excess of 20 percent were not met for arthritis of the right ankle. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5271 (2012). 14. For the period from August 31, 2000 through May 23, 2007, the criteria were met for a 10 percent rating for arthritis of the left ankle. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5271 (2012). 15. For the period from May 24, 2007 through June 18, 2009, the criteria for a rating in excess of 10 percent were not met for arthritis of the left ankle. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5271 (2012). 16. Effective June 19, 2009, the criteria for a rating in excess of 20 percent were not met for arthritis of the left ankle. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5271 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist Prior to consideration of the merits of the Veteran's appeal, the Board must determine whether VA has met its statutory duty to assist him in the development of the issues of entitlement to service connection for a low back disorder and increased ratings for arthritis of the ankles, hips, and knees. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. After reviewing the record, the Board finds that VA has met that duty. On August 31, 2000, VA received the Veteran's claim of entitlement to service connection for a back disorder, claimed as arthritis, as well as entitlement to service connection disorders of the feet, ankles, knees, and hips. In January 2002, the RO denied those claims. The Veteran disagreed and appealed to the Board. In December 2002, the Board granted entitlement to service connection for bilateral pes planus. The following month, the RO assigned a 30 percent rating for that disorder. The Veteran disagreed with the amount of that rating, and, again, filed an appeal. In June 2007, the RO raised that rating to 50 percent; however, it retained the effective date of August 31, 2000. In March 2003, the Veteran submitted a claim for a TDIU. However, in June 2003, the RO denied that claim. In June 2003, the RO did grant entitlement to service connection for arthritis of the following joints and assigned the indicated ratings, effective August 31, 2000: left hip, 10 percent; right hip, 10 percent; right knee, 10 percent; left knee, noncompensable; left ankle, noncompensable; right ankle, noncompensable; left metatarsophalangeal joint, noncompensable; and right metatarsophalangeal joint, noncompensable. The Veteran disagreed with those ratings, as well as the denial of entitlement to a TDIU, and this appeal ensued. In conjunction with his appeals for increased ratings and a TDIU, VA notified the Veteran of the information and evidence necessary to substantiate and complete his claims, including the evidence to be provided by him, and notice of the evidence VA would attempt to obtain. VA informed the Veteran that in order to establish increased ratings for his service-connected disabilities, the evidence had to show that such disabilities had worsened and the manner in which such worsening had affected his employment and daily life. 38 U.S.C.A. § 5103(a). VA also informed him of the criteria for a TDIU. Following the notice to the Veteran, VA fulfilled its duty to assist him in obtaining identified and available evidence necessary to substantiate his claims. VA obtained or ensured the presence of the Veteran's service treatment records; records and reports from the Social Security Administration; records and reports reflecting his treatment and evaluations by W. R. W., M.D. from September 2000 through October 2008; an August 2001 report from M. G., D.P.M.; records and reports reflecting the Veteran's VA treatment from February 2003 through April 2006; records and reports reflecting the Veteran's treatment and evaluations by A. F. W., D.P.M. from August 2002 through May 2011; a May 2005 Emergency Room Report from the Riverside Regional Medical Center; transcripts of May 2007 and June 2009 hearings held at the RO before a VA Decision Review Officer; records and reports reflecting the Veteran's treatment and evaluations by P. M., M.D. from April 2010 through March 2012; a May 2011 report from Williamsburg-Riverside Medical Arts, Urgent Care; and medical literature concerning pes planus, peripheral neuropathy, and spinal disorders. In March and November 2003, June and October 2009, January 2010, and August 2012 VA examined the Veteran to determine the nature and etiology and extent of impairment attributable to his service-connected arthritis of the hips, knees, and ankles. The VA examination reports show that the examiners reviewed the Veteran's medical history, interviewed and examined the Veteran, documented his medical conditions, reviewed pertinent medical research, and rendered diagnoses and opinions consistent with the remainder of the evidence of record. Therefore, the Board concludes that the VA examinations are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2009); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As noted, in June 2007, the RO granted entitlement to a TDIU, effective August 31, 2000. That was a full grant of benefits sought with respect to that issue; and, therefore, the Board has no further jurisdiction over that issue. In January 2009, the RO denied the Veteran's claim of entitlement to service connection for a low back disorder, diagnosed as degenerative arthritis. The Veteran disagreed with that decision and that claim was added to the appeal. In January 2010, the RO granted the increased ratings for the following disorders on the effective dates indicated: left knee arthritis, 10 percent effective May 24 2007; left ankle arthritis, 10 percent effective May 24, 2007 and 20 percent, effective June 19, 2009; right ankle arthritis, 10 percent effective May 24, 2007 and 20 percent, effective June 19, 2009; right knee arthritis, 20 percent, effective June 19, 2009; and right hip arthritis, 20 percent, effective June 19, 2009. Because those ratings did not represent a full grant of benefits sought on appeal, those issues were returned to the Board for further appellate consideration. In March 2010, the Veteran requested a hearing at the RO before a Veterans Law Judge. In May 2010, the Veteran withdrew that request and has not requested that his hearing be rescheduled. In sum, the Veteran has been afforded a meaningful opportunity to participate in the development of his appeal. He has not identified any outstanding evidence which could support his claim for service connection for a low back disorder or his claims for increased ratings for his ankles, knees, or hips. There is no evidence of any VA error in notifying or assisting the Veteran that could result in prejudice to him or that could otherwise affect the essential fairness of the adjudication of those issues. Accordingly, the Board will to the merits of those issues. The Merits of the Appeal The Board will discuss the relevant law it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published at Title 38 of the Code of Federal Regulations ("38 C.F.R."); and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction; the Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). Service Connection for a Low Back Disorder The Veteran contends that his low back disorder is primarily the result of stresses on his low back caused by an antalgic gait, primarily associated with his service-connected bilateral pes planus. Therefore, he maintains that service connection is warranted for a low back disorder on a secondary basis. After carefully considering the claim in light of the record and the applicable law, the Board will grant the claim and the appeal will be allowed. Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). However, service connection may also be granted when the evidence shows that a particular disability is proximately due to or the result of a disability for which service connection has already been established. 38 C.F.R. § 3.310(a). Any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. Id. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In August 2000, reports of radiographic studies performed at the Riverside Regional Medical Center confirmed the presence of degenerative changes in the Veteran's lower lumbar spine, as well as his hips. In August 2002, A. F. W., D.P.M. stated that abnormal forces from the Veteran's service-connected pes planus had an effect on the Veteran's joints and could aggravate his hips and low back. In May 2007 and October 2008, W. R. W., M.D., found a nexus between the Veteran's low back arthritis and his service-connected pes planus. Dr. W. found it more likely than not that the arthritis in the Veteran's low back was effected by the same forces from the Veteran's pes planus that had caused him to develop arthritis in his service-connected feet, ankles, knees, and hips. In light of these opinions, the Veteran was examined by VA to determine the nature and etiology of any low back disorder found to be present. Following the June 2009 VA examination, the examiner opined that there was less than a 50 percent chance that the Veteran's service-connected pes planus had caused him to develop degenerative joint disease in the lumbar spine. The VA examiner acknowledged that abnormal weight bearing could be a contributing factor in the development of other problems, such as degenerative joint disease in the lumbar spine, but that there was no clear evidence to that effect in the Veteran's case. In January 2010, the examiner reiterated that opinion. The Veteran does need not prove his claim with absolute certainty. Rather, in order to prevail, he must present competent evidence, which when weighed and evaluated, is in relative equipoise; that is, an approximate balance of evidence both for and against the claim. Although such evidence may not satisfactorily prove or disprove the claim, the Board may be able to grant the claim, after resolving all reasonable doubt in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In August 2012, a VA nurse practitioner reviewed the Veteran's claims file. She noted the evidence both for and against the claim but found that the medical literature did not support a nexus between the Veteran's low back disorder and his service-connected pes planus. She noted that the literature was plentiful in substantiating a nexus between pes planus and the development of arthritis in the first metatarsal phalangeal joint, the ankle, and the knee. However, she found no evidence that childhood pes planus, such a experienced by the Veteran, did not cause degenerative joint disease of the spine. In addition, the VA examiner noted that the Veteran had additional risk factors for the development of lumbar spine arthritis, including obesity, age, trauma in 2002, and construction work. The Veteran noted, however, that he had never worked in the construction industry and that the 2002 trauma did not cause back problems. While the VA examiner stated that back arthritis manifested in 2008, the August 2000 radiographic studies were already reported to have shown degenerative changes. There is an approximate balance of evidence which neither proves nor disproves the claim that the Veteran's low back disorder is proximately due to or has been aggravated by his service-connected pes planus. Therefore, resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran meets the criteria for service connection for a low back disorder on a secondary basis. Therefore, service connection is warranted; and, to that extent, the appeal is allowed. The Increased Rating Claims The Veteran seeks entitlement to increased ratings for his service-connected arthritis of the hips, ankles, and knees. Disability evaluations are determined by comparing the manifestations of a particular disability with the criteria set forth in the Diagnostic Codes of the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155, 38 C.F.R. Part 4 (2012). The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity (in civilian occupations) resulting from service-connected disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, a veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (When service connection is granted and an initial rating award is at issue (as in this case with respect to radiculopathy of the left lower extremity) separate ratings can be assigned for separate periods from the time service connection became effective.). Therefore, the following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Degenerative arthritis, established by X-ray findings, is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When, however, 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 or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, degenerative arthritis is rated as follows: A 20 percent rating is warranted when there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent rating is warranted when there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups. For the purpose of rating disability from arthritis, the shoulder, elbow, wrist, hip, knee, and ankle are considered major joints; multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities, the interphalangeal, metatarsal and tarsal joints of the lower extremities, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae, are considered groups of minor joints, ratable on a parity with major joints. The lumbosacral articulation and both sacroiliac joints are considered to be a group of minor joints, ratable on disturbance of lumbar spine functions. 38 C.F.R. § 4.45 (f). However, the law provides that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 1. The law also provides that with any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. 38 C.F.R. § 4.59. In determining the adequacy of assigned disability ratings, consideration must be given to factors affecting functional loss. DeLuca v. Brown, 8 Vet. App. 202 (1995). Such factors include a lack of normal endurance and functional loss due to pain and pain on use, specifically limitation of motion due to pain on use including that experienced during flare ups. 38 C.F.R. § 4.40. Consideration must also be given to weakened movement, excess fatigability, and incoordination, as well as the effects of the disability on the veteran's ordinary activity. 38 C.F.R. § 4.10, 4.45. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. As regards the joints the factors of disability reside in reductions of their normal excursion of movements in different planes, inquiry will be directed to these considerations: (a) Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.). (b) More movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.). (c) Weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.). (d) Excess fatigability. (e) Incoordination, impaired ability to execute skilled movements smoothly. (f) Pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. For the purpose of rating disability from arthritis, the shoulder, elbow, wrist, hip, knee, and ankle are considered major joints; multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities, the interphalangeal, metatarsal and tarsal joints of the lower extremities, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae, are considered groups of minor joints, ratable on a parity with major joints. The lumbosacral articulation and both sacroiliac joints are considered to be a group of minor joints, ratable on disturbance of lumbar spine functions. 38 C.F.R. § 4.45. In regard to the effect of the Veteran's arthritis on his daily activities, including his ability to work, since service connection became effective for arthritis of the hips, knees, and ankles on August 31, 2000, the Veteran has had a TDIU. Such a rating is consistent with the significant effects VA has attributed to his service-connected disabilities. The Veteran alleges, and his health care providers indicate that the Veteran has difficulty walking, primarily due to his service-connected pes planus. For example, in August 2003 and April 2006, it was noted that the Veteran walked several times a week for a total of one to two miles. In April 2006, it was noted that his primary limiting problem was arthritis in his feet. Consequently, such difficulty will not be considered with respect to the claims for increased ratings for his hip, knees, and ankles. To do so, would violate VA's prohibition against pyramiding, that is, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes. 38 C.F.R. § 4.14 (2012). That said, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes. However, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259-261-62 (1994); VAOPGCPREC 23-97. The Hips The Veteran's hip disabilities are rated based on limitation of motion of affected part, i.e., the thigh. 38 C.F.R. § 4.71a, Diagnostic Codes 5251, 5252 and 5253. Under Diagnostic Code 5251, a 10 percent rating is warranted when extension of the hip is limited to 5 degrees. Under Diagnostic Code 5252, a 10 percent rating is warranted when flexion of the thigh is limited to 45 degrees. A 20 percent rating is warranted when flexion of the thigh is limited to 30 degrees. A 30 percent rating is warranted when flexion of the thigh is limited to 20 degrees, and a 40 percent rating is warranted when flexion of the thigh is limited to 10 degrees. Under Diagnostic Code 5253, a 10 percent rating is warranted when there is limitation of motion of the thigh, such that the affected leg cannot toe our more than 15 degrees or adduction is limited such that the Veteran cannot cross his legs. A 20 percent rating is warranted when there is limitation of abduction such that thigh motion is lost beyond 10 degrees. The Right Hip Rating, Effective August 31, 2000 through June 18, 2009 During the period from August 31, 2000 through June 18, 2009, the Veteran had a rating of 10 percent for his right hip arthritis. The evidence, including that from private health care providers shows that during that time, he reported bilateral hip pain. However, the hips demonstrated no point tenderness or swelling, and he demonstrated the following ranges of hip motion: flexion of the right hip to 90 degrees with pain coming at 70 degrees and abduction of the right hip from at least 0 to 20 degrees. During VA outpatient treatment in February 2004 and April 2005, the Veteran's strength was reported full at 5/5, and his sensation and deep tendon reflexes in the lower extremities were intact. In May 2005, the Veteran was treated at the Riverside Regional Medical Center for a 24 hour history of shooting pain in his right hip. Although he demonstrated very tight hamstrings, his motor and sensory examinations were normal. In sum, despite the Veteran's complaints of right hip pain, he did not demonstrate the limitation of flexion, extension, abduction, adduction, or rotation which met or more nearly reflected the schedular criteria for a rating in excess of 10 percent under any of the applicable diagnostic codes. Therefore, for the period from August 31, 2000 through June 18, 2009, an increased initial rating for right hip arthritis was not warranted. In arriving at this decision, the Board considered the possibility of rating the Veteran's right hip disorder under other diagnostic codes potentially applicable to rating hip disability. However, the Veteran did not demonstrate anklyosis of the hip, a flail hip joint, or impairment of the femur, manifested by a fracture or anatomical neck of the femur with nonunion or malunion, so as to trigger the applicability of those codes . 38 C.F.R. § 4.71a, Diagnostic Codes 5250, 5254, and 5255. The Right Hip Rating, Effective June 19, 2009 The Veteran seeks a rating in excess of 20 percent for his arthritis of the right hip which became effective June 19, 2009. On that date, the Veteran's right hip was again examined by VA. The Veteran continued to complain of hip pain. He also demonstrated decreased strength in hip flexion and extension at 4/5, each, decreased sensation in the lower extremities and decreased ankle reflexes. However, his muscle tone was normal, and there was no evidence of associated muscle atrophy of disuse. In October 2009, the Veteran was reexamined by VA. He reported tenderness to palpation in his hips and hip pain, bilaterally, even at rest. He also reported right hip pain when standing, and there was objective evidence of right pain. He demonstrated the following ranges of right hip motion: flexion of the right hip from 0 to 30 degrees; extension of the right hip from 0 to 20 degrees; and abduction of right hip from 0 to 20 degrees. The examiner was unable to test additional ranges of hip motion due to pain. Nevertheless, in view of the additional limitation of flexion, the RO raised the Veteran's rating for his right hip disability to 20 percent. There was no basis for an increased rating based on limitation of extension, as the Veteran continued to demonstrate full extension. Despite the increased rating, however, that does not end the inquiry. During the October 2009 VA examination, the Veteran was unable to cross his legs or toe out more than 15 degrees, each a distinct manifestation of thigh impairment under 38 C.F.R. § 4.71a, Diagnostic Code 5253 and each motion ratable as 10 percent disabling. Those separate ratings should then have been combined under 38 C.F.R. § 4.25 and a 20 percent rating should have been granted for impairment of the left thigh. In arriving at this decision, the Board recognizes that both motions are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5253. However, the fact that they are separately identifiable, compensable manifestations warrants the separate rating, effective October 22, 2009. See generally 38 C.F.R. § 4.14 (the evaluation of the " same disability " or the " same manifestation " under various diagnoses is to be avoided) and Esteban v. Brown, 6 Vet. App. 259 (1994) (while pyramiding of disabilities is to be avoided pursuant to 38 U.S.C. § 1155 and 38 C.F.R. § 4.14 , it is possible for a veteran to have separate and distinct manifestations from the same injury permitting two different disability ratings). To that extent, the appeal is granted. The Left Hip Rating, Effective August 31, 2000 The Veteran also seeks entitlement to an initial rating in excess of 10 percent for arthritis of left hip. Since service connection became effective August 31, 2000, the Veteran's left hip disability has been manifested by complaints of pain, limitation of motion, and weakness. During his VA examinations in March 2003 and October 2009 , he experienced pain with left hip motion and at rest. Although he was able to fully extend the hip to 0 degrees, he was unable to consistently flex the hip fully. In March 2003, he was able flex the knee to at least 70 degrees, and in October 2009, he was unable to flex it to more than 40 degrees. Such limitation of motion with pain more nearly approximated the initial 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5252. Despite his complaints of weakness in the left hip, there was no corroborating objective evidence, such as abnormal muscle tone or atrophy of disuse. Moreover, during an April 2003 consultation with the VA Rehabilitation Medicine Service, and during VA treatment in February 2004 and April 2005, the Veteran's strength was found to be full at 5/5. On balance, the Board finds that the manifestations of the Veteran's left hip disorder were contemplated by the initial 10 percent rating, under 38 C.F.R. § 4.71a, Diagnostic Code 5252 and 5251. Similar to the Board's disposition of the right thigh issue, however, during his VA examination on October 22, 2009, the Veteran was unable to cross his legs or toe out more than 15 degrees. As with the right hip, such findings warranted a separate 10 percent rating under Diagnostic Code 5253, and the appeal will be granted to this extent. 38 C.F.R. § 4.14 and Esteban, supra. The Knees Limitation of motion of knee is rated in accordance with 38 C.F.R. §§ 4.71a, Diagnostic Codes 5260 and 5261. A noncompensable rating is warranted when flexion is limited to 60 degrees or when extension is limited to 5 degrees. A 10 percent rating is warranted when flexion is limited to 45 degrees or when extension is limited to 10 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees or when extension is limited to 15 degrees. A 30 percent rating is warranted when flexion is limited to 15 degrees or when extension is limited to 20 degrees. Also potentially applicable in rating the Veteran's right knee disability is 38 C.F.R. §§ 4.71a, Diagnostic Code 5257 the Diagnostic Code used to rate knee impairment associated with recurrent subluxation or lateral instability. A 10 percent rating is warranted for slight impairment, manifested by recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate impairment, while a 30 percent rating is warranted for severe impairment. In rating the Veteran's knee disabilities. the Board has considered whether the Veteran is entitled to separate ratings for instability and arthritis as well as for lost flexion and extension. Esteban, VAOGCPREC 23-97 (Multiple Ratings for Knee Disability, 62 Fed. Reg. 63,604 (1997)); VAOGCPREC (Multiple Ratings for Musculoskeletal Disability and Applicability of 38 C.F.R. §§ 4.40, 4.45, and 4.59, (holding that separate ratings may be assigned in cases where a service-connected knee disability includes both limitation of motion due to arthritis and instability, provided that the degree of disability is compensable under each set of criteria); Vet. Aff. Op. Gen. Couns 9-04 (Rating Limitation of Flexion and Extension of the Leg, 69 Fed. Reg. 59990 (2004)) (holding that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260 and a compensable limitation of extension under Diagnostic Code 5261 provided that the degree of disability is compensable under each set of criteria). The Right Knee Rating, Effective August 31, 2000 through June 18, 2009 The Veteran seeks an initial rating in excess of 10 percent for his service-connected arthritis of the right knee, effective August 31, 2000 through June 18, 2009. The evidence shows that during that period, the Veteran's right knee impairment was manifested primarily by pain and weakness. However, the March and November 2003 VA examinations show that he was able to flex the right knee to at least 120 degrees and to extend it fully to at least 0 degrees. Moreover, there was no instability at that time. Thus, while a 10 percent rating was granted to compensate the Veteran for the right knee pain and weakness, there was no basis for a higher rating under the diagnostic codes applicable to rating limitation of motion of the knee or instability. In this regard, the Board notes that the Veteran was not additionally limited by pain, fatigue, lack of endurance or incoordination. Therefore, the initial 10 percent rating for the Veteran's arthritis of the right knee is confirmed and continued for the period from August 31, 2000 through June 18, 2009. The Right Knee Rating , Effective June 19, 2009 The Veteran seeks a rating in excess of 20 percent for right knee arthritis, effective June 19, 2009. During the VA examination in October 2009, the Veteran continued to demonstrate pain, crepitus, full right knee extension to 0 degrees and right knee flexion to 120 degrees. However, pain associated with repetitive motion reduced the right knee flexion to 30 degrees, a level commensurate with a 20 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5260. In May 2011, during treatment at Williamsburg-Riverside Medical Arts - Urgent Care, the Veteran was treated for a two day history of sciatic pain. At that time, his deep tendon reflexes were normal at 2+ and symmetric. There were no pathologic reflexes, and his sensation was intact. In March 2012, Dr. M. suggested that the Veteran exercise as much as possible and recommended that he resume playing golf. He did so, playing 5 to 9 holes per week. In May 2012, during a visit to Dr. M., the Veteran reported that walking was not viable and noted that he had suspended playing golf again. There was no evidence, however, that the Veteran had further limitation of motion of the right knee or that there was any instability. Therefore, the Veteran did not meet the criteria for a rating in excess of 20 percent for his right knee arthritis. The Left Knee Rating, Effective August 31, 2000 through May 23, 2007 The Veteran seeks an initial compensable rating for his service-connected left knee arthritis for the period from August 31, 2000 through May 23, 2007. The report of the Veteran's March 2003 VA examination shows that the Veteran was able to flex his left knee to 140 degrees and extend it to at least 0 degrees, both ranges considered normal under VA regulations. 38 C.F.R. § 4.71, Plate II. He was also able to extend it fully to at least zero degrees, and there was no mobility of the meniscus or of the tendons. Private medical records, such as a September 2003 report from A. F. W., D.P.M., show that the Veteran's patellar reflexes were normal, but the Veteran's sensation was decreased. During the Veteran's November 2003 VA examination, the Veteran continued to demonstrate a normal range of left knee motion from 0 to 140 degrees. He reported constant pain which interfered with his daily function, especially those requiring physical endurance. He reported that he took Tylenol for the pain. His posture was normal, and there was no evidence of left knee deformity, lack of endurance, incoordination, or additional limitation of repeated left knee motion. During VA treatment in February 2004 and April 2005, the Veteran's strength was normal, and his sensation and deep tendon reflexes were intact. Although the Veteran reported knee pain as for example in the March and November 2003 VA examinations, there was no objective evidence of pain during range of motion measurements. There were no changes in the Veteran's facial expression, wincing, pressure or manipulation, muscle spasm, or crepitus. Absent objective manifestations of pain, weakness, limitation of motion, or instability, the Veteran did not meet the criteria for a compensable rating for his left knee arthritis for the period from August 31, 2000 through May 23, 2007. Accordingly, an increased initial rating is not warranted, and the appeal is denied. The Left Knee Rating, effective May 24, 2007 The Veteran seeks a rating in excess of 10 percent for left knee arthritis, effective May 24, 2007. During treatment by Dr. W. in May 2007, the Veteran reported left knee pain and during the June 2009 VA examination he demonstrated 120 degrees of left knee motion. However, on repetitive testing, that range of flexion was reduced to 70 degrees. Such objective evidence of knee pain warranted a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5260. However, there was no evidence of further limitation of motion, left knee instability, fatigue, lack of endurance or incoordination. . Accordingly, the Veteran met the schedular criteria for a 10 percent rating, and no more, effective May 24, 2007. The Ankles Limitation of motion of the ankle is rated in accordance with 38 C.F.R. § 4.71a, Diagnostic Code 5271. A 10 percent rating is warranted for moderate limitation of motion, while a 20 percent rating is warranted for severe limitation of motion. The terms "moderate" and "marked" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2012). It should be noted, however, that the standard range of motion of an ankle includes 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II (20201208). The Right Ankle Rating, Effective August 31, 2000 through May 23, 2007 During his March 2003 VA examination, the Veteran demonstrated the following ranges of right ankle motion: dorsiflexion from 0 to 20 degrees, with pain; plantar flexion from 0 to 45 degrees with pain; eversion 0 to 20 degrees; and inversion, 0 to 30 degrees. As noted above, the ranges of dorsiflexion and plantar flexion were full for VA purposes. 38 C.F.R. § 4.71, Plate II. In August 2003, an examination by A. F. W., D.P.M., revealed that the Veteran had zero to 1 degree of dorsiflexion in his ankles and 0 to at least 15 degrees of plantar flexion. There was tenderness to palpation; mild, bilateral ankle edema; and decreased sensation. During his November 2003 VA examination, however, the Veteran again demonstrated dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. Both ranges of motion were accomplished without pain, and there was no evidence of deformity. During VA treatment in February 2004 and April 2005, the Veteran's strength was normal, and his sensation and deep tendon reflexes were intact. For the period from August 30, 2000 through May 23, 2007, the evidence shows that the Veteran's right ankle motion was full and that there was no evidence of instability, weakness, or deformity. In addition, there was no evidence of lack of endurance or incoordination. However, the addition of pain on motion met or more nearly approximated the criteria for a 10 percent evaluation under 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5271. There is an approximate balance of evidence both for and against the claim that the Veteran's right ankle arthritis warranted a 10 percent rating for the period from August 31, 2000 through May 23, 2007. Under such circumstances, all reasonable doubt is resolved in favor of the Veteran, and the appeal will be granted on that basis. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. To that extent, the appeal is allowed. The Right Ankle Rating, Effective May 24, 2007 through June 18, 2009 The Veteran seeks a rating in excess of 10 percent for his right ankle disorder, effective May 24, 2007 through June 18, 2009. In October 2007, Veteran was evaluated by A. F. W., D.P.M. The Veteran had a grade I loss of motor strength involving his feet and ankles, and there was some tenderness to palpation about the ankles. However, his Achilles reflexes were normal, and his pulses were strong. Moreover, there were no reports of muscle atrophy or impaired muscle tone, or range of motion studies showing more than moderate ankle impairment. In addition, there was no evidence of additional limitation of motion following repeat testing, Therefore, the Veteran did not meet or more nearly approximate the criteria for a higher rating under any of the applicable diagnostic codes. Therefore, the Board continues the 10 percent rating for the Veteran's right ankle disability, effective May 24, 2007 through June 18, 2009. During the interval between May 2007 and June 2009, the Veteran was also evaluated/treated on several additional occasions by W. R. W., M.D. and A. F. W., D.P.M., e.g. October 2007, October 2008, and January 2009. However, those evaluations were primarily to determine the nature and etiology of the Veteran's low back disorder and whether or not special monthly compensation was warranted due to his contentions that his service-connected disabilities had caused him to lose the use of both feet and/or buttocks and/or had required the regular aid and attendance of another person due to the impairment caused by his service-connected disabilities. As noted above, service connection has been established for the Veteran's low back disorder, and the questions related to special monthly compensation are addressed in the remand section, below. The Right Ankle Rating, Effective June 19, 2009 The Veteran seeks a rating in excess of 20 percent for arthritis of the right ankle, effective June 19, 2009. On that date, the Veteran was examined by VA, in part to determine the extent of impairment attributable to his service-connected right ankle arthritis. The Veteran reported that both ankles were getting progressively worse and were manifested by constant pain and stiffness, weakness, instability, and giving way. However, he denied incoordination, decreased speed of joint motion, locking, effusion, dislocation, subluxation, or inflammation. He demonstrated crepitus in each ankle, instability, and objective evidence of pain with increased pain to palpation. Despite his complaints of weakness, there was no evidence of impaired muscle tone or atrophy due to disuse of the muscle. However, the range of right ankle motion was significantly impaired. Dorsiflexion was accomplished from 0 to 5 degrees and plantar flexion was accomplished from 0 to 7.5 degrees. Such findings were compatible with marked impairment warranting a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5271. That is the maximum schedular rating permitted under Diagnostic Code 5271. In this regard, the Board has considered the possibility of higher rating under Diagnostic Codes 5262 and 5270. However, the Veteran does not demonstrate ankylosis of the ankle. Similarly, a higher rating is not warranted under Diagnostic Code 5262, because the Veteran does not demonstrate malunion or nonunion of the tibia or fibula or more than moderate ankle impairment. Therefore, a 20 percent rating and no more is warranted since June 19, 2009. Therefore, the current rating is confirmed and continued. The Left Ankle Rating. Effective August 31, 2000 through May 23, 2007 The Veteran seeks an initial compensable rating for his service-connected left ankle arthritis, effective August 31, 2000 through May 23, 2007. During his March 2003 VA examination, he demonstrated the following ranges of left ankle motion: dorsiflexion from 0 to 20 degrees, without pain; plantar flexion from 0 to 45 degrees with pain; eversion 0 to 20 degrees; and inversion, 0 to 30 degrees. The ranges of dorsiflexion and plantar flexion were full . 38 C.F.R. § 4.71, Plate II. In August 2003, an examination by A. F. W., D.P.M., revealed that the Veteran had zero to 1 degree of dorsiflexion in his ankles and 0 to at least 15 degrees of plantar flexion. There was tenderness to palpation; mild, bilateral ankle edema; and decreased sensation. During his November 2003 VA examination, the Veteran again demonstrated dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. Both ranges of motion were accomplished without pain, and there was no evidence of deformity. Moreover, VA treatment in February 2004 and April 2005, revealed that the Veteran's strength was normal, and his sensation and deep tendon reflexes were intact. On balance, the foregoing findings show little, if any, left ankle impairment due to limitation of motion, instability, weakness, lack of endurance or incoordination, or impaired sensation or reflexes. However, he has had complaints of pain on more than one occasion and objective tenderness to palpation was confirmed by A. F. W., D.P.M. As above, for the period from August 31, 2000 through May 23, 2007, the Veteran's left ankle pain warrants a 10 percent rating under 38 C.F.R. § 4.59. At the very least, there was, again, an approximate balance of evidence both for and against the claim for that a 10 percent rating for his service-connected left ankle arthritis. Therefore, all reasonable doubt is resolved in favor of the Veteran, and an initial 10 percent rating is warranted on that basis. 38 U.S.C.A. § 5107(b) ; 38 C.F.R. § 4.3. To that extent, the appeal is also allowed. The Left Ankle Rating effective May 24, 2007 through June 18, 2009 The Veteran seeks a rating in excess of 10 percent for arthritis of the left ankle for the period from May 24, 2007 through June 18, 2009. In October 2007, Veteran was evaluated by A. F. W., D.P.M. The Veteran had a grade I loss of motor strength involving his feet and ankles, incoordination, and some tenderness to palpation about the ankles. However, his Achilles reflexes were normal, and his pulses ere strong. Moreover, there were no reports of muscle atrophy or range of motion studies showing more than moderate ankle impairment. Therefore, the Veteran did not meet or more nearly approximate the criteria for a higher rating under any of the applicable diagnostic codes. Accordingly, the Board confirms and continues the 10 percent rating for the Veteran's service-connected left ankle arthritis for the period from May 24, 2007 through June 18, 2009. During the interval between May 2007 and June 2009, the Veteran was evaluated/treated on several occasions by W. R. W., M.D. and A. F. W., D.P.M., e.g. October 2007, October 2008, and January 2009. However, those evaluations were primarily to determine the nature and etiology of the Veteran's low back disorder and whether or not special monthly compensation was warranted due to his contentions that his service-connected disabilities had caused him to lose the use of both feet and/or buttocks and/or had required the regular aid and attendance of another person due to the impairment caused by his service-connected disabilities. As noted above, service connection has been established for the Veteran's low back disorder, and the questions related to special monthly compensation are addressed in the remand section, below. The Left Ankle Rating, Effective June 19, 2009 The Veteran seeks a rating in excess of 20 percent for arthritis of the left ankle, effective June 19, 2009. During his June 19, 2009 VA examination, the Veteran reported that both ankles were getting progressively worse. He reported constant pain and stiffness, weakness, instability, and giving way. However, he denied incoordination, decreased speed of joint motion, locking, effusion, dislocation, subluxation, or inflammation; and despite his complaints of weakness, there was no evidence of atrophy or impaired muscle tone due to disuse of the muscle. The Veteran demonstrated crepitus in each ankle, instability, and objective evidence of pain with increased pain to palpation. Although there was no evidence of ankylosis, the range of right ankle motion was significantly limited. Dorsiflexion was accomplished from 0 to 5 degrees and plantar flexion was accomplished from 0 to 10 degrees. Such findings were compatible with marked impairment warranting a 20 percent rating. That is the maximum schedular rating permitted under Diagnostic Code 5271. In this regard, the Board has considered the possibility of higher rating under Diagnostic Codes 5270, 5272, 5273, and 5274. However, the Veteran does not demonstrate ankylosis of the ankle, subastralgar or tarsal joint, malunion of the os calcis or astragalus, or an astragalectomy. Similarly, a higher rating a higher rating for ankle impairment is not warranted under Diagnostic Code 5262, because the Veteran does not demonstrate malunion or nonunion of the tibia or fibula. Thus, a 20 percent rating, and no more, was warranted under 38 C.F.R. § 4.71a, Diagnostic Code 5271. Extraschedular Considerations In arriving at the foregoing rating decisions, the Board has considered the possibility of referring this case to the Director of the VA Compensation and Pension Service for possible approval of an extraschedular rating for the Veteran's service-connected arthritis of the hips, knees, and ankles. 38 C.F.R. § 3.321(b)(1) (2012). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun v. Peake, 22 Vet. App. 111, 114 (2008). However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) . There is a three-step inquiry for determining whether a claimant is entitled to an extraschedular rating. Thun, 22 Vet. App. at 115. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Board must compare the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Id. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular evaluation is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors, such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a claimant's disability picture with such related factors as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Neither the Veteran nor his representative has expressly raised the matter of entitlement to an extraschedular rating with respect to the service-connected arthritis of the hips, knees, and/or ankles. The Veteran's contentions have been limited to those discussed above, i.e., that his disability is more severe than is reflected by the currently assigned schedular ratings. See Brannon v. West, 12 Vet. App. 32 (1998) (while the Board must interpret a claimant's submissions broadly, the Board is not required to conjure up issues that were not raised by the claimant). In this regard, the schedular criteria contemplate pain, limitation of motion, weakness, instability, and crepitation. In addition, the rating schedule contemplates excess fatigability and incoordination. In short, the Veteran does not have symptoms associated with arthritis of the hips, knees, or ankles that have been left uncompensated or unaccounted for by the assignment of a schedular rating. Thun, 22 Vet. App. at 115 .Accordingly, the evidence does not support the proposition that those disorders present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards. Accordingly, further action is not warranted under 38 C.F.R. § 3.321 (b)(1). ORDER Entitlement to service connection for a low back disorder is granted. For the period from August 31, 2000 through June 18, 2009, entitlement to an initial rating in excess of 10 percent for arthritis of the right hip is denied. Effective June 19, 2009, entitlement to a rating in excess of 20 percent for arthritis of the right hip is denied. Effective June 19, 2009, entitlement to a separate 20 percent rating for impairment of the right thigh is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to an initial rating in excess of 10 percent for arthritis of left hip. is denied. Effective June 19, 2009, entitlement to a separate 20 percent rating for impairment of the left thigh is granted, subject to the law and regulations governing the award of monetary benefits. For the period from August 31, 2000 through June 18, 2009, entitlement to an initial rating in excess of 10 percent for arthritis of the right knee is denied. Effective June 19, 2009, entitlement to a rating in excess of 20 percent for arthritis of the right knee is denied. For the period from August 31, 2000 through May 23, 2007, entitlement to an initial compensable rating for arthritis of the left knee is denied. Since May 24, 2007, a rating in excess of 10 percent for arthritis of the left knee is denied. For the period from August 31, 2000 through May 23, 2007, entitlement to an initial 10 percent rating is granted for arthritis of the right ankle, subject to the law and regulations governing the award of monetary benefits. For the period from May 24, 2007 through June 18, 2009, entitlement to a rating in excess of 10 percent is denied for arthritis of the right ankle. Since June 19, 2009, entitlement to a rating in excess of 20 percent is denied for arthritis of the right ankle. For the period from August 31, 2000 through May 23, 2007, entitlement to an initial 10 percent rating is granted for arthritis of the left ankle, subject to the law and regulations governing the award of monetary benefits. For the period from May 24, 2007 through June 18, 2009, entitlement to a rating in excess of 10 percent is denied for arthritis of the left ankle. Since June 19, 2009, entitlement to a rating in excess of 20 percent is denied for arthritis of the left ankle. REMAND In May 2009, the RO confirmed and continued the initial noncompensable rating for the Veteran's arthritis of the first metatarsal phalangeal joints of each foot. Later that month, the Veteran disagreed with those ratings. However, he was not issued a Statement of the Case. Since the Veteran submitted a timely notice of disagreement regarding the issue of entitlement to an increased rating for arthritis of the first metatarsal phalangeal joints of each foot, the Board is required to remand this issue to the RO for issuance of a Statement of the Case. See Manlincon v. West, 12 Vet. App. 238 (1999). The Veteran also seeks entitlement to special monthly compensation due to loss of use of both feet, loss of use of both buttocks, and on the basis of the need for the regular aid and attendance of another person. 38 U.S.C.A. § 1114 (West 2002); 38 C.F.R. §§ 3.350, 3.352 (2012). The foregoing decision granting entitlement to service connection for a low back disorder, could affect the outcome of those unresolved claims. Therefore, it would be premature for the Board to consider those claims prior to the RO, as such action could result in prejudice to those claims. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993); VAOPGCPREC 16-92. Accordingly, the case is REMANDED for the following actions to the RO through the Appeal Management Center in Washington, D.C.: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Issue a Statement of the Case concerning the claims of entitlement to initial compensable ratings for arthritis of the first metatarsal phalangeal joints of each foot. If, and only if, the Veteran completes his appeal by filing a timely substantive appeal on the aforementioned issues should they be returned to the Board. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.200, 202 (2012). 2. Undertake any indicated development, and then readjudicate the issues of entitlement to special monthly compensation due to loss of use of both feet, loss of use of both buttocks, and on the basis of the need for the regular aid and attendance of another person. If the benefits sought on appeal are not granted to the Veteran's satisfaction, he and his representative must be furnished a Supplemental Statement of the Case and afforded an opportunity to respond. Thereafter, if in order, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to the final disposition of any unresolved issue. The Veteran need take no action unless he is notified to do so. However, he is advised that he has the right to submit any additional evidence and/or argument on the matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369, 372-73 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ VITO A. CLEMENTI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs