Citation Nr: 1319397 Decision Date: 06/14/13 Archive Date: 06/21/13 DOCKET NO. 08-10 211 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an initial rating in excess of 20 percent for right shoulder instability with glenohumeral osteoarthritis prior to May 2, 2007. 2. Entitlement to an initial rating in excess of 30 percent for right shoulder instability with glenohumeral osteoarthritis from May 2, 2007. 3. Entitlement to a rating in excess of 10 percent for degenerative changes of the right knee, status post medial meniscus tear. 4. Entitlement to a rating in excess of 20 percent for arthritis of the right ankle. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty from September 1972 to December 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In a May 2006 rating decision, the RO granted service connection for right shoulder instability with glenohumeral osteoarthritis, and assigned a 20 percent rating effective December 27, 2005. The RO also deferred an increased rating for degenerative changes of the right knee, status post right medial meniscus tear. In October 2006, the RO denied entitlement to a rating in excess of 10 percent for degenerative changes of the right knee, status post right medial meniscus tear. In a March 2007 rating decision, the RO continued the 20 and 10 percent ratings for the right shoulder and right knee, respectively. In an August 2007 rating decision, the disability rating for the right shoulder was increased to 30 percent, effective May 2, 2007. In addition, the disability rating for arthritis of the right ankle was increased to 20 percent, effective May 2, 2007. The disability rating for the right knee disability was continued as 10 percent disabling. This matter was previously remanded by the Board in November 2011 for additional development, and now returns to the Board for further review. A portion of the Veteran's records are contained in the Virtual VA system. Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide a Veteran's claim for benefits. Because the current appeal was processed as part of the Virtual VA system, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The Veteran recently submitted additional evidence in support of his claim, along with an appropriate waiver of RO consideration. Therefore, the appeal may proceed. See 38 C.F.R. § 20.1304(c) (2012) (any pertinent evidence accepted directly at the Board must be referred to the agency of original jurisdiction (AOJ) for initial review unless this procedural right is waived by the appellant). FINDINGS OF FACT 1. Prior to May 2, 2007, for right shoulder instability with glenohumeral osteoarthritis was manifested by recurrent episodes of dislocation with guarding of all arm movements. 2. From December 27, 2005, right shoulder instability with glenohumeral osteoarthritis was not manifested by a fibrous union of the humerus, or range of motion limited to 25 degrees from the side. 3. Degenerative changes of the right knee, status post medial meniscus tear, are manifested by x-ray findings of arthritis with some limitation of motion; locking, effusion, and ankylosis have not been demonstrated. 4. Right ankle arthritis is manifested by ankylosing osteoarthritis with zero degrees of dorsiflexion. CONCLUSIONS OF LAW 1. Prior to May 2, 2007, the criteria for a 30 percent rating for right shoulder instability with glenohumeral arthritis have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5201, 5202 (2012). 2. From December 27, 2005, the criteria for a rating in excess of 30 percent for right shoulder instability with glenohumeral arthritis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5201, 5202 (2012). 3. The criteria for a separate 10 percent rating, but not higher, for degenerative changes of the right knee, status post medial meniscus tear have been met; the criteria for a rating in excess of 10 percent for instability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5257, 5261 (2012). 4. The criteria for a 30 percent rating, but not higher, for right ankle arthritis have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5270 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 A. Duty to Notify Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2012). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to his right shoulder claim, the Veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, the U.S. Court of Appeals for Veterans Claims (Court) held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. Moreover, letters dated in February 2006, May 2007, and November 2011 were sent to the Veteran in accordance with the duty to notify provisions of the VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was notified of the evidence that was needed to substantiate his claims; what information and evidence that VA will seek to provide and what information and evidence the Veteran was expected to provide, and that VA would assist him in obtaining evidence, but that it was his responsibility to provide VA with any evidence pertaining to his claims. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). B. Duty to Assist Pursuant to the Board's November 2011 remand, VA was to obtain the Veteran's recent treatment records, and provide him with examinations to assess the severity of his service-connected disabilities on appeal. A review of the records shows that the Veteran's service treatment records, VA treatment records, private treatment records, and lay statements have been associated with the claims file. The Veteran was also afforded VA examinations, most recently in December 2011. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations obtained in this case are adequate as they are collectively predicated on a review of the claims file; contain a description of the history of the disabilities at issue; document and consider the relevant medical facts and principles; and record the relevant findings for rating the Veteran's shoulder, knee, and ankle conditions. VA's duty to assist with respect to obtaining a VA examination or opinion for the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The directives of the Board's November 2011 remand have been satisfied. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Court or the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders). VA has provided the Veteran with the opportunity to submit evidence and argument in support of his claims. The Veteran has not made the Board aware of any additional evidence that needs to be obtained prior to appellate review, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Increased Ratings A. Applicable Law Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that 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 (2008). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The Court has held that the RO must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" 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) did not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The Board notes that the guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. However, pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (holding that pain alone does not constitute function loss, but is just one fact to be considered when evaluating functional impairment). B. Right Shoulder The Veteran's right shoulder instability with glenohumeral osteoarthritis is rated under Diagnostic Code 5202. He is assigned a 20 percent rating from December 27, 2005 to May 1, 2007, and a 30 percent rating thereafter. The Veteran is right hand is his dominant (major) upper extremity. Diagnostic Code 5202 provides a 20 percent rating for impairment of the major extremity caused by malunion resulting in moderate deformity, or for recurrent dislocation of the scapulohumeral joint with infrequent episodes, and guarding of movement at the shoulder level. The next higher 30 percent rating is warranted for malunion resulting in marked deformity, or for recurrent dislocation of the scapulohumeral joint with frequent episodes, and guarding of all arm movements. A 50 percent rating applies to a fibrous union of the humerus. A 60 percent rating is assigned for nonunion of the humerus (false flail joint). An 80 percent rating applies to loss of head of the humerus (flail shoulder). 38 C.F.R. § 4.71a. Diagnostic Code 5201 provides that limitation of motion of the arm at shoulder level warrants a 20 percent rating. Limitation of motion of the arm from midway between the side and shoulder level warrants a 30 percent rating for a major extremity. Limitation of motion to 25 degrees from the side warrants a 40 percent rating for a major extremity. Id. Both measurements of forward flexion and abduction are relevant to determine range of motion in the affected shoulder, for purpose of applying Diagnostic Code 5201. See Mariano v. Principi, 17 Vet. App. 305, 314-16 (2003). Normal range of motion for the shoulder is defined as from 0 degrees of extension to 180 degrees of forward flexion; abduction from 0 to 180 degrees, and external and internal rotation from 0 to 90 degrees. See 38 C.F.R. § 4.71a, Plate I. Diagnostic Code 5203, which addresses impairment of the clavicle or scapula, does not provide for a rating in excess of 20 percent. Furthermore, there is no evidence of shoulder ankylosis, and therefore Diagnostic Code 5200 is not applicable. In a December 2005 letter, the Veteran's private physician stated that the Veteran had a longstanding history of right shoulder instability requiring previous reductions under anesthesia, and evolving increasing pain and progressive disability. The Veteran underwent a VA examination in April 2006. He reported having instability, pain, stiffness, and weakness. He experienced dislocations once or twice a year. There was no history of locking or effusion. He also experienced flare-ups every 3 or 4 months which lasted 1 or 2 days. These flare-ups were manifested by increased pain and stiffness. On examination, the Veteran had 120 degrees of flexion and abduction, with the onset of pain at the end range of motion. There was no additional limitation following repetitive testing. The examiner noted that there were recurrent shoulder dislocations, with associated guarding of movement at shoulder level only. There was no inflammatory arthritis or joint ankylosis present. The condition had severe effects on exercise, sports, and recreation activities. Effects on dressing and grooming were moderate. Private treatment records dated July 2006 also noted chronic instability of the right shoulder due to recurrent dislocations. The Veteran had 120 degrees of abduction, but experienced pain with impingement and with crossover. A November 2006 letter from the Veteran's private physician noted that the Veteran reported having to guard all arm movements to avoid dislocation. Additional records dated April 2007 noted that the Veteran had difficulty with abduction and rotation. Shoulder strength was described as "poor." In June 2007, the Veteran had pain with extreme shoulder motion. The Veteran underwent a VA examination in June 2007. He reported experiencing dislocations several times per week. He denied any locking or effusion. On examination flexion and abduction were both 90 degrees, with the onset of pain at the end range of motion. There was no additional limitation following repetitive testing. The examiner noted recurrent dislocations, and noted the presence of guarded motion due to pain. The Veteran's condition prevented sports activities. There were severe effects on exercise activities. Feeding, recreation, and chores were moderately affected. Shopping, bathing, dressing, toileting, and grooming were mildly affected. VA treatment records dated November 2008 noted no pain or tenderness in the joints, with "good" range of motion in the shoulder. Additional records dated November 2010 noted limited range of motion in the overhead fields. In October 2011, the Veteran was noted to have pain in the anterior shoulder and rotator cuff. Range of motion in the shoulder was relatively well-maintained, but was very painful in extremes in the overhead fields. The Veteran underwent another VA examination in December 2011. Right shoulder flexion and abduction were both 85 degrees, with the onset of pain at 60 degrees. There was no additional limitation following repetitive testing. There was guarding of the right shoulder. Ankylosis of the shoulder joint was not present. The examiner noted frequent episodes of recurrent dislocations, with associated guarding of all arm movements. Based on the evidence of record, a 30 percent rating is warranted from December 27, 2005 to May 1, 2007. The April 2006 VA exam noted guarding of movements at shoulder level only, with shoulder dislocations occurring only once or twice a year. However, the subsequent November 2006 letter from the Veteran's private physician noted recurrent dislocations, and the Veteran reported having to guard all arm movements. These findings are consistent with a higher 30 percent rating under Diagnostic Code 5202, which contemplates frequent dislocations with guarding of all arm movements. However, a rating in excess of 30 percent is not warranted at any time since December 27, 2005. A higher rating under Diagnostic Code 5202 requires findings of a fibrous union of the humerus. However, this manifestation was not demonstrated at any point during the period on appeal, despite several VA examinations and additional treatment records. To the extent that the Veteran himself has asserted that his shoulder condition includes a fibrous union, lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, as to the specific issue in this case, a fibrous union of the humerus falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Veteran has not demonstrated the necessary knowledge or expertise to diagnose such a condition. Similarly, a higher 40 percent rating is not warranted under Diagnostic Code 5201. At no time during the period on appeal has the Veteran's right shoulder range of motion been limited to 25 degrees for either flexion or abduction, including limitations due to pain. Notably, certain records refer to limited range of motion without referencing specific degree measurements. However, of those findings which include such measurements, the Veteran's range of motion was, at worst, 60 degrees of flexion and abduction. This is not consistent with a higher rating under Diagnostic Code 5201. C. Right Knee The Veteran is currently assigned a 10 percent rating under Diagnostic Code 5257 for his degenerative changes of the right knee, status post medial meniscus tear. There are several Diagnostic Codes applicable to the Veteran's claim. Under Diagnostic Code 5003, degenerative arthritis, when substantiated by X-rays, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent disability rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent disability rating is warranted with x-ray evidence of involvement of two or more major joints or two or more minor joint groups. Note 1 accompanying Diagnostic Code 5003 states that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based upon limitation of motion. 38 C.F.R. § 4.71a. Diagnostic Code 5260 provides ratings based upon the limitation of flexion in the leg. A noncompensable rating is assigned when flexion is limited to 60 degrees. 10 percent rating is assigned when flexion is limited to 45 degrees. A 20 percent rating is assigned when flexion is limited to 30 degrees. A 30 percent rating is assigned when flexion is limited to 15 degrees. Id. Diagnostic Code 5261 provides ratings based upon the limitation of extension in the leg. A noncompensable rating is assigned when extension is limited to 5 degrees. A 10 percent rating is assigned when extension is limited to 10 degrees. A 20 percent rating is assigned when extension is limited to 15 degrees. A 30 percent rating is assigned when extension is limited to 20 degrees. A 40 percent rating is assigned when extension is limited to 30 degrees. A 50 percent rating is assigned when extension is limited to 45 degrees. Id. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. Id. The VA General Counsel held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and under Diagnostic Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (September, 2004). Diagnostic Code 5257 provides ratings for recurrent subluxation or lateral instability of the knee. A 10 percent rating is warranted for a slight knee disability. A 20 percent rating is warranted for a moderate knee disability. A 30 percent rating is warranted for a severe knee disability. 38 C.F.R. § 4.71a. The Board observes that the words "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. It should also be noted that use of terminology such as "mild" and "moderate" by VA examiners or other physicians, 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. The VA General Counsel has also held that a claimant who has arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9- 98, (August, 1998). VA's General Counsel further explained that if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. Id. In this regard, in applying Diagnostic Code 5003, the Court has held in the case of Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991), that "painful motion of a major joint . . . caused by degenerative arthritis, where the arthritis is established by X-ray, is deemed to be limited motion and entitled to a minimum 10 percent rating, per joint, combined under Diagnostic Code 5003, even though there is no actual limitation of motion." See also 38 C.F.R. § 4.59 (2012). Finally, Diagnostic Code 5258 provides that dislocated semilunar cartilage with frequent episodes of "locking," pain and effusion into the joint is rated at 20 percent. 38 C.F.R. § 4.71a. The Board notes there are other pertinent diagnostic criteria for rating knee disabilities. However, these criteria do not allow for ratings in excess of 10 percent, or the objective evidence of record does not contain any of the relevant findings: ankylosis of the knee (rated under Diagnostic Code 5256); removal of semilunar cartilage (rated under Diagnostic Code 5259); nonunion or malunion of the tibia and fibula (rated under Diagnostic Code 5262); or genu recurvatum (rated under Diagnostic Code 5263). 38 C.F.R. § 4.71a. Private records dated December 2005 show the Veteran reported difficulty with flexion and extension. Examination revealed pain in the right knee, as well as obvious crepitus with flexion and extension. X-rays showed degenerative arthrosis. Additional records dated July 2006 noted similar findings, but found no gross instability in the knee. A November 2006 letter from the Veteran's private physician shows the Veteran reported difficulty with his gait. He had problems traversing stairs, and he had to watch how he traversed terrain to avoid twisting. Additional records dated April 2007 show the Veteran described having difficulty with standing and sitting. He received injections to treat his knee pain. In June 2007, he was noted to have pain with extreme motion. He was prescribed a sleeve to wear on his knee. A VA examination was conducted in June 2007. He reported a gradual onset of pain and locking after his initial injury in service. He reported being unable to stand for more than a few minutes and being unable to walk for more than a few yards. He experienced pain and weakness in the knee. On examination, the Veteran had a normal gait. Range of motion was 0 degrees extension to 50 degrees of flexion, with the onset of pain at 50 degrees. There was no additional limitation following repetitive testing. No crepitation, grinding, or instability was present. The examiner stated that the Veteran's condition had moderate effects on chores, shopping, exercise, sports, recreation, and traveling. Bathing and dressing were mildly affected. VA treatment records dated October 2007 noted decreased range of motion in the right knee, but did not provide specific measurements. Private records dated January 2008 showed the Veteran complained of severe knee pain. On examination, he had full extension and flexion with mild patellofemoral crepitation. There was pain with varus and valgus stressing, but no instability was present. He had a normal gait. A trace effusion may have been present. VA records from November 2008 indicated that range of motion was "good," but no specific measurements were provided. Private records dated November 2010 and October 2011 noted that the Veteran had full range of motion of the knee. Mild crepitus was present, and the Veteran experienced pain with extreme motion. He had a slightly antalgic gait. The Veteran underwent another VA examination in December 2011. He reported having pain but denied any flare-ups. Right knee flexion was 140 degrees, with the onset of pain at 60 degrees. Extension was 10 degrees. There was no additional limitation following repetitive testing. Pain was present with palpation. Strength was 5/5. There was no anterior or posterior instability. Lateral instability could not be tested. The examiner noted that there was no evidence of any recurrent subluxation or dislocation. The Veteran had a history of a meniscus tear with meniscectomy. The examiner noted that the Veteran had frequent episodes of pain, but no episodes of locking or effusion. The Veteran's condition impaired his functioning as a teacher as a result of pain with standing. Based on the evidence, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's right knee condition under DC 5257. However, a separate 10 percent rating under Diagnostic Code 5261 is appropriate. First, although the Veteran has a history of semilunar cartilage dislocation, the evidence does not reflect that this has resulted in frequent episodes of locking, pain, and effusion. Although he reported a gradual onset of locking during his June 2007 VA examination, there were no additional complaints of locking in any other examination or treatment record, and no objective findings of locking were ever noted. Locking was specifically noted to be absent in the December 2011 examination. Similarly, there are no findings of frequent effusions into the knee. A trace effusion may have been present in January 2008, but otherwise the record is negative for any findings or complaints of effusion. Therefore, a higher rating under Diagnostic Code 5258 is not warranted. A rating under Diagnostic Code 5260 is also not warranted. The record reflects some difficulty with flexion, and the Board notes that some records show decreased range of motion without including specific measurements. However, at no point during the period on appeal was flexion noted to be 45 degrees or less, even when accounting for pain and other limiting factors. At worst, flexion of the knee was limited to 50 degrees. Therefore, the criteria for a compensable rating for flexion have not been met. As noted above, the Veteran is currently assigned a 10 percent rating under Diagnostic Code 5257. While the Veteran was prescribed a sleeve for his knee, the record is negative for any findings of instability, and the Veteran did not report any subjective complaints of instability or giving way. Therefore, a higher rating under this Diagnostic Code is not warranted. The Board has also considered a rating under Diagnostic Code 5261 for limitation of extension. For most of the period on appeal, there were no specific findings that extension was limited to a compensable level (10 degrees) until the December 2011 VA examination. Extension was noted to be limited to 10 degrees at that time, which meets the criteria for a 10 percent rating under DC 5261. However, the Veteran's condition has been manifested by arthritis, with findings of limited motion and crepitation, throughout the period on appeal. See 38 C.F.R. § 4.59. Therefore, in addition to the currently assigned 10 percent rating under Diagnostic Code 5257, a separate 10 percent rating under Diagnostic Code 5261 is also warranted throughout the entire appellate period, based upon additional disabling symptomatology. A higher 20 percent rating under 5261 is not appropriate, however, as extension was not shown to be limited to 15 degrees at any time. As a separate rating under Diagnostic Code 5261 has been awarded, a rating under Diagnostic Code 5003 is not appropriate. D. Right Ankle The Veteran is currently assigned a 20 percent rating under Diagnostic Code 5010-5271 for his right ankle arthritis. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5271 addresses limited motion of the ankle. The assigned 20 percent rating contemplates "marked" limitation of ankle motion and is the maximum rating available. Similarly, Diagnostic Code 5010, which addresses arthritis, does not provide for ratings in excess of 20 percent. There are also other Diagnostic Codes for rating ankle disabilities which do not allow for ratings higher than 20 percent. These include ankylosis of the subastragalar or tarsal joint (rated under Diagnostic Code 5272); malunion of the os calcis or astragalus (rated under Diagnostic Code 5273); or astragalectomy (rated under Diagnostic Code 5274). 38 C.F.R. § 4.71a. Under Diagnostic Code 5270, a 20 percent evaluation also is assigned for ankylosis of the ankle in plantar flexion less than 30 degrees. A higher 30 percent rating is assigned for ankylosis of the ankle in plantar flexion, between 30 and 40 degrees, or in dorsiflexion, between 0 and 10 degrees. A 40 percent rating is assigned for ankylosis of an ankle if the ankylosis is in plantar flexion at more than 40 degrees, in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. Id. Therefore, the pertinent question in this case is whether the Veteran's right ankle condition is manifested by ankylosis. Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996), citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."); see also Coyalong v. West, 12 Vet. App. 524, 528 (1999). A February 2008 letter from the Veteran's private physician stated that the Veteran's condition including ankle joint ankylosing with equinous and Achilles tendon contracture. Additional records from November 2008 include an assessment of Achilles tendon contracture of the right ankle joint with ankylosing osteoarthritis and zero degrees of dorsiflexion. A June 2007 VA examination documented 0 degrees of dorsiflexion and 25 degrees of plantar flexion. No ankylosis was noted. Records dated October 2007 and November 2008 noted "decreased" range of motion. Additional records dated October 2010 noted complaints of tenderness and aching, but reduced range of motion and instability were not present. However, a December 2011 VA examination noted that right ankle ankylosis was present in dorsiflexion between 0 and 10 degrees. Range of motion was recorded as 0 degrees of dorsiflexion and 20 degrees of plantar flexion, with the onset of pain at 10 degrees. Based on this evidence, a 30 percent rating is warranted for the Veteran's right ankle arthritis. The question of whether there is ankylosis is a medical determination. See 38 C.F.R. § 3.159(a)(1), (2). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Here, the Veteran was diagnosed with ankylosing osteoarthritis by his private physician, and the December 2011 VA examiner also noted the presence of ankylosis. Moreover, the Veteran's ankylosis was noted to be in ankle dorsiflexion of 0 degrees by both physicians, which equates to a 30 percent rating under Diagnostic Code 5270. A higher 40 percent rating is not warranted, however, as ankylosis was never documented as occurring in plantar flexion greater than 40 degrees, or in dorsiflexion greater than 10 degrees. There was also no abduction, adduction, inversion, or eversion deformity noted. E. Extraschedular Consideration In evaluating the Veteran's claims for higher ratings, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). As part of the evaluation for an extraschedular rating, the Board has considered the provisions of Mittleider v. West, 11 Vet. App. 181, 182 (1998), which holds that the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition. The Board has attributed all potentially service-connected symptoms to the Veteran's service-connected conditions in considering if the Veteran is entitled to an extraschedular rating. According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's shoulder, knee, and ankle disabilities, with the established criteria found in the rating schedule for those disabilities, shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology, as discussed above. That is, the Veteran's symptoms of ankle pain and limited motion, knee pain and limited motion, and shoulder pain and recurrent dislocations, are expressly contemplated by the rating schedule. See also 38 C.F.R. §§ 4.40, 4.45, 4.59. The assigned disability ratings also adequately compensate the Veteran for additional effects such as altered gait and effects on daily activities. None of the Veteran's disabilities on appeal result in any symptoms that fall so far outside the rating schedule as to render it inadequate. ORDER A 30 percent rating , and not higher, for right shoulder instability with glenohumeral osteoarthritis is granted from December 27, 2005 to May 1, 2007, subject to the laws and regulations governing the award of monetary benefits. A rating in excess of 30 percent for right shoulder instability with glenohumeral osteoarthritis is denied from May 2, 2007 forward. A separate 10 percent rating, and not higher, under Diagnostic Code 5261 for degenerative changes of the right knee, status post medial meniscus tear, is granted, subject to the laws and regulations governing the award of monetary benefits. A rating in excess of 10 percent under Diagnostic Code 5257 for degenerative changes of the right knee, status post medial meniscus tear, is denied. A 30 percent rating, and not higher, for arthritis of the right ankle is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs