Citation Nr: 1317401 Decision Date: 05/28/13 Archive Date: 06/06/13 DOCKET NO. 08-02 011 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease and patella femoral pain syndrome of the right knee. 2. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease and patella femoral pain syndrome of the left knee. 3. Entitlement to a compensable rating for bilateral pes planus, prior to February 22, 2013. 4. Entitlement to a rating in excess of 30 percent for bilateral pes planus, from February 22, 2013. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1981 to August 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2005 and January 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In the April 2005 rating decision, the RO granted service connection for degenerative joint disease and patella femoral pain syndrome of the right knee and of the left knee and evaluated the disabilities as 10 percent disabling each. In the January 2006 rating decision, the RO denied increased disability evaluations for the right and left knee disabilities and denied a compensable disability evaluation for the bilateral pes planus disability. As discussed in the January 2013 Board remand, in July 2005, within one year of the April 2005 rating decision, the Veteran submitted a statement requesting an increased disability evaluation for both the right and left knee disabilities and requested the RO obtain VA treatment records as medical evidence of the severity of the bilateral knee disabilities. The Board found that the provisions of 38 C.F.R. § 3.156(b) applied and the additional evidence was considered to have been filed with the initial claim pending at the beginning of the appeal period. As the April 2005 rating decision was therefore not yet final, the issues of entitlement to initial ratings greater than 10 percent for service-connected patellofemoral pain syndrome of the right and left knees remained on appeal. In September 2012, a Travel Board hearing was held before the undersigned Veterans Law Judge and a transcript of that hearing is of record. This case was previously before the Board and remanded in January 2013 for additional development. In a March 2013 rating decision, the VA Appeals Management Center (AMC) granted a higher rating of 30 percent effective February 22, 2013, for bilateral pes planus. The Court has held that a "decision awarding a higher rating, but less than the maximum available benefit . . . does not . . . abrogate the pending appeal . . . ." AB v. Brown, 6 Vet. App. 35, 38 (1993). As the rating decision did not grant the full benefits sought on appeal, the issue remains before the Board. For the reasons discussed below, the Board finds that there has been substantial compliance with the mandates of the January 2013 remand and will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACT 1. During the period on appeal, the Veteran's service-connected degenerative joint disease and patella femoral pain syndrome of the right knee has been manifested by flexion limited to no less than 90 degrees, full extension, and pain. 2. Prior to July 22, 2004, the Veteran's service-connected degenerative joint disease and patella femoral pain syndrome of the left knee was manifested by flexion limited to no less than 100 degrees, full extension, and pain. 3. From July 22, 2004, to December 23, 2004, the Veteran's service-connected degenerative joint disease and patella femoral pain syndrome of the left knee was manifested by flexion limited to no less than 80 degrees, extension limited to no less than 15 degrees, and pain. 4. From December 23, 2004, to March 10, 2005, the Veteran's service-connected degenerative joint disease and patella femoral pain syndrome of the left knee was manifested by flexion limited to no less than 80 degrees, extension limited to no less than 30 degrees and pain. 5. From March 10, 2005, the Veteran's service-connected degenerative joint disease and patella femoral pain syndrome of the left knee was manifested by flexion limited to no less than 95 degrees, full extension, and pain. 6. Prior to February 22, 2013, the Veteran's pes planus was manifested by pain on use of the feet bilaterally. 7. From February 22, 2013, the Veteran's pes planus is no more than severe, manifested by pain on use not relieved by arch supports, built up shoes or orthotics and marked pronation of both feet, and is not manifested by extreme tenderness of plantar surfaces of the feet, inward displacement or severe spasm of the tendo Achilles on manipulation. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 10 percent for degenerative joint disease and patella femoral pain syndrome of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Codes 5010, 5260, 5261 (2012). 2. Prior to July 22, 2004, the criteria for an initial evaluation in excess of 10 percent for degenerative joint disease and patella femoral pain syndrome of the left knee were not met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Codes 5010, 5260, 5261 (2012). 3. From July 22, 2004, to December 23, 2004, the criteria for entitlement to a staged initial rating of 20 percent, but no higher, for degenerative joint disease and patella femoral pain syndrome of the left knee were met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Codes 5010, 5260, 5261 (2012). 4. From December 23, 2004, to March 10, 2005, the criteria for entitlement to a staged initial rating of 40 percent, but no higher, for degenerative joint disease and patella femoral pain syndrome of the left knee were met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Codes 5010, 5260, 5261 (2012). 5. From March 10, 2005, the criteria for entitlement to a staged initial rating in excess of 10 percent for degenerative joint disease and patella femoral pain syndrome of the left knee are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Codes 5010, 5260, 5261 (2012). 6. Prior to February 22, 2013, the criteria for a rating of 10 percent, but no higher, for pes planus were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.71a, Diagnostic Code 5276 (2012). 7. From February 22, 2013, the criteria for a rating in excess of 30 percent for pes planus have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.71a, Diagnostic Code 5276 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). More specific notice is required in claims for increased compensation. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In regard to the claim for a higher rating for pes planus, prior to adjudication, appropriate notice was provided in a September 2005 letter. A letter addressing the assignment of a disability rating and/or effective date, in the event of award of the benefit sought was issued in March 2006. Dingess/Hartman, 19 Vet. App. at 490. In regard to the Veteran's claims for higher initial ratings for her right and left knee disabilities, the Veteran is appealing the initial rating assignment. Because the April 2005 rating decision granted the Veteran's claim of entitlement to service connection, such claim is now substantiated. Her filing of a notice of disagreement as to the initial rating assigned in the April 2005 determination does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3). Rather, the Veteran's appeal as to the initial rating assignment here triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. Under 38 U.S.C.A. § 7105(d), upon receipt of a notice of disagreement in response to a decision on a claim, the agency of original jurisdiction must take development or review action it deems proper under applicable regulations and issue a statement of the case if the action does not resolve the disagreement either by grant of the benefits sought or withdrawal of the notice of disagreement. If VA receives a notice of disagreement in response to notice of its decision on a claim that raises a new issue, section 7105(d) requires VA to take proper action and issue a statement of the case if the disagreement is not resolved; however, section 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate the newly raised issue. See VAOPGCPREC 8-03 (December 22, 2003); 69 Fed. Reg. 25180 (2004); 38 C.F.R. § 3.159(b)(3) (2012). As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here. The statement of the case (SOC), under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant diagnostic code (DC) for rating the disability at issue, and included a description of the rating formulas for all possible schedular ratings under this diagnostic code. The Veteran was thus informed of what was needed not only to achieve the next-higher schedular rating, but also to obtain all schedular ratings above the initial evaluation that the RO assigned. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher rating for the service-connected disabilities at issue. VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. In a February 2013 letter, the AMC requested that the Veteran complete enclosed VA 21-4142 consent forms so that VA could obtain private treatment records from Dr. P and Dr. C. The AMC also notified the Veteran that VA needed to obtain copies of any underlying medical evidenced or Office of Workers' Compensation Program (OWCP) with the State of Georgia pertaining to the worker's compensation claim filed by her. The Veteran did not respond to the letter. The Board finds that as the AMC requested the records, VA has satisfied its duty to assist in regard to these records in compliance with the January 2013 remand. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). VA provided the Veteran with appropriate VA examinations of the knees in June 1996, June 1999, October 2005, and March 2013. VA provided the Veteran with appropriate VA examinations of his service-connected pes planus in October 2005 and February 2013. The February 2013 and March 2013 VA examinations were obtained in compliance with the Board's January 2013 remand. The examinations are adequate, particularly the most recent examinations from March 2013, because they are based on a thorough examination, a description of the Veteran's pertinent medical history, and appropriate diagnostic tests, to include x-ray. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the Veteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). The Veteran has not reported receiving any recent treatment specifically for this condition and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disorders since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. The VA examination reports are thorough and provided findings pertinent to the rating criteria. The examinations in this case are adequate upon which to base a decision. III. Knee Claims Legal Criteria Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the appellant. Id. § 4.3. An appeal from the initial assignment of a disability rating, such as the appeals in this case, requires consideration of the entire time period involved, and contemplates staged ratings where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's knee disabilities are currently rated under Diagnostic Code 5010. Diagnostic Code 5010 provides that traumatic arthritis, due to trauma and substantiated by x-ray findings, is to be evaluated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. 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. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by the 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, a 10 percent rating is assigned when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is assigned when there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (2012). Under diagnostic code 5260, flexion limited to 60 degrees warrants a noncompensable rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Extension limited to 5 degrees warrants a noncompensable rating, to 10 degrees warrants a 10 percent rating, to 15 degrees warrants a 20 percent rating, to 20 degrees warrants a 30 percent rating, to 30 degrees warrants a 40 percent rating, and to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Slight recurrent subluxation or lateral instability warrants a 10 percent evaluation; moderate recurrent subluxation or lateral instability warrants a 20 percent evaluation; and severe recurrent subluxation or lateral instability warrants a 30 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words "slight," "moderate" and "severe" as used in 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). Instability of the knee and limitation of motion of the knee are two separate disabilities. As such, it is permissible to award separate ratings under both a range of motion code and an instability code, without violating the prohibition on pyramiding under 38 C.F.R. § 4.14. See VAOPGCPREC 23-97. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the 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 visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. As discussed above, the Veteran's claim is for higher initial ratings for his service-connected left and right knee disabilities. Service connection was granted effective September 1, 1995. As such, the rating period on appeal is from September 1, 1995. 38 C.F.R. § 3.400(o)(2) (2009). Analysis The Veteran was afforded a VA examination in June 1996. The Veteran reported that her knee joints occasionally became painful off and on, particularly the right knee joint. On examination, the knee joints showed no deformity or tenderness. Range of motion of the knee joints was within normal limits. The impression was right knee joint pain, probably mild arthralgia. An August 1996 VA treatment record reflects that the Veteran complained of intermediate pain in the right knee. On examination, there was swelling in the left knee. There was a good range of motion in both knees and the knees were stable. An August 1997 X-ray of the X-ray found no significant arthropathy. There was a question of subchondral bony fracture of the right patella, the radiologist noted that clinical correlation would be helpful. A February 1997 VA treatment record indicates that the Veteran complained of bilateral knee pain. The left knee was worse. There was a small amount of joint fluid. Range of motion was full. An April 1997 private treatment record reflects that the Veteran had acute arthralgia of the knees. A May 1997 VA treatment record indicates the Veteran had a provisional diagnosis of a torn medial meniscus of the left knee. A June 1997 VA treatment record reflects that the Veteran reported bilateral knee pain with the left greater than the right. She described constant pain with walking. On physical examination of the left knee there was small effusion, mild PF crepitus, positive medial joint line tenderness, ACL/PCL inst., positive medial McMurray's and a range of motion of 0 to 100. A June 1997 X-ray report of the left knee indicates that there was very minimal narrowing of the medial tibiofemoral joint space. A December 1997 VA treatment record indicates the Veteran complained of bilateral knee pain. On examination, there was no effusion. There was medial joint line tenderness on the left. Lachman and drawer tests were negative. Varus and valgus instability tests were negative but there was medial pain with valgus stress. McMcurray's test was positive. The diagnosis was left medial meniscus tear and left patellofemoral pain. A February 1998 VA treatment record reflects that the knees had good range of motion and were stable. The assessment was chondromalacia patella of the left knee. The Veteran was afforded another knee examination in June 1999. The Veteran reported that she did not use braces for support, or use a crutch or cane. On examination of both knees, there was no heat, no effusion, no erythema, no deformity, and no Baker's cyst. Both knees had a full range of motion. They extended from neutral and flexed to 120 plus degrees. There was a negative McMurray's and a negative drawer's sign bilaterally. There was no pain around the patella with patella manipulation. Radiographic examinations of both knees were unremarkable. An August 2000 VA treatment record reflects that the Veteran was issued a large patellar stabilization braced for the right knee as her brace had been lost. A February 2001 VA treatment record noted that the Veteran reported having constant knee pain when standing or walking. She reported she used a ten machine for the front of the knee but not on the back of the knee. A March 2002 X-ray report indicates the Veteran reported that the Veteran had chronic right knee pain and giving way. The X-ray study was negative. A September 2003 VA treatment record reflects that the Veteran reported having intermittent knee pain with no irradiation which was worse with walking. A January 2004 VA treatment record reflects that the Veteran appeared to favor bilateral legs with a slight limp. Range of motion was within full limits. An August 2004 private treatment record indicates the Veteran had left knee internal derangement with a suspected meniscal tear. She had significant tenderness in the medial and lateral posterior joint lines and mild underlying arthritis. She was limited in job activities and recreational activities. Symptoms were worse with climbing stairs and pivoting. On physical examination, she had a markedly antalgic gait. Mild effusion was present. There was normal coloration and normal range of motion on the right knee. The left knee had a range of motion of 15 to 80 degrees. The patella tracked normally. There was no varus or valgus or anterior or posterior instability. The Veteran did have some significant guarding. The right knee had no instability. She had normal muscle tone bilaterally. A September 2004 private treatment record noted that the physical exam was essentially unchanged from before with mild swelling. She received a steroid injection in the left knee. A December 2004 private treatment record reflects that the Veteran had range of motion of the left knee of 30 to 80 degrees with marked medial joint line tenderness. Her skin was intact over the knee. Mild swelling was present. Distally she was neurovascularly intact. Lachman was negative, but there was guarding present. There was no varus or valgus instability. The private physician stated that they would keep her out of work for a week unless they had sitting work only. A January 2005 private treatment record noted that they tried another injection that day and she was asked to return to work on Monday. A February 2005 private treatment record also noted that it was ok for her to work. An October 2004 MRI report of the right knee showed definite cartilaginous defect in the patellofemoral compartment. The remaining structures in the right knee were intact and there was no significant knee joint effusion. The findings were likely due to chondraomalacia patellae. A March 2005 private treatment record reflects that the Veteran had tenderness over the lateral joint line of the left knee and full extension. A March 2005 VA treatment record indicates that the Veteran reported that her left knee bothered her a lot when she walked or went up the stairs for the past 3 days. She described the pain in her left knee as sharp with movement. She reported that ibuprofen was not helping with the pain. An April 2005 follow-up private treatment record indicates that an MRI was consistent with foramen of the menisci and medial compartmental mild osteoarthrosis. The physician stated that they were going to try an injection in her knee. A June 2005 VA treatment record reflects that the Veteran reported she had problems with recurrent knee pain bilaterally, left worse than the right. A September 2005 VA treatment record noted that the Veteran wore knee braces. The Veteran was afforded another VA examination in October 2005. On examination, the bilateral knees had swelling with loss of normal curvature bilaterally. Extension was 0 bilaterally. Flexion was 120 degrees bilaterally. McMurray's test was positive bilaterally. There was evidence of weakness, pain, lack of endurance, fatigue and incoordination with repetition of three bilaterally. X-rays of the bilateral knees showed degenerative changes with patellofemoral syndrome, bilateral knees. The Veteran reported that she lost six months from work during the last year because of her knees. She noted that her job involved climbing 30 steps several times a day which increased pain and swelling in both knees. A November 2005 VA treatment record reflects that the Veteran reported having daily pain in the knees that was dull/sharp. An October 2005 VA X-ray report reflects that the Veteran had degenerative changes of both knees. In a January 2008 substantive appeal, the Veteran reported that she had additional limitations of motion in both of her knees as well as extreme pain and swelling. She stated that she was getting to the point that she could no longer do her job. At a VA examination in February 2007, the Veteran's gait was normal and she did not use assistive devices. A March 2008 VA treatment record noted that the Veteran reported she had swelling of the legs intermittently for months. Leg swelling was worse with standing. A September 2008 VA treatment record notes that the Veteran reported that her right knee was swollen and painful. She reported the pain radiated upward to the thigh. Another September 2008 VA treatment record noted that the Veteran had severe right knee pain after she twisted her knee seven days ago. There was some swelling. Pain was constant. The examiner could not do an exam because she complained of severe pain. A September 2008 VA treatment record noted that the Veteran had now progressed to developing degenerative arthritis. This progression was likely due to her weight. A January 2010 VA quote reflects that the Veteran was medically required to use knee braces (both knees). The note requested that the Veteran be allowed to use the braces while working. A March 2010 VA X-ray report indicates that the Veteran had mild bilateral tricompartmental osteoarthritis of the knees. An August 2010 VA treatment record reflects that the Veteran reported having numbness behind her left knee for the last 3 weeks. A September 2010 VA treatment record noted the Veteran continued to have problems with her knees and had bilateral osteoarthritis. At the September 2012 Travel Board hearing, the Veteran reported that she had a sharp pain in both of her knees upon movement, bending, standing, prolonged sitting and prolonged standing. (September 2012 Hearing Transcript (Tr.) at 2) She reported that she wore braces in both knees. The Veteran reported that she went to physical therapy once or twice a week. She also stated that her work environment had become a little bit more hostile lately due to her disabilities. (Tr. at 5) She stated that she had restrictions at work due to her knees and back. (Tr. at 6) An October 2012 VA treatment record reflects that the Veteran's knee was examined in the pain clinic and there was no evidence of internal instability or drawer signs. The note indicated the Veteran was referred to aquatherapy for her knees and back. An October 2012 X-ray report reflects that both knees showed three compartment osteoarthritis. The most advanced athropathy was in the left patellofemoral compartment, and the patellofemoral disease also predominated on the right. A November 2012 VA treatment note reflects that the Veteran stated that she had persistent pain in the knees. A January 2013 VA treatment record reflects that the Veteran had an antalgic gait. The knees had no effusion and a tender medial joint line. The Veteran was afforded a VA examination in March 2013. The diagnosis was mild to moderate degenerative joint disease in both knees. The Veteran did not report that flare-ups impacted the function of the knees. On examination, the right knee had flexion ending at 90 degrees with objective evidence of painful motion beginning at 90 degrees. Extension of the right knee was 0 degrees. The Veteran had left knee flexion of 95 degrees with objective evidence of painful motion beginning at 95 degrees. The left knee had extension of 0 degrees. The Veteran was able to perform repetitive use testing with 3 repetitions. The Veteran had right knee post-test flexion of 0 degrees and 0 degrees of extension. The Veteran had left knee post-test flexion of 90 degrees and extension of 0 degrees. The Veteran had additional limitation in range of motion of the knee and lower leg following repetitive-use testing. The Veteran did not have functional loss and/or functional impairment of the knee and lower leg. The Veteran had less movement than normal in the left knee, excess fatigability in both knees, and pain on movement in both knees. The Veteran had pain to palpation for joint line or soft tissues of both knees. The Veteran had normal strength in both knees of 5/5 on flexion and extension. Joint stability was normal in both knees based on anterior, posterior and medial-lateral instability testing. There was no patellar subluxation/dislocation. The Veteran did not have shin splints or meniscal conditions. There were no scars related to the disabilities. The Veteran used a brace regularly. A February 2013 X-ray indicated there was no acute fracture or dislocation in the knee joints. There was mild to moderate degenerative joint disease, most advanced in the medial compartment, greater on the right, advanced since 2005. The Board finds that the above evidence of record is against a finding that the Veteran is entitled to an initial rating in excess of 10 percent for her right knee. As noted above, the Veteran's knees are rated under Diagnostic Code 5010. The evidence of record reflects that the right knee had extension of the knee limited to no more than 0 degrees and flexion of the knee limited to no more than 90 degrees, including due to pain and after repetitive use. The June 1996 and June 1999 VA examinations, and the August 1996, February 1997 and February 1998 VA treatment records indicated the Veteran had a full or good range of motion of both knees. The June 1997 VA treatment record reflected that the Veteran had bilateral range of motion of 0 to 100. The June 1999 VA examiner noted that both knees extended from neutral and flexed to 120 plus degrees. The August 2004 private treatment record indicated the Veteran had a normal range of motion in the right knee. The October 2005 VA examination report indicated that the Veteran had extension of 0 degrees and flexion of 120 degrees in both knees. At the March 2013 VA examination, the Veteran had right knee flexion of 90 degrees and extension of 0 degrees. The Veteran had post-test flexion of 90 degrees in both knees and 0 degrees extension. As the evidence of record does not reflect that the Veteran had right knee flexion limited to 60 degrees or extension limited to 5 degrees or more, a compensable rating is not warranted under Diagnostic Codes 5260 and 5261 for limitation of motion of the right knee. In regard to the Veteran's left knee, as noted above, she generally had full or good range of motion throughout the rating period on appeal. However, the August 2004 private treatment record noted that the Veteran's left knee had a range of motion of 15 to 80 degrees. A March 2005 private treatment record noted that the Veteran had full extension of the left knee. At the March 2013 VA examination, the Veteran had left knee flexion of 95 degrees and extension of 0 degrees, and post-test left knee flexion of 90 degrees and 0 degrees extension. The evidence of record reflects that the left knee did not have flexion limited to 60 degrees, which would warrant a noncompensable rating. The August 2004 private treatment record indicates the Veteran had extension limited to 15 degrees, which warrants a 20 percent rating under Diagnostic Code 5261. The Veteran reported that the symptoms of pain and loss of motion of her knee started on July 22nd. As the Veteran's statements are consistent with the August 2004 private treatment record, the Board finds them to be credible. The Veteran is competent to report symptoms capable of lay observation such as limited motion and pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The December 2004 private treatment record reflects that the Veteran had range of motion of the left knee of 30 to 80 degrees. Extension limited to 30 degrees warrants a 40 percent rating under Diagnostic Code 5261. The next available range of motion test result reflects that the Veteran had full extension of the left knee in March 2005, which would not warrant a compensable rating under Diagnostic Code 5261. Similarly, at the March 2013 VA examination, the Veteran had full extension of the left knee. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). As the evidence reflects that the Veteran had left knee extension limited to 15 degrees in August 2004, the Board finds that a staged initial rating of 20 percent is warranted for the left knee from July 22, 2004, to December 23, 2004, and a staged initial rating of 40 percent from December 23, 2004 to March 10, 2005. The dates reflect the date the Veteran stated that the loss of motion of the left knee began that was shown objectively in the August 2004 private treatment record, and the dates of the private treatment records from December 2004 and March 2005. However, as the Veteran had normal extension of the left knee during the rest of the period on appeal, a higher rating is not warranted for those periods under Diagnostic Code 5261 for limited extension. The Board has considered whether the Veteran is entitled to a higher rating under DeLuca due to functional impairment. See 38 C.F.R. §§ 4.40, 4.45 and 4.59 (2012). The Veteran has consistently reported pain in both knees on motion. The Board finds her statements to be consistent with the evidence of record and thus credible. The October 2005 VA examination report also indicated that the Veteran had evidence of weakness, pain, lack of endurance, fatigue and incoordination with repetitions of three, bilaterally. The report did not note whether there was loss of range of motion following repetition. However, the Board finds that the evidence of record does not reflect that, aside from the period from July 2004 to March 2005 in the left knee, that the Veteran had motion limited to a compensable degree due to painful motion, weakened movement, or excess fatigability. At the March 2013 VA examination, the Veteran specifically denied having flare-ups that impacted the function of the knees. The VA examiner found the Veteran was able to perform repetitive use testing with 3 repetitions. The Veteran's post-test range of motion test results in the right knee were the same as the first range of motion result. The Veteran had post-test left knee flexion that was limited to 90 degrees, which was 5 degrees worse than the original result of 95 degrees flexion. Extension of the left knee was the same post-test. The Veteran did not have functional loss and/or functional impairment of the knee and lower leg. The Veteran reported having pain on motion of both knees throughout the period on appeal. However, the Veteran is already rated as 10 percent disabling in each knee under Diagnostic Code 5010 for limitation of motion due to painful motion. Consequently, the Board finds that a higher rating is not warranted under DeLuca for additional functional impairment due to painful motion, weakened movement, or excess fatigability. As noted above, the knee may also be rated separately for instability. The Veteran asserted that she had instability of the knee several times during the period on appeal. See e.g. March 2000 VA X-ray report. She also consistently wore a knee brace. However, there was no objective evidence of instability or subluxation. The December 1997 VA treatment record indicated varus and valgus instability tests were negative. The February 1998 VA treatment record noted that the knees were stable. The August 2004 private treatment record noted that on examination there was no varus, valgus, anterior or posterior instability in the left knee. The right knee also had no instability. The December 2004 private treatment record also noted that there was no varus or valgus instability of the knee. The January 2010 VA record noted the Veteran was medically required to use knee braces. The October 2010 VA treatment record indicated that there was no evidence of internal instability or drawer signs in the knees. The March 2013 VA examination report also noted that joint stability was normal in both knees and there was no patellar subluxation/dislocation. As noted above, the Veteran is competent to report symptoms capable of lay observation such as instability or giving way and the Board generally finds her statements to be credible. However, the objective evidence of record consistently showed the Veteran's knees did not have instability or subluxation. Additionally, the Veteran did not consistently report symptoms of instability. The Board finds the objective evidence of record to be more probative than the Veteran's statements. The Board has considered whether the Veteran is entitled to a higher rating in either knee under another Diagnostic Code. The Veteran's knee has a range of motion and no clinical evidence of atrophy, thus a rating under Diagnostic Code 5256 for ankylosis is not warranted. The evidence does not reflect the Veteran had dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion in the joint . Thus, a higher rating is not warranted under Diagnostic Code 5258. As the Veteran's knee disabilities are already rated as 10 percent disabling and the maximum ratings under Diagnostic Codes 5259 and 5263 is 10 percent, those Diagnostic Codes are not applicable. The evidence does not reflect that there is malunion of the tibia and fibula with moderate knee disability. Thus, a higher rating is not warranted under Diagnostic Code 5262. Finally, there is no evidence the Veteran has a scar related to his service-connected left and right knee disabilities. Thus, a separate rating is not warranted for a scar. The Board has considered whether extraschedular consideration is warranted based on the evidence of functional, including occupational, impairment secondary to the right and left knee disabilities. See Barringer v. Peake, 22 Vet. App. 242 (2008). The discussion above reflects that the symptoms of the Veteran's right and left knee disabilities are contemplated by the applicable rating criteria. The competent medical evidence of record shows that the right and left knee disabilities are primarily manifested by pain and some limitation of motion. The applicable diagnostic codes used to rate the Veteran's disability provide for ratings based on limitation of motion, and the effects of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). TDIU is an element of all appeals for an increased evaluation. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, however, TDIU consideration is not warranted. The Veteran has not contended and the evidence does not indicate that the Veteran is unemployable as a result of her right and left knee disabilities. Although the Veteran reported losing time at work in the October 2005 VA examination due to her knees, the evidence of record reflects that the Veteran had a full-time job during the period on appeal. In conclusion, the Board finds that the evidence is against a finding that the Veteran is entitled to a rating greater than 10 percent for service-connected degenerative changes and patellofemoral pain syndrome of the right knee during the period on appeal. The Board finds that the evidence is against a rating greater than 10 percent for service-connected degenerative changes and patellofemoral pain in the left knee prior to July 22, 2004. The Board finds that the evidence supports a staged initial rating of 20 percent for the left knee disability from July 22, 2004, to December 23, 2004. The Board finds that a staged initial rating of 40 percent for the left knee from December 23, 2004, to March 10, 2005, is warranted. From March 10, 2005, the Board finds that the evidence is against a finding that the Veteran is entitled to a rating greater than 10 percent for her left knee disability. IV. Pes Planus Legal Criteria Disability evaluations are determined by comparing a veteran's present symptomatology with the criteria set forth in the Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 4.1 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the appellant. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Nevertheless, where, as here, the appellant is appealing the rating for an already established service-connected condition, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's bilateral pes planus is currently evaluated under Diagnostic Code 5276. Under Diagnostic Code 5276. Under that diagnostic code, a noncompensable rating is warranted for mild symptoms relieved by built-up shoe or arch support. A 10 percent rating is warranted for moderate; weight-bearing line over or medial to great toe, inward bowing of the tendon Achilles, pain on manipulation and use of the feet, bilateral or unilateral. For severe objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, unilateral flatfoot warrants a 20 percent rating and bilateral flatfoot warrants a 30 percent rating. For pronounced bilateral flatfoot disability, demonstrating marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances, a 30 percent rating is warranted for unilateral flatfoot and a 50 percent raging is warranted for bilateral flatfoot. 3 8 C.F.R. § 4.71a, Diagnostic Code 5276 (2012). The Board observes that the words "marked," "severe" and "pronounced" as used in the various diagnostic codes are not defined in VA's 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. The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). However, because Diagnostic Code 5276 is not predicated on a limited range of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 do not apply. Johnson v. Brown, 9 Vet. App. 7 (1996). It is now well settled that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The medical evidence of record shows that the Veteran's disabilities of the feet encompass bilateral pes planus and degenerative joint disease of the feet. Symptomatology for each separate foot disability has not been delineated in the medical reports. Hence, the Board will consider all of the Veteran's symptomatology in conjunction with his claim for an increased rating. Prior to February 22, 2013 The Veteran's claim for an increased evaluation was received on July 14, 2005. As such, the rating period on appeal is July 14, 2004. 38 C.F.R. § 3.400(o)(2) (2012). The Veteran was afforded a VA examination in October 2005. The Veteran complained of pain in both feet with walking more than 50 yards. She used supports in shoes which helped. She had early morning stiffness and no swelling. The condition did not interfere with conditions of daily living. She had increased pain at work due to her feet. On examination, her gait was steady. Her feet had no swelling bilaterally. Inversion was 0 to 30 degrees bilaterally. Eversion was 0 to 20 degrees bilaterally. Ankle dorsiflexion was 0 to 20 degrees bilaterally. Plantar flexion was 0 to 45 degrees bilaterally. The results indicated a normal range of motion. The assessment was bilateral mild pes planus. She had good range of motion, both passive and active, against resistance and gravity, bilaterally. There were no callosities or breakdown bilaterally. The skin was warm and dry bilaterally. The Achilles tendon had normal alignment with weight bearing and non-weight bearing, bilaterally. There was no pain, weakness, fatigue, lack or endurance or incoordination with repetition of five bilaterally. An X-ray showed degenerative/arthritic changes which appeared to have slightly increased compared to the previous examination of 1999. The assessment was mild pes planus bilaterally. A June 2005 VA podiatry note reflects that the Veteran reported pain in both feet. She stated that she had experienced the pain for several months and it was getting worse. She stated that she was on her feet all day long. On examination, neurovascular was within normal limits. There was no gross orthopedic deficiency. There were no skin lesions. Pain to palpation across metatarsal heads bilaterally. Her feet were molded for orthotics. A June 2006 X-ray of the feet found there was degenerative change in the navicular-medial cuneiform articulation and small calcaneal spurs. A June 2006 VA treatment note noted that the Veteran had osteoarthritis of her feet. The physician stated that there was nothing more she could offer her since she was already taking NSAIDS and had inserts. Another June 2006 VA treatment record from a general evaluation noted that the feet had no swelling and normal arches bilaterally. There was minimal tenderness on the left foot. A June 2006 ankle X-ray report found the Veteran's ankles had osteoarthritis. A July 2006 VA treatment record noted that the Veteran reported that foot pain was always present. A June 2007 VA treatment record noted that the Veteran had foot cellulitis and foot lymphangitis. She reported having sharp foot pains on the top of her feet and they were swollen. In another note, the Veteran reported her feet problems were interfering with her ability to work. An August 2007 VA treatment record reflects that the Veteran reported having pain in the mid and distal parts of both feet for months. She reported that she was on her feet all day and the pain was worse with walking and standing. There was no change in pain. A November 2008 VA treatment record reflects that the Veteran reported that she took Darvocet for chronic foot pain, but the pain was not being controlled. She described the pain as moderate to severe. A February 2012 VA treatment record notes that the Veteran stated her feet were hurting across the top and bothering her a lot. She took Tylenol #3 and Topiromate with no relief. On examination of the feet, she appeared to be in some discomfort when she ambulated. Her feet had no redness or swelling. She denied any recent injury. A September 2012 VA treatment record notes that the Veteran asked for new inserts for her shoes due to painful feet. She also asked for physical therapy for her ankles. At the February 2013 hearing, the Veteran reported that she had shooting pain in her feet whenever she walked, especially prolonged walking. She noted that she walked on concrete because she worked at an old prison. She stated that she tried to compensate by walking on the sides of her feet. (Tr. at 8) In a February 2013 VA treatment note addendum, dated prior to February 22, the Veteran noted that she had new pain in her feet in her Achilles tendons. Based on the evidence of record prior to February 22, 2013, the Board finds that a 10 percent rating is warranted, prior to February 22, 2013. As noted above, a 10 percent rating is assigned for moderate symptoms including pain on manipulation and use of the feet. A noncompensable rating is warranted for mild symptoms relieved by built-up shoe or arch support. Throughout the rating period on appeal, the Veteran consistently report having pain on use of her feet. At the October 2005 VA examination, the Veteran complained of pain in both feet when walking more than 50 yards. The June 2005 VA podiatry note indicated the Veteran had pain to palpation across metatarsal heads bilaterally. The June 2006 VA treatment record noted that there was minimal tenderness on the left foot. The June 2006, June 2007 and August 2007 VA treatment records also reflect that the Veteran reported having pain. The November 2008 VA treatment record noted that the Veteran reported taking Darvocet for chronic foot pain but the pain was not being controlled. On examination in February 2012, the Veteran appeared to have some discomfort when she ambulated. She also reported that the medication she took for pain gave no relief. The September 2012 VA treatment record noted that the Veteran asked for new inserts for her shoes due to painful feet. She reported shooting pain in her feet whenever she walked at the February 2013 hearing. As a lay person, the Veteran is competent to report symptoms of pain. As the Veteran consistently reported symptoms of pain on walking throughout the rating period on appeal, the Board finds her statements to be credible. As her statements are competent and credible, they are probative. The Veteran did not indicate that her symptoms were relieved by arch support. Based on the Veteran's reports of pain on use of her foot and resolving the evidence in her favor, the Board finds that a higher rating of 10 percent for moderate symptoms of pes planus is warranted, prior to February 22, 2013. The Board finds that a rating in excess of 10 percent is not warranted. The October 2005 VA examination report indicated that on examination, the Veteran's feet did not have pain, weakness, fatigue, lack or endurance or incoordination with repetition of five bilaterally. The Veteran had a good range of motion and her gait was steady. The VA examiner evaluated the condition as mild. The June 2006 VA treatment record noted the Veteran had normal arches bilaterally and minimal tenderness on the left foot. The February 2012 VA treatment record noted that on examination, the feet had no redness or swelling. Thus, the overall evidence does not reflect that the Veteran had severe or pronounced symptoms of flatfoot, prior to February 22, 2013. As noted above, as 38 C.F.R. §§ 4.40 and 4.45 relate to functional loss due to pain, they do not apply when a Diagnostic Code, such as Diagnostic Code 5276, is not predicated on loss of range of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). However, even if they did apply, the Veteran would not be entitled to a higher rating for functional loss due to pain. Pain is a listed criterion for DC 5276, and the record does not otherwise point to the existence of functional loss due to pes planus to a degree warranting an increase at any time beyond the 10 percent level. The grant of a 10 percent rating is primarily based upon the Veteran's reports of pain in her feet on use. The pain she experiences due to her bilateral pes planus is adequately accounted for in her currently assigned disability evaluation. As such, an increased rating pursuant to 38 C.F.R. §§ 4.40, 4.45 is not for application in this case, including on use. See 38 C.F.R. 4.40, 4.45; DeLuca, 8 Vet. App. at 202. The Board has considered whether the Veteran is entitled to a higher rating under another Diagnostic Code. However, the Veteran did not have symptoms of weak foot, claw foot, metatarsalgia, hallux valgus, hallux rigidus, hammer toe, malunion or nonunion of the tarsal or metatarsal bones, or other foot injuries. Thus, Diagnostic Codes 5277, 5278, 5279, 5280, 5281, 5282, 5283, and 5284 are not applicable. The February 2013 VA examiner found the Veteran had degenerative joint disease in her feet. However, under Diagnostic Code 5003, degenerative arthritis is rated on the basis of limitation of motion. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate Diagnostic Codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. The evidence does not reflect that the Veteran had limitation of motion of the foot due to degenerative joint disease. The October 2005 VA examination report results reflected that the Veteran's dorsiflexion was 0 to 20 and ankle plantar flexion was 0 to 45 degrees bilaterally, indicating a normal range of motion. Thus, the Veteran is not entitled to a rating in excess of 10 percent under Diagnostic Code 5003. In sum, the Board finds that a higher rating of 10 percent, but no higher is warranted for her service-connected bilateral pes planus, prior to February 22, 2013. From February 22, 2013 The Veteran's feet were evaluated at a VA examination in February 2013. The VA examiner found the Veteran had a diagnosis of bilateral pes planus. The Veteran had pain on use in both feet. She did not have pain on manipulation of the feet and there was no indication of swelling on use. The Veteran did not have characteristic calluses or any calluses caused by the flatfoot condition. The Veteran's symptoms were not relieved by arch supports or built up shoes or orthotics. The Veteran did not have extreme tenderness of the plantar surface of one or both feet. The Veteran had decreased longitudinal arch height on weight-bearing bilaterally. There was objective evidence of marked deformity of both feet. There was marked pronation of both feet. The condition was not improved by orthopedic shoes or appliances. The weight-bearing line did not fall over or medial to the great toe. There was no lower extremity deformity other than pes planus causing alteration of the weight bearing line. The Veteran did not have "inward" bowing of the Achilles' tendon. The Veteran did not have marked inward displacement and severe spasm of the Achilles tendon on manipulation. The Veteran did not have any scars related to any conditions or the treatment of any conditions. The VA examiner found that due to the Veteran's condition, there was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. There was X-ray evidence of arthritis in both feet. The VA examiner found the Veteran's flatfoot condition did not impact her ability to work. The impression was no acute fracture or dislocation in the foot, bilaterally, mild degenerative joint disease, a slight loss in height of the plantar longitudinal arch, tiny plantar calcaneal spurs and calcific enthesopathy. The Board finds that from February 22, 2013, a rating in excess of 30 percent is not warranted. As noted above, a 50 percent rating requires pronounced symptoms of marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances. At the February 2013 VA examination, the Veteran did not have pain on manipulation of the feet and there was no indication of swelling on use. The February 2013 VA examination report reflects that the Veteran's primary symptoms were pain on use in both feet and pronation of the feet which was not improved by orthopedic shoes or appliances. The Board finds that although the Veteran has serious symptoms of flatfeet, the symptoms are not pronounced. At the February 2013 VA examination, the Veteran did not have marked inward displacement and severe spasm of the Achilles tendon on manipulation. The Veteran also did not have characteristic calluses or any calluses caused by the flatfoot condition or extreme tenderness of the plantar surface of one or both feet. On examination, the Veteran did not have pain on manipulation of the feet. The VA examiner found the Veteran had mild degenerative joint disease and a slight loss in height of the plantar longitudinal arch. The Board finds that these diagnoses are consistent with severe, but not pronounced symptoms of flatfoot, warranting a rating no higher than 30 percent. As discussed above, even if the criteria of DeLuca did apply, pain is a listed criterion for DC 5276, and the record does not otherwise point to the existence of functional loss due to pes planus to a degree warranting an increase at any time beyond the 30 percent level. There was no evidence pain on manipulation in either foot in the February 2013 VA examination. The pain she experiences due to her bilateral pes planus is adequately accounted for in her currently assigned disability evaluation. As such, an increased rating pursuant to 38 C.F.R. §§ 4.40, 4.45 is not for application in this case, including on use. See 38 C.F.R. 4.40, 4.45; DeLuca, 8 Vet. App. at 202. Consequently, the Board concludes that the clinical findings do not more closely approximate symptoms compatible with a finding of pronounced disability. Hence, a 50 percent rating may not be assigned at any time during the appeal period. The Board has considered whether the Veteran is entitled to a higher rating under another Diagnostic Code. Diagnostic Code 5278 provides for a 50 percent rating for acquired claw foot (pes cavus). However, the evidence of record does not reflect that the Veteran has been diagnosed with pes cavus or has marked contraction of plantar fascia with dropped forefoot. Consequently, a higher rating is not warranted under that Diagnostic Code. No other Diagnostic Code relating to the foot provides for a rating in excess of 30 percent. Additionally, the Veteran had degenerative joint disease of the feet. Degenerative arthritis is rated on the basis of limitation of motion for the feet, which has not been shown in the case at bar. Moreover, the maximum available in the absence of limitation of motion is 20 percent for involvement of two or more major joint or minor joints. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Thus, the Veteran is not entitled to a higher rating under Diagnostic Code 5003. In reaching its decision, the Board has considered the Veteran's statements regarding her pain and functional limitations. The Board finds that the Veteran is competent to report that she has pain and to observe and report any functional limitations. The Board finds the Veteran's statements regarding her symptoms, including pain, are credible. However, the Board finds that the pain and functional impairment reported, consistent with the documented symptoms, do not warrant a higher rating. On examination in February 2013, the Veteran did not report having pain on manipulation of her feet or extreme tenderness of the plantar surface of one or both feet. For these reasons, the Board finds that the preponderance of the evidence is against the claim for an initial rating higher than 30 percent for pes planus. 38 U.S.C.A. § 5107(b). Other Considerations The Board has considered whether extraschedular consideration is warranted based on the evidence of functional, including occupational, impairment secondary to the right and left knee disabilities. See Barringer v. Peake, 22 Vet. App. 242 (2008). The discussion above reflects that the symptoms of the bilateral pes planus is contemplated by the applicable rating criteria. The competent medical evidence of record shows that the bilateral pes planus is primarily manifested by pain, including pain on use. The effects of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). TDIU is an element of all appeals for an increased evaluation. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, however, TDIU consideration is not warranted. The Veteran has not contended and the evidence does not indicate that the Veteran is unemployable as a result of her right and left knee disabilities. The March 2013 VA examiner found that the Veteran's flatfoot condition did not impact her ability to work. ORDER Entitlement to an initial rating in excess of 10 percent for degenerative joint disease and patella femoral pain syndrome of the right knee is denied. Entitlement to a staged initial rating in excess of 10 percent for degenerative joint disease and patella femoral pain syndrome of the left knee, prior to July 22, 2004 is denied. Entitlement to a staged initial rating of 20 percent for degenerative joint disease and patella femoral pain syndrome of the left knee is granted, from July 22, 2004, to December 23, 2004. Entitlement to a staged initial rating of 40 percent for degenerative joint disease and patella femoral pain syndrome of the left knee is granted, from December 23, 2004, to March 10, 2005. Entitlement to a staged initial rating in excess of 10 percent for degenerative joint disease and patella femoral pain syndrome of the left knee is denied, from March 10, 2005. Entitlement to 10 percent rating, but no higher, for bilateral pes planus, prior to February 22, 2013, is granted. Entitlement to a rating in excess of 30 percent for bilateral pes planus, from February 22, 2013, is denied. ____________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs