Citation Nr: 1318019 Decision Date: 06/03/13 Archive Date: 06/11/13 DOCKET NO. 08-35 689 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a left knee disability, to include as secondary to service-connected disabilities of degenerative joint disease of the right knee and bilateral pes planus with plantar fasciitis. 2. Entitlement to service connection for a bilateral leg disability (claimed as leg pain), to include as secondary to service-connected disabilities of degenerative joint disease of the right knee and bilateral pes planus with plantar fasciitis. 3. Entitlement to a rating in excess of 30 percent for bilateral pes planus with plantar fasciitis prior to February 22, 2011, and to a rating in excess of 50 percent thereafter. 4. Entitlement to a rating in excess of 10 percent for lumbar strain prior to March 1, 2010, and to a rating in excess of 20 thereafter. 5. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the right knee (excluding period(s) of temporary total evaluation(s)). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD John Kitlas, Counsel INTRODUCTION The Veteran served on active duty from June 1987 to September 1999. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a May 2007 decision by the Department of Veterans Affairs (VA) Regional Office (RO) which denied secondary service connection for a bilateral leg disability (claimed as leg pain) and a left knee disability, and denied increased ratings for the Veteran's low back, bilateral foot, and right knee disabilities; each rated 10 percent disabling. Following the May 2007 rating decision, the RO assigned a temporary total rating for the right knee by an October 2008 rating decision, effective from July 16, 2008, with the 10 percent rating resumed effective September 1, 2008. By a May 2010 rating decision, the RO assigned an increased rating to 20 percent for the low back disability; effective from March 1, 2010 (date of VA examination). Thereafter, by an April 2012 rating decision, the Appeals Management Center (AMC) in Washington, D.C., assigned a 30 percent rating for the service-connected bilateral pes planus with plantar fasciitis effective from October 26, 2006 (date of claim), and a 50 percent rating from February 22, 2011 (date of VA examination). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in November 2010. A transcript of this hearing has been associated with the Veteran's VA claims folder. This case was previously before the Board in January 2011 and October 2012. In January 2011, the Board denied service connection for left knee and bilateral leg disabilities and remanded the increased rating claims for additional development to include new VA examinations to evaluate the current nature and severity of these disabilities. Thereafter, the Veteran appealed the Board's decision regarding his left knee and bilateral leg disabilities to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a January 2012 joint motion for remand (JMR), the Court vacated the Board's decision with respect to the left knee and bilateral leg disabilities, and remanded the matter for compliance with the terms of the JMR. In October 2012, the Board remanded the case for further development to include obtaining additional records, and according the Veteran a VA medical examination to address the service connection claims. In this case, the record reflects the Veteran was accorded new VA examinations of his service-connected bilateral pes planus with plantar fasciitis, lumbar strain, and right knee in February 2011. He was also accorded a VA medical examination regarding his service connection claims in November 2012. As detailed below, the Board finds that these examinations are adequate for adjudication of the appellate claims. All other development directed by the Board's remands in this case appear to have been substantially accomplished. Therefore, a new remand is not required in order to comply with the holding of Stegall v. West, 11 Vet. App. 268 (1998). See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (Remand not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACT 1. The preponderance of the competent medical and other evidence of record is against a finding that the Veteran developed a chronic left knee disorder as a result of his active service, or as secondary to a service-connected disability. 2. The preponderance of the competent medical and other evidence of record is against a finding that the Veteran developed a chronic bilateral leg disorder as a result of his active service, or as secondary to a service-connected disability. 3. Prior to February 22, 2011, the Veteran's service-connected bilateral pes planus with plantar fasciitis was not manifested by pronounced symptomatology to include marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement or severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 4. For the period from February 22, 2011, the Veteran has been in receipt of the maximum schedular rating assigned for bilateral pes planus. 5. Prior to March 1, 2010, the Veteran's service-connected lumbar strain was not manifested by forward flexion of the thoracolumbar spine of 60 degrees or less; combined range of motion of the thoracolumbar spine of 120 degrees or less; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 6. For the period from March 1, 2010, the Veteran's service-connected lumbar spine was not manifested by forward flexion of the thoracolumbar spine of 30 degrees or less. 7. The Veteran's service-connected lumbar spine has not been manifested by ankylosis, incapacitating episodes as defined by VA regulations, or associated neurologic impairment at any time during the pendency of this case. 8. Excluding the period(s) of temporary total evaluation(s), the Veteran's service-connected right knee is not manifested by flexion limited to 30 degrees or less, impairment of extension, or recurrent subluxation or lateral instability. CONCLUSIONS OF LAW 1. The criteria for a grant of service connection for a chronic left knee disorder are not met, to include as secondary to a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. The criteria for a grant of service connection for a chronic bilateral leg disorder are not met, to include as secondary to a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.310 (2012). 3. The criteria for a rating in excess of 30 percent for bilateral pes planus prior to February 22, 2011, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012);38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2012). 4. The criteria for a rating in excess of 50 percent for bilateral pes planus from February 22, 2011, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276 (2012). 5. The criteria for a rating in excess of 10 percent for lumbar strain prior to March 1, 2010, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2012). 6. The criteria for a rating in excess of 20 percent for lumbar strain since March 1, 2010, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2012). 7. The criteria for a rating in excess of 10 percent for degenerative joint disease of the right knee (excluding period(s) of temporary total evaluation(s)) are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Board notes at the outset that, in accord with the Veterans Claims Assistance Act of 2000 (VCAA), VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The Court has indicated that VCAA notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA must provide a claimant VCAA notice before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Dingess/Hartman, supra; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran was sent pre-adjudication notice via a letter dated in January 2007, which is clearly prior to the May 2007 rating decision that is the subject of this appeal. He was also sent additional notification via letters dated in June 2008 and October 2012, followed by readjudication of the appeal by the October 2008 Statement of the Case (SOC) and various Supplemental SOCs, with the most recent being in March 2013. In pertinent part, the aforementioned VCAA letters informed the Veteran of what was necessary to substantiate his current appellate claims, what information and evidence he must submit, what information and evidence will be obtained by VA, as well as the information used by VA to determine disability rating(s) and effective date(s). The June 2008 letter also included the specific schedular criteria used to evaluate the service-connected disabilities that are the subject of this case. Consequently, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claims and the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. In any event, the Veteran has not demonstrated any prejudice with regard to the content or timing of any notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). In addition, the Board finds that the duty to assist a claimant in the development of his case has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records. Further, the Veteran has had the opportunity to present evidence and argument in support of his claims, to include at the November 2010 Board hearing. Nothing indicates he has identified the existence of any relevant evidence that has not been obtained or requested. For example, he has not identified outstanding evidence which relates the etiology of his current left knee disorder to service or as secondary to a service-connected disability. Also, he has not identified outstanding evidence documenting symptoms of his service-connected pes planus, lumbar strain, and right knee that are not reflected by the evidence already of record. With respect to the November 2010 hearing, the Board is cognizant of the fact that the Court held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, the VLJ accurately noted the current appellate claims at the November 2010 hearing, and asked questions to clarify the Veteran's contentions and treatment history. Although the VLJ did not specifically note the bases of the prior determinations or the elements that were lacking to substantiate the Veteran's appellate claims, the Veteran, through his testimony and other statements of record, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has he identified any prejudice in the conduct of this hearing. As such, the Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. 3.103(c)(2) have been satisfied. The Board further notes that the Veteran was accorded VA medical examinations regarding this case in February 2007, March 2010, February 2011 and November 2012 which included relevant findings regarding the symptomatology of the service-connected pes planus, lumbosacral strain, and right knee. In addition, VA examinations in March 2010 and November 2012 (with a January 2013 supplemental opinion) included opinions that addressed the etiology of the claimed left knee and bilateral leg disorders. As these opinions were based upon both a medical evaluation of the Veteran, and an accurate understanding of his medical history based upon review of his VA claims folder, the Board finds they are supported by an adequate foundation. The Board also notes that these examiners provided rationale in support of their opinions that dealt with all theories of entitlement. No competent medical evidence is of record which specifically refutes the findings of these VA examiners. Moreover, the Veteran has not identified any inaccuracies or prejudice with respect to these examinations, or that any of his service-connected disabilities have increased in severity since the most recent examination thereof. Accordingly, the Board finds that these examinations are adequate for resolution of this case. The Board also observes that the January 2012 JMR contended, in essence, that as the Veteran was claiming he had a left knee and bilateral leg disabilities secondary to the service-connected right knee and pes planus, the development directed by the Board on these increased rating claims may impact the resolution of the service connection claims. Therefore, it was contended that the Board erred in adjudicating the service connection claims before the development on these increased rating claims had been accomplished. As all such development directed by the Board's remands in this case has been substantially accomplished, there is no prejudice under the provisions of the JMR by the Board proceeding with adjudication of these claims. In view of the foregoing, the Board finds that the duty to assist the Veteran has been satisfied in this case. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. 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). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (Noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). I. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Additional disability resulting from the aggravation of a non service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In this case, the Veteran's service treatment records contain no findings indicative of a left knee or bilateral leg disorder while on active duty, nor for years after service. The Court has indicated that the normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of low back condition); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability.). Moreover, the Veteran does not contend his left knee or leg disorder is directly related to his active service. Rather, he contends that these disabilities are secondary to his service-connected right knee disorder and/or pes planus. The Board observes, however, that in the January 2013 medical opinion, it was noted that the Veteran was found to have Osgood Schlatter's disease on X-rays of the lower extremities, and that this condition was well documented in the medical literature to occur in the early teen/adolescent years usually between the ages of 9-16 years old in the athletic youth during periods of growth spurts. The examiner also noted that it resolved once skeletal maturity is reached at about 16-17 years old. When X-rays were taken in later years (after skeletal maturity) Osgood Schlatter's was an "incidental" finding and may be reported by a radiologist. The examiner noted that September 2000 X-rays of the right knee included findings of "old" Osgood Schlatter's of the right knee, and that the use of the term "old" indicated that it was an incidental finding and not an active disease process. The examiner also stated that X-rays of both knees in March 2010 included findings of tibial tuberosity fragmentation which was again evidence of old Osgood Schlatter's disease/syndrome. Since Osgood Schlatter's was known to occur prior to skeletal maturity the examiner opined that this Veteran had Osgood Schlatter's disease in his youth and prior to military duty. Further, review of the entire service treatment records did not reveal any medical evidence to support a claim that this Veteran's developmental Osgood Schlatter's disease was aggravated beyond the natural progression by his military duty. The examiner reiterated that X-ray findings of "old" Osgood Schlatter's disease was an incidental finding and not indicative of an active disease process that had been aggravated or progressed. Although the January 2013 supplemental opinion concludes that Osgood Schlatter's existed prior to service, no such disability was noted at the time of the Veteran's entry into active service to include his June 1986 enlistment examination and concurrent Report of Medical History. To rebut the presumption of sound condition under section 1111 of the statute for disorders not noted on the entrance or enlistment examination, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). A preexisting injury or disease will be considered to have been aggravated by active military service, where there is an increase in disability during such service, unless there is specific finding that the increase in disability is due to the natural progress of the disease. 38 C.F.R. § 3.306(a). Temporary flare-ups will not be considered to be an increase in severity. Hunt v. Derwinski, 1 Vet. App. 292, 295 (1991). In this case, as already noted, there was no indication of any left knee or leg problems during active service or for years thereafter. Simply put, there is no indication that this disability increased in severity during active service. Moreover, as detailed in the January 2013 supplemental opinion, the evidence of such disability was first noted in X-rays taken after his separation from service. The examiner's opinion that this condition pre-existed service is based upon the fact that it is a developmental condtion that generally occurs during teen-age years. However, the examiner's opinion is such that this condtion also resolved during the teen-age years, and that the current evidence does not demonstrate an active disease process. Moreover, the Veteran has not contended he had a left knee disorder that was aggravated by service. In any event, as there is no evidence which specifically refutes the January 2013 supplemental opinion, the findings of Osgood Schlatter's disease clearly and unmistakably pre-existed service and was not aggravated therein. Based on the foregoing, it does not appear that the findings of Osgood Schlatter's disease is a chronic disability that was incurred in or aggravated by the Veteran's active service. Turning to the Veteran's contention of secondary service connection, the Board observes that the affect one disability has upon another involves complex medical issues. Further, in Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) the Federal Circuit held in the context of a claimant contending secondary service connection that a veteran's own conclusory generalized statement that his service illness caused his present medical problems was not enough to entitle him to a medical examination. As such, competent medical evidence is required to resolve this matter. Here, nothing on file shows that the Veteran has the requisite knowledge, skill, experience, training, or education to render a medical opinion. Consequently, his contentions cannot constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1) In this case, the only competent medical opinions to address the Veteran's claims of secondary service connection are that of the March 2010 and November 2012 VA examinations. As detailed below, these opinions are against the Veteran having either a left knee or bilateral leg disorder secondary to his service-connected disabilities. In March 2010, the VA examiner opined, in essence, that the Veteran's left patellofemoral syndrome was not caused by, the result of, or aggravated by his service-connected right knee and/or bilateral foot disabilities. The examiner indicated that the Veteran had a normal gait and did not demonstrate any evidence of unequal weight-bearing, and concluded that the claimed disabilities were less likely than not related to the service-connected disabilities. In November 2012, the VA examiner opined that the Veteran's current left knee strain was less likely than not secondary to or permanently aggravated by the service-connected right knee disorder. The examiner stated that the pathology of one knee joint rarely results in pathology in the contralateral knee or permanent aggravation of the contralateral knee joint without major injury and significant weight bearing alteration which the Veteran did not exhibit on examination. Regarding the claimed bilateral leg disorder, the Board acknowledges that it previously identified the claimed disability as shin splints in the January 2011 decision. However, the March 2010 VA examiner diagnosed bilateral shin pain, and did not specifically diagnose shin splints. Further, because of these complaints the examiner ordered X-rays which showed no radiographic abnormality. In short, it does not appear that shin splints was actually diagnosed on this examination. As such, it does not appear the Veteran had such a disability at that time. Similarly, the November 2012 VA examiner noted that the Veteran reported it "was suggested" he had shin splints in the military, but that the physical examination showed no tenderness to direct palpation on the shins and no appreciable pain elicited at shin with foot flexion and extension. The examiner essentially found that the Veteran had slight fragmentation of the tibial tuberosity which was probably developmental. To the extent the evidence of record demonstrates complaints of bilateral shin pain but no actual diagnosis of shin splints, the Board notes that the Court has previously held that pain, alone, without a diagnosed or identifiable underlying condition, is not a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), vacated in part, appeal dismissed in part sub nom., Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001) (Dismissing challenge to the issue whether pain, alone, can be considered a disability). The Board is cognizant of the fact that the Court held in McLain v. Nicholson, 21 Vet. App. 319 (2007), that the requirement that a claimant have a current disability before service connection may be awarded for that disability is also satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if no disability is present at the time of the claim's adjudication. However, even if the Board were to find that the Veteran had a bilateral leg disability such as shin splints, the claim would still be denied. See Holbrook v. Brown, 8 Vet. App. 91 (1995) (The Board has the fundamental authority to decide a claim in the alternative.). For example, the March 2010 VA examiner opined that the Veteran's claimed bilateral leg disorder was a separate entity and less likely as not secondary to his right knee pain and bilateral plantar fasciitis. The November 2012 VA examiner opined that the findings of slight fragmentation of the tibial tuberosity was probably developmental. The examiner also opined that it was less likely than not secondary to or permanently aggravated by the right knee disorder. As noted above, the examiner opined in the January 2013 supplemental opinion that this was a developmental condition that developed and resolved in the Veteran's teen-age years and was not aggravated by service. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this case, both the March 2010 and November 2012 VA examiners were aware of the Veteran's medical history regarding the left knee and both legs from review of the VA claims folder. The examiners were also aware of the contentions of secondary service connection. Further, neither examiner expressed their opinions in equivocal or speculative language. Moreover, they supported their opinions with stated rationale. In essence, both examiners found that the Veteran did not have the type of impairment from his service-connected right knee and/or pes planus that would have led to the development or aggravation of chronic disabilities of the left knee and/or the legs. Therefore, the Board finds that these opinions are persuasive and entitled to significant weight regarding the Veteran's claim of secondary service connection. The Board acknowledges that the November 2012 VA examiner did not specifically address whether the claimed left knee and/or bilateral leg disorders were secondary to the service-connected plantar fasciitis. However, this matter was previously addressed by the March 2010 VA examination, which the Board determined in the January 2011 decision was adequate for resolution of this case. Although the Board did remand this case in October 2012 for a new examination, it is noted that the JMR which was the basis for the Court's vacating the prior denial did not identify any error regarding the March 2010 VA examination nor did it require a new examination in this case. The Court has stated that advancing different arguments at successive stages of the appellate process does not serve the interests of the parties or the Court, and that such a practice hinders the decision-making process and raises the undesirable specter of piecemeal litigation. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) ("Court will [not] review BVA decisions in a piecemeal fashion"); see also Fugere v. Derwinski, 1 Vet. App. 103, 105 (1990), aff'd, 972 F.2d 331 (Fed. Cir. 1992) ("Advancing different arguments at successive stages of the appellate process does not serve the interests of the parties or the Court"). The Board is therefore confident that if the Court had any substantive comments concerning the adequacy of the March 2010 VA examination, such would have surfaced in the JMR or the Court Order so that any deficiencies could be corrected. Moreover, the Board reiterates that it has determined that competent medical evidence is necessary to resolve these claims, and no competent medical evidence is of record which supports a finding of secondary service connection. Therefore, the Board finds no prejudice to the Veteran by the November 2012 VA examination's lack of specific reference to the plantar fasciitis. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (harmless error). In view of the foregoing, the Board finds that the preponderance of the competent medical and other evidence of record is against a finding that the Veteran developed a chronic left knee or bilateral leg disorder as a result of his active service, to include as secondary to a service-connected disability. As the preponderance of the evidence is against this claim, the benefit of the doubt doctrine is not for application in the instant case. See generally Gilbert, supra; see also Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Consequently, the benefit sought on appeal with respect to these claims must be denied. II. Increased Rating A. General Criteria Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations applies, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). In this case, the Board acknowledges that the Veteran complained of pain with respect to his pes planus, lumbar strain, and right knee. As such, the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59, are for consideration and will be taken into account in adjudicating these disabilities. Further, as detailed below, repetitive testing was conducted as part of the VA medical examinations of these disabilities in an attempt to determine the extent of additional impairment during flare-ups. The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, 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). With regard to the Veteran's request for an increased schedular evaluation, the Board will only consider the factors as enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). The terms "mild," "moderate," and "severe" are not defined in the Schedule. 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 use of terminology such as "moderate" or "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. B. Pes Planus Bilateral pes planus is evaluated pursuant to criteria set forth at 38 C.F.R. § 4.71a , Diagnostic Code 5276. Mild symptoms which are relieved by a built-up shoe or arch supports will be rated as noncompensable disabling. Where symptoms are moderate, with a weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, and pain on manipulation and use of the feet, a 10 percent rating will be granted. Severe manifestations, such as evidence of marked deformity, accentuated pain on manipulation and use, indications of swelling on use, and characteristic callosities will be granted a 30 percent rating. Pronounced bilateral pes planus, with marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, none of which are improved by orthopedic shoes or appliances, will be awarded a 50 percent rating. Prior to February 22, 2011, the Veteran's service-connected bilateral pes planus with plantar fasciitis was not manifested by pronounced symptomatology to include marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement or severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. The Board acknowledges that the Veteran consistently complained of pain with respect to his pes planus. For example, as part of the February 2007 VA examination he reported daily pain in the plantar aspect of the arches, rated as a 7 on a scale of 1 to 10. He did not experience flare-ups. He also indicated on both this examination and in March 2010, that medication did not alleviate his symptoms, and that they were more severe with standing and walking although they were also present with rest. Despite this reported symptomatology, the record does not demonstrate the type of functional impairment necessary for a rating in excess of 30 percent under Diagnostic Code 5276 prior to February 22, 2011. In pertinent part, the Board observes that the February 2007 VA examination noted that the Veteran had no weakness, stiffness, swelling, heat, redness, instability, fatigability, or decrease in endurance. On examination, all ten toes were found to have active and passive full range of motion without pain and no change with repetition. Strengths were 5/5 for all ten digits. His gait, stand, and walk were all found to be normal. Although he was noted as having tinea pedis in the soles of the feet, and onychomycosis to the great nails, there was no abnormal callosities otherwise. The March 2010 VA examination noted that the Veteran was able to wiggle the toes of both feet without pain. Although he had heel calluses, he did not have foot edema. Peripheral pulses were grade 1+. The examiner described the Veteran's flat feet as "mild" both weight bearing and non-weight bearing. Although the Board is not required to accept the examiner's description of the service-connected disability as "mild" it is evidence for consideration, and suggests little overall functional impairment from the pes planus. The Board also observes that while there are references to painful feet in the treatment records for this period, to include records dated in May 2010, there are little or no findings regarding the actual functional ability of the feet. In view of the foregoing, the Board finds that the Veteran's service-connected bilateral pes planus is adequately reflected by the current 30 percent rating for the period prior to February 22, 2011. As noted above, this rating reflects severe symptomatology. The objective competent medical findings, in part, indicate full range of motion of the feet despite the Veteran's complaints of pain. Moreover, both the February 2007 and March 2010 VA examinations indicated that the Veteran's shoe inserts did provide some relief, although the February 2007 examination indicated relief for the left but not the right. Nevertheless, there does not appear to be any such qualifier on the March 2010 examination. The Board also notes that the criteria for the 50 percent rating provide that none of the symptoms are relieved by orthopedic shoes, and this is evidence of some relief from inserts. The Board also notes that there is no indication of marked pronation, marked inward displacement and/or severe spasm of the tendo achillis on manipulation of the feet during the period prior to February 22, 2011. In addition, the February 2007 VA examination found there was no tenderness to palpation over the plantar aspect of the calcaneus bilaterally. Granted, the March 2010 VA examination did find tenderness to palpation of the left Achilles tendon. However, given the overall description of the flat feet as "mild" it does not appear to be the type of tenderness contemplated by the criteria for a 50 percent rating. There was no tenderness to palpation of the right Achilles tendon. For these reasons, the Board finds that the Veteran does not meet or nearly approximate the criteria for a rating in excess of 30 percent for his service-connected bilateral pes planus prior to February 22, 2011, even when taking into account his complaints of pain. With respect to the period from February 22, 2011, the Veteran is already in receipt of the maximum schedular rating assigned for bilateral pes planus for this period; the rating schedule does not provide for a rating in excess of 50 percent for bilateral pes planus. Therefore, there is no legal basis for the Board to assign a higher schedular rating. C. Lumbar Strain Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Further, the normal ranges of motion for each component of spinal motion are the maximum that can be used for calculation of the combined range of motion. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2), as added by 68 Fed. Reg. 51,454 (Aug. 27, 2003). The General Rating Formula for Diseases and Injuries of the Spine provides that with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. An evaluation of 20 percent is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. An evaluation of 40 percent is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. An evaluation of 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine. An evaluation of 100 percent requires unfavorable ankylosis of the entire spine. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5), as added by 68 Fed. Reg. 51,454 (Aug. 27, 2003). The evaluation criteria are meant to encompass and take into account the presence of pain, stiffness, or aching, which are generally present when there is a disability of the spine. Therefore, an evaluation based on pain alone would not be appropriate, unless there is specific nerve root pain, for example, that could be evaluated under the neurologic sections of the rating schedule. See 68 Fed. Reg. 51,455 (Aug. 27, 2003). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that an evaluation of 10 percent is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. An evaluation of 20 percent is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. An evaluation of 40 percent is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. Finally, an evaluation of 60 percent requires intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. For the purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. See 38 C.F.R. § 4.71a, Intervertebral Disc Syndrome, Note (1); see also 69 Fed. Reg. 32, 449 (June 10, 2004). Prior to March 1, 2010, the Veteran's service-connected lumbar strain was not manifested by forward flexion of the thoracolumbar spine of 60 degrees or less; combined range of motion of the thoracolumbar spine of 120 degrees or less; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Although he complained of pain at the February 2007 VA examination, which he described as a 5 on a scale of 1 to 10, the Veteran had active and passive forward flexion to 115 degrees. In addition, right and left lateral flexion, as well as extension, were to 20 degrees active and passive. Left and right rotation were to 35 degrees active and passive. There was no change with any of these motions with repetition. Moreover, there was no palpable spasm, tenderness to palpation, or weakness; posture and musculature were both normal. The Board also finds there was no indication in the treatment records of the type of impairment necessary for a rating in excess of 10 percent prior to March 1, 2010. For these reasons, the Board finds that the Veteran does not meet or nearly approximate the criteria for a rating in excess of 10 percent prior to March 1, 2010, under the General Rating Formula for Diseases and Injuries of the Spine. Regarding the period from March 1, 2010, the Veteran's service-connected lumbar spine has not been manifested by forward flexion of the thoracolumbar spine of 30 degrees or less. Both the March 2010 and February 2011 VA examination found he had forward flexion to 60 degrees. Although it was noted that this diminished to 40 degrees with repetition on both examinations secondary to pain, this is still in excess of 30 degrees. Nothing in the treatment records on file for this period indicates evidence of forward flexion to 30 degrees or less, even when taking into account his complaints of pain. The November 2012 VA examination did not contain any relevant findings regarding the service-connected lumbar strain. The Board also notes that there is no indication of ankylosis of the thoracolumbar spine at any time during the pendency of this case, to include the period since March 1, 2010. No such diagnosis is shown on the VA examinations or the treatment records on file. Moreover, ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992). In this case, the aforementioned forward flexion findings, as well as the other range of motion findings in this case, clearly reflect the Veteran has mobility of the lumbar spine; i.e., the lumbar spine is not immobile. For these reasons, the Board finds that the Veteran does not meet or nearly approximate the criteria for a rating in excess of 20 percent under the General Rating Formula for Diseases and Injuries of the Spine, for the period from March 1, 2010. The Board also notes that the record does not reflect any associated neurologic impairment that would warrant a separate evaluate pursuant to Note 1 of this Formula. No neurologic impairment is documented on the VA examinations in this case, or the treatment records. The Veteran also denied bowel or bladder incontinence on the February 2007 and March 2010 VA examinations. He also denied bladder incontinence on the February 2011 VA examination. Although he did report 4 episodes of bowel incontinence over the past 2 years, he attributed them to gastrointestinal (GI) issues. He is already service-connected for gastritis. In regard to the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, the Board observes that the Veteran is not service-connected for intervertebral disc syndrome. As such, it is not clear that the service-connected disability even warrants consideration of this Formula. In any event, there is no indication of incapacitating episodes as defined by VA regulations on the February 2007 VA examination or treatment records on file, and the Veteran specifically denied having any incapacitating episodes on the March 2010 and February 2011 VA examinations. Therefore, the Veteran is not entitled to a rating in excess of 10 percent prior to March 1, 2010, or in excess of 20 percent thereafter under this Formula. D. Right Knee Diagnostic Code 5010 provides that traumatic arthritis substantiated by X-ray findings is to be rated as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a. Under Diagnostic Code 5003, degenerative arthritis, established by X-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. However, when 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 major joint or groups 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. 38 C.F.R. § 4.71a , Diagnostic Code 5003; Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). In the absence of limitation of motion, a 10 percent rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups. With X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent rating is warranted. However, the 10 and 20 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. For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f) . Diagnostic Code 5260 provides for limitation of flexion of the leg. Where flexion is limited to 60 degrees, a 0 percent rating is provided; when flexion is limited to 45 degrees, 10 percent is assigned; when flexion is limited to 30 degrees, 20 percent is assigned; and when flexion is limited to 15 degrees, 30 percent is assigned. 38 C.F.R. § 4.71a. Diagnostic Code 5261 provides for limitation of the extension of the leg. When there is limitation of extension of the leg to 5 degrees, a zero percent rating is assigned; when the limitation is to 10 degrees, a 10 percent rating is assignable; when the limitation is to 15 degrees, 20 percent is assigned; when extension is limited to 20 degrees, 30 percent is assigned; when extension is limited to 30 degrees, 40 percent is assigned; and when it is limited to 45 degrees, 50 percent is assigned. 38 C.F.R. § 4.71a. The Board notes that full range of motion of the knee consists of 0 degrees extension and 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. With respect to range of motion, the Board observes that the record does not reflect the Veteran had flexion limited to 30 degrees or less, or that he had any impairment of extension, during the pendency of this case even when taking into account his complaints of pain. For example, he had flexion to 140 degrees on the February 2007 VA examination with no change after repetition. The March 2010 VA examination showed flexion to 90 degrees with no change after repetition. The February 2011 VA examination showed flexion to 50 degrees with no change after repetition. Finally, the November 2012 VA examination showed the right knee had flexion to 100 degrees, pain noted at 80 degrees, with no change after repetition. Although these results show a decrease in flexion for the right knee, they are all in excess of 30 degrees which is necessary for a rating in excess of 10 percent under Diagnostic Code 5260. Nothing in the treatment records reflect he had any such limitation either. The Board observes that there is no indication of any impairment of extension of the right knee in this case. The February 2007, March 2010, and February 2011 VA examinations all indicated the Veteran had normal extension to zero degrees, with no change after repetition. Nothing in the treatment records indicates impairment of extension either. Thus, he is clearly not entitled to a rating under Diagnostic Code 5261 based upon such impairment. (The Board notes that in VAOPGCPREC 9-2004 VA's Office of General Counsel held in that separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same joint. However, as there is no impairment of extension that would warrant even a compensable rating under Diagnostic Code 5261, separate ratings are clearly not warranted.) Other criteria for disabilities of the knee and leg are found at 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5259 and 5263. Diagnostic Code 5256 provides for ankylosis of the knee. Under this Code, favorable ankylosis of either knee warrants a 30 percent evaluation. Ankylosis is considered to be favorable when the knee is fixed in full extension, or in slight flexion at an angle between 0 degrees and 10 degrees. A 40 percent evaluation requires that the knee be fixed in flexion at an angle between 10 degrees and 20 degrees. When the knee is fixed in flexion between 20 degrees and 45 degrees, a 50 percent rating is assigned. A 60 percent rating is warranted for extremely unfavorable ankylosis, with the knee fixed in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a. Under Diagnostic Code 5257, slight impairment of either knee, including recurrent subluxation or lateral instability, warrants a 10 percent evaluation. A 20 percent evaluation requires moderate impairment, while a 30 percent evaluation requires severe impairment. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, when there is cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint, a 20 percent is assignable. 38 C.F.R. § 4.71a. Under Diagnostic Code 5259, a 10 percent rating is assigned for cartilage, semilunar, removal of, symptomatic. This Code does not provide for a disability rating in excess of 10 percent. 38 C.F.R. § 4.71a. Diagnostic Code 5262 provides criteria for impairment of the tibia and fibula. With malunion and slight knee or ankle disability, a 10 percent rating is assigned. Moderate knee or ankle disability warrants a 20 percent rating. A 30 percent rating is assigned when there is marked knee or ankle disability. When there is nonunion with loose motion, requiring brace, a 40 percent rating is warranted. 38 C.F.R. § 4.71a. Under Diagnostic Code 5263, when there is genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated), a 10 percent rating is warranted. This Code does not provide for a disability rating in excess of 10 percent. 38 C.F.R. § 4.71a. In this case, the Board notes that the required manifestations for evaluation under Diagnostic Codes 5256 (knee, ankylosis), 5262 (tibia and fibula, impairment of), and 5263 (genu recurvatum) are not applicable, as the presence of ankylosis of the right knee, dislocation or removal of the semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum have not been demonstrated. The Board acknowledges that the Veteran did undergo surgery in July 2008 for a torn medial and lateral meniscus. However, to the extent this indicates evidence of dislocated cartilage, it does not appear such impairment was documented prior to this procedure, and the impairment has been adequately reflected by the temporary total evaluation assigned under 38 C.F.R. § 4.30 for the period from July 16, 2008, with the 10 percent rating being restored September 1, 2008. Moreover, Diagnostic Codes 5259 which contemplates the residuals from such a procedure does not provide for a rating in excess of 10 percent which is the benefit sought on appeal. Similarly, Diagnostic Code 5263 does not provide for a rating in excess of 10 percent either. The Board further finds that there is no indication of recurrent subluxation or lateral instability of the right knee during the pendency of this case so as to warrant even a compensable rating under Diagnostic Code 5257. For example, the February 2007 VA examination found there were no episodes of dislocation or subluxation, and there was no evidence of instability. On the March 2010 VA examination, the Veteran reported his right knee did not lock or give way. There was also no evidence of ligamentous laxity on this examination. Although the Veteran reported that his knee gave way at the February 2011 VA examination, it did not lock or swell and there was no history of subluxation, dislocation, or inflammatory arthritis. Moreover, anterior, posterior, and medial-lateral instability tests were all normal for both knees on the November 2012 VA examination; and there was no evidence of subluxation/dislocation. The treatment records contain no evidence of any such impairment either. In VAOPGCPREC 23-97, VA's Office of General Counsel held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. General Counsel stated that when a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion which at least meets the criteria for a zero-percent rating under Diagnostic Code 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more) in order to obtain a separate rating for arthritis. General Counsel subsequently held in VAOPGCPREC 9-98 that a separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59; see also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). Where additionally disability is shown, a veteran rated under 5257 can also be compensated under 5003 and vice versa. However, as there is no evidence of recurrent subluxation or lateral instability so as to warrant a compensable rating under Diagnostic Code 5257, a separate rating for such impairment is not warranted. For these reasons, the Board finds that the Veteran does not meet or nearly approximate the criteria for a rating in excess of 10 percent for his service-connected right knee under any of the potentially applicable Diagnostic Codes, excluding the period(s) of temporary total evaluation(s). E. Other Considerations In evaluating the Veteran's service-connected pes planus, lumbar strain, and right knee, the Board considered the potential applicability of "staged" rating(s) pursuant to Fenderson, supra, and Hart, supra. The Veteran is already in receipt of such "staged" ratings for his pes planus and lumbar strain. Nevertheless, a thorough review of the record does not indicate any distinctive period(s) where any of these disabilities met or nearly approximated the criteria for rating(s) in excess of those currently in effect. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's symptomatology of the Veteran's service-connected pes planus, lumbar strain, and right knee. As detailed above, these service-connected disabilities are primarily manifested by complaints of pain and limitation of function/motion, manifestations that are contemplated in the rating criteria. None of these disabilities appear to be manifested by symptoms not contemplated by the pertinent schedular criteria. The rating criteria are therefore adequate to evaluate these service-connected disabilities and referral for consideration of extraschedular rating is not warranted. Lastly, the Board notes that notes that, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim of entitlement to a total rating based upon individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the Board notes that the record reflects the Veteran's service-connected disabilities have caused impairment with his work. Nevertheless, the record reflects he has been gainfully employed throughout the pendency of this case. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1. Indeed, 38 C.F.R. § 4.1 specifically states: "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (Noting that the disability rating itself is recognition that industrial capabilities are impaired). Therefore, the Board finds that the level of occupational impairment has been adequately reflected by the current schedular evaluations, and does not warrant consideration of a TDIU. ORDER Service connection for a left knee disability, to include as secondary to service-connected disabilities of degenerative joint disease of the right knee and bilateral pes planus with plantar fasciitis, is denied. Service connection for a bilateral leg disability (claimed as leg pain), to include as secondary to service-connected disabilities of degenerative joint disease of the right knee and bilateral pes planus with plantar fasciitis, is denied. A rating in excess of 30 percent for bilateral pes planus with plantar fasciitis prior to February 22, 2011, is denied. A rating in excess of 50 percent for bilateral pes planus with plantar fasciitis from February 22, 2011, is denied. A rating in excess of 10 percent for lumbar strain prior to March 1, 2010, is denied. A rating in excess of 20 percent for lumbar strain from March 1, 2010, is denied. A rating in excess of 10 percent for degenerative joint disease of the right knee (excluding period(s) of temporary total evaluation(s)) is denied. ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs