Citation Nr: 1328362 Decision Date: 09/05/13 Archive Date: 09/16/13 DOCKET NO. 07-07 622 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for service connection for a right hand condition, to include as secondary to a service-connected left knee disability. 2. Entitlement to service connection for a right elbow condition, to include as secondary to a service-connected left knee disability. 3. Entitlement to service connection for a bilateral foot condition, to include as secondary to a service-connected left knee disability. 4. Entitlement to a disability rating in excess of 20 percent for instability associated with a left knee disability. 5. Entitlement to a disability rating in excess of 10 percent for limitation of motion associated with a left knee disability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD J.A. Flynn, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1973 to November 1974. These matters come before the Board of Veterans' Appeals (Board) on appeal from two rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. A May 2005 rating decision denied the claim for an increased rating for a left knee disability. A March 2008 rating decision denied service connection for a right hand disability, a right elbow disability, and a bilateral foot disability. These matters have previously been before the Board, most recently in August 2012, at which time the Board remanded the claims for additional development of the evidence of record. The Board errs as a matter of law when it fails to ensure compliance with remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that there has been substantial compliance with the remand instructions. Dyment v. West, 13 Vet. App. 141 (1999). The Veteran has submitted lay statements after the issuance of the most recent supplemental statement of the case in September 2012 without a waiver of review by the RO in the first instance. The Board finds that a waiver of RO consideration in the first instance is not required because that evidence is duplicative of evidence already of record or irrelevant to the Veteran's claims. 38 C.F.R. § 20.1304(c) (2012). FINDINGS OF FACT 1. A right hand disability was not shown during service or for many years thereafter, and the weight of the probative evidence is against a finding that a current right hand disability is related either to active service or to a service-connected left knee disability. 2. A right elbow disability was not shown during service or for many years thereafter, and the weight of the probative evidence is against a finding that a current right elbow disability is related either to active service or to a service-connected left knee disability. 3. A bilateral foot disability was not shown during service or for many years thereafter, and the weight of the probative evidence is against a finding that a current bilateral foot disability is related either to active service or to a service-connected left knee disability. 4. The Veteran's left knee disability is manifested by a range of motion limited by pain and weakness to no worse than 100 degrees of flexion and 5 degrees of extension, x- ray evidence of arthritis, but no clinical evidence showing severe instability. CONCLUSIONS OF LAW 1. A right hand disability was not incurred in or aggravated by active service, it is not the result of or aggravated by a service-connected disability, and a relationship between a right hand disability and active military service may not be presumed. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.309, 3.310 (2012). 2. A right elbow disability was not incurred in or aggravated by active service, it is not the result of or aggravated by a service-connected disability, and a relationship between a right elbow disability and active service may not be presumed. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.309, 3.310 (2012). 3. A bilateral foot disability was not incurred in or aggravated by active service, it is not the result of or aggravated by a service-connected disability, and a relationship between a bilateral foot disability and active service may not be presumed. 38 U.S.C.A. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.309, 3.310 (2012). 4. The criteria for a rating in excess of 10 percent for a left knee disability based on limitation of motion have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2012). 5. The criteria for a rating in excess of 20 percent for a left knee disability based on instability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5258, 5259 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board must provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence of record. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed in this decision. Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. When the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Duties to Notify and Assist Upon receipt of a complete or substantially complete application, VA must provide notice to the claimant that: (1) informs the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) informs the claimant about the information and evidence that VA will seek to provide; and (3) informs the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO sent correspondence in February 2005, April 2005, December 2007, May 2008, and August 2012; rating decisions in May 2005, March 2008, and May 2011; and statements of the case in January 2007, and October 2008. Those documents discussed specific evidence, particular legal requirements applicable to the claims, evidence considered, pertinent laws and regulations, and reasons for the decisions. VA made all efforts to notify and to assist the Veteran with evidence obtained, the evidence needed, and the responsibilities of the parties in obtaining the evidence. The Board finds that any defect of timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claims with an adjudication of the claims by the RO subsequent to the claimant's receipt of compliant notice. There has been no prejudice to the Veteran, and any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Thus, VA has satisfied its duty to notify the Veteran and had satisfied that duty prior to the final adjudication in the September 2012 supplemental statement of the case. A statement of the case or supplemental statement of the case can constitute a readjudication decision that complies with all applicable due process and notification requirements if adequate notice is provided prior to that adjudication. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The provision of adequate notice prior to a readjudication, including in a statement of the case or supplemental statement of the case, cures any timing defect associated with inadequate notice or the lack of notice prior to the initial adjudication. Prickett v. Nicholson, 20 Vet. App. 370 (2006). In addition, all relevant, identified, and available evidence has been obtained, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not referred to any additional, unobtained, relevant, available evidence. The VA obtained medical examinations in relation to the claim for increased ratings for a left knee disability. The Board notes that the Veteran was scheduled for a VA examination to evaluate the claims for service connection in December 2006, but did not report, and an opinion as to causation of the Veteran's joint pain was offered by the knee examiner at the November 2007 VA examination. The Board notes that the duty to assist is not a one-way street. If a Veteran wants help in developing a claim, the Veteran cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). Where the veteran fails to report to an examination in conjunction with a claim for service connection, the claim must be adjudicated based on the evidence of record. 38 C.F.R. § 3.655 (2009). In any event, although a rescheduled VA examination to evaluate the claims of service connection was not provided, the evidence does not indicate that the disabilities may be associated with an event, injury, disease in service, or a service-connected disability, and the evidence does not show good cause for failing to report to the examination. VA is not required to provide the Veteran with a medical examination absent a showing by the Veteran of a causal connection between the claimed disability and service. Therefore, remanding for VA medical examination is not warranted. McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4)(i). Thus, the Board finds that VA has satisfied both the notice and duty to assist provisions. Furthermore, the Board finds that if there is any deficiency in the notice to the Veteran or the timing of the notice it is harmless error because the appellant had a meaningful opportunity to participate effectively in the processing of the claims. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Board erred in relying on post-decisional documents for concluding adequate notice was provided, but the Veteran was afforded a meaningful opportunity to participate effectively in the adjudication of his claims, and therefore the error was harmless). The Veteran participated in a videoconference hearing before the undersigned in April 2009, and a transcript of that hearing has been associated with the record. Accordingly, the Board finds that the duties to notify and assist have been met, and the Board will proceed with a decision. Service Connection The Veteran has advanced two theories of entitlement for service connection. The Veteran has claimed that his right hand, right elbow, and bilateral foot disabilities are directly related to his active duty service. The Veteran also claims that those disabilities are secondarily related to his service-connected left knee disability. In general, service connection may be granted for disability or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be granted for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d) (2012); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." For certain chronic diseases, set forth in 38 C.F.R. § 3.309(a), a continuity of symptomatology is required when the condition noted during service is not shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b) (2012); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). To the extent that the Veteran's claimed disabilities represent an arthritic process, arthritis is among the chronic diseases listed in 38 C.F.R. § 3.309(a), and it therefore may be established based on a continuity of symptomatology. Furthermore, service incurrence will be presumed for certain chronic diseases, including arthritis, if manifest to a compensable degree within the year after active service. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012); Harder v. Brown, 5 Vet. App. 183 (1993). Additional disability resulting from the aggravation of a non-service-connected disability by a service-connected disability is also service connected. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). To establish service connection for a claimed disability on a secondary basis, there must be medical evidence of a current disability, a service-connected disability, and medical evidence of a nexus between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). The medical treatment records demonstrate that the Veteran has gout that has affected his bilateral feet, right elbow, and right hand. Accordingly, the Veteran has demonstrated the presence of a current disability. With respect whether in-service event, disease, or injury is shown, the Veteran has alleged, for example in October 2012, that his service treatment records show complaints and symptoms associated with the onset of gout. The Board has closely reviewed the Veteran's service treatment records, and finds that the record contain no complaints, diagnoses, or treatment for gout affecting the right hand, right elbow, or bilateral foot. The Board acknowledges that the Veteran is competent to attest to his in-service experiences. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran has not, however, demonstrated the competence to attribute in-service complaints of pain in his left knee to a systemic medical diagnosis such as gout. The Board finds that the Veteran has not demonstrated an in-service disease or injury, and the Veteran's claim for service connection fails on that basis alone. Although the weight of the evidence indicates that the Veteran did not incur an in- service disease or injury, for the sake of completeness and in the interest of clarity, the Board will additionally address whether any evidence relates the current disability to service. Luallen v. Brown, 8 Vet. App. 92 (1995); Holbrook v. Brown, 8 Vet. App. 91 (1995). The Veteran is service-connected for a left knee disability that will be considered for the secondary service connection claims. Regarding the determination of the relationship, if any, between the Veteran's current claimed disabilities and his service or his service-connected left knee condition, the Board finds that the evidence is essentially medical in nature. Turning to the medical evidence of record, the Board observes that an August 1991 clinical treatment note found that the Veteran had arthritis in the right wrist. April 2000 private treatment records noted bilateral swelling of the lower extremities after the Veteran fell and injured the fourth and fifth left toes. Clinical treatment notes from 2001 showed complaints of right elbow and right forefinger pain and swelling. The treating clinician noted ongoing treatment for gout. December 2002 clinical records indicated that the Veteran had gout in the right hand and wrist. A March 2007 VA clinical treatment record noted a history of gout, with the first gout attack 10 years prior, with complaints of swelling of the foot, right wrist, and right elbow. In October 2007, the Veteran provided a history of severe gouty arthritis since 2002. The Veteran stated that flares of gout left him incapable of moving his hands, and prevented him from walking. The Veteran indicated that he developed degenerative joint changes in the right elbow and right ring finger coincident with onset of flare-ups of gout. At a VA joints examination in November 2007, the examiner opined that swelling of the Veteran's left knee was related to his nonservice-connected gout. The examiner explained that his other joints swelled with the knee and treatment for gout effectively improved his condition. In January 2008, the Veteran reported left shoulder pain after he braced himself after a fall that occurred when his knee buckled. During his April 2009 hearing before the undersigned, the Veteran stated that he injured his right hand while breaking a fall after his left knee buckled. The Veteran stated that he had not experienced any problems with his right hand before the fall. The Veteran stated that when his left knee flared up, it gravitated to his right elbow, his hands, and his foot. The pain began in his left knee, but spread to the right side of his body. The Veteran additionally suggested that he injured his right elbow while bracing himself after he fell when his left knee buckled. The Veteran further alleged that the arthritis in his right knee was gravitating towards his foot. The Veteran indicated that no VA clinicians had stated that the foot condition was related to his knee condition. To the extent that the Veteran believes that his bilateral foot condition, right elbow condition, or right hand condition is related to either his service or to his service-connected left knee condition, the Board notes that the Veteran is competent to provide testimony concerning factual matters of which he has first-hand knowledge, such as experiencing a physical symptom such as pain. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Further, under certain circumstances, lay statements may support a claim for service connection by supporting the occurrence of lay- observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lay persons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). As to the etiology of a bilateral foot condition, right elbow condition, or right hand condition, the issue of causation of a medical condition is a medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, although the Board has carefully considered the lay contentions of record suggesting that the Veteran's disabilities are related either to his service or to his service-connected left knee condition, the Board ultimately affords the objective medical evidence of record, which does not find a connection between the Veteran's claimed conditions and either his military service or his service- connected left knee condition, greater probative weight than the lay opinions. Although the record contains evidence that the Veteran experienced falls in April 2000 and January 2008, there is nothing in the record consistent with a finding that a fall caused by the service-connected left knee disability led the Veteran to develop a bilateral foot, right hand, or right elbow disability. Moreover, the evidence of record does not attribute the claimed disabilities to the service-connected left knee disability. Instead, the post-service treatment records consistently show that the Veteran's complaints of pain and swelling of the hands, lower extremities, right elbow, and wrist, are associated with flare-ups of nonservice-connected gouty arthritis. Significantly, in November 2007, a VA examiner opined that the Veteran's left knee swelling was related to his nonservice-connected gout, and that other joints swelled with the knee and were improved by treatment for gout. Therefore, the Board finds that the evidence shows that the claimed disabilities are more likely the result of nonservice-connected gout. There is no competent evidence of record to suggest that any gout is related to the Veteran's service. The Board has also considered whether the Veteran has presented a continuity of symptomatology associated with the symptoms associated with his bilateral foot condition, right elbow condition, or right hand condition, and it finds that he has not done so. 38 C.F.R. § 3.309 (2012). There is no competent medical evidence indicating that the Veteran was treated for pain associated with those conditions until 2000, approximately 26 years after separation from service in 1974. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Thus, while the Board has considered the lay contentions that the Veteran experienced problems associated with his claimed conditions after military service, the Board finds that the weight of the evidence does not support a finding of continuous symptoms since active duty. Thus, a medical nexus is not shown by continuity of symptomatology with regard to the Veteran's claimed bilateral foot condition, right elbow condition, or right hand condition. The Board acknowledges that VA is statutorily required to resolve reasonable doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. However, the Board finds that the preponderance of the evidence is against the claims. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the competent and probative evidence of record indicates that the Veteran's bilateral foot condition, right elbow condition, or right hand condition are not related either to his active service or to his service-connected left knee disability. Accordingly, as the preponderance of the evidence is against the claims for service connection, the claims must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2012). When there is a question as to which of two ratings shall be applied, the higher ratings will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). In general, when an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is completely dependent on the facts of a particular case. Butts v. Brown, 5 Vet. App. 532 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Separate disabilities arising from a single disease entity are to be rated separately. 38 C.F.R. § 4.25 (2012); Esteban v. Brown, 6 Vet. App. 259 (1994). Pyramiding, or rating the same manifestation of a disability under different diagnostic codes, is to be avoided when rating service-connected disabilities. 38 C.F.R. § 4.14 (2012). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2012). When making a rating determination, VA must consider whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. 38 C.F.R. § 4.45 (2012); Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202 (1995). Degenerative arthritis established by x-ray findings is to 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, Diagnostic Code 5003 (2012). For the purpose of rating disabilities due to arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (2012). When limitation of motion of the specific joint or joints is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is to be applied for each such major joint or group of minor joints affected by limitation of motion. That rating cannot be combined with a limitation of motion rating of the same joint. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). The normal range of motion of the knee is 0 degrees of extension and 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (2012). Limitation of flexion to 60 degrees warrants a 0 percent rating. Flexion limited to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). Limitation of extension to 5 degrees warrants a 0 percent rating. Extension limited to 10 degrees warrants a 10 percent rating. Extension limited to 15 degrees warrants a 20 percent rating. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). Slight impairment due to recurrent subluxation or lateral instability of the knee is rated 10 percent. Moderate impairment due to recurrent subluxation or lateral instability is rated 20 percent. Severe impairment due to recurrent subluxation or lateral instability is rated 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). A claimant who has arthritis or limitation of motion, and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257. However, any separate rating must be based on additional disabling symptomatology that meets the criteria for a compensable rating. VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56,704 (1998). Separate ratings under Diagnostic Code 5260 for limitation of flexion of the leg and Diagnostic Code 5261 for limitation of extension of the leg, may be assigned for disability of the same knee. However, any separate rating must be based on additional disabling symptomatology that meets the criteria for a compensable rating. VAOGCPREC 9-2004 (2004); 69 Fed. Reg. 59990 (2004). Increased Rating Based on Limitation of Motion The Veteran underwent a VA examination in March 2005. The examiner noted that the Veteran had a small effusion of the knee, but no increased heat. The knee had palpable crepitus. The Veteran had extension to 0 degrees and flexion to 100 degrees, with pain. There was no increased pain or loss of motion upon repetitive movement. The examiner diagnosed the Veteran with degenerative joint disease of the left knee. The examiner indicated that the Veteran had no additional limitation with repetitive use or during flare-ups. The Veteran submitted a statement in later March 2005 indicating that he suffered from flare-ups of pain that could last from four to five hours and a severe flare-up resulted in the Veteran losing the ability to walk for three to five days. In a January 2007 VA examination, the Veteran complained of intermittent pain and swelling of his knee. During periods of acute flare-up of symptoms, the Veteran used a cane. The Veteran indicated that he had experienced about six episodes in the past year of requiring bed-rest for his knee pain. The Veteran had extension to 0 degrees and flexion to 110 degrees with some discomfort. The Veteran was slightly tender around the knee. Repetitive motion did not reduce the Veteran's range of motion or cause additional pain. There was a well-healed scar on the knee. In a November 2007 VA examination, the Veteran complained of intermittent left knee pain occurring every three days, which was mainly elicited by prolonged standing, walking, or climbing. The Veteran described a long history of gout, and he experienced associated left knee swelling with redness approximately once per month. The swelling resolved with medications taken in treatment of the gout. The Veteran denied experiencing additional weakness or restricted range of motion of the knee with flare-ups. The Veteran had limitations standing, walking, squatting, and he could not run. The Veteran indicated that he had been incapacitated for 21 days over the preceding 12 months, usually averaging three days with each occurrence. Upon physical examination, the Veteran had a normal gait, and the left knee appeared normal, with the exception of healed surgical scars over the medial left knee. There was no evidence of redness, swelling, heat, or tenderness to palpation. The Veteran had extension to 5 degrees and flexion to 100 degrees, with pain. There was no additional weakness, fatigability, incoordination, loss of motion, or functional impairment upon repeated testing. The examiner diagnosed the Veteran with degenerative joint disease. In September 2009, a VA clinician observed that the Veteran's left knee had a full range of motion and was non- tender. In January 2010, a VA clinician observed that the Veteran had a full range of active and passive motion in all of his extremities. The Veteran underwent a VA examination in December 2010, at which time the Veteran complained of daily discomfort in his left knee. The pain was mild in severity, increasing to moderate with increased use and with flare-ups of his gout. The Veteran complained of daily discomfort and swelling in his knees. The Veteran had not been hospitalized in the last 12 months, nor had he been totally incapacitated in the last 12 months. The Veteran could walk for 50 yards, stand for 15 minutes, and sit for 15 minutes. The Veteran would not run, and he had decreased his squatting. With flare-ups that could last several days, the Veteran would decrease his walking and standing. The examiner observed that the Veteran walked with a limp, and the knee had slight swelling. There was no redness or increased heat. There was a surgical scar that was superficial, linear, not raised or inverted, and blended well with the surrounding tissue. The scar was not hypersensitive, hyposensitive, or tender. It was not affixed or adherent to underlying tissue, and it did not affect joint function. The Veteran had extension to 0 degrees and flexion to 120 degrees, with pain. Turning to an evaluation of this evidence of record, the Board has considered the applicability of each of the Diagnostic Codes applicable to the knees. There is no evidence of ankylosis, impairment of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5262, and 5263 do not apply. 38 C.F.R. § 4.71a (2012). With those diagnostic codes excluded, the issue is whether the Veteran is entitled to a greater level of compensation under the diagnostic codes that are potentially applicable to the Veteran's left knee limitation of motion disability: Diagnostic Code 5003, applicable to degenerative arthritis; Diagnostic Code 5260, applicable to limitation of flexion of the leg; or Diagnostic Code 5261, applicable to limitation of extension of the leg. 38 C.F.R. § 4.71a (2012). The Board will first evaluate whether a greater rating is available to the Veteran under the Diagnostic Codes, 5260 and 5261, based on limitation of motion of the leg. With regard to flexion, the Veteran consistently demonstrated flexion to 100 degrees or greater. Accordingly, with flexion never limited to 60 degrees or fewer, a compensable rating is unavailable to the Veteran on the basis of impairment of flexion. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2012). With regard to extension, the Veteran consistently demonstrated extension to 5 degrees or fewer. Accordingly, with extension never limited to 10 degrees or greater, a compensable rating is unavailable to the Veteran on the basis of impairment of extension. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2012). The Board must additionally consider functional loss due to pain and weakness that causes additional disability beyond that which is reflected on range of motion measurements. 38 C.F.R. § 4.40 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board must consider the effects of weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45 (2012). VA examiners and clinicians have noted the Veteran's complaints such as pain and weakness, and the Board has taken those complaints into consideration in its above discussion. The Board finds that the evidence does not support a finding that the Veteran's functional loss causes disability beyond the above-discussed range of motion testing. While the Board accepts the credible contentions of the Veteran that his left knee disability causes him to experience significant pain, the Board has taken that into account in its consideration of the range of motion of the Veteran's knee. The rating schedule does not require a separate rating for pain itself. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Accordingly, a greater rating is not warranted based on functional loss, and separate compensable ratings for limitation of flexion and extension are not warranted. With regard to a higher rating based on arthritis, when x- ray evidence of degenerative arthritis is presented but the associated loss of range of motion is noncompensable, a 10 percent disability rating is warranted under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010, 5003 (2012). The evidence of record indeed indicates that the Veteran is in receipt of a 10 percent rating of his knee disability throughout the period on appeal based on arthritis. The Diagnostic Code applicable to degenerative arthritis does not provide for a rating in excess of 10 percent with the involvement of a single major joint. A greater increased rating based on arthritis is accordingly unavailable to the Veteran. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 10 percent for limitation of motion of the left knee. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Based on Instability A separate rating may be assigned for knee instability. The Veteran is in receipt of a 20 percent rating under Diagnostic Code 5257. That Diagnostic Code provides that recurrent subluxation or lateral instability is rated at 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). The words "slight," "moderate," and "severe" are not defined in the VA Schedule for Rating Disabilities. Clinicians' use of terms such as "moderate" and "severe," although an element that the Board will consider, is not dispositive of the issue. Rather than applying a mechanical formula, the Board must evaluate all of the evidence in order to ensure that its decisions are equitable and just. 38 C.F.R. § 4.6 (2012). In March 2005, a VA examiner could not detect any instability of the knee. In January 2007, a VA examiner could not detect any lateral instability of the knee or cause any subluxation. The Veteran, however, described having instability of the knee after making a quick turn or ascending stairs. In November 2007, the Veteran wore a knee brace daily. Upon stress testing, the examiner observed moderate laxity along the medial collateral ligament region. The patella track was normal without appreciable laxity or crepitus. The examiner diagnosed the Veteran with moderate ligament laxity along the medial collateral joint line. In December 2010, the Veteran complained of popping in his knee and instability that caused him to fall. The Veteran denied any subluxation, dislocation, or instability. The Veteran wore a knee brace and used a cane routinely. Lachman's test and collateral ligament testing were negative, and the McMurray test was negative. Patella movement was normal, and there was no laxity. The Board finds that the evidence does not support the award of a rating in excess of 20 percent for knee instability. A rating in excess of 20 percent for knee instability requires a finding that the Veteran has "severe" recurrent subluxation or lateral instability. The evidence does not support such a finding. At worst, clinicians have characterized the Veteran's left knee instability as moderate in severity. The Board acknowledges the Veteran's contention regarding the severity of his condition. Considering the lack of clinical findings of severe instability, however, the Board places greater probative weight on the medical evidence of record than on the Veteran's subjective accounts of instability. The narrative medical reports do not describe symptomatology of recurrent subluxation or lateral instability that the Board finds meets the level of severe. Accordingly, the Board finds that a rating in excess of 20 percent based on instability is not warranted at any time during the period under consideration. The Board finds that the preponderance of the evidence is against the assignment of a higher rating based on instability. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Ratings The Board has also considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. The VA Rating Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57 (1993). There is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. Thun v. Peake, 22 Vet App 111 (2008). The Board finds that the evidence does not show such an exceptional disability picture due to left knee disability that the available schedular rating for a knee disability, with consideration of functional loss under 38 C.F.R. § 4.45, is inadequate. A comparison between the level of severity and symptomatology of the Veteran's left knee functional loss with the established criteria found in the rating schedule and regulation governing functional loss shows that the criteria reasonably describe the Veteran's disability level and symptomatology. Higher ratings are available, but the Veteran does not meet the criteria to be assigned a higher rating. Therefore, the Board finds that referral for consideration of an extra-schedular rating is not warranted. 38 C.F.R. § 3.321(b)(1) (2012). ORDER Service connection for a right hand condition is denied. Service connection for a right elbow condition is denied. Service connection for a bilateral foot condition is denied. A disability rating in excess of 20 percent for instability associated with a left knee disability is denied. A disability rating in excess of 10 percent for limitation of motion associated with a left knee disability is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs