Citation Nr: 1324227 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 06-30 179 ) 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 10 percent for osteoarthritis of the left knee. 2. Entitlement to an initial rating in excess of 10 percent for plantar fasciitis with degenerative changes. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran served on active duty from March 1985 to March 2005. These matters come before the Board of Veterans' Appeals (Board) from a September 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Board has reviewed the Veteran's claims file and the record maintained in the Virtual VA paperless claims processing system. In September 2010 and again in September 2012 the Board remanded the case for further development. Thereafter, a January 2013 rating decision granted service connection for obstructive sleep apnea and assigned an initial 30 percent rating effective April 1, 2005; which was increased to a 50 percent rating effective December 6, 2006. That decision also granted an increase from a 10 percent rating for service-connected bilateral pes planus, to 30 percent effective November 23, 2012. The Veteran has not disagreed with the initial 30 percent or 50 percent ratings assigned for obstructive sleep apnea or the effective dates assigned, nor has he disagreed with the rating assigned or the effective date for the increased rating for bilateral pes planus. As there is no jurisdiction conferring Notice of Disagreement (NOD) to the downstream elements of effective dates or compensation levels, no such issues are now in appellate status. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). As to the claim for service connection for a sleep disorder, to include sleep apnea, this rating decision constitutes a full grant of the benefit sought on appeal and, so, that issue is no longer in appellate status. The case has now been returned to the Board for appellate consideration. FINDINGS OF FACT 1. Since the date of service connection, the Veteran's left knee arthritis has been manifested by essentially full, albeit painful motion in the affected joint. There has been no locking or instability, nor any need for an assistive device for ambulation. 2. Since the date of service connection, the Veteran's left plantar fasciitis with degenerative changes has been productive of pain on use and calcaneal spurring, but has not required the regular use of an assistive device for ambulation. 3. Since the effective dates of service connection, the record has not presented an exceptional or unusual disability picture with such related factors as a marked interference with employment or frequent periods of hospitalization due to the Veteran's service-connected left knee arthritis and left plantar fasciitis with degenerative changes so as to render impractical the application of the regular schedular standards. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for osteoarthritis of the left knee have not been not met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.2, 4.7, 4.10, 4.14, 4.21, 4.40, 4.41, 4.45, 4.59, Diagnostic Codes 5010 - 5261 (2012). 2. The criteria for an initial rating in excess of 10 percent for plantar fasciitis of the left foot with degenerative changes have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.2, 4.7, 4.10, 4.14, 4.21, 4.40, 4.41, 4.45, 4.59, 4.71a, Diagnostic Codes 5099 -5020, 5276 (2012). 3. The criteria for referral for consideration of initial increased ratings for osteoarthritis of the left knee and plantar fasciitis of the left foot with degenerative changes on an extraschedular basis have not been met. 38 C.F.R. § 3.321(b)(1) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Duty to Notify The VCAA and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Here, the Veteran was provided appropriate VCAA notice of what was required to substantiate his claims for service connection for his now service-connected left knee disability and his now service-connected left foot disability, by RO letter in April 2005, prior to the initial adjudication, and grant of service connection for those disabilities by the September 2005 RO rating decision. This appeal arises from the Veteran's disagreement, by filing his NOD in November 2005, with the initial rating assigned upon granting service connection. Once service connection is granted the claim is substantiated, additional notice is not required and 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). Accordingly, the Board finds that VA satisfied its duties to notify the Veteran in this case. Duty to Assist As to VA's duty to assist, VA has associated with the claims file the Veteran's service treatment records (STRs); and, in part pursuant to the Board remands, VA treatment records are on file or available through the Virtual VA paperless claims. Also, he has been afforded VA rating examinations, including in part in compliance with the Board remands. There is no evidence that there has been a change in the service-connected disabilities since the last examination. The report of the VA examinations conducted in this case show that the examinations were thorough in scope and in depth and supported by the outpatient treatment records. The adequacy of the examinations has not been challenged. The Board is entitled to assume the competence of a VA examiner. See Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011); Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed. Cir. 2010); Rizzo v. Shinseki, 580 F.3d 1288, 1290-91 (Fed. Cir. 2009); and Cox v. Nicholson, 20 Vet. App. 563, 569 (2007); and Hilkert v. West, 12 Vet. App. 145, 151 (1999). Thus, the examinations are deemed adequate for rating purposes. In September 2010 and November 2012, in compliance with the Board remands in those months, the Veteran was requested to provide any additional information pertaining to treatment for the disabilities at issue. In February 2013 the Veteran responded that he had no additional evidence to submit. And all this was in substantial compliance with the Board remands. Substantial, rather than absolute or strict, remand compliance is the appropriate standard for determining remand compliance under Stegall v. West, 11 Vet. App. 268 (1998)). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. In sum, as there is neither an indication that the Veteran was unaware of what was needed for claim substantiation nor any indication of the existence of additional evidence for claim substantiation, the Board finds these actions have satisfied VA's duty to assist and that no additional assistance is required. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Factual Background On VA general medical examination in May 2005 the Veteran's claim file was not available for review. He believed that his left knee was wearing out due to compensating for the "left" (right) knee. He described diffuse left knee pain, but his right knee pain was worse that the left knee pain. As to his left foot, he described an event over 20 years earlier, during basis training, from which his left heel had started to hurt. He was not really treated for it over the years. He had had a "heel spur resection" in 1990, after a chain fell on top of his foot. He described the pain as mainly being located at the base of the left heel. While he complained of bilateral pes planus, his pain was mainly around his left foot, at the base of the heel. On physical examination the Veteran had a normal posture and normal gait. He had a well healed scar on his left foot due to a childhood injury. Range of motion of the left knee was from 0 degrees of extension to 130 degrees of flexion with no pain at the "streams" (extremes) of these motions. There was no ligamentous instability. Strength in the tested muscles was 5/5. Sensations were intact in all dermatomes. Dorsalis pedis pulse was palpable. His left foot was tender at the base of the heel, on the plantar aspect of the foot. He reported that his pain was worse in the morning when getting out of bed. He had bilateral pes planus, but he could go up on his toes but his heels did not come into a very significant varus position. The assessments were likely bilateral knee osteoarthritis, with the right probably being post-traumatic; plantar fasciitis; and mild bilateral pes planus. X-rays of the Veteran's feet found no fracture or dislocation but there were mild degenerative changes along the left dorsal hindfoot and a plantar calcaneal spur on the left. Knee X-rays revealed degenerative changes, with the greatest in the right patellofemoral compartment. VAOPT records show that in May 2006 the Veteran complained of significant left foot pain, for which he took Celebrex. He used a cane for ambulation. He believed that at one time screws had been surgically implanted in the past in his left foot. On physical examination his left foot was edematous. There was erythematous at the "MTP" joint of the left great toe. He had pain over the 3rd and 4th metatarsals. The calcaneal area was edematous and painful. The dorsum of the left foot was slightly edematous. Neurologically, he was within normal limits. X-rays revealed degenerative changes which were mild, relative to his age. There was some mild widening of the tarsal tunnel. On VA neurology examination in August 2006 the Veteran had mild to moderate decreased sensation to pin prick, touch, vibration, proprioception, two-point discrimination, and double simultaneous stimulation of both feet to the knees. Deep tendon reflexes were 2+ and equal. Tandem gait was moderately unsteady. There was moderate swaying on Romberg's test. The diagnosis was peripheral neuropathy. On VA orthopedic examination in August 2006 the Veteran's claim files were not available for review. The Veteran complained of constant bilateral knee pain and swelling, especially upon activity, which was eased by Celebrex. He also complained of constant pain and frequent swelling of both feet, especially upon activity, which was eased by Celebrex. Reportedly, he had been told in 2001 that X-rays revealed a fracture in his left foot and shortly thereafter he had surgery, without relief. He was also told he had pes planus, and he was given a splint and inserts, which did not provide relief. On physical examination the Veteran was overweight. He had no swelling, fluid, heat, erythema or tenderness of either knee. He had mild to moderate knee crepitus, bilaterally, on extension. There was no subluxation, contracture, laxity or instability. McMurray's sign was negative, bilaterally. Lachman's, as well as anterior and posterior Drawer's tests were negative, bilaterally. Extension each knee was to 0 degrees and flexion was to 135 degrees. He had a 3 inch well healed surgical scar along the medial aspect of the left foot. There was mild, diffuse swelling and tenderness, bilaterally. There was no heat or erythema or any changes of temperature or color, and his vasculature of the feet was normal. All digits of the feet had normal range of motion. There was "no" mild to moderate pes planus. There was no significant callus formation. The fracture was clinically well healed. There was no angulation, shortening or false motion. The Veteran could arise and stand normally. His gait was independent and slow. He had a cautious and moderately broad-based gait, but had no specific limp. He walked poorly on his heels and on his toes. He could not hop. He could squat with moderate difficulty. Recent X-rays of his feet revealed mild degenerative changes and a left heel spur. The diagnoses were degenerative joint disease (DJD) of the knees, status post arthroscopic right knee surgery; and bilateral pes planus with left calcaneal spur. There was no evidence of weakened movement, excess fatigability or incoordination. There was no evidence that these factors or pain decreased motion during exacerbations or repetitive activities. There was no evidence of heat, redness, or instability. His pain was constant, so there were no specific flare-ups. Precipitating and alleviating factors had been discussed. There was no evidence of any additional limitation of motion or functional impairment during flare-ups. He did not use or require an assistive device, e.g., a cane, crutch or walker. There had been no episodes of dislocations or recurrent subluxation. There was no diagnosis of inflammatory arthritis. He was able to perform his activities of daily living. There was no ankylosis. Active and passive ranges of motion were identical. There was no objective evidence of pain on motion. There was no hindfoot, mid-foot or forefoot deformity. There was no hammertoe or high arch deformity. There was no valgus or varus deformity. The Achilles tendons were well aligned and non-tender. There were no skin breakdowns and no callosities. He was wearing inserts. There was no evidence of unequal shoe wear. There was no evidence that the foot problem significantly altered his general functional ability. Private clinical records show that the Veteran had a total right knee replacement in 2007. During private hospitalization in February 2008 the Veteran had an intracranial shunt due to hydrocephalus. He had diabetes. On examination he had bilateral lower extremity motor strength of 4 out of 5 but his gait was ataxic, with a waddle type gait. His sensations were intact. The impressions included obstructive hydrocephalus, cavernoma. A left knee MRI in April 2008 revealed mild meniscal degenerative with small surface tear of the posterior horn of the medial meniscus and mild fraying of the central aspect of the body and posterior horn of the lateral meniscus; degenerative changes in the lateral compartment and patellofemoral joint, with focal cartilage effect of the posterior aspect of the lateral femoral condyle; mild joint effusion and possible tiny intra-articular body posterior to the "PCL; and marked cartilage thinning of the lateral patellar facet. On examination later that month, left knee flexion was to 110 degrees and there was no flexion contracture or ligament laxity. He had medial left joint line tenderness and patellar crepitus but no generalized left knee tenderness. VA CAPRI records contained in the Virtual VA processing system reveal that VA outpatient treatment (VAOPT) records in October 2012 show that the Veteran reported exercising on a regular basis. He complained of intermittent bilateral knee pain. It was reported that he had undergone surgery on his left foot, and a total right knee replacement in 2007. With respect to his musculoskeletal system, he denied having areas of anesthesia, paresthesias, or weakness in the lower extremities. On physical examination there was no edema of his extremities. Deep tendon reflexes were normal. Motor, sensory and cerebellar examinations were normal. His gait was normal and he had normal coordination. The pertinent assessments were that his bilateral knee pain was intermittent and he was stable on prescription medication; also his bilateral pes planus was stable with inserts. On VA examination in November 2013 of the Veteran's pes planus, his claim files were reviewed. It was reported that the Veteran had pain on use of his feet, which was accentuated, on use, in the left foot. He did not have pain on manipulation of the feet. He had swelling of the left foot upon use. He did not have any characteristic calluses, or any calluses, caused by pes planus. His pes planus symptoms were not relived, bilaterally, by arch supports. He did not have extreme tenderness of the plantar surfaces of the feet. He did not have decreased longitudinal arch height on weight-bearing and there was no evidence of marked deformity of the feet, e.g., pronation or abduction. Weight-bearing line was not over or medial to the great toes. There was no lower extremity deformity, other than pes planus, which caused an alteration of the weight-bearing line. He did not have inward bowing of the Achilles' tendons, i.e., hindfoot valgus, with lateral deviation of the heel. He did not have marked inward displacement and severe spasm of the Achilles tendons (rigid hindfoot) on manipulation. He did not use any assistive devices, other than corrective shoes or orthotic inserts, as a normal mode of locomotion. As to pes planus, there was no functional impairment such that no effective function remained other than that which would be equally well served by amputation with prosthesis. It was also reported that X-rays had revealed arthritis of both feet. The X-rays revealed no fracture of dislocation of the left foot. There was hallux valgus, and there was joint space narrowing and sclerosis of the 1st metatarsophalangeal joint, and moderate pes planus. There was a large bone spur of the plantar surface of the left calcaneus. The radiological impressions were bilateral pes planus; degenerative changes of both 1st metatarsophalangeal joint, greater on the right than the left; and bone spurs of the calcanei, bilaterally. The examiner stated that the Veteran's bilateral pes planus impacted the Veteran's ability to work because it precluded prolonged standing or walking. During a November 2013 VA joints examination, the Veteran reported that following his total right knee replacement his right knee was now giving out frequently. He also complained of chronic left knee pain that had worsened over the years such that he now had constant left knee pain. He took Mobic for left knee pain, which he alternated with Motrin. He had flare-ups in that his right knee would give out. On physical examination left knee flexion was to 130 degrees, with pain at 130 degrees. Extension was to 0 degrees, with pain at that point. He was able to perform repetitive-use testing and after three repetitions left knee flexion was to 130 degrees and extension was to 0 degrees. He did not have additional limitation in range of motion of the knee following repetitive use testing. However, it was reported that after repetitive testing he had less movement, weakened movement, and pain on movement in both knees. He had tenderness or pain to palpation of the joint line or soft tissue of the left knee. Strength of left knee flexion and extension was 4/5. Testing for instability, anteriorly, posteriorly, medially, and laterally was negative for each knee. There was no evidence of or history of recurrent patellar subluxation or dislocation. He had not had any menisceal surgical procedures for a menisceal condition. However, he reportedly had frequent locking and "pseudolocking" of the right knee following the total knee replacement. He did not use any assistive device as a normal mode of locomotion. There was no functional impairment such that no effective function remained other than that which would be equally well served by amputation with prosthesis. He had X-ray evidence of degenerative or traumatic left knee arthritis but there was no X-ray evidence of patellar subluxation. His disabilities of the knees impacted his ability to work by precluding bending, squatting and prolonged walking or standing. He had no scars of the left lower extremity. On VA examination in November 2013 of the Veteran's feet, for other than pes planus, the Veteran complained of continuous left foot pain and being unable to stand for long periods due to increased left foot pain. He did not have Morton's neuroma or metatarsalgia. He did not have, and had not had, any hammertoes or hallux valgus. He did not have hallux rigidus or pes cavus (claw foot). He did not have malunion or nonunion of any tarsal or metatarsal bones. There was no evidence of bilateral week foot. He did not have any scars. He did not use any assistive device. There was no functional impairment such that no effective function remained other than that which would be equally well served by amputation with prosthesis. His foot condition impacted upon his ability to work by precluding prolonged standing or walking. It was commented that the "Veteran with[out] any symptoms or complaint of plantar fasci[i]tis at time of visit." Analysis: Initial Increased Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7; see also 38 C.F.R. § 4.21. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. The factors of joint disability reside in reductions of normal excursion of movements in different planes. Also for consideration are more or less than normal movement, weakened movement, excess fatigability, incoordination, painful motion, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. When evaluating joint disabilities rated on the basis of limited of motion, a higher rating may be warranted when there is functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Moreover, although pain may be a cause or manifestation of functional loss, limited motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. Functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). In sum, Mitchell held that pain on motion is not, itself, "functional loss," but "may result in functional loss ... only if it limits the ability 'to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance'." Id. at *5 (quoting 38 C.F.R. § 4.40). VA must determine the overall functional impairment of joint disability due to the factors listed above. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Painful motion with joint or periarticular pathology is productive of disability, and actually painful, unstable, or malaligned joints, due to healed injury, warrant at least the minimum compensable rating. 38 C.F.R. § 4.59. Osteoarthritis of the Left Knee The September 2005 rating decision granted service connection for traumatic osteoarthritis of the left knee. Under Diagnostic Code (DC) 5010, traumatic arthritis, documented by X-rays, is rated as degenerative arthritis under DC 5003. In this regard, the September 2005 rating decision assigned an initial noncompensable rating, effective April 1, 2005, the day after discharge from the Veteran's active service. But, an October 2007 rating decision found clear and unmistakable error (CUE) in the assignment of a noncompensable rating and rectified that error by retroactively assigning a 10 percent rating decision, effective April 1, 2005. DC 5003 provides three rating methods for rating degenerative arthritis. First, when there is X-ray evidence rate based on limited motion under the appropriate DCs for the specific joint or joints involved. Second, when motion is not limited or limited only to a noncompensable degree, a minimum, rating of 10 percent is assigned for each major joint or group of minor joints affected by limitation of motion, to be combined not added. Limited motion must be confirmed by swelling, muscle spasm or satisfactory evidence of painful motion. Third, when there is no limited motion but X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent is warranted but if there are occasional incapacitating exacerbations 20 percent is warranted. With respect to the first method, the appropriate DCs to rate limited motion of a knee are DC 5260, which provides for a minimum, 10 percent, compensable rating for flexion of a knee limited to 45 degrees; and DC 5261, which provides for a minimum, 10 percent, compensable rating for extension of a knee limited to 10 degrees. The second method for rating degenerative arthritis under DC 5003 provides that with no limitation of motion or when the limitation of motion of the specific joint or joints involved is noncompensable, even if due to pain, under the appropriate DCS, 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. Separate ratings for limitation of motion in flexion and in extension of a knee may be assigned. See VAOGPREC 9-2004 (September 17, 2004). Also, a compensable degree of limited motion under DCs 5260 and 5261 need not be shown; rather, a compensable rating may be granted, in addition to a rating for instability under DC 5257, if there is X-ray evidence of arthritis and also painful motion under 38 C.F.R. § 4.59. 38 C.F.R. § 4.71a, DC 5260 (limitation of flexion of the leg) provides that a 10 percent evaluation is warranted for flexion limited to 45 degrees. A 20 percent evaluation is warranted for flexion limited to 30 degrees and a 30 percent evaluation is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5261 (limitation of extension of the leg) provides for a 10 percent evaluation when extension is limited to 10 degrees. A 20 percent evaluation is warranted for extension limited to 15 degrees; a 30 percent evaluation is warranted for extension limited to 20 degrees. Normal range of motion of the knee is 0 degrees of extension and 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. 38 C.F.R. § 4.71a, DC 5257 provides that a 10 percent disability rating is warranted for slight recurrent subluxation or lateral instability; a 20 percent disability rating is warranted for moderate recurrent subluxation or lateral instability; and 30 percent disability rating is assigned for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. 38 C.F.R. § 4.71a, DC 5258 provides that a 20 percent evaluation, the highest and only rating available under that schedular provision, is assigned where there is evidence of dislocated cartilage, with frequent episodes of "locking," pain, and effusion into the knee joint. Symptomatic residuals of removal of a semilunar cartilage warrant a maximum 10 percent rating. 38 C.F.R. § 4.71a, DC 5259. Ratings under DC 5259 require consideration of 38 C.F.R. §§ 4.40 and 4.45 because removal of a semilunar cartilage may result in complications producing loss of motion. VAOGCPREC 9-98. 38 C.F.R. § 4.71a, DC 5256 provides that favorable ankylosis of a knee, at an angle in full extension, or in slight flexion between 0 degrees and 10 degrees warrants a minimum rating of 30 percent. 38 C.F.R. § 4.71a, DC 5262 provides that malunion of the tibia or fibula with slight knee disability warrants a 10 percent rating; with moderate knee disability 20 percent is assigned; and with marked knee disability a 30 percent rating is assigned. The words "slight", "moderate" and "severe" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. 38 C.F.R. § 4.71a, DC 5263 provides that genu recurvatum with weakness and insecurity in weight-bearing objectively demonstrated, warrants a 10 percent rating. The Board finds, based on the evidence of record and the applicable laws and regulations, that an increased evaluation under DC's 5260 and 5261 is not warranted as the Veteran does not have the requisite limitation of motion necessary for a disability rating greater than 10 percent. Furthermore, an increased evaluation under the criteria of DC 5256 or 5258 is not warranted as there is no evidence of ankylosis or dislocated cartilage. He has not had left knee cartilage, or any, surgery, and there is no malunion of the tibia or fibula. Taking into consideration both the Veteran's subjective complaints of increased symptomatology with use as corroborated in the clinical records, and the objective findings from the VA examinations, the Board concludes that the Veteran does have impairment of the knee due to painful arthritic motion so as to warrant the currently assigned 10 percent evaluation. However, the Board further finds that the Veteran's current symptomatology is more analogous to the criteria of a 10 percent evaluation than the moderate disability required for a 20 percent evaluation. Specifically, even with painful arthritic motion he has almost full flexion of the left knee and no limitation of extension of the left knee. Moreover, there is no documented locking, recurrent subluxation or lateral instability and, so, a separate compensable rating for any menisceal or ligamentous pathology is not warranted, even though a private MRI revealed some intra-articular changes. The only time that the Veteran used a cane was in May 2006, but at no other time. His unusual gait during a period of private hospitalization is not subsequently documented and, from this, the Board concludes that it was neurologically based pathology because he had a waddling type gait due to a central nervous system disorder, as reflected in the diagnosis at that time, and from he subsequently recovered but he did not limp due to the left knee. The decreased sensation found on the 2006 VA neurology examination, from both of the Veteran's feet to both knees, is consistent with his nonservice-connected diabetes and there is nothing which suggests that this sensory impairment is related to either of his service-connected knee disabilities, or his service-connected bilateral pes planus or plantar fasciitis of the left foot. In fact, the evidence shows that despite the total right knee replacement the Veteran has no atrophy of the muscles governing left knee function, he has not have any, much less repeated episodes, of falling due to instability of left knee, and additionally repeated examinations have not documented instability of the ligaments of that knee. Moreover, he does not have any locking of the left knee. Although the 2013 VA examination found that the left knee disability impaired his ability for prolonged standing, walking, bending, and squatting, that examination did not find that he was unable to perform the activities of daily living or that he had flare-ups, weakened movement, excess fatigability or incoordination or that these or pain decreased motion on repetitive motion. In fact, these findings were specifically found not to exist on VA examination in 2006. The primary difference in the 2006 and 2013 VA examinations appears to be primarily a matter of the Veteran's subjective complaints, and not objective findings. Also, any scarring from inservice surgery is not shown to be other than asymptomatic. See generally 38 C.F.R. § 4.118. Overall, the disability of the left knee is not demonstrated to be of such severity as to warrant a schedular rating in excess of 10 percent, even when consideration is given to functional impairment due to pain and other factors. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Mitchell v. Shinseki, 25 Vet. App. 32 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995). Plantar Fasciitis of the Left Foot with Degenerative Changes The Veteran's service-connected foot disorder has been rated analogously as synovitis under 38 C.F.R. § 4.71a, DC 5020. A disorder not listed in the rating schedule may be rated as if it were a closely related disease or injury, when (1) the functions affected, (1) the anatomical localization, and (3) symptoms are closely analogous. 38 C.F.R. §§ 4.20, 4.27; see also Lendenmann v. Principi, 3 Vet. App. 345, 351 (1992) and Archer v. Principi, 3 Vet. App. 433 (1992). The Board finds that the use of DC 5020, for rating plantar fasciitis is appropriate because the functions affected, anatomical localization, and symptomatology are closely analogous. "Plantar fasciitis is defined as inflammation involving the plantar fascia especially in the area of its attachment to the calcaneus and causing pain under the heel in walking and running." Hoag v. Brown, 4 Vet. App. 209, 211 (1993). Plantar fasciitis is inflammation of the sole of the foot, associated with eosinophilia, edema, and swelling. Fenderson v. West, 12 Vet. App. 119, 122 (1999) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 609 - 10, 1300 (28th ed.1994). Synovitis is rated on the basis of limitation of motion of the part affected, as degenerative arthritis. The Board acknowledges that, in addition to the foot disability at issue on appeal, the Veteran is in receipt of a separate award of service connection for bilateral pes planus. Specifically, the record reflects that he has been assigned a noncompensable rating for mild pes planus symptoms, effective April 1, 2005 (day after service discharge); a 10 percent rating for moderate symptoms, effective May 24, 2006, and a 30 percent rating for severe symptoms, effective November 23, 2012. 38 C.F.R. § 4.71a, DC 5276. Under DC 5276, for rating pes planus, these ratings encompass, when mild, symptoms relieved by built-up shoe or arch support, a noncompensable rating is warranted; when moderate, weight-bearing line over or medial to great toe, inward bowing of the tendo-achillis, pain on manipulation and use of the feet, and when severe; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. Here, while mindful that the Veteran appears to have met the diagnostic criteria for a 10 percent rating for pes planus prior to May 24, 2006, the Board finds that his underlying symptoms were effectively contemplated by equivalent rating assigned under DC 5020 during that time period. 38 C.F.R. §§ 4.71a, DCs 5020, 5276. Moreover, the Board is precluded from assigning separate ratings under both diagnostic codes because this would result in double compensation, i.e., the use of the same symptom twice in determining the appropriate disability evaluation, called pyramiding, which is prohibited. See 38 C.F.R. § 4.14. Accordingly, the Board will now consider whether additional compensation is warranted under the other applicable provisions of the Rating Schedule. Under 38 C.F.R. § 4.71a, DC 5277 bilateral weak foot, a symptomatic condition secondary to many constitutional conditions, characterized by atrophy of the musculature, disturbed circulation, and weakness, is rated on the basis of the underlying condition, with a minimum rating of 10 percent. Under 38 C.F.R. § 4.71a, DC 5278, pes cavus (claw foot) when slight warrants a noncompensable rating. With the great toe dorsiflexed, some limitation of dorsiflexion at ankle, definite tenderness under metatarsal heads and unilateral or bilateral, a 10 percent rating is warranted. When manifested by all toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads, and unilateral a 20 percent rating is warranted and when bilateral a 30 percent rating is warranted. When manifested by marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, and marked varus deformity, and unilateral a 30 percent rating is warranted and when bilateral a 50 percent rating is warranted. Metatarsalgia, anterior (Morton's disease), when unilateral or bilateral, warrants a maximum 10 percent rating under 38 C.F.R. § 4.71a, DC 5279. Under 38 C.F.R. § 4.71a, DC 5280, unilateral hallux valgus, when operated with resection of the metatarsal head, or if severe and equivalent to amputation of a great toe, warrants a maximum rating of 10 percent. Under 38 C.F.R. § 4.71a, DC 5281, severe unilateral hallux rigidus is rated as severe hallux valgus but is not to be combined with a rating for pes cavus (claw foot, under DC 5278). Under 38 C.F.R. § 4.71a, DC 5282 hammer toe of a single toe warrants a noncompensable rating. Hammer toe of all toes of one foot without claw foot, warrants a maximum rating of 10 percent. Under 38 C.F.R. § 4.71a, DC 5283 malunion or nonunion of the tarsal, or metatarsal bones, when moderate warrant a 10 percent rating; when moderately severe 20 percent is warranted; and when severe 30 percent is warranted. Note that with actual loss of use of the foot, a 40 percent rating is warranted. Under 38 C.F.R. § 4.71a, DC 5284 residuals of foot injuries when moderate warrant a 10 percent rating; when moderately severe 20 percent is warranted; and when severe warrant a 30 percent is warranted. Note that with actual loss of use of the foot, a 40 percent rating is warranted. Here, the Veteran's 10 percent rating encompasses dysfunction due to pain, primarily in the left heel, and particularly during flare-ups. However, he does not have hallus rigidus or any malunion or nonunion of any tarsal or metatarsal bones nor is any abnormality of any toes of the left foot, e.g., hammertoes, shown. Likewise, he does not have a Morton's neuroma, atrophy of the musculature, disturbed circulation or weakness of the left foot. Although his plantar fasciitis with degenerative changes does impact upon his functional ability by precluding prolonged standing or walking, it does not do so to the extent that he requires an assistive device for walking. Moreover, any past surgical scarring is now asymptomatic. Overall, the disability of the left foot disorder is not demonstrated to be of such severity as to warrant a schedular rating in excess of 10 percent, even when consideration is given to functional impairment due to pain. Lay Evidence Considerations In making its determinations in this case, the Board has carefully considered the Veteran's contentions with respect to the nature of his service-connected disabilities at issue and notes that his lay statements are competent to describe certain symptoms associated with these disabilities. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); 38 C.F.R. § 3.159(a)(2); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Significantly, however, the Board finds that, overall, the Veteran's history and symptom reports, including as presented in the medical evidence discussed above, have been adequately contemplated by the disability ratings that have been heretofore assigned. Moreover, the Board finds that the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disabilities at issue. See Guerrieri v. Brown, 4 Vet. App. 467 (1993); Gabrielson v. Brown, 7 Vet. App. 36 (1994) (noting that the credibility and weight to be attached to medical opinions are within the province of the Board as adjudicator). As such, while the Board accepts the Veteran's lay statements with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected conditions at issue. Mittleider and Staged-Rating Considerations In reaching the aforementioned determinations, the Board has considered the holding in Mittleider v. West, 11 Vet. App. 181, 182 (1998), "when it is not possible to separate the effects of the [service-connected condition and [a] non-service-connected condition], VA regulations at 38 C.F.R. § 3.102, which require that reasonable doubt on any issue be resolved in the appellant's favor, clearly dictate that such signs and symptoms be attributed to the service-connected condition." As applied in this case, the Board has attributed all potentially service-connected symptoms to the left knee and left foot disabilities. The Board has also considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected disabilities; however, the Board finds that his symptomatology has been stable throughout the appeal. Therefore, assigning staged ratings for such disabilities is not warranted. Extraschedular Consideration Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration for any of the disabilities at issue. An extra-schedular disability rating is warranted if 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 application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 claimant's disability picture requires the assignment of an extra-schedular rating. Id. The rating criteria for the left knee and left foot disabilities contemplates the primary impairment from those disabilities, i.e., interference with function and this is encompassed in the award of a 10 percent rating for each. The governing rating criteria encompass a wide range of signs and symptoms and these service-connected disorders require application of the holding in Deluca, supra, and Mitchell, supra, which, in turn, requires consideration of 38 C.F.R. §§ 4.40 and 4.45. 38 C.F.R. § 4.40 requires consideration of functional loss, including the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, pain, weakness, and atrophy. Likewise, 38 C.F.R. § 4.45 requires consideration of, in part, incoordination, impaired ability to execute skilled movements, painful motion, swelling, deformity, disuse atrophy, instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing. Also, 38 C.F.R. § 4.59 requires consideration of such matters as unstable or mal-aligned joints, and crepitation as well as any painful arthritic motion. Comparing the Veteran's current disability levels and symptomatology to the Rating Schedule, the degree of disability for each disorder is contemplated by the Rating Schedule and the assigned schedular ratings are adequate. There are no additional symptoms of each disability that are not addressed by the rating schedule or considered in this decision. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability levels and symptomatology of his service-connected disabilities. Thus, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). "Because the VA disability rating schedule is designed to consider the disabling effect of disabilities separately, no single DC provision will adequately assess the variety of symptoms involved with multiple service-connected disabilities." Johnson v. Shinseki, No. 10-1785, slip op. at 10 (Vet. App. Mar. 27, 2013) (en banc). Thus, as to the question of "whether [38 C.F.R.] § 3.321(b)(1) requires VA to consider multiple service-connected disabilities on a collective basis" the Court held that it did not. Johnson v. Shinseki, No. 10-1785, slip op. at 4 (Vet. App. Mar. 27, 2013) (en banc) (noting that a concurring opinion in Brambley v. Principi, 17 Vet. App. 20, 27 (2003) that there should have been a determination of "whether the appellant's service-connected disabilities as a whole [sic] entitled [a Veteran] to [an extraschedular rating] under § 3.321(b)(1)" had never been adopted by the Court and concurring opinions are not binding on the Court" (citing Maryland v. Wilson, 519 U.S. 408, 412-13). Stated in other terms, an extraschedular rating may not be assigned for the cumulative impact of the service-connected disabilities herein at issue. TDIU Consideration Finally, the Board has considered whether the evidence addressed above has raised an implicit claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). The January 2013 rating decision which granted service connection for obstructive sleep apnea and assigned initial staged ratings of 30 percent and 50 percent and which also granted an increase from a 30 percent rating for service-connected bilateral pes planus, resulted in an increase in the Veteran's combined disability rating from 80 percent to 90 percent. This meets the percentage requirements TDIU under 38 C.F.R. § 4.16(a). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the Veteran's December 2012 VA Form 21-4138, Statement in Support of Claim, in response to the Board's September 2012 remand stated that he was employed as an overseas contractor. Thus, the evidence does not raise an implied or informal claim for a TDIU rating. See Comer v. Peake, 552 F.3d 1362, 1366 (Fed. Cir. 2009) (VA must consider a TDIU rating when there is "cogent evidence of unemployability."). In sum, the Board finds that the issue of entitlement to a TDIU is not expressly raised by the Veteran or reasonably raised by the record and, consequently, further consideration of such is not necessary. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims of entitlement to initial evaluations in excess of 10 percent for osteoarthritis of the left knee and for plantar fasciitis of the left foot with degenerative changes. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER An initial rating in excess of 10 percent for osteoarthritis of the left knee is denied. An initial rating in excess of 10 percent for plantar fasciitis of the left foot with degenerative changes is denied. ____________________________________________ E. WOODWARD DEUTSCH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs