Citation Nr: 1802646 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 11-05 651A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a rating higher than 10 percent for pes planus prior to January 11, 2016. 2. Entitlement to a rating higher than 50 percent for bilateral pes planus as of January 11, 2016. 3. Entitlement to a rating higher than 10 percent for degenerative joint disease, bilateral great toes. 4. Entitlement to a rating higher than 10 percent for chondromalacia patella and patellar tendonitis, right knee. 5. Entitlement to a rating higher than 10 percent of chondromalacia patella and patellar tendonitis, left knee, with arthritic changes. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Bridgid D. Houbeck, Counsel INTRODUCTION The Veteran served on active duty from May 1972 to May 1979. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In February 2017, the Board remanded this case for a Travel Board hearing. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in July 2017. A transcript of the hearing is associated with the claims file. FINDINGS OF FACT 1. Prior to January 11, 2016, the Veteran's bilateral pes planus manifested as no more than foot pain and tenderness to palpation. 2. As of January 11, 2016, the Veteran's bilateral pes planus manifests as no more than extreme tenderness of plantar surfaces of both feet that was not improved by orthopedic shoes or appliances. 3. The Veteran's degenerative joint disease of bilateral great toes is confirmed by x-rays and manifests as pain. 4. The Veteran's right knee disability manifests as pain, noncompensable limitation of motion, weakness, insecurity on weight bearing, and crepitus. 5. The Veteran's left knee disability manifests pain, noncompensable limitation of flexion, compensable limitation of extension, weakness, insecurity on weight bearing, and crepitus. CONCLUSIONS OF LAW 1. Prior to January 11, 2016, the criteria for a rating higher than 10 percent for pes planus have not all been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.16, 4.21, 4.71a, Diagnostic Code (DC) 5276, 5280, 5281 (2017). 2. As of January 11, 2016, the criteria for a rating higher than 50 percent for bilateral pes planus have not all been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.16, 4.21, 4.71a, Diagnostic Code (DC) 5276, 5280, 5281 (2017). 3. The criteria for a rating higher than 10 percent for degenerative joint disease, bilateral great toes have not all been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.16, 4.21, 4.71a, Diagnostic Code (DC) 5010 (2017). 4. The criteria for a rating higher than 10 percent for chondromalacia patella and patellar tendonitis, right knee have not all been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.16, 4.21, 4.71a, Diagnostic Code (DC) 5260 (2017). 5. The criteria for a rating higher than 10 percent of chondromalacia patella and patellar tendonitis, left knee, with arthritic changes have not all been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.16, 4.21, 4.71a, Diagnostic Code (DC) 5010-5261 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C. §§ 5103, 5103A (2012) and 38 C.F.R. § 3.159 (2017). In the instant case, VA provided adequate notice in a letter sent to the Veteran in April 2008. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service and VA treatment records are associated with the claims file. VA provided relevant examinations as discussed in further on in the decision. Although the VA examinations that predate the Court's decision in Correia v. McDonald, 28 Vet. App. 158, 168 (2016), do not address ranges of motion with weight-bearing, this is remedied by the Veteran's submission of a January 2016 Disability Benefits Questionnaire (DBQ), which does provide the necessary information. There is no indication of additional existing evidence that is necessary for a fair adjudication of the claim that is the subject of this appeal. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. II. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). III. Pes Planus and Toes The Veteran was originally granted service connection for bilateral pes planus in an October 1982 rating decision. At that time this disability was rated noncompensable (0 percent) effective May 20, 1982. In a June 1992 rating decision, this was increased to 20 percent effective January 31, 1992. The Veteran appealed this rating to the Board and in a June 1996 decision the Board denied a rating higher than 20 percent. In a January 1999 rating decision, this disability was recharacterized as bilateral pes planus with secondary degenerative joint disease of both great toes. The Veteran filed his current claim for an increased rating in April 2008. In the September 2008 rating decision on appeal, the Veteran was assigned separate 10 percent ratings for pes planus of each foot and for degenerative joint disease of both great toes. In a February 2016 rating decision, the Veteran's rating for bilateral pes planus was increased to 50 percent effective January 11, 2016. Pes planus is rated under Diagnostic Code (DC) 5276. Under this diagnostic code, mild flatfoot with symptoms relieved by built-up shoe or arch support is rated as noncompensably (0 percent) disabling. 38 C.F.R. § 4.71a. Moderate flatfoot with weight-bearing line over or medial to the great toe, inward bowing of the atendo achillis, pain on manipulation and use of the feet, bilateral or unilateral, is rated 10 percent disabling. 38 C.F.R. § 4.71a, DC 5276. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, is rated 20 percent disabling for unilateral disability, and is rated 30 percent disabling for bilateral disability. Id. Pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation, that is not improved by orthopedic shoes or appliances, is rated 30 percent disabling for unilateral disability, and is rated 50 percent disabling for bilateral disability. Id. With regard to the great toes, DC 5010 provides that traumatic arthritis substantiated by x-ray findings is rated as degenerative arthritis (DC 5003); meaning that a rating under this DC will be based either on limitation of motion of the affected joint under the appropriate diagnostic code or, if only a noncompensable limitation of motion is found, a 10 percent rating will be assigned for each affected major joint or group of minor joints. 38 C.F.R. § 4.71a. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent rating is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Id. The great toes are minor joints. See 38 C.F.R. § 4.45. Additionally, a separate 10 percent rating is available for unilateral hallux valgus/hallux rigidus if there is an operation with resection of the metatarsal head or if it is severe enough to equate to the amputation of the great toe. 38 C.F.R. § 4.71a, DC 5280, 5281. In Copeland v. McDonald, 27 Vet. App. 333, 338 (2015), the United States Court of Appeals for Veterans Claims (Court) held that the eight specifically named foot disabilities noted in the Rating Schedule could not be, as a matter of law, rated to by analogy under DC 5284. As the Veteran's disability is repeatedly described in the record as flat feet/pes planus with degenerative joint disease of the bilateral great toes, the appropriate diagnostic codes for consideration as DC 5276 and 5010, not DC 5284. A. Pes Planus Prior to January 11, 2016 July 2007 and December 2007 VA treatment record show follow up on severe bilateral pes planus with no improvement. Pain was noted on the medial aspect of the bilateral feet and along the Achilles tendon of the right foot. He was diagnosed with plantar fasciitis and Achilles tendonitis. In May 2008, the Veteran underwent a VA examination in conjunction with this appeal. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation. Therefore, this examination is adequate for VA purposes. At that time the Veteran reported constant bilateral foot pain for fifteen years. This pain could be elicited by physical activity and work. It was relieved by rest, on its own, and with medication. At the time of pain, he could function with medication. At rest he had pain, but no weakness, stiffness, swelling, or fatigue. He was never hospitalized for this condition and never had any surgery. He did not experience any functional impairment from this condition. Physical examination found his posture and gait to be within normal limits. His feet did not show any signs of abnormal weight bearing, breakdown, callosities, or any unusual shoe wear pattern. Examination of both feet revealed tenderness and painful motion, but not edema, disturbed circulation, weakness, or atrophy of the musculature. There was active motion in the metatarsal joints of both great toes. Pes planus was present. There was no forefoot/midfoot malalignment in either foot. There was deformity of the medial tilting of the upper border of the talus in both feet. Palpation of both feet plantar surface revealed moderate tenderness. Both Achilles tendons had good alignment. There was moderate valgus on the right which could be corrected with manipulation. There was severe valgus present on the left foot, which could be corrected by manipulation. Physical examination did not find pes cavus, hammer toes, Morton's metatarsalgia, hallux valgus, or hallux rigidus. The Veteran had limitations with standing and walking that prevented prolonged standing or walking. He required arch supports, but not orthopedic shoes, corrective shoes, foot supports, buildup of the shoes, or shoe inserts. These arch supports did not relieve his pain or symptoms. X-rays of the right foot showed mild degenerative joint disease of the right great toe, pes planus, and plantar spur. X-rays of the left foot showed degenerative joint disease of the left great toe, mild pes planus, and plantar spur. The Veteran was diagnosed with bilateral pes planus with secondary great toe degenerative joint disease and plantar spurs. A February 2009 private treatment record notes the Veteran's complaints of bilateral pain in his heels, instep, and Achilles tendons. He also reported morning stiffness and point tenderness. Pain was elicited on palpation of the plantar medial calcaneal tubercle in the region of the origin of the intrinsic musculature and plantar fascia but no pain on medial lateral compression of the calcaneus. His posterior tibial tendon was intact with full strength. Ankle joint dorsiflexion was 0 degrees with the knee extended bilaterally. There were no significant foot or ankle deformities bilaterally and no pain with straight leg raise test. Foot type was flexible pes planus. Pain to palpation was observed about the bilateral Achilles tendon and posterior tibial tendon. The area was not inflamed. There was pain along the tendon sheath, tendon insertion, and myotendonous junction. The Veteran was diagnosed with bilateral plantar fasciitis with associated heel spur syndrome/infracalcaneal bursitis and gastrocnemius equinius contracture, neuritis, Achilles tendinitis, and arthralgia. A March 2011 VA radiology report shows small heel spurs. In a June 2012 statement the Veteran stated that he had tried every type of prosthetic with no relief. He continued to have pain in his instep and heels. He had also tried various medications and injections. He was limited in his medication options due to a liver condition. A March 2015 VA treatment record notes pain in both heels due to heel spurs. The Veteran denied recent fall or injury. A June 2015 VA podiatry consult notes intermittent foot pain. The Veteran denied any other symptoms. He denied recent illness, injury, and/or hospitalization. A September 2015 VA treatment record notes the Veteran's report that his feet were about the same, but his pain was more at the outside of the feet now. He had tried many types of orthotics, which made his ankles roll, and injections. He wore the boot at home but not outside and thought it helped a little. Physical examination found pedal pulses palpable bilaterally. There was tenderness to palpation in the plantar heel, medial calcaneal tubercle, and posterior heel bilaterally and mild tenderness to palpation in the medial arch. He also had tenderness to palpation lateral midfoot at fifth metatarsal base/peroneal tendon insertion on the left and just proximal to insertion on the right. He had decreased medial longitudinal arch bilaterally, decreased ankle joint dorsiflexion bilaterally. He was diagnosed with plantar fasciitis/heel spur syndrome and flat foot and peroneal tendonitis bilaterally. A December 2015 VA treatment record notes stable foot spurs. Based on the above, prior to January 11, 2016 the Veteran's bilateral pes planus was characterized by foot pain, tenderness to palpation, and degenerative joint disease of the great toes. He treated this condition with rest, medications, injections, arch supports, and orthotics. This is consistent with a 10 percent rating for the bilateral feet. See 38 C.F.R. § 4.71a, DC 5276. A higher rating would require objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and/or severe spasm of the tendo Achilles on manipulation. See id. None of these symptoms are present here. Thus a rating higher than 10 percent is not warranted under this diagnostic code. The Board notes that the Veteran has been awarded separate 10 percent ratings for each foot despite specific rating criteria noting that moderate flatfoot, whether unilateral or bilateral, warrants a single 10 percent rating. See 38 C.F.R. § 4.71a, DC 5276. Despite this, the Board will not disturb the existing separate rating for left foot pes planus. B. Pes Planus as of January 11, 2016 A January 11, 2016 Disability Benefits Questionnaire (DBQ) describes the Veteran's symptoms as chronic daily pain, his instep hurt, and his skin felt tight like it was going to tear. The Veteran stated that sometimes had to walk on lateral aspect of his feet due to pain. He got cramps on both feet when he wiggled his toes, and his feet occasionally swelled. He described this daily pain as feeling like his skin was going to tear and like someone was sticking spikes into his heels. This pain only subsided with rest. He treated this disability with orthotic shoes and inserts, heel cups, and physical therapy. Functionally, he was unable to exercise, unable to ride his stationary bike, and his feet swelled up if he walked more than a half mile. He did not report flare-ups. Physical examination found pain on use of feet that was accentuated on use and pain on manipulation of feet that was accentuated on manipulation of feet. There was indication of swelling on use of both feet. The Veteran did not have characteristic calluses on either foot. He used arch supports and orthotics on both feet. He had extreme tenderness of plantar surfaces of both feet that was not improved by orthopedic shoes or appliances. He had decreased longitudinal arch height or both feet on weight bearing. There was no objective evidence of marked deformity of either foot and no marked pronation of either foot. The weight bearing line did not fall over or medial to the great toe of either foot. There was no lower extremity deformity other than pes planus causing alteration of the weight bearing line. The Veteran did not have inward bowing of the Achilles' tendon of either foot. He did not have marked inward displacement and severe spasm of the Achilles' tendon on manipulation of either foot. He had mild or moderate hallux rigidus of both feet and documented degenerative joint disease of the bilateral great toes. He did not have Morton's neuroma, metatarsalgia, hammer toe, hallux valgus, acquired pes cavus, malunion or nonunion of tarsal or metatarsal bone, or any other foot injury or foot condition. The Veteran had not undergone foot surgery. Physical examination found pain in both feet. This resulted in less movement than normal, weakened movement, excess fatigability, pain on movement, pain on weight bearing, pain on non weight bearing, swelling, interference with standing, and lack of endurance. The examiner was unable to determine additional functional loss during flare-ups or when the foot was used repeatedly over time without resorting to mere speculation. The examiner explained that there was no conceptual or empirical basis for making such a determination without directly observing function under these conditions. The Board finds this to be an adequate explanation for why a determination could not be made without resort to speculation. It is noted that the examiner had before him the Veteran's reports of his functional loss and therefore considered them in arriving at this explanation. The Veteran did not have any associated scars or other pertinent physical findings, complications, conditions, signs or symptoms related these disabilities. He required regular use of a brace and cane for normal locomotion. The Veteran's bilateral foot disabilities did not result in functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis. These disabilities prevented prolonged standing and walking. The Veteran was retired from the postal service and reported losing less than one week of time from work over the prior 12 months. There was no objective evidence of bilateral plantar fasciitis or bone spurs. As of January 11, 2016, the Veteran's bilateral foot condition is rated 50 percent, which is the highest rating available under DC 5276. This rating reflects the extreme tenderness of plantar surfaces of both feet that was not improved by orthopedic shoes or appliances. See 38 C.F.R. § 4.71a, DC 5276. Thus a rating higher than the current 50 percent is not warranted under this diagnostic code. Therefore, the Board finds that the preponderance of the evidence is against a schedular rating higher than 50 percent for bilateral pes planus as of January 11, 2016. Hence the appeal as to a higher rating for this disability must be denied. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. C. Toes During the entire period, the Veteran has received a separate 10 percent rating for his degenerative joint disease of the bilateral great toes. This is consistent with the criteria for a 10 percent rating for arthritis affecting minor joint groups under DC 5010. See 38 C.F.R. § 4.71a. The January 2016 DBQ noted bilateral hallux rigidus and so the Board has also considered whether a higher rating is warranted under DC5281. Separate 10 percent ratings for each toe are available for this disability if there is an operation with resection of the metatarsal head or if it is severe enough to equate to the amputation of the great toe. 38 C.F.R. § 4.71a, DC 5280, 5281. In this case, neither toe has been treated with surgery or had symptoms that equate to amputation of the great toe. As such, separate 10 percent ratings for each toe are not warranted for hallux rigidus. Therefore, the Board finds that the preponderance of the evidence is against a schedular rating higher than 10 percent for degenerative joint disease of the bilateral great toes. Hence the appeal as to a higher rating for this disability must be denied. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. IV. Knees The Veteran was originally granted service connection for chondromalacia patella and patellar tendonitis of the bilateral knees in a May 1997 rating decision. At that time each knee was assigned a separate 10 percent rating effective January 31, 1992. The Veteran filed his current claim for an increased rating in April 2008. The Veteran's right knee is currently rated under Diagnostic Code (DC) 5260 for limitation of flexion of the leg. His left knee is rated under hyphenated DC 5010-5261. Hyphenated DCs are used when a rating under one DC (DC) requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. In this case, DC 5010 provides rating criteria for traumatic arthritis and DC 5261 provides rating criteria for limitation of extension of the leg. DC 5010 provides that traumatic arthritis substantiated by x-ray findings is rated as degenerative arthritis (DC 5003); meaning that a rating under this DC will be based either on limitation of motion of the affected joint under the appropriate diagnostic code or, if only a noncompensable limitation of motion is found, a 10 percent rating will be assigned for each affected major joint or group of minor joints. 38 C.F.R. § 4.71a. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent rating is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Id. Under DC 5260, a 10 percent rating will be assigned for limitation of flexion of the knee to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the knee to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the knee to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Additionally, DC 5261 dictates that limitation of extension of the knee to 10 degrees is 10 percent disabling, extension limited to 15 degrees is 20 percent disabling, and extension limited to 20 degrees is 30 percent disabling. 38 C.F.R. § 4.71a, DC 5261. If the criteria for a compensable rating under both DC 5260 and DC 5261 are met, separate ratings can be assigned. VAOPGCPREC 9-2004 (Sept. 17, 2004). Similarly, a claimant who has both arthritis and instability of the knee may be rated separately under DC 5010 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). Normal range of motion of the knee is zero to 140 degrees. 38 C.F.R. § 4.71a, Plate II. Knee instability is evaluated under DC 5257. 38 C.F.R. § 4.71a. A 10 percent evaluation is warranted for slight recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. A 20 percent evaluation is warranted for moderate recurrent subluxation or lateral instability. Id. A 30 percent evaluation, which is the maximum available under this diagnostic code, is warranted for severe subluxation or lateral instability. Id. The Board notes that the terms "slight," "moderate," and "severe" 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." 38 C.F.R. § 4.6. A June 2007 VA treatment record notes chronic bilateral knee pain diagnosed as chondromalacia. He also had a history of right knee anterior cruciate ligament (ACL) injury in 1999. The Veteran continued to have anterior knee pain symptoms, pain with stairs, pain with kneeling, and pain with squatting. He denied mechanical symptoms such as swelling, locking, and buckling of the knee. He was noncompliant with NSAIDS, quadriceps exercises, and weight reduction. He was in no acute distress and ambulated well. His left knee was stable with positive patella grind test. The Veteran's symptoms were a little out of proportion to his physical examination and radiographic findings. In May 2008, the Veteran underwent a VA examination in conjunction with this appeal. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation. At that time the Veteran reported pain in the bilateral knees for 31 years, weakness, stiffness, and giving way, but not swelling heat, redness, lack of endurance, locking, fatigability, or dislocation. The pain traveled to his bilateral hips and right foot. The pain could be elicited by physical activity and stress. It was relieved by rest and on its own. Additionally, his left knee pain was relieved by medication. At the time of pain he could function with medication. He did not have any prosthetic implants of the joint. He did not experience any functional impairment from these conditions. Physical examination found his posture and gait to be within normal limits. Both knees were tender. Neither knee showed signs of edema, effusion, weakness, redness, heat, or guarding of movement. There was no subluxation. Both knees showed traumatic genu recurvatum with weakness, insecurity on weight bearing, and crepitus. There was no locking pain. Range of motion for both knees was from zero to 100 degrees with pain beginning at 100 degrees. Joint function in both knees was additionally limited by pain and fatigue with pain having the major functional impact. This resulted in no additional limitation of motion of the knees. Medial and lateral meniscus testing in both knees was slightly abnormal. All other stability testing was normal. Right knee x-rays were within normal limits. Left knee x-rays showed arthritic changes. The Veteran was diagnosed with right knee chondromalacia of the patella and patellar tendonitis, genu recurvatum with slight instability of the right knee and left knee chondromalacia of the patella and patellar tendonitis, degenerative joint disease, genu recurvatum with slight instability of the left knee. A March 2015 VA treatment record notes arthritis on both knees. The Veteran denied recent fall or injury. A July 2015 VA treatment record notes the Veteran's request for new knee braces noting that the previous ones were wearing out. An August 2015 VA treatment record notes that the Veteran reported being fitted for knee braces. A January 2016 Disability Benefits Questionnaire (DBQ) describes the Veteran's symptoms as bilateral knee pain every day, aggravated by activity, specifically at his kneecaps, inability to climb stairs even with a cane, and occasionally popping "like bubble wrap." He denied any recent physical or occupational therapy for his knees. Pain was relieved with rest and pillows between his knees. He did not report flare-ups. Functionally, he reported that these disabilities prevented prolonged standing, waiting in line at stores, bending down, squats, climbing stairs, and mowing grass even with self-propelled lawnmower. Range of motion testing found flexion limited to 130 degrees in the right knee and 125 degrees in the left. Extension was normal in the right knee and limited to 10 degrees in the left. The range of motion itself did not contribute to a functional loss in either knee. Pain was noted on examination in flexion and extension of both knees, but did not result in or cause functional loss. There was no evidence of pain with weight bearing on either knee. This the Board finds sufficient to meet the requirements of 38 C.F.R. 4.59 as explained in Correia v. McDonald, 28 Vet. App. 158 (2016). The Veteran was able to perform repetitive-use testing with at least three repetitions for both knees without additional loss of range of motion or functional loss. Both knees showed objective evidence of crepitus. The Veteran was not being examined immediately after repetitive use over time and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner was unable to say, without resorting to mere speculation whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time, noting that there is no conceptual or empirical basis for making such a determination without directly observing function under these conditions. Similarly, the Veteran was not being examined during a flare-up and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss during a flare-up. The examiner was unable to say, without resorting to mere speculation whether pain, weakness, fatigability or incoordination significantly limit functional ability during a flare-up, noting that there is no conceptual or empirical basis for making such a determination without directly observing function under these conditions. This is an adequate explanation as the examiner had the Veteran's symptoms before him and therefore considered the Veteran's reported symptoms. There were no other contributing factors of disability. There was no reduction of muscle strength or atrophy. There was no ankylosis. There was no history of recurrent subluxation or lateral instability for either knee. There was no history of recurrent effusion. Stability testing was performed and no joint instability was found for either knee. The Veteran did not currently or historically have recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He did not currently or historically have a meniscus condition. He had not undergone any knee surgery. The Veteran did not have any associated scars or other pertinent physical findings, complications, conditions, signs or symptoms related these disabilities. He required regular use of a brace and cane for normal locomotion. The Veteran's bilateral knee disabilities did not result in functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis. Imaging studies showed arthritis in the left knee only. The Veteran's knee disabilities prevented prolonged standing and walking. The Veteran was retired from the postal service and reported losing less than one week of time from work over the prior 12 months. Based in the above, the Veteran's bilateral knee disabilities are characterized by pain, limitation of motion, weakness, insecurity on weight bearing, and crepitus. Although painful, at no point did either knee's limitation of flexion rise to a compensable level under DC 5260, meaning limitation of flexion to 45 degrees or less. See 38 U.S.C.A. §38 C.F.R. § 4.71a. Likewise, the right knee has not been shown to have limited extension. Thus, the record does not show symptoms warranting a rating higher than the current 10 percent assigned for painful motion of the right knee. A compensable limitation of left knee extension was shown in the January 2016 DBQ. See 38 U.S.C.A. §38 C.F.R. § 4.71a, 5261. A higher rating for this limitation of extension would require limitation to 15 degrees or more, which is not shown here. Thus, the record does not show symptoms warranting a rating higher than the current 10 percent assigned for limitation of motion of the left knee. The Board has also considered whether separate ratings are warranted for instability of either knee. In this case, the only medical evidence of instability in the May 2008 VA examination, which noted medial and lateral meniscus testing in both knees was slightly abnormal. All other stability testing was normal. Medical records from before and after that examination repeatedly show stable bilateral knees. As the examination is the lone outlier, the Board does not find sufficient evidence of recurrent lateral instability of either knee. Likewise, the record does not show recurrent subluxation. Thus, a separate compensable rating under DC 5257 is not warranted for either knee. Therefore, the Board finds that the preponderance of the evidence is against a schedular rating higher than 10 percent for chondromalacia patella and patellar tendonitis, right knee and against a schedular rating higher than 10 percent for chondromalacia patella and patellar tendonitis, left knee, with arthritic changes. Hence the appeals as to higher ratings for these disabilities must be denied. There is no reasonable doubt to be resolved as to these issues. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. V. Extraschedular The Board has considered whether referral for an extraschedular rating under 38 C.F.R. § 3.321(b)(1) is warranted in this case. The Board finds that the Veteran's symptoms of bilateral pes planus, degenerative joint disease of the bilateral great toes, and bilateral knee disabilities are contemplated by the schedular rating criteria. Neither the facts of the case nor the Veteran's allegations raise the issue of extraschedular consideration. Thus, no analysis is required. See Yancy v. McDonald, 27 Vet. App. 484, 494 (2016) (holding that an extraschedular analysis is not warranted where it is not "specifically sought by the claimant nor reasonably raised by the facts found by the Board") (citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007). See also Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (explaining that the Board had no obligation to analyze whether referral is warranted for extraschedular consideration if an extraschedular rating is not specifically sought by the claimant or reasonably raised by the facts found by the Board). Similarly, the Board recognizes that a claim for a total rating based on individual unemployability (TDIU) may be raised as a separate claim, or in the context of an initial rating or a claim for an increase. See Rice v. Shinseki, 22 Vet. App. 447, 452-53 (2009). In this case, the Veteran retired from his job as a mail carrier in 2103. At his hearing, he testified that this was due to a combination of physical ailments including his service connected disabilities and a non-service connected shoulder disability. He has not argued and the medical evidence does not suggest that his service connected disabilities alone would render him unemployable. Thus, neither the claimant nor the record has raised the question of unemployability due to his service-connected disabilities alone. Therefore no further discussion of a TDIU is necessary. ORDER A rating higher than 10 percent for pes planus prior to January 11, 2016, is denied. A rating higher than 50 percent for bilateral pes planus as of January 11, 2016, is denied. A rating higher than 10 percent for degenerative joint disease of the bilateral great toes is denied. A rating higher than 10 percent for chondromalacia patella and patellar tendonitis, right knee is denied. A rating higher than 10 percent of chondromalacia patella and patellar tendonitis, left knee, with arthritic changes is denied. ______________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs