Citation Nr: 1339613 Decision Date: 12/02/13 Archive Date: 12/18/13 DOCKET NO. 05-08 910 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to a rating in excess of 10 percent for degenerative joint disease, left knee, for the period from September 24, 2003 to September 28, 2005. 2. Entitlement to a rating in excess of 10 percent for left knee grade IV chondromalacia of the patella, medial femoral condyle, and lateral femoral condyle, with grade II changes of the trochlea, with recurrent subluxation, for the period prior to January 4, 2005. 3. Entitlement to a rating in excess of 10 percent for left knee grade IV chondromalacia of the patella, medial femoral condyle, and lateral femoral condyle, with grade II changes of the trochlea, with recurrent subluxation, for the period from March 1, 2005 to September 28, 2005. 4. Entitlement to a rating in excess of 30 percent for left total knee arthroplasty associated with degenerative joint disease, left knee, for the period from November 1, 2006 to March 1, 2007. 5. Entitlement to a rating in excess of 30 percent for left total knee arthroplasty associated with degenerative joint disease, left knee, for the period on and after June 1, 2007. 6. Entitlement to a rating in excess of 10 percent for residuals fracture, right medial malleolus with arthritis. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD M. Hudson, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1957 to December 1958. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Veteran was scheduled for a Travel Board hearing at the Atlanta RO in October 2011. The Veteran did not appear at the scheduled hearing and a videoconference hearing was scheduled for March 2013. However, in a March 2013 signed statement, the Veteran withdrew his request for a hearing. The Veteran has not requested another hearing and therefore, his hearing request is deemed withdrawn. See 38 C.F.R. § 20.704(e) (2012). In April 2012, March 2013 and August 2013, the Board remanded the case to the RO for additional evidentiary development. The Board finds there was substantial compliance with its remand orders and that it may therefore proceed with a determination of the issues on appeal. See Stegall v. West, 11 Vet. App. 268 (1998). This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. From September 24, 2003 to September 28, 2005, the Veteran's service-connected degenerative joint disease, left knee, was manifested by painful flexion to 120 degrees, painful extension to zero degrees, range of motion limited by pain, fatigue, weakness, lack of endurance and incoordination and painful motion of a major joint group. 2. Prior to January 4, 2005 and from March 1, 2005 to September 28, 2005, the Veteran's left knee grade IV chondromalacia of the patella, medial femoral condyle, and lateral femoral condyle, with grade II changes of the trochlea, with recurrent subluxation, was manifested by no worse than slight recurrent subluxation. 3. From November 1, 2006 to March 1, 2007 and since June 1, 2007, the Veteran's left total knee arthroplasty associated with degenerative joint disease has been manifest by no worse than intermediate degrees of residual weakness, pain or limitation of motion. 4. Throughout the appellate period, the Veteran's residuals of a right ankle fracture, right medial malleolus with arthritis, have been shown to be productive of no more than marked limited motion; there has been no objective evidence of ankylosis or nonunion of the tibia and fibula with marked ankle disability. CONCLUSIONS OF LAW 1. From September 24, 2003 to September 28, 2005, the criteria for a rating in excess of 10 percent for service-connected degenerative joint disease, left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5260-5010 (2013). 2. Prior to January 4, 2005 and from March 1, 2005 to September 28, 2005, the criteria for a rating in excess of 10 percent for service-connected left knee grade IV chondromalacia of the patella, medial femoral condyle, and lateral femoral condyle, with grade II changes of the trochlea, with recurrent subluxation, have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5257. 3. From November 1, 2006 to March 1, 2007 and since June 1, 2007, the criteria for a rating in excess of 30 percent for service-connected left total knee arthroplasty associated with degenerative joint disease, left knee, have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.71a, DCs 5055, 5256, 5261, 5262. 4. The criteria for the assignment of an evaluation of 20 percent, but no higher, for the service-connected residuals of a right ankle fracture, right medial malleolus with arthritis have been met. 38 U.S.C.A. §§ 1155, 5107, 7104; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.71, DCs 5003, 5010, 5262, 5270-74. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist 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). See also Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). Notice was provided to the Veteran in October 2003, April 2004 letters and March 2006. As for the duty to assist, all of the Veteran's pertinent VA treatment records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c); see Board Decisions, March 2013 and August 2013. The Veteran has not claimed to be in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c)(2). The Veteran has not identified, and the record does not otherwise indicate, any additional relevant medical records that have not been obtained and associated with her file. In April 2012, the case was remanded to obtain a current VA examination of the Veteran's left knee and right ankle. No VA examination was conducted; therefore, a March 2013 Board remand was necessary to again request a current VA examination. A VA examination of the Veteran's left knee and right ankle was performed in May 2013. Taken together, the Veteran's October 2003 VA left knee examination and May 2013 left knee and right ankle VA examination are sufficient as the VA examiners considered the entire record, noted the history of the disabilities, addressed relevant evidence and provided medical information necessary to reach a decision. 38 C.F.R. § 3.159(c)(4); see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300-01 (2008). VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Increased Rating The Veteran was previously granted service connection for left knee degenerative joint disease from September 24, 2005 to September 28, 2005 and assigned a 10 percent disability rating, granted service connection for left knee grade IV chondromalacia of the patella, medial femoral condyle, and lateral femoral condyle, with grade II changes of the trochlea, with recurrent subluxation and assigned a 10 percent disability rating prior to January 4, 2005 and from March 1, 2005 to September 28, 2005, granted service connection for left total knee arthroplasty associated with degenerative joint disease and assigned a 30 percent disability rating from November 1, 2006 to March 1, 2007 and since June 1, 2007, and granted service connection for right medial malleolus with arthritis at a 10 percent disability rating, effective from October 18, 1971. In September 2003, the RO received correspondence from the Veteran asserting that he is entitled to a higher evaluation for such disabilities. The Veteran underwent surgeries to repair his left knee in January 2005, September 2005 and March 2007. As a result of these surgeries, the Veteran was awarded temporary total ratings from January 4, 2005 to February 28, 2005, September 29, 2005 to October 31, 2006, and from March 2, 2007 to May 31, 2007. See 38 C.F.R. § 4.30; see also 38 C.F.R. § 4.71a, DC 5055. Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122, 128 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to a veteran). In determining the degree of limitation of motion, several regulatory provisions are taken into consideration: the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the Veteran's ordinary activity. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. The effects of pain on use, functional loss, and incoordination were taken into account in assessing the range of motion of the Veteran's service-connected left knee and right ankle disabilities. 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). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In determining whether a claimed benefit is warranted, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Knee Degenerative Joint Disease, From September 24, 2003 to September 28, 2005 The Veteran is rated under DC 5260-5010 at 10 percent for the left knee from September 24, 2003 to September 28, 2005. See 38 C.F.R. § 4.71a, DC 5260-5010. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. The first hyphenated code may be read to indicate that limitation of flexion is the service-connected disorder and it is rated as if the residual condition is degenerative arthritis under DC 5010. The Board will consider all appropriate diagnostic codes. Diagnostic Code 5010 provides that traumatic arthritis, due to trauma and substantiated by X-ray findings, is to be evaluated as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. Degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, 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 the limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is assigned when there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is assigned when there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45. For rating purposes, normal range of motion in a knee joint is from 0 degrees to 140 degrees. 38 C.F.R. § 4.71, Plate II. DC 5260 provides for a noncompensable evaluation where flexion of the leg is limited to 60 degrees. For a 10 percent evaluation, flexion must be limited to 45 degrees. A 20 percent evaluation is warranted where flexion is limited to 30 degrees. A 30 percent evaluation may be assigned where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. DC 5261 provides for a noncompensable evaluation where extension of the leg is limited to five degrees. A 10 percent evaluation requires extension limited to 10 degrees. A 20 percent evaluation is warranted where extension is limited to 15 degrees. A 30 percent evaluation may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent evaluation, extension must be limited to 30 degrees. And finally, where extension is limited to 45 degrees, a 50 percent evaluation may be assigned. 38 C.F.R. § 4.71a, DC 5261. An Augusta VA Medical Center (VAMC) treatment note from October 2003 found the Veteran had chronic pain in his left knee and that walking made his pain worse. The Veteran stated he could no longer cut his grass and it takes him a long time to do housework. Upon physical examination, the doctor found some moderate coarse crepitance on range of motion but that the Veteran's range of motion was preserved. There was no warth, effusion, erythema or popliteal fullness. An X-ray showed arthritic changes in the Veteran's left knee and the assessment was left knee degenerative joint disease. The Veteran filed a claim for increased rating in September 2003. During the Veteran's VA examination in October 2003, he was diagnosed with degenerative joint disease of the left knee. The examiner found the Veteran's gait abnormal and that he used a cane and a walker; however, there was no sign of abnormal weight bearing. The Veteran's left knee had flexion to 120 degrees and extension to zero degrees, however, both were painful. The VA examiner noted that the Veteran's range of motion was additionally limited by pain, fatigue, weakness, lack of endurance and incoordination. Drawer and McMurray's signs were normal and there was no evidence of locking pain, effusion, crepitus or recurrent subluxation of either knee. X-rays of the left knee showed degenerative changes with associated spurring and a possible loose body in the joint. Mental health treatment notes throughout 2004 report the Veteran had difficulty ambulating and chronic pain due to his arthritis. During a March 2004 nursing follow-up, the Veteran complained of left knee pain of a 7 out of 10. A March 2004 primary care note found the Veteran's left knee mildly tender with no warmth, no effusion, no erythema, no popliteal fullness and with preserved range of motion. Due to the Veteran's arthritic pain, the examiner prescribed him Percocet. During a May 2004 visit to the Augusta VAMC, the Veteran was found to be in a wheelchair with a left knee brace, although he claimed to ambulate at times. He complained of chronic pain in his left knee. A June 2004 orthopedic surgery consult found the Veteran's left knee with 1+ effusion, pain on grind, positive medial joint line thrombotic thrombocytopenic purpura (TTP), stable to varus and valgus stress, with negative Lachman's, negative anterior and posterior drawer, pain on McMurray medially and range of motion between 5 degrees and 95 degrees. An X-ray showed the Veteran's left knee joint spaces appeared well-maintained with mild medial joint space narrowing, osteophyte to lateral femoral condyle and lateralization of patella on sunrise. Between July 2004 and August 2004, the Veteran received three Hyalgan injections in his left knee but they did not provide any relief. A July 2004 MRI of the Veteran's left knee showed probable cartilaginous defect of the lateral patellar fat with subchondral cystic change and degenerative changes with tricompartmental joint space narrowing. During an October 2004 orthopedic surgery consult, the Veteran complained of constant pain and difficulty with stairs and walking any significant distance. The Veteran was wearing a medial off-loader brace on his left knee, which was helping some. Upon examination, the doctor found mild TTP medial joint line, TTP anterior tibial plateau, no effusion, stable to varus and valgus stress, anterior drawer mildly positive, 1+ but good end point. The Veteran's range of motion was between 5 degrees and 90 degrees. A December 2004 treatment record indicates the Veteran's left knee had mild effusion, range of motion was from zero degrees to 110 degrees, with normal strength, crepitus and grinding with range of motion. The left knee had a stable varus and valgus stress, with pain and tenderness along the medial joint line. An X-ray showed slight narrowing of the medial compartment with lateral subluxation/tilt patella. On January 4, 2005, the Veteran underwent a left knee arthroscopy with lateral release. The post-operative diagnosis was Grade IV chondromalacia patella, medial femoral condyle, and lateral femoral condyle, with grade III changes of the trochlea. At the Veteran's January 12, 2005 follow-up appointment, his left knee showed a 1+ effusion with range of motion between 10 degrees and 90 degrees. A February 2005 orthopedic surgery note found that the Veteran's left knee scope did not relieve his pain and the Veteran now feels that his left knee is unstable and that it gives way. A March 2005 mental health treatment note documents the Veteran's chronic pain due to arthritis and use of a walker. A September 2005 pre-operative orthopedic surgery consult found the Veteran's left knee with mild effusion, tenderness along the medial and lateral joint lines, pain, crepitance and tenderness of the patella femur (PF) joint with range of motion, positive patella compression test, negative Lachman and drawers, stable to valgus and varus stress and with range of motion between zero degrees and 95 degrees. An X-ray showed severe osteoarthritic changes of the PF joint with lateral tilt and lateral facet collapse with narrowing of the medial compartment with evidence of degenerative joint disease. On September 29, 2005, the Veteran underwent a total left knee arthroplasty. The findings were severe tricompartmental degenerative joint disease with Grade IV changes. From September 24, 2003 to September 28, 2005, the Veteran's left knee disability was manifest by limitation of extension no worse than 10 degrees and limitations of flexion no worse than 90 degrees. See Augusta VAMC Treatment Records, January 4, 2005 and October 2004. Additionally, from September 24, 2003 to September 28, 2005, X-rays showed degenerative joint disease in the Veteran's left knee. See e.g., VA Examination, October 2003. Thus, the Board finds that a rating in excess of 10 percent for limitation of motion, degenerative joint disease of the left knee from September 24, 2003 to September 28, 2005, is not warranted. See DC 5260-5010. There is no evidence of actual of function limitation of flexion to 60 degrees such that a separate rating for limitation of flexion would be warranted and of extension limited to 15 degrees or worse. See DCs 5260, 5261. The Veteran avers that pain and reduced motion involving his left knee warrants more than a 10 percent rating. The Veteran is competent to state what he experiences through his senses, to include the occurrence and frequency of pain. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). While his complaints of pain are credible and otherwise substantiated by the record, his contention that an increased rating is warranted is not corroborated by the evidence on file. Rather, a preponderance of the evidence is against the assignment of a schedular evaluation in excess of 10 percent under DC 5260-5010 or any analogous Diagnostic Code. The Board has considered whether a higher disability evaluation is warranted under DC 5260-5010 during this period on the basis of functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca, 8 Vet. App. at 205-07. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. While the October 2003 VA examiner found the Veteran's knee function was additionally limited by pain, fatigue, weakness, lack of endurance and incoordination, the additional limitation did not limit the joint function by more than 120 degrees of flexion and zero degrees of extension, with pain. While the Veteran has used a wheelchair, walker and knee brace, none of the examinations or treatment records show the Veteran had muscle atrophy or other indications of disuse. In evaluating the Veteran's claim under DeLuca, the Board notes that the Veteran's limits in range of motion, including as due to pain, are contemplated by the 10 percent rating assigned herein from September 24, 2003 to September 28, 2005. The preponderance of the evidence does not support the grant of a disability rating higher than 10 percent based upon functional loss due to pain, weakness and fatigue during this timeframe. The Board has considered whether there is any other schedular basis for granting a higher rating, but has found none. There is no evidence of left knee ankylosis, dislocated semilunar cartilage with frequent episodes of "locking" with pain and effusion into the joint, removal of semilunar cartilage, symptomatic, impairment of the tibia and fibula, or genu recurvatum. See DCs 5256, 5258, 5259, 5262, 5263. Thus, from September 24, 2003 to September 28, 2005, a rating in excess of 10 percent for the Veteran's left knee degenerative joint disease is not warranted. Left Knee Grade IV Chondromalacia of the Patella, Medial Femoral Condyle, and Lateral Femoral Condyle, with Grade II Changes of the Trochlea, with Recurrent Subluxation, Prior to January 4, 2005 and From March 1, 2005 to September 28, 2005 The Veteran's service-connected left knee chondromalacia of the patella, medial femoral condyle, and lateral femoral condyle, with grade II changes of the trochlea, with recurrent subluxation, is currently assigned a 10 percent rating under DC 5257 for slight subluxation prior to January 4, 2005 and from March 1, 2005 to September 28, 2005. Recurrent subluxation or lateral instability warrants a 10 percent evaluation if it is slight, a 20 percent evaluation if it is moderate, or a 30 percent evaluation if it is severe. See 38 C.F.R. § 4.71a, DC 5257. The words "slight," "moderate" and "severe" as used in various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of 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 Pertinent medical findings during the relevant time periods are summarize above. Prior to January 4, 2005 and from March 1, 2005 to September 28, 2005, based on the X-ray findings of lateral subluxation, the Veteran's complaint of left knee instability, and the Veteran use of a knee brace, cane, walker and wheelchair to assist him with walking, the Board finds that the Veteran's left knee chondromalacia of the patella, medial femoral condyle, and lateral femoral condyle, with grade II changes of the trochlea, with recurrent subluxation most nearly approximates slight recurrent subluxation or lateral instability under DC 5257. The objective medical findings of record generally do not tend to indicate that the Veteran's left knee subluxation was more than mild in degree. Notably, as discussed above, the October 2003 VA examiner found no evidence of abnormal weight bearing and no evidence of locking pain or recurrent subluxation; June 2004 testing found the Veteran's left knee stable to varus and valgus stress, with negative Lachman's and negative anterior/posterior drawer; and October 2004, December 2004 and September 2005 testing showed the left knee was stable to varus and valgus stress tests. Thus, the Board finds that a rating in excess of 10 percent for recurrent subluxation of the left knee is not warranted. See DC 5010-5257. The Board notes that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 , should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Here, DC 5257 (subluxation or lateral instability) is not predicated on limitation motion. Therefore, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are not applicable in this context. The Board has considered whether there is any other schedular basis for granting a higher rating, but has found none. There is no evidence of left knee ankylosis, dislocated semilunar cartilage with frequent episodes of "locking" with pain and effusion into the joint, removal of semilunar cartilage, symptomatic, impairment of the tibia and fibula, or genu recurvatum. See DCs 5256, 5258, 5259, 5262, 5263. In sum, a rating in excess of 10 percent is not warranted prior to January 4, 2005 and from March 1, 2005 to September 28, 2005, for the Veteran's service-connected left knee chondromalacia of the patella, medial femoral condyle, and lateral femoral condyle, with grade II changes of the trochlea, with recurrent subluxation. Left Total Knee Arthroplasty Associated with Degenerative Joint Disease, From November 1, 2006 to March 1, 2007 and Since June 1, 2007 The Veteran's service-connected left total knee arthroplasty associated with degenerative joint disease is currently assigned a 30 percent rating under DC 5055 from November 1, 2006 to March 1, 2007 and since June 1, 2007. DC 5055 is applicable when there is knee replacement (prosthesis). Following a total rating, the minimum rating that may be assigned a prosthetic knee is 30 percent. A 30 percent rating is warranted with intermediate degrees of residual weakness, pain or limitation of motion; rated by analogy to diagnostic codes 5256, 5261, or 5262. A 60 percent rating is warranted with chronic residuals consisting of severe painful motion or weakness in the affected extremity. 38 C.F.R. § 4.71a, DC 5055. DC's 5260 and 5261 govern the limitation of motion of the knee. DC 5260 concerns limitation of leg flexion. A noncompensable evaluation is assigned where flexion is limited to 60 degrees. A 10 percent rating is warranted where flexion is limited to 45 degrees. A 20 percent evaluation is for application where flexion is limited to 30 degrees. A 30 percent evaluation is for application where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. DC 5261 pertains to limitation of leg extension. A noncompensable evaluation is assigned where extension is limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent evaluation is for application where extension is limited to 20 degrees. A 40 percent evaluation is for application where extension is limited to 30 degrees. 38 C.F.R. § 4.71a, DC 5261. The words "intermediate" and "chronic" as used in various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of 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 Veteran underwent a total left knee replacement in September 2005. In a January 2006 rating decision, service connection was granted for left total knee arthroplasty, with an evaluation of 100 percent assigned from September 29, 2005 to October 31, 2006. A subsequent 30 percent disability rating was assigned under 38 C.F.R. § 4.71a, DC 5055, effective November 1, 2006. Additionally, the Veteran underwent a patellar resurfacing and tibial poly exchange of his left knee on March 2, 2007. A December 2007 rating decision granted a temporary total disability rating from March 2, 2007 to May 31, 2007 and assigned a 30 percent evaluation from June 1, 2007 under DC 5055. October 2006 orthopedic surgical notes document the Veteran's left knee range of motion with extension limited to five degrees and flexion limited to 110 degrees with stability throughout all aspects. A February 2007 orthopedic surgical consult noted the Veteran's complaints of anterior knee pain since surgery that has not improved with brace treatment or physical therapy. Upon physical examination, there was no effusion, there was crepitance and pain with palpation and range of motion, joint stability in all aspects, and "excellent" range of motion with extension to zero degrees and flexion to 120 degrees. X-rays showed good alignment with a very minimally tilted patella. On March 2, 2007, the Veteran underwent a left knee patellar resurfacing and tibial poly exchange. Orthopedic surgery attending notes from the date of surgery find that the Veteran "has achieved excelled ROM going from 0 to 125. The knee is stable to manual testing with no ligamentous instability. The alignment is anatomic . . . There is not an obvious reason for [the Veteran's] pain." See Augusta VAMC, Surgery Ortho Attending Note, March 2, 2007. A May 2007 treatment note found the Veteran continued to have pain in his left knee, but that his pain has reduced since his surgery and that his knee occasionally gives way. The examiner found the Veteran's left knee was stable, with normal quad and hamstring strength and range of motion with extension to zero degrees and flexion to 110 degrees. The Veteran was afforded a VA examination of his left knee in May 2013. The Veteran was diagnosed with degenerative joint disease of the left knee. The Veteran complained of pain in his knee joint that keeps him up at night. He wears a knee brace, which helps his knee not hurt as much and he ices his knee three times a week. The Veteran reported no flare-ups. The Veteran's left knee flexion ends at 120 degrees with evidence of painful motion beginning at 120 degrees. The Veteran's left knee extension ends at zero degrees or any degree of hyperextension with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions without any loss of range of motion. The VA examiner found the Veteran had no functional loss or impairment of the knee or lower leg. There was no tenderness or pain to palpation. Joint stability testing showed the Veteran's left knee with normal anterior, posterior and medial-lateral stability. There was no evidence or history of patellar subluxation or dislocation or any tibial or fibular impairment. The VA examiner noted the Veteran's 2005 total knee joint replacement surgery and opined that the Veteran has intermediate degrees of residual weakness, pain or limitation of motion as a result of this surgery. The Veteran was noted to use a wheelchair occasionally and a knee brace and cane regularly. A May 2013 X-ray of the left knee revealed no acute fracture or subluxation and no joint effusion. The impression was status post left total knee arthroplasty with satisfactory alignment and position of hardware. Given the above evidence, the Veteran does not warrant a disability rating in excess of 30 percent for his service-connected left total knee arthroplasty associated with degenerative joint disease from November 1, 2005 to March 1, 2007 or since June 1, 2007. See 38 C.F.R. § 4.71a, DC 5055. Taking into account the Veteran's consistent complaints of pain, his "excellent" range of motion, consistent findings of knee stability and no additional limitation of motion due to pain, fatigue, weakness or lack of endurance as found on his May 2013 VA examination, the evidence does not reflect that the Veteran experienced chronic severe painful motion, or weakness of the left knee to warrant the next higher 60 percent rating under 38 C.F.R. § 4.71a, DC 5055. The Board acknowledges the Veteran's diagnosis of degenerative joint disease and has considered whether evaluating his left knee disability separately for instability and arthritis would yield a higher rating than the current single rating under DC 5055. While the Veteran complained in May 2007 that his knee occasionally gives way, the examiner found his knee was stable. Additionally, in February 2007 the Veteran's knee joint was stable in all aspects, in March 2007 the left knee was stable to manual testing with no ligamentous instability, and the May 2013 VA examiner found the Veteran's left knee with normal anterior, posterior and medial-lateral stability. Further, the May 2013 left knee X-ray showed no subluxation. Thus, DC 5257 is not for application. Further, the Veteran's flexion has been limited to no less than 120 degrees with consideration of the DeLuca criteria, which is noncompensable under DC 5260. The Veteran has exhibited left knee extension limitation no worse than five degrees. Pursuant to DC 5261, the Veteran is entitled to a zero percent disability rating for extension of the left knee limited to five degrees with consideration of the DeLuca criteria, which is less than his current 30 percent disability rating. In addition, there is no evidence of malunion of the tibia and fibula nor left knee ankylosis, thus, DCs 5256 and 5262 are not applicable. Similarly, DC 5258 is not applicable in the present case, as there is no evidence of "locking" pain, and the maximum rating under such code is 20 percent, less than the Veteran's current 30 percent rating. Likewise, DC 5263 is inapplicable, as the evidence fails to show genu recurvatum, and the maximum rating under such code is 10 percent. As the evidence of record demonstrates mild limitation of flexion and extension and degenerative joint disease, the Board finds that from November 1, 2005 to March 1, 2007 and since June 1, 2007, a rating in excess of 30 percent for the Veteran's service-connected left total knee arthroplasty associated with degenerative joint disease is not warranted. Residuals Fracture, Right Medial Malleolus with Arthritis The Veteran was originally granted service-connection with a disability rating of 10 percent for residuals fracture, right medial malleolus with arthritis, effective October 1971. The Veteran's right ankle has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5010. As the ankle condition involves arthritis, the ankle disability may be rated under provisions for evaluating arthritis. Arthritis due to trauma is rated as degenerative arthritis according to Diagnostic Code 5003. 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. When, however, 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. In the absence of limitation of motion, the disability is to be rated as follows: with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, 20 percent; with X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent. 38 C.F.R. § 4.71a, DC 5003. Read together, Diagnostic Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by X-ray study, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no compensable limitation of motion. Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991); Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Impairment of a tibia and fibula with slight knee or ankle disability may be assigned a 10 percent evaluation. Impairment of a tibia and fibula with moderate knee or ankle disability may be assigned a 20 percent evaluation; impairment of a tibia and fibula with marked knee or ankle disability may be assigned a 30 percent evaluation and nonunion with loose motion requiring a brace or malunion may be assigned a 40 percent evaluation. 38 C.F.R. § 4.71a; DC 5262. Ankylosis of the ankle in plantar flexion, less than 30 degrees may be assigned a 20 percent evaluation; between 30 degrees and 40 degrees or in dorsiflexion between zero and 10 degrees may be assigned a 30 percent evaluation; at more than 40 degrees or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity may be assigned a 40 percent evaluation. 38 C.F.R. § 4.71a, DC 5270. Moderate limited motion of the ankle may be assigned a 10 percent evaluation. Marked limited motion of the ankle may be assigned a 20 percent evaluation. Ankylosis of the subastragalar or tarsal joint in good weight-bearing position may be assigned a 10 percent evaluation, while ankylosis of the subastragalar or tarsal joint in poor weight-bearing position may be assigned a 20 percent evaluation. Moderate deformity of the os calcis or astragalus may be assigned a 10 percent evaluation. Marked deformity of the os calcis or astragalus may be assigned a 20 percent evaluation. 38 C.F.R. § 4.71a, DCs 5271-5273. The Board notes that the terms "moderate" and "marked" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. For VA rating purposes, normal ranges of ankle motions are 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. 38 C.F.R. § 4.71, Plate II. Having carefully considered the Veteran's claim in light of the evidence of record, as well as the applicable law and regulation, the Board finds that the Veteran is entitled to an increased 20 percent disability rating for his right ankle disability due to marked limited of motion of the right ankle throughout the appeals period. See 38 C.F.R. § 4.71a, DC 5272. No higher rating is warranted at this time, to include "staged" ratings. 38 C.F.R. § 4.7. At the outset, the Board would note that higher ratings were considered based on limitation of motion for arthritis under DCs 5003 and 5010; however, there has been no showing of ankylosis to warrant a 30 percent rating under DC 5270. The Veteran does not contend, nor does the objective evidence of record show that he is experiencing nonunion of the right tibia and fibula so as to warrant a 30 percent rating under DC 5262. The Veteran is now receiving the maximum allowable for limited motion of the right ankle under DC 5271, ankylosis of the subastragalar or tarsal joint under DC 5272, and malunion of os calcis or astragalus under DC 5273. 38 C.F.R. § 4.71a. The record documents that in October 2003, the Veteran sought medical treatment at the Augusta VAMC due to ankle pain. He reported that approximately one month prior as was going up steps, his right ankle gave way and he heard a "snap." Since that incident, the Veteran has experienced increased pain in his right ankle. There were no signs of inflammation or deformity of his right ankle. X-rays showed small spurs at the insertion of the plantar aponeurosis and the anterior ankle joint with no fractures or foreign bodies. The assessment was a suspected soft tissue strain with possible partial tear of the muscle tendon with preserved function. A May 2004 treatment note documented that the Veteran had limited range of motion in his right foot and ankle. There was no swelling, heat, erythema or other signs of inflammation noted. The Veteran had pain on percussion noted to lateral ankle joint and the dorsum of the first three toes. It was recommended that the Veteran continue to use an ankle brace with a good shoe for better support and stability. May 2004 X-rays of the Veteran's right ankle showed no fractures or dislocations, a small calcaneal spur and no soft tissue abnormality. There was no change when compared with the October 2003 right ankle X-ray. In November 2004, the Veteran presented in a wheelchair and complained of pain in his right ankle. There was pain on right ankle range of motion. The assessment was right ankle arthropathy with instability secondary to trauma and plantar fasciitis. A prosthetic boot and brace were ordered. An April 2005 podiatry surgery note documents the Veteran's follow-up for his painful right ankle condition. The Veteran was very pleased with his right ankle brace and stated there was a greater than 90 percent reduction in pain and greater stability for gait. An MRI of the right ankle showed a tear of a ligament of the tarsal sinus, probable old or chronic injury of the peroneus longus tendon and slight region of marrow edema involving the talar dome. An October 2005 physical examination found the Veteran's right ankle with limited movement and he complained of pain of a 7 out of 10. February 2007 treatment records document the Veteran wearing a right ankle brace, complaining of ankle pain of a 5 out of 10, and a finding of immobility and weakness in the Veteran's right ankle. September 2006, March 2007 and December 2007 treatment records note the Veteran's complaints of ankle pain. Upon VA examination in May 2013, the Veteran was diagnosed with a fractured right medial malleolus. The Veteran reported that his ankle "gives out," that he has pain, swelling and uses a brace to keep his ankle stable. The Veteran has no flare-ups that impact the function of his right ankle. His right ankle plantar flexion was to 35 degrees, with pain beginning at 35 degrees (normal endpoint is 45 degrees). The right ankle dorsiflexion (extension) was to 5 degrees with no evidence of painful motion (normal endpoint is 20 degrees). The Veteran was able to perform repetitive-use testing with three repetitions and did not suffer any additional loss of range of motion. The Veteran also did not have any functional loss or impairment due to his right ankle condition. There was no localized tenderness or pain on palpation of the Veteran's right ankle. Muscle strength for the ankle plantar flexion and dorsiflexion was normal. There was no laxity, no ankylosis and no history of a total ankle joint replacement or any other kind of ankle surgery. In order to assist with locomotion, the Veteran utilizes a wheelchair occasionally and a brace and cane regularly. X-rays of the Veteran's right ankle showed an old laterally displaced fracture of the medial malleolus, with mild degenerative change affecting its articulation with the talus. There was no acute fracture, subluxation or soft tissue swelling shown on the X-ray. Based on the evidence of record, the Board finds that the Veteran's right ankle disability warrants a rating of 20 percent, but no higher. The Veteran's disability picture is consistent with that of marked limited motion of the right ankle. Specifically, throughout the appeal period, the Veteran has consistently complained of chronic right ankle pain, he has found it necessary to utilize a wheelchair, cane and ankle brace for ambulatory assistance, and he has experienced a limited range of motion in his right ankle with 10 degrees of motion loss on plantar flexion and 15 degrees of motion loss on dorsiflexion. In light of the Veteran's complaints of pain experienced in his right ankle, fatigability, pain on movement, and weakness, were considered and are reflected in the current rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206-7. The Board is cognizant that the Veteran continues to experience pain in his right ankle; however, these complaints do not give rise to manifestations consistent with ankylosis. As noted above, in 2013, there was no additional limitation of motion with repetitive motion testing and no flare-ups. The Veteran's complaints of pain are reflected in the current rating for marked limitation of motion at 20 percent. There has been no showing of ankylosis of the right ankle, nor is there evidence of nonunion of the tibia or fibula to warrant higher ratings under Diagnostic Code 5262 or 5270. 38 C.F.R. § 4.71a. In sum, a rating of 20 percent, but no higher, for the Veteran's service-connected residuals fracture, right medial malleolus with arthritis, is warranted. Extraschedular Consideration During the applicable timeframes, the Veteran's left knee degenerative joint disease, left knee grade IV chondromalacia of the patella, medial femoral condyle, and lateral femoral condyle, with grade II changes of the trochlea, with recurrent subluxation, left total knee arthroplasty associated with degenerative joint disease, and residuals fracture, right medial malleolus with arthritis have been manifest by pain, lack of endurance, and some limited range of motion that impairs the Veteran's ability to walk for moderate periods. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to disabilities of the knee and ankle provide disability ratings on the basis of limitation of motion. See 38 C.F.R. § 4.71a, DCs 5256, 2560, 5261, 5270, 5271. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. Given the variety of ways in which the rating schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture, which is manifested by impairment in walking for moderate periods. In short, there is nothing exceptional or unusual about the Veteran's left knee and right ankle disabilities because the rating criteria reasonably describe his disability level and symptomatology. See Thun, 22 Vet. App. at 115. ORDER Entitlement to a rating in excess of 10 percent for degenerative joint disease, left knee, for the period from September 24, 2003 to September 28, 2005, is denied. Entitlement to a rating in excess of 10 percent for left knee grade IV chondromalacia of the patella, medial femoral condyle, and lateral femoral condyle, with grade II changes of the trochlea, with recurrent subluxation, for the period prior to January 4, 2005, is denied. Entitlement to a rating in excess of 10 percent for left knee grade IV chondromalacia of the patella, medial femoral condyle, and lateral femoral condyle, with grade II changes of the trochlea, with recurrent subluxation, for the period from March 1, 2005 to September 28, 2005, is denied. Entitlement to a rating in excess of 30 percent for left total knee arthroplasty associated with degenerative joint disease, left knee, for the period from November 1, 2006 to March 1, 2007, is denied. Entitlement to a rating in excess of 30 percent for left total knee arthroplasty associated with degenerative joint disease, left knee, for the period on and after June 1, 2007, is denied. Entitlement to a rating of 20 percent, but no higher, for residuals fracture, right medial malleolus with arthritis, is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs