Citation Nr: 1336165 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 04-18 651 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a right ankle disability. 2. Entitlement to service connection for a low back disability, as secondary to service-connected hallux valgus of the right foot with degenerative changes and/or service-connected residuals of a left knee sprain. 3. Entitlement to an increased initial rating for the residuals of a left knee sprain, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD D. M. Donahue, Associate Counsel INTRODUCTION The Veteran had active service from June 1963 to October 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal of November 2002 and August 2005 rating actions by the Department of Veterans Affairs (VA) Regional Office (RO) located in Waco, Texas. In the November 2002 rating action, the RO, in pertinent part, denied the Veteran's claims for service connection for a left knee disability and a low back disability, as secondary to the service-connected right foot disability, on the basis that the Veteran had failed to submit new and material evidence to reopen such claims. The RO also denied the Veteran's claim for service connection for a right ankle disability. Subsequently, the Veteran submitted a timely appeal with respect to the aforementioned claims. In the February 2005 rating action, the RO granted service connection for the residuals of a left knee sprain and assigned a 10 percent disability rating. In May 2005, the Veteran requested that his service-connected left knee disability be reevaluated for a higher rating. By an August 2005 rating action, the RO denied the Veteran's claim for an increased rating for his service-connected left knee disability. The Veteran subsequently filed a timely appeal. In a December 2008 decision, the Board denied service connection for a right ankle disability. The Board also concluded that new and material evidence had not been presented to reopen the claims for service connection for a left ankle disability and rheumatoid arthritis. However, the Board determined that new and material evidence had been presented to reopen the claim for service connection for a low back disability, as secondary to the service-connected right foot disability. Thus, the aforementioned claim was reopened and remanded for additional development. The Board also remanded the claim for an increased rating for the left knee disability. The Veteran appealed the December 2008 decision to the United States Court of Appeals for Veterans Claims (Court). While this case was pending before the Court, the Office of General Counsel for VA, on behalf of VA, and the Veteran, by and through his attorney-representative, filed a Joint Motion for Partial Remand (Joint Motion), dated in June 2009. In an Order, dated in June 2009, the Court granted the Joint Motion, and that part of the Board's December 2008 decision that denied service connection for a right ankle disability and determined that new and material evidence had not been received to reopen the claims for service connection for a left ankle disability and rheumatoid arthritis, was vacated. The Court also stated that because the Board had reopened and remanded the claim for service connection for a low back disability, as secondary to the service-connected right foot disability, and remanded the claim for an increased rating for the service-connected left knee disability, those issues were outside of the Court's jurisdiction. The case was remanded to the Board for compliance with the directives stipulated in the Joint Motion. In January 2010, August 2011, and April 2012, the Board remanded this case for additional development. In April 2012, the Board ordered additional VA examinations to determine the nature and etiology of the Veteran's claimed back and right ankle disorders. The Board also ordered an additional VA examination to determine the current severity of the Veteran's left knee disorder. The examinations took place in May 2012, with an additional right ankle examination in February 2013. An additional supplemental statement of the case is dated in April 2013. The Board is satisfied there was substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claims. The Board has reviewed the documents in both the paper claims file and the electronic claims file in rendering this decision. In a February 2013 statement, the Veteran raised the issues of entitlement to service connection for lower extremity neuropathy and a total disability rating due to individual employability, which have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over the issues, and they are REFERRED to the AOJ for appropriate action. FINDINGS OF FACT 1. The evidence is in equipoise finding that the Veteran's currently diagnosed right ankle disability is etiologically related to active service. 2. The preponderance of the evidence is against finding that the Veteran's currently diagnosed low back disability is etiologically related to a disease, injury, or event in service. 3. Residuals of a left knee sprain are manifested by subjective complaints of pain causing a reduction in physical activity; objective evidence of degenerative joint disease on x-ray; objective evidence of limitation of flexion to no worse than 70 degrees, including limitation due to pain; no limitation of extension; and no objective evidence of instability or lateral subluxation. CONCLUSIONS OF LAW 1. A right ankle disability was incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 2. A low back disability was not incurred in or aggravated by service, nor may a low back disability be presumed to have occurred therein. 38 U.S.C.A. §§ 1101, 1110, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 3. The criteria for the assignment of a disability rating in excess of 10 percent for residuals of a left knee sprain have not been met or approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his or her possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VCAA letters dated in May 2002, July 2007, and January 2010 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claims. The letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. A July 2007 letter explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Service treatment records and post-service VA and private treatment records have been associated with the claims file. All identified and available treatment records have been secured. The Board finds that VA has fulfilled its duty to assist in obtaining such records. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c)(4) (2012). Here, the Veteran was most recently examined in May 2012 and February 2013. The Board finds that these examinations were thorough and provided sufficient findings so as to allow the Board to evaluate the claims under the relevant rating criteria and to determine eligibility for service connection. Additionally, the Veteran has not stated nor is there evidence indicating that there has been a material change in the severity of his left knee disorder since he was last examined. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95 (April 7, 1995). The Board concludes that this examination report is adequate for purposes of rendering a decision in the instant appeal. See 38 CF.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and his representative have not contended otherwise. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Legal Criteria - General Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). If certain diseases, such as arthritis, become manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of such disease during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. An alternative method of establishing the second and third elements of service connection for those disabilities identified as a "chronic condition" under 38 C.F.R. § 3.309(a) is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A claimant can establish continuity of symptomatology with competent evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between a current disability and the post-service symptomatology. 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Secondary service connection will be awarded when a disability is proximately due to or the result of a service- connected disease or injury. 38 C.F.R. § 3.310 (a). Additional disability resulting from aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (a). Libertine v. Brown, 9 Vet. App. 521, 522 (1996); see also Reiber v. Brown, 7 Vet. App. 513 (1995); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Factual background Service treatment records, including examination and associated medical history reports dated in June 1963, April 1966, and May 1970, are negative for complaints or diagnoses of back or right ankle disorders. In a July 1981 VA examination, the Veteran reported he is on his feet a lot in his present work, and prolonged walking or standing or doing any squatting hurts across the forefoot with occasional aching all the way up the leg, but centered around the first metatarsal in the metatarsalphalangeal (MP) joint. Upon examination, he walked well without limping. There was no visible swelling in the ankles. Ankles had full range in motion with good strength. In a February 1986 substantive appeal (for another issue), the Veteran complained of ankle pain when crossing his legs. A February 1987 VA examination also noted full range of motion in both ankle joints. In a February 1987 VA progress note, the Veteran complained of mid-back pain that radiates around to the right side, worse with movement. The diagnosis was lumbar strain. During a May 1987 VA examination, the Veteran complained of chronic low back pain. X-ray testing showed all disk spaces well maintained and no significant evidence of arthritic changes other than some possible degenerative changes in the articular facets in the lowest lumbar segments. The right ankle showed no significant abnormalities on physical examination and x-ray testing. In a June 1987 VA rheumatology note, the Veteran complained of 10 years of low back and ankle pain with swelling. During August and December 1987 follow-ups, the Veteran continued to complaint of back pain. During a September 1987 private employment physical, the examiner noted that the Veteran has been told he has rheumatoid arthritis with involvement of both feet, shoulders, and more particularly in 1987 the low back. His back is stiff in the morning, and there is limited motion in addition to considerable pain. Upon x-ray evaluation, no significant degenerative changes were noted in the lumbar spine, though there was some slight narrowing with L5-S1. A December 1987 VA rheumatology note indicated that the Veteran' back pain was more likely due to lumbar sacral strain or to altered gait. In a January 1988 statement, the Veteran claimed that the doctor told him that his back condition was connected to his foot problems. During a March 1988 VA examination, the Veteran reported he began having back trouble without any definite history of injury in 1986. He claimed that his foot problems have caused him to have walked and used his back in a manner which would cause him to have back trouble. After a physical examination, the Veteran was advised that no pathology was demonstrated in the low back. A March 1988 VA x-ray report showed minimal osteophyte formation, otherwise, no radiographic evidence of abnormality. VA x-ray reports dated in August 1996 and August 2002, as well as a November 2003 and July 2009 VA MRI reports, showed degenerative disc disease in the lumbar spine. During a January 2005 VA examination, the Veteran asserted that in 1965 he started having swelling in his ankles. He would elevate his legs for the swelling to go down. He still has swelling in his ankles, though no one has told him what causes the swelling. The Veteran also reported he developed pain in his low back after discharge from service. His back pain has been progressively worsening and he now has daily pain that radiates down his right leg. After a physical examination, the diagnoses were degenerative arthritis of the lumbar spine, degenerative disc disease of the lumbar spine, and chronic sprain of the right and left ankles. The examiner stated that the Veteran's ankle examination was essentially normal. There is no intrinsic disease of the ankles that would be related to his left knee impairment. The examiner also opined that there are no unusual gait disturbances that would account for his lumbar spine pain. His lumbar spine pain is of a degenerative nature and a product of the degenerative aging process; therefore, it is less likely than not that his lumbar spine is secondary to his right big toe injury and degenerative changes. During a February 2010 VA examination, the Veteran reported he injured his right ankle in 1964 while playing softball and re-injured it approximately a year later playing football. He complained of cramping and swelling with dependence of the extremity. An x-ray report showed minimal degenerative change at the tip of the medial, lateral, and posterior malleoli as well as moderate calcaneal spur. Minimal calcification was showed in in the Achilles tendon attachment to the calcaneus. After a physical examination, the examiner noted that as there are no complaints in service of a right ankle injury and with a current normal ankle exam, there could be no service connection. In a September 2011 addendum, a VA examiner found that it is unlikely that his current normal ankle examination is anatomically or physiologically related to any spine or foot disorder. The examiner noted that mild degenerative changes found on x-ray studies should be considered normal for a male who is 66 years old. During a May 2012 VA examination, the examiner noted a diagnosis of multilevel degenerative disc disease of the lumbar spine with associated chronic lumbar pain. The Veteran stated that he began having lumbar pain after a fall in 1966 in which he was seen for his left knee injury. He stated that he began having lumbar pain at that time, and he has had lumbar spine pain on a daily basis since 1966. It has gradually increased since discharge from service in 1970. Despite the pain, the Veteran was able to work as a mail clerk for over 28 years, since discharge from service, until his retirement from the postal service in 2007. After a physical examination, the examiner opined that it is less likely as not that the current lumbar condition was caused or the result of active military service. The examiner stated that there is no evidence of a chronic or recurrent lumbar condition in service and the separation examination noted no problems with his back. The Veteran was able to work over 20 years on his feet with the post office without serious back problems. The examiner also opined it is less likely as not that the current lumbar condition was caused or aggravated by his service-connected right foot disorder. The examiner noted that there is no medical authority which supports the contention that chronic hallux valgus with reparative surgery is causative to the development of multilevel degenerative disc disease of the lumbar spine. The degenerative disease is the result of many years of wear on the disc mechanism, and is found in the majority of patients the Veteran's age. Further, it is less likely as not that his current lumbar condition was caused or aggravated by the Veteran's service-connected left knee. There is no medical authority to support the contention and the Veteran's gait is nonantalgic. The May 2012 VA examiner also evaluated the Veteran's right ankle. The diagnosis was right ankle mild generative joint disease. The Veteran complained of bilateral ankle pain with current calf muscular cramping for the last 4 years. After a physical examination, the examiner opined that the Veteran's right ankle condition is less likely as not caused by or the result of active military service. There are no complaints of a right ankle condition during service and the ankle pain began many years after discharge from military service. The Veteran worked at a standing job for 27 years. The currently level of degenerative disease is no worse than would be expected based on age alone. The Veteran's right ankle condition was also not caused or aggravated by the Veteran's right foot disorder. There is no medical authority which support the contention that hallux valgus with secondary degenerative joint disease and reparative surgery can be causative to the development of degenerative joint disease of the ankle. Furthermore, the Veteran's gait is nonantalgic. An August 2012 private MRI of the lumbar spine found lower lumbar spine degenerative disc and facet disease resulting in central canal and neural foraminal stenosis. In a February 2013 VA examination, the Veteran reported he injured his right ankle the first time in 1964 while stationed in Korea. He reported a second injury to the right ankle around 1965 while playing football. The Veteran asserted that he has had daily pain in his right ankle with weight bearing continuously since his 1970 discharge from service. The diagnosis was chronic right ankle sprain with secondary mild degenerative joint disease of the right ankle. The examiner determined that it is at least as likely as not that the Veteran's current ankle condition was caused by and the result of active military service. Based on the Veteran's history, both regarding the injury noted above, and the chronic daily symptoms noted since his discharge in 1970, it is at least as likely as not that the current right ankle condition was caused by and the result of active military service. Analysis Initially, the Board finds that there is an approximate balance of positive and negative evidence regarding whether the Veteran's right ankle disorder was incurred in or a result of active service. Though the May 2012 VA examiner suggested that he Veteran's right ankle disorder could have been due to his post-service employment or aging, the same VA examiner determined in February 2013 that it is at least as likely as not that the current right ankle condition was caused by and the result of active military service. Under the 'benefit-of-the-doubt' rule, where there exists 'an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,' the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). The mandate to accord the benefit of the doubt is triggered when the evidence has reached such a stage of balance. In this matter, the Board is of the opinion that this point has been attained. Because, at the very least, a state of relative equipoise has been reached in this case, the benefit of the doubt rule will be applied. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Brown v. Brown, 5 Vet. App. 413, 421 (1993). In light of the foregoing, entitlement to service connection for a right ankle disorder is granted. For the Veteran's low back disorder claim, the Board finds that the Veteran has a current low back disability. Specifically, the Board recognizes there was evidence of degenerative disc disease of the lumbar spine in an August 2012 MRI report. However, there is no competent evidence that the Veteran's currently diagnosed degenerative disc disease was manifested to a degree of 10 percent or more within one year of his discharge from active service. From the Veteran's May 1970 separation from service until 1987, more than 15 years, there is no medical evidence of complaints or any diagnosis of a low back disorder. Thus, presumptive service connection for degenerative disc disease is not warranted. The Board has considered the case of Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), wherein the Court held that the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. However, this is not a case in which the record is merely silent regarding whether he experienced a continuity of back problems following separation from active service. Rather, the Veteran specifically denied a history of back problems and physical examination of the spine at separation was negative. In addition, during service, the Veteran sought treatment for additional issues, including treatments for upper respiratory infections and his right foot disorder. Post-service, the Veteran underwent two VA examinations in July 1981 and February 1987 for his service-connected right foot disorder. The Board finds it reasonable to conclude that had the Veteran been experiencing ongoing back problems that he would have reported these problems at the same time as other complaints. In essence, the Board does not find the Veteran's contentions regarding a continuity of symptoms since service for his claimed disability are credible. The Board also considered whether service connection for a low back disorder was warranted on direct or secondary bases. However, the only medical etiology evidence of record are the January 2005 and May 2012 VA examination reports, indicating that it is less likely than not that the Veteran's current low back disability is caused or aggravated by service or service-connected disabilities as the Veteran's left knee disorder does not produce an antalgic gait. The reports were based on an interview of the Veteran, his reported medical history, appropriate diagnostic testing, physical examination, and complete review of the claims file, including service treatment records. Further, a complete and thorough rationale is provided for the opinions rendered. The Veteran has offered no medical opinion which contradicts the VA examiners' findings. The Board also has considered the statements of record from the Veteran attempting to etiologically link his current low back disorder to his military service. The Board acknowledges that he can attest to factual matters of which he has first-hand knowledge, such as experiencing a back injury and ongoing back problems, and his assertions in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Laypersons, however, are not generally competent to render an opinion as to the cause or etiology of any current disability because they do not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). In this case, the Board concludes that any expressed opinions as to etiology are significantly outweighed by the opinion of the May 2012 medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). In summary, considering the medical evidence of record, and the Veteran's testimony, and all evidence of record, the Board finds that the preponderance of the evidence of record is against a grant of service connection for a low back disability. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); See Gilbert, 1 Vet. App. 49. Claim for Increased Rating Legal Criteria - General Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The Court has held that 'staged' ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. A December 1975 RO decision granted service connection for a left knee disorder under Diagnostic Code 5257, which contemplates 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 of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Other relevant diagnostic codes for evaluating knee disabilities include Diagnostic Codes 5260 and 5261 govern the rating criteria with regard to limitation of motion of the knee. Under Diagnostic Code 5260, limitation of flexion of the knee warrants a zero percent rating when flexion is limited to 60 degrees; a 10 percent rating when limited to 45 degrees; a 20 percent rating when limited to 30 degrees; and a 30 percent rating when limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limitation of extension of the leg warrants a zero percent rating when extension is limited to 5 degrees; a 10 percent rating when extension is limited to 10 degrees; a 20 percent rating when limited to 15 degrees; 30 percent when limited to 20 degrees; 40 percent when limited to 30 degrees; and 50 percent when limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The regulations define normal range of motion for the leg as zero degrees of extension and 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate I. The Board also points out that, in a precedent opinion, the VA General Counsel held that separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261 for disability of the same joint. VAOPGCPREC 9-2004 (September 17, 2004). Diagnostic Code 5258, Cartilage, Semilunar, Dislocated, provides a 20 percent rating for frequent episodes of locking, pain, and effusion. 38 C.F.R. § 4.71a. Diagnostic Code 5259, Cartilage, Semilunar, Removal, symptomatic, provides for a 10 percent rating. 38 C.F.R. § 4.71a. The Board has reviewed all the evidence in the Veteran's claims file. 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 Veteran 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 claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Factual background The RO granted service connection for a left knee disorder based on an in-service knee injury and a January 2005 VA examination which provided a positive nexus between the Veteran's in-service injury and his current knee complaints. Service treatment records indicate the Veteran injured his left knee while playing football. He had tender swelling laterally. X-ray testing was negative. An August 1987 VA examination report found no abnormalities of the knee joints. An April 1999 VA x-ray report noted ossification/calcification anterior superior aspect of the patella. The knees were otherwise unremarkable. An August 2002 VA x-ray report showed mild degenerative changes in the bilateral knees. Private treatment records dated from November 2003 to January 2004 indicate on-going treatment for left knee pain to include injections. During a January 2005 VA examination, the Veteran reported he injured his knee playing football around 1966. He has had pain since that time including arising from the sitting position. He had recently received three injections of hyaluronic acid in his knees with some relief. He reported he uses braces in both knees. Upon physical examination, the Veteran had flexion to 95 degrees and extension to zero degrees without pain. He had no crepitation, and cruciate and collateral ligaments appeared to be intact. There was some mild joint line tenderness, but there did not appear to be any effusion. The diagnosis was chronic sprain of the left knee. During a July 2005 VA examination, the Veteran complained of daily knee pain. There is no increased limitation with flare-ups or repetitive motion. He uses a cane, both for his knee and his back. There was no evidence or history of instability. There is no incoordination or excess fatigability. He uses a brace, which he did not have at the examination. He is able to drive and take care of his activities of daily living. Upon physical examination, the Veteran's left knee showed no effusion and had some mild joint line tenderness. He could actively flex the knee to 70 degrees and passively flex to 100 degrees. He had zero degrees of extension. There was no pain on testing. The cruciate and collateral ligaments appeared to be intact. The diagnosis was sprain of the left knee. A November 2005 private x-ray report showed enthesopathic degenerative changes are present at the quadriceps insertion site on the superior patella. During an April 2007 VA examination, the Veteran reported he has daily mechanical left knee pain. He reported that his ability to stand or walk is limited to five minutes or less. He is still able to drive and perform his activities of daily living around his apartment. He complained of some left knee instability symptoms consistent with patellar pseudo-locking, but no true symptoms of ligamentous or meniscal instability. Upon physical examination, the examiner found no effusion or ligamentous instability. There is positive patellar compression test without crepitus. Range of motion testing was to 110 degrees of flexion and zero degrees of extension. There was no apparent weakness, fatigability, or loss of coordination during or following three repetitions of range of motion. The Veteran complained of retropatellar pain on the extremes of knee flexion. During a May 2012 VA examination, the Veteran reported chronic knee pain since he sprained his left knee in service. He complained of chronic anterior left knee pain, increased with squatting, kneeling, standing over 30 minutes, and walking over half a block. The Veteran denied flare-ups. Range of motion was noted as flexion to 120 degrees and extension to zero degrees. Upon repetitive testing, flexion was noted to 140 degrees, and extension was to zero degrees. The examiner noted the Veteran did not have additional limitation of range of motion of the knee following repetitive-use testing. There was no functional loss, weakened movement, excess fatigability, incoordination, swelling, deformity, atrophy of disuse, instability, or interference with sitting, standing and weight bearing. There was some pain on movement. Instability testing was normal, and there was no history or evidence of recurrent patellar subluxation/dislocation. Degenerative or traumatic arthritis was now shown on imagine study. The Veteran's left knee disability causes the Veteran to have to sit intermittently and not engage in prolonged standing, walking, squatting, or kneeling. The examiner determined he is able to engage in sedentary employment. Analysis Having reviewed the record in this regard, the Board concludes that the Veteran's left knee disability is not manifested by any symptoms other than those for which he is already compensated by his 10 percent evaluation. Although the Veteran's left knee disorder is currently rated under Diagnostic Code 5257 for instability, at no point has the Veteran's left knee shown objective evidence of instability. The Board finds the Veteran's left knee is more appropriately evaluated under Diagnostic Code 5003 for degenerative arthritis. As noted above, an August 2002 VA x-ray report showed mild degenerative changes of the left knee. However, the Veteran still does not warrant a higher rating than his currently assigned 10 percent disability rating for his left knee. Degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic 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 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). The Board notes that the evidence has not demonstrated flexion limited to 60 degrees or extension limited to 5 degrees to warrant a compensable rating under Diagnostic Codes 5260 or 5261, respectively, for the left knee. Furthermore, there is no evidence of arthritis with limitation of motion warranting separate disability rating. 38 C.F.R. §§ 4.71a, Diagnostic Codes 5003, 5260, 5261. As stated previously, the Veteran's left knee disorder has exhibited no evidence of moderate or severe recurrent subluxation or lateral instability of the left knee warranting an increased evaluation under Diagnostic Code 5257 for instability. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2012). There is no indication that the Veteran's left knee disability warrants an increased or separate rating under any diagnostic code not discussed above. The claims folder contains no medical evidence indicating that the Veteran's left knee disability is manifested by ankylosis, impairment of the tibia and fibula, dislocated or removed semilunar cartilage, or symptoms other than those discussed above. As such, an increased rating cannot be assigned for the knee under Diagnostic Codes 5256, 5258, 5259, 5262, or 5263. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, 5263. Further, there is no evidence to support a higher compensable disability rating for the left knee based on consideration of limitation of motion or with functional loss, as the Veteran has not exhibited a sufficient degree of limited flexion or extension, even when accounting for the factors of functional loss. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). As noted by the April 2007 and May 2012 VA examiners, there is no evidence that he experiences a degree of additional functional loss due to pain, weakness, fatigability, incoordination or pain on movement of a joint to warrant a higher rating. Therefore, an increased rating under DeLuca is not warranted. Based upon the guidance of the Court in Hart, 21 Vet. App. 505 (2007), the Board has considered whether staged ratings are appropriate; however, in the present case, no staged ratings are warranted by the Veteran's symptomatology. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as 'governing norms.' Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected left knee is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. There is no evidence in the medical records of an exceptional or unusual clinical picture, and his left knee disability alone has not caused the Veteran to miss work frequently, nor have they required frequent hospitalizations. The Board, therefore, has determined that referral of this claim for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to service connection for a right ankle disability is granted. Entitlement to service connection for a low back disability, as secondary to service-connected hallux valgus of the right foot with degenerative changes and/or service-connected residuals of a left knee sprain, is denied. Entitlement to an increased initial rating for the residuals of a left knee sprain, currently rated as 10 percent disabling is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs