Citation Nr: 1318848 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 00-14 066 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an initial compensable disability rating prior to May 23, 2002, and a rating in excess of 10 percent thereafter, for impairment of the right knee, subluxation (previously characterized as patellofemoral pain syndrome of the right knee). 2. Entitlement to an initial compensable disability rating prior to May 23, 2002, and a rating in excess of 10 percent thereafter, for impairment of the left knee, subluxation (previously characterized as patellofemoral pain syndrome of the left knee). 3. Entitlement to a rating in excess of 10 percent for limitation of flexion of the right knee. 4. Entitlement to a rating in excess of 10 percent for limitation of flexion of the left knee. 5. Entitlement to an initial compensable disability rating for right heel plantar fasciitis with Achilles bursitis. 6. Entitlement to an initial compensable disability rating for status-post open reduction internal fixation (ORIF) of right distal fibula fracture with residual scar. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The Veteran had active service from July 1993 to November 1999 and from January 2003 to November 2003. The Veteran also has additional service in the Marine Corps Reserve. He was awarded the Combat Action Ribbon. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 1999 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in San Diego, California, that, in pertinent part, granted service connection for patellofemoral pain syndrome of the right knee, patellofemoral pain syndrome of the left knee, right heel plantar fasciitis with Achilles bursitis, and status-post ORIF of right distal fibular fracture with residual scar. The RO assigned initial noncompensable disability ratings to each of the disabilities effective November 16, 1999. The Veteran disagreed with this decision in April 2000, and perfected a timely appeal in September 2000. The Veteran currently resides within the jurisdiction of the RO in Los Angeles, California. That facility retains jurisdiction over this appeal. In November 2003, the Board denied the Veteran's claims on the basis that he had failed to report for VA examinations. VA subsequently was informed that the Veteran had been deployed to Iraq in support of Operation Iraqi Freedom at the time of his VA examinations. Accordingly, in December 2006, the Board vacated its November 2003 decision. Separately, the Board also remanded the Veteran's appeal in December 2006 for additional development. In November 2009, the Board denied the Veteran's claims, and the Veteran appealed. In a January 2012 Memorandum Decision, the United States Court of Appeals for Veterans Claims (Court) vacated the Board's November 2009 decision and remanded the appeal to the Board for further proceedings consistent with that decision. In June 2012, the Board remanded the Veteran's claims for additional development to include scheduling him for VA examinations. Subsequently, by rating action in December 2012 the Veteran's bilateral patellofemoral pain syndrome was recharacterized by the RO as impairment of the right and left knees, subluxation. The assigned ratings for these disabilities were unchanged. Additionally, service connection was granted for limitation of flexion of the right and left knees and separate ratings of 10 percent were assigned for each knee. Because this award was granted out of the appeal of the initial claims for higher ratings for right and left knee disabilities, and ratings higher than the combined 20 percent ratings now assigned may be available, and because a claimant is presumed to be seeking the maximum available rating for a service-connected disability, the claims for higher ratings for flexion of the right and left knees has been assumed by the Board and are considered to be in appellate status, as reflected on the title page. See AB v. Brown, 6 Vet. App. 35, 38 (1993). By rating action in March 2013 service connection for a left shoulder disability was granted. As this is a full grant of the benefit sought this issue is no longer in appellate status. The instant decision awards an earlier effective date of May 23, 2002, for the assignment of a 10 percent rating for each knee based on subluxation; accordingly, the issues on appeal have been recharacterized as shown on the title page. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. The Veteran's right knee disability has been manifested by greater than 10 degrees of extension throughout the rating period on appeal. 2. The Veteran's right knee disability has been manifested by greater than 60 degrees of flexion throughout the rating period on appeal. 3. The Veteran's right knee disability did not demonstrate slight subluxation prior to May 23, 2002; and beginning May 23, 2002, the Veteran's right knee demonstrated slight subluxation, but not more. 4. The Veteran's right knee disability has been manifested by greater than 10 degrees of extension throughout the rating period on appeal. 5. The Veteran's right knee disability has been manifested by greater than 60 degrees of flexion throughout the rating period on appeal. 6. The Veteran's left knee disability did not demonstrate slight subluxation prior to May 23, 2002; and beginning May 23, 2002, the Veteran's right knee demonstrated slight subluxation, but not more. 7. Throughout the rating period on appeal, the Veteran's right heel plantar fasciitis with Achilles bursitis is not shown to have been manifested by more than slight limitation of motion or mild disability. 8. The Veteran's status post ORIF of the right distal fibula fracture with residual scar is not shown to have been manifested by more than slight limitation of motion of the right ankle or impairment of the tibia and fibula with slight ankle disability. The residual scar is linear and superficial, is not tender or painful, and does not limit the function of the right foot. CONCLUSIONS OF LAW 1. The criteria for an earlier effective date of May 23, 2002, for the award of a 10 evaluation for impairment of the right knee, subluxation, have been met. 38 U.S.C.A. §§ 5107, 5110 (West 2002); 38 C.F.R. §§ 3.1, 3.155, 3.157, 3.400 (2012). 2. The criteria for an earlier effective date of May 23, 2002, for the award of a 10 evaluation for impairment of the left knee, subluxation, have been met. 38 U.S.C.A. §§ 5107, 5110 (West 2002); 38 C.F.R. §§ 3.1 , 3.155, 3.157, 3.400 (2012). 3. The criteria for establishing an initial compensable disability rating prior to May 23, 2002, and a rating in excess of 10 percent thereafter, for impairment of the right knee, subluxation, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (2002); 38 C.F.R. §§ 3.159, Part 4, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5257 (2012). 4. The criteria for establishing an initial compensable disability rating prior to May 23, 2002, and a rating in excess of 10 percent thereafter, for impairment of the left knee, subluxation, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (2002); 38 C.F.R. §§ 3.159, Part 4, 4.7, 4.14, 4.40, 4.45, 4.71a, DC 5257 (2012). 5. The criteria for a rating in excess of 10 percent for limitation of flexion of the right knee from April 11, 2006, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (2002); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5260 (2012). 6. The criteria for a rating in excess of 10 percent for limitation of flexion of the left knee from April 11, 2006, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (2002); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5260 (2012). 7. The criteria for an initial compensable disability rating for right heel plantar fasciitis with Achilles bursitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (2002); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5299-5019 (2012). 8. The criteria for an initial compensable disability rating for status-post open reduction internal fixation (ORIF) of right distal fibula fracture with residual scar have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (2002); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5299-5262 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's claims arise from an appeal of the initial evaluations following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c) (4). The Board finds that all necessary assistance has been provided to the Veteran. The RO has obtained the Veteran's service treatment records and post-service VA and private medical records. After review of these examination reports, the Board finds that they provide competent, non-speculative evidence regarding the current nature and severity of the Veteran's service-connected right and left knee disabilities, right heel plantar fasciitis, and status-post ORIF of right distal fibula fracture. The Veteran was afforded fee based VA examinations in October 1999 and April 2006; and VA examinations in May and September 2007, and August 2012. He also underwent a VA scars examination in February 2013. After review of these examination reports, the Board finds that they are thorough and adequate upon which to base a decision with regard to the increased ratings claims. The VA examiners personally interviewed and examined the Veteran, including eliciting his medical history, and provided the information necessary to decide the claims. Brief but relevant and important opinions were provided. The Board finds the opinions to be adequate, as they were predicated on a full reading of the claims file and the Veteran's own statements. In sum, the Board finds that the duty to assist and duty to notify provisions of the VCAA have been fulfilled and no further action is necessary under the mandates of the VCAA. II. Legal Criteria/ Analysis Initially, the Board notes all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal, has been reviewed. Although there is an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran contends that his service-connected bilateral knee disorders, right heel plantar fasciitis with Achilles bursitis, and SP ORIF of right distal fibula fracture with residual scar are more disabling than currently evaluated. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21(2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Where the Rating Schedule does not provide for a noncompensable evaluation for a diagnostic code, a noncompensable evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (2012). Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14 (2012). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Also, functional loss due to pain must be supported by pathology and shown through objective observation. Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997) (citing 38 C.F.R. § 4.40). Pain alone does not constitute functional loss under VA regulations that evaluate disabilities based upon loss of motion. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2012). The Board must evaluate disabilities under multiple diagnostic codes to determine if there is any basis to increase the assigned rating. Such evaluations involve consideration of the level of impairment of a veteran's ability to engage in ordinary activities, to include employment, as well as an assessment of the effect of pain on those activities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2012). The Board notes that the terms "slight," "moderate" and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 Diagnostic Code 5010 instructs raters to evaluated traumatic arthritis as degenerative arthritis under Diagnostic Code 5003. See 38 C.F.R. § 4.71a. Under Diagnostic Code 5003 degenerative arthritis established by x-ray findings will be rated either based on the limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. 38 C.F.R. § 4.71a, DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Painful motion of a major joint or groups of minor joints caused by arthritis, established by X-ray, is deemed to be limited motion and entitled to the minimum 10 percent rating even though there is no actual limitation of motion. Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). The standard range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. Knee instability is evaluated under Diagnostic Code 5257. A 10 percent evaluation is warranted for slight recurrent subluxation or lateral instability; 20 percent is warranted for moderate recurrent subluxation or lateral instability; and, 30 percent is warranted for severe recurrent subluxation or lateral instability. This is the maximum available under this diagnostic code. 38 C.F.R. § 4.71a. Limitation of motion of the knee is evaluated under Diagnostic Code 5260 (for limitation of flexion) and Diagnostic Code 5261 (for limitation of extension). Compensable (a 10 percent rating) limitation of flexion must be limited to no less than 60 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Compensable (a 10 percent rating) limitation of extension must be limited to no more than five degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. If the criteria for a compensable rating under both these diagnostic codes are met, separate ratings can be assigned. VAOPGCPREC 9-2004 (September 17, 2004), 69 Fed. Reg. 59990 (2004). If limitation of motion of the affected joint is not compensable, a 10 percent rating is applicable for noncompensable limitation of motion confirmed by findings such as swelling, muscle spasm, or painful motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board notes that each of the Veteran's knees is currently evaluated as 10 percent disabling under 5260 for limitation of flexion of the knees. Additionally, separate evaluations are available for separate symptoms, such as arthritis and instability of the knee. See VAOPGCPREC 23-97. Specifically, the VA General Counsel has held that when X-ray findings of arthritis are present and a Veteran's knee disability is evaluated under Code 5257, the Veteran would be entitled to a separate compensable evaluation under Diagnostic Code 5003 if the arthritis results in at least noncompensable limitation of motion. See VAOPCGPREC 9-98 (August 14, 1998). In this case, all of the Veteran's ratings were discontinued effective January 6, 2003, and were reinstated effective November 9, 2003, because he was on active duty during this time period. a. Earlier effective date for 10 percent award of subluxation, bilateral knees The effective date of an increase in disability compensation is the earliest date as of which it is factually ascertainable that an increase in disability has occurred if a claim is received within one year of such date. Otherwise, the effective date is the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o) (2) (2012). The Court has held that 38 U.S.C.A. § 5110(b) (2) and 38 C.F.R. § 3.400(o) (2) are applicable only where an increase in disability precedes a claim for an increased disability rating; otherwise the general rule of 38 C.F.R. § 3.400(o) (1) applies. See Harper v. Brown, 10 Vet. App. 125, 126 (1997). Thus, three possible dates may be assigned depending on the facts of a case: (1) if an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose) (38 C.F.R. § 3.400(o) (1); (2) if an increase in disability precedes the claim by a year or less, the date that the increase is shown to have occurred (factually ascertainable) (38 C.F.R. § 3.400(o) (2); or (3) if an increase in disability precedes the claim by more than a year, the date that the claim is received (date of claim) (38 C.F.R. § 3.400(o) (2). Harper, 10 Vet. App. at 126. Thus, determining an appropriate effective date for an increased rating under the effective date regulations involves an analysis of the evidence to determine (1) when a claim for an increased rating was received and, if possible, (2) when the increase in disability actually occurred. 38 C.F.R. §§ 3.155, 3.400(o) (2) (2012). As noted above, this case arises from the Veteran's initial claim filed prior to separation from service in October 1999, and his disagreement with the initial noncompensable rating assigned in the December 1999 rating decision. The September 2006 rating decision that assigned a staged rating and increased the initial noncompensable disability ratings to 10 percent for the patellofemoral pain syndrome of the right and left knees from December 9, 2003 (based on the April 2006 VA examination) erroneously noted that the rating was increased, "effective December 9, 2003, the date of recipe of your reopened claim." In fact, this was not a reopened claim but an appeal from the initial rating decision. As discussed further below, during a private orthopedic consult on May 23, 2002, the examiner noted a hypermobile patella and stable ligaments, and a tender medial patellar facet. The Board notes that the hypermobile patella is indicative of subluxation of the pattelae and is the earliest date within the appeal period that an increase is shown to have occurred (date entitlement arose) (38 C.F.R. § 3.400(o) (1). As such the Board has changed the effective date of the compensable evaluations for patellofemoral pain syndrome of the right and left knees from December 9, 2003 to May 23, 2002. There is no evidence of instability of either knee prior to May 23, 2002. Thus, it follows that instability of either knee was not factually ascertainable within the year prior to the Veteran's claim. Moreover, as entitlement arose after the filing of the claim, the Veteran is not in this case entitled to an award effective from the date of filing. In sum, there is no basis for an effective date prior to May 23, 2002, based on application of the regulations set forth above. b. Initial compensable disability ratings prior to May 23, 2002, and ratings in excess of 10 percent thereafter, for impairment of the right and left knees (previously characterized as patellofemoral pain syndrome of the right and left knees) The Veteran's service-connected right and left knee disabilities manifested by subluxation are each currently evaluated as noncompensably disabling effective November 16, 1999, and as 10 percent disabling effective May 23, 2002, pursuant to 38 C.F.R. § 4.71a , DC 5257. See 38 C.F.R. § 4.71a, DC 5257-5260 (2012). The Veteran was subsequently granted service connection for limitation of flexion of the right and left knees. Each knee is evaluated as 10 percent disabling, effective April 11, 2006. This disability evaluation was rated under Diagnostic Code 5260. The Board notes that this component of the disability as characterized by the RO was based on limitation of motion and separately rated from the initial service connected knee disorders. From November 16, 1999, to May 23, 2002, the Veteran is in receipt of a noncompensable rating under DC 5257 for patellofemoral syndrome of the right and left knees. Based on all available evidence for this applicable period, the Board does not find that compensable ratings are warranted from November 16, 1999 to May 23, 2002. As will be discussed below, at no point does the evidence show any subluxation or instability of either knee. Indeed, there are no significant objective findings supporting pathology of pain to award an increase. However from May 23, 2002 on, the medical evidence reveals slight bilateral knee impairment, subluxation. At an October 1999 fee based VA examination, prior to service separation, the Veteran complained of bilateral knee pain since September 1993, diagnosed as bilateral patellofemoral pain syndrome. He reported pain, weakness, stiffness, recurrent subluxation, swelling, inflammation, instability, fatigue, and lack of endurance. Symptoms were constant and brought on by daily activities and alleviate with rest. He reported that his knees were painful upon standing, running and hiking. During flare-ups his physical ability was impaired. He denied constitutional symptoms. He received physical therapy and was taught knee exercises without improvement. Physical examination of the knees revealed no heat, redness, swelling, effusion, drainage, abnormal movement, instability, or weakness. The examiner noted a normal gait with no limitation of standing and walking. There was slight laxity of the patellofemoral complexes noted without tenderness. The knees had 140 degrees of flexion and zero degrees of extension that was not affected by pain, fatigue, weakness, or lack of endurance. X-rays, drawer and McMurray tests, neurological and motor strength tests were all normal. There was no generalized muscle weakness or wasting shown. The diagnosis was bilateral knee patellofemoral pain syndrome, in remission. The post-service medical evidence includes VA outpatient treatment in April 2000. A physical examination at that time reveals full range of motion in the knees with crepitus but no swelling. The assessment was post-traumatic osteoarthritis of the knees. In sum, the objective evidence during this period in question fails to demonstrate even mild instability of either knee sufficient to warrant a compensable evaluation. The Board acknowledged that the Veteran is competent to report knee instability. Layno v. Brown, 6 Vet. App. 465 (1994). However, while he reported pain during treatment, he did not complain of instability or giving away. Overall, the lay evidence does not here overcome the absence of findings of instability upon examination. Consideration has been given to other potentially applicable Diagnostic Codes. The Board finds, however, that the symptomatology associated with the Veteran's bilateral knee impairment, subluxation is already contemplated by the 0 percent rating assigned for recurrent subluxation and lateral instability prior to May 23, 2002. The 0 percent rating contemplates asymptomatic residuals of subluxation and instability. Since May 23, 2002, the Veteran has been rated at 10 percent under DC 5257 for patellofemoral syndrome of the right and left knees. Based on all available evidence for this applicable period, an increased rating is not warranted because the evidence fails to show more than slight bilateral knee instability. Turning back to the evidence of record, private outpatient treatment records dated in May 2002 reflect complaints of right knee pain for 9 years. X-rays were negative. Objective examination showed a full range of motion in the right knee. The assessment was chronic right knee pain. On a private orthopedic consult on May 23, 2002, the Veteran complained of right knee pain on both sides of the patella that had been ongoing for 9 years. He reported his right knee pain was 5/10 on a pain scale and sometimes required him to limp. Physical examination showed a hypermobile patella, stable ligaments, flexion from 0 to 130 degrees, tender medial patellar facet, and no joint line tenderness. X-rays were within normal limits with a slight tilt. The diagnosis was patellofemoral pain syndrome. VA MRI of the right knee in August 2005 showed mild myxoid degeneration of the posterior horn of the medial meniscus without evidence of a frank tear and mild joint effusion. VA MRI of the left knee in September 2005 showed normal medial and lateral menisci and collateral ligaments, intact anterior and posterior ligaments, and no joint effusion. On VA outpatient treatment in December 2005, the Veteran complained of bilateral knee pain, left greater than right, of 12 years duration. He reportedly had been told that he had patellofemoral pain syndrome. His bilateral knee pain was worse with running and when he worked out regularly. He had a neoprene sleeve for his knee. Symptoms were described as dull and achy pain in the anterior part of the knees increased by increased activities. There was no catching, locking or giving way of the knees. Physical examination of the knees showed crepitus in the left knee. There was no evidence of effusion and no pain on full ROM. Flexion was to 115 degrees, and extension was to 0 degrees. There was no tenderness to palpation over the joint line or with pressure over the patella. Varus/ valgus/Lachman/ and McMurray tests were all negative. There was mild pain with palpation to the underside of the patellae. X-rays revealed joint spaces were well preserved with no osteophytes. There was mild decrease in the joint space medial compartment, right knee. MRI found no ligament or menici tears, the right knee had myxoid changes posterior horn medial meniscus. The assessment was patellofemoral pain syndrome in the knees, left greater than right. On VA examination in April 2006, the Veteran's complaints included bursitis and patellofemoral pain syndrome in both knees. He stated that he had been diagnosed as having patellofemoral pain syndrome during boot camp. He reported bilateral knee weakness, instability, stiffness, swelling, locking, occasional giving way, a lack of endurance, and fatigability. He also reported constant bilateral knee pain under his knee caps brought on by physical activity. It was relieved with rest and he was able to function without medication. He was not seeing a physician or taking medication for his knees. He was unable to run, and during pain was unable to perform his job. He lost about 1 day a month due to his bilateral knee pain. Physical examination showed a normal gait. The Veteran could ambulate without assistance and was able to sit up from a supine position and transfer from a chair to the examination table "without major difficulties." The knees showed no edema, effusion, weakness, tenderness, redness, heat, abnormal or guarding movement. There was slight bilateral knee subluxation without locking pain, joint effusion, or crepitus. There was no ankylosis. Range of motion testing of the knees was normal with flexion to 140 degrees and extension to 0 degrees without pain, fatigue, weakness, lack of endurance, or incoordination in each knee. The VA examiner noted that, after repetitive use, the Veteran would experience about 10 degrees additional limitation of motion in each knee because repetitive use caused increased knee joint strain. Varus/valgus, drawer and McMurray tests were within normal limits. The Veteran used no assistive devices and there was no limitation of function of standing or walking. Sensory and muscle testing of the lower extremities was normal. There was no muscle atrophy, fasciculation or fibrillation noted. X-rays of the knees were normal. The diagnosis was bilateral knee patellofemoral pain syndrome and bursitis bilateral knees. On VA outpatient treatment in August 2006, the Veteran's complaints included bilateral knee pain, left greater than right. The assessment included patellofemoral pain syndrome in the bilateral knees, left greater than right. On VA joints examination in May 2007, the Veteran's complaints included bilateral knee pain, left greater than right, since boot camp 12 years earlier. He wore an open patella knee brace with lateral and medical support and took Naprosyn for pain. There was no history of neoplasm or trauma, hospitalization or knee surgery. He reported the bilateral knees giving way, instability, pain, stiffness, weakness, and left knee locking. He reported severe flare-ups twice a week alleviated by resting, sitting, or driving in his patrol car. Physical examination showed a normal gait with no evidence of abnormal weight bearing. He needed no assistive devices and had no functional limitation on standing. or walking. X-rays of the knees showed no evidence of definitive abnormalities. The examiner noted that there was no evidence of any additional functional loss due to pain or flare-up of symptoms on repetitive flexion or extension. Although the Veteran stated that his symptoms had progressively worsened, his objective findings were not congruent with his subjective complaints. The rationale was that the Veteran had worked full time without restrictions as a VA police officer for the past two year. VA police officers had strenuous functional standards such as heavy lifting, 45 pounds and over, able to run in pursuit of suspects and to pass annual physical fitness examinations. The Veteran reported missing only one day on sick leave during the past 12 months (due to low back pain). He has not missed any days of work for his lower extremity conditions. The diagnosis was bilateral patella femoral pain syndrome which had no significant effects on general occupational function or activities of daily living. A May 2007 MRI of both knees revealed no evidence of definitive abnormality. In a September 2007 addendum to this examination report, it was noted that the Veteran's right and left knee flexion was from 0 to 140 degrees, and right knee extension was to 0 degrees without pain. On VA outpatient treatment in December 2007, the Veteran reported that, although he had experienced knee pain "a couple of months ago," it was "almost gone." The assessment included patellofemoral pain syndrome in the bilateral knees, left greater than right. A March 2009 MRI of the left knee indicated pes anserinus bursitis; patellar contusion; and, no evidence of internal derangement of the left knee. At an August 2012 VA examination, the examiner noted the Veteran developed bilateral knee pain in October 1993 during a 6 mile run. This was diagnosed as bilateral patellofemoral pain syndrome which reportedly has worsened over the years. The Veteran currently had knee pain especially when running. At that time, he was running 3 miles, 3 times a week. Once the pain/soreness began it took 3 days to resolve. Prolonged standing/walking (5 hours) also caused knee pain. He reported occasional swelling, and flare-ups which impact the function of his knees and lower legs. Examination revealed ROM of the right knee was 140 degrees of flexion and 0 degrees extension without objective evidence of painful motion. ROM of the left knee was 140 degrees of flexion and 0 degrees extension with objective evidence of painful motion at 140 degrees of flexion. The Veteran was able to perform 3 repetitions without LOM. The examiner noted that there was no evidence of any additional functional loss due to pain or flare-up of symptoms on repetitive flexion or extension. There was no evidence of tenderness or pain to palpation for the joint line or for soft tissue of either knee. Muscle strength, Lachman, posterior drawer, and varus/valgus testing was all normal bilaterally. The Veteran denied any arthroscopies or knee surgeries. There were no scars, effusion, heat, or erythema. There was evidence of slight bilateral recurrent patellar subluxation or dislocation, and very slight crepitus and occasional popping on the right knee. He occasionally used a knee brace. In consideration of the above evidence, the Board concludes that ratings in excess of 10 percent are not warranted here for the Veteran's instability of the knees from May 23, 2002. Indeed, the findings detailed above indicate no more than slight subluxation of the knees throughout the period in question. Thus, a rating in excess of 10 percent is not warranted under DC 5257. No other codes are found to be relevant here. For example, there is no evidence of dislocated semilunar cartilage with locking pain and effusion. Thus, Diagnostic Codes 5258, is not for application. Moreover, while the Veteran endorsed instability of the knees, such as at his April 2006 VA examination, the lay evidence does not sufficiently demonstrate a disability picture commensurate with the next-higher 20 percent rating for any portion of the rating period on appeal. Rather, the objective findings showing only mild instability is deemed the most probative evidence of record in this regard. In conclusion, the evidence fails to support a compensable rating for knee disability manifested by instability prior to May 23, 2002, and fails to support an evaluation in excess of 10 percent from that point forward, for either knee. Moreover, as the diagnostic criteria in question with respect to the Veteran's knee instability are not predicated on limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45, are not for consideration. Johnson v. Brown, 9 Vet. App. 7 (1996). In reaching the above conclusions, the Board has appropriately applied the benefit of the doubt doctrine. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). c. Entitlement to ratings in excess of 10 percent for disability manifested by limitation of motion of the knees. To this point, the Board has considered the propriety of the ratings assigned for the component of the Veteran's bilateral knee disabilities manifested by instability. From April 11, 2006, he is also in receipt of 10 percent ratings, left and right, based on limitation of motion. The Board finds no basis for assignment of ratings in excess of 10 percent, as will be discussed below. The relevant evidence of record has been detailed in the analysis above and need not be repeated here. Based on such evidence, an increased rating is not warranted for either knee for any portion of the rating period on appeal. Indeed, for the period in question since April 11, 2006, the evidence does not demonstrate limitation of flexion of either knee to 30 degrees. In fact, a review of the medical evidence since April 11, 2006 does not reveal any evidence of compensable limitation of flexion by examination. Additionally, there is no showing of extension limited to 15 degrees to warrant a higher evaluation pursuant to DC 5261. Moreover, as the record fails to establish both loss of flexion and extension to compensable levels separate ratings under each are not warranted. See VAOPGCPREC 9-2004 (September 17, 2004). In determining that higher evaluations are not warranted, the Board has considered additional functional limitation due to symptoms such as pain and weakness. See DeLuca, 8 Vet. App. 202. In this regard, the Veteran has reported upon examination that his knees were painful upon standing, running and hiking. The examination reports and other clinical records further reflect consistent complaints of knee pain. However, despite the Veteran's consistent pain complaints, there is no objective showing of additional functional loss resulting from such pain such as to enable a finding that his disability picture for either knee more nearly approximates the next-higher 20 percent rating. Again, pain alone does not constitute functional loss under VA regulations that evaluate disabilities based upon loss of motion. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). The Board has also considered whether a higher evaluation may be granted under other potentially applicable diagnostic codes is warranted. However, there is no evidence of ankylosis. Thus, DC 5256 is not for application. In sum, from April 11, 2006, there is no basis for a rating in excess of 10 percent for disability of the knees manifested by limitation of motion. In reaching this conclusion, the Board has appropriately applied the benefit of the doubt doctrine. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). II.d. Compensable disability rating for right heel plantar fasciitis with Achilles bursitis; and, SP ORIF, right distal fibula fracture with residual scar. The Veteran's service-connected right heel plantar fasciitis with Achilles bursitis currently is evaluated as noncompensable, effective November 16, 1999, by analogy to 38 C.F.R. § 4.71a , DC 5299-5019. See 38 C.F.R. § 4.71a, DC 5299-5019 (2012). The rating schedule provides that bursitis should be rated on the limitation of motion of the affected part, as arthritis, degenerative. 38 C.F.R. § 4.71a, Diagnostic Code 5019 (2012). Diagnostic code 5284 provides a 10 percent rating for moderate foot injury, and a 20 percent rating for moderately severe foot injury. 38 C.F.R. § 4.71a, Diagnostic Code 5281 (2012). Diagnostic code 5271 provides a 10 percent rating for moderate ankle limited motion, and a 20 percent rating for marked ankle limited motion. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2012). The Veteran's SP ORIF of the right distal fibula fracture with residual scar is evaluated under Diagnostic Code 5299-5262 for tibia and fibula, impairment of. Under Diagnostic Code 5262, a 10 percent evaluation is warranted for malunion of the ankle with slight knee or ankle disability; 20 percent is warranted for moderate disability; 30 percent is warranted for marked disability; and, 40 percent is warranted for nonunion, or loose motion requiring a brace. This is the maximum available under this diagnostic code. 38 C.F.R. § 4.71a. As the Veteran's SP ORIF of the right distal fibula fracture includes a residual scar, the Board will also consider a separate rating for such scar. Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against a compensable evaluation at any time during this appeal for right heel plantar fasciitis with Achilles bursitis; or, SP ORIF, right distal fibula fracture with residual scar. Neither the lay nor the medical evidence more nearly reflects the criteria for compensable evaluations. On VA examination in October 1999, the Veteran's complaints included right foot and heel pain since November 1996, and continued right ankle symptoms since his in-service right ankle distal fibular fracture and ORIF. He was treated with open reduction and internal fixation (ORIF) and placement of a plate with screws. This hardware was since removed. There was a scar, as well as some reduction in range of motion (ROM). He reported pain, weakness, stiffness, recurrent subluxation, swelling, inflammation, instability, fatigue, and lack of endurance. He further reported that his right ankle/Achilles area and foot were tight and sore due to the right ankle surgery. Symptoms were constant and brought on by daily activities and alleviate with rest. During flare-ups his physical ability was impaired. He denied that any prosthetic devices remained in his body. Physical examination of the ankles showed no heat, redness, swelling, effusion, drainage, abnormal movement, instability, or weakness. The examiner noted a normal gait with no limitation of standing and walking. There was a linear surgical scar on the right side of the distal leg and ankle, 10 cm long and 0.5 wide, well-healed, nontender, and without disfiguration, loss of motion (LOM) or limitation of daily activities. The right ankle had 15 degrees of dorsiflexion and 45 degrees of plantar flexion which was not affected by pain, fatigue, weakness, or lack of endurance. Examination of the feet revealed no signs of painful motion, edema, instability, weakness, or tenderness. X-rays revealed evidence of old trauma with internal fixation at the distal fibula; and no acute abnormality. The examiner noted no evidence of plantar fasciitis or Achilles bursitis at this examination. The diagnoses included status-post right ankle distal fibular fracture, status-post ORIF with placement and removal of hardware with residual reduction of range of motion and scar, right Achilles bursitis/right heel plantar fasciitis in remission. VA outpatient treatment in April 2000 reflect complaints of constant right ankle pain. Physical examination showed a right ankle scar, right ankle dorsiflexion to 10 degrees actively and 15 degrees passively, and right ankle plantar flexion to 20 degrees actively and 35 degrees passively. The assessment was post-traumatic osteoarthritis of the right ankle. A May 2000 VA record shows 5/5 strength in the right ankle. He had dorsiflexion to 4 (subtalar neutral). VA X-rays of the right ankle and tibia and fibula in June 2000 showed a few small corticated bone densities inferior to the medial malleolus probably on a congenital or old post-traumatic basis and a healed fracture involving the distal fibula with the residual of previous orthopedic hardware in the area. VA X-rays of the right tibia and fibula in June 2005 showed no obvious recent fracture or dislocation. On VA examination in April 2006, the Veteran's complaints included right tibia and fibula impairment, and bursitis in both ankles. He reported bilateral ankle weakness, instability, swelling, giving way, and a lack of endurance. His in-service right fibula fracture was noted. He reported intermittent right ankle pain "about 3 times a week lasting for 3 hours." It was a crushing aching pain with stiffness relieved with rest. He was able to function without medication. He rated it as 10/10. He was not seeing a physician or taking medication for his right ankle. He reported lack of endurance during physical activity. Functional impairment resulting from his joint condition was that ROM of his right ankle was impaired and his joints hurt with prolonged standing. He lost no time from work. Physical examination of the tibia and fibula was normal bilaterally. The examiner noted a linear scar 8.5 cm at the lateral aspect, right distal leg and ankle 0.5 wide, with disfigurement and hyperpigmentation and abnormal texture without tenderness, ulceration, adherence, instability, inflammation, edema, tissue loss, keloids, or hypopigmentation. Examination of the ankles showed no edema, effusion, weakness, tenderness, redness, heat, abnormal movement, guarding, subluxation, or ankylosis. Range of motion testing of the right ankle showed dorsiflexion to 20 degrees and plantar flexion to 45 degrees without pain, fatigue, weakness, lack of endurance, or incoordination. Examination of the feet revealed no evidence of abnormal weightbearing, callus formation or skin breakdown. The Veteran used no assistive devices and there was no limitation of function of standing or walking. Sensory and muscle testing of the lower extremities was normal. There was no muscle atrophy, fasciculation or fibrillation noted. X-rays revealed evidence of old trauma with internal fixation at the right tibia and fibula; and no acute abnormality. The VA examiner noted that the Veteran would experience pain, fatigue, weakness, lack of endurance, and incoordination at the end of the normal range of motion in the right ankle but could not express this in terms of additional degrees of lost motion. X-rays had no significant findings except for small lucencies in the right distal fibula which suggested previous internal fixation abnormalities. The diagnoses included bursitis of the bilateral ankles, and tibia and fibula impairment. On VA general medical examination in May 2007, the Veteran's complaints included right heel plantar fasciitis, right Achilles bursitis, and chronic right ankle pain while walking and standing. The examiner reviewed the claims file, including his service treatment records. The Veteran denied any swelling, heat, redness, or weakness. He reported stiffness, fatigability, and a lack of endurance. His right heel felt as if there was no cushioning and he was unable to stay on his feet for long periods (greater than 1 hour). When he woke both feet were in pain, as if he was walking on pins and needles. He wore night splints to keep his feet dorsiflexed. He reported current treatment but the condition has progressively worsened. He also noted weekly flare-ups of pain which lasted between 30 minutes and 1 hour. Physical examination of the right foot showed no painful motion, swelling, tenderness, instability, weakness, or abnormal weight bearing. There was no evidence of hammertoes, hallux valgus or rigidus, skin or vascular abnormality, pes cavus, or malunion or non union of the metatarsal bones. There was normal Achilles alignment with no pain or spasm on manipulation. There also was mild pronation. X-rays of the right foot showed a post-traumatic deformity versus post-surgical changes involving the distal fibula, and a very small osteophyte off the posterior distal tibia. The diagnoses were SP right fibula fracture without residuals; SP right Achilles bursitis, in remission; and, right heel, plantar fasciitis, in remission. These had no significant effects on general occupational function or activities of daily living. The examiner noted that although the Veteran stated that his symptoms had progressively worsened his objective findings were not congruent with his subjective complaints. The rationale was that the Veteran had worked full time without restrictions as a VA police officer for the past two year. VA police officers had strenuous functional standards such as heavy lifting, 45 pounds and over, able to run in pursuit of suspects and to pass annual physical fitness examinations. The Veteran reported missing only one day on sick leave during the past 12 months due to low back pain. He had not missed any days of work for his right ankle or right foot conditions. At an August 2012 VA examination, the examiner noted the Veteran ran 3 miles 3 times a week. Prolonged standing/walking (5 hours) also causes pain. He reported occasional swelling, and flare-ups which impact the function of his lower legs. On examination of the feet, the examiner noted a history of bilateral plantar fasciitis. The Veteran developed bilateral foot problems in 1994-1995. He reported heel soreness and was told he had collapsed arches. Currently he had increased pain in his right heel and arch. He used orthotics with some relief. He had similar problems to a lesser degree on the left foot. The pain was worse in the morning upon awakening. The examiner noted a history of a right ankle injury during service in 1996. He had an ORIF with insertion of a plate and screws which had since been removed. The scar remained sensitive. The right ankle aches if he walks or stands for a prolong period. He reported daily pain and flare-ups but does not take medication. On examination of the feet, there was no evidence of deformity, pain on manipulation, heat, redness, swelling, effusion, drainage, abnormal movement, instability, or weakness. There was no pain or tenderness on palpation of the soft tissue or joint of either ankle. Muscle strength was normal bilaterally. Anterior drawer, and talar tilt testing was normal bilaterally. There was no evidence of ankylosis. There was no evidence of Morton's neuroma, hammertoes, hallux valgus or rigidus, pes cavus, or malunion or non union of the metatarsal bones, bilateral weak foot, or any other foot injury. Right ankle dorsiflexion was to 20 degrees, and there was 45 degrees of plantar flexion without objective evidence of pain on motion. The Veteran was able to perform 3 repetitions without additional LOM. There was no functional loss or impairment of the bilateral ankles noted. Imaging studies of the feet found degenerative or traumatic arthritis of the right foot. There was a very small osteophyte protruding off the posterior distal tibia. The examiner noted the Veteran had no evidence of Achilles bursitis on either foot or ankle as evidenced by lack of swelling, tenderness to palpations, or increased warmth around the Achilles tendons. The examiner remarked that right ankle pain occurred on a regular basis and was consistent with his level of traumatic arthritis of the right ankle joint seen on X-rays. Over time the examiner noted the condition was expected to worsen as the ankle was a major weightbearing joint. The right ankle joint pain does affect ordinary activity and would affect employment that required prolonged standing/walking/weight bearing. The diagnosis was a post traumatic deformity vs. post surgical changed involving the distal fibula, right foot. At a February 2013 VA scars examination, the examiner noted the Veteran had a right ankle scar resulting from an ORIF for a right fibula fracture in 1996. The Veteran currently wore boots that rubbed against his ankle scar, making it more sensitive. The examiner noted that the scar was not painful, or unstable with loss of covering skin over the scar. The right ankle scar was a well healed linear scar, with no inflammation or infection. The scar had no impact on the Veteran's ability to work. He was currently working as campus security and was in the Marine Reserves. During this appeal, the medical evidence has not reflected that the right heel plantar fasciitis with Achilles bursitis or the SP ORIF of the right distal fibula fracture with residual scar causes limitation of right foot motion comparable to moderate limitation of ankle motion or comparable to a moderate foot injury DC 5271, 5284. Likewise, the medical evidence has not reflected that the SP ORIF, right fibula fracture residuals has caused any malunion of the ankle with slight ankle disability. DC 5262. Likewise, while there is X-ray evidence of traumatic arthritis of the right heel plantar fasciitis with Achilles bursitis, and SP ORIF of the right distal fibula fracture with residual scar, the August 2012 VA examination revealed full right ankle ROM of 20 degrees of dorsiflexion, and 45 degrees of plantar flexion without objective evidence of pain on motion. VA examinations in October 1999, April 2006, May 2007, and August 2012 revealed no limitation of motion of the right foot or impairment of the right distal fibula that would support a minimum compensable evaluation under Diagnostic Codes 5019, 5262, 5271, or 5284. These separate reports of VA examination show no more than slight occasional limitation of motion of the right foot. There was no evidence of right ankle disability shown by examination. While the Veteran reported flare-ups of pain with running, standing, and walking, neither his statements, nor the medical findings, reflect that the range of motion of the right foot was more than slightly limited at any time during the appeal period. Likewise, neither his statements nor the medical findings reflect that the SP ORIF right tibia residuals appear to be symptomatic throughout the appeal period. Compensable evaluations for right heel plantar fasciitis with Achilles bursitis under Diagnostic Code 5019 and for SP ORIF, right distal fibula fracture with residual scar under Diagnostic Code 5262 are not warranted by direct application or when considering the tenets of 38 C.F.R. §§ 4.40, 4.45, and 4.59. The Board has considered DeLuca, 8 Vet. App. 202, but finds no weakened movement, excess fatigability, or incoordination to award an increase on that basis. DeLuca, 8 Vet. App. 202 was considered in determining the rating for the right heel plantar fasciitis with Achilles bursitis; and for SP ORIF, right distal fibula fracture with residual scar. The Board acknowledges the Veteran's complaints of pain with walking and with activity, as well as complaints of weakness, stiffness, giving way and lack of endurance. Although the medical evidence shows some evidence of traumatic arthritis of the right heel, in general the range of motion testing was accomplished without pain in the right foot. The examiners have consistently found no pain on range of motion testing and that after repetitive motion, the range of motion of the right foot/ankle was not further limited by pain, fatigue, weakness, lack of endurance, or incoordination. While the Veteran has consistently complaints of frequent flare-ups that cause limited ambulation and difficulty walking, the VA examination consistently have noted that the Veteran had no additional limitation of motion after repetitive range of motion testing as a result of pain, fatigue, weakness, lack of endurance or incoordination. In fact examiners have found no evidence of right heel Achilles bursitis. In any event, the Board acknowledges that no VA examiner has expressly quantified any additional loss of motion during periods of flare-up. However, in this case such deficiency does not require further development. Indeed, any decrease in functionality is deemed insignificant from a rating standpoint based on other evidence available in the record. Again, the same August 2012 VA examination report that notes flare-ups also notes the Veteran's report of running 3 miles 3 times per week. Thus, any functional impact from flare-ups would be so minimal as to not warrant any change in rating. In fact, it appears that the Veteran runs during flare-ups, and simply has pain at such times. Again, pain alone does not constitute functional loss under VA regulations that evaluate disabilities based upon loss of motion. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Consideration has also been given to increased evaluations under other potentially applicable diagnostic codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The medical evidence reveals that there is no instability of the Veteran's right heel plantar fasciitis with Achilles bursitis on examination and no more than slight limitation of motion of the right foot. Although the Veteran has complained of limitation of motion, pain and giving way of the right foot, the medical evidence of record consistently reflects that there is no more than slight loss of motion due to the right heel plantar fasciitis with Achilles bursitis. Consequently, a separate rating on this basis is not warranted for the right heel plantar fasciitis with Achilles bursitis. 38 C.F.R. § 4.71a, Diagnostic Code 5271, 5284. The Board finds that, for the period in question, the evidence does not demonstrate more than slight limitation of motion of the right foot/ankle. In addition, the Veteran's SP ORIF right tibia with scar does not exhibit any related ankle disability. In addition, a scars examination in February 2013 found the scar to be superficial, not painful, unstable, or limiting the function of the right ankle. It was a well healed linear scar, with no inflammation or infection, and did not impact on the Veteran's ability to work. In so finding, the Board has considered the Veteran's statements regarding his right foot/ ankle and SP ORIF, right tibia symptomatology, to include those noted above, as well as his reports upon examination that he had symptoms that were constant and brought on by daily activities and alleviated with rest. While competent to make such statements, they fail to establish a disability picture evidencing more than slight limitation of motion of the right heel plantar fasciitis with Achilles bursitis, or any SP ORIF of the right distal fibula disability particularly in light of the objective testing performed by medical professionals. For the above reasons, there is no support for an increased rating for either right heel plantar fasciitis with Achilles bursitis or for status post ORIF. The Board has also considered whether a separate compensable rating was warranted for the residual surgical scar from the Veteran's SP ORIF, right distal fibula fracture. This scar may be separately rated under the provisions of 38 C.F.R. § 4.118, which rates scars based on varying manifestations. In this regard, the Board notes that as of October 23, 2008, revised provisions for evaluating scars were enacted. This new regulation, however, indicates that the revised provisions are applicable only to claims received on or after October 23, 2008, unless the Veteran requests his claim be evaluated under the new criteria. 73 Fed. Reg. 54708 (Sept. 23. 2008). He has not done so in this case. Under both the regulations in effect prior and since October 23, 2008, Diagnostic Code 7800 rates scars of the head, face, or neck, and does not apply in this case as the residual scar is located on the Veteran's right lower leg. 38 C.F.R. § 4.118. The pre-amended Diagnostic Code 7801 provides ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. The pre-amended Diagnostic Code 7802 provides ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. In this case, the residual scar has not been shown to cover an area or areas of 144 square inches (929 sq. cm.) or greater. The scar has been shown to variously be 8.5 to 10 cm by 0.5 cm. In addition, the residual scar has been shown to be linear. The pre-amended Diagnostic Code 7803 provides ratings for superficial unstable scars, and does not apply in this case as the residual scar has not been shown to be unstable. The pre-amended Diagnostic Code 7804 provides a 10 percent rating for superficial scars that are painful on examination. In this case, the residual scar has not been shown to be unstable or painful on examination. Finally the pre-amended Diagnostic Code 7805 provides ratings for scars based on limitation of function of affected part. Id. In this case, the residual scar has not been shown to limit the function of the right lower extremity or to have any disabling effects. Further regarding scars, the August 2012 VA examination indicated that the residual scar from the 1996 right ankle ORIF remained sensitive. However, a subsequent scar examination in February 2013 determined that the scar was not painful, or unstable with loss of covering skin over the scar. The right ankle scar was a well healed linear scar, with no inflammation or infection and did not impact on the Veteran's ability to work. As the February 2013 examination was specifically rendered to evaluate the scar, it is deemed the most probative evidence as to the Veteran's scar symptomatology. The isolated and somewhat nonspecific August 2012 finding of sensitivity is not deemed adequate to warrant a compensable evaluation for that period on appeal. For the foregoing reasons, a separate rating for the scar residual is not warranted under any applicable diagnostic codes concerning scars. Extraschedular Rating Although the Board is precluded by regulation from assigning extraschedular ratings under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for a service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology related to his left and right knee painful motion; his left and right knee instability; right heel plantar fasciitis with Achilles bursitis; and, SP ORIF, right distal fibula fracture with residual scar, and provide for higher ratings for more severe symptoms. As the disability pictures are contemplated by the Rating Schedule, the assigned schedular ratings are, therefore, adequate. Consequently, an additional referral for extraschedular consideration at this time is not required under 38 C.F.R. § 3.321(b) (1). ORDER An earlier effective date for the award of a 10 percent evaluation for impairment of the right knee and the left knee (previously characterized as patellofemoral pain syndrome of the right and left knees), from December 9, 2003 to May 23, 2002 is granted. An initial compensable disability rating prior to May 23, 2002, and a rating in excess of 10 percent thereafter, for impairment of the right knee (previously characterized as patellofemoral pain syndrome of the right knee), is denied. An initial compensable disability rating prior to May 23, 2002, and a rating in excess of 10 percent thereafter, for impairment of the left knee (previously characterized as patellofemoral pain syndrome of the left knee), is denied. A rating in excess of 10 percent for limitation of flexion of the right knee is denied. A rating in excess of 10 percent for limitation of flexion of the left knee is denied. A compensable disability rating for right heel plantar fasciitis with Achilles bursitis is denied. A compensable disability rating for status-post open reduction internal fixation (ORIF) of right distal fibula fracture with residual scar is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs