Citation Nr: 1334133 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 03-30 480 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a right elbow disorder, to include as secondary to service-connected disabilities. 2. Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected disabilities. 3. Entitlement to an initial rating in excess of 10 percent for lumbar spine disc bulge at L3-L4. 4. Entitlement to an initial rating in excess of 10 percent for right shoulder acromioclavicular (AC) joint arthritis. 5. Entitlement to an initial rating in excess of 20 percent for residuals of a left ankle fracture with traumatic arthritis. 6. Entitlement to an initial rating in excess of 10 percent for right ankle traumatic arthritis. 7. Entitlement to an evaluation in excess of 20 percent for service-connected residuals of Lisfranc's dislocation, right foot, prior to March 1, 2013. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney ATTORNEY FOR THE BOARD M. Scott Walker, Counsel INTRODUCTION The Veteran had active duty service from October 1978 to December 1979, and reserve component service, including active duty for training. This matter comes before the Board of Veterans' Appeals (Board) on appeals from multiple rating decisions by the St. Louis, Missouri, Regional Office (RO) of the Department of Veterans Affairs (VA). The issue of entitlement to an evaluation in excess of 20 percent for service-connected residuals of Lisfranc's dislocation of the right foot was originally before the Board in September 2005, at which time the Board denied the claim. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In February 2006, the parties submitted a Joint Motion for Remand (Joint Motion). By an Order issued in February 2006, the Court vacated the September 2005 Board decision and remanded the claim to the Board for readjudication. In June 2006, the right foot claim was again before the Board when it was remanded for additional evidentiary development. The issues of entitlement to an increased rating for the right foot, the left ankle and the right ankle, along with the issues of whether new and material evidence had been received to reopen the claims of entitlement to service connection for a right shoulder disorder and a low back disorder, were before the Board in August 2007. The increased ratings claims for the right foot and left ankle were denied and the additional claims were remanded for the issuance of a statement of the case (SOC). The Veteran appealed the August 2007 Board decision, which denied the increased rating claims for the right foot and left ankle, to the Court. In a September 2009 Memorandum Decision, the Court set aside the Board's denials of increased ratings for the right foot and left ankle disabilities and remanded the claims back to the Board for adjudication consistent with the Memorandum Decision. In an August 2010 decision, the Board granted an earlier effective date for the Veteran's right shoulder disability, denied an earlier effective date for his right ankle and low back disabilities, and remanded the increased rating issues decided herein, as well as the issue of entitlement to service connection for a right elbow disorder, for additional development. The issues of entitlement to service connection for a cervical spine and a psychiatric disorder, as well as the issues of entitlement to special monthly compensation (SMC) based on the need for the aid and attendance of another, and entitlement to a total disability rating based on individual unemployability (TDIU), were referred to the RO for appropriate action. Since that time, the issues of entitlement to a TDIU, entitlement to SMC, and entitlement to service connection for an acquired psychiatric disorder have been denied by the RO (see Rating Decision, August 2013), and a formal appeal has not been filed for any of these issues. The Board further notes that the Veteran's 20 percent rating for a right foot disability was reduced to a non-compensable rating by the RO in December 2012, effective March 1, 2013. However, the Veteran has not filed a formal appeal for this issue. As such, these issues are not before the Board at this time. The issues of entitlement to service connection for a right elbow disorder, as well as a cervical spine disorder, each to include as secondary to service-connected disabilities, are addressed in the REMAND portion of the decision below and are REMANDED to the RO. VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. The Veteran's lumbar spine disability is manifested by flexion of the thoracolumbar spine, at worst, to 70 degrees, with spinal function not additionally limited following repetitive use due to pain, fatigue, weakness, and lack of endurance. 2. The Veteran's right shoulder disability is manifested by limitation of motion at the shoulder level, or less, but not limitation midway between the side and shoulder level. 3. The Veteran's residuals of a left ankle fracture with traumatic arthritis are manifested by pain and marked limitation of motion with no ankylosis. 4. The Veteran's right ankle traumatic arthritis is manifested by pain and marked limitation of motion with no ankylosis. 5. Residuals of a Lisfranc's dislocation of the right foot are manifested by no more than moderately severe functional limitation. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for lumbar spine disc bulge at L3-L4 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2013). 2. The criteria for an initial rating of 20 percent, but no higher, for right shoulder acromioclavicular joint arthritis have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5023, 5256-5262 (2013). 3. The criteria for an initial evaluation in excess of 20 percent for a left ankle fracture with traumatic arthritis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5270, 5271 (2013). 4. The criteria for an initial evaluation of 20 percent, but no higher, for right ankle traumatic arthritis have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5270, 5271 (2013). 5. The criteria for an evaluation in excess of 20 percent for residuals of Lisfranc's dislocation of the right foot, prior to March 1, 2013, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5284 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims decided herein. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See 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 which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. 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 all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act of 2000 (VCAA) Before addressing the merits of the issues decided herein, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified in July 2003, August 2003, August 2006, October 2006, September 2007, and December 2009 of the criteria for establishing service connection and for establishing increased ratings, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. These letters accordingly addressed all notice elements and predated the initial adjudication by the RO in each instance. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded. Nothing more is required in this case. The Veteran is challenging the initial evaluations assigned following the grants of service connection for his back, shoulder, and bilateral ankle disabilities. In Dingess, the Court held that in cases where service connection has been granted and an initial disability evaluation has been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91; also see Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Thus, because the notice that the Veteran was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied for these issues. As for the duty to assist, pertinent post-service medical records have been obtained, to the extent available. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board therefore finds that no additional evidence, which may aid the Veteran's claims decided herein or might be pertinent to the bases of these claims, has been submitted, identified or remains outstanding, and the duty to assist requirement has been satisfied. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See Green v. Derwinski, 1 Vet. App. 121 (1991). Here, the Veteran was afforded a VA examination to address his increased rating claims, most recently, in June 2012. To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examination report is adequate to decide the claims addressed on the merits herein, as the examination report included a thorough review of the file, as well as examination findings relevant to the issues at hand. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Increased Rating Claims The Veteran claims that his currently service-connected disabilities addressed herein are more severe than indicated by his current disability ratings. The Board points out that disability evaluations are based upon the average impairment of earning capacity as contemplated by the schedule for rating disabilities. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). 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. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (2002). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the Veteran. See 38 C.F.R. § 4.3 (2013). VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, the evidence of record does not establish additional, distinct time periods in any disability on appeal resulted in symptoms that warrant a staged rating. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2013). However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C.A. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). Assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case," Butts v. Brown, 5 Vet. App. 532, 538 (1993), and one Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must, however, be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2013). When determining the severity of musculoskeletal disabilities such as the ones at issue, which are at least partly rated on the basis of range of motion, VA must also consider the extent the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated due to the extent of pain/painful motion, limited or excess movement, weakness, incoordination, and premature/excess fatigability, etc., particularly during times when the symptoms "flare up," such as during prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. See DeLuca v. Brown, 8 Vet. App. 202 (1995), see also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2013). Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be non-compensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. 38 C.F.R. § 4.71a, Diagnostic Code 5010. The criteria for rating traumatic arthritis under this code direct that the evaluation of arthritis be conducted under Diagnostic Code 5003, which states that degenerative arthritis 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, Diagnostic Codes 5003, 5010. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5010. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010, Note 1. Lumbar Spine The Veteran's low back disability has been rated under Diagnostic Codes 5299-5243. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5243 requires application of a General Rating Formula for Diseases and Injuries of the Spine, or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, as follows: General Rating Formula for Diseases and Injuries of the Spine With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease: Unfavorable ankylosis of the entire spine.............100 Unfavorable ankylosis of the entire thoracolumbar spine .....................................................50 Unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine.....................................40 Forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine.............................................................30 Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis....................................................20 Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height.........................................................10 Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes With incapacitating episodes having a total duration of at least six weeks during the past 12 months.............60 With incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months..........................................................40 With incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months..........................................................20 With incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months..........................................................10 38 C.F.R. § 4.71a, Diagnostic Codes 5235 - 5243 (2013). Note (1), following the IVDS section notes that an "incapacitating episode" is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. The Veteran was first afforded a VA examination to address his lumbar disability in June 2008. At that time, he reported moderate, constant lumbar pain, fatigue, decreased motion, stiffness, weakness, and spasms, with no radiation. He also noted flare-ups, which he described as severe. Over a 12-month period, he reported weekly flare-ups lasting 2-3 days. On examination, there were no objective signs of spasm, atrophy, guarding, tenderness, or weakness. His posture was normal and his spine was symmetric, though his gait was antalgic. There was no abnormal spinal curvature, to include gibbus, kyphosis, list, lumbar flattening, lordosis, scoliosis, or reverse lordosis. Motor examination revealed no abnormalities, save for some ankle limitation (addressed in detail below). Sensory examination was normal. As to range of motion, flexion was from 0 to 70 degrees, with pain at 70 degrees. Extension was from 0 to 15 degrees with pain at 15 degrees. Bilateral lateral flexion was from 0 to 30 degrees with pain at 30 degrees. Bilateral lateral rotation was from 0 to 29 degrees on the right and to 30 degrees on the left, with pain beginning at 29 and 30 degrees, respectively. There was no additional limitation following repetitive use. The Veteran was diagnosed with a bulging disc at L4-5 with associated lumbar pain. There were no significant occupational effects, though activities of daily living were affected (ranging from moderate to prevented). The Veteran was next afforded a VA spinal examination in June 2012. A diagnosis of lumbar strain was indicated by the Veteran's history. The Veteran again reported flare-ups, noting that some days he has more pain than others. Flexion was to 80 degrees, with pain at 80 degrees. Extension was to 10 degrees, with pain at 10 degrees. Bilateral lateral flexion was to 30 degrees, with pain at 30 degrees. Bilateral lateral rotation was to 30 degrees, with pain at 30 degrees. Those degrees were unchanged following repetition. There was no localized tenderness of the lumbar area, nor was there guarding or muscle spasm. Strength was 5/5, with no atrophy. Sensory examination was normal, and no radicular pain or numbness was reported or identified. No neurologic abnormalities were evident following objective testing. The examiner determined that the Veteran did not suffer from IVDS, and therefore incapacitating episodes were not reported. It was noted that the Veteran used a cane for ambulation, though he is service connected for bilateral ankle disabilities, as well as a right foot disability, as addressed below. Arthritis of the lumbar spine was demonstrated by x-ray findings, as well as a bulge at L4-5, and L5-S1. As far as occupational impairment, it was noted that the Veteran's back was very weak and therefore his disability would prevent physical employment. The Board notes that the Veteran's extensive VA outpatient reports were reviewed, to include repeated complaints of pain and limitation of motion. However at no time did those reports provide objective evidence to demonstrate that the Veteran's disability was more severe than demonstrated during VA examinations of record. Based on these findings, the Board finds that a 20 percent evaluation is not warranted for the Veteran's low back disability. During each VA examination, it was noted that flexion of the thoracolumbar spine was, at worst, to 70 degrees, and that spinal function was not additionally limited following repetitive use due to pain, fatigue, weakness, and lack of endurance. As the record does not demonstrate any instance wherein the Veteran's forward flexion was limited to 60 degrees, the Veteran's forward flexion does not meet the criteria for a higher rating of 20 percent, as limitation to 60 degrees has not been demonstrated. Further, the Veteran denied radiculopathy symptoms, and sensation was intact in both lower extremities. While pain was noted, there was no additional limitation of motion, pain, weakness, fatigability, or incoordination following repetitive movement. As such, a higher rating is not warranted per DeLuca criteria. There is no evidence of record to demonstrate muscle spasm or guarding severe enough to result in an abnormal gait of abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Instead, each of these manifestations were specifically addressed during the VA examinations described above, and all were negative. In addition, there is no evidence of ankylosis during the appellate period. There was no report of incapacitating episodes, and the Board notes that there is no evidence of prescribed bed rest currently of record. Therefore, entitlement to an initial evaluation in excess of 10 percent for a lumbar spine disability is not warranted at this time. Right Shoulder The Veteran contends that he is entitled to an increased disability evaluation for a right shoulder disability, evaluated as 10 percent disabling under Diagnostic Code 5203. Under Diagnostic Code 5203, malunion of a clavicle or scapula, or nonunion without loose movement, warrants a 10 percent rating. A 20 percent rating requires nonunion with loose movement or dislocation. These disabilities may also be rated on the basis of impairment of function of the contiguous joint. The 20 percent rating is the maximum rating available under Diagnostic Code 5203. 38 C.F.R. § 4.71a. In turn, limitation of motion of the shoulder is rated pursuant to Diagnostic Code 5201. Under Diagnostic Code 5201, limitation of motion to shoulder level (e.g., flexion to 90 degrees) in the major extremity warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2013). Limitation of motion to midway between side and shoulder level in the major extremity warrants a 30 percent evaluation. Limitation of motion to 25 degrees from the side in the major extremity warrants a 40 percent evaluation. In determining whether the Veteran had limitation of motion to shoulder level, it is necessary to consider reports of forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-16 (2003). Normal ranges of motion of the shoulder are flexion (forward elevation) from 0 to 180 degrees, abduction from 0 to 180 degrees, and both internal and external rotation from 0 to 90 degrees. 38 C.F.R. § 4.71, Plate I (2013). Here, the Veteran's right extremity is the major extremity. VA outpatient reports demonstrate a diagnosis of AC joint arthritis confirmed by x-ray findings. On examination in June 2008, the Veteran reported locking episodes, weakness, stiffness, instability, and giving way. Flexion was to 70 degrees, with pain at 70 degrees. Abduction was to 140 degrees, with pain at 140 degrees. Internal and external rotation were to 90 degrees with pain at 90 degrees. There was no loss of a bone, or part of a bone. There was no indication of recurrent shoulder dislocations, inflammatory arthritis, or joint ankylosis. Additional exercises did not result in weakness, fatigability, or incoordination which affected his range of motion. In June 2012, the Veteran denied flare-ups of the right shoulder. Forward elevation ranged from 0 to 105 degrees, no objective evidence of painful motion; abduction was from 0 to 115 degrees, with no objective evidence of painful motion. The Veteran was unable to perform 3 repetitive tests due to complaints of pain; however, additional testing did not indicate any additional limitation to range of motion of the shoulder or arm. Localized tenderness was present, as was guarding. Muscle strength was 5/5, and ankylosis of the shoulder joint was not present. The Hawkins' Impingement test and the Empty Can test were both negative, as were the infraspinatus strength test and the lift-off subscapularis test. There was no history of mechanical symptoms (clicking, catching), nor of recurrent dislocation. The examiner found that there was no impairment of the clavicle or scapula, though the AC joint was tender to palpation. X-ray findings revealed no fracture or dislocation. Mild degenerative changes of the AC joint were noted (possibly traumatic). Finally, it was noted that the Veteran's service-connected right shoulder would not hinder his ability to work. Once again, the Board notes that the Veteran's extensive VA outpatient reports were reviewed, to include repeated complaints of pain and limitation of motion. However at no time did those reports provide objective evidence to demonstrate that the Veteran's disability was more severe than demonstrated during VA examinations of record. Based on this evidence, the Veteran's right shoulder disability, which is currently rated 10 percent based on malunion of the AC joint, should be increased to 20 percent during the entire appeal period, based on painful limitation of motion. As 10 percent is the maximum rating available for a single major joint under Code 5003, consideration must turn to the Code 5201 criteria (for ratings based on limitation of motion). To warrant the next higher (20 percent) rating under Code 5201, limitation of motion at the shoulder level must be demonstrated. Here, some limitation of motion has been demonstrated, and flexion and abduction have been, at worst, 70 and 115 degrees, respectively. Each of these measurements is greater than midway between the side and shoulder level, and as such a 30 percent rating is not warranted per Diagnostic Code 5201. However, the Veteran's flexion was to 70 in June 2008, which means that he was unable to flex to shoulder level, even though he was able to abduct well past the shoulder at that time. Thus, with consideration of the DeLuca factors of pain, and the inability to flex following repetitive use, the ranges of motion found show limitation at the shoulder level (or less) so as to warrant the next higher, 20 percent, rating (the minimum compensable rating under Code 5201). As stated, a higher rating is not appropriate under this Diagnostic Code. Other potentially applicable Diagnostic Codes include Diagnostic Code 5200 (for scapulohumeral ankylosis), Diagnostic Code 5202 (for impairment of the humerus, including loss of head of the humerus; nonunion, fibrous union, or malunion of the humerus; or recurrent dislocation at the scapulohumeral joint), and Diagnostic Code 5203 (for impairment of the clavicle or scapula, based on malunion, nonunion or dislocation). As the record is silent for any such pathology, a higher initial rating under these diagnostic codes is not indicated. Bilateral Ankles, Right Foot In this case, the Veteran's bilateral ankle disabilities are rated pursuant to Diagnostic Code 5271. Diagnostic Code 5271 states that a 10 percent evaluation is warranted for moderate limitation of motion of the ankle, whereas a 20 percent evaluation is in order for marked limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. The Board notes that the rating schedule does not define the terms "mild," "moderate," or "severe." Therefore, when rating under this Diagnostic Code, or the ankle under Diagnostic Code 5271, the Board must evaluate the evidence of record and reach a decision that is equitable and just. See 38 C.F.R. § 4.6 (2013). Diagnostic Code 5270, for ankylosis of the ankle, assigns a 20 percent evaluation for ankylosis in plantar flexion, at less than 20 degrees; and a 30 percent evaluation for ankylosis in plantar flexion between 30 and 40 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5270. Standard range of ankle dorsiflexion is from 0 to 20 degrees, and plantar flexion from 0 to 45 degrees. See 38 C.F.R. § 4.71, Plate II. The Veteran's service-connected right foot disability is rated under Diagnostic Code 5284, other foot injuries. 38 C.F.R. § 4.71a. The rating criteria do not have a specific diagnostic code for Lisfranc's dislocation. The disorder is, therefore, rated as "other foot injury." See 38 C.F.R. § 4.20. Under Diagnostic Code 5284, a 10 percent evaluation is provided for a "moderate" foot injury, a 20 percent evaluation is provided for a "moderately severe" foot injury, and a 30 percent evaluation is provided for a "severe" foot injury. The Note to Diagnostic Code 5284 indicates that a maximum 40 percent rating will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a. "Loss of use of a foot" is defined as no effective function remaining other than that which would be equally well served by an amputation stump at the site of election below the knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function of balance, propulsion, etc., which could be accomplished equally well by an amputation stump with prosthesis. 38 C.F.R. § 4.63 (2013). Under 38 C.F.R. 4.63, loss of use of a foot includes extremely unfavorable ankylosis of the knee, complete ankylosis of two major joints of an extremity, shortening of the lower extremity of 3-1/2 inches or more, or complete paralysis of the external popliteal nerve and consequent foot drop, equally well served by amputation. VA's General Counsel stated that Diagnostic Code 5284 is a more general Diagnostic Code under which a variety of foot injuries may be rated; that some injuries to the foot, such as fractures and dislocations for example, may limit motion in the subtalar, midtarsal, and metatarsophalangeal joints; and that other injuries may not affect range of motion. Thus, the VA General Counsel concluded that, depending on the nature of the foot injury, Diagnostic Code 5284 may involve limitation of motion, and therefore requires consideration under 38 C.F.R. §§ 4.40, 4.45, and the DeLuca case. See VAOPGCPREC 9-98. In the present case, consideration of functional loss and DeLuca is warranted since the Veteran's right disability involves his complaints of painful motion. Turning to the medical evidence of record, in an April 2002 VA outpatient report, the Veteran complained of persistent left ankle pain. The examiner noted that the Veteran's complaints of pain were not substantiated by clinical findings. In September 2002, the Veteran complained of left foot pain which had been present for many years but was worse the last few months. It was noted that the Veteran had severe musculoskeletal pain, primarily in the ankles. During a VA examination conducted in November 2002, the Veteran complained of difficulty negotiating inclines and reported that normal gait was not possible. He reported that if he carried anything heavier than a 12-pack, his ankles would "give out" and he would fall. He did not have pain on firm palpation. The examiner concluded that it was not possible to evaluate the range of motion of the ankles, as the Veteran's efforts to move his feet were inadequate. On VA examination in January 2003, the Veteran complained of pain in the right ankle. A physical examination revealed tenderness over the lateral and medial condyles of both feet. The range of motion of both feet was flexion to 5 degrees, plantar flexion to 10 degrees, eversion to 10 degrees, and inversion of the foot to 10 degrees. The diagnosis was a history of Lisfranc's syndrome associated with severe pain in the right ankle. In August 2003, the Veteran reported persistent pain in the feet and ankles, and that he fell several times a month. The Veteran's pain medications included valium and codeine. A bone scan conducted in September 2003 revealed an uptake pattern consistent with degenerative and post-traumatic changes. In July 2004, the Veteran reported that he had a "cramp" in his ankle. In August 2004, the Veteran complained of pain all over which had been present for 20 years. A physical examination revealed a very slow gait. Range of motion was full in all joints. However, any type of examination was noted to produce severe pain. The assessment was that the Veteran had pain all over which was more likely myofascial pain versus a fibromyalgia type of pain. The examiner also opined that the pain was due to depression. In September 2004, it was noted that the Veteran had chronic pain in the bilateral legs and feet. The pain was reported as a 6 out of 10. In September 2004, a VA physician wrote that the Veteran had gait instability and incoordination accompanied by complaints of frequent falling spells which the Veteran attributed to foot pain and left ankle pain, and limitation of motion. The Veteran walked with an unsteady gait with the aid of a cane. The author found that the Veteran had gait instability, incoordination, and chronic pain due to previous foot and ankle injuries which markedly interfere with employment possibilities. October 2004 nerve conduction (NCS) and electromyelogram (EMG) reports reveal that the Veteran complained of bilateral numbness in both feet as well as pain in the dorsal aspect of both feet, right worse then left. The impression was that the EMG and NCS were consistent with a mild L5 radiculopathy on the right. In January 2005, the Veteran complained, in pertinent part, of his legs giving out at the ankles. He also complained that his feet were cold all the time. In January 2006, the Veteran complained of cold, restless feet. He reported that it felt as if his bone marrow was frozen. A separate record dated the same month indicates that the Veteran sought treatment for painful feet. In February 2006, the Veteran reported that his right foot gave out and he shifted his weight to his left foot. A VA orthopedic examination was conducted in November 2006. The Veteran complained of bilateral ankle pain, weakness, stiffness, swelling, increased heat, a feeling of instability or giving way, and a locking sensation in the right ankle, as well as easy fatigability and lack of endurance. Daily flare-ups of pain reportedly were caused by walking and performing activities of daily living. The Veteran reported that he had additional limitation of motion and functional impairment during these flare-ups. There were no recurrent episodes of dislocation or subluxation, nor symptoms of inflammatory arthritis. There were no constitutional symptoms relating directly to the ankles, though the Veteran did have a diagnosis of myofascial pain syndrome. Physical examination of the ankles revealed them to be exquisitely tender. The left foot was in a 3 degree valgus position with the vertical axis of the Achilles tendon. The right ankle plantar flexion was to 61 degrees and dorsiflexion lacked 15 degrees from reaching the zero position. The left ankle plantar flexed to 51 degrees, and lacked 15 degrees of reaching the zero position in dorsiflexion. All movements of the ankle were exquisitely painful. The right foot was felt to lack 40 percent of the strength when compared to the left ankle, and the left ankle had a 20 percent decrease in strength as to what would be expected for normal. The Veteran was unable to invert or evert his feet to any measurable degree. He could stand on his feet for less than five minutes, allegedly due to pain. The diagnosis was posttraumatic degenerative joint disease, bilaterally, and status left ankle fracture with status open reduction and fixation. The examiner opined that the Veteran was severely compromised from a central nervous system standpoint. Speech was slurred, and the Veteran was found to be a historian of poor reliability. The examiner found that interpretation of the physical examination was extremely difficult because of the Veteran's overt responses of pain (emphasis added). An additional VA foot examination was conducted in November 2006. At that time, the Veteran reported pain in the right foot during walking, sitting, and at rest. The Veteran reported that he had pain 24 hours per day with an intensity of 9/10. He reported frequent flare-ups of pain which resulted in 10/10 pain. He also reported that he was likely to fall when his foot was fatigued. The Veteran stated that, with flare-ups, there was additional limitation of motion of the foot, as well as functional impairment. He ambulated using a cane, or a walker with rollers. He had been fitted with a foot cup, which was an orthopedic device. It was noted that the Veteran no longer worked, and that he left the workforce due to cocaine addiction. Physical examination revealed the right foot to be exquisitely tender. There was no evidence of abnormal bony protrusions. The foot was not swollen. There was no increased heat or redness. The examiner noted that the Veteran's gait was extremely antalgic, requiring a cane for balance, but the Veteran also complained of pain in the low back, both ankles, and both feet. There was no limitation of motion of the foot itself, but rather about the ankle (emphasis added). The Veteran was unable to stand on his toes or heels, reportedly due to pain. There were no foot deformities such as hammertoe, high arch, claw foot, or pes planus. The diagnosis was status Lisfranc dislocation of the right foot with resultant pain and disability. There is no X-ray evidence of further dislocations of the foot from that examination. The examiner noted that the Lisfranc dislocation was a dislocation between the tarsal and metatarsal bones. The examiner noted that there was no objective clinical evidence of any current dislocation or fracture of the foot. The residuals of the right foot dislocation were primarily pain, and a feeling of instability which was in all probability caused by the pain. There was no visible evidence of an alteration of the bone alignment due to the dislocation. The examiner noted that the Veteran displayed a slight decrease in sensation of the lateral right foot as compared with the medial side, but it was believed that this symptomatology was more related to radicular pathology from the low back and not related to the foot dislocation. There were no muscle or bone residuals from the right foot dislocation. It was the examiner's opinion that the right foot pain and weakness resulting from the right foot dislocation can at least as likely as not be disassociated from the Veteran's generalized pain disorder, myofascial pain syndrome, lumbar radiculopathy, and other causes of pain. Limitation of motion of the right foot could not be detected on physical examination. The right foot dislocation, and subsequent disability, caused excessive fatigability and incoordination which created a tendency for the Veteran to fall. It was the examiner's opinion that the residuals of the right foot dislocation were not of such severe disability that the Veteran would be better served with amputation followed by prosthesis. In February 2007, it was observed that the Veteran was able to ambulate with a single point cane without difficulties. In March 2007, it was noted that the Veteran was able to ambulate without significant difficulty. In April 2007, a VA psychologist wrote that the Veteran was treated in the mental health department for multiple medical and psychiatric problems including chronic pain from foot and ankle injuries, myofascial pain syndrome, lumbar radiculopathy, irritable bowel syndrome, major depressive disorder and anxiety disorder. The author indicated that the Veteran was unable to walk long distances to a bus stop secondary to pain. The author observed difficulties with social functioning due to the physical conditions. Unsteady gait and incoordination, consistent with complaints of physical pain, were also observed. It was the psychologist's opinion that the Veteran's conditions impacted the Veteran's social and occupational functioning in a range from moderate to severe. In May 2007, the Veteran complained of falls, and that control of his legs was so impaired that he had to ask his mother to drive him. The impressions were spastic paraparesis of an undetermined cause and possible peripheral neuropathy. On examination in June 2008, the Veteran reported pain with loss of motion. The Veteran also reported giving way, instability, stiffness, and weakness. There were no reported episodes of dislocation or subluxation, though locking occurred daily. An abnormal gait was noted, with evidence of abnormal weight bearing. The Veteran was able to dorsiflex his right ankle to 20 degrees, with pain at 20 degrees, with no additional loss of motion with repetitive use. Plantar flexion was from 0 to 15 degrees, with pain at 15 degrees. On repetitive movement, range of motion was reduced to 10 degrees. For the left ankle, dorsiflexion was to 25 degrees, with pain at 20 degrees and no additional loss of motion on repetitive testing. Plantar flexion was to 20 degrees, with pain at 20 degrees, and on repetitive use range of motion was reduced to 15 degrees. Joint ankylosis was absent. Most recently, the Veteran was afforded a VA examination to address the bilateral feet in June 2012. At that time, the Veteran again reported ankle flare-ups that had an impact upon the function of the ankles. Right ankle plantar flexion was to 10 degrees, with no objective evidence of painful motion. Right ankle dorsiflexion was to 5 degrees, with no objective evidence of pain. Left ankle plantar flexion was to 10 degrees, with no pain, and dorsiflexion was to 5 degrees, with no pain. The Veteran was able to perform three repetitions for each ankle, and the range of motion was unchanged throughout. The examiner noted that functional loss included less than normal movement, bilaterally, along with weakened movement on the left, as well as deformity and interference with sitting, standing, and weight-bearing. There was no tenderness to palpation for either ankle, and muscle strength was 5/5 for both. There was no laxity on objective testing, and no ankylosis. There was neither evidence nor reports of shin splints. X-rays did not indicate any right foot deformity, and x-rays of the right ankle were also negative, with no signs of fracture or dislocation, bony abnormality, or abnormal joints. X-rays of the left ankle demonstrated the Veteran's prior fracture, with no other abnormality. Considering the pertinent evidence in light of the applicable criteria, and in a light most favorable to the Veteran, the Board finds that a rating of 20 percent for the Veteran's service-connected right ankle disability is warranted during the entire appeal period. The Board finds that the symptomatology attributable to this disability approximates marked limitation of motion, consistent with a 20 percent rating. In June 2008, findings were not indicative of any significant ankle impairment, with normal range of motion in the right ankle. While pain was reported, it was reported at, or beyond, the normal range of motion. However, looking back to January 2003 (which is prior to the appellate period here, but noted for reference purposes), the Veteran's right ankle dorsiflexion was to 5 degrees, with plantar flexion to 10 degrees. The Board further notes that range of motion testing was significantly less than normal as of the most recent VA examination in June 2012. Plantar flexion was 10 degrees without pain, and dorsiflexion was 5 degrees without pain. Although there have been numerous instance of documented "over-reporting" of ankle symptomatology throughout the Veteran's record, as he has been labeled a very inaccurate historian, these two instances contain no such disclaimer. As such, the Board may not dispute the findings by either examiner. Because markedly decreased range of motion of the right ankle has been demonstrated prior to the appellate period at issue, and also most recently, a 20 percent rating is awarded pursuant to Diagnostic Code 5271. Regarding the left ankle, the Board finds that the Veteran's disability is accurately rated at 20 percent disabling. On more than one occasion, the Veteran's range of motion in the right foot has been normal (April 2002, August 2003, June 2008). However, other reports, which were not directly contested by the examiner at the time, do indicate significantly-limited range of motion. In January 2003, dorsiflexion was to 5 degrees and plantar flexion was to 10 degrees. Abnormal readings were reported in November 2006, and the most recent VA examination in June 2012 indicated that dorsiflexion was to 5 degrees, and plantar flexion was to 10 degrees. As these readings are identical to those in January 2003, the Board finds that a rating of 20 percent is appropriate throughout the appellate period, despite the numerous reports of over-reporting of symptomatology and the several normal examinations of record. As to whether a rating in excess of 20 percent is warranted for either ankle, the Board notes that Diagnostic Codes 5270 and 5272 are not for application, as ankylosis of the either ankle has not been demonstrated on any VA examination report. While the Court, in September 2009, found that the Board erred by not discussing whether "status left ankle fracture with status open reduction and fixation," noted in November 2006, amounted to ankylosis of that joint, the several reports of record, prior to and from that report, have consistently denied the presence of ankylosis. There is also no evidence of a malunion of the os calcis or astragalus, or of astragalectomy, and therefore Diagnostic Codes 5273 and 5274 are not for application. Therefore, a rating in excess of 20 percent is not warranted for either ankle at this time. The Board also has considered the Veteran's functional impairment due to pain and other factors during the periods in question. However, the medical evidence during the appeal period simply does not reflect any additional functional loss due to pain, weakness, excess fatigability, or incoordination. Each VA examiner of record noted the point at which pain began during each range of motion test, and the analysis above reflects those findings. As such, the Board finds that the DeLuca factors provide no basis for assignment of ratings in excess of 20 percent for either ankle, especially considering that each has been assigned a rating which reflects marked limitation of motion. In addition, a rating in excess of 20 percent for the Veteran's right foot is not warranted at any time since the Veteran filed his current claim for an increased rating. In order to qualify for a rating of 30 percent under Diagnostic Code 5284, the record would need to demonstrate that the Veteran's right foot injury is severe in nature. The Board has taken note of the September 2009 Memorandum Decision, which found that the Board had erred by failing to address reports of excessive fatigability and additional limitation of motion during flare-ups. The Court also noted that actual functional loss should be addressed, and not strictly limitation of motion. While it is difficult in this case to separate the Veteran's right ankle disability from the Veteran's right foot disability, the Board points out that the only relevant Diagnostic Code pertaining to the foot which may contemplate loss of range of motion is Diagnostic Code 5284, other foot injuries. Here, the Veteran's right foot disability pertains to a specific diagnosis of Lisfranc's dislocation, which was not present on x-ray findings from June 2012. Prior to that date, the record is replete with the Veteran's complaints of foot pain, weakness, and subjective instability. The Veteran's complaints of pain in April 2002 were not substantiated by clinical findings at that time. In November 2002, the Veteran complained of difficulty negotiating inclines, and that he had difficulty carrying more than a "12-pack." However, the examiner associated that complaint with his ankle disability, which, as noted, is classified as markedly severe and is separately rated. At that time, functional loss could not be determined, as the Veteran provided inadequate effort to move his feet when prompted. Severe pain was noted in August 2003, which the examiner attributed to either myofascial pain or depression, and not to Lisfranc's dislocation. Right foot numbness was reported in September 2004, though NCS and EMG studies found that these complaints were associated with radiculopathy, which is an entirely-separate physiological entity. Weakness and pain were again reported in November 2006, as well as daily flare-ups, though the Veteran denied episodes of dislocation (the Veteran's actual disability at issue) or subluxation, and there were no constitutional symptoms related to his ankles. Instead, he was diagnosed with myofascial pain syndrome which, once again, is not the source of the Veteran's current disability rating. While all movement was found to be exquisitely painful at that time, the Veteran was again deemed a poor historian, and that interpretation of the physical examination was extremely difficult due to the Veteran's overt responses of pain. Also that month, the Veteran reported constant foot pain and fatigue, which led to falls. However, this was not confirmed by objective testing. In fact, the examiner found that there was no objective clinical evidence of any current dislocation or fracture of the right foot (emphasis added). Instead, the examiner attributed these complaints to a generalized pain disorder, myofascial pain syndrome, lumbar radiculopathy, and other causes of pain. The report went on to state that the residuals of a right foot dislocation, which once again was not even present at the time, were not of such severity that the Veteran would be better served by a prosthesis. In February and March 2007, the Veteran was able to ambulate with a cane without difficulty. In June 2008, there were no reports of dislocation or subluxation. In June 2012, muscle strength was 5/5, there was no laxity on testing, and x-rays did not indicate any right foot deformity. As such, the Board finds that a severe disability is not shown such as to warrant a 30 percent disability rating under Diagnostic Code 5284 at any point in the appellate period. Furthermore, other diagnostic codes for foot disabilities that provide for a rating higher than 20 percent are not more appropriate because the evidence of record does not support their application. See 38 C.F.R. § 4.71a, Diagnostic Code 5276 (flat foot), Diagnostic Code 5278 (claw foot), and Diagnostic Code 5283 (malunion or nonunion of the tarsal or metatarsal bones). Therefore, these diagnostic codes cannot be applied. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). Thus the Veteran's Lisfranc dislocation, now absent, is properly rated under Diagnostic Code 5284. With regard to establishing loss of function due to pain, it is necessary that complaints be supported by adequate pathology and be evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. The effects of pain reasonably shown to be due to the Veteran's service-connected right foot disability are contemplated in the currently assigned 20 percent rating for the Veteran's right foot disability, even despite the numerous reports of over-reporting of pain symptoms. Even with consideration of the Veteran's reports of pain and instability, there is no indication that such symptoms, due to disability of the right foot, caused functional loss greater than that contemplated by the currently-assigned evaluation. As noted, the functional loss of his right foot has been attributed, in part to a myriad of other diagnoses. While it is clear that the service-connected right foot disability is manifested by excess fatigability, incoordination, and pain, this is recognized in the assignment of the current 20 percent rating for moderately severe symptoms. These are the primary, if not only, residuals of the Lisfranc's dislocation. There is no abnormality on x-ray and no limitation of motion of the foot. It is with recognition of excess fatigability, pain, and instability that a rating of 20 percent is warranted for the time period at issue; that is, prior to March 1, 2013. 38 C.F.R. §§ 4.40, 4.45; DeLuca. Conclusion In reaching the above conclusions, the Board has not overlooked the Veteran's statements regarding the severity of his service-connected disabilities. The Veteran is competent to report on factual matters of which he has first-hand knowledge, such as experiencing pain in the joints. Washington v. Nicholson, 19 Vet. App. 362 (2005). However, while the Board may consider the Veteran's subjective statements regarding the severity of his disabilities, the Board notes that with respect to the Rating Schedule, the criteria set forth therein generally require medical expertise which the Veteran has not been shown to have and the types of findings are not readily observable by a layperson, and that objective medical findings and opinions provided by the VA examiners are afforded the greater probative weight. The 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 the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the Board as adjudicator. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Here, the Board finds the findings and opinions provided by the VA examiners of record should be afforded the greater probative weight. See Guerrieri v. Brown, supra. The above determinations are based upon consideration of applicable rating provisions. It should also be noted that there is no showing that the Veteran's disabilities have reflected so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2013). The symptoms of each disability have been accurately reflected by the schedular criteria. Further, the Board points out that each disability rating encompasses a degree of occupational impairment relative to that rating. While some VA reports of record noted that the Veteran's bilateral foot and ankle disabilities may result in significant occupational impairment, the Veteran's claim for entitlement to a TDIU was addressed by the RO in August 2013 and subsequently denied. Moreover, the Veteran's evaluation for a right foot disability has been reduced to non-compensable, as the most recent evidence of record is silent for a current right foot disorder. Without sufficient evidence reflecting that the Veteran's disability picture is not contemplated by the rating schedule, referral for a determination of whether the Veteran's disability picture requires the assignment of an extraschedular rating or ratings is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). ORDER Entitlement to an initial rating in excess of 10 percent for lumbar spine disc bulge at L3-L4 is denied. Entitlement to an initial rating of 20 percent, but no higher, for right shoulder AC joint arthritis is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to an initial rating in excess of 20 percent for residuals of a left ankle fracture with traumatic arthritis is denied. Entitlement to an initial rating of 20 percent, but no higher, for right ankle traumatic arthritis is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to an evaluation in excess of 20 percent for service-connected residuals of Lisfranc's dislocation, right foot, is denied. REMAND Although the Board regrets any further delay in adjudicating the Veteran's remaining claims, pursuant to the duty to assist, the issues of entitlement to service connection for right elbow and cervical spine disorders, to include as secondary to service-connected disabilities, must be remanded for further development. Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F.3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Here, the Veteran was afforded a VA examination in conjunction with his right elbow claim in June 2012, with an addendum opinion provided in August 2012. At that time, the Veteran complained that falls, caused by his service-connected disabilities and well-documented throughout the claims file, led to a current right elbow disorder. The Board notes that the Veteran does have a diagnosis of right elbow strain (June 2012), and he was noted to have a tender right elbow lateral epicondyle (April 2004, October 2009). While the examiner noted that the Veteran's service-connected disabilities were not the cause of his right elbow complaints, the examiner failed to address whether the Veteran's service-connected disabilities aggravated any current right elbow diagnosis. With regard to the Veteran's cervical spine claim, the Board notes that he carries a diagnosis of narrowing at C5-6, marked articular facet arthrosis at C3-4, C4-5, and C5-6, as well as encroachment into the neural foramina and bilateral foramenal narrowing. The Board also points out that numerous VA providers have indicated that the Veteran's instability, linked on numerous occasions to his service-connected back, ankle, and foot disabilities, have resulted in falls which may have resulted in injury to his cervical spine. However, neither a VA examination, nor a VA opinion, has been provided to date so as to assess the etiology of his current cervical spine diagnoses. The Board has determined that the Veteran should be afforded additional VA examination to determine the etiology of any right elbow or cervical spine disorder, and that the examiner must also consider whether any current right elbow or cervical spine disorder has been aggravated beyond its normal progression as a result of the Veteran's service-connected disabilities, to include falling. Accordingly, the case is REMANDED for the following actions: 1. The RO shall schedule the Veteran for an appropriate VA orthopedic examination in order to assess the nature and etiology of any currently-diagnosed right elbow or cervical spine disorder. The Veteran's claims folder must be made available to the examiner for review. The examiner shall specifically note a review of the Veteran's claims file in the examination report. The examiner shall provide an opinion as to the following: Whether it is at least as likely as not that any currently-diagnosed right elbow or cervical spine disorder is (a) proximately due to or the result of any service-connected disability, or (b) aggravated or permanently worsened by a service-connected disability. If it is determined that any such disorder is related to a service-connected disability, to the extent that is possible, the examiner should indicate the approximate degree of disability or baseline before the onset of the aggravation. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. Note: The term "aggravated" in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. Note: The requested opinions on aggravation should be premised on the baseline level of severity of the disorder before the onset of aggravation, or by the earliest medical evidence created at any time between the onset of aggravation and the examiner's current findings. Rationale for the requested opinion shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. After undertaking any other development deemed appropriate, readjudicate the remaining claims on appeal. If any issue remains denied, furnish the Veteran and his representative with a supplemental statement of the case and afford them an opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs