Citation Nr: 1334781 Decision Date: 10/31/13 Archive Date: 11/06/13 DOCKET NO. 09-21 862 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an initial compensable rating prior to July 31, 2009, for mild anterior wedging of L1 with mild disc space narrowing of the lumbar spine at L1-L4, and to a rating higher than 10 percent thereafter. 2. Entitlement to a rating higher than 10 percent for left knee osteoarthritis. 3. Entitlement to a rating higher than 10 percent for gouty arthritis of the left ankle. ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran served on active duty from November 2001 to November 2004, and from May 2006 to February 2008. This case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Pursuant to the Veteran's request, a Travel Board hearing before a Veterans Law Judge was scheduled for July 2013. However, he failed to appear for the hearing and provided no explanation for his absence. Thus, his hearing request is deemed withdrawn. 38 C.F.R. §§ 20.702(d); 20.704(d) (2013). FINDINGS OF FACT 1. From February 12, 2008, the Veteran's lumbar spine disability has been productive of complaints of pain; degenerative changes; forward flexion greater than 60 degrees and a combined range of motion greater than 120 degrees. There is no evidence of muscle spasm, guarding, or localized tenderness resulting in abnormal gait or contour or incapacitating episodes. 2. The Veteran's left knee osteoarthritis is manifested by complaints of knee pain, locking, stiffness, lack of endurance and swelling; normal left knee extension; and limitation of flexion to 130 degrees with pain. Recurrent subluxation or lateral instability was not demonstrated. 3. The Veteran describes left ankle pain with exacerbations several times a year with severe pain and swelling; there is medical evidence of tenderness with no more than moderate limitation of motion of the left ankle, but no evidence of active disease process or symptoms producing definite impairment of health, and no documentation of the described exacerbations. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 10 percent, but not higher, for mild anterior wedging of L1 with mild disc space narrowing of the lumbar spine at L1-L4, have been met for the entire appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5237 (2013). 2. The criteria for a rating higher than 10 percent for left knee osteoarthritis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (2013). 3. The criteria for a disability rating higher than 10 percent for gouty arthritis of the left ankle have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5002, 5017, 5271 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The notice requirements were accomplished in a letter sent in an April 2008. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). The letter also provided notice of the type of evidence necessary to establish a disability rating or effective date for the claimed disability under consideration, pursuant to the recent holding in Dingess v. Nicholson, 19 Vet App 473 (2006). The notice was timely because the claim was readjudicated in the February 2013 supplemental statements of the case. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. The Veteran's service treatment records and available VA treatment records have been obtained. In addition, he has been provided with appropriate VA examinations in connection with the claims which sufficiently describe the manifestations of the Veteran's claimed disabilities for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Moreover, he has not indicated there are any additional records that VA should seek to obtain on his behalf. Therefore, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claims, and no further assistance to develop evidence is required. Higher Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2013); see also 38 C.F.R. §§ 4.45, 4.59 (2013). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (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). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Lumbar Spine In August 2008, the RO granted service connection for mild anterior wedging of L1 with mild disc space narrowing of the lumbar spine at L1-L4 with radiculopathy of the left leg, and assigned a noncompensable disability rating effective February 12, 2008, the day after release from active service. By a rating decision in February 2013, the RO increased the Veteran's lumbar spine disability rating to 10 percent effective July 31, 2009, and assigned a separate 10 percent disability rating for radiculopathy of the left lower extremity. The Veteran has not appealed the decision concerning the radiculopathy. The Veteran contends that he is entitled to an initial compensable rating for his lumbar spine disability prior to July 31, 2009, and to a rating higher than 10 percent thereafter. The Veteran's lumbar spine disability is currently rated under Diagnostic Code 5237 for lumbosacral strain. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine for Diagnostic Codes 5235 to 5243. Diagnostic Code 5243 may also be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The Veteran's service-connected lumbar spine disability is rated under the General Rating Formula (General Formula) for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2012). Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees, or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine not greater than 120 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. A maximum rating in this case of 40 percent is warranted where there is forward flexion of the thoracolumbar spine of 30 degrees or less. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2013). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2 (2013). Any associated objective neurologic abnormalities are evaluated separately under the appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a rating of 10 percent is warranted where there are incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A rating of 20 percent is warranted where there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A rating of 40 percent is warranted where there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A maximum rating of 60 percent is warranted where the evidence reveals incapacitating episodes having a total duration of at least six weeks during the past 12 months. Incapacitating episodes are defined as requiring bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (2012). Prior to July 31, 2009, the Veteran's lumbar spine disability was assigned a noncompensable disability rating. By way of background, service treatment records for the period of service from May 2006 to February 2008, documented complaints of chronic low back pain. A June 2007 MRI of the lumbar spine was within normal limits. The impression was multi-level spondylitic changes, most prominent at L5-S1, where a focal left sided protrusion appeared to contact the exiting L5 nerve root. A November 2007 Medical Evaluation Board report noted complaints of chronic lumbar pain with radicular symptoms down the left lower extremity since March 2007. The pain was aggravated by heavy lifting and bending. He rated the pain as 8-9/10. He also related numbness and a burning sensation down his left lower extremity. There was no bowel or bladder dysfunction. On VA examination in May 2008, the Veteran reported onset of back pain in 2006. He could not recall any specific injury. Symptoms included recurrent weakness, stiffness, and sharp pain and numbness that radiated to the left thigh. At its highest, the pain would be 9/10. He took over the counter medication as needed to treat the pain. Neurological examination of the lower extremities, to include motor and sensory evaluations, was within normal limits. Reflexes were 2+ bilaterally. Gait was normal. Range of motion of the lumbar spine was normal with no radiation of pain on movement. Straight leg raising was normal. Flexion was to 90 degrees, extension was to 30 degrees, right and left lateral flexion was to 30 degrees, bilaterally, and right and left lateral rotation was to 30 degrees, bilaterally. There was no additional limitation of motion, fatigue, lack of endurance or incoordination following repetitive use. Inspection of the spine revealed normal spine curvature. There was no intervertebral disc syndrome. X-rays of the spine revealed mild anterior wedging of L1, and mild disc space narrowing at L1-S2, L2-L3, and L3-L4. The examiner determined that the lumbar spine disability was not manifested by any pathology to render a diagnosis. Initially, the Board notes that throughout the period on appeal the evidence of record does not demonstrate that the Veteran was prescribed bed rest by a physician at any time during the appeal. Indeed, the clinicians who have examined the Veteran have found no evidence of intervertebral disc syndrome present at any time. As such, the Veteran does not satisfy the criteria for an increased rating under Diagnostic Code 5243 for intervertebral disc syndrome because the record does not show documented periods of acute signs and symptoms that required bed rest prescribed by a physician and treatment by a physician. Accordingly, the Board finds that he is not entitled to a higher disability rating based upon incapacitating episodes at any time throughout the appeal. As the Veteran is not entitled to an increased rating based upon incapacitating episodes, it is necessary to determine whether he is entitled to higher ratings under the General Rating Formula for Diseases and Injuries of the Spine Prior to July 31, 2009, resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran is entitled to a 10 percent rating, and no more, for his service-connected lumbar spine disability. This rating is assigned because the evidence of record revealed that the Veteran has degenerative changes and painful motion in his lumbar spine. Specifically, x-rays of the spine in May 2008 revealed mild anterior wedging of L1, and mild disc space narrowing at L1-S2, L2-L3, and L3-L4. Indeed, it is VA policy to recognize actually painful motion as warranting at least the minimum compensable rating. 38 C.F.R. § 4.59. This provision is applicable to any orthopedic disability. See Burton v. Shinseki, 25 Vet. App. 1 (2010); see also 38 C.F.R. § 4.59 (2013). A higher rating is not warranted based on limitation of motion, even with consideration of the DeLuca precepts. As noted, at the May 2008 VA examination, the Veteran's lumbar spine range of motion was normal, with forward flexion greater than 60 degrees. His combined range of motion was greater than 235 degrees, including with consideration of functional limitation due to pain. The ranges of motion demonstrated do not, however, exceed the criteria for a 10 percent rating. Additionally, there was no evidence of muscle spasm, guarding, or localized tenderness resulting in abnormal gait or contour; or vertebral body fracture. The VA and private treatment records prior to July 31, 2009 were negative for any range of motion findings or any other evidence that would warrant a higher rating. The Board further finds that the 10 percent rating adequately portrays the Veteran's functional loss due to pain in accordance with 38 C.F.R. §§ 4.40, 4.45, and 4.59, and demonstrates that any such functional loss is contemplated. The evidence fails to show that the Veteran's lumbar spine disability more nearly approximates the criteria for a higher rating since July 31, 2009. A VA clinical treatment note dated on July 31, 2009, reflects that the Veteran complained of chronic low back since service. On examination, there was mild tenderness over the lumbar spine with good general range of motion, except for a left tilt. August 2009 lumbar spine x-rays revealed slight disc narrowing at L4/L5, with a 3 mm retrolisthesis of L5 on S1 measured on the lateral coned down study. An MRI in November 2009 showed degenerative changes with no significant spinal canal stenosis. At L5-S1 there was a 4 mm posterior disc bulge at the left paracentral/foraminal predominance with left recess narrowing and mass effect on the traversing Left S1 nerve. Also noted was left foraminal/lateral predominance of disc bulge at L3-4 with mass effect on the exiting left L3 nerve and mild left foraminal narrowings at L3-4, and L5-S1. Subsequent VA treatment records show continued complaints of back pain. The Veteran underwent a VA spine examination in October 2012. Reportedly, the back condition had worsened since its onset, and was productive of functional limitations, to include prolonged standing, walking, sitting, repetitive bending and heavy lifting. Flexion of the lumbar spine was to 90 degrees with onset of pain at 75 degrees, and extension was to 30 degrees with onset of pain at 15 degrees. Lateral flexion was to 30 degrees with onset of pain at 20 degrees, bilaterally, and lateral rotation was to 30 degrees with onset of pain at 20 degrees, bilaterally. There was additional limitation of motion due to pain, on repetitive use, as noted. There was mild tenderness of the thoracolumbar spine on palpation. There was no evidence of muscle spasms or guarding. Gait and spinal contour were normal. Muscle strength was normal and there was no muscle atrophy. Reflexes in the lower extremities were normal and sensory examination revealed no abnormalities. Straight leg raising was normal. The examiner noted mild radiculopathy manifested by intermittent pain in the left lower extremity due to involvement of L4/L5/S1/S2/S3 (sciatic nerve). There were no other symptoms associated with the left leg and examination of the right leg revealed no abnormalities. No bladder or bowel abnormalities were found on examination. Intervertebral disc syndrome was not shown. X-rays of the lumbar spine revealed vertebrae normally aligned. There was anterior compression of L1 with about 20 percent loss of height anteriorly. Disc spaces were normal, posterior arches appeared intact and facet joint were unremarkable. The impression was 20 percent loss of height at L1 with no other significant findings. The examiner opined that the Veteran's lumbar spine disability was productive of inability to stand, sit or walk for a prolonged period of time, and limited his ability to do heavy lifting or repetitive bending. The ranges of motion of the Veteran's lumbar spine, as shown on VA examination in October 2012, fall at most within the requirements for a 10 percent rating: forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. His combined range of motion was greater than 120 degrees, including with consideration of functional limitation due to pain. The ranges of motion demonstrated do not support an evaluation in excess of 10 percent. Additionally, there was no evidence of muscle spasm, guarding, or localized tenderness resulting in abnormal gait or contour; or vertebral body fracture at any time under consideration. 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2013). Thus, a higher rating is not warranted. The rating criteria provide for separate ratings for neurologic and orthopedic manifestations. However, there is no evidence of any abnormal neurologic manifestations related to the lumbar spine prior to October 15, 2012, other than subjective complaints of pain and numbness in the left lower extremity, so a separate compensable rating for neurologic manifestations of the lumbar spine disability is also not warranted. Specifically, the Board notes that on VA examination in May 2008, neurological examination of the lower extremities, to include motor and sensory evaluations, was within normal limits. Reflexes were 2+ bilaterally. Gait and straight leg raising were normal. A January 2010 outpatient treatment report noted the Veteran had a negative straight leg raise, 5/5 motor strength and normal sensation in both lower extremities. As radiating pain is specifically contemplated in the General Rating Formula for Diseases and Injuries of the Spine and objective evidence of slight incomplete paralysis of the sciatic nerve has not been shown, a separate rating for radiculopathy is not warranted prior to October 15, 2012. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (rating spine conditions with or without symptoms such as pain, whether or not it radiates); 4.124a, Diagnostic Code 8520. As of October 15, 2012, the Veteran is already in receipt of a separate compensable rating for left sided radiculopathy under 38 C.F.R. § 4.124a, Diagnostic Code 8520. In a rating decision in February 2013, the RO granted a separate disability rating for left lower extremity radiculopathy and assigned a 10 percent disability rating, effective October 15, 2012. The Veteran has not disagreed with that rating. There were no other neurological symptoms identified. The Board finds that the preponderance of the evidence is against a finding of any additional neurological impairment consistent with a separate and distinct neurological disability associated with the Veteran's lumbar spine disability warranting a separate compensable rating. In sum, the Board finds that a 10 percent disability rating for the lumbar spine disability, and no higher, is warranted for the entire appeal. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Knee The Veteran claims that he is entitled to a rating higher than 10 percent for osteoarthritis of the left knee. The Veteran's left knee disability is rated under 38 C.F.R. § 5010 and 5260. Under 38 C.F.R. § 4.71a, Diagnostic Code 5010, traumatic arthritis is rated as degenerative arthritis under 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Degenerative arthritis is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. When there is arthritis and at least some limitation of motion, but the limitation of motion would be rated noncompensable under a limitation of motion code, a 10 percent rating may be assigned for each affected major joint. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010. Limitation of flexion of a leg to 60 degrees warrants a 0 percent rating. A 10 percent rating requires that flexion be limited to 45 degrees. A 20 percent rating requires that flexion be limited to 30 degrees. A 30 percent is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of a leg to 5 degrees warrants a 0 percent rating. A 10 percent rating requires that extension be limited to 10 degrees. A 20 percent rating requires that extension be limited to 15 degrees. A 30 percent rating requires that extension be limited to 20 degrees. A 40 percent rating requires that extension be limited to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5257, knee impairment with recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. 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, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2013). It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). Precedent opinions of the VA's General Counsel have held that dual ratings may be given for a knee disorder, with one rating for instability (Diagnostic Code 5257) and one rating for arthritis with limitation of motion (Diagnostic Codes 5003 and 5010). VAOPGCPREC 9-98 (63 Fed. Reg. 56,704 (1998)) and 23-97 (62 Fed. Reg. 63,604 (1997)). Another such opinion held that separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension) may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (69 FR 59988 (2004)). By way of background, by a rating decision in November 2004, the RO granted service connection for osteoarthritis of the left knee and assigned a 10 percent disability rating, effective November 2004. In December 2007 the Veteran submitted the current claim for an increased disability rating. On VA examination in May 2008, the Veteran reported being diagnosed in service with left knee osteoarthritis following an x-ray of the knee. He complained of intermittent symptoms, to include swelling, lack of endurance, stiffness, weakness and locking. He treated the pain with over the counter medication as needed. Neurological examination of the lower extremities, to include motor and sensory, was within normal limits. Reflexes were 2+ bilaterally. Gait was normal. Examination of the left knee was normal with extension to zero degrees and flexion to 140 degrees. There was no additional limitation of motion, fatigue, lack of endurance or incoordination following repetitive use. The examiner noted that there was no change in the diagnosed left knee osteoarthritis because on examination there was no pathology associated with the left knee to render a diagnosis. A VA clinical treatment note dated on July 31, 2009, examination of the knees revealed no abnormalities. X-rays of the left knee showed no degenerative knee joint narrowing. Subsequent VA treatment records show continued complaints of left knee pain. On VA knee examination in October 2012, the Veteran reported that his knee would become symptomatic according to gout flare-ups. His current complaints included frequent flare-ups of knee arthralgias with swelling and hyperemia, productive of functional limitations, to include prolonged standing, walking, climbing stairs, repetitive kneeling, squatting and running. The Veteran reported non-incapacitating exacerbations related to arthritis occurring 4 or more times per year. Specifically, he reported exacerbation of left knee arthralgias with swelling in August 2012, which lasted 2 months. There were no periods of incapacitation. The Veteran denied current treatment with prescription medications. The Veteran did not require the use of assistive devices for ambulation. Extension of the left knee was to zero degrees and flexion was to 140 degrees with no objective evidence of pain. On repetitive movement, left knee flexion was limited to 130 degrees due to pain. Muscle strength was normal. There was no anterior, posterior, or medial-lateral instability, nor was the condition manifested by a history of recurrent patellar subluxation or dislocation. The Veteran's left knee condition impaired prolonged ambulation. With regard to limitation of left knee flexion, during the period on appeal the Veteran demonstrated flexion to at least 130 with pain on repetitive movement. As flexion is not limited to 30 degrees, the criteria for a higher rating of 20 percent under Diagnostic Code 5260 are not demonstrated, even when considering any additional functional loss due to pain and painful movement. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2013); DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). As the Veteran's extension was full (to zero degrees), entitlement to a higher rating or separate rating under Diagnostic Code 5261 is not warranted, even considering his complaints of pain. With any pain, extension was still not limited such that the criteria for a compensable rating for limitation of extension were met. Id. With regard to knee instability, although the Veteran reported intermittent swelling, lack of endurance, stiffness, weakness and locking on VA examination in May 2008, there was no evidence of giving way, instability, locking, grinding, or episodes of dislocation or subluxation. Thereafter, in October 2012 the VA examiner specifically found no anterior, posterior, or medial-lateral instability. It was further noted that the left knee was not manifested by a history of recurrent patellar subluxation or dislocation. Additionally, there is no evidence of removal or dislocation of any knee cartilage. Accordingly, in the absence of evidence of recurrent subluxation or lateral instability, or removal or dislocation of any knee cartilage, the Board finds that the assignment of a higher and/or separate rating under Diagnostic Codes 5257, 5258, or 5259 is not warranted. The evidence also does not show ankylosis, tibia or fibula impairment, or genu recurvatum to warrant consideration of Diagnostic Codes 5256, 5262, or 5263. 38 C.F.R. § 4.71a (2013). In sum, the Board finds that the weight of the credible evidence is against higher or separate disability ratings for the Veteran's left knee disability, and the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert, supra. Gouty Arthritis of the Left Ankle The Veteran claims that he is entitled to a rating higher than 10 percent for his left ankle disability. Pursuant to Diagnostic Code 5017, gout will be rated under Diagnostic Code 5002 for "rheumatoid arthritis." Under this code, a 100 percent rating is warranted for rheumatoid arthritis (atrophic) as an active process with constitutional manifestations associated with active joint involvement, totally incapacitating. When less than the criteria for a 100 percent rating but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times per year or a lesser number over prolonged periods, a 60 percent rating may be assigned. With symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times per year, a 40 percent rating evaluation may be assigned. One or two exacerbations per year in a well-established diagnosis warrant a 20 percent rating. Alternatively, chronic residuals can be rated based on limitation of motion, with a 10 percent assigned for limited motion which is noncompensable under the appropriate rating codes for the joints. See 38 C.F.R. § 4.71a, Diagnostic Codes 5107, 5002 (2013). For chronic residuals such as limitation of motion or ankylosis, favorable or unfavorable, the disability is rated under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion, and the ratings for active process will not be combined with the residual ratings for limitation of motion or ankylosis; rather, the higher evaluation should be assigned. Id. Limitation of motion of the ankle is rated under Diagnostic Code 5271. Under this diagnostic code, a 10 percent evaluation is assigned for moderate limitation of motion, and a 20 percent rating is assigned for marked limitation of motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. Words such as "moderate" and "marked" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). However, the Rating Schedule provides some guidance by defining full range of motion of the ankle as from zero to 20 degrees of dorsiflexion and from zero to 45 degrees of plantar flexion. See 38 C.F.R. § 4.71, Plate II (2012). By way of background, by a rating decision in November 2004, the RO granted service connection for left ankle gouty arthritis and assigned an evaluation of 10 percent, effective November 2004. In December 2007 the Veteran submitted the current claim for an increased disability rating. On VA examination in May 2008, the Veteran reported a history of acute swelling in the left ankle in 2001. He was told at the time that he had gouty arthritis. He was treated with medication with some temporary relief, which he subsequently discontinued. The Veteran works as a sushi chef and currently treated the pain with over the counter medication as needed. He reported his ankle was intermittently weak and would occasionally swell. The Veteran experienced pain four to five times a week on prolonged standing or walking. He rated the pain as 8/10. The examiner noted that with regards to the Veteran's claimed gouty arthritis of the left ankle, there was no change in diagnosis. A VA clinical treatment note in July 2009, recorded a history of gout in the Veteran's left ankle as diagnosed in service. Reportedly, he experienced gout attacks on a weekly basis when he was in service and was prescribed medication at that time. However, the Veteran denied any current gouty attacks. On examination, the left ankle was stiffer than the right and there was slightly painful motion. X-rays of the left ankle in August 2009, were unremarkable. Subsequent VA treatment records show continued complaints of left ankle pain with no recent treatment. The Veteran underwent a VA examination in October 2012. The examiner noted that historically, the Veteran had been diagnosed gouty arthritis of the left ankle in service. The diagnosis was based on a clinical finding of elevated uric acid level in 2002. His current complaints included frequent flare-ups of left ankle arthralgias with swelling and hyperemia. He denied treatment with prescription medications. The Veteran denied weight loss or anemia. The Veteran reported non-incapacitating exacerbations related to arthritis occurring 4 or more times per year. Specifically, he reported exacerbation of left ankle arthralgias with swelling in August 2012, which lasted 2 months. There were no periods of incapacitation. On examination, the Veteran did not require the use of assistive devices for ambulation. Plantar flexion of the left ankle was to 45 degrees with pain at 40 degrees, and dorsiflexion was to 20 degrees with onset of pain at 15 degrees on repetitive use. The ankle was tender on palpation. Muscle strength was normal. No laxity was shown. The examiner opined that the Veteran's gouty arthritis of the left ankle impaired prolonged ambulation. Review of the medical evidence of record reveals no ankylosis of the ankle. However, limitation of motion is shown. Specifically, VA examination in October 2012 showed plantar flexion of the left ankle limited to 40 degrees with pain, and dorsiflexion was limited to 15 degrees with pain on repetitive use, and there was tenderness on palpation. The Board finds that this evidence reflects no more than moderate limitation of ankle motion, such that the overall disability picture does not approximate the criteria for a 20 percent rating for the left ankle under Diagnostic Code 5271, even considering any functional loss due to pain and painful movement. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2013); DeLuca, 8 Vet. App. 202. As to whether the Veteran's disorder may be rated as an "active disease process", the Board notes that there is no medical evidence confirming the presence of active disease process or documenting the Veteran's described attacks. While the Veteran has reported weekly flare-ups of gout during appeal and on VA examination in October 2012 he endorsed non-incapacitating exacerbations 4 or more times per year, there were no gout attacks noted in the VA treatment records. In fact, a VA clinical treatment note in July 2009 contained the Veteran's reported denial of any current gouty attacks, as previously experienced in service. The Board finds the treatment records more probative than the lay assertions. In addition, there is no objective evidence that the gout has associated symptoms otherwise producing definite impairment of health. In this regard, the evidence shows that during the appeal there is no evidence of weight loss or anemia, and the Veteran denied treatment with prescription medication. Instead, he used over the counter medication as needed. As stated above, the disability is rated either as an "active disease process" or according to chronic residuals. The Board does not find disability so severe as to more closely approximate the criteria for a 20 percent rating for disability as an "active disease process". Id. Therefore, the Board finds that the preponderance of the evidence is a rating higher than 10 percent for gouty arthritis of the left ankle. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert, supra. Other considerations The Board has considered the statements of the Veteran regarding the severity of the service-connected lumbar spine disability, osteoarthritis of the left knee, and gouty arthritis of the left ankle. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). In this case, the Veteran is competent to report symptoms because that requires only personal knowledge as it comes to him through his senses, and the Board has considered these statements. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds, however, the medical evidence during the appeal to be more probative than the Veteran's lay assertions as to severity provided for purposes of his compensation claim. See Cartright v. Derwinski, 2 Vet. App. 24 (1991). As a final matter, the Board has also considered whether the Veteran's lumbar spine disability, osteoarthritis of the left knee, and gouty arthritis of the left ankle, present an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2013); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology and provide for additional or more severe symptoms than currently shown by the evidence. The Board has considered the various diagnostic codes for evaluating the lumbar spine, the knee and gouty arthritis of the left ankle, but finds that his symptomatology is adequately addressed by the evaluations assigned. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluations are, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. ORDER Subject to the law and regulations governing payment of monetary benefits, an initial disability rating of 10, but no higher, for mild anterior wedging of L1 with mild disc space narrowing of the lumbar spine at L1-L4, is granted. A rating higher than 10 percent for osteoarthritis of the left knee is denied. A rating higher than 10 percent for gouty arthritis of the left ankle is denied. ____________________________________________ K.A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs