Citation Nr: 1338768 Decision Date: 11/25/13 Archive Date: 12/06/13 DOCKET NO. 08-00 925 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for a left knee disability from June 25, 2008, to the present. 2. Entitlement to a disability rating in excess of 10 percent for a right knee disability from June 25, 2008, to the present. 3. Entitlement to a disability rating in excess of 10 percent for a left ankle disability from June 25, 2008, to the present. 4. Entitlement to a disability rating in excess of 10 percent for a right ankle disability from June 25, 2008 to the present. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Adams, Counsel INTRODUCTION The Veteran had active service from November 1972 to January 1994. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In July 2007, the Veteran testified before a Decision Review Officer (DRO) during a formal hearing held at the RO. A transcript of that hearing has been associated with the claims file. In January 2012, the Board denied the claims for a disability rating in excess of 10 percent each for left knee, right knee, left ankle and right ankle disabilities from January 24, 2006, to June 24, 2008; granted service connection for a low back disorder; and Remanded the claims for increased ratings in excess of 10 percent each for left knee, right knee, left ankle and right ankle disabilities from June 25, 2008, to the present for further development and for due process reasons. In October and November 2012, the Veteran submitted additional evidence in support of his claims, accompanied by a waiver of initial Agency of Original Jurisdiction (AOJ) review. 38 C.F.R. § 20.1304. In the September 2013 Informal Hearing Presentation (IHP), the Veteran raised a claim for service connection for GERD and heart problems secondary to medication prescribed for treatment of service-connected disabilities. While the record reflects that the Veteran has been granted service connection for his low back disorder, the September 2013 IHP also raised the issue of clear error in the March 2008 Supplemental Statement of the Case which continued to deny service connection for the low back disorder. While these issues have been raised by the record, they have not been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board does not have jurisdiction over them and they are referred to the AOJ for appropriate action. The Board has reviewed the Veteran's claims file and the record maintained in the Virtual VA paperless claims processing system. FINDINGS OF FACT 1. For the period from June 25, 2008, to the present, the competent medical evidence or record does not show that the Veteran's left knee flexion was limited to 45 degrees or his left knee extension was limited to 10 degrees. 2. For the period from June 25, 2008, to the present, the competent medical evidence or record does not show that the Veteran's right knee flexion was limited to 45 degrees or his right knee extension was limited to 10 degrees. 3. For the period from June 25, 2008, to the present, the competent medical evidence or record does not show that the Veteran's left ankle disability was manifested by marked limitation of motion. 4. For the period from June 25, 2008, to the present, the competent medical evidence or record does not show that the Veteran's right ankle disability was manifested by marked limitation of motion. 5. On July 22, 2011, the Veteran underwent a left knee arthroscopy with partial medial meniscectomy; his left knee is shown to have been manifested by symptoms analogous to symptomatic removal of the semilunar cartilage. CONCLUSIONS OF LAW 1. For the period from June 25, 2008, to the present, the criteria for a disability rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1-4.3, 4.7, 4.14, 4.40, 4.41, 4.45, 4.71a, Diagnostic Codes (DCs) 5010, 5260, 5261 (2013). 2. For the period from June 25, 2008, to the present, the criteria for a disability rating in excess of 10 percent for a right knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1-4.3, 4.7, 4.14, 4.40, 4.41, 4.45, 4.71a, DCs 5010, 5260, 5261 (2013). 3. For the period from June 25, 2008, to the present, the criteria for a disability rating in excess of 10 percent for a left ankle disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1-4.3, 4.7, 4.40, 4.41, 4.45, 4.71a, DC 5271 (2013). 4. For the period from June 25, 2008, to the present, the criteria for a disability rating in excess of 10 percent for a right ankle disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1-4.3, 4.7, 4.40, 4.41, 4.45, 4.71a, DC 5271 (2013). 5. As of July 22, 2011, the criteria for a separate 10 percent disability rating, and no more, for residuals of a left knee medial meniscectomy have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.71a DC 5259 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental SOC (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The U.S. Supreme Court has held that an error in VCAA notice should not be presumed prejudicial, and that the burden of showing harmful error rests with the party raising the issue, to be determined on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In this case, the Veteran has not alleged any prejudicial or harmful error in VCAA notice. In this case, prior to and after the initial adjudication of the claims, the RO provided notice to the Veteran in letters dated February 2006 and March 2008 that explained what information and evidence was needed to substantiate the claims for an increased rating, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The Veteran does not appear to have been specifically informed of how VA determines effective dates. However, as the instant decision denies increased ratings, no effective date will be assigned. Any absence of Dingess notice is moot. No further development is required regarding the duty to notify. VA also has a duty to assist the Veteran in the development of a claim. This includes assisting the Veteran in procuring service treatment records (STRs) and other relevant treatment records and providing a VA examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, VA obtained the Veteran's STRs as well as pertinent VA and private outpatient treatment records. In addition, as noted in the Introduction, in October and November 2012 the Veteran submitted additional private treatment records with a waiver of RO adjudication. The file also contains statements and contentions made by the Veteran and his representative. No outstanding evidence has been identified that has not otherwise been obtained. VA Disability Benefits Questionnaire (DBQ) examinations were conducted during the course of the appeal period in March 2012. The VA examination reports were quite comprehensive and adequately addressed the Veteran's bilateral knee and ankle complaints. The Board notes that the Veteran's VA examinations from March 2012 are over one-year old. The mere passage of time since those examinations is not reason enough, alone, to require reexamination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Here, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's bilateral knee and ankle disabilities since this most recent examinations. The Veteran has not argued the contrary. Thus, the Board finds that remand for an additional VA examination is not required in this instance. Accordingly, the Board concludes that during the administrative appeal process, the Veteran was provided the information necessary such that the purposes of the notification have been met. Moreover, there has been substantial compliance with the November 2011 Board Remand instructions as the January 2012 VA DBQ examination was developed, additional VA treatment records were obtained, and private treatment records were submitted; therefore, no further remand is required. See also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall where Board's remand instructions were substantially complied with). Neither the Veteran nor his representative throughout the course of this appeal has made the RO or the Board aware of any other evidence relevant to his appeal that needs to be obtained. Based on the foregoing, 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 adjudicated herein. Therefore, in view of the foregoing, the Board will proceed with appellate review. II. Increased Ratings-Generally Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (2002). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the Veteran. See 38 C.F.R. § 4.3 (2013). VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, the evidence of record does not establish additional, distinct time periods in which the issue on appeal resulted in symptoms that would warrant staged ratings. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2013). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). In evaluating musculoskeletal disabilities, consideration must be given to additional functional limitation due to factors such as pain, weakness, fatigability, and incoordination. See 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The Court has held that diagnostic codes predicated on limitation of motion do not prohibit consideration of a higher rating based on functional loss due to pain on use or due to flare-ups under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See Johnson v. Brown, 9 Vet. App. 7 (1996); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). However, in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court clarified that there is a difference between pain that may exist in joint motion as opposed to pain that actually places additional limitation of the particular range of motion. Words such as "mild," "moderate," "moderately severe," and "severe" 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. Use of terminology such as "severe" by VA examiners and others, although evidence 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. The Secretary shall give the benefit of the doubt to the Veteran when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence for the rating period 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. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. 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 instant claims. A. Left Knee and Right Knee Disabilities The Veteran claims that his left and right knee disabilities are more severe than what is reflected by the currently assigned, separate 10 percent disability ratings. Both disabilities are rated under Diagnostic Code 5010-5260. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5260 pertains to limitation of flexion of the leg. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5010 pertains to arthritis due to trauma. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Under Diagnostic Code 5260, limitation of flexion of the knee to 30 degrees warrants a 20 percent rating and limitation of flexion to 15 degrees warrant a 30 percent evaluation. Diagnostic Code 5260. Diagnostic Code 5261 provides that limitation of extension of the knee to 10 degrees warrants a 10 percent rating, limitation to 15 degrees warrants a 20 percent rating and limitation to 20 degrees warrants a 30 percent rating. The Board notes that separate ratings under Diagnostic Code 5260 and Diagnostic Code 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. Standard motion of a knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. The Board notes that Diagnostic Code 5010 instructs that traumatic arthritis is to be evaluated as degenerative arthritis under Diagnostic Code 5003. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When, however, the limitation of motion of the specific joint or joints involved is no compensable under the diagnostic codes, an evaluation of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Diagnostic Code 5003. For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). Separate ratings may be assigned for a knee disability under Diagnostic Codes 5257 (knee, other impairment) or 5258-5259 (cartilage impairments), and 5010 (for arthritis due to trauma), where there is X-ray evidence of arthritis in addition to recurrent subluxation, lateral instability, or symptoms of locking, pain, and effusion related to the removal or dislocation of semilunar knee cartilage, but only if there is additional disability due to limitation of motion. See VAOPGCPREC 23-97 and VAOPGCREC 9-98. Turning to the merits of the claims, private treatment records dated in May 2011 show that the Veteran complained of a painful left knee since late March with sudden pain and instability. He denied swelling, but had symptoms of giving out. He complained of medial pain. On examination, the [left] knee was very tender along the medial compartment without effusion. Range of motion revealed flexion to 110 degrees. There was no evidence of instability, but any stress across the medial compartment aggravated his discomfort. The ligaments were stable to anterior, posterior, medial, and lateral stress testing. Non-weightbearing X-rays in April 2011 showed some medial joint space narrowing. Weightbearing X-rays showed medial degenerative joint disease. The impression was medial arthritis and internal derangement of the knee. He received an injection to the left knee. A June 2011 report shows that the left knee injection provided good pain relief. However, the Veteran had recurring pain on the medial side that was aggravated by weightbearing and felt like the left knee was going to give out. On examination, he walked with a bit of a limp. His left knee had medial joint line tenderness, but there was no evidence of clicking or popping. The ligaments felt stable to anterior, posterior, medial, and lateral stress testing without effusion. The impression was internal derangement of the left knee in a patient developing degenerative joint disease (DJD). The physician thought there was degenerative meniscus tear and recommended arthroscopy. In July 2011, the Veteran presented with limping and mechanical pain. Surgery was scheduled for later that month. In late July 2011, the Veteran underwent left knee arthroscopy with partial medial meniscectomy; there was evidence of chondromalacia of the medial femoral condyle and the patella. He had good flexion to 120 degrees and full extension. There was an osteophyte in the medial gutter from the medial femoral condyle, but there were no loose bodies. The medial meniscus tear was identified and the cartilage wear was seen on the medial femoral condyle. The anterior cruciate ligament was seen to be intact and the lateral compartment was normal. The meniscus tear was resectioned. The post-operative diagnoses included a torn medial meniscus, chondromalacia of the patella, and chondromalacia of the medial femoral condyle. VA treatment records include an August 2011 report which shows that the Veteran was wearing a left knee brace that he initially received in 2007. Private treatment records dated in September 2011 shows that range of motion of the left knee revealed flexion to 125 degrees. There was no effusion. The impression was that the Veteran was doing well postoperatively with some residual discomfort with twisting. In December 2011, the Veteran complained of persistent medial pain in the left knee. Surgery was successful, but there was persistent aching discomfort. He had no complaints of swelling or giving out and took Tylenol. On examination, he had full knee range of motion from 0 to 120 degrees with pain along the medial compartment with palpation and throughout range of motion. The impression was medial arthritis. He received a left knee injection at that time. He received a third left knee injection in February 2012. A March 2012 report reflects diagnoses of left knee torn medial meniscus and chondromalacia in the medial compartment near the patellofemoral joint. It was noted that he completed SUPARTZ injections in February 2012 and had very good relief for several weeks. His symptoms returned, but were not as severe or as frequent. He reported that some days he experienced a bit more pain and discomfort as well as limping. On examination, he had good gait pattern with just a little bit of a limp. Left knee range of motion was from 0 to 120 degrees with some medial pain in deep flexion. The impression was that he was developing a degenerative knee. Continued conservative management with Tylenol was recommended and a Medrol Dose Pak was prescribed for residual inflammation. Pursuant to the Board's January 2012 Remand, the Veteran underwent a VA DBQ knee and lower leg conditions examination in March 2012 at which time the Veteran complained of bilateral knee pain, with the left knee worse than the right. The left knee occasionally gave out at times, but did not lock up and the Veteran denied any flare-ups. Right knee flexion ended at 115 degrees with painful motion at 100 degrees. Extension was normal with no objective evidence of painful motion. Left knee flexion ended at 105 degrees with pain at 100 degrees. Extension was normal. On repetitive use testing, there was no additional limitation in range of motion of either knee. However, there was functional loss and/or functional impairment manifested by less movement; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight-bearing. There was also tenderness or pain to palpation for the joint line or soft tissues of the knees. Muscle strength and joint stability tests for both knees were normal. It was noted that he underwent a meniscus condition or surgical procedure on the left knee which revealed a meniscal tear and that he had frequent episodes of joint pain. There was a scar on the left knee, but it was not painful and/or unstable, and the total area of all related scars was less than 39 square centimeters (6 square inches). He always wore a brace on the left knee with occasional use on the right knee. There was documented arthritis in both knees, but there was no X-ray evidence of patellar subluxation. A September 2009 X-ay examination of the right knee indicated minimal tricompartmental osteophytosis. No other significant osseous, joint, or soft tissue abnormalities were identified. An October 2009 X-ray examination of the left knee showed tricompartmental knee joint osteoarthritis. It was noted that his bilateral knee and/or lower leg condition affected his ability to work in that he could not be on his feet all day because of pain. The examiner further opined that there was no way to determine if the Veteran had any additional loss of range of motion of the knees if he used them repeatedly over a period of time without resort to speculation. However, he had no flare-ups and there was only slight instability of the left knee. The examiner diagnosed DJD of both knees and status post left medial meniscectomy. Private treatment records show that in April 2012, the Veteran was diagnosed with a left knee torn medial meniscus and chondromalacia in the medial compartment and the patellofemoral joint; he was developing a degenerative knee. He was reportedly doing well and not having bad pain. He tried to exercise more, but there was a constant dull achy soreness that did not go away. On examination, left knee range of motion was from 0 to 120 degrees. There was no effusion. The impression was that he was doing pretty well, but still had chronic soreness. He was given an injection. In June 2012, the Veteran presented with complaints of left knee pain, but reported some improvement with ice and Tylenol. He was given a second left knee injection at that time. In August 2012, the Veteran presented with a bit of a limp and left knee range of motion was from 0 to 125 degrees. There was a little bit of effusion. The impression was DJD in the left knee. He was given a third injection and agreed to another series of injections. In September 2012, he received two more injections with minimal relief. Based on the evidence of record, and for the reasons set forth below, the Board finds that while a separate 10 percent rating is assignable for the left knee from July 22, 2011, separate ratings or ratings in excess of 10 percent assigned for a left knee disability or a right knee disability, for the period from June 24, 2008, to the present, are not warranted under any applicable diagnostic code. As noted above, a 10 percent disability rating is warranted under Diagnostic Codes 5260 and 5261 for limitation of flexion of the knee to 45 degrees and limitation of extension of the knee to 10 degrees. The medical evidence in this case shows that the Veteran's left and right knee range of motion was from 0 to at least 100 degrees, with pain. Thus, the medical evidence of record does not show that compensable disability ratings are warranted for either knee based on a limitation of the range of motion under either Diagnostic Codes 5260 or 5261. The Board also finds that the Veteran is not entitled to an increased rating for his bilateral knee disability under Diagnostic Code 5003. Limitation of motion is conceded. However, even presuming there is limited albeit noncompensable motion, as the Veteran is already in receipt of 10 percent disability ratings under a diagnostic code predicated upon limitation of motion (DC 5260), he is not entitled to a separate 10 percent rating under Diagnostic Code 5003. 38 C.F.R. § 4.71a, DC 5003, Note 1. In addition, the Board further finds that there is no additional limitation of motion due to pain, fatigue, or similar symptoms as contemplated by DeLuca. VA and private treatment records reflect the Veteran's complaints of bilateral knee pain. However, the Board finds that the Veteran's complaints of pain and functional impairment are consistent with, and encompassed by, the assigned 10 percent disability ratings for the period from June 25, 2008, to the present. As such, the preponderance of the evidence is against ratings in excess of 10 percent, for the period from June 25, 2008, to the present. The Board has also considered whether higher disability ratings may be assigned under other relevant diagnostic codes. However, as there is no evidence of ankylosis of the left or the right knee, Diagnostic Code 5256 is inapplicable in this case. 38 C.F.R. § 4.71a, DC 5256. Indeed, the Veteran has displayed an ability to flex and extend both knees as noted above. Higher ratings under Diagnostic Code 5257 for knee impairment with recurrent subluxation or lateral instability are also not warranted based on the evidence of record. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. While the Veteran has reported that his left knee would give way, the March 2012 VA examination was negative for objective evidence of lateral instability or subluxation in either knee. As there is no indication of recurrent subluxation or lateral instability, separate ratings under Diagnostic Code 5257 are not warranted. In considering the applicability of other diagnostic codes, the Board notes that Diagnostic Code 5258 provides the rating criteria for dislocation of semilunar cartilage and Diagnostic Code 5259 provides the rating criteria for symptomatic removal of semilunar cartilage. See 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. With regard to Diagnostic Code 5258, there is no evidence of dislocated semilunar cartilage with frequent locking pain and effusion in the left knee or right knee to warrant a separate rating under Diagnostic Code 5258. With regard to Diagnostic Code 5259, there is no history of meniscus tear or surgery to the right knee to warrant a separate rating under this diagnostic code. However, with regard to the left knee, the record clearly indicates that the Veteran's left knee disability status post left medial meniscectomy is indicative of symptomatic removal of semilunar cartilage. The Board finds that the Veteran's symptoms of pain and giving way are attributable, at least in part, to his left knee surgery. The Board therefore finds that a separate rating of 10 percent is warranted for residuals of a left knee medial meniscectomy, under Diagnostic Code 5259, as of the date of the left knee surgery, i.e., July 22, 2011. See VAOPGCPREC 9-98 (August 14, 1998). The Board has also considered the applicability of Diagnostic Code 5262 (impairment of the tibia and fibula) and Diagnostic Code 5263 (genu recurvatum), but finds that they are not applicable here, as the medical evidence does not show that the Veteran has any of these disabilities. 38 C.F.R. § 4.71a, DCs 5262, 5263. Finally, the Board has considered whether a separate rating can be assigned for the left knee scar which resulted from the July 2011 surgery. However, a separate compensable rating for the Veteran's scar is not warranted as neither the March 2012 VA examination or treatment records have shown that they are deep or cause limited motion and cover areas at least six square inches (39 sq. cm.); are superficial and do not cause limited motion and cover areas of 144 square inches (929 sq. cm.) or greater; are superficial and unstable; or cause other disabling affects. Therefore, the criteria for a compensable rating for a left knee surgical scar have not been met. 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 (as in effect prior to October 23, 2008). See 73 Fed. Reg. 54,710 (Sept. 23, 2008). Therefore, with the exception of the award of a separate 10 percent rating under Diagnostic Code 5259 for residuals of the Veteran's left knee surgery, the Board finds that the preponderance of the evidence is against the claims for increased ratings for the service-connected bilateral knee disabilities, and the claims must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. B. Left Ankle and Right Ankle Disabilities With respect to these claims, the Veteran contends that his left ankle and right ankle disabilities warrant ratings higher than the currently assigned, separate 10 percent ratings. The Veteran's left and right ankle disabilities are currently rated under Diagnostic Code 5010-5271. Diagnostic Code 5010 pertains to traumatic arthritis and Diagnostic Code 5271 provides the rating criteria for limited motion of the ankle. Under Diagnostic Code 5271, a 20 percent rating for marked limitation of ankle motion. A 20 percent disability rating is the highest possible schedular rating under Diagnostic Code 5271. Higher disability ratings of 30 and 40 percent are possible under Diagnostic Code 5270 with evidence of ankylosis. Normal motion of the ankle is described as dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. See 38 C.F.R. § 4.71, Plate II. Ratings higher than 20 percent may be assigned under Diagnostic Code 5270 upon a showing of ankylosis. Ankylosis has been defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992). Under Diagnostic Code 5270, a 20 percent rating is assigned for ankylosis of the ankle in plantar flexion less than 30 degrees. A 30 percent rating is warranted for ankylosis of the ankle in plantar flexion between 30 and 40 degrees, or in dorsiflexion between 0 and 10 degrees. A 40 percent rating is warranted for ankylosis of the ankle in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion or eversion deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5270. A 40 percent rating is the maximum rating permitted under the amputation rule. See 38 C.F.R. § 4.68. Turning the merits of the claims, VA and private treatment records dated from April 2008 to September 2012 do not indicate complaints or treatment of any left or right ankle disability. On VA DBQ ankle conditions examination in March 2012, the Veteran presented with complaints of bilateral ankle pain and swelling. However, he denied any flare-ups that impacted the function of the ankle. Right ankle plantar flexion was normal at 45 degrees or greater, and dorsiflexion was normal at 20 degrees or greater. Left ankle plantar flexion was normal with 15 degrees dorsiflexion. There was no objective evidence of pain with any movement. The Veteran was able to complete repetitive use testing with no additional limitation in range of motion of either ankle following repetitive use. He had functional loss and/or impairment of the ankles manifested by swelling, and disturbance of locomotion and there was localized tenderness or pain on palpation of the joints/soft tissue. Muscle strength testing was normal and ankle plantar and dorsiflexion was normal. Anterior drawer test did not reveal any laxity and there was no evidence of ankylosis of the ankle, subtalar and/or tarsal joints. The Veteran had not undergone surgery on either ankle. X-ray examinations of the ankle indicated soft tissue swelling. On March 2012 X-ray examination, the impression was soft tissue swelling without fracture or dislocation seen at that time. There was a small calcaneal spur. The diagnosis was bilateral ankle strain with no evidence of DJD ankles on multiple recent X-rays. However, the examiner diagnosed bilateral ankle strain and mild DJD of the ankles. Based on the evidence of record, the Board finds that separate ratings in excess of 10 percent for a left ankle and a right ankle disability, for the period from June 25, 2008, to the present, are not warranted under any applicable diagnostic code. Since June 25, 2008, the competent medical evidence of record does not show that the Veteran has marked limitation of the left or right ankle. The March 2012 examination revealed a normal range of motion of the right ankle and normal plantar flexion of the left ankle with 15 degrees plantar dorsiflexion. Essentially, the available medical evidence does not show that the Veteran had significant loss of plantar flexion or dorsiflexion of either ankle. Since the Veteran's bilateral ankle disabilities were not characterized by marked loss of range of motion of the ankle for this time period, an increased 20 percent rating is not warranted under Diagnostic Code 5271 for either ankle. In the present case, the evidence of record reveals complaints of ankle pain. Indeed, while ankle pain is recognized, the objective evidence simply fails to demonstrate that such pain resulted in additional functional limitation comparable to the next-higher 20 percent rating under Diagnostic Code 5271 for either ankle. Thus, the Board finds that there was no limitation of motion shown that more nearly approximated or rose to the level of marked as envisioned by the rating schedule. In addition, the Board further finds that there is no additional limitation of motion due to pain, fatigue, or similar symptoms as contemplated by DeLuca. VA and private treatment records reflect the Veteran's complaints of bilateral ankle pain and swelling. However, the Board finds that the Veteran's complaints of pain and functional impairment are consistent with, and encompassed by, the separately assigned 10 percent disability ratings for the period from June 25, 2008, to the present. As such, the preponderance of the evidence is against ratings in excess of 10 percent, for the period from June 25, 2008, to the present. The Board has considered whether a higher rating may be warranted under another diagnostic code. As the evidence does not reflect ankylosis of either ankle, a higher rating is not warranted under Diagnostic Code 5270, pertaining to ankylosis of the ankle. Therefore, the Board finds that the preponderance of the evidence is against the claims for increased ratings for the service-connected bilateral ankle disabilities, and the claims must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. All Claims In reaching the above conclusions, the Board has also not overlooked the Veteran's statements in support of his claims. In this regard, the Veteran is competent to report on factual matters of which he has first-hand knowledge, e.g. bilateral knee and ankle pain. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, while the Board may consider the Veteran's subjective statements regarding the severity of the disabilities, the Board notes that with respect to the Rating Schedule, the criteria set forth therein generally require medical expertise which the Veteran has not been shown to have. See King v. Shinseki, 700 F.3d 1339, 1344 (Fed. Cir. 2012). Furthermore, the Board finds the objective medical findings provided in the VA treatment records should be accorded the greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches . . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators."). The above determination is based upon consideration of applicable rating provisions. It should also be noted that there is no showing that the Veteran's disabilities have reflected so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-schedular basis. See 38 C.F.R. § 3.321(b) (1). In this case, there has been no showing that the Veteran's disability picture for his left knees and ankles could not be contemplated adequately by the applicable schedular rating criteria discussed above. The criteria provide for higher ratings, but as has been explained thoroughly herein, the currently assigned ratings adequately describe the severity of the Veteran's symptoms for these disabilities during the period of appeal. Given that the applicable schedular rating criteria are adequate, the Board need not consider whether the Veteran's bilateral knee and ankle disability picture includes such exceptional factors as periods of hospitalization and interference with employment. Referral for consideration of the assignment of a disability rating on an extraschedular basis is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). In addition, the Board notes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for a higher rating is whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board notes, however, that in this case while it appears that the Veteran is currently unemployed (see the March 2008 VA examination) the record does not indicate and the Veteran has not asserted that he is unemployable due to his service-connected bilateral knee and ankle disabilities. In light of the foregoing, the Board finds that while the evidence supports the assignment of a separate 10 percent rating for residuals of a left medial meniscectomy as of July 22, 2011, separate ratings in excess of 10 percent for the left knee and right knee, and separate ratings in excess of 10 percent for the left ankle and right ankle are not warranted as manifestations of these disabilities were not shown to meet the criteria for a higher rating under any applicable Diagnostic Code. As such, the claims for higher ratings must be denied. Since the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application with regard to these claims. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has considered additional staged ratings, under Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), but concludes that they are not warranted. ORDER A rating in excess of 10 percent for a left knee disability from June 25, 2008, to the present, is denied. A rating in excess of 10 percent for a right knee disability from June 25, 2008, to the present, is denied. A rating in excess of 10 percent for a left ankle disability from June 25, 2008, to the present, is denied. A rating in excess of 10 percent for a right ankle disability from June 25, 2008 to the present, is denied. As of July 22, 2011, a separate 10 percent rating, and no more, is granted for residuals of a left knee medial meniscectomy, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs