Citation Nr: 1335124 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 08-34 446 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a right ankle disability. 2. Entitlement to service connection for a left ankle disability. 3. Entitlement to an initial compensable rating for right knee retropatellar pain syndrome. 4. Entitlement to an initial compensable rating for left knee retropatellar pain syndrome. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from July 1997 to February 2002. These matters come before the Board of Veterans' Appeals (Board) from an April 2007 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Portland, Oregon. In December 2010, the Veteran testified at a Travel Board hearing before a Veterans Law Judge who is no longer employed by the Board. A transcript of that hearing is of record. In correspondence dated in May 2013, the Veteran requested a hearing before another Veterans Law Judge. The Veteran was scheduled for a videoconference Board hearing in September 2013. In correspondence dated in August 2013, the Veteran stated that he would not attend the hearing and that he did not wish it to be rescheduled. He requested that his claims be forwarded to the Board for adjudication. Accordingly, the Board considers the Veteran's request for a hearing to be withdrawn and will proceed to adjudicate the case based on the evidence of record. See 38 C.F.R. § 20.704 (d), (e) (2012). These matters were previously before the Board in February 2011 and were remanded for further development. They have now returned to the Board for further appellate consideration. As is discussed in further detail below, the Board finds that there has been substantial compliance with its remand. FINDINGS OF FACT 1. The clinical evidence of record is against a finding that the Veteran has a right ankle disability causally related to, or aggravated by, active service. 2. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has a right ankle disability causally related to, or aggravated by, active service. 3. The clinical evidence of record is against a finding that the Veteran has a left ankle disability causally related to, or aggravated by, active service. 4. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has a left ankle disability causally related to, or aggravated by, active service. 5. During the rating period on appeal, the Veteran's right knee disability has been manifested by complaints of pain, giving way, locking up, and swelling; objectively, the Veteran has flexion which is not limited to 60 degrees or worse, and extension which is not limited to 5 degrees or worse. 6. During the rating period on appeal, the Veteran's left knee disability has been manifested by complaints of swelling, pain, giving way, and swelling; objectively, the Veteran has flexion which is not limited to 60 degrees or worse, and extension which is not limited to 5 degrees or worse. CONCLUSIONS OF LAW 1. The criteria for service connection for a right ankle disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). 2. The criteria for service connection for a left ankle disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). 3. The criteria for a compensable initial disability for right knee retropatellar pain syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R.§§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5263 (2013). 4. The criteria for a compensable initial disability for left knee retropatellar pain syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R.§§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5263 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided in August 2006. VA has a duty to assist the appellant in the development of the claims. The claim file includes service treatment records (STRs), post service medical records, and the statements of the Veteran in support of the claims, to include his testimony at a Board hearing. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that adequate examinations and opinions have been obtained. The claim file includes a March 2011 VA examination report. The report is based on examination of the Veteran, radiographic findings, the Veteran's reported symptoms, and the Veteran's STRs. Adequate rationale has been provided. The report also provides findings relevant to the criteria for rating the knee disabilities at issue. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008), Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Rating Disabilities in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating musculoskeletal disabilities Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. 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 it 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 that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40 and 4.45 (2013), see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2013). The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. Id. § 4.45. Pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss. Pain may cause a functional loss but itself does not constitute functional loss; rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). Flexion and Limitation of the Lower extremity DC 5260 provides a noncompensable rating when flexion is limited to 60 degrees or more. A 10 percent rating is warranted for leg flexion limited to 45 degrees. A 20 percent evaluation is for leg flexion limited to 30 degrees. A 30 percent evaluation is for leg flexion limited to 15 degrees. DC 5261 provides a noncompensable rating when extension is limited to 5 degrees or less. A 10 percent rating is warranted for leg extension limited to 10 degrees. A 20 percent evaluation is for leg extension limited to 15 degrees. A 30 percent evaluation is for leg extension limited to 20 degrees. A 40 percent evaluation is for leg extension limited to 30 degrees. A 50 percent evaluation is for leg extension limited to 45 degrees. In VAOPGCPREC 9 - 2004 (Sept. 17, 2004), it was held that a claimant who had both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. As such, if the evidence of record reflects compensable loss of both flexion and extension of either leg, the Veteran would be entitled to the combined evaluation under Diagnostic Codes 5260 and 5261, per the combined ratings table in 38 C.F.R. § 4.25. Instability of the knee Instability of the knee and limitation of motion of the knee are two separate disabilities. As such, it is permissible to award separate ratings under both a range of motion code and an instability code (DC 5257), without violating the prohibition on pyramiding. See VAOPGCPREC 23-97. DC 5257 is predicated on instability, rather than limitation of motion, therefore, an analysis under DeLuca does not apply. See Johnson v. Brown, 9 Vet. App. 7 (1996). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to the claims on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Right and Left Ankle Disabilities The Veteran avers that he has a right ankle disability and a left ankle disability as a result of active service, to include as due to road marches, and carrying/lifting heavy weight. An essential element of a claim for service connection is evidence of a current disability. A March 2011 VA examination report reflects diagnoses of "chronic ligamentous inflammation and scarring of the lateral ankle ligaments." Thus, this element has been met. A second element of a claim for service connection is medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease. The Veteran's STRs contain several notations with regards to the Veteran's lower extremities. A January 1998 STR reflects that the Veteran had complaints of pain on the right side of the foot. He had some swelling, limitations with range of motion, and pain with palpation. A March 1998 STR reflects that the Veteran reported left foot pain for four days. He reported that it hurt when he walked. (The year is not noted on the STR; however, it reflects that the Veteran was 19 years old. As the Veteran was born in November 1978, he was 19 years old in March 1998.) The STR reflects that the Veteran had been on a road march earlier that week and twisted his foot. He further reported that the pain was worse while standing and running, was intermittent, and radiated. The Veteran was prescribed to run at his own pace. A November 1998 STR reflects that the Veteran reported that his left arch was swollen. He reported that left foot pain "comes and goes". It was positive for swelling on the left foot arch. A subsequent November 1998 STR reflects that the Veteran had continued complaints of pain for three weeks. He reported that the pain "radiates from arch (where it started originally) to back of the lower leg." He was prescribed no running, jumping, or marching for 10 days. A December 1998 STR reflects that the Veteran had continued complaints of left "arch ankle" pain for one month in duration. It was noted that the Veteran had left arch pain which had first begun during a road march. The Veteran stated that this was his third visit for this complaint and that he had already used arch supports which were "no help." It was noted that the Veteran's feet were swollen from a 12 mile road march the previous day. It was also noted that pain stayed in the foot. A June 2001 STR reflects that the Veteran reported he had strained his left Achilles tendon while playing basketball and had had pain since the previous day. He had full range of motion of the right Achilles tendon and ankle, but limited range of motion on the left Achilles and ankle accompanied by a "bit of pain". The assessment was left Achilles strain. The Veteran's October 2001 report of medical history for separation purposes is of record. It reflects that the Veteran denied foot trouble or impaired use of the legs or feet. He denied swollen or painful joints, other than the knees. The Veteran noted numerous disabilities and complaints to include a tonsillectomy, two hernias, broken fingers (all of them), multiple wasp bites, a perforated ear drum, right wrist pain "sometimes", frequent lower back pain, numbness or tingling sometimes while running - "one leg will go numb", Osgood-Schlatter disease in both knees, knees that "pop, frequent swelling/ sometimes hurt", yellow jaundice when born, infrequent hemorrhoids, spotted skin, and genital warts. Notably, the Veteran did not list any ankle or foot pain in either the left or right ankle. The Veteran separated from service in February 2002. He filed a claim for entitlement to service connection for a bilateral ankle disability in August 2006, more than four years after separation from service. The Board notes that there is no clinical evidence that he complained of, or sought treatment for a left foot, ankle, or Achilles tendon problem between June 2001 (his last documented complaint in service) and 2006, when he filed his claim. There is no clinical evidence that he complained of, or sought treatment for a right foot, ankle, or Achilles tendon problem between January 1998 (his last documented complaint in service) and 2006, when he filed his claim. The Board acknowledges the Veteran's testimony that he did not seek treatment because he did not have insurance; however, this does not adequately explain why he did not seek treatment, if necessary, between his last documented complaints in service and separation, or why he denied any trouble upon separation. While the Board acknowledges that the absence of any corroborating medical evidence supporting assertions, in and of itself, does not render lay statements incredible, such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of Veteran's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). See also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent to establish a diagnosis when . . . a layperson is competent to identify the medical condition.) In this regard, the Board notes that the Veteran reported approximately 13 physical complaints upon his 2001 separation history report, to include his knees. The Board finds that if the Veteran had chronic or continued complaints with regard to the feet or ankles, it would have been reasonable for him to have reported it, and for it to have been noted, when his other complaints were reported and noted; they are not. To the contrary, the Veteran denied any such trouble. Any contention by the Veteran that he has had chronic pain since service is less than credible with consideration of the evidence of record as a whole, to include the above noted facts. A third element of a claim for service connection is medical evidence of a nexus between the current disability and the in-service disease or injury, or, for diseases listed in 38 C.F.R. § 3.309(a), continuity of symptomatology. For the reasons noted below, the Board finds that the third element has not been met. Continuity of symptoms, as an avenue to achieve service connection, is warranted for chronic diseases listed in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. Feb. 21, 2013). However, even if the Board were to find that the Veteran was credible with regard to a statement of pain since service, the Veteran has not been diagnosed with a chronic disease under 38 C.F.R. § 3.309. In the present claim, there is no clinical opinion which supports a causal relationship between an ankle disability and active service. In addition to a lack of a clinical opinion relating the Veteran's ankle disabilities to service, the claim file includes a March 2011 VA examination report. The report reflects that the Veteran reported that he had no foot problems "at all now". He complained of pain along and around the tip of the lateral malleolus of both ankles. The examiner noted that "when the patient was questioned and pressed about whether or not these ankle issues and ankle symptoms are those that he had in the military he admits that they are not. It was noted that in the military he was treated for different issues and that his plantar fasciitis and Achilles tendinitis." The report, in pertinent part, also reflects that the Veteran reported "off and on problems with the ankles where some days he has no problems at all and then he has other days where he does have some discomfort." It was noted as follows: the veteran indicates that he has more good days than symptomatic days. The veteran reports that when he does have some problems it is usually after standing and walking all day long and that he may have a flare-up on the end of the week on a Friday that lasts all weekend and then by Monday they are better without any treatment at all. The veteran denies any swelling. He reports a sharp soreness as he describes it on the outside of the ankle. He rates this as a 2-3 when it occurs. The veteran specifically denies any giving way episodes in the ankle and denies also locking and popping of the ankles. Upon examination, the examiner noted that the ankles reveal some slight enlargement particularly around the anterior aspect of the lateral malleolus. The examiner found, in pertinent part, as follows: This area seems to be on palpation more thickening and scarring of the tissue than swelling. This seems to be a chronic condition. There are no bony abnormalities felt about the ankle and there is no severe tenderness. There is no crepitans on motion of the ankle. There is no instability of either ankle. The veteran has excellent power of his ankle tendons and muscles against resistance in all directions. Right ankle motion examination reveals flexion of 58 degrees, dorsiflexion of 5 degrees, and inversion of 32 degrees and eversion of 8 degrees. All of these motions remained the same with repetition and produce no pain. Left ankle, the motions reveal 60 degrees of flexion, 2 degrees of dorsiflexion, 4 degrees of eversion and 32 degrees of inversion all without pain and all without changes on repetition. Radiographs of the feet and ankles revealed no narrowing of the ankle joint space, no osteochondral defects, no loose bodies, and no spurring around the ankle joint at all. The examiner noted that he saw "no abnormalities whatsoever". The examiner opined that the Veteran's current chronic ligamentous inflammation and scarring of lateral ankle ligaments did not produce any chronic instability condition. The examiner also opined that the Veteran's conditions in service were related to the feet and the Achilles tendon and did not involve the ankle joint. The examiner also opined that the Veteran's current ankle condition is not related "at all" to his military service. The Veteran testified at the December 2010 Board hearing that he went on frequent road marches in service, and that such marches included carrying significant weight, (e.g. 120 pounds) and that he was frequently called upon to do heavy lifting in service. (See Board hearing transcript pages 5 and 18.) The Veteran is competent to attest to factual matters of which he has first-hand knowledge (e.g., pain). To this extent, the Board finds that the Veteran is competent to report that he has current pain and that he had pain in service; however, the Veteran has stated that the symptoms which he currently has are not the same as that which he had in service. (See March 2011 VA examination report.) The Board also notes that at the Board hearing, the Veteran indicated that he is not competent to distinguish between different parts of the feet and ankle. He testified that it is not easy for him to tell the difference between an ankle problem, a foot problem, and an Achilles tendon problem. (See Board hearing transcript page 12.) The examiner in this case is a doctor, who therefore, has the training, experience, and education necessary to distinguish between various complaints and diagnoses of the feet and ankles. In addition, the medical providers in service also have had medical training, education, and experience as certified physician's assistants. Thus, the Board finds that the diagnoses provided by the medical professionals are more probative than the Veteran's lay statements with regard to diagnoses. The Veteran has also not been shown to have the experience, training, or education necessary to make an etiology determination with regard to his current ankle disabilities. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issues in this case in light of the education and training necessary to make a finding with regard to chronic ligamentous inflammation many years after separation from service and with intermittent symptoms, and scarring of lateral ankle ligaments. The Board finds that such etiology findings fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In conclusion, there has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has a right and/or left ankle disability causally related to, or aggravated by, active service; the clinical evidence is against such. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Entitlement to an initial compensable rating for right knee retropatellar pain syndrome and an initial compensable rating for left knee retropatellar pain syndrome Service connection for residuals of right knee retropatellar pain syndrome and left knee retropatellar pain syndrome, both evaluated as noncompensable, has been established since August 25, 2006. A February 2007 VA examination report is of record. The report reflects that the Veteran reported daily pain for which he does not take medication. He also reported flare-ups approximately three times a month with pain going up into the 7-8 degree range and lasting 5-10 minutes at a time. The Veteran reported that his range of motion was not limited due to the problem. It was noted that the Veteran did not need any assistive devices, had not missed any school, and that his daily activities are not limited as long as he does not run. Upon clinical examination in 2007, the Veteran had mild tenderness over the patella bilaterally. There was also mild crepitus bilaterally. There was no effusion or instability. The Veteran had normal range of motion with regard to flexion and extension (0 to 140 degrees). Repetitive range of motion testing did not cause discomfort, nor did it decrease the range of motion. Range of motion was not limited by pain, fatigue, weakness, or lack of endurance following repetitive use. The examiner found that the medial and lateral collateral ligaments were intact bilaterally. The anterior and posterior drawer signs, and the McMurray's test were negative bilaterally. The Veteran's gait was normal. The impression was bilateral retropatellar pain syndrome. The Veteran testified that he did not obtain treatment for his knees after service because he did not have insurance and was unaware that he could obtain free treatment through the VA system. (See Board hearing transcript page 15.) He also testified that he had instability of the knees, which has caused him to fall down on three occasions. He stated that his "left knee almost constantly hurts. Specifically there are times when my left knee, that the inside tendons will completely lock up in going from an extended to a non-extended position, causes me severe, severe pain. There are times when I will spend the whole day limping on my left leg, I mean, without cause. Just I wake up and my knee is. . . not throbbing, but an acute sharp pain. Like I said, my knee always hurts, but sometimes it especially hurts and it especially gives me problem." With regard to his right knee, he testified that it hurts, but "nowhere near as bad as the left knee". (See Board hearing transcript page 13.) A March 2011 VA examination report is also of record. It reflects that the Veteran had reported in November 2001 that he had problems with both knees with knee trouble consisting of patellar tendinitis, recurrent pain and running jumping sports at age 13. (The Veteran's October 2001 report of medical examination for separation purposes reflects that he reported knee braces when he was 13 years old for Osgood-Schlatter's disease.) The 2011 VA examination report also reflects that the Veteran reported that since the last examination his knees have been about the same. He reported that his problems with knee pain cover a wide range and that he has both pain when standing and at rest. The Veteran further reported that the left knee has pain when sitting flexed for long periods of time and that both tend to swell. He reported very infrequent giving way and when it does give way it is usually the left knee that gives way after it has had painful flare-ups. The Veteran indicated that stairs increase the pain in both knees. The Veteran reported that he wore support on his knees in the 7th grade but has not worn any support since then. He denied any aspirations or injections to his knees. It was noted that the "veteran has not seen an orthopedic surgeon in the last 5 years for either knee and has not taken any medications for either knee. The veteran indicates he is a full time student and on an average day he can walk a half to one mile." The 2011 examiner noted that the Veteran was able to stand and walk across the room without any problem, and with no limping noted and no cane used. The Veteran was also noted to be able to get up and down off the examining table without difficulty. The Veteran was asked to squat but he stated that he would rather not do so because it would hurt his knees. Upon examination in 2011, the Veteran was noted to have some mild crepitus over the left knee, and some "minimal if any" crepitus over the right knee. He had minimal tenderness about and underneath the patella on the right knee and moderate tenderness underneath the patella of the left knee. The examiner noted that the Veteran "has no swelling at all, there is no effusion, there is no instability of either knee, and there is no varus or valgus deformity of either knee. There are no bony projections around either knee." The Board also notes that the examiner noted that the Veteran had significant knee problems prior to service and a right knee injury after separation from service. (e.g. S. Albany Chiropractic Clinic record reflects a motor vehicle accident in June 2006 during which the Veteran's right knee struck the dashboard.) The examiner opined, in pertinent part, as follows: [t]he conditions and visits that were treated while in the military to the right knee would have been expected to have caused only temporary symptoms and not permanent problems. The condition of the knees today therefore is felt by this examiner to be the result more likely than not of activities outside of the military service. Military service injuries and conditions treated in the military treatment records would have been expected to produce only temporary conditions and not to conditions seen today in both knees." In this regard, the Board notes that the Veteran was granted service connection for his knees based, in part, on the February 2007 VA examination report; however the February 2007 examiner did not have access to the claim file to review the Veteran's prior records, and the examination report does not reflect that she was aware that the Veteran had reportedly had knee problems, and worn knee braces prior to service due to Osgood-Schlatter's disease. Nevertheless, the Veteran is service-connected for right and left knee retropatellar pain syndrome, and the Board, at this time, will rate him without regard to the 2011 VA examiner's opinion which appears to indicate that the Veteran should not be service-connected. With regard to range of motion, the Veteran had full extension of both knees and full extension on the 4th movement in both knees without any pain. Flexion measurements of the left knee revealed flexion of 116 degrees, 115 degrees, 110 degrees and 115 degrees, all without pain. Right knee flexion was 120 degrees, 125 degrees, 122 degrees and 120 degrees without pain. The Veteran had 5/5 power of extension both knees against resistance without pain, 5/5 power of flexion of both knees without pain. In rating the Veteran's right and left knee disabilities, the Board has considered the Veteran's subjective complaints and the objective findings on examinations. As noted above, the Veteran's disabilities are currently rated as noncompensable. Under DC 5261, the Veteran would be entitled to a 10 percent rating if he had leg extension limited to 10 degrees. The evidence is against such a finding. The Veteran had bilateral full extension in both 2007 and 2011. Moreover, such extension was without pain, and there was no limitation due to factors such as fatigability, weakness, or incoordination as the Veteran was able to complete four moves with full extension. Thus, a compensable evaluation is not warranted. The evidence shows that the Veteran does not experience functional loss to a degree that would warrant a compensable rating. Under DC 5260, the Veteran would be entitled to a 10 percent rating if he had flexion limited to 45 degrees. The evidence is against such a finding. The Veteran had full flexion with no pain in both knees in 2007. In 2011, he had flexion of the left knee to at least 110 degrees without pain. He had flexion of the right knee to at least 120 degrees without pain. thus, a compensable rating is not warranted under DC 5260. The Board has also considered whether there is any other applicable diagnostic code which would provide a compensable rating for the right and/or left knee, but finds, as discussed below, that there is not. DC 5256 is not for application because the evidence of record fails to establish ankylosis. DC 5257 is not for application because the evidence is against finding of recurrent subluxation or lateral instability. The Board notes that the Veteran has reported instability; however, his report of the sensation of his knee giving way or instability is subjective in nature. Joint instability can be objectively diagnosed upon clinical examination. The clinical evidence of record is against a finding of instability. The 2007 examination report reflects that the medial and lateral collateral ligaments were intact bilaterally. The 2011 examination report also reflects that there was no instability of either knee. The Board finds that these objective findings are more probative than the Veteran's subjective complaints made for rating purposes. As both examiners found the knee to be stable, the Board finds a compensable rating for instability is not warranted. DC 5258 is not for application because the evidence is against a finding of dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. While the Veteran has stated that he has had locking, the objective clinical evidence does not reflect dislocated semilunar cartilage and effusion into the joint. DC 5259 is not for application because the Veteran has not had removal of his semilunar cartilage. DC 5262 is not for application because the evidence is against a finding of malunion of the tibia and fibula with knee or ankle disability, or nonunion with loose motion requiring a brace. DC 5263 is not for application because there is no showing of genu recurvatum. The Board has also considered DC 5003 (degenerative arthritis) which provides that arthritis based on x-ray findings will be based on limitation of motion, or if noncompensable, a 10 percent rating. However, the evidence of record is against a finding that the Veteran arthritis. The March 2011 radiographs revealed "totally normal knee films". Thus a rating under DC 5003 is not warranted. The Board has also considered 38 C.F.R. § 4.59 and again notes that the Veteran did not have painful joint motion or instability on examination. The Board has considered the Veteran's statements regarding his pain and his desire not to squat due to pain; however, the Board also notes that the Veteran has reported that he does not take medication for his alleged pain, has not sought treatment for his alleged pain (even after the 2010 hearing wherein he was told that he was entitled to free treatment at a VA facility), does not use assistive devices, and is able to walk 1 mile. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2013), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extraschedular Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). See also Thun v. Peake, 22 Vet App 111 (2008). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. The established rating criteria reasonably describe the Veteran's disability level and symptomatology. The ratings consider symptoms such as limitation of motion, instability, and that pain can cause limitation of motion. The simple fact that the Veteran's disability does not provide the Veteran with a compensable rating does not place his symptomatology outside of that contemplated by the rating schedule or make application of the rating schedule impracticable in this case. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is moot. See Thun, supra. ORDER Entitlement to service connection for a right ankle disability is denied. Entitlement to service connection for a left ankle disability is denied. Entitlement to an initial compensable rating for right knee retropatellar pain syndrome is denied. Entitlement to an initial compensable rating for left knee retropatellar pain syndrome is denied. ______________________________________________ M. C. GRAHAM Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs