Citation Nr: 1802818 Decision Date: 01/12/18 Archive Date: 01/23/18 DOCKET NO. 15-10 239 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a left foot disability. 2. Entitlement to an initial rating in excess of 10 percent for a left ankle disability. 3. Entitlement to an initial rating in excess of 10 percent for left knee degenerative joint disease from September 5, 2003 to March 5, 2013. 4. Entitlement to an initial rating in excess of 10 percent for left knee laxity from September 5, 2003 to March 5, 2013. 5. Entitlement to a rating in excess of 30 percent for left knee degenerative joint disease status post total knee replacement since May 1, 2014. 6. Entitlement to a rating in excess of 30 percent for residuals of a right knee injury with traumatic arthritis status post total knee replacement since May 1, 2014. 7. Entitlement to an initial rating in excess of 10 percent for right ankle sprain. REPRESENTATION Appellant represented by: James G. Fausone, Attorney at Law ATTORNEY FOR THE BOARD Mary E. Rude, Counsel INTRODUCTION The appellant served on active duty from December 1979 to June 1989. This matter originally came to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In a January 2013 Board decision entitlement to a rating in excess of 20 percent for residuals of a right knee injury with traumatic arthritis was denied. That decision is final. 38 U.S.C. § 7104 (2012). In April 2013, the Veteran requested a temporary total evaluation for her right knee disability. In a May 2014 rating decision the Veteran was granted entitlement to a temporary total evaluation for residuals of right and left knee surgeries, to include a period of convalescence, from March 6, 2013 to April 30, 2014; as well as special monthly compensation under 38 U.S.C. § 1114(s)(1) (2012). This constitutes the maximum evaluation for these disabilities during this period. As such, this period is no longer on appeal regarding the claims of entitlement to increased ratings for right and left knee disorders. In August 2016, the Veteran perfected an appeal regarding the evaluation assigned to her right knee disability since May 1, 2014. The current appeal therefore addresses only the period since May 1, 2014 for the right knee. The appeal regarding the left knee stems from a January 2015 rating decision which granted entitlement to service connection and assigned a 10 percent evaluation for left knee degenerative joint disease, as well as a separate a 10 percent evaluation for left knee laxity, effective September 5, 2003. The Veteran submitted a notice of disagreement regarding this evaluation and perfected a timely appeal of the entire initial rating. Therefore the periods from September 5, 2003 to March 5, 2013 and since May 1, 2014 are on appeal regarding the left knee disabilities. The issues of entitlement to service connection for a left ankle disability, entitlement to an initial rating in excess of 10 percent for a left ankle disability, and entitlement to an initial rating in excess of 10 percent for a right ankle sprain are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. From September 5, 2003 to March 5, 2013, the Veteran's left knee degenerative joint disease was not manifested by flexion limited to 45 degrees or extension limited to 10 degrees. 2. From September 5, 2003 to March 5, 2013, the Veteran's left knee laxity was not manifested by moderate recurrent subluxation or lateral instability. 3. Since May 1, 2014, the Veteran's left knee degenerative joint disease status post total knee replacement has not been manifested by ankylosis, flexion limited to 45 degrees, extension limited to 10 degrees, impairment of the tibia and fibula, and it has not been manifested by chronic residuals of severe painful motion or weakness. 4. Since May 1, 2014, the Veteran's residuals of a right knee injury with traumatic arthritis status post total knee replacement have not been manifested by ankylosis, flexion limited to 45 degrees, extension limited to 10 degrees, by impairment of the tibia and fibula, and it has not been manifested by chronic residuals of severe painful motion or weakness. CONCLUSIONS OF LAW 1. From September 5, 2003 to March 5, 2013, the criteria for an initial rating higher than 10 percent for left knee degenerative joint disease, based on limitation of motion, were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5260-5261 (2017). 2. From September 5, 2003 to March 5, 2013, the criteria for an initial rating higher than 10 percent for left knee laxity were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2017). 3. Since May 1, 2014, the criteria for a rating higher than 30 percent for left knee degenerative joint disease status post total knee replacement have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5055, 5257, 5260, 5261, 5262 (2017). 4. Since May 1, 2014, the criteria for a rating higher than 30 percent for residuals of a right knee injury with traumatic arthritis, status post total knee replacement, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5055, 5257, 5260, 5261, 5262. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017). The Veteran contends that her left knee laxity and left knee degenerative joint disease warrant higher ratings from September 5, 2003 to March 5, 2013, and that her right and left knee disabilities, each status post total knee replacement, warrant higher ratings since May 1, 2014. Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of the 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 (2017). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45. In DeLuca, it was held that when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id. at 206. Diagnostic Codes 5260 and 5261 pertain to a limitation of knee motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. In this regard, a normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. A limitation of leg flexion allows for a 10 percent evaluation when it is limited to 45 degrees, a 20 percent evaluation when it is limited to 30 degrees, and a 30 percent evaluation when it is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A limitation of leg extension is assigned a 10 percent evaluation when it is limited to 10 degrees, a 20 percent evaluation when it is limited to 15 degrees, and a 30 percent evaluation when it is limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Separate ratings for knee disabilities may be assigned for disability of the same joint, if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04 (2004); 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14. Under Diagnostic Code 5257, recurrent subluxation or lateral instability can be rated as slight (10 percent), moderate (20 percent), or severe (30 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5259, a 10 percent rating can be assigned for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5258, a 20 percent evaluation can be assigned for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. The Veteran, however, has never been found to have a meniscal or cartilage impairment. Hence, this rating criteria will not be further discussed. Evaluations for knee impairment can also be assigned due to ankylosis or genu recurvatum, but as the Veteran has not at any time been found to have ankylosis or genu recurvatum, these diagnostic codes are also not applicable and will not be further discussed. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5263 (2017). The Veteran has been diagnosed with degenerative joint disease in both knees. Diagnostic Code 5003 states that 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Under Diagnostic Code 5055, residuals of a knee replacement are assigned a 100 percent rating for one year following the surgery. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Following the end of that period, the Veteran is assigned a minimum rating of 30 percent. Id. With intermediate degrees of residual weakness, pain, or limitation of motion, residuals of a the replacement are rated by analogy to Diagnostic Codes 5256, 5261, or 5262. A rating of 60 percent is assigned when there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. Id. Diagnostic Code 5262 evaluates impairment of the tibia and fibula, and assigns a 10 percent rating for slight knee or ankle disability, a 20 percent rating for moderate knee or ankle disability, a 30 percent rating for malunion with marked knee or ankle disability, and a 40 percent rating for nonunion with loose motion, requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Left Knee Disabilities, September 5, 2003 to March 5, 2013 From September 5, 2013 to March 5, 2013, the Veteran was assigned a 10 percent rating for left knee degenerative joint disease under Diagnostic Codes 5003 and 5260, and a separate 10 percent rating for left knee laxity, under Diagnostic Code 5257. The Veteran's VA and private treatment records show continuous treatment for left knee arthritis throughout the period from September 2003 to March 2013. In August 2003, the Veteran complained of worsening left knee pain and was found to have knee pain, tenderness, and subluxation of the patella. Her active range of motion was from 0 to almost 90 degrees, but there was pain. Drawer and Lachman tests were negative. In November 2003, she was treated for moderate generalized laxity with posttraumatic osteoarthritis. At a December 2003 physical therapy session the Veteran reported that she had received knee braces and that they helped her knees to feel better. Her knee range of motion and strength were within normal limits. She gave resistance to extension due to pain. The Veteran continued to have knee pain and swelling in April 2004, and in June 2004, she could perform 50 percent of a full squat, but movement appeared slow and labored. In August 2007, the Veteran reported that her left patella did not "stay on track." Examination revealed no significant joint effusion, but there was mild crepitus upon passive range of motion. X-rays showed suspected mild patellar subluxation with moderate osteoarthritis. In April 2009, her knee range of motion was within normal limits. Her gait was independent, with "no instability noted." In May 2009, she reported being unable to go up or down stairs and having significant night pain. Reportedly pain was worse with activity. Physical examination revealed a range of motion from 0 to 125 degrees. There was tenderness to palpation, and the knee was stable throughout range of motion. She was found to have patellofemoral maltracking. The appellant reported in July 2009 that left knee pain had increased with walking and stairs. On examination her gait appeared normal, and she was wearing a left knee brace. Range of motion was within full limits. There was patellar grind with nominal pressure, and she was diagnosed with chondromalacia patella with lateral patellar subluxation. At a November 2009 physical therapy session the Veteran reported that her left knee cap "pops out" and that she was taping her knee to reduce pain. She reported that pain caused functional limitations in lower body dressing, bathing, bed mobility, transfers, ambulation, bending, and lifting. She was found to have decreased strength and range of motion, and negative Drawer and Lachman tests. In December 2009, the Veteran demonstrated a range of motion from -5 to 130 degrees, with effusion, positive patella grind, and medial joint line pain. There was medial pain with hyperflexion. In March 2010, she was walking with a limping gait, but was able to bear weight adequately. She had mild edema and moderate pain with range of motion. In November 2010, the Veteran reported that she fell the previous year and had increased left knee swelling since. Later that month an orthopedic assessment found chronic edema of the knees, and there was mild tenderness over the medial line joint. Range of motion was from 0 to 110 degrees. At a March 2011 orthopedic surgery assessment, she was found to have left medial laxity patella with pain and mild effusion. In April 2011, the Veteran was given a cane due to left knee pain. The appellant reported that in May 2011 she missed a step in her garage and fell on her knees, which caused her to be unable to stand for long periods of time. She reported needing to change job positions at work so that she was no longer required to be on her feet all day. She reported having falls when her knees would "give out." In June 2011, she was treated for knee pain, but found to have full range of motion with no effusion or bruising. In August 2011, the Veteran had range of motion of 0 to 110 degrees, but had discomfort beyond 90 degrees. The Veteran had tenderness but no instability in December 2011, and her range of motion was from 0 to 110 degrees. In April 2012, the Veteran had effusion and positive patella grind, with medial joint line pain. Range of motion was shown from 0 to 130 degrees. There was no erythema or warmth. In January 2013, the Veteran was noted to have pain and a decreased range of motion. Examination found swelling and tenderness of the knee. At an evaluation later that month, she reported joint catch/locking, swelling, a limited range of motion, and trouble walking, as well as instability causing multiple falls. She stated that stair-climbing, sitting for a long period of time, and weight bearing increased her pain. Physical examination found mild tenderness, no effusion, negative Drawer and Lachman tests. Her range of motion was from 0 to 120 degrees. She was found to have severe arthritic changes in her knees, and she was recommended for total knee arthroplasty. In a February 2013 preoperative visit before her total knee replacement, the Veteran reported having buckling episodes that caused her to fall, having severe pain that was aching in quality and interfered with activities of daily living, and taking pain medication for pain relief. Her left knee had range of motion from 0 to 100 degrees. There was no effusion and reflexes were normal, but there was tenderness. The Veteran has also attended multiple VA examinations of the knees during this period. At an April 2004 VA examination, the Veteran reported having daily left knee pain, and that her left knee swelled depending on how much work she has done and how much she has been on her feet. She stated that left knee pain was worse with humidity, increased work, walking, and cold weather. She stated that the disorder interfered with work, that she could not get around easily, climb stairs, or lift things, and that it interfered with other daily activities. Physical examination found mild edema. Flexion was from 0 to 100 degrees, with pain at "100 degrees minus 40 degrees." Extension was to 0 degrees, with pain at 0 degrees. Her ligaments and meniscus were stable. McMurray and Lachman tests were negative. There was no real fatigue, weakness, or incoordination with active range of motion. There was mild left patella subluxation. The Veteran next attended a VA examination in January 2005. She demonstrated an active range of motion from 0 to 120 degrees, with pain from 80 to 120 degrees. Passive range of motion was from 0 to 140 degrees, with pain from 80 to 120 degrees. She reported flare ups which caused increased pain and loss of another 10 to 20 degrees of flexion. She had 1+ medial and lateral instability and small effusion. The Veteran reported that her bilateral knee disabilities had caused her to miss 10 days of work in the last 12 months and prevented her from performing normal housework chores. At a September 2005 VA examination, she demonstrated a range of motion from 0 to 125 degrees. There was inferior and medial tenderness, slight crepitus with flexion, slightly positive Lachman test, and laxity with valgus compression of minimal degree. The Veteran next attended a VA examination in September 2010. Physical examination found no instability, meniscus abnormality, grinding, or clicks and snaps. There was crepitation and patellofemoral crepitus. Left knee flexion was to 115 degrees, and extension was to 5 degrees. There was no objective evidence of pain with active motion or additional limitation with repetitive motion. At an October 2011 VA examination she showed left knee flexion to 90 degrees, with painful motion at 80 degrees, and extension to 0 degrees. After repetitive motion testing, her range of motion was unchanged. The examiner noted that the Veteran's functional loss was caused by weakened movement, excess fatigability, incoordination, pain, swelling, and interference with sitting, standing, or weight-bearing. The Veteran reported having flare ups that caused difficulty with standing and walking. Strength and stability testing was normal. The Veteran did have slight patellar subluxation/dislocation. No meniscal condition was found. The Board has reviewed all of the medical evidence of record, but finds that no higher rating than 10 percent for left knee degenerative joint disease and 10 percent for left knee laxity from September 5, 2003 to March 5, 2013 can be assigned. Range of motion testing throughout this period shows that her left knee range of motion consistently did not meet the criteria for a compensable rating under Diagnostic Codes 5260 or 5261. The Veteran's treatment records showed flexion between 90 and 130 degrees, and at the Veteran's five separate VA examinations, her flexion was between 90 and 125. The January 2005 and October 2011 VA examinations found that the Veteran had pain starting at 80 degrees, and the April 2004 VA examiner found pain at "100 degrees minus 40 degrees," which would indicate pain at 60 degrees. But even these findings are well above a finding of flexion limited to 45 degrees, which is the requirement for a 10 percent evaluation under Diagnostic Code 5260. At all times, the Veteran has had extension to 0 degrees or better, and therefore a compensable rating is also not warranted under Diagnostic Code 5261. The Veteran did, however, have decreased flexion in the left knee, and X-rays had confirmed that she had a diagnosis of left knee degenerative joint disease. On this basis, she was assigned a 10 percent rating for left knee degenerative joint disease under Diagnostic Code 5003. The Board finds that this was the appropriate evaluation, and no higher rating due to limitation of motion or the presence of arthritis can be assigned, as Diagnostic Code 5003 allows for only a 10 percent evaluation for each major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board acknowledges that the VA treatment records, VA examination reports, and lay statements indicate that she reports having chronic knee pain, and the Board has considered 38 C.F.R. § 4.59 regarding painful motion. Under 38 C.F.R. § 4.59, with any form of arthritis, actually painful joints are entitled to at least the minimum compensable rating. See also Petitti v. McDonald, 27 Vet. App. 415, 425 (2015) ("Under 38 C.F.R. § 4.59, the trigger for a minimum disability rating is an 'actually painful, unstable, or malaligned joint [].'"). In this case, however, the Veteran has already been assigned at least the minimum compensable rating, 10 percent, for her left knee. See Petitti, 27 Vet. App. at 425. That 10 percent evaluation takes into account the Veteran's limitation of motion hampered by pain, repetitive motion, and flare ups, as these symptoms were evaluated on his examination. Furthermore, pain, by itself, does not constitute functional loss. Rather, there must be actual limitation of motion that is caused by pain. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). The Board is also unable to assign a rating higher than 10 percent for left knee laxity from September 5, 2003 to March 5, 2013. A 20 percent rating would require a finding that the Veteran had recurrent subluxation or lateral instability that was at least "moderate." 38 C.F.R. § 4.71a, Diagnostic Code 5257. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6 (2017). The majority of the Veteran's stability testing throughout this period was negative, save for a finding of slight instability in January 2005. All subsequent instability testing was normal. The Veteran was, however, diagnosed with subluxation of the patella and patellofemoral maltracking, and she described this as feeling that her patella did not "stay on track" or that it "pops out." The Veteran was still able to ambulate independently however. In April 2009, she was noted to have an independent gait with no instability. In July 2009 she was also noted to have normal gait. In March 2010 she was found to have a limping gait, but she was able to bear weight adequately. Additionally, the April 2004 VA examiner described the Veteran's left patella subluxation as "mild," and an August 2007 X-ray showed only "suspected mild" lateral patellar subluxation. At no time during the period on appeal has any examiner ever described the Veteran's subluxation or its related symptoms as "moderate" or "severe." More importantly, moderate or severe pathology due to subluxation or lateral instability has never been demonstrated. The Board acknowledges that the Veteran has asserted that she believes she has had falls caused, at least in part, by instability in her left knee. The preponderance of the medical evidence does not show, however, that her patellar subluxation has caused any falls. In April 2011, the Veteran reported that she fell while using stairs when she missed a step, and there is no other clinical evidence showing that patellar subluxation. While the Veteran has reported that she feels that her knees become weak and that this contributes to falling, the most probative medical evidence shows only mild patellar subluxation, and does not confirm that this specific condition has been the proximate cause of any falls. Therefore the weight of the probative, medical evidence indicates that the Veteran's left knee recurrent subluxation, characterized as left knee laxity by the RO, does not warrant a rating higher than 10 percent under Diagnostic Code 5257. Id. The Board considered the Veteran's lay statements regarding the functional impact of her left knee disabilities, including difficulty with prolonged walking or standing and climbing stairs. The Veteran is competent to report her own observations with regard to the severity of his disability, including reports of pain and decreased mobility. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Her statements are consistent with the ratings assigned. The occurrence of pain and increased difficulty while performing physical activities are not additional symptoms, but rather the practical effect of the symptoms of pain and limited range of motion which have been clinically observed and measured in the Veteran's medical records. To the extent that the Veteran argues her symptomatology is more severe than shown on evaluation, her statements must be weighed against the other evidence of record. Here, the specific examination findings of trained health care professionals are of greater probative weight than the Veteran's more general lay assertions. Based on the foregoing, the Board finds that entitlement to initial ratings higher than 10 percent for left knee degenerative joint disease and 10 percent for left knee laxity are not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; as the preponderance of the evidence is against assignment of any higher ratings, it is not applicable. See 38 U.S.C. § 5107(b). Bilateral Knee Disabilities since May 1, 2014 The Veteran underwent right and left total knee replacement surgery in March 2013, and was then assigned a 100 percent temporary total evaluation, plus special monthly compensation under 38 U.S.C. § 1114(s)(1), from March 6, 2013 to May 1, 2014. At the end of this term the Veteran was assigned 30 percent for left knee degenerative joint disease status post total knee replacement, and a 30 percent for residuals of a right knee injury with traumatic arthritis status post total knee replacement. Each rating was assigned under Diagnostic Code 5055. The Veteran's VA treatment records show that her knee symptomatology has generally improved since her knee surgery. In May 2015, the Veteran went to the emergency room and reported that sometimes her knees get weak, and that she had fallen onto her knees that morning, causing pain. She also stated that she had tripped over someone's foot, which caused her to fall and hit her knees. Imaging showed the knee prostheses were in place, and she was diagnosed with knee pain and discharged. In September 2015, she reported having sore knees, but was walking without a cane. She had full knee strength, although there was ecchymosis of the legs and knees, and her right knee was tender. She demonstrated a full range of motion, and no hot, swollen, or boggy knees. The Veteran attended a VA examination in March 2014. The Veteran reported having flare ups, stiffness, aggravation by cold and wet weather, and knee pain that "comes and goes." She did not use any assistive devices post-surgery and reported that since the surgery, her pain was much better. Range of motion testing found right knee flexion to 100 degrees, with painful motion at 100 degrees, and extension to 0 degrees. Left knee flexion was to 95 degrees, with painful motion at 95 degrees, and extension to 0 degrees. There was no change in range of motion after repetitive motion. The examiner noted that pain on movement caused functional loss, and that there was pain to palpation. The Veteran had decreased knee strength, but normal stability and no recurrent patellar subluxation/dislocation. The examiner specified that the Veteran's residuals of total knee replacement surgery were stiffness and aching, especially in cold weather, and stated that the condition would not impact her ability to work. There were no shin splints or any other impairment of the tibia or fibula. The examiner wrote that there were no flare ups at the time of examination, and that it would be mere speculation to express in terms of the degrees of additional range of motion loss due to pain, weakness, fatigability, or incoordination due to flare ups. The Veteran most recently attended a VA examination in July 2016. She reported that being in a car accident in September 2015, and that she experienced increased pain and swelling in both knees and decreased range of motion in the left knee since. She stated that the swelling was intermittent, and that her left knee would give way slightly, but did not result in her falling. She reported intermittent flare ups with prolonged standing or walking. She reportedly avoided kneeling and had difficulty squatting and using stairs. Range of motion testing found right knee flexion to 105 degrees and extension to 0 degrees, with pain noted on examination, but which did not result in further functional loss. The left knee had flexion to 115 degrees and extension to 0 degrees, with pain again noted on examination, but which did not result in further functional loss. There was no pain with weight-bearing or crepitus, but there was tenderness in the left knee. There was no further functional loss after repetitive motion, and pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over a period of time. The examiner stated that the examination was neither medically consistent or inconsistent with the Veteran's statements about functional loss during flare ups. The examiner also found that pain, weakness, fatigability, and incoordination would not significantly limit functional ability with a flare up. There was no ankylosis, muscle strength was normal, and joint stability was normal, including a finding of no recurrent subluxation. There was no tibia or fibular impairment. The Veteran's residual symptoms of total knee replacement surgery included mild pain and limited range of motion. The examiner noted that the Veteran also had small left knee effusion, without erythema or increased warmth. The Veteran did not require an assistive device, although she sometimes used a scooter to do prolonged shopping. She reported that she worked as a clerk for VA, and that her job was primarily sedentary, although she occasionally had to stand and walk around the facility. She reported that she typically did not miss work as a result of her knee condition, although she missed two-three days after the fall in 2015. After reviewing the evidence, the Board finds that entitlement to a rating higher than 30 percent for either left or right knee status post total knee replacement residuals is not warranted. The Veteran does not meet the criteria for a 60 percent rating under Diagnostic Code 5055 for either knee. The appellant has not been found to have chronic residuals consisting of severe painful motion or weakness. The Veteran has reported knee pain, but stated at the March 2014 VA examination that is "comes and goes." While the March 2014 VA examiner found decreased knee strength, she was noted in September 2015 and July 2016 to have full strength in her knees, and she no longer uses a cane to ambulate. At no time since May 1, 2014 has any treatment provider or examiner found that the Veteran had "severe" painful motion or weakness. As such, a 60 percent rating under Diagnostic Code 5055 is therefore not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Diagnostic Code 5055 states that intermediate degrees of residual weakness, pain, or limitation of motion be rated by analogy to Diagnostic Codes 5256, 5261, or 5262. The Board does not find, however, that these diagnostic codes would allow for a rating higher than the 30 percent already assigned. The Veteran has never been found to have ankylosis involving either knee, and the March 2014 and July 2016 VA examiners specifically indicated that the Veteran did not have any impairment of the tibia or fibula. There is therefore no evidence indication that a compensable rating could be assigned under Diagnostic Codes 5256 or 5262. The Veteran's range of motion was also not of sufficient severity to allow for a compensable rating based on either flexion or extension, even with painful motion taken into account. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. The most favorable rating code to apply to the Veteran's knee disabilities post-total knee replacement is therefore Diagnostic Code 5055, which allows for a 30 percent minimum rating. 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Board has taken into consideration the Veteran's reports of painful motion, but she is already assigned the minimum rating for both her right and left knees since May 1, 2014, and the criteria under Diagnostic Code 5055 specifically takes into consideration the Veteran's painful motion. No higher rating is therefore warranted based on painful motion alone. See 38 C.F.R. § 4.59; Petitti, 27 Vet. App. at 425. In sum, the Board finds that entitlement to ratings higher than 30 percent for left knee degenerative joint disease status post total knee replacement, and for residuals of a right knee injury with traumatic arthritis status post total knee replacement since May 1, 2014 are not warranted. The Board has again considered the applicability of the benefit of the doubt doctrine, but the preponderance of the evidence is against assignment of any higher ratings. See 38 U.S.C. § 5107(b). Lastly, the question of entitlement to referral for consideration of an extraschedular rating is neither an issue argued by the claimant nor reasonably raised by the record through evidence of the collective impact of the claimant's service-connected disabilities. Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). ORDER Entitlement to an initial rating in excess of 10 percent for left knee degenerative joint disease from September 5, 2003 to March 5, 2013 is denied. Entitlement to an initial rating in excess of 10 percent for left knee laxity from September 5, 2003 to March 5, 2013 is denied. Entitlement to a rating in excess of 30 percent for left knee degenerative joint disease status post total knee replacement since May 1, 2014 is denied. Entitlement to a rating in excess of 30 percent for residuals of a right knee injury with traumatic arthritis status post total knee replacement since May 1, 2014 is denied. REMAND The Veteran contends that she has a left foot disability that was either incurred in service or has been caused or aggravated by her service-connected knee and ankle disorders. The Veteran's VA treatment records show complaints of foot pain in the heel and arch, as well as plantar fascia tenderness. She has been diagnosed with plantar fasciitis and underwent left foot fasciotomy surgery in November 2011. An August 2001 X-ray also found possible soft tissue damage, which the Veteran reported could have been caused by stepping on broken glass. The Veteran has not yet been afforded a VA examination regarding the nature and etiology of her claimed foot disorder. Because the claimant has asserted that she has had foot problems since service and that her foot pain is aggravated by her service-connected disorders, this issue is remanded so that a VA examination can be conducted prior to further adjudication. The Veteran and her attorney have also asserted that her last VA examination of her left ankle disability, held in March 2014, is no longer representative of the current severity of her left ankle disorder, which has continued to worsen. The Board therefore remands this issue so that a new VA examination can be conducted. In a January 2015 rating decision VA granted entitlement to service connection for right ankle sprain and assigned an evaluation of 10 percent, effective September 5, 2003. The Veteran submitted a timely notice of disagreement in January 2016, but a statement of the case has not yet been issued addressing this issue. See Manlincon v. West, 12 Vet. App 238, 240-241 (1999). This issue is therefore remanded in order to address this procedural deficiency. Accordingly, the case is REMANDED for the following action: 1. The AOJ should issue a statement of the case addressing the claim of entitlement to an initial rating in excess of 10 percent for a right ankle sprain. Thereafter, the Veteran should be given an opportunity to perfect an appeal by submitting a timely substantive appeal. The AOJ should advise the Veteran that the Board will not exercise appellate jurisdiction over this claim absent a timely perfected appeal. 2. Provide the Veteran with another opportunity to submit a completed release form (VA Form 21-4142) authorizing VA to secure any additional, relevant private treatment records. The Veteran should be advised that she can also submit those records himself. If the Veteran provides a completed release form, then request the identified treatment records. All attempts to secure those records must be documented in the Veteran's claims file, and she and her attorney should be notified of any unsuccessful efforts. 3. Request all relevant VA treatment records from the Central Texas Veterans Health Care System dating since April 2016. All records obtained should be associated with the claims file. If the AOJ cannot locate any Federal records requested herein, it must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The AOJ must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. The claimant must then be given an opportunity to respond. 4. Thereafter schedule the Veteran for an appropriate VA examination with a qualified examiner to address the nature and etiology of any diagnosed left foot disorder. The examiner must specify in the report that all VBMS and Virtual VA records have been reviewed. Any indicated evaluations or studies should be conducted. Based on examination findings, medical principles, and historical records, including available service treatment records, the examiner must discuss: a) What are the Veteran's current left foot disabilities, to include any disabilities that may have resolved during the course of the appeal? Please specifically discuss the etiology of Veteran's diagnosed left foot plantar fasciitis. b) For each diagnosed left foot disorder is it at least as likely as not that the disorder had its onset during, or was otherwise related to any event or injury in the Veteran's service? The examiner must discuss the Veteran's lay statements that she has had increasing foot pain since service. c) For each diagnosed left foot disorder, is it at least as likely as not that the Veteran's left foot disorder was either (i) caused or (ii) aggravated (worsened beyond the natural progression) by her service-connected right and left knee disabilities, right ankle sprain, and/or left ankle disability. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 5. Schedule the Veteran for an appropriate VA examination with a qualified examiner to assess the current severity of her service-connected left ankle disability. The examiner must specify in the report that all VBMS and Virtual VA records have been reviewed. Any indicated evaluations or studies should be conducted. The examiner should render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination. If pain on motion is observed, the physician should indicate the point at which pain begins. The examiner should also evaluate the Veteran's right ankle, and indicate whether there is a change in range of motion findings for the left ankle during active or passive motion and with and without weight-bearing. The examiner must indicate whether, and to what extent, the Veteran experiences functional loss of the due to pain and/or any of the other symptoms noted above during flare ups and/or with repeated use; to the extent possible. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups she experiences. Based on the Veteran's lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 6. The Veteran is hereby notified that it is her responsibility to report for any scheduled examinations and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 7. Thereafter, the readjudicate the issues. If any benefit sought is not granted, the appellant and her attorney must be furnished with a supplemental statement of the case and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs