Citation Nr: 1334389 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 07-17 728 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for a left knee disability. 2. Entitlement to an evaluation in excess of 10 percent for a right knee disability. 3. Entitlement to an evaluation in excess of 10 percent for a left ankle disability. 4. Entitlement to an evaluation in excess of 10 percent for a right ankle disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran served on active duty from August 1986 to May 1988 and September 1991 to September 1993. This matter comes to the Board of Veterans' Appeals (Board) from a September 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. This case was previously before the Board in October 2010 and February 2013 when it was remanded for additional development. As noted in the February 2013 Board remand, in an August 2012 rating decision, the RO granted service connection for degenerative arthritis of the lumbar spine. As that award constitutes a full grant of the Veteran's low back claim, that issue is no longer before the Board. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). FINDINGS OF FACT 1. The left knee manifests evidence of arthritis with painful motion and residuals of meniscectomy but without compensable loss of motion. 2. The right knee manifests evidence of arthritis with painful motion and residuals of meniscectomy but without compensable loss of motion. 3. The left ankle presents only "moderate" limitation of motion when considering pain and other factors of functional loss; ankylosis is not demonstrated. 4. The right ankle presents only "moderate" limitation of motion when considering pain and other factors of functional loss; ankylosis is not demonstrated. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent disabling for post surgery, left knee with arthralgias based upon loss of range of motion, are not met. 38U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5260, 5261, 5262 (2013). 2. The criteria for a separate 10 percent evaluation, and no more, for left knee residuals of meniscectomy, are met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5259 (2013). 3. The criteria for an evaluation in excess of 10 percent disabling for post surgery, right knee with arthralgias based upon loss of range of motion, are not met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5260, 5261, 5262 (2013). 4. The criteria for a separate 10 percent evaluation, and no more, for right knee residuals of meniscectomy, are met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5259 (2013). 5. The criteria for the assignment of an evaluation in excess of 10 percent disabling for a left ankle disability are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.21, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5270, 5271, 5272, 5273, 5274 (2013). 6. The criteria for the assignment of an evaluation in excess of 10 percent disabling for a right ankle disability are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.21, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5270, 5271, 5272, 5273, 5274 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if applicable, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and 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. This notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Further, in Dingess v. Nicholson, the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. 19 Vet. App. 473 (2006); see also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. In a claim for an increased evaluation, the requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Here, the duty to notify was satisfied by way of a letter sent to the appellant in May 2006 that fully addressed all notice elements and was sent prior to the initial AOJ decision in this matter. The letter informed the appellant of what evidence was required to substantiate the claims and of the appellant's and VA's respective duties for obtaining evidence. The letter also informed the Veteran that should an increase in disability be found, a disability rating and an effective date would be assigned. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA treatment records. The appellant was afforded VA medical examinations in September 2006, July 2012, and April 2013. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Higher Evaluation Disability evaluations 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; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal arises from the initially assigned rating, consideration must be given as 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). Moreover, staged ratings are 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). Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14. It is possible, however, for a Veteran to have separate and distinct manifestations attributable to the same injury, which would permit a rating under several diagnostic codes. The critical element permitting the assignment of multiple ratings under several diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. A. Left and Right Knee Disabilities The Veteran contends that his left and right knee disabilities are more disabling than currently evaluated. The Veteran's knee disabilities are each currently evaluated as 10 percent disabling pursuant to Diagnostic Code 5262. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). 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 a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The Veteran's left and right knee disabilities include a diagnoses of degenerative joint disease and arthritis. As the Veteran is in receipt of service-connected benefits for post operative, left knee with arthralgias and post operative, right knee with arthralgias, the Veteran's arthritis of the left and right knees cannot be dissociated from the Veteran's service-connected disabilities and will be considered as part of the evaluation. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Furthermore, as noted below, the record does not reveal malunion of the tibia and fibula. As such, the Board finds that the Veteran's left and right knee disabilities are more appropriately evaluated pursuant to Diagnostic Code 5003 for arthritis. The Board finds it appropriate to proceed with adjudication under Diagnostic Code 5003 as the Veteran's knee disabilities have been considered under the codes for limitation of range of motion and the Veteran was provided with the regulations in regard to limitation of motion. As such the procedural due process requirements have been met. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board notes that 38 C.F.R. § 4.71a, Diagnostic Code 5003 establishes, essentially, three methods of evaluating degenerative arthritis that is established by X-rays: (1) when there is a compensable degree of limitation of motion, (2) when there is a noncompensable degree of limitation of motion, and (3) when there is no limitation of motion. Generally, when documented by X-rays, arthritis is rated on the basis of limitation of motion under the appropriate diagnostic code for the joint involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasms, or satisfactory evidence of painful motion. Read together, Diagnostic Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, that is established by X-ray, is deemed to be limitation of motion and warrants the minimum compensable rating for the joint, even if there is no actual limitation of motion. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). The Burton Court further held that the provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. See Burton v. Shinseki, 25 Vet. App. 1 (1991). Under Diagnostic Code 5260, which concerns limitation of flexion of the leg, a noncompensable (zero percent evaluation) is assigned for flexion limited to 60 degrees; a 10 percent evaluation is assigned for flexion limited to 45 degrees; a 20 percent evaluation is assigned for flexion limited to 30 degrees; and a 30 percent evaluation is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, which concerns limitation of extension of the leg, a noncompensable evaluation is assigned for extension limited to 5 degrees; a 10 percent evaluation is assigned for extension limited to 10 degrees; a 20 percent evaluation is assigned for extension limited to 15 degrees; a 30 percent evaluation is assigned for extension limited to 20 degrees; a 40 percent evaluation is assigned for extension limited to 30 degrees; and a 50 percent evaluation is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45. Normal range of motion of the knee is to zero degrees extension and zero to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. Separate knee evaluations for limitation of motion and instability under the appropriate Diagnostic Codes may be assigned when specific symptoms are shown. See VAOPGCPREC 23-97; see also VAOPGCPREC 9-98. In addition, separate evaluations under Diagnostic Code 5260 (limitation of flexion) and Diagnostic Code 5261 (limitation of extension) for disability of the same joint may be assigned. See VAOPGCPREC 9-2004 (Sept. 17, 2004). Under Diagnostic Code 5257, which concerns "other impairments of" the knees, a 10 percent evaluation is assigned for slight recurrent subluxation or lateral instability of the knee; a 20 percent evaluation is assigned for moderate recurrent subluxation or lateral instability of the knee; and a 30 percent evaluation is assigned for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint is rated as 20 percent disabling. Diagnostic Code 5259 provides for a 10 percent rating based on evidence of symptomatic, removed semilunar cartilage. A semilunar cartilage is one of the menisci of the knee joint. See Stedman's Medical Dictionary, 296 (27th ed., 2000). Diagnostic Code 5262 provides a 10 percent rating for malunion of the tibia and fibula resulting in slight knee or ankle disability, a 20 percent rating for moderate knee and ankle disability, and a 30 percent rating for marked knee or ankle disability. Nonunion of the tibia and fibula, with loose motion requiring a brace, warrants a 40 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5262. X-ray of the right knee in August 2005 revealed no evidence of dislocation. There was mild narrowing of the medial compartment with minimal sclerosis of the tibial plateau. No chondrocalcinosis was seen. There was no evidence of foreign matter or loose body. The impression was mild degenerative joint disease. X-ray of the right knee in December 2005 revealed no acute fracture, minimal narrowing of the medial compartment of the joint with prominent tibial spine, and no significant joint effusion. The impression was mild degenerative changes to the knee without interval change since the previous study. Magnetic Resonance Imaging (MRI) of the right knee in December 2005 revealed no abnormal focal marrow signals, mild thinning of the articular cartilage at the medial tibiofemoral compartment, and minimal joint effusion. The anterior, posterior cruciate ligaments as well as the menisci appeared to be grossly unremarkable without any focal signal abnormalities. The collateral ligaments were identified without any obvious signal changes. The patella and patellofemoral joint appeared to be grossly unremarkable. There were no focal bony signal changes. The impression was mild degenerative changes. In January 2006 the Veteran underwent left knee arthroscopy. Examination under anesthesia revealed flexion to at least 120 degrees and was limited by the table. He had full extension. There was no varus or valgus laxity. Lachman's was negative. During evaluation with the camera in the knee the anterior drawer test was showed that the anterior cruciate ligament tensioned appropriately. The fibers were visualized and the anterior cruciate ligament was felt to be intact. The meniscus was "pristine". There was a large horizontal cleavage tear of the posterior horn of the medial meniscus with a large amount of fraying of the inner meniscal edges. There was large tear of the posterior horn medially which was displaced and there was a coinciding defect in the femur of approximately 0.5 centimeters which corresponded to this displaced meniscal lesion. The remainder of the femur only showed some scattered grade one changes. There was no indication to proceed with the primary repair. Debridement and partial meniscectomy was done down to nice, clean, smooth edges. The diagnosis was left knee medial meniscal tear. The Veteran underwent right knee arthroscopy in January 2006. The Veteran was noted to have progressive medial right-knee pain that had been persistently present over the prior several months. This was worsened with ambulation. He had begun to limit his activities of daily living. He reported that he had occasional swelling as well as some episodic locking and catching. Examination under anesthesia revealed the meniscal cyst that was evident on MRI was not able to be palpated. The knee was ligamentously stable with a good endpoint to Lachman's testing. There was no crepitus on range of motion. Examination of the interior of the knee with a camera revealed the medial and lateral facets of the patella were pristine though there were some grade II cartilage changes in the central portion of the patella. There was no plica evident. The medial and lateral gutters were free of foreign bodies. There was some grade I changes on both femoral and tibial surfaces. There was fraying with some mild delamination of the medial meniscus likely secondary to his previous operations. There was no frank tear visible. The medial meniscus was stable in all portions to probing. The cartilage was slightly soft in the medial compartment. The anterior cruciate ligtament was easily visible and tightened nicely with anterior drawer testing. The lateral compartment appeared pristine except for some mild grade I cartilage changes on the tibial side. The trochlea and patella tracking was examined. The patella centralized and tracked well. There was no evidence of any wear in the area of the trochlea. The Veteran was noted to be diagnosed with right knee pain with chondromalacia of the patella after the operation. X-ray of the left knee in September 2006 revealed very mild degenerative changes of the left knee with no significant interval progression. The Veteran was afforded a VA medical examination in September 2006. In regard to his knees, the Veteran reported that he began having bilateral knee pain in 1991. He had two surgeries on each knee, one in 1984 on the left knee and the last in January 2006 on his right knee. He had a cyst on the medial aspect of his right knee but they were unable to remove it during the surgery due to its location. He had constant pain in his knees which on average is a five to six on a ten point scale. He took hydrocodone, up to six tablets a day, for this pain. He reported that at times his pain will increase to a nine to ten on a ten point scale. His knee pain is aggravated by increased walking or walking on concrete. He had knee braces that he wore intermittently. He applied biofreeze which helps to a small degree. He had locking of his right knee and giving way of both knees intermittently. He also had swelling. He wore boots which were made especially for him and wore these most of the time. He was able to perform his activities of daily living despite his knee condition but he cannot stand on his feet for long periods of time. He had difficulty working on his 80 acre farm due to his knee condition. He was not employed. He was able to do sports in the past and used to coach but could no longer do that. He was not able to bear hunt because he could not stand on his feet for long periods of time. He used a walking stick when he walked on his farm. He did not use a cane otherwise. Physical examination of the knees revealed no obvious swelling. There was a subcutaneous medial cyst on the right knee at the joint line. It was tender to palpation. There was no erythema. He had positive crepitus with range of motion in both knees. He had pain with full extension of the right knee. Anterior and posterior drawer tests were negative bilaterally. Range of motion of his knees was right knee full extension with pain between -10 and zero degrees, and flexion of 124 degrees with pain throughout the entire range of motion following repetitive motion. Range of motion of the left knee was full extension zero degrees and flexion to 124 degrees. He did not experience much pain with range of motion of the left knee. Following repetitive movement there was no change in the range of motion or pain level. The Veteran was diagnosed with degenerative joint disease bilateral knees with chronic pain and decreased function. In October 2006 the Veteran reported that he had two surgeries in each knee, 1984 and 2001 for the left, and 1985 and 2003 for the right. X-ray of the right knee in August 2007 revealed minimal right knee medial joint space narrowing. X-ray in February 2009 revealed no change. In August 2011 the Veteran canceled a scheduled occupational therapy session due to fatigue. In November 2011 it was noted that the Veteran wanted a knee injection. The note indicated that the Veteran was last seen in July 2009. However, in December 2011 it was noted that the Veteran reported that orthopedics had never injected his knees, only his hips. In December 2011 the Veteran was noted to have bilateral knee tenderness without effusion or warmth. The knees were positive for crepitus. The Veteran was afforded a VA medical examination in July 2012. The Veteran was noted to be diagnosed with chondromalacia right patella, right medial meniscus tear status post right knee arthroscopy with partial meniscectomy, and left medial meniscus tear status post left knee arthroscopy with partial meniscectomy. In regard to the Veteran's left knee, it was noted that the Veteran complaint of constant discomfort, worse with standing and walking. He was using a wheeled walker for a right hip condition. In regard to the Veteran's right knee he complained of constant right knee ache, worse with prolonged standing and walking. The knee pain was worse in the right than the left. There was no history of frank locking or giving way. He reported flare-ups that were described as constant discomfort, worse with standing and walking. He noted start up pain and stiffness. Physical examination revealed the range of motion of the right knee to be 135 degrees of flexion with objective evidence of pain beginning at 130 degrees and zero degrees of hyperextension (no limition of extension) with no objective evidence of painful motion. Left knee range of motion was 135 degrees of flexion with objective evidence of pain at 130 degrees and zero degrees of hyperextension (no limition of extension) with no objective evidence of painful motion. The range of motion of both knees was unchanged with repetitive use testing. There was no additional limitation of range of motion or functional loss or function impairment with repetitive use testing. Muscle strength testing was normal with knee flexion and extension bilaterally. Tests for anterior stability (Lachman test), posterior instability (Posterior drawer test), and medial-lateral instability were normal bilaterally. There was no evidence or history of recurrent patellar subluxation/dislocation. The Veteran did not have or ever have "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran was noted to have had a meniscus tear bilaterally and to have had a meniscectomy bilaterally. He did not have any residual signs and/or symptoms due to a meniscectomy. He had not undergone a total knee replacement. The Veteran had scars related to his surgeries. The scars were not painful and/or unstable and did not cover an area greater than 39 square centimeters (6 square inches). The Veteran had very mild subpatellar crepitation with flexion and extension of the right knee. He used a walker for a right hip condition. The Veteran's knee condition was noted to impact his ability to work due to constant knee pain that was worse with standing and walking. X-rays of the knees were unremarkable in July 2012. The Veteran underwent a VA medical examination for scars in July 2012. The Veteran was noted to have scars due to right medical meniscus tear status post arthroscopy with partial meniscectomy and left medical meniscus tear status post arthroscopy with partial meniscectomy. These scars were not painful or unstable. Each knee had two, one centimeter, well healed scars. The Veteran underwent bilateral knee injections in December 2012. He was noted to have degenerative joint disease and osteoarthritis. He had full range of motion with crepitus palpated bilaterally. There was no tenderness with range of motion and no edema or erythema was noted. The Veteran was afforded a VA medical examination in April 2013. The Veteran was diagnosed with arthritis, meniscus tear and surgery, and patellofemoral joint syndrome in both knees. Physical examination revealed right knee flexion of 120 degrees with objective evidence of pain at 110 degrees. The Veteran had extension of the right knee measured as zero or any degree of hyperextension. There was no evidence of painful motion and no limitation of extension. Left knee flexion was measured as 124 degrees with objective evidence of pain beginning at 115 degrees. The Veteran had extension of the left knee measured as zero or any degree of hyperextension with no evidence of painful motion and no limitation of extension. Repetitive-use testing revealed the same results. The Veteran had less movement than normal, weakened movement, excess fatigability, pain on movement, swelling, disturbance of locomotion, and interference with sitting, standing and weight bearing in both knees. The Veteran had tenderness or pain to palpation of the joint line or soft tissues of both knees. Muscle strength was 4/5 for flexion and extension of both knees. Stability tests (Lachman, posterior drawer, and valgus/varus pressure) was normal in both knees. There was no evidence or history of recurrent patellar subluxation/dislocation. The Veteran had a meniscal tear, frequent episodes of joint locking, frequent episodes of joint pain, and frequent episodes of joint effusion in both knees. The Veteran had residual signs and/or symptoms due to meniscectomy including clicking, locking, pain and swelling in both knees. He regularly used a cane and walker. The examiner found that the Veteran's lower extremity conditions impact his ability to work. The Veteran was able to perform sedentary work involving brief standing and brief ambulation. Work involving bending the knees for lifting would be limited to light weights. The Veteran received bilateral knee injections in April 2013. Entitlement to an evaluation in excess of 10 percent disabling pursuant to Diagnostic Code 5003 is not warranted. As noted above, there is painful motion of both knees, a reduction of the range of motion in both knees, and there is evidence of arthritis of both knees. However, at no point during the period on appeal does the Veteran's left or right knee disability manifest a compensable loss of range of motion. As such, the Veteran is not entitled to more than the minimum compensable evaluation for the joint. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991); Burton v. Shinseki, 25 Vet. App. 1 (2011). Therefore, entitlement to an evaluation in excess of 10 percent disabling for post surgery, left knee with arthralgias based upon loss of range of motion, is denied, and entitlement to an evaluation in excess of 10 percent disabling for post surgery, right knee with arthralgias based upon loss of range of motion, is denied. Review of the record reveals that VA medical examiners have found that the Veteran has undergone meniscectomies on both knees. Although a July 2012 VA examiner did not find residual signs and/or symptoms due to a meniscectomy, a VA examiner in April 2013 noted that the Veteran has residual symptoms of his meniscectomies including clicking, locking, pain and swelling in both knees. As such, the Board finds that the evidence is at least in equipoise that the Veteran has symptomatic, removed semilunar cartilage, bilaterally. Therefore, the Veteran is granted a separate 10 percent disabling evaluation for left knee residuals of meniscectomy and a separate 10 percent disabling evaluation for right knee residuals of meniscectomy. The Board has considered whether the Veteran's left and right knee disabilities warrant additional evaluation pursuant to Diagnostic Code 5257 for instability. However, at no point during the period on appeal have either of the Veteran's knees manifested objective evidence of instability. Tests for laxity performed at the VA medical examinations have been negative. In addition, the Board notes that any other symptoms of knee disability are contemplated by Diagnostic Code 5259 under which the Board has granted a separate 10 percent disabling evaluation for each knee. As such, the Board finds that additional separate compensable evaluations for instability of the Veteran's knees is not warranted. The Board notes that at no point during the period on appeal did the Veteran's left or right knee manifest a moderate knee disability. In August 2005 the Veteran was noted to have mild degenerative joint disease and in December 2005 the Veteran was found to have mild degenerative changes. Arthroscopies in January 2006 noted mild changes and an x-ray in September 2006 revealed mild degenerative changes of the left knee. A September 2006 VA medical examination revealed mild range of motion changes. August 2007 x-ray of the right knee revealed minimal right knee medial joint space narrowing. Treatment records beginning in 2011 reveal multiple knee injections and bilateral knee tenderness without effusion or warmth. Examination in July 2012 revealed near full range of motion and normal muscle strengths. Examination in April 2013 revealed residual signs and/or symptoms due to meniscectomy including clicking, locking, pain and swelling in both knees; however, the examination revealed only mild reduction in range of motion. As the Veteran's knees do not reveal more than mild disability, entitlement to an evaluation in excess of 10 percent disabling for the left knee and entitlement to an evaluation in excess of 10 percent disabling for the right knee pursuant to Diagnostic Code 5262 is not warranted. Separate rating for the scars associated with the Veteran's knee surgeries is not warranted in this case, as there is no evidence that the Veteran scars are deep, cause limited motion, exceed 144 square inches (929 square centimeters), are unstable, are painful on examination, or cause limitation of function. 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805 (2008). Accordingly, separate evaluation for scars is not warranted. B. Left and Right Ankle Disabilities The Veteran contends that his left and right ankle disabilities are more disabling than currently evaluated. The Veteran's ankle disabilities are each currently evaluated as 10 percent disabling pursuant to Diagnostic Code 5271. Diagnostic Code 5271 provides ratings based on limitation of motion of the ankle. A 20 percent rating is warranted for marked limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5271. The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6 (2013). Normal range of motion for the ankle is from 0 to 20 degrees dorsiflexion, and from 0 to 45 degrees plantar flexion. 38 C.F.R. § 4.71a, Plate II. The Veteran was afforded a VA medical examination in September 2006. In regard to his ankles, the Veteran had recurrent ankle sprains bilaterally. On the right side he had a severe sprain around 1992 and was placed in a cast for about six weeks. He reported that the ankle did not heal correctly. He had braces that he wore if he was going to be doing a lot of work. He usually wore combat boots which helped give him added support. He had giving way of his ankles on a recurrent basis with his right being more affected that his left. He also had swelling especially if he twisted his ankle. Following repetitive motion he had increased pain. He was not able to play sports because of his ankle condition. He could not stand on hard surfaces. He had not had any ankle surgery. He was able to perform his activities of daily living but he had difficulty standing for long periods of time. He was able to work on his farm but was limited in the amount of time he can be on his feet due to his ankles. Physical examination of the ankles revealed no obvious swelling, erythema, or increased warmth. He had palpable tenderness just below the right malleolus on the lateral aspect, anterior and posterior drawer test was negative bilaterally. His ankle joints felt somewhat loose. Range of motion of the right ankle was plantar flexion to 40 degrees, dorsiflexion to 10 degrees, inversion to 10 degrees, and eversion to 15 degrees. Following repetitive movement, there was no change in the range of motion, but mild increased pain. He had pain with range of motion of his right ankle especially with eversion and inversion. Left ankle plantar flexion to 40 degrees, dorsiflexion to 15 degrees, eversion to 15 degrees, and inversion to 15 degrees. He did not experience pain with range of motion of his left ankle. Following repetitive movement there was no change in the range of motion or pain level. The Veteran was diagnosed with bilateral recurrent ankle sprains, right greater than left with chronic pain. X-ray of the left ankle in September 2006 revealed very mild degenerative joint disease. In October 2006 the Veteran reported that his ankles will move far beyond the normal range which causes weakness and failure in the joints and often causes him to fall. In July 2012 the Veteran was afforded a VA medical examination. The Veteran was noted to be diagnosed with right and left ankle sprain. The Veteran reported that he experiences right greater than left ankle pain with standing and walking. He rated the right ankle pain when present at five to six out of ten and left ankle pain at four to five out of ten. He had no past history of ankle surgery. The Veteran reported flare-ups of increased pain with standing and walking. Physical examination revealed range of motion of right ankle plantar flexion of 40 degrees with objective evidence of painful motion at 40 degrees and dorsiflexion of 20 degrees or greater with no objective evidence of painful motion. There was left ankle plantar flexion of 40 degrees with no objective evidence of painful motion, and left ankle plantar dorsiflexion of 20 degrees or more with no objective evidence of painful motion. Repetitive-use testing revealed right ankle plantar flexion to 40 degrees and dorsiflexion to 20 degrees or greater. Left ankle plantar flexion of 40 degrees and dorsiflexion to 20 degrees or greater. The Veteran had no additional limitation of range of motion after repetitive use. The Veteran had no functional loss or functional impairment of the ankle. He had localized tenderness of pain on palpation of the joints/soft tissue of the right ankle. Muscle strengths were normal in plantar flexion and dorsiflexion bilaterally. Anterior drawer test and talar tilt test revealed no laxity. There was no ankylosis. The Veteran did not have or ever had "shin splints," stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneous (os calcis) or talus (astragalus), or talectomy (astragalectomy). He had not undergone a joint replacement and did not have any residual signs or symptoms due to arthroscopic or other ankle surgery. The Veteran used a walker occasionally. However, the use of the walker was noted to be for a right hip condition. The Veteran's gait with the walker was normal. The examiner rendered the opinion that the Veteran's ankle condition did not impact on his ability to work. X-ray of the left and right ankle in July 2012 was unremarkable. The Veteran was afforded a VA medical examination in April 2013. The Veteran was noted to be diagnosed with bilateral ankle sprain. After a discussion of the Veteran's history the Veteran was noted to report that he continues to have ankle pain with standing and walking with the right worse than the left. He rated his right ankle pain as a five to six out of ten and his left ankle pain as a four to five out of ten. He had no past history of surgery. He reported flare-ups of intermittent episodes of pain. Physical examination revealed right ankle plantar flexion of 45 degrees or greater with no objective evidence of pain and right ankle dorsiflexion of 20 degrees or greater with objective evidence of pain at 20 degrees or greater. Left ankle plantar flexion was 45 degrees or more with no objective evidence of painful motion and plantar dorsiflexion of 20 degrees or more with objective evidence of pain at 20 degrees or more. Repetitive-use testing revealed the same ranges of motion. There was no additional limitation of range of motion of the ankles following repetitive-use testing. The Veteran had functional loss and/or functional impairment of the ankle after repetitive use categorized as weakened movement, excess fatigability, pain on movement, swelling, disturbance of locomotion, and interference with sitting, standing, and weight-bearing in both ankles. It was also noted that swelling was uncommon, all other complaints are daily, and getting worse with use. The Veteran had localized tenderness or pain on palpation of joints/soft tissue or both ankles. Muscle strengths were normal bilaterally in plantar flexion and dorsiflexion. The anterior drawer test and talar tilt test did not reveal laxity. There was no ankylosis. The Veteran did not have or ever had "shin splints," stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneous (os calcis) or talus (astragalus), or talectomy (astragalectomy). He had not undergone a joint replacement and did not have any residual signs or symptoms due to arthroscopic or other ankle surgery. The Veteran used a cane and walker on a regular basis. The cane and walker were used when walking depending on the distance. The Veteran's ankle disabilities were noted to impact on his ability to work. The Veteran reported pain in both ankles but the examinations revealed no significant abnormalities. The examiner indicated that the Veteran was able to perform sedentary work or work involving standing, and ambulation. The limitations were reported to be as likely as not attributed to the concurrent knee condition. Entitlement to an evaluation in excess of 10 percent disabling is not warranted at any point during the period on appeal for either the left or the right ankle. At no point during the period on appeal did the Veteran's left or right ankle manifest marked limitation of motion or ankylosis. Physical examination in September 2006 revealed near normal plantar flexion in both ankles at 40 degrees and dorsiflexion limited to 10 degrees in the right and 15 degrees in the left. Physical examination in July 2012 revealed plantar flexion of 40 degrees and dorsiflexion of 20 degree in both ankles. These measurements represent near normal to moderately limited ranges of motion. In addition, the Veteran had normal muscle strengths and there was no laxity on examination. Physical examination in April 2013 revealed normal ranges of motion that remained after repetitive use testing. The Board notes that the Veteran had function loss of weakened movement, excess fatigability, pain on movement, swelling, disturbance of locomotion, and interference with sitting, standing, and weight-bearing in both ankles. Testing was again normal for muscle strengths and did not reveal laxity. Although the Veteran's ankle disabilities manifest pain, the ranges of motion found on examination do not reveal that the Veteran has marked limitation of motion. The Board has considered whether the Veteran is entitled to a higher evaluation pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272, 5272, and 5274. However, as the Veteran's ankles do not manifest any ankylosis, malunion of calcaneous (os calcis), any ankylosis of the subastragalar or tarsal joint, or any surgery including talectomy/astragalectomy, these Diagnostic Codes are not for application. As the preponderance of the evidence is against a finding that the Veteran's left ankle warrants an evaluation in excess of 10 percent disabling or right ankle warrants an evaluation in excess of 10 percent disabling, the appeals are denied. C. Extraschedular The discussion above reflects that the rating criteria reasonably describe and contemplate the severity and symptomatology of the Veteran's service-connected disabilities. The Veteran's disabilities are manifested by impairment of range of motion, residuals of meniscectomy, and pain and the rating criteria contemplate these impairments. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). D. TDIU A claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been considered. Although a VA examiner in September 2006 indicated that the Veteran was unemployed, the same examiner noted that the Veteran worked on his 80 acre farm. It was reported that the Veteran had to modify what he does based upon his shoulder disorder. In addition, another September 2006 VA examination report indicated that the Veteran was able to work on his farm. In September 2011 the Veteran was noted to be off work for surgery for four weeks, then allowed to do one-arm jobs for another eight weeks. In addition, in a VA treatment note dated in February 2012, the Veteran indicated that he was employed with Homeland Security. In a VA examination in July 2012 in regard to the Veteran's back the Veteran was noted to be unable to do mechanic work, which he did in the past due to chronic lower back pain. Although VA examiners have indicated that the Veteran's disabilities impacted the Veteran's ability work, none of the VA examinations of record indicate that the Veteran is unemployable due to his service-connected disabilities. Accordingly, consideration of TDIU pursuant to Rice is not warranted. ORDER Entitlement to an evaluation in excess of 10 percent disabling for post surgery, left knee with arthralgias based upon loss of range of motion, is denied. Entitlement to a separate 10 percent evaluation, and no more, for left knee residuals of meniscectomy, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to an evaluation in excess of 10 percent disabling for post surgery, right knee with arthralgias based upon loss of range of motion, is denied. Entitlement to a separate 10 percent evaluation, and no more, for right knee residuals of meniscectomy, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to an evaluation in excess of 10 percent for a left ankle disability is denied. Entitlement to an evaluation in excess of 10 percent for a right ankle disability is denied. ____________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs