Citation Nr: 1758028 Decision Date: 12/14/17 Archive Date: 12/28/17 DOCKET NO. 13-31 206 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an increased rating for a low back disorder in excess of 20 percent prior to January 27, 2014 and in excess of 40 percent thereafter. 2. Entitlement to an increased rating in excess of 10 percent for osteoarthritis of the left knee, based on limitation of motion. 3. Entitlement to service connection for a fractured left fibula. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD Shana Z. Siesser, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from October 1985 to April 1989 and from October 2000 to November 2004. The Veteran's claims initially came before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California and Oakland, California. The case comes to the Board from the Los Angeles, RO. The Veteran filed a claim for an increased rating for his back disorder in January 2011. An April 2011 rating decision continued his 20 percent rating. The Veteran appealed this decision. A rating decision in February 2014 increased the rating to 40 percent, effective January 27, 2014. The Veteran was granted service connection for a left knee status post trauma, anterior cruciate ligament reconstruction in a July 2005 rating decision and was assigned a 20 percent rating under Diagnostic Code 7804-5262. In a September 2007 rating decision, that rating was increased to 30 percent under Diagnostic Code 7804-5257. In a February 2009 rating decision, the Veteran was granted a separate 10 percent rating for osteoarthritis of the left knee under Diagnostic Code 5010. That same rating decision continued the 30 percent rating under 7804-5257. Although the April 2011 rating decision proposed a decrease of the Veteran's 30 percent rating, no decrease was ever implemented. Therefore, that rating is not for consideration by the Board. The issue before the Board concerns only limited motion secondary to arthritis. In April 2014, the Veteran appeared at a hearing before a Decision Review Officer (DRO) at the RO. In March 2016, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). Transcripts of these hearings have been associated with the claims folder. These claims were previously before the Board in July 2016. At that time, the Board denied the Veteran's claims for increased ratings for his low back and left knee disorders and remanded the claim of service connection for a fractured left fibula for additional development. The Veteran appealed the denial of the increased ratings claims to the United States Court of Appeals for Veterans Claims (Court). In a September 2017 Order Granting the Parties' Joint Motion for Partial Remand (JMR), the Court vacated the Board's decision and remanded the issues to the Board for further consideration. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into consideration the existence of these electronic records. FINDINGS OF FACT 1. Prior to January 27, 2014, the most probative evidence shows the chronic lumbar strain is manifested by thoracolumbar flexion of 60 degrees. 2. From January 27, 2014, the most probative evidence shows the Veteran chronic lumbar disorder is manifested by 5 degrees of thoracolumbar flexion. 3. During the entire period on appeal, the evidence does not show the Veteran's lumbar spine disorder caused incapacitating episodes or unfavorable ankylosis of the entire thoracolumbar spine. 4. The Veteran's left knee disorder is manifested by arthritis confirmed by x-ray findings resulting in some limitation of motion. 5. Prior to May 1, 2015, the Veteran's left knee disorder manifests in limitation of flexion at 45 degree s, at worst, with consideration of pain, flare-ups, and repetitive use. There was full extension. 6. From May 1, 2015, the Veteran's left knee disorder manifests in limitation of flexion to 25 degrees, at worst, with consideration of pain, flare-ups, and repetitive use. There was full extension. 7. During the entire period on appeal, the Veteran's left knee disorder disability picture does not show limitation of extension to a compensable degree, nor is there any evidence of ankylosis, or dislocation or removal of the cartilage. 8. The Veteran's residuals of a left fibula fracture were not incurred as a result of service and are not secondary to or aggravated by a service-connected disorder. CONCLUSIONS OF LAW 1. Prior to January 27, 2014, the criteria for a rating in excess of 20 percent for a low back disorder are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2017). 2. Since January 27, 2014, the criteria for a rating in excess of 40 percent for chronic lumbar spine strain with spinal stenosis and degenerative changes have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.14, 4.40-4.45, 4.71a, Diagnostic Codes 5238-5237, 5243 (2017). 3. Prior to May 1, 2015, the criteria for an evaluation in excess of 10 percent for left knee osteoarthritis are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5260 (2017). 4. From May 1, 2015, the criteria for an evaluation of 20 percent and no higher, for left knee osteoarthritis are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5260 (2017). 5. The criteria for a grant of service connection for residuals of a left fibula fracture, including as secondary to or aggravated by service-connected disorders are not met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the VCAA, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). As service connection, an initial rating, and an effective date have been assigned for the disabilities considered above, the notice requirements of 38 U.S.C.A. § 5103(a) have been met in this instance. The Veteran has been provided satisfactory and timely VCAA notice in advance of the rating decision on appeal. VA's duty to assist has been fulfilled through obtaining medical records, along with adequate VA examinations. The Veteran testified at a Board hearing, during which he received proper assistance in developing the claim. See 38 C.F.R. § 3.103. Moreover, the Veteran was represented by a member of the Service Organization who was aware of the criteria needed for establishing the benefits requested. There is sufficient basis upon which to issue a decision. The RO and the Board have complied with the Board and Court remand directives. The Board finds that the necessary development has been accomplished and that appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). For the reasons discussed below, the Board finds that the evidence of record is adequate to adjudicate the claims on appeal. Law and analysis - Increased rating claims Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. Relevant regulations do not require that all cases show all findings specified by the Schedule; however, findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). A claimant, however, may experience multiple distinct degrees of disability, resulting in different levels of compensation, from the time the increased rating claim is filed to the time a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. An effective date may be assigned up to one year preceding the date of the claim if the contemporaneous evidence shows that an increase in disability occurred during that time period. See Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010). If the increase in disability is shown to have occurred prior to that one-year period, an earlier effective date is not assignable one year prior to the date of the claim. Id. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Lumbar spine disorder The Veteran's chronic lumbar strain and intervertebral disc syndrome (IVDS) has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237, and is therefore evaluated under the General Rating Formula for Diseases and Injuries of the Spine. The General Rating Formula for Diseases and Injuries of the Spine provides a 20 percent disability rating is warranted upon evidence of forward thoracolumbar flexion is greater than 30 degrees, but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Forward thoracolumbar flexion to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine is rated as 40 percent disabling. Unfavorable ankylosis of the entire thoracolumbar spine is evaluated as 50 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. See 38 C.F.R. § 4.71a, Plate V. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are evaluated separately under the appropriate diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, Note (1). In addition to the General Rating Formula for Diseases and Injuries of the Spine, intervertebral disc syndrome may be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2015). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that when intervertebral disc syndrome is productive of incapacitating episodes having a total duration of at least one week but less than two weeks during the past twelve months, a 10 percent rating is assigned. When incapacitating episodes have a total duration of at least two weeks but less than four weeks during the past twelve months, a 20 percent rating is assigned. When incapacitating episodes have a total duration of at least four weeks but less than six weeks during the past twelve months, a 40 percent rating is assigned. When incapacitating episodes have a total duration of at least six weeks during the past 12 months, a maximum 60 percent rating is assigned. Note (1) following 38 C.F.R. § 4.71a, Diagnostic Code 5243 provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) following 38 C.F.R. § 4.71a, Diagnostic Code 5243 provides that if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever results in a higher evaluation for that segment. The Veteran's chronic lumbar strain has been evaluated as 20 percent disabling prior to January 27, 2014; and 40 percent disabling thereafter. See February 2014 Rating Decision. The Veteran was afforded a VA examination of the spine in June 2005. He reported experiencing pain in the low back since 1986. The pain was constant and radiated to his legs and was brought on by physical activity. The Veteran also specified one period of incapacitation for five days in the prior year, although he denied losing time from work due to his back disorder. A physical examination of his thoracolumbar spine showed flexion to 60 degrees, extension to 20 degrees, bilateral flexion to 30 degrees, and bilateral rotation to 35 degrees, with pain at the end of all ranges. Regarding DeLuca criteria, range of motion was limited by pain but not by fatigue, weakness, lack of endurance, or incoordination after repetitive use. Regarding functional limitations, the examiner opined that the Veteran should avoid frequent bending, stopping, and crouching. At a June 2007 VA examination, the Veteran reported recurrent low back pain for years. He stated that the pain occurs five times per day and is elicited by physical activity and comes on by itself. It is relived with Motrin. The Veteran denied any incapacitation or functional impairment. He was performing his usual job duties. A physical examination showed no radiation of pain on movement, tenderness, or muscle spasm. Range of motion was normal with flexion to 90 degrees, extension to 30 degrees, and bilateral flexion and rotation to 30 degrees with slight stiffness at the limits. After repetitive use, the thoracolumbar spine joint function was additionally limited by pain but not by fatigue, weakness, lack of endurance, or incoordination after repetitive use. The examiner found no intervertebral disc syndrome, sensory deficit, motor weakness, or bladder or bowel dysfunction. At a December 2008 VA examination, the Veteran reported that his low back constantly hurt, and he rated the pain at a 9 out of 10 which increased due to physical activity. He was functionally limited in his ability to lift, bend, or engage in prolonged walking. The Veteran underwent a VA examination in March 2011. The claimant reported being diagnosed with IVDS, HNP, L4-L5 and L5-S1. The condition has existed for 10 years. He reported that he has experienced falls due to the spine condition and that he experiences symptoms that include stiffness, fatigue, spasms, decreased motion, paresthesia and numbness. He also has weakness of the spine, leg and foot. The Veteran denied bowel and bladder problems and erectile dysfunction in relation to the spine condition. Regarding his pain, the Veteran stated he experiences moderate, constant pain in the lower back and it travels to left leg and foot. The pain can be exacerbated by physical activity and it is relieved by rest, Motrin, and brace. During the flare-ups, he experiences functional impairment, including pain in activities such as prolonged sitting, standing, walking, repetitive bending, and heavy lifting. The Veteran denied hospitalization, surgery, or incapacitation. A physical examination revealed the Veteran's posture was normal and he walked with an antalgic gait due to left knee pain. The examination revealed no evidence of radiating pain on movement. Muscle spasm was present and described as paralumbrosacral, mild. There was also tenderness. There was no guarding, weakness, or ankylosis. Range of motion was flexion to 75 degrees with pain at 60 degrees; extension to 20 degrees with pain at 10 degrees, bilateral flexion to 30 degrees with pain at 20 degrees, and bilateral rotation to 30 degrees with pain at 25 degrees. Repetitive motion was possible with additional limitations of pain, fatigue, and lack of endurance. An inspection of the spine revealed normal head position with symmetry in appearance and symmetry of spinal motion with normal curves of the spine. Sensory changes were said likely related to the superficial peroneal nerve. The examiner changed the prior diagnosis of chronic lumbar strain to lumbar spine IVDS, HNP at L4-L5 and L5-S1, mild anterior wedging of L1 and L2, based on the MRI report. At a December 2011 VA examination, the Veteran reported pain, stiffness, and decreased motion due to his back disorder. He denied bladder, bowel, or erectile dysfunction due to his back disorder. He complained of constant, severe, localized pain in his lower back that is exacerbated by physical activity. A physical examination showed range of motion as flexion to 85 degrees, extension to 30 degrees, bilateral flexion to 30 degrees, and bilateral rotation to 30 degrees. There was objective evidence of painful motion at the end of all ranges. The Veteran was able to perform repetitive use testing with no additional limitations in range or function. An x-ray report showed a 15 to 20 percent loss of height anteriorly at L1-L2 and mild disc degeneration at L4-L5. The examiner noted diagnoses of disc degeneration and chronic lumbar strain and noted that the impact of his thoracolumbar spine disorders on the Veteran's ability to work is having difficulty standing or walking for long periods. At a January 2014 VA examination, the examiner noted diagnoses of chronic lumbar strain, retrolisthesis on L5-S1, and spinal canal stenosis. The Veteran stated that he wears a lumbar brace daily and that his pain has progressively worsened, even while attending regular physical therapy. The Veteran's initial range of motion was flexion to 40 degrees with pain at 5 degrees; extension to 25 degrees, with pain at 5 degrees; bilateral flexion to 25 degrees with pain at 15 degrees; and bilateral rotation to 15 degrees with pain at 5 degrees. During a flare-up, the Veteran is limited to 30 degrees of flexion, 20 degrees of extension, 10 degrees of bilateral flexion, and 0 degrees of bilateral rotation. After repetitive motion testing, the Veteran was additionally limited to 30 degrees of flexion. The Veteran's functional impairment was due to decreased movement, excess fatigueability, pain, and interference with sitting, standing, and/or weight-bearing. The examination also showed localized tenderness or pain on palpation and muscle spasms resulting in abnormal gait or spinal contour. There was no guarding or atrophy. The Veteran appeared before a Decision Review Officer (DRO) at a hearing in April 2014. He testified that he was wearing a back brace at the time of the March 2011 VA examination and that he did not recall the examiner using a device to measure the degree of motion. He stated that he agreed with the 40 percent rating assigned effective January 2014, but believes that it should have been implemented the date of his original claim. At a May 2015 VA examination, the Veteran reported pain in his lower back. He also stated that he cannot feel sensation in his back. During a flare-up, the Veteran is unable to bend or twist his body. Additionally, his back disorder precludes running and strenuous work and the Veteran can only walk with the assistance of a cane or walker. Range of motion testing showed flexion to 5 degrees; extension to 5 degrees; right lateral flexion to 5 degrees, and zero degrees of left lateral flexion and bilateral rotation. The Veteran was unable to perform repetitive-use testing due to pain. The examiner also noted moderate localized tenderness or pain on palpation. The Veteran also had an abnormal gait due to muscle spasm, but with normal spinal contour. The Veteran had functional loss due to decreased movement, weakened movement, pain, swelling, disturbance of locomotion, and interference with standing and sitting. The examiner noted no ankylosis. The examiner also found that the Veteran had a diagnosed of IVDS; however, he had no incapacitating episodes requiring bed rest prescribed by a physician over the prior 12 months. On an October 2015 Disability Benefits Questionnaire (DBQ), the Veteran reported pain and decreased function and movement due to his back disorder. Range of motion testing showed flexion to 35 degrees, extension to 20 degrees, bilateral flexion to 20 degrees, and bilateral rotation to 20 degrees. There was evidence of pain with weight bearing and objective evidence of location tenderness along the lumbar spine. The Veteran was able to perform repetitive-use testing with his range of motion additionally limited by five degrees at the end of all ranges. The examiner also noted muscle spasms and localized tenderness not resulting in abnormal gait or spinal contour. No ankylosis was noted. The examiner also found that the Veteran has IVDS; however, he has had no incapacitating episodes requiring physician-prescribed bed rest in the prior 12 months. Regarding pain, the Veteran stated that he has experienced pain in his back since 2004, wears a back brace constantly, cannot bend well, cannot stand or walk for prolonged periods, and needs to use a cane when he walks. He medicates with Motrin and Vicodin to treat the pain. He also reported flare-ups that prevent him from getting out of bed. The Veteran appeared at a Board hearing in March 2016. He testified that he has a bulging disc in his back and experiences paralysis due to the disc and a pinched nerve. He has difficulty bending and wears a copper brace. Specifically, he testified that at times, he cannot move or function and needs to wear a brace and hold a cane for stability. He rated his pain as an eight or nine on a 10 point scale. After a review of the evidence of record, the Board finds that prior to January 27, 2014; the Veteran's limitation of motion was, at worst, limited to 60 degrees of flexion and 10 degrees of extension. Although the Veteran testified at the April 2014 DRO hearing that he did not recall whether the examiner used a goniometer to measure his range of motion, both the March 2011 and December 2011 VA examination report show the Veteran's range of motion in degrees. While treatment records prior to January 27, 2014 indicate the Veteran had back pain, there is no probative evidence to support a finding that his range of motion was limited beyond the objective findings of the VA examination. Therefore, a rating in excess of 20 percent is not warranted. Furthermore, from January 27, 2014, the Board does not find that a rating in excess of 40 percent is warranted. In the May 2015 VA examination, the examiner noted first that the Veteran's flexion was to 5 degrees and extension was to 5 degrees and the Veteran was unable to perform repetitive-use testing due to the pain. Although the examiner noted no ankylosis, the examination shows that the Veteran was unable to perform repetitive-use testing. Therefore, with resolution of the doubt in favor of the Veteran, the Board finds that the Veteran's spine was limited to zero degrees of flexion at that time. The Board finds this to be comparable to favorable ankylosis of the thoracolumbar spine. See Note (5): Fixation of a spinal segment in neutral position (zero degrees) approximates favorable ankylosis. At no point during the periods on appeal does the evidence of record show that the Veteran experiences unfavorable ankylosis, that is, a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. See Note (5). Therefore, prior to January 27, 2014, the Board finds that a 20 percent rating for the Veteran's low back disorder is warranted. In the absence of credible evidence of forward thoracolumbar flexion to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine, a 40 percent rating cannot be assigned during that period. From January 27, 2014, a 40 percent rating and no higher is warranted as there is no evidence, lay or medical, of unfavorable ankylosis. The Board has considered the Veteran's lay statements in reaching this decision. While the Veteran is competent to testify as to the symptoms he personally experiences and the Board finds his statements to be credible, the objective findings of the VA examiners are more probative as to the application of the rating criteria. The Board has also considered whether the Veteran is entitled to a separate rating for radiculopathy of the right lower extremity. Most recent examinations, in 2015, seem to suggest findings of bilateral radiculopathies. The Veteran is already in receipt of service connection for a sensory deficit of the left lower extremity, superficial peroneal nerve, and that rating is not before the Board. The Veteran was separately granted service connection for a radiculopathy of the right and left lower extremities, sciatic nerve, effective January 27, 2014. Those issues are not presently on appeal before the Board. Osteoarthritis of the left knee The Veteran's left knee osteoarthritis disability is currently evaluated at 10 percent disabling. The Veteran's disability is manifested by arthritis established by X-ray findings, and loss of motion. Thus, the Board will consider the rating criteria set forth at 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5010, 5260 and 5261. The Board notes that the Veteran has a separately assigned 30 percent rating under Diagnostic Code 7804-5257 for instability. That rating is not presently on appeal before the Board. Under Diagnostic Codes 5010, 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 involves is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affect by limitation of motion. Under Diagnostic Code 5260, a noncompensable rating is assigned when flexion of the leg is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5258, dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion into the joint, warrants a 20 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a 10 percent disability evaluation is assigned for the symptomatic removal of semilunar cartilage. Under Diagnostic Code 5262, pertaining to impairment of the tibia and fibula, a 10 percent disability rating is assigned for malunion with slight knee or ankle disability, and a 20 percent rating is warranted for malunion with moderate knee or ankle disability. A 40 percent disability rating is appropriate where there is nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under Diagnostic Code 5263, a 10 percent disability rating is assigned for acquired, traumatic genu recurvatum with weakness and insecurity in weight-bearing objectively demonstrated. 38 C.F.R. § 4.71a, Diagnostic Code 5263. The Veteran contends that his left knee osteoarthritis warrants a rating in excess of 10 percent. In January 2005, the Veteran filed a claim for service connection for a left knee disability and a low back disability. In June 2005, he underwent a VA examination. The Veteran reported constant left knee pain with three periods of incapacitation over the prior year. He stated that he had difficulty running and his knee pain prevented him from driving a car. The Veteran's left knee motion was limited and painful. The Veteran was afforded a VA examination in August 2007. He reported stiffness, buckling, popping, and aching, sharp, intermittent pain. He is able to function with medication. An examination showed flexion of the left knee to 127 degrees with pain and normal extension to zero degrees. Pain was the predominant issue after repetitive use; however, the examiner also noted fatigue, weakness, and lack of endurance. An x-ray of the left knee was normal. At a December 2008 VA examination, the Veteran reported weakness, stiffness, and giving way of the left knee with constant pain rated at 8 out of 10 in severity. In a March 2011 treatment record, the Veteran reported left knee pain. He stated that he had left knee surgery many years prior but was involved in a motor vehicle accident (MVA) in January 2011 and had since been experiencing a constant ache in the posterior knee, non-radiating, with popping, intermittent swelling, locking, buckling, and instability. The Veteran stated that he was unable to bend or squat. Testing showed patellar grind/tracking was positive, as was McMurray's and joint line tenderness tests. The Veteran underwent a VA examination in March 2011. The claimant reported being diagnosed with status post left knee ACL reconstruction with residual osteoarthritis. The condition has existed since 1987. He reported the following symptoms: giving way, lack of endurance, locking, tenderness and pain. The Veteran denied weakness, stiffness, swelling, heat, redness, fatigability, deformity, drainage, effusion, subluxation, and dislocation. He stated that he experiences flare-ups daily, which are precipitated by physical activity and alleviated by rest, Motrin, and a brace. During the flare-ups, he experiences pain in prolonged standing, walking, repetitive kneeling, squatting, and running. A physical examination revealed tenderness, but no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, drainage, subluxation, locking, genu recurvatum, or crepitus. Upon examination of the knee, there was no ankylosis. Range of motion was from 0 to 140, with pain at 130 degrees with additional limitation to 130 degrees after repetitive motion by pain, fatigue, and lack of endurance. The medial/lateral collateral ligaments stability test, the anterior/posterior cruciate ligaments stability test, and the medial/lateral meniscus stability test were all within normal limits for the left knee. The examiner diagnosed osteoarthritis of the left knee, status post trauma, anterior cruciate ligament reconstruction. The effect of the condition on the Veteran's occupation and daily activity is impaired prolonged sitting, standing, walking, running, repetitive bending, kneeling, squatting, and heavy lifting. An August 2011 treatment record showed no limitation in range of motion for all four extremities. In September 2011, the Veteran was fitted for a knee brace. A November 2011 record showed knee motion was painless. At a December 2011 VA exam, the Veteran stated that osteoarthritis of the left knee began 1986. He reported the following symptoms: weakness, giving way, locking, and pain and denied stiffness, swelling, heat, redness, lack of endurance, fatigability, deformity, tenderness, drainage, effusion, subluxation, and dislocation. Upon physical examination, the examiner noted no ankylosis. The Veteran denied shin splints, stress fractures chronic exertional compartment syndrome, or acquired traumatic genu recurvatum. Range of motion testing showed flexion to 135 degrees and extension to 45 degrees, with no additional limitation or functional loss or impairment after repetitive movement. The examiner noted no tenderness or pain on palpation of joints line or soft tissue. Lachman test, posterior drawer test, and medial-lateral instability test were normal. There was no evidence or history of bilateral recurrent patellar subluxation or dislocation and his lower extremities had no diminished function. An October 2012 treatment record shows the Veteran had limitation in the range of motion of his knee. The degree of limitation was not noted. A July 2013 radiology report showed no significant findings of the left knee. The Veteran underwent a VA examination of the left knee in July 2013. A physical examination showed range of motion of the left knee was 90 degrees of flexion with objective evidence of pain at 65 degrees, and 0 degrees of extension with no evidence of painful motion. The Veteran was able to perform repetitive-use testing with no additional limitations. Functional loss was based on decreased movement and pain. Joint stability testing was normal and there was no evidence or history of recurrent patellar subluxation or dislocation. The Veteran endorsed regular use of a knee brace. A VA examination was conducted in May 2015. The examiner noted diagnoses of ACL tear, status post repair with residuals, left knee anterior cruciate ligament tear, and shin splints. Range of motion testing showed left knee flexion to 50 degrees and extension to 0 degrees. The Veteran stated that he was unable to perform repetitive-use testing due to pain. Pain was noted upon movement and weight-bearing. There was objective evidence of moderate localized tenderness or pain of the left knee joint and objective evidence of crepitus. Muscle strength testing was two out of five, indicating there was active movement with gravity eliminated. There was also a reduction in muscle strength but not atrophy. No ankylosis was noted. Joint stability testing showed no evidence or history of recurrent subluxation or lateral instability. The Veteran ambulated with a brace, cane, and/or walker. The examiner noted that no degenerative or traumatic arthritis has been documented by imaging studies. In the September 2015 DBQ, the Veteran reported that he could no longer stand or walk for prolonged periods of time due to his knee disorders and could not squat, kneel, or run. He experienced flare-ups of his knee pain and regularly experiences pain, swelling, locking, and popping. He takes Motrin for pain and wears a brace for stability. Range of motion testing showed flexion to 30 degrees with evidence of pain and tenderness. The examiner noted that functional ability with repeated use of a period of time causes limitation of flexion to 25 degrees and it was further limited to 20 degrees during a flare-up. Muscles strength testing of the left knee was 4 out of 5. There was a history of swelling and effusion and the examiner noted frequent episodes of locking, joint pain, and joint effusion. The Veteran ambulates with a constant use of a brace and cane. At the March 2016 Board hearing, the Veteran testified that that he wears a brace on his knee and has functional loss, including limitation of ambulation, difficulty with stairs, along with limitation of motion and instability. At a December 2016 VA examination of the Veteran's knee, the examiner noted left knee flexion to 50 degrees and extension to zero degrees. The examination showed objective evidence of pain causing functional loss. The Veteran was able to perform repetitive use testing with no additional loss of range of motion and there was no additional loss of functional ability with repeated use over a period of time or during a flare-up. There was no ankylosis. Muscle strength testing on the left side was 4 out of 5 with no atrophy. An x-ray of the left knee showed suspected knee joint effusion and no fracture or significant arthritis. The Board has reviewed all of the relevant treatment reports of record. None of the treatment reports of record document specific range of motion of the left knee, or provide any evidence of ankylosis or dislocated or removal of cartilage. Prior to the May 1, 2015 VA examination, the Veteran's flexion of the left knee was limited, at most, to 65 degrees. Although the December 2011 VA examination appears to show a finding that his extension was limited to 45 degrees, the entirety of the record shows only findings of limitation of extension to zero degrees. The December 2011 VA examination report also showed that the Veteran did not have functional loss or impairment of the left knee or lower leg. The Board finds the notation of limited extension to 45 degrees to be inconsistent with the other findings of record and not reflective of the overall disability picture. Therefore, the Board finds that the preponderance of the evidence shows that a compensable rating is not warranted for either limitation of flexion or extension under Diagnostic Codes 5260 or 5261 and a rating in excess of 10 percent is denied. From the May 1, 2015 VA examination, the evidence shows flexion limited to 45 degrees during flare-ups and an inability to perform repetitive-use testing. In the October 2015 DBQ, the Veteran was noted to have flexion limited to 20 degrees with considerations of repetitive use and flare-ups. Therefore, the Board presently grants a 20 percent rating under Diagnostic Code 5260 for limitation of motion. As the evidence does not show limitation of extension, no separate compensable rating is warranted under Diagnostic Code 5261. The Board acknowledges the Veteran's subjective complaints of painful motion, weakness, and difficulty engaging in activities such as walking, sitting and standing. However, the objective evidence of record indicates such pain does not limit the Veteran's functional range of motion to a degree higher than the presently assigned ratings, and as such, it does not serve as a basis for higher evaluations. See Mitchell v. Shinseki, 25 Vet. App. 32 ("pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system"). In determining the actual degree of disability, an objective examination is more probative of the degree of the Veteran's impairment. The opinions and observations of the Veteran alone cannot meet the burden imposed by the rating criteria under 38 C.F.R. § 4.71a with respect to determining the severity of his service-connected disabilities. Moray v. Brown, 2 Vet. App. 211, 214 (1993). As the objective findings show that the Veteran's limitation of motion is, at worst, limited to 45 degrees of flexion with pain prior to May 1, 2015 and to 25 degrees from that date, ratings in excess of 10 percent is not warranted prior to May 1, 2015 and in excess of 20 percent thereafter. The Board has also considered other potentially applicable diagnostic codes pertaining to the left knee. The record demonstrates that the Veteran does not have left knee ankylosis, a dislocated or absent semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum (Diagnostic Codes 5256, 5258, 5259, 5262, and 5263). In addition, the Veteran has not contended that he has such symptomatology. Therefore, these diagnostic codes are inapplicable in this case. Extraschedular Consideration In arriving at these decisions, the Board has considered the possibility of referring this case to the Under Secretary for Benefits or the Director, Compensation Service, for possible approval of an extraschedular rating for the Veteran's service-connected back and knee disabilities. 38 C.F.R. § 3.321 (2017). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but would still be adequate to address the average impairment in earning capacity caused by the disability. Thun v. Peake, 22 Vet. App. 111 (2008). However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321 (2017). There is a three-step inquiry for determining whether a claimant is entitled to an extraschedular rating. Thun, supra. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Board must compare the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Second, if the schedular evaluation is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors, such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a claimant's disability picture with such related factors as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. The first Thun element is not satisfied here. The Veteran's service-connected back and knee disabilities are manifested primarily by complaints of pain, limitation of motion, functional impairment, and a need for assistive devices. He also experiences increased pain, weakness, fatigability, and/or incoordination on repetitive testing or during flare-ups. 38 C.F.R. § 4.71a. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which, as noted above, may be manifested by decreased or abnormal excursion, speed, coordination, or endurance. 38 C.F.R. § 4.40 (2017); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as excess fatigability and pain on movement. 38 C.F.R. §§ 4.45, 4.59 (2017); Mitchell, supra; DeLuca, supra. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. The Board has addressed the Veteran's symptoms, both the ones contained in the objective medical records and those proffered by the Veteran in his lay statements. The Board finds that the schedular criteria address his symptoms and his 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. The evidence fails to show anything unique or unusual about the Veteran's low back disorder or left knee disorder that would render the schedular criteria inadequate. There are no additional symptoms due to the disorder that are not addressed by the Rating Schedule. To the extent that the disorder interferes with his employability and activities of daily life, such interference is contemplated by the schedular rating criteria and the Veteran has been awarded a total disability rating for individual unemployability (TDIU). 38 C.F.R. § 4.1; VAOPGCPREC 6-96; see also Bagwell v. Brown, 9 Vet. App. 337, 338 (1996) (Generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability.) Finally, under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. In this case, however, even after applying the doctrine of reasonable doubt, there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Law and analysis - service connection claim Service connection may be established on a direct basis for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Further, service connection can be established when a disability is proximately due to, the result of, or aggravated by a service connected disability. 38 C.F.R. § 3.310. The Veteran contends that service connection is warranted for his status post left fibula fracture. The Veteran underwent a VA examination in July 2013. The examiner noted a diagnosis of left fibular fracture status post-surgical repair with residual scar. By way of history, the Veteran stated that his left fibula injury was a fracture that occurred in 2012 after being hit by a car. The examiner opined that the Veteran's left fibula fracture was less likely than not due to service or secondary to a service-connected disorder because the Veteran endorsed a history of it occurring during an accident in 2012 when he was hit by a motor vehicle. The Veteran was afforded another VA examination in December 2016. The examiner diagnosed left fracture fibula status post surgery (ORIF), residuals. The examiner opined that the Veteran's disorder was less likely than not aggravated by his service-connected low back, left knee, left leg radiculopathy, and right ankle disorders. In support of his opinion, the examiner noted that the Veteran's fibular fracture is status post ORIF and has improved over time. He stated that his opinion is based on a review of the claims file and relevant medical literature. Therefore, the Board finds that service connection is not warranted. Based on a review of the record, the Board is unable to reasonably associate the Veteran's current left fibular fracture, first persuasively documented many years following service discharge, with his period or periods of active military service. Nor has it been demonstrated that the injury was aggravated by a service-connected disorder, rather, the VA examiners both found improvement. Accordingly, the Veteran's claims for service connection must be denied. ORDER Prior to January 27, 2014, a rating in excess of 20 percent for the Veteran's low back disorder is denied as is a rating in excess of 40 percent thereafter. Prior to May 1, 2015, entitlement to an increased rating in excess of 10 percent for a left knee disorder is denied. From May 1, 2015, entitlement to a 20 percent rating, but no higher, for a left knee disorder is granted, subject to the law and regulations governing the award of monetary benefits. Service connection for residuals of a left fibula fracture is denied. ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs