Citation Nr: 1327291 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 05-30 419 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for residuals of a ruptured right Achilles tendon. 2. Entitlement to a disability rating in excess of 10 percent for a right hip disability. 3. Entitlement to a disability rating in excess of 10 percent for right knee patellofemoral syndrome. 4. Entitlement to special monthly compensation based on loss of use of the right leg. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Saira Spicknall, Counsel INTRODUCTION The Veteran served on active duty from August 1965 to October 1967. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision of the Hartford, Connecticut Department of Veterans Affairs (VA) Regional Office (RO), located in Newington, Connecticut. In December 2008, the Board remanded the issues of increased ratings for residuals of a ruptured right Achilles tendon, right hip disability and patellofemoral syndrome of the right knee and special monthly compensation based on claimed loss of use of the right leg for additional development. The Board again remanded the case in August 2010 to schedule the Veteran for a Board hearing. The Veteran testified at a hearing before the undersigned Veterans Law Judge of the Board via a video conference (video conference hearing) in June 2012. A transcript of that hearing has been associated with the claims file. This case was remanded by the Board in September 2012 for additional development, when it was again remanded. A review of the Virtual VA paperless claims processing system reflects that additional records have been added to the present appeal. These records include VA medical records. A supplemental statement of the case (SSOC) was issued in February 2013, which addressed this additional evidence. FINDINGS OF FACT 1. The Veteran's residuals of a ruptured right Achilles tendon is productive of subjective complaints of pain, stiffness and weakness with objective findings of pain, limitation of motion in dorsiflexion to 15 degrees, and degenerative joint disease. 2. The Veteran's right hip disability is productive of subjective complaints of pain, instability, giving out, weakness, fatigability and a lack of endurance with objective findings of pain, flexion to 120 degrees, at worst, extension greater than 5 degrees, abduction not lost beyond 10 degrees, adduction not limited such that the Veteran could not cross his legs and rotation limited such that the Veteran could not toe-out more than 15 degrees; there were no objective findings of instability or degenerative joint disease. 3. The Veteran's right knee patellofemoral syndrome was productive of subjective complaints of pain, swelling, locking, giving way, and instability with objective findings of pain, swelling, flexion to 90 degrees, at worst, and extension to zero degrees (full extension), and 1+ medial-lateral instability; there were no objective findings of subluxation or degenerative joint disease 4. The Veteran's right lower extremity has not been shown to be so limited that the Veteran would be equally well-served by an amputation stump at any level. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for residuals of a ruptured right Achilles tendon have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5271 (2012). 2. The criteria for a disability rating in excess of 10 percent for a right hip disability have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5251, 5252, 5253 (2012). 3. The criteria for a disability rating in excess of 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5258, 5260, 5261 (2012). 4. The criteria for special monthly compensation based on loss of use of the right leg are not met. 38 U.S.C.A. § 1114 (West 2002); 38 C.F.R. §§ 3.350, 4.63 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act (VCAA) The VCAA, codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations were created, codified at 38 C.F.R. § 3.159 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012). The United States Court of Appeals for Veterans Claims (Court) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2002), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Prior to the initial adjudication of the Veteran's claims for increased ratings in the November 2007 rating decision, he was provided notice of the VCAA in April 2007 and July 2007. He was subsequently also provided notice of the VCAA in June 2008 and January 2009 letters. The VCAA letters indicated the types of information and evidence necessary to substantiate the claim, and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. The Veteran also received notice in July 2007 and January 2009 pertaining to the downstream disability rating and effective date elements of his claims. The Veteran's actions are also indicative of his actual knowledge of the requirements for substantiating his increased rating claim. The Veteran has reported his current symptoms of the disability to VA examiners in connection with his claims and has provided testimony before the Board in a June 2012 video conference hearing as to why his current disabilities should be rated higher and why his right leg disability constitutes a loss of use of the right leg. Based on this evidence, the Board is satisfied that the Veteran had actual knowledge of what was necessary to substantiate his increased rating claim. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claims in this Board decision. Rather, remanding this case to the RO for further VCAA development would be an essentially redundant exercise and would result only in additional delay with no benefit to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993); see also 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 Veteran are to be avoided). All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. The evidence of record includes private medical records, VA outpatient treatment reports, VA examinations and statements and testimony from the Veteran, his wife, and his representative. The Board notes that the October 2012 VA examination reports reflect that the examiner reviewed the Veteran's past medical history, documented his current medical condition, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Consequently, the Board concludes that the medical examination is adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). This case was previously remanded by the Board in September 2012 to locate and associate any temporary files with the claims file, obtain outstanding private and VA medical records and provide the Veteran with adequate VA examinations for the right hip, right ankle, right knee and loss of use of the right leg. As the temporary claims file and private and VA medical records have been associated with the record and the October 2012 VA examiner performed all the tests necessary to evaluate the Veteran's current disabilities and complied with the Board's remand instructions, the Board is satisfied that the development requested by its September 2012 remand has now been satisfactorily completed and substantially complied with regarding the claims on appeal. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall, 11 Vet. App. 268 where Board's remand instructions were substantially complied with). In June 2012, the Veteran was afforded a video conference hearing before the undersigned. The transcript reflects that the Veterans Law Judge conducted the hearing in accordance with the statutory duties to "explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position," pursuant to 38 C.F.R. § 3.103(c)(2), as explained by the Court in Bryant v. Shinseki, 23 Vet. App. 488 (2010). The transcript of the hearing reflects that the Veterans Law Judge identified the material issues on appeal. The Veterans Law Judge also asked the Veteran questions regarding the severity of each of the disabilities on appeal and how they affect his daily activities and asked about information regarding other outstanding treatment records which may be relevant to the claim. Thus, the Board finds that the hearing officer's duties in 38 C.F.R. § 3.103(c)(2) were met and that the Veteran was not prejudiced by the hearing that was provided. See Bryant, 23 Vet. App. at 498 (citing to 38 U.S.C. § 7261(b)(2); Shinseki v. Sanders, 129 S. Ct. 1696, 1704 (2009)). The June 2012 hearing was legally sufficient. The Board observes that a claim for a total disability rating based upon individual unemployability (TDIU), has not been raised in connection with the increased rating claims on appeal as the Veteran has already been awarded this benefit. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has not indicated that he has any further evidence to submit to VA, or which VA needs to obtain. There is no indication that there exists any additional evidence that has a bearing on this case that has not been obtained. The Veteran and his representative have been accorded ample opportunity to present evidence and argument in support of his appeal. Thus, the Board finds that VA has obtained, or made reasonable efforts to obtain, all evidence that might be relevant to the issues on appeal, and that VA has satisfied the duty to assist. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2012). Factual Background VA outpatient treatment reports from November 2005, within a year of the Veteran's claim, to May 2013 reflect that the Veteran had reported a history of degenerative disease of the right knee with instability and arthralgias of the right knee, right ankle and hips. These records also reflect that he was treated for and diagnosed with diffuse arthralgias, osteoarthritis, degenerative joint disease of the right knee, degenerative arthritis of the right hip and knees, degenerative disease of both hips and right knee, and osteoarthritis of the right knee. VA outpatient treatment reports also reflect that the Veteran used several assistive devices for mobility including a brace for the right knee, crutches, a walker and a power wheelchair which were provided due to his left leg below-knee amputation as well as his right leg disabilities. In a September 2006 letter, C.J.Z., C.P., reported that the Veteran was under his care for all of his prosthetic needs. He stated that, due to the fact that the Veteran's lateral collateral ligament had laxity, a medial joint needed to be added to his prosthesis to increase his knee's medial-lateral stability. He did not specify to which knee, right or left, he was referring. In a May 2007 VA examination, the Veteran reported his current symptoms included pain in the right Achilles and entire foot, causing problems with walking. Pain at worst was at a five out of 10 in severity. He reported having a history of falls due to his right knee giving out or if he did not wear his brace, with the most recent fall only a couple of weeks earlier. With respect to his right knee, the Veteran reported that he had sharp pain most of the time, which was reportedly at an eight to nine out of 10 in severity. He had equal pain in the right knee with going up and down stairs. He stated he needed to hold onto a rail and use his cane or crutches. At home, the Veteran reported he often used a wheelchair, which he felt was safer. He reported experiencing increased phantom pain and left limb pain due to overuse. The Veteran moved from his two story house to a one floor ranch home because of the stairs, which afforded him the opportunity to use his wheelchair. The examiner noted that, as an afterthought, the Veteran returned with a note, reporting that he had problems with his left residual limb with pain, sores and skin breakdown due to increase weight bearing on the prosthesis because of weakness and instability of the right knee and ankle. He felt he had a good range of motion, balance and the ability to push off the right ankle. He also reported his right foot was sometimes numb and the right ankle fatigued easily. The Veteran stated he had to use cruise control while driving a car. The Veteran reported the right hip and back had gotten worse over time and he was using the prosthetic side more for support. He had to have an extended metal joint for additional support on the left side. The Veteran reported having difficulty getting in and out of the shower due to the lack of right leg stability. The Veteran was unable to do basic yard work or keep up the house and his wife had to do the shopping. The Veteran reported symptoms of: weakness in the right leg; swelling in the right knee with more activity; instability and giving way, which was worse without the use of a brace; the right knee seemed to move laterally; knee and foot fatigue; lack of endurance; and pain in the right ankle and right knee, which caused sleep disturbance. No stiffness, heat, redness or locking were reported. The Veteran stated he could not walk any distance without resting, sitting due to pain in the right lower extremity and problems with his left below-knee amputation. Flare-ups were reported with standing for any length of time, going up and down stairs, and excessive walking. The Veteran reported he was unable to walk without a brace and needed to wear the brace all the time except for sleeping. He stated he had to get up at night to urinate and used crutches or a wheelchair to get to the bathroom. Pain with flare-ups was reportedly at an eight to nine out of ten in severity, lasted a few hours. Flare-ups were reportedly daily. Alleviating factors included resting, sitting, medication (Meloxicam) and elevating his legs. Additional limitation of motion or functional impairment due to flare-ups included that the Veteran was unable to walk and needed to use a wheelchair. Assistive devices included crutches and a wheelchair. No episodes of dislocation or recurrent subluxation were reported. No symptoms of inflammatory arthritis were noted. The Veteran reported closing his dental laboratories business in 2005 and that he had been unemployed since. A right knee brace was noted as having been customized for the Veteran. A physical examination revealed that the Veteran was ambulating with bilateral customized crutches, left below-knee amputation prosthesis, and a right knee brace. He had fatigue with walking from the waiting room to the office, approximately 20 feet. The examiner noted outside heel wears with the Veteran's abnormal weight bearing and that he was unable to wear a shoe unless he had a wide supportive bottom. He also noted the bottom of the right ankle would twist outward. There was right knee suprapatellar pain laterally. No edema or effusion was found. The Veteran was noted to be extremely unsteady without the right knee brace. No inflammatory arthritis was noted. Right knee range of motion revealed flexion from zero to 90 degrees with pain and full extension. Stability testing of the medial and lateral collateral ligaments included varus/valgus in neutral and in 30 degrees of flexion was normal with no motion. Anterior and posterior cruciate ligaments in 30 degrees of flexion with the right foot stabilized was normal, less than 5 mm of motion ( noted as 1/4 inch - Lachman's test). Medial and lateral meniscus stability was tested by McMurray's test which yielded negative results. The examiner found the right knee joint was painful on motion and the range of motion or joint function was additionally limited by pain, fatigue, weakness and a lack of endurance following repetitive use. A physical examination of the right ankle revealed the ankle was in neutral position with the foot at 90 degrees to the ankle. Right ankle dorsiflexion was from 0 to 20 degrees with pain and right plantar flexion was from 0 to 45 degrees without pain. No varus or valgus angulation of the os calcis in relation to the long axis of the tibia and fibular was found. The examiner found the right ankle joint was painful on motion and the range of motion of the joint function was additionally limited by pain, fatigue, weakness following repetitive use. Muscle strength was at 4 out of 5 in the right ankle and right foot and the Veteran was noted to be able to move the right ankle joint through normal range of motion with discomfort, decreased endurance and decreased strength to accomplish activities of daily living. The muscle group was able to move the right ankle joint independently through useful ranges of motion, but with limitation by pain, easy fatigability or weakness. A May 2007 x-ray report of the right knee revealed no evidence of fracture, abnormal calcification or radiopaque foreign body, or soft tissue pathology and the right knee was found to be unremarkable. The Veteran was diagnosed with degenerative joint changes in the right knee, per his primary care physician note, versus the May 2007 x-ray, causing increased pain and instability of the right knee. Due to the service-connected left below-knee moderate to severe medial collateral laxity, the examiner found that the Veteran was placing more stress/strain on the right lower extremity, which was likely contributing to the right knee instability and pain/strain, as well as likely contributing to the right Achilles tendonitis. A June 2007 letter was provided by the Veteran's private physician, S.C.D., M.D. In this letter, S.C.D., M.D. reported that the Veteran had increasing disability and/or increasing inability to walk due to pain and instability in his right lower extremity, specifying the right knee. He stated that, due to his injury to the left lower extremity, the Veteran had overcompensated with the use of his right lower extremity, which had led to a rupture of his Achilles tendon in the past, in 2003. He also reported the Veteran had progressive osteoarthritis in the right knee with laxity of his collateral ligaments and an unstable knee. S.C.D., M.D., noted that Dr. C. at the Newington VA medical center (VAMC), placed a support brace on the right knee one and a half years ago. He also noted the Veteran was unable to ambulate without a cane and/or crutches and used a wheelchair to aid in his mobility. S.C.D., M.D. believed that the Veteran required further help and intervention in the treatment of his problems with his right knee, in terms of stabilizing the knee surgically, and thereby decreasing his pain and suffering. A June 2007 VA x-ray of the right knee revealed no evidence of fracture, no abnormal calcification or radiopaque foreign body, and no soft tissue abnormality. The Veteran was assessed with an unremarkable right knee. In July 2007 and August 2007 private medical reports related to treatment of the Veteran's prostate cancer, he reported having a history of occasional right lower back, hip and knee pain related to his arthritis as well as chronic arthritis of the back and hips. In an August 2007 VA examination, the Veteran reported that he had pain in the right hip, which at its worst was at an eight out of 10 in severity. Pain would vary throughout the day from a three to eight out of 10 in severity. He also complained of right hip stiffness, instability, giving out, pain, weakness, fatigability and a lack of endurance. The Veteran reported he would need to shift his weight to the left hip due to pain and some weakness. No heat or redness was reported. Treatment of the right hip included medication, Naproxen and Mobic, Capsaicin cream, heating pad, and hot tub soak, although he reported having difficulty getting out of the tub. Flare-ups were reported with increased activity, if the Veteran walked more than usual or was on his feet for more than an hour shopping at the grocery store. Pain with flare-ups was rated as an eight to nine out of 10 in severity, which occurred a couple of times a week and lasted for a couple of hours until he rested. The Veteran reported using a heating pad and Capsaicin cream for flare-ups. Precipitating factors included increased activity and alleviating factors included the treatment noted above. With flare-ups, the Veteran needed to stop the cause of the flare-up and sit or lay down. Assistive devices included crutches, right knee brace, cane and wheelchair, depending on the amount of activity during the day. A physical examination of the right hip revealed the Veteran arrived in a wheelchair with crutches and had a left below-knee amputation but was not wearing a prosthesis to the examination. He was able to get out of the wheelchair and use crutches to transfer to the examination table without difficulty. Right hip extension was from zero to 20 degrees with pain and passive range of motion with hip extension was from zero to 22 degrees with pain. Adduction was from zero to 25 degrees without pain. Abduction was from zero to 40 degrees with pain and no further motion. External rotation was from zero to 60 degrees and internal rotation was from zero to 40 degrees. The examiner found that the right hip was painful on motion and the range of motion and joint function was additionally limited by pain, fatigue, weakness or lack of endurance following repetitive use with two to three repetitions. Positive sensation, reflexes and peripheral pulses were noted in the right lower extremity. An August 2007 x-ray of the right hip revealed no evidence of acute bony trauma or destruction, the joint was noted to be well preserved and multiple vascular calcifications in the pelvis were noted. The Veteran was diagnosed with right hip sprain/strain which was more likely than not related to his status post left below-knee amputation. The examiner noted he needed to put more weight on the right lower extremity leading to mild to moderate functional limitations. In an October 2007 statement, the Veteran's wife reported that he had experienced a significant decrease in mobility over the past few years and she believed this was due to the constant wear and tear on his lower limbs, especially his right hip, right knee and right Achilles tendon and ankle. She stated he had to wear a brace on his right knee, which helped but his mobility was severely limited. She reported that he began experiencing difficulties five years ago which had continued to limit his activities and he now had to use a cane or crutches all of the time, including from the short walk from the house to the car. His wife also reported that the Veteran was unable to participate in activities likely fishing, hiking, attending shows or travel. She stated activities such as getting into or out of a tub or shower were limited and he had become dependent on her for assistance. The Veteran's wife noted he usually had to remove his prosthesis and brace and use a wheelchair to get around. An October 2008 private medical record reflects that the Veteran was seen for a neurological consultation by W.R.C., M.D. Nerve conduction studies revealed L4-5 radiculopathy in the right lower extremity which was found to further impede his ability to ambulate. In a December 2008 statement, the Veteran's spouse reported that the Veteran had decreased functions due to the pain from his right knee, right hip and spine. She stated that he required assistance for simple daily functions. She noted that, although he used a walker, cane and crutches, she had to help him with showers, baths and, at most times, getting into and out of vehicles. She stated he spent more time in a wheelchair, compared to a few years earlier. She also stated that their social activities were now dependent on the Veteran's right knee, hip and spine pain, in addition to the already existing problems with both legs. Finally the Veteran's spouse reported that the Veteran also required the use of a brace on the right leg. At a March 2009 VA examination, the Veteran reported that he was not working, having closed his dental lab facility after 25 years of business. He also reported he closed his business due to multiple medical conditions, including PTSD, a rupture of the right Achilles tendon, complications with his left below-knee amputation stump and prosthesis, and difficulty holding small instruments with his hands. The Veteran stated he currently had right hip, right knee and right ankle pain associated with his mobility difficulty. He and his wife reported he was very unstable and noted two recent falls that year. He stated his right knee gave way while standing and walking with his prosthesis or crutches and that this instability had increased over the past six months. The Veteran used a wheelchair most of the time and he used a cane, crutches or walker for distances more than 30 feet. He also reported the use of a right knee metal hinged brace and scooter. He reported having a wheelchair ramp in his house, however, his house had not been retrofitted with handicapped bars and safety devices to allow for safer gripping and transfers when in the bathroom or going up or down stairs. Regarding his right Achilles tendon, the Veteran reported having no pain with sitting, however, if he stood or walked for greater than 10 minute, he got a sharp burning pain that was reported as a six out of 10 in severity. He also reported having right ankle joint stiffness and weakness with no swelling, heat or redness. He reported that the ankle joint appeared unstable, fatigued easily and had no endurance. The Veteran treated the right ankle with medication, Gabapentin, Naproxen, and Meloxicam, with fair relief. He reported increased right Achilles pain with cold or damp weather and weight bearing. The only significant alleviating factor was rest. The Veteran did not use an ankle brace. Assistive devices consisted of a left below-knee amputation prosthesis, crutches, cane, right knee metal hinged brace, scooter and walker. There were no episodes of right ankle dislocation, however, the Veteran reported significant and frequent stiffness. He also reported having pain in the right knee, right hip, left hip, left knee and stump which resulted in an abnormal gait and stance. As a result of his right and left lower extremity conditions, the Veteran reported significant impairments including dependence with activities of daily living requiring assistance with bathing, moving onto and off of the toilet, dressing, ambulating and positioning. Due to the pain, the Veteran was unable to stand or walk for more than 10 minutes and was unable to walk up or down stairs unassisted. He was right lower extremity dominant. With respect to the right knee patellofemoral syndrome, the Veteran reported having no significant pain when not weight bearing, however, after standing or walking for two or three minutes, he developed pain which was a nine out of 10 in severity. Pain was described as burning pain at the distal portion of the mid-patella. The Veteran reported having right knee joint weakness, stiffness, giving way, fatigability, and lack of endurance but no swelling, heat, redness, or locking. He treated the right knee pain with medication, Gabapentin, Naproxen, and Meloxicam, with fair relief. He also reported having increased right knee pain with cold and damp weather and weight bearing. No episodes of right knee dislocation were noted, however he reported significant and frequent stiffness. As a result of his right and left lower extremity conditions, the Veteran reported having significant impairments as noted above with his activities of daily living as well as with gait and positioning. Regarding the right hip, the Veteran reported having right hip pain with weight bearing that was at an eight out of 10 in severity. Pain was relieved after 10 minutes of sitting. He reported having a feeling of right hip weakness with stiffness, instability, fatigability, and lack of endurance, but no swelling, heat, redness, or giving way. The Veteran reported treatment with medication, Gabapentin, Naproxen, and Meloxicam, with fair relief. He reported increased right hip pain with cold and damp weather and weight bearing. No episodes of right hip dislocation were noted, however, he reported significant and frequent stiffness. A physical examination revealed the Veteran sat in a wheelchair wearing a metal hinged right knee brace with a left below-knee amputation with no prosthesis on. The right hip joint was without significant deformity. There was no crepitance with right hip flexion, extension or rotation. There was no increased temperature or sign of inflammation. There was no weakness, apparent fatigue or incoordination with repetitive flexion and extension of the right hip joint during the examination against resistance of the examiner's hand. Moderate tenderness to palpation was noted along the proximal aspect of the right greater trochanter. The Veteran reported pain over the right greater trochanter with resisted right hip abduction, adduction, internal and external rotation and flexion but not extension. Active and passive right hip range of motion were equal and measured from: zero to 120 degrees of flexion, zero to 20 degrees of extension, zero to 20 degrees of adduction, zero to 40 degrees of abduction, zero to 50 degrees of external rotation, and zero to 40 degrees of internal rotation. The Veteran complained of mild right greater trochanter region pain throughout range of motion in all directions, without resistance as well. He also reported increased right hip pain with repetitive use, in addition to fatigue, weakness, and a lack of endurance. The right hip joint was stable during posturing maneuvers. A physical examination of the right knee revealed the knee joint was without significant deformity. The right patella was non tender and not ballotable. There was no crepitance with right knee joint flexion and extension. Fluid was not palpable in the suprapatellar bursae and there was neither increased temperature nor sign of inflammation. There was no weakness, apparent fatigue or incoordination with repetitive flexion and extension of the right knee joint during examination against resistance to the examiner's hand. Mild tenderness to palpation along the medial and lateral aspect of the right mid patella tendon was noted. No pain was found with valgus, varus and rotational stresses applied to the joint. There was notable instability of the Veteran's posture when bearing weight on the right knee to maneuver his body with significant weakness demonstrated with right knee joint extension maneuvers to elevate his body and a report of significant pain when forcibly extending the right knee joint against his body weight. Right knee joint flexion was from zero to 120 degrees actively with no pain and passively from 120 to 140 degrees with reported pain. Extension was normal, to zero degrees. Right knee joint medial and lateral collateral ligaments were stable with no motion to varus and valgus stresses at zero and 30 degrees of flexion. Right knee joint anterior and posterior cruciate ligaments were stable with no motion at 30 and 90 degrees of flexion. Right knee joint medial and lateral menisci were stable with negative McMurray's test. A physical examination of the right Achilles tendon revealed mild tenderness to palpation throughout with no sign of inflammation. The right ankle joint was without significant deformity. There was nonspecific tenderness to palpation at the proximal lateral and proximal medial malleolus with no edema. There was no increased temperature of the right ankle. The Veteran complained of increased diffuse but nonspecific right ankle joint pain with right ankle joint range of motion in all directions, with and without weight bearing. Patellar tendon and dorsalis pedis pulses were normal and at 2. Active and passive right ankle joint range of motion were equal and measured with a goniometer, demonstrating plantar flexion from zero to 60 degrees, dorsiflexion from zero to 30 degrees, inversion to 30 degrees and eversion to 15 degrees. The right ankle joint was stable with postural maneuvers. A neurological examination revealed right knee jerk and ankle jerk reflexes were +1. Sensation to sharp touch, soft touch, vibration and temperature were intact in the right lower extremity and were mildly decreased. Motor strength was at 4+ out of 5 in the right lower extremity for the hip, knee and ankle motion with a report of pain against resistance. X-rays of the right ankle, right hip and right knee were included in the VA examination report. A March 2009 right ankle x-ray revealed mild degenerative changes and small calcaneal spur. An August 2007 x-ray of the right hip revealed no evidence of acute bony trauma or destruction. A May 2007 x-ray of the right knee revealed an unremarkable right knee. The examiner found that the Veteran's status post left below-knee amputation was complicated by his right hip greater trochanteric bursitis, right knee patellofemoral syndrome and right ankle joint degenerative joint disease. He also noted the Veteran was status post right Achilles tendon rupture repair. The examiner found that radiological examination demonstrated no abnormalities of the right hip and right knee and mild degenerative changes of the right ankle joint. He then pointed out that the physical examination was significant for pain with range of motion of the right lower extremity joints, which increased with the resistance force of weight bearing and when maneuvering his body with the right lower extremity. There was no joint ankylosis or significant muscle group abnormality. The examiner found the combination of the right greater trochanteric bursitis, right patellofemoral syndrome, right ankle degenerative joint disease and right Achilles tendon condition, however, collectively resulted in moderate to severe degrees of impairment of the right lower extremity with instability with standing and walking and a very poor ability to transfer his body weight through the use of the right lower extremity. The examiner found that, as a result of the right lower extremity impairment, and left lower extremity below-knee amputation, the Veteran was not independent with activities of daily living, including bathing and toileting, walking and standing. He also found that, based on a recent history of two falls over the past two months, he had a significant risk for future falling and would benefit if his home was retrofitted with safety bars and other devices that would facilitate stability during transfers. The examiner also pointed out that the Veteran's cancer treatment likely resulted in significant fatigue that contributed to impairment with gait and transfers. With respect to the additional limitation of joint function, the examiner noted that the right hip, knee and ankle joint did not individually demonstrate overall a significant change in range of motion with repetition during examination of each joint independently. However, he found that during body transfers, using the right lower extremity, the Veteran had a very significant reduction in the use of the right lower extremity combined as a result of pain, fatigue, weakness, lack of endurance, and incoordination. He was not found to be capable of repetitively transferring himself based on the above, and the examiner noted he did so with very poor stability. In a May 2009 VA physical therapy report, a physical examination revealed range of motion was within full limits in the bilateral lower extremities. Strength was at five out of five in the bilateral lower extremities and pain free except for the right hip flexion which was at 4+ with suprapatellar pain. The Veteran was able to independently move from sitting to standing from his scooter to his standard walker. He was able to ambulate for 20 feet with a standard walker and with a proper gait pattern and good safety, although he needed reminders to reach for the chair when sitting. The Veteran was found to benefit from a knee walker. One day later, in a subsequent May 2009 VA outpatient treatment report, the Veteran reported having fallen the day before, due to a loss of balance and had hyperextended his right knee which led to pain and swelling. A May 2009 VA x-ray revealed findings of no joint effusion and no fracture. In a June 2012 video conference hearing, the Veteran testified that his right knee symptoms included locking and collapsing, which occurred periodically. He also reported problems with falling due to his right knee having given out on him, which occurred a couple of times a week. The Veteran testified that he had fallen in the shower and had to go to the emergency room for treatment. He also reported his right knee did not have full extension or flexion. He stated that his lateral and collateral ligaments were lax and had been proven by his doctors. The Veteran testified he wore his brace for the right knee all of the time, except when sleeping. He reported that his physicians had stated that he might have arthritis in the knee referred to an x-ray that had been done of the right knee. He stated his right knee also included symptoms of pain and swelling, which he alleviated with stopping, sitting down and putting his leg up. He reported having gone to physical therapy for the right knee and using cortisone injections for the right knee. The Veteran testified that stairs and escalators caused anxiety about the possibility of falling. With respect to the right hip, the Veteran testified that his right hip had limitation of motion and limitations with bending, stretching, and sitting for any period of time. He also reported having problems with sleeping because of right hip pain. He stated his right hip also exhibited clicking in the joint pretty often and swelling. The Veteran testified that he used a wheelchair, crutches and a cane and that his car was specially adapted. With respect to mobility, he reported having difficulty with moving his right hip joint as well. Regarding the right Achilles tendon, the Veteran testified that this disability caused a lot of pain toward the heel and which traveled up his calf. He reported pain was severe, at an eight to nine out of 10 in severity. He stated he had difficulty pushing off his foot and the weight bearing strained his Achilles area, causing pain. The Veteran testified that he had a popping, snapping sound in the heel whenever he extended his foot too far. He reported his Achilles affected him on a regular basis. He stated he sat and relaxed to help alleviate the pain and took pain medication for the right Achilles tendon, on and off. The Veteran testified that he was concerned that his tendon would rupture again, especially with moving on an incline or on stairs. With respect to his claim for loss of use of the right leg, the Veteran testified that his right leg limited him so much that he would be equally served by an amputation with the use of a prosthetic appliance, because except for the hip, due to his knee and ankle he believed he would not have any pain if he had a prosthesis. The limitations due to the right leg impacted the Veteran on a daily basis and he reported having his wife do a lot of things for him. He also stated his limitations included walking any distance. In a July 2012 letter, the Veteran's private physician, S.C.D., M.D., reported that due to the stressors on the Veteran's right lower extremity he had developed serious osteoarthritis in the right hip, patellofemoral syndrome of the right knee and a ruptured Achilles tendon. S.C.D., M.D. also noted the Veteran had degenerative disc disease of the lumbar spine with sciatica and peripheral neuropathy. He found that all the above symptoms were very likely directly and/or indirectly related to his initial trauma of the left lower extremity from a land mine explosion. S.C.D., M.D. also reported that the above noted disabilities had limited the Veteran's ability to function in a reasonably normal fashion. He found the Veteran needed a suitable prosthetic device for his right lower extremity to decrease pain and suffering and increase functionality. In an October 2012 VA examination of the right ankle, the Veteran was diagnosed with ankle osteoarthritis. He reported that flare-ups impacted the function of the ankle, noting pain and swelling which made it difficult to walk. Range of motion of the right ankle revealed plantar flexion to 45 degrees or greater, with no objective evidence of painful motion. Right ankle dorsiflexion was to 15 degrees with pain at 15 degrees. After three repetitions, the right ankle range of motion included plantar flexion to 45 degrees or greater and right ankle dorsiflexion to 15 degrees. Additional limitation of motion in the range of motion of the ankle was not found. Functional loss and/or functional impairment of the ankle was found, noted as less movement than normal in the right ankle and the examiner noted left below-knee amputation. Localized tenderness or pain on palpation of the right ankle was noted. Muscle strength testing in the right was at five out of five with both plantar flexion and dorsiflexion. The Veteran was unable to be tested for joint stability. No ankylosis was present. No additional conditions were noted, including shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus or talus or talectomy. No total ankle joint replacement was found. The examiner noted the Veteran underwent surgical repair of the right Achilles tendon rupture. Residuals signs or symptoms of the Achilles tendon rupture included decreased right ankle dorsiflexion. The examiner also noted the right ankle anterior/posterior laxity and talar tilt test were not deemed to be abnormal and could not be compared to the Veteran's left ankle due to a left below-knee amputation. Assistive devices included regular use of a wheelchair and crutches, constant use of a cane, occasional use of a walker and constant use of a motorized scooter and electric wheelchair. The examiner found there was no functional impairment of the extremity such that no effective function remained other than that which would be equally served by an amputation with prosthesis due to the ankle condition. Abnormal diagnostic testing revealed degenerative or traumatic arthritis of the right ankle. A March 2009 x-ray was noted to reflect mild degenerative changes in the right ankle and small calcaneal spur. The Veteran's ankle condition was found to impact his ability to work and the examiner noted the Veteran retired in 2006 from being self-employed. The Veteran reported he would have a problem picking up and delivering dental products, especially if stairs were involved. The examiner concluded that the Veteran's physical examination revealed a slight limitation in the right ankle dorsiflexion, which was a common occurrence following surgical repair of a ruptured right Achilles tendon. He found that there was no evidence of right ankle effusion of other objectively verifiable physical examination findings that would support an opinion that the Veteran experienced an increase in his service-connected disability from the mild decrease in right ankle dorsiflexion. Thus, the examiner found the expected severity of the right ankle impairment/disability was mild. He also found the effects of the Veteran's service-connected neuropathy of the right leg did not affect the Veteran's right ankle impairment/disability. The Veteran's right ankle radiographs in March 2009 were also noted as being interpreted by the radiologist as mild degenerative changes of the right ankle, which the examiner found would not be expected to result in greater than a mild degree of impairment/disability. In an October 2012 VA examination of the right hip, the Veteran was not provided any diagnosis of a hip condition and the examiner found the Veteran did not have or ever had a hip or thigh condition. The Veteran reported his right hip became painful in 2004 and 2005, which he attributed to his left below-knee amputation. He stated he had right lower extremity neuropathy from the chemotherapy administered for his non-Hodgkin's lymphoma. These right leg symptoms included tingling and numbness. Flare-ups of the hip and thigh were not noted. The right hip range of motion included flexion to 125 degrees or greater with no objective evidence of painful motion and extension to greater than 5 degrees with no objective evidence of painful motion. Abduction was not found to be lost beyond 10 degrees. Adduction was not limited such that the Veteran could not cross his legs. Rotation was not found to be limited such that the Veteran could not toe-out more than 15 degrees. Repetitive use testing revealed flexion to 125 degrees or greater, extension to 5 degrees or greater. Repetitive testing did not reveal abduction lost beyond 10 degrees, adduction limited such that the Veteran could not cross his legs or rotation limited such that the Veteran could not toe-out more than 15 degrees. No additional limitation of range of motion following repetitive testing was found. No additional functional loss or functional impairment was found. No tenderness to palpation of joints or soft tissue of the hip was noted. Muscle strength testing reveled findings of five out of five for right hip flexion, abduction and extension. Ankylosis of the hip, malunion or nonunion of the femur flail hip joint or leg length discrepancy were not found. Other pertinent physical findings, complications, conditions, signs and/or symptoms related to the hip included left below-knee amputation. Assistive devices included regular use of a wheelchair and crutches, constant use of a cane, occasional use of a walker and constant use of a motorized scooter and electric wheelchair. No functional impairment of the right extremity, such that no effective function remained other than that which would be equally served by an amputation with prosthesis due to the hip and/or thigh condition was found. No traumatic arthritis was found. An August 2007 x-ray of the right hip was noted in the report and revealed no evidence of acute bony trauma or destruction. The Veteran's hip and/or thigh disability was found to have impacted his work and the examiner noted the Veteran retired in 2006 from being self-employed. The Veteran reported he would have a problem picking up and delivering dental products, especially if stairs were involved. The examiner concluded in the diagnosis that there were no objectively verifiable physical examination findings or radiographic findings existing at the time of the examination to support a definitive diagnosis explaining the Veteran's subjective complaints. The examiner found that based upon verifiable objective medical evidence, the current severity of the Veteran's right hip impairment/disability was no greater than mild. The examiner also concluded that effects of the Veteran's service-connected neuropathy of the right leg did not affect his right hip impairment/disability. In an October 2012 VA examination of the right knee, the Veteran was not provided any diagnosis of a knee condition and the examiner found the Veteran did not have or ever had a knee or lower leg condition. The Veteran reported that his right knee pain began in 2004 and 2005 and he attributed the right knee condition to his left below-knee amputation. He also reported a history of right lower extremity neuropathy from the chemotherapy administered for his non-Hodgkin's lymphoma with symptoms including tingling and numbness. Flare-ups of the right knee were not reported. Range of motion of the right knee revealed flexion to 140 degrees or greater with no objective evidence of painful motion and extension to zero degrees with no objective evidence of painful motion. After repetitive testing, range of motion testing revealed right knee flexion to 140 degrees or grater and extension to zero degrees. No additional range of motion of the knee was found, although functional loss and/or functional impairment of the knee was noted. The examiner noted functional loss/impairment included less movement than normal in the left knee only. No tenderness or pain to palpation for joint line or soft tissues of either knee was noted. Muscle strength was at five out of five in the right knee with flexion and extension. Anterior instability test (Lachman's test) and posterior instability test (posterior drawer test) were normal in the right knee. Medial lateral instability was at 1+ in the right knee (zero to 5 mm). No evidence or history of recurrent patellar subluxation or dislocation as noted. No additional right knee conditions, including shin splints, stress fracture, chronic exertional compartment syndrome, traumatic genu recurvitum, or leg length discrepancy were found. No meniscal condition was found. No meniscectomy, total knee replacement or arthroscopic or other knee surgeries were noted. Other pertinent physical findings, complications, conditions, signs and/or symptoms related to the hip included left below-knee amputation. Assistive devices included regular use of a wheelchair and crutches, constant use of a cane, occasional use of a walker and constant use of a motorized scooter and electric wheelchair. No functional impairment of the right extremity, such that no effective function remained other than that which would be equally served by an amputation with prosthesis due to the right knee was found. A May 2007 x-ray of the right knee was noted and revealed unremarkable findings. The Veteran's right knee disability was found to have impacted his work and the examiner noted the Veteran retired in 2006 from being self-employed. The Veteran reported he would have a problem picking up and delivering dental products, especially if stairs were involved. The examiner found in the diagnosis section that there were no objectively verifiable physical examination findings or radiographic findings existing at the time of the examination to support a definitive diagnosis explaining the Veteran's subjective complaints. The examiner concluded that based upon the verifiable objective medical evidence, the current severity of the Veteran's right knee impairment/disability was no greater than mild and the level of impairment of the Veteran's right knee impairment/disability was no greater than mild. The examiner found that the effects of the Veteran's service-connected neuropathy of the right leg did not affect his right knee impairment/disability. The examiner also concluded that the mild valgus/varus laxity of the Veteran's right knee would not be expected to result in instability or result in or cause greater than a mild impairment/disability. A. Increased Ratings Pertinent Laws and Regulations - Generally Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. See 38 U.S.C.A. § 1155; 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 for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When, as here, the Veteran is requesting an increased rating for an established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, the most recent examination is not necessarily and always controlling; rather, consideration is given not only to the evidence as a whole but to both the recency and adequacy of examinations. See Powell v. West, 13 Vet. App. 31, 35 (1999). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different "staged" ratings may be warranted for different time periods. When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases in which the veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath, 1 Vet. App. at 592. Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Analysis 1. Residuals of a Right Achilles Tendon Rupture The Veteran's residuals of a right Achilles rupture is currently rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5276-5019 (2012). 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. This hyphenated diagnostic code may be read to indicate that pes planus is the service-connected disorder, and it is rated as if the residual condition bursitis of the ankle under Diagnostic Code 5019. Diagnostic Code 5019 provides ratings for bursitis. 38 C.F.R. § 4.71a (2012). The rating criteria specify that the diseases listed under Diagnostic Codes 5013 to 5024 will be rated on limitation of motion of affected parts, as arthritis, degenerative, except gout, which will be rated under Diagnostic Code 5002. 38 C.F.R. § 4.71a. Therefore, the Board has analyzed the claim under the appropriate diagnostic codes applicable to the residuals of a right Achilles tendon rupture pertaining to degenerative arthritis and limitation of motion of the ankle. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5271 (2012). Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. Id. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent 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. Id. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. Id. Normal ranges of motion of the ankle include dorsiflexion from 0 degrees to 20 degrees, and plantar flexion from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II (2012). Diagnostic Code 5271 provides ratings based on limitation of extension of the ankle. Moderate limitation of motion of the ankle is rated as 10 percent disabling; and marked limitation of motion of the ankle is rated as 20 percent disabling. 38 C.F.R. § 4.71a. After a careful review of the evidence of record, the Board finds that the Veteran's residuals of a right Achilles tendon rupture do not warrant a disability rating in excess of 10 percent at any time during the pendency of the appeal under Diagnostic Code 5271. The evidence of record, including lay statements and testimony, private and VA medical records and VA examinations, demonstrates that the Veteran's residuals of a right Achilles tendon rupture were productive of subjective complaints of pain, stiffness and weakness with objective findings of pain, limitation of motion in dorsiflexion and degenerative joint disease. This disability has not been productive of marked limitation of motion, so as to warrant a higher disability rating under Diagnostic Code 5271. 38 C.F.R. § 4.71a. The May 2007 VA examination revealed physical findings of right ankle dorsiflexion from 0 to 20 degrees with pain and right plantar flexion from 0 to 45 degrees without pain. In addition, no varus or valgus angulation of the os calcis in relation to the long axis of the tibia and fibular was found and the Veteran's muscle strength was at four out of five in the right ankle and right foot. The March 2009 VA examination revealed findings of right ankle mild tenderness to palpation throughout with no sign of inflammation and no significant deformity. Active and passive right ankle joint range of motion were equal with plantar flexion from zero to 60 degrees, dorsiflexion from zero to 30 degrees, inversion to 30 degrees and eversion to 15 degrees. The right ankle joint was stable with postural maneuvers. The March 2009 VA examination noted that a March 2009 right ankle x-ray revealed mild degenerative changes and small calcaneal spur. The October 2012 VA examination of the right ankle revealed plantar flexion to 45 degrees or greater, with no objective evidence of painful motion and dorsiflexion was to 15 degrees with pain at 15 degrees. No additional limitation of motion in the range of motion, functional loss or functional impairment of the ankle was found. In addition, this examination revealed that no additional conditions were noted, including shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus or talus or talectomy. The examiner noted that residuals signs or symptoms of the Achilles tendon rupture included decreased right ankle dorsiflexion. The examiner concluded that the Veteran's physical examination revealed a slight limitation in the right ankle dorsiflexion, which was a common occurrence following surgical repair of a ruptured right Achilles tendon. Most significantly, the October 2012 VA examiner found the expected severity of the right ankle impairment/disability was mild. He also noted the right ankle radiographs in March 2009 were also interpreted by the radiologist as mild degenerative changes of the right ankle, which the examiner found would not be expected to result in greater than a mild degree of impairment/disability. On review of the evidence, the Board also points out that the Veteran's range of motion has been essentially normal with plantar flexion from 0 degrees to 45 degrees. Dorsiflexion was at worst limited to 15 degrees, which is only 5 degrees less than normal. Even considering the Veteran's subjective complaints as outlined above, the medical evidence of record does not reflect any additional limitation of motion demonstrated upon repetitive motion that would more nearly approximate marked limitation of motion so as to support a higher evaluation at any time. While the May 2007 VA examination demonstrated findings of painful motion and additional limitation of the range of motion of the joint function by pain, fatigue, weakness following repetitive use, there was no additional limitation of the Veteran's range of motion noted in degrees or in severity and the examiner did not indicate that the noted limitation of function revealed any increase in severity of the Veteran's right ankle disability. Thereafter, the March 2009 and October 2012 VA examinations revealed, upon repetitive motion, no additional limitation of motion in the range of motion, functional loss or functional impairment of the ankle. Although the evidence does show that the Veteran experiences painful motion, it does not result in a higher rating unless it actually results in additional functional loss. See Mitchell, 25 Vet. App. at 38-43; DeLuca, 8 Vet. App. at 204-7. Other appropriate diagnostic codes for application have been considered. However, as the Veteran's service-connected residuals of a right Achilles tendon rupture do not reflect findings of ankylosis, malunion of the os calcis or astragalus, or astragalectomy at any time during the pendency of the appeal, Diagnostic Codes 5270, 5272, 5273 and 5274 do not apply. 38 C.F.R. § 4.71a. The Board has also considered whether Diagnostic Code 5311 is applicable; however, the March 2009 VA examination stated that there was no significant muscle group abnormality. Absent degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, which is not the case here, a higher disability rating is not warranted under Diagnostic Codes 5003 and 5010. See 38 C.F.R. §§ 4.45, 4.71a, Diagnostic Codes 5003, 5010. Absent marked limitation of motion of the right ankle, a higher disability rating, in excess of 10 percent is not warranted under Diagnostic Code 5271. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. All things considered, the record as a whole does not show symptoms that equal or more nearly approximate the criteria for an evaluation higher than 10 percent at any time since the date of claim. That is to say, the Veteran's disability has been no more than 10 percent disabling since the date of his claim, so his rating cannot be "staged" because this represents his greatest level of functional impairment attributable to this condition. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. 38 C.F.R. § 4.3; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The benefit sought on appeal is accordingly denied. 2. Right Hip Disability The Veteran's right hip disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5019 (2012). 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. This hyphenated diagnostic code may be read to indicate that arthritis is the service-connected disorder, and it is rated as if the residual condition is bursitis of the hip under Diagnostic Code 5019. Diagnostic Code 5019 provides ratings for bursitis. 38 C.F.R. § 4.71a (2012). The rating criteria specify that the diseases listed under Diagnostic Codes 5013 to 5024 will be rated on limitation of motion of affected parts, as arthritis, degenerative, except gout, which will be rated under Diagnostic Code 5002. 38 C.F.R. § 4.71a. Therefore, the Board has analyzed the claim under the appropriate diagnostic codes applicable to the right hip disability pertaining to degenerative arthritis and limitation of motion of the hip. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5251, 5252, 5253 (2012). Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. Id. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent 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. Id. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. Id. Normal ranges of motion of the hip include flexion from 0 degrees to 125 degrees, and abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II (2012). Under Diagnostic Code 5251, limitation of extension of the thigh to 5 degrees warrants a 10 percent rating. 38 C.F.R. § 4.71a. Under Diagnostic Code 5252, limitation of flexion of the thigh to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; flexion limited to 20 degrees warrants a 30 percent rating; and flexion limited to 10 degrees warrants a 40 percent rating. Id. Impairment of the thigh is rated under Diagnostic Code 5253. Limitation of rotation of the thigh, cannot toe-out more than 15 degrees, in the affected leg warrants a 10 percent rating. Limitation of adduction of the thigh, cannot cross legs, also warrants a 10 percent rating. Limitation of abduction of the thigh with motion lost beyond 10 degrees warrants a 20 percent rating. Id. Ankylosis of the hip is evaluated under Diagnostic Code 5250. Favorable ankylosis, in flexion at an angle between 20 degrees and 40 degrees, and slight adduction or abduction warrants a 60 percent rating. Intermediate ankylosis warrants a 70 percent rating. Unfavorable ankylosis with extremely unfavorable ankylosis, the foot not reaching the ground, crutches necessitated warrants a 90 percent rating. (Special monthly compensation also is entitled if the criteria for the 90 percent rating are met.) Id. After a careful review of the evidence of record, the Board finds that the Veteran's right hip disability does not warrant a disability rating in excess of 10 percent at any time during the pendency of the appeal under Diagnostic Codes 5251, 5252, 5253. The evidence of record, including lay statements and testimony, private and VA medical records and VA examinations, demonstrates that the Veteran's right hip disability was productive of subjective complaints of pain, instability, giving out, weakness, fatigability and a lack of endurance and degenerative joint disease with objective findings of pain, flexion to 120 degrees, at worst, extension greater than 5 degrees, abduction not lost beyond 10 degrees, adduction not limited such that the Veteran could not cross his legs and rotation limited such that the Veteran could not toe-out more than 15 degrees. There were no objective findings of instability or degenerative joint disease. This disability has not been productive of limitation of thigh extension to 5 degrees, limitation of thigh flexion to 30 degrees or limitation of abduction, lost beyond 10 degrees, so as to warrant a higher disability rating under Diagnostic Codes 5251, 5252, 5253. 38 C.F.R. § 4.71a. Although the Veteran has been diagnosed with degenerative joint disease of the hips, there is no objective evidence of degenerative joint disease of the hips. In this case, an August 2007 x-ray of the right hip, noted in the August 2007 VA examination, revealed no evidence of acute bony trauma or destruction, the joint was noted to be well preserved and multiple vascular calcifications were noted in the pelvis. The August 2007 VA examination of the right hip demonstrated that the examiner had found that the right hip was painful on motion and the range of motion and joint function was additionally limited by pain, fatigue, weakness or lack of endurance following repetitive use with two to three repetitions, although no further limitation of range of motion in degrees was specified by the examiner. The March 2009 VA examination revealed the right hip joint was without significant deformity and moderate tenderness to palpation was noted along the proximal aspect of the right greater trochanter. The Veteran complained of mild right greater trochanter region pain throughout range of motion in all directions, without resistance as well. The right hip joint was stable during posturing maneuvers. The examiner found that radiological examination demonstrated no abnormalities of the right hip. With respect to the additional limitation of joint function, the examiner noted that the right hip, knee and ankle joint did not individually demonstrate overall a significant change in range of motion with repetition during examination of each joint independently. In the October 2012 VA examination of the hip, physical examination findings demonstrated no additional limitation of range of motion, functional loss or functional impairment following repetitive testing. No tenderness to palpation of joints or soft tissue of the hip was noted. In addition, ankylosis of the hip, malunion or nonunion of the femur flail hip joint or leg length discrepancy were not found. The examiner characterized the right hip disability as no greater than mild and that there were no objectively verifiable physical examination findings or radiographic findings existing at the time of the examination to support a definitive diagnosis explaining the Veteran's subjective complaints. Even considering the Veteran's subjective complaints as outlined above, the medical evidence of record does not reflect any additional limitation of motion demonstrated upon repetitive motion that would support a higher evaluation at any time. While the August 2007 VA examination demonstrated findings of the right hip was painful on motion and the range of motion and joint function was additionally limited by pain, fatigue, weakness or lack of endurance following repetitive use with two to three repetitions, there was no additional limitation of the Veteran's range of motion noted in degrees and the examiner did not indicate that the noted limitation of function revealed any increase in severity of the Veteran's right hip disability. Thereafter, the March 2009 and October 2012 VA examinations revealed no additional limitation of motion in the range of motion, functional loss or functional impairment of the hip. Although the evidence does show that the Veteran experiences painful motion, it does not result in a higher rating unless it actually results in additional functional loss. See Mitchell, 25 Vet. App. at 38-43; DeLuca, 8 Vet. App. at 204-7. Other appropriate diagnostic codes for application have been considered. However, as the Veteran's service-connected right hip disability does not reflect findings of ankylosis, hip flail joint, or impairment of the femur at any time during the pendency of the appeal, Diagnostic Codes 5250, 5254 and 5255 do not apply. 38 C.F.R. § 4.71a. Absent degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, which is not the case here as the x-ray evidence of record does not reflect degenerative arthritis of the right hip, a higher disability rating is not warranted under Diagnostic Codes 5003 and 5010. See 38 C.F.R. §§ 4.45, 4.71a, Diagnostic Codes 5003, 5010. Absent limitation of thigh extension to 5 degrees, limitation of thigh flexion to 30 degrees or limitation of abduction, lost beyond 10 degrees, a higher disability rating, in excess of 10 percent is not warranted for a right hip disability under Diagnostic Codes 5251, 5252 or 5253. See 38 C.F.R. § 4.71a, Diagnostic Codes 5251, 5252 and 5253. All things considered, the record as a whole does not show symptoms that equal or more nearly approximate the criteria for an evaluation higher than 10 percent at any time since the date of claim. That is to say, the Veteran's disability has been no more than 10 percent disabling since the date of his claim, so his rating cannot be "staged" because this represents his greatest level of functional impairment attributable to this condition. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. 38 C.F.R. § 4.3; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The benefit sought on appeal is accordingly denied. 3. Patellofemoral Syndrome of the Right Knee The Veteran's patellofemoral syndrome of the right knee is currently rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5257 (2012). 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. This hyphenated diagnostic code may be read to indicate that arthritis is the service-connected disorder, and it is rated as if the residual condition is instability of the right knee under Diagnostic Code 5257. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. Id. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent 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. Id. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. Id. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5257 provides ratings for other impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated 30 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Id. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Codes 5003 (providing rating for arthritis) and instability of a knee under Diagnostic Code 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). When x-ray findings of arthritis are present and a veteran's knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998). VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003/5010 and 5257, respectively. More recently, the VA General Counsel held that a separate rating could also be provided for limitation of knee extension and flexion of the same knee joint. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). After a careful review of the evidence of record, the Board finds that the Veteran's right knee patellofemoral syndrome does not warrant a disability rating in excess of 10 percent at any time during the pendency of the appeal under Diagnostic Codes 5257, 5258, 5260 and/or 5261. The evidence of record, including lay statements and testimony, private and VA medical records and VA examinations, demonstrates that the Veteran's right knee patellofemoral syndrome was productive of subjective complaints of pain, swelling, locking, giving way, instability and degenerative joint disease with objective findings of pain, swelling, flexion to 90 degrees, at worst, and extension to zero degrees (full extension). However, there were no objective findings of degenerative joint disease on x-ray of the right knee. Although range of motion or joint function was found to be additionally limited by pain, fatigue, weakness and a lack of endurance following repetitive use, no significant change in range of motion in degrees was found. This disability has not been productive of recurrent subluxation or more than mild instability, dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint, limitation of leg flexion to 30 degrees or less or limitation of leg extension to 15 degrees or more, so as to warrant a higher disability rating under Diagnostic Codes 5257, 5258, 5260 and 5261. 38 C.F.R. § 4.71a. At worst, range of motion was from 0 to 90 degrees, which does not even meet the criteria for a 0 percent rating under DC 5260 or 5261. Even considering the Veteran's subjective complaints as outlined above, the medical evidence of record does not reflect any additional limitation of motion demonstrated upon repetitive motion that would support a higher evaluation at any time. While the May 2007 VA examination demonstrated findings of the right knee joint was painful on motion and the range of motion or joint function was additionally limited by pain, fatigue, weakness and a lack of endurance following repetitive use, there was no additional limitation of the Veteran's range of motion noted in degrees and the examiner did not indicate that the noted limitation of function revealed any increase in severity of the Veteran's right knee disability. Thereafter, the March 2009 and October 2012 VA examinations revealed no additional limitation of motion in the range of motion, functional loss or functional impairment of the right knee. Although the evidence does show that the Veteran experiences painful motion, it does not result in a higher rating unless it actually results in additional functional loss. See Mitchell, 25 Vet. App. at 38-43; DeLuca, 8 Vet. App. at 204-7. The Board has also considered whether separate ratings under DC 5260 and/or 5261 and DC 5257 are warranted. However, despite some diagnoses of degenerative joint disease in the treatment records, this was not confirmed on x-rays of the right knee. The Veteran has been diagnosed with degenerative joint disease of the right knee and provided a history thereof in both private and VA medical records. However, a May 2007 x-ray report of the right knee revealed no evidence of fracture, abnormal calcification or radiopaque foreign body, or soft tissue pathology and the right knee was found to be unremarkable. Subsequently, a June 2007 VA x-ray of the right knee revealed no evidence of fracture, no abnormal calcification or radiopaque foreign body, and no soft tissue abnormality. The Veteran was assessed with an unremarkable right knee. Finally, pursuant to a recent fall with pain and swelling noted in the right knee, x-rays were ordered in a May 2009 VA outpatient treatment report and the results of the May 2009 VA x-ray revealed findings of no joint effusion and no fracture. Therefore, the Board finds that the most probative evidence of record, i.e., the diagnostic studies of the knee, show that the Veteran does not have arthritis. Thus, a separate rating under the range of motion codes is not warranted. See VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998). The evidence of record is also absent of any objective medical evidence of more than mild instability of the right knee. The May 2007 VA examination revealed normal stability testing of the medial and lateral collateral ligaments, anterior and posterior cruciate (also noted as Lachman's test) and the medial and lateral meniscus (tested by McMurray's test). The Board observes that the March 2009 VA examination noted instability of the Veteran's posture when bearing weight on the right knee to maneuver his body with significant weakness demonstrated with right knee joint extension maneuvers to elevate his body and also noted a report of significant pain when forcibly extending the right knee joint against his body weight; however, the objective testing revealed the right knee joint medial and lateral collateral ligaments, anterior and posterior cruciate ligaments, and medial and lateral menisci were all stable. In the October 2012 VA examination of the right knee, anterior instability test (Lachman's test) and posterior instability test (posterior drawer test) were normal in the right knee and medial lateral instability was noted at 1+ in the right knee (zero to 5 mm), however, the VA examiner concluded that the mild valgus/varus laxity of the Veteran's right knee would not be expected to result in instability or result in or cause greater than a mild impairment/disability. Finally, the VA examiner characterized the current severity of the Veteran's right knee disability and the level of impairment as no greater than mild. Thus, a rating in excess of 10 percent is not warranted under DC 5257. Other appropriate diagnostic codes for application have been considered. However, as the Veteran's service-connected right knee disability does not reflect findings of ankylosis, impairment of the tibia or fibula or genu recuvatum at any time during the pendency of the appeal, Diagnostic Codes 5256, 5262 and 5263 do not apply. 38 C.F.R. § 4.71a. Absent degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, which is not the case here as the x-ray evidence of record does not reflect degenerative arthritis of the right knee, a higher disability rating is not warranted under Diagnostic Codes 5003 and 5010. See 38 C.F.R. §§ 4.45, 4.71a, Diagnostic Codes 5003, 5010. Absent recurrent subluxation or more than mild lateral instability, dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint, limitation of leg flexion to 30 degrees or less or limitation of leg extension to 15 degrees or more, a higher disability rating in excess of 10 percent is not warranted for right knee patellofemoral syndrome under Diagnostic Codes 5257, 5258, 5260 and 5261. See 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5258, 5260 and 5261. All things considered, the record as a whole does not show symptoms that equal or more nearly approximate the criteria for an evaluation higher than 10 percent at any time since the date of claim. That is to say, the Veteran's disability has been no more than 10 percent disabling since the date of his claim, so his rating cannot be "staged" because this represents his greatest level of functional impairment attributable to this condition. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. 38 C.F.R. § 4.3; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The benefit sought on appeal is accordingly denied. Lay Statements The Board observes that the Veteran and his wife are competent to report on factual matters of which they had firsthand knowledge, e.g., experiencing or witnessing pain or weakness, etc. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board finds that the statements provided by the Veteran and his wife regarding the effects of his current right ankle, right hip and right knee symptoms on his daily life are competent and credible. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Baldwin v. West, 13 Vet. App. 1 (1999) (the Board must analyze the credibility of the evidence). With respect to the Rating Schedule, where the criteria set forth therein require medical expertise which the Veteran has not been shown to have or where these types of findings are not readily observable by a lay person, the Board has accorded greater probative weight to objective medical findings and opinions provided by the Veteran's treatment reports and his VA examination reports. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) ("[t]he probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . the credibility and weight to be attached to these opinions [are] within the province of the adjudicator.") Thus, the Board has considered the reports of the Veteran and his wife with respect to experiencing symptoms in evaluating his disability ratings in this decision. Extra-schedular Consideration The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedural Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the RO or the Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by regulation as "governing norms" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. In this case, the Board finds that the schedular criteria are adequate to rate the disability under consideration. The rating schedule fully contemplates the described symptomatology and provides for ratings higher than those assigned based on more significant functional impairment. In this regard, the Board points out that the diagnostic criteria for the right hip, right ankle and right knee all provide disability ratings based on additional limitation of motion of the joints and/or increased severity of degenerative joint disease, if present, with incapacitating exacerbations. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5251, 5252, 5253, 5260, 5261, and 5271. Additionally, the rating criteria for the knee provide additional and separate ratings based on instability, subluxation, and cartilage impairment, which were not demonstrated by the evidence of record in this case. 38 C.F.R. § 4.71a, Diagnostic Codes 5257 and 5258. Moreover, the rating criteria provide other applicable diagnostic codes for additional disabilities of the hip, knee and ankle, including ankylosis, impairment of the femur, flail joint of the hip, impairment of the tibia or fibula, genu recurvatum, malunion of os calcis or astragalectomy, however none of these disabilities were demonstrated in the record. See 38 C.F.R. § 4.71a, Diagnostic Codes 5250, 5254, 5255, 5256, 5262, 5263, 5270, 5272, 5273 and 5274. This matter was implicitly considered and rejected by the RO. See SSOC, dated February 2013 citing 38 C.F.R. § 3.321(b)(1). Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). B. Special Monthly Compensation If a Veteran, as the result of service-connected disability, loses the use of a lower extremity, including the foot, he is entitled to additional monthly compensation, which is referred to as special monthly compensation. 38 U.S.C.A. § 1114(k) (West 2002 & Supp. 2012); 38 C.F.R. § 3.350(a) (2012). Special monthly compensation based on the loss of use of the right lower extremity (or foot) is held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the knee with the use of a prosthesis. 38 C.F.R. §§ 3.350(a)(2), 4.63 (2012). The determination will be made on the basis of the actual remaining function of the foot, whether the acts of balance and propulsion, etc., in the case of the foot, could be accomplished equally well by an amputation stump with prosthesis. Id. Extremely unfavorable complete ankylosis of the knee, or complete ankylosis of two major joints of an extremity, or shortening of the lower extremity of 3 and 1/2 inches or more, will constitute loss of use of the foot involved; complete paralysis of the external popliteal nerve (common peroneal) and consequent foot drop, accompanied by characteristic organic changes including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve, will be taken as loss of use of the foot. 38 U.S.C.A. § 1114 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.350, 4.63 (a), (b) (2012). Entitlement to special monthly compensation benefits requires that the conditions described be due to service-connected disability. In this case, the disabilities for which service connection has been granted include: below the knee amputation of the left lower extremity; posttraumatic stress disorder (PTSD); degenerative joint disease of the lumbosacral spine; arthritis of the hands associated with below the knee amputation of the left lower extremity; neuropathy of the right lower extremity, associated with degenerative joint disease of the lumbosacral spine; residuals of prostate cancer, status post radiation therapy; right knee patellofemoral syndrome associated with below the knee amputation of the left lower extremity; tinnitus; arthritis of the right hip associated with below the knee amputation of the left lower extremity; ruptured right Achilles tendon associated with below the knee amputation of the left lower extremity; organic mental impairment; residuals of hookworm infestation; bilateral high frequency sensorineural hearing loss; erectile dysfunction associated with residuals of prostate cancer, status post radiation therapy; and non-Hodgkin's lymphoma. His combined disability rating is 100 percent. The Veteran has already been granted special monthly compensation under 38 U.S.C. § 1114(k) and 38 C.F.R. § 3.350(a) on account of anatomical loss of use of one foot. He has also been granted special monthly compensation under 38 U.S.C. § 1114(k) and 38 C.F.R. § 3.350(a) on account of loss of use of a creative organ. He has also been granted special monthly compensation under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i) on account of residuals of prostate cancer status post radiation therapy rated 100 percent and additional service-connected disabilities of arthritis of the hands, patellofemoral syndrome of the right knee associated with left below the knee amputation of the left lower extremity, degenerative joint disease of the lumbosacral spine, PTSD, tinnitus, below the knee amputation left lower extremity, independently ratable at 60 percent or more from June 26, 2007 to October 1, 2013. The Veteran has also been found entitled to automobile and adaptive equipment, specially adapted housing and basic eligibility under 38 U.S.C. Chapter 35. The Board finds that a preponderance of the evidence is against a finding that the Veteran's right leg disabilities are manifested by loss of use of the right foot or right lower extremity. The evidence of record demonstrates that Veteran's problems with ambulation, falling and instability, which he attributes to the right lower extremity, namely his right leg, are not solely affected by his right lower extremity disabilities of the right hip, right knee and right ankle. Rather, the medical evidence of record demonstrates that factors other than the right leg have contributed to his overall problems with ambulation, falling and instability, including the left below-knee amputation, and treatment for non-Hodgkin's lymphoma. The May 2007 VA examiner found that due to the service-connected left below-knee moderate to severe medial collateral laxity, the examiner found that the Veteran was placing more stress/strain on the right lower extremity, which was likely contributing to the right knee instability and pain/strain, as well as likely contributing to the right Achilles tendonitis. The August 2007 VA examination of the right hip noted the Veteran was able to get out of the wheelchair and use crutches to transfer to the examination table without difficulty. The March 2009 VA examiner found that the physical examination was significant for pain with range of motion of the right lower extremity joints, which increased with the resistance force of weight bearing and when maneuvering his body with the right lower extremity, however, there was no joint ankylosis or significant muscle group abnormality. He found that the combination of the right greater trochanteric bursitis, right patellofemoral syndrome, right ankle degenerative joint disease and right Achilles tendon condition, however, collectively resulted in moderate to severe degrees of impairment of the right lower extremity with instability with standing and walking and a very poor ability to transfer his body weight through the use of the right lower extremity. The examiner March 2009 VA examiner also found that, as a result of both the right lower extremity impairment and left lower extremity below-knee amputation, the Veteran was not independent with activities of daily living, including bathing and toileting, walking and standing. He also pointed out that the Veteran's cancer treatment likely resulted in significant fatigue that contributed to impairment with gait and transfers. With respect to the additional limitation of joint function, the examiner noted that the right hip, knee and ankle joint did not individually demonstrate overall a significant change in range of motion with repetition during examination of each joint independently. However, he found that during body transfers, using the right lower extremity, the Veteran had a very significant reduction in the use of the right lower extremity combined as a result of pain, fatigue, weakness, lack of endurance, and incoordination. The Veteran was not found to be capable of repetitively transferring himself based on the above, and the examiner noted he did so with very poor stability. Despite the severe level of impairment of the right lower extremity when collectively assessing the right hip, right knee and right ankle, the Board finds there is no indication that the Veteran's right leg/right lower extremity would be equally well served by an amputation stump at the site of election below the knee with the use of a prosthesis. In addition, in the March 2009 VA examination, the Veteran himself attributed his difficulty with gait, stance, impairment with activities to both the right and left lower extremities. Specifically, he reported having pain in the right knee, right hip, left hip, left knee and stump which resulted in an abnormal gait and stance. In addition, he stated that, as a result of his right and left lower extremity conditions, he had significant impairments including dependence with activities of daily living requiring assistance with bathing, moving onto and off of the toilet, dressing, ambulating and positioning. The October 2012 VA examiner noted in each of the examinations for the right ankle, right hip and right knee that assistive devices included regular use of a wheelchair and crutches, constant use of a cane, occasional use of a walker and constant use of a motorized scooter and electric wheelchair. He concluded however, that there was no functional impairment of the extremity such that no effective function remained other than that which would be equally served by an amputation with prosthesis due to the right ankle, right hip or right knee condition. Finally the examiner found that the right ankle, right hip and right knee disabilities were all productive of mild impairment and that the effects of the Veteran's service-connected neuropathy of the right leg did not affect the Veteran's right ankle, right hip or right knee disability. The Board finds that the Veteran and his wife are competent to provide their opinions as to the functionality of his right leg disabilities, both that he experienced personally and that she had witnessed. However, neither the Veteran nor his wife are competent to determine that the disabilities of right hip, right knee or right ankle would be equally served by an amputation. Moreover, they are not competent to evaluate the extent and etiology of his gait and balance problems as they have not been demonstrated to have the appropriate medical expertise in this area. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the functionality of the Veteran's right leg as it would be equally served by an amputation 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 testified that he felt his right leg would be equally served by amputation only in that it would reduce his overall right leg pain. See June 2012 video conference hearing transcript. The clinical record clearly shows that this is a complex matter requiring a nuanced understanding of the physiological and neurological components of the Veteran's various right leg disabilities, and necessitating analysis by a medical professional. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, the Board accords his lay statements little probative value with respect to this matter. The preponderance of the evidence is against a finding that the Veteran's service-connected residuals of a right Achilles rupture, right hip disability, right knee patellofemoral syndrome, or alternatively, his service-connected neuropathy of the right lower extremity, results in loss of use of the right foot or right lower extremity, and the doctrine of reasonable doubt is not for application. See 38 U.S.C.A. § 5107(b) (West 2002). Therefore, the claim must be denied. ORDER A disability rating in excess of 10 percent for residuals of a ruptured right Achilles tendon is denied. A disability rating in excess of 10 percent for a right hip disability is denied. A disability rating in excess of 10 percent for right knee patellofemoral syndrome is denied. Special monthly compensation based on claimed loss of use of the right leg is denied. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs