Citation Nr: 1805361 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 10-08 461A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to a higher initial rating for a thoracolumbar spine disability, rated 10 percent from November 14, 2008, to September 7, 2011; 20 percent from September 8, 2011, to June 2, 2015; and 40 percent as of June 3, 2015. 2. Entitlement to an initial rating higher than 20 percent for a right ankle disability. 3. Entitlement to an initial rating higher than 10 percent for a right hip disability. 4. Entitlement to an initial rating higher than 10 percent for a left hip disability. 5. Entitlement to an initial rating higher than 10 percent for a left knee disability. 6. Entitlement to a total rating for compensation purposes based on individual un-employability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran served on active duty from July 1997 to November 2008. These matters come before the Board of Veteran's Appeals (Board) on appeal from a November 2008 rating decision by the Winston-Salem, North Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA). Jurisdiction over the case was subsequently transferred to the RO in Seattle, Washington. In September 2011, the Veteran testified during a hearing before the undersigned Veterans Law Judge at the RO. A transcript of that hearing is of record. In May 2013 and May 2017, the Board remanded the claims for additional development. A March 2016 rating decision assigned a 20 percent rating for a right ankle disability, effective from the initial date of service connection. Higher ratings of 20 percent, effective September 8, 2011, and 40 percent, effective June 3, 2015, were assigned for the service connected back disability. A September 2017rating decision assigned a 10 percent rating for right hip, left hip, and left knee disabilities, effective from the initial date of service connection. However, as a higher rating is available for those disabilities, and the Veteran is presumed to seek the maximum available benefit, the claims for higher ratings remain on appeal. AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. The Veteran's lumbar spine disability has not resulted in forward flexion of the thoracolumbar spine to 60 degrees or less prior to September 8, 2011, or to 30 degrees or less from June 3, 2015; no ankylosis has been shown throughout the period of appeal; and there is not competent and credible evidence of incapacitating episodes having a total duration of at least two weeks. 2. Throughout the period of appeal, the Veteran's right ankle disability has been manifested by severe neurological symptoms best described as severe; marked limitation of motion; and a painful scar. 3. Throughout the period of appeal, the right hip disability was characterized by pain resulting in a noncompensable limitation of motion. 4. Throughout the period of appeal, the left hip disability was characterized by pain resulting in a noncompensable limitation of motion. 5. Throughout the pendency of this claim, the Veteran's left knee disability has been manifested by flexion limited, at worst, to 120 degrees and extension to 0 degrees; it has not been manifested by flexion limited to 30 degrees or less, extension limited to 10 degrees or less, ankylosis, objective evidence of recurrent subluxation or lateral instability, dislocated or removed semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 6. Throughout the period of appeal, the Veteran was able to maintain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating greater than 10 percent from November 14, 2008, to September 8, 2011; 20 percent from September 8, 2011, to June 3, 2015; and 40 percent as of June 3, 2015, for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5237, 5243 (2017). 2. The criteria for a 40 percent rating for a right ankle disability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.40, 4.45, 4.7, 4.71a, 4.68, 4.118, 4.124a, Diagnostic Codes 5165, 5271, 7804, 8525 (2017). 3. The criteria for a rating greater than 10 percent for a right hip disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5003 (2017). 4. The criteria for a rating greater than 10 percent for a left hip disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5003 (2017). 5. The criteria for a rating greater than 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5256-63 (2017). 6. The criteria for a TDIU are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION While the Board must provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by or on behalf of the Veteran. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence of record. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not given to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. When the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Duties to Notify and Assist VA has a duty to notify a Veteran of the information and evidence necessary to substantiate a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). VA also has a duty to assist Veterans in the development of claims. 38 U.S.C. §§ 5103, 5103A (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C. § 5103(a) (2012); 38 C.F.R. § 3.159(b) (2017); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will to provide; and (3) that the claimant is expected to provide. The notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements apply to all five elements of a service-connection claim, to include (1) Veteran status; (2) existence of a disability; (3) a connection between service and the disability; (4) degree of disability; and (5) effective date of the disability. The notice should include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Concerning the service connection claims, correspondence dated in January 2013 provided all necessary notification to the Veteran. For initial rating claims or claims for an earlier effective date, where service connection has been granted and the initial rating and effective date have been assigned, the claim of service connection has been more than substantiated, as it has been proven, thereby making 38 U.S.C. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating or the effective date of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice requirements. Dingess v. Nicholson, 19 Vet. App. 473 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA has done everything reasonably possible to assist the Veteran with respect to the claims for benefits. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). The service medical records have been associated with the claims file. All identified and available treatment records have been secured, which includes VA examinations and VA medical records. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). When VA provides an examination, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has been provided with VA examinations, most recently in July 2017. The examiners reviewed the claims file and past medical history, and made appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board concludes that the VA examination reports are adequate for the purpose of making a decision. 38 C.F.R. § 4.2 (2016); Barr v. Nicholson, 21 Vet. App. 303 (2007). Additionally, in light of the communications with the Veteran, the treatment records that have been obtained and associated with the record, performance of the requested examinations, and the further adjudicatory actions taken by the RO, the Board finds that there has been substantial compliance with the prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141 (1999). The Board is satisfied that all relevant facts have been adequately developed to the extent possible and that no further assistance is required to comply with the duty to assist. Accordingly, the Board will proceed with a decision. Increased Ratings Disability ratings are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Where there is a question as to which of two ratings shall be applied, the higher rating 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). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). The Veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1 (2017); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2017). However, that does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). Rating a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint. 38 C.F.R. §§ 4.45 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). 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. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 (2017). When rating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45 (2017). The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention 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 (2017). Lumbar Spine Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine for Diagnostic Codes 5235 to 5243, unless 5243 is used under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a (2017). The disabilities of the spine that are rated under the General Rating Formula for Diseases and Injuries of the Spine include vertebral fracture or dislocation (Diagnostic Code 5235), sacroiliac injury and weakness (Diagnostic Code 5236), lumbosacral or cervical strain (Diagnostic Code 5237), spinal stenosis (Diagnostic Code 5238), unfavorable or segmental instability (Diagnostic Code 5239), ankylosing spondylitis (Diagnostic Code 5240), spinal fusion (Diagnostic Code 5241), and degenerative arthritis of the spine (Diagnostic Code 5242). Degenerative arthritis of the spine can also be rated using Diagnostic Code 5003. 38 C.F.R. § 4.71a (2017). The General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a (2017). A 20 percent rating is assigned for forward flexion of the thoracolumbar spine 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. 38 C.F.R. § 4.71a (2017). A 40 percent rating is assigned for forward flexion of the thoracolumbar spine of 30 degrees or less; or, unfavorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a (2017). Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2017). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, Plate V, General Rating Formula for Diseases and Injuries of the Spine, Note (2) (2017). The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (4) (2017). In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion. Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (3) (2017). For VA compensation purposes, unfavorable ankylosis 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. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5) (2017). Disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (6) (2017). Diagnostic Code 5243 provides that intervertebral disc syndrome is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 10 percent rating is warranted for intervertebral disc syndrome with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted with incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (2017). 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. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1) (2017). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (2) (2017). Service connection for a lumbar spine disability was granted in a November 2008 RO decision. A 10 percent disability rating was assigned, effective November 14, 2008. The Veteran disagreed with the initial rating assigned. During the course of the appeal, a 20 percent rating was assigned, effective September 8, 2011, and a 40 percent rating was assigned, effective June 3, 2015. On review of all the evidence of record, both lay and medical, the Board finds that the Veteran's lumbar spine disability has not more nearly approximated a rating in excess of 10 percent prior to September 8, 2011; in excess of 20 percent from September 8, 2011, to June 2, 2015; and in excess of 40 percent as of June 3, 2015. In August 2008, the Veteran underwent EMG testing at a private facility. The paraspinal muscles at the L4-L5 and L5-S1 levels were found to be normal. The examiner found evidence for some chronic reinnervation change in the tibialis anterior, but there were no confirmatory abnormalities in the other limb muscles that would suggest the presence of lumbosacral radiculopathy. However, the examiner was suspicious that the Veteran may have some mild lumbosacral radicular dysfunction. An X-ray of the thoracic spine taken in September 2008 was within normal limits. The interpreter did not see any evidence of fracture, dislocation, or bony destructive change of the thoracic spine. There were mild hypertrophic changes of the lumbar spine. On VA examination in September 2008, the Veteran reported back stiffness and numbness. He did not report loss of bladder control or loss of bowel control. He experienced back pain that rated a 5 on a 1 (low) to 10 (high) pain scale. He experienced numbness in his right thigh. The Veteran said that his condition had not resulted in any incapacitation. Objective examination revealed no evidence of radiating pain on movement or muscle spasm. There was negative straight leg raising test on the right and left. There was no ankylosis. Flexion of the lumbar spine was to 90 degrees. Extension was to 30 degrees. Right and left lateral flexion were each to 30 degrees. Right and left rotation were each to 30 degrees. The joint function of the spine was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. There were no signs of Intervertebral Disc Syndrome with chronic and permanent nerve root involvement. A private treatment record from November 2008 reflects that the Veteran had decreased sensation in the lateral and medial malleolar area, posterior calf, and lateral aspect of the thigh in a lumbosacral pattern on the right. Ankle jerk was absent on the right. The examiner remarked that the Veteran had features of right L5-S1 radiculopathy. A nerve block was recommended. A March 2009 VA treatment record indicates that the Veteran had a lumbar radiculopathy on the right side. January 2010 EMG testing found electrodiagnostic evidence consistent with tarsal tunnel syndrome on the right, and no electrodiagnostic evidence of an acute or chronic right-sided lumbar motor radiculopathy. EMG testing conducted in May 2010 was negative for acute or chronic denervation. A private treatment record from May 2011 shows that the Veteran had neuropathic symptoms in the right leg that were consistent with an MRI showing the L5 nerve root being contacted by a disk, and right sided L5-S1 disc protrusion with impaction on the right S1 nerve root. A private physical therapy record from September 2011 shows that the Veteran could demonstrate 45 degrees of forward flexion and 20 degrees of extension. Lower extremity strength on the right was 5/5 in hip flexion, knee flexion, and knee extension. Plantar and dorsiflexion were weak. The Veteran had difficulty ambulating on heels and toes. There was severe pain with palpation over the Achilles tendon. Inversion and eversion at the ankle were uncomfortable. The Veteran had reduced sensation along the lateral aspect of the right foot. A September 2011 private MRI report shows that the Veteran had mild degenerative changes of the lumbar spine. There was moderate L4-L5 central herniated nucleus pulposus with mild bilateral foraminal narrowing. There was also a large broad-based disk protrusion at L5-S1 with moderate bilateral foraminal stenosis and displacement of the right S1 nerve root. At a September 2011 Board hearing, the Veteran reported experiencing pain on a daily basis. His back pain impeded his work, recreation, and hobbies. He reported back spasms. He had pain that radiated down his right leg. He stated that he had back spasms that required bed rest. He specified that doctors told him that if his back went out, he should lay down immediately. He had been prescribed muscle relaxants. In November 2011, the Veteran described severe pain radiating into the right lower extremity. On VA examination in June 2015, the examiner diagnosed thoracolumbar degenerative disc disease and disc protrusion. The Veteran used a TENS unit and felt stiffness, stabbing pain, and restriction of movement. No flare-ups were reported. Forward flexion of the thoracolumbar spine was to 30 degrees with pain at 30 degrees. Extension was to 10 degrees with pain at 0 degrees. Right lateral flexion was to 20 degrees with pain at 20 degrees. Left lateral flexion was to 20 degrees with pain at 20 degrees. Right lateral rotation was to 20 degrees with pain at 20 degrees. Left lateral rotation was to 20 degrees with pain at 20 degrees. No additional loss of motion was found following repetitive-use testing. No guarding or muscle spasm was observed. No muscle atrophy was found. Right ankle reflex was absent. The examiner indicated that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. No other neurologic abnormalities related to a thoracolumbar spine condition were found. The examiner specified that the Veteran did not have intervertebral disc syndrome. On VA examination in July 2017, the Veteran reported constant low back pain that increased with repetitive bending and standing for long time periods. The Veteran currently worked as a supervisor for the Border Patrol. His job was sedentary. The Veteran reported flare-ups of stabbing radiating pain. Forward flexion of the thoracolumbar spine was to 70 degrees. Extension was to 25 degrees. Right lateral flexion was to 25 degrees. Left lateral flexion was to 30 degrees. Right lateral rotation was to 30 degrees. Left lateral rotation was to 25 degrees. Pain was noted on examination, but pain did not result in or cause functional loss. The examiner found no evidence of pain on weight bearing. There was objective evidence of mild pain on palpation. Repetitive use testing did not result in any additional loss of function or range of motion. The Veteran did not have guarding or muscle spasm of the thoracolumbar spine. Sensory examination showed decreased sensation of the right thigh and lower leg. The examiner indicated that the Veteran had radicular pain in the right lower extremity. The symptoms of radiculopathy included moderate constant pain, mild paresthesias and/or dysesthesias, and moderate numbness of the right lower extremity. No other signs or symptoms of radiculopathy were present. No response was given regarding the nerve roots involved. The examiner then indicated that the Veteran's right side was not affected by radiculopathy. There was no ankylosis of the spine. No other neurologic abnormalities related to a thoracolumbar spine condition were found. The examiner indicated that the Veteran did not have intervertebral disc syndrome. The examiner opined that the Veteran's decreased right ankle dorsiflexion and plantar flexion strength was at least as likely as not due to the Veteran's service-connected right ankle condition; that conclusion was supported by the January 2010 EMG which showed no evidence of right lumbar motor radiculopathy. Concerning employment, the examiner opined that employment that required repetitive bending at the waist and standing for long time periods would be impacted and require rest periods. However, sedentary employment was not impacted. Initially, the Board notes that there is no medical evidence of ankylosis of the thoracolumbar spine during the course of the appeal. Thus, a higher rating cannot be assigned on that basis. Moreover, at no time prior to September 8, 2011, has the evidence found forward flexion of the lumbar spine limited to 60 degrees or less, or a 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. The VA examination report prior to September 8, 2011, noted forward flexion, at worst, to 90 degrees with pain after repetitive use testing, and the combined range of motion was 240 degrees. Further, objective examination revealed no evidence of muscle spasm. The examiner observed that, at that time, the Veteran had a normal gait. At no time prior to June 3, 2015, has the evidence found forward flexion of the lumbar spine limited to 30 degrees or less. The treatment records for the period from September 8, 2011, to June 3, 2015, show forward flexion, at worst, to 45 degrees with pain. The other treatment records show continuing complaints of pain and flare-ups. However, the treatment records do not show functional impairment that more nearly approximates the range of motion criteria to support a higher rating under the General Rating Formula, even considering the Veteran's subjective complaints prior to June 3, 2015. Considering the period from June 3, 2015, no ankylosis, either favorable or unfavorable, has been shown. The Board has also considered the Veteran's reported impairment of function, and has considered additional limitations of motion due to pain, incoordination, fatigability, excess motion, weakened motion, or on flare up. Even considering additional limitation of motion or function of the spine due to pain or other symptoms such as weakness, fatigability, pain, or incoordination the evidence still does not show that the lumbar spine disability more nearly approximate the criteria for higher ratings. Upon repetitive use testing, range of motion of the spine did not show any additional loss of range of motion consistent with flexion of the thoracolumbar spine limited to 60 degrees or less prior to September 8, 2011, or limited to 30 degrees or less prior to June 3, 2015, or ankylosed from June 3, 2015, and while the Veteran experienced pain during flare-ups, overall he remained able to function. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). The factors that may additionally limit motion and function were considered and assessed by the examination reports. The VA and private examiners noted less movement than normal, pain on movement, and interference with sitting, standing, and weight-bearing. The Veteran described flare-ups were manifested by increased pain but continued ability to function. The Board finds that pain and reduced range of motion is fully contemplated in the current 10, 20, and 40 percent ratings assigned. The evidence does not show that any additional factors reduce thoracolumbar flexion to 60 degrees or less prior to September 8, 2011, or to 30 degrees or less prior to June 3, 2015, or any ankylosis thereafter. The Board has also considered whether a higher rating could be assigned under the IVDS formula based on incapacitating episodes. However, although the Veteran has said that doctors told him to rest following flare-ups, the evidence shows that throughout the entire period of appeal, the Veteran was never prescribed bed rest by a physician as due to IVDS. Therefore, he has not been shown to have incapacitating episodes requiring bed rest prescribed by a physician and treatment by a physician of a total duration of at least two weeks prior to September 8, 2011, or for a total duration of at least four weeks prior to June 3, 2015, or for a total duration of at least six weeks thereafter. As a final matter, the Board notes that the Veteran clearly experiences neurological symptoms in the right lower extremity. Some medical examiners have indicated that the Veteran experiences radiculopathy in his right lower extremity, such as in a November 2008 private treatment record and March 2009 VA treatment record. However, the conclusions reached by those examiners do not appear to have been based on the results of EMG testing. Other medical examiners have indicated that the Veteran does not have radiculopathy, such as in a June 2015 VA examination report and a July 2017 VA examination report. These examiners based their conclusions on the results of an EMG test. Ultimately, the Board places more weight on the January 2010 EMG test results which found electrodiagnostic evidence consistent with tarsal tunnel syndrome on the right, and no electrodiagnostic evidence of an acute or chronic right-sided lumbar motor radiculopathy. Therefore, the neurological symptoms that the Veteran experiences in his right lower extremity will be discussed and rated below in connection with the service-connected right ankle disability. There are no other neurological disabilities which have been attributed to the Veteran's lumbar spine disability by a medical professional. The competent evidence does not show any other objective neurologic abnormalities associated with the low back disability so as to warrant any separate rating. Accordingly, the Board finds that a rating in excess of 10 percent from November 14, 2008, to September 8, 2011; 20 percent from September 8, 2011, to June 3, 2015; and 40 percent as of June 3, 2015, for the Veteran's lumbar spine disability is not warranted. The Board finds that the preponderance of the evidence is against the claim for increase and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). Right Ankle Under Diagnostic Code 5271 for rating limited motion of the ankle, moderate limitation of motion of the ankle warrants a 10 percent rating and marked limitation of motion of the ankle warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2017). Standard range of ankle dorsiflexion is from 0 to 20 degrees, and plantar flexion from 0 to 45 degrees. 38 C.F.R. § 4.71, Plate II (2016). The terms slight, moderate, and marked are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just, and all evidence must be evaluated in deciding rating claims. 38 C.F.R. § 4.6 (2017). Diagnostic Code 8525 provides the rating criteria for paralysis of the posterior tibial nerve. Disability ratings of 10 percent, 10 percent, and 20 percent are assigned for incomplete paralysis that is mild, moderate, or severe. Complete paralysis of the posterior tibial nerve is rated 30 percent and contemplates paralysis of all muscles of sole of foot. 38 C.F.R. § 4.124a , Diagnostic Code 8525 (2017). The term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The rating schedule does not define the terms mild, moderate, or severe as used in the diagnostic codes. Instead, adjudicators must evaluate all of the evidence and make a decision that is equitable and just. 38 C.F.R. § 4.6 (2017). When assigning ratings, the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. 38 C.F.R. § 4.68 (2017). Amputation at a level lower than the knee, which would permit a prosthesis controlled by natural knee action, warrants a 40 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5165 (2017). Therefore, in accordance with the amputation rule, the combined rating for disabilities affecting the right lower leg cannot exceed a rating of 40 percent. 38 C.F.R. § 4.68 (2017). Service connection for a right ankle condition was granted in a November 2008 RO decision. A 10 percent disability rating was assigned, effective November 14, 2008, pursuant to Diagnostic Code 5271 for limited ankle motion. The Veteran disagreed with the initial rating assigned. During the course of the appeal, in a March 2016 decision, an increased 20 percent rating was granted, effective November 14, 2008. The RO also changed the Diagnostic Code employed to 5271-8525, recognizing that there was a neurological component to the right ankle disability. The RO indicated that the ankle condition was previously evaluated based on joint range of motion criteria, but it was more appropriately evaluated under neurological criteria, as the disability affected the posterior tibial nerve. The RO stated that a compensable rating under both joint and neurological criteria was not warranted because of symptom overlap, and VA regulations prohibit the use of the same symptoms to support more than one rating. A September 2008 X-ray of the right ankle found no evidence of fracture, dislocation, or bony destructive change. The X-ray was interpreted as normal. On VA examination in September 2008, the Veteran reported experiencing tingling and numbness, abnormal sensation, and pain of the right ankle. He stated that his pain rated a 7 on a 1 (low) to 10 (high) pain scale. There was no weakness or paralysis of the affected parts. The Veteran said he experienced intermittent shooting pain which emanated from his ankle. The Veteran limped on the right ankle. There was tenderness and guarding of movement. Dorsiflexion of the right ankle was to 15 degrees with pain at 10 degrees. Plantar flexion was to 20 degrees with pain at 8 degrees. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Neurological examination showed that motor function was within normal limits. Sensory function was abnormal with findings of decreased sensation of the lateral plantar aspect of the right foot. With regard to the posterior tibial nerve, the peripheral nerve examination found neuritis. Three was sensory dysfunction demonstrated by decreased sensation over the lateral aspect of the right foot. There was no motor dysfunction. A November 2008 private treatment record shows that the Veteran walked with a slight limp favoring the right ankle. The Veteran did not dorsiflex the ankle well without pain. The Veteran was not able to stand on the foot easily without ankle pain. The Veteran had difficulty pushing up on his toes due to pain in the ankle area. There was weakness with dorsiflexion of the right ankle due to ankle pain and some weakness on eversion of the right ankle. Ankle jerk was absent on the right. January 2010 EMG testing found electrodiagnostic evidence consistent with tarsal tunnel syndrome on the right. A May 2010 VA treatment record shows that the Veteran had difficulty bearing weight through the right foot, and he could only stand or walk for five minutes due to excruciating pain at the medial ankle. He experienced severe pain. A private physical therapy record from September 2011 shows that the Veteran had difficulty ambulating on heels and toes. There was severe pain with palpation over the Achilles tendon. Inversion and eversion at the ankle were uncomfortable. The Veteran had reduced sensation along the lateral aspect of the right foot. At the September 2011 Board hearing, the Veteran reported having two surgeries on the right ankle while he was on active duty. He had a limited range of motion of the right ankle, and he experienced stabbing pains. He had foot weakness. He was unable to exercise due to ankle inflammation. An MRI of the right ankle taken in October 2011 found thickening and scarring of the flexor retinaculum overlying the proximal tarsal tunnel. There was minimal osteophytic spurring at the inferior margin of the medial ankle gutter. A chronic sprain was unchanged. Moderate tendinosis was unchanged. There was also nonspecific ankle, subtalar, and tarsal sinus synovitis. On VA examination in June 2015, the examiner noted that the Veteran had previously undergone bone spur removal surgery and tarsal tunnel release in the right ankle. The Veteran reported occasional shooting pain and stated that it was difficult to walk. The examiner was unable to conduct range of motion testing due to the severity of pain on superficial palpation. The examiner opined that the expression of pain was out of proportion to the injury. Moderate to severe flare-ups were reported two to three times per week. The examiner indicated that the right ankle demonstrated instability, less movement than normal, disturbance of locomotion, and interference with standing. Plantar flexion and dorsiflexion were rated as 3/5. The examiner was not sure if the Veteran really had reduction in muscle strength due to the claimed condition. The examiner was not able to properly assess the Veteran due to severe pain complaints. No muscle atrophy or ankylosis was present. The Veteran occasionally used a cane. It was noted that the Veteran was gainfully employed. The examiner observed that the Veteran was able to take his shoes and socks off and on, and he was able to put one knee on the other when getting his socks on. On VA examination in July 2017, the examiner diagnosed right ankle trigonum and tarsal tunnel syndrome post-op tarsal tunnel release, and post-op bone spur removal surgery. The Veteran reported constant pain in the right ankle which increased with walking and standing. He experienced painful flare-ups. Dorsiflexion of the right ankle was to 10 degrees. Plantar flexion was to 30 degrees. There was evidence of pain with weight bearing. There was no additional loss of function or range of motion after repetitive-use testing. The Veteran reported sharp, moderate pain with superficial light palpation over the medial and lateral malleolus. There was a reduction in right ankle strength. Plantar flexion and dorsiflexion showed active movement against some resistance. No ankylosis was present. The examiner specified that the Veteran's ankle surgery resulted in decreased range of motion. The Veteran occasionally used a cane. The examiner opined that employment that required extensive walking and standing would be impacted by the ankle disability. Sedentary employment was not impacted. Considering the evidence as a whole, the Board finds that there are both orthopedic and neurologic components to the service-connected right ankle disability. Specifically, the service medical records show that in April 2005, the Veteran underwent removal of loose bodies in the right ankle, and in January 2008, the Veteran underwent surgery for a right tarsal tunnel release. The RO recognized that by assigning the disability a hyphenated Diagnostic Code of 5271-8525. While recognizing that the Rating Schedule specifically provides a prohibition against pyramiding, and the rating of the same manifestation under different diagnoses is to be avoided, the Veteran's ankle disability has both orthopedic and neurologic manifestations. Therefore, to the extent that they can be separated, separate disability ratings are warranted to account for the separate orthopedic and neurologic manifestations of the service-connected ankle disability. The Veteran is currently assigned a 20 percent rating throughout the period of appeal for the neurologic manifestations of the ankle disability pursuant to Diagnostic Code 8525. The Board finds that no higher rating is warranted for the neurologic symptoms. The medical evidence shows that the nerve involved is the posterior tibial nerve. Therefore, Diagnostic Code 8525 is the appropriate Diagnostic Code. While the Veteran has clearly experienced neurological symptoms best described as severe throughout the period of appeal, a higher 30 percent rating is available under Diagnostic Code 8525 only for complete paralysis of the posterior tibial nerve. As reviewed above, the medical evidence does not show, and the Veteran himself has not claimed, that there is complete paralysis of the posterior tibial nerve. Therefore, the Board finds that a higher rating is not warranted for neurological symptoms. However, a separate 20 percent disability rating could be warranted for orthopedic symptoms pursuant to Diagnostic Code 5271. The Board finds that the Veteran's right ankle disability is manifested by marked limited motion. The September 2008 examination indicated limited dorsiflexion of the right ankle to 10 degrees with pain and limited plantar flexion to 8 degrees with pain. The July 2017 examination indicated limited dorsiflexion to 10 degrees and limited plantar flexion to 30 degrees. The standard range of ankle motion is to 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II (2017). The Veteran described additional loss of function of the right foot due to pain, problems with weight bearing, and flare-ups involving the ankle which caused him to use a cane. The Board notes that the examination and the Veteran's testimony indicate that the limitations resulted in functional loss that more nearly approximates a marked limitation of ankle motion. Therefore, a separate 20 percent rating would be warranted for orthopedic symptoms pursuant to Diagnostic Code 5271. The Veteran's treatment records do not indicate any ankyloses, malunion, or astragalectomy. Therefore, the remaining diagnostic codes are not applicable to the Veteran's disability. 38 C.F.R. § 4.71a (2017). In this decision, the Veteran has been assigned ratings under Diagnostic Code 5271 for limited motion of ankle of 20 percent and under Diagnostic Code 8525 for incomplete paralysis of the posterior tibial nerve. Additionally, the Board notes that the Veteran is in receipt of a rating of 10 percent for right ankle scars under Diagnostic Code 7804, and a 0 percent rating for right foot hallux valgus under Diagnostic Code 5276-5280. All of those ratings are for the right extremity at a level lower than the right knee. In light of the amputation rule, the Board finds that a single rating of 40 percent, and no higher, for the right lower extremity disabilities should be assigned to the Veteran for right lower extremity disabilities below the knee. 38 C.F.R. § 4.68 (2017). The Board finds that the evidence supports the assignment of a 40 percent rating, but that the preponderance of the evidence is against the assignment of any higher rating. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). Right and Left Hips Limitation of motion of the hip is rated under either Diagnostic Code 5251, 5252, or 5253. Under Diagnostic Code 5251, the criterion for a 10 percent rating, which is the maximum rating for limitation of extension, is extension limited to five degrees. Under Diagnostic Code 5252, the criterion for a 10 percent rating is flexion limited to 45 degrees. The criterion for the next higher rating, 20 percent, is flexion limited to 30 degrees. Under Diagnostic Code 5253, the criterion for a 10 percent rating is the inability to cross the legs or external rotation limited to 15 degrees. The criterion for the next higher rating, 20 percent, is abduction limited to 10 degrees. 38 C.F.R. § 4.71a (2017). Normal extension of the hip is to 0 degrees and normal flexion is to 125 degrees. Normal abduction is to 45 degrees. 38 C.F.R. § 4.71a, Plate II (2017). Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is non-compensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Ratings under Diagnostic Code 5003 cannot be combined with ratings based on limitation of motion of the same joint. 38 C.F.R. § 4.71a (2017). In the absence of limitation of motion, a 20 percent rating is assigned for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent rating is assigned for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2017). The intent of the Rating Schedule is to recognize actually painful, unstable, or malaligned joints as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2017); Burton v. Shinseki, 25 Vet. App. 1 (2011). Service connection for right hip and left hip disabilities was established in a November 2008 RO decision. During the course of the appeal, a 10 percent disability rating was assigned for each hip, effective November 14, 2008. The Veteran disagreed with the initial rating assigned. An X-ray taken in September 2008 found mild degenerative changes of both hips. On VA examination in September 2008, the Veteran reported stiffness, lack of endurance, locking, and fatigability of both hips. He did not report weakness, swelling, heat, redness, giving way, or dislocation of either hip. He reported pain that rated an 8 on a 1 (low) to 10 (high) pain scale. Flexion of both hips was to 125 degrees. Extension was to 30 degrees. Adduction was to 25 degrees. Abduction was to 45 degrees. External rotation was to 60 degrees. Internal rotation was to 40 degrees. Joint function of both hips was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. At the September 2011 Board hearing, the Veteran reported experiencing pain both hips. On VA examination in June 2015, the examiner diagnosed osteoarthritis of the right and left hips. The Veteran stated that sitting and walking caused pain. Flare-ups were not reported. Flexion of the right hip was to 135 degrees. Extension was to 30 degrees. Abduction was to 45 degrees. Adduction was to 25 degrees. External rotation was to 60 degrees. Internal rotation was to 40 degrees. Pain was noted on rest. There was no additional loss of function or range of motion after repetitive use testing. Flexion of the left hip was to 125 degrees. Extension was to 30 degrees. Abduction was to 45 degrees. Adduction was to 25 degrees. External rotation was to 60 degrees. Internal rotation was to 40 degrees. Pain was noted on rest. There was no additional loss of function or range of motion after repetitive use testing. Muscle strength testing was 5/5 for flexion, extension, and abduction of both hips. No ankylosis was found. On VA examination in July 2017, the examiner diagnosed bilateral hip arthritis. The Veteran reported constant bilateral hip pain that increased during cold and wet weather. He took Ibuprofen daily for pain. He experienced flare-ups of aching pain. Flexion of the right hip was to 125 degrees. Extension was to 30 degrees. Abduction was to 45 degrees. Adduction was to 25 degrees. External rotation was to 60 degrees. Internal rotation was to 40 degrees. No pain was noted on examination. The Veteran reported mild pain with palpation over the greater trochanter. There was no additional loss of function or range of motion after repetitive use testing. Flexion of the left hip was to 125 degrees. Extension was to 30 degrees. Abduction was to 45 degrees. Adduction was to 25 degrees. External rotation was to 60 degrees. Internal rotation was to 40 degrees. No pain was noted on examination. The Veteran reported mild pain with palpation over the greater trochanter. There was no additional loss of function or range of motion after repetitive use testing. Muscle strength testing was 5/5 for flexion, extension, and abduction of both hips. No ankylosis was found. The examiner remarked that employment that required standing for long time periods would be impacted and require rest periods, but sedentary employment was not impacted. The Board finds that the Veteran's left and right hip arthritis disabilities' symptomatology did not more nearly approximate that required for a higher rating than 10 percent for either hip under any potential Diagnostic Code. Throughout the entire period of appeal, the Veteran's left and right hip disabilities did not create limitation of motion more nearly approximating that required for a compensable rating under the applicable Diagnostic Codes. The evidence for the applicable period contains no report of limitation of extension of either hip to five degrees, as required for a compensable rating under Diagnostic Code 5251. The evidence also contains no notation suggesting limitation of flexion of either hip to 45 degrees, as required for a compensable 10 percent rating under Diagnostic Code 5252. The objective medical evidence contains no findings suggesting either an inability to cross the legs or a limitation of external rotation to 15 degrees as required for a compensable 10 percent rating under Diagnostic Code 5253 38 C.F.R. § 4.71a (2017). Ankylosis of the hips is not shown. As the record contains no indication that either hip disability during the applicable rating periods more nearly approximated hip ankylosis, flail joint, or impairment of the femur, the Board finds that Diagnostic Codes 5250, 5254, and 5255 are not applicable. 38 C.F.R. § 4.71a (2017). The Veteran's hip arthritis throughout the applicable rating periods has consistently shown to be productive of otherwise noncompensable limitation of motion of each hip throughout the applicable rating periods. As each hip is a major joint, a 10 percent rating, but not higher, is warranted for each hip under Diagnostic Code 5003 and 38 C.F.R. § 4.59. 38 C.F.R. § 4.71a (2017). Regarding the possibility of increased ratings in excess of the separate 10 percent ratings assigned, the Board finds also that the evidence, both lay and medical does not indicate functional loss of the either hip due to service-connected arthritis, to include flare-ups due to pain, fatigability, incoordination, and weakness, so as to approximate abduction of either hip functionally limited to 10 degrees or less; ankylosis of the hip; flexion of either hip functionally limited to 30 degrees or less; or abduction of either hip functionally limited to 10 degrees or less. 38 C.F.R. §4.71a (2017), Diagnostic Codes 5250, 5252, 5253, DeLuca v. Brown, 8 Vet. App. 202 (1995). Moreover, the record contains no evidence of a hip flail joint or any impairments of the Veteran's femur; therefore, the criteria under Diagnostic Codes 5254 and 5255 are inapplicable in this matter. C.F.R. § 4.71a (2017). The Board finds that the preponderance of the evidence is against the assignment of any higher rating. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). Left Knee Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II (2017). Under Diagnostic Code 5260, limitation of flexion of the knee is rated 10 percent for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2017). Under Diagnostic Code 5261, limitation of extension of the knee is rated 10 percent for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2017). Diagnostic Code 5257 provides that a 10 percent rating is warranted for slight recurrent subluxation or lateral instability of a knee. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe knee impairment with recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2017). Subluxation of the patella is the incomplete or partial dislocation of the knee cap. Rykhus v. Brown, 6 Vet. App. 354 (1993). The words slight, moderate, and severe as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2017). In addition, separate ratings may be assigned for compensable limitation of both flexion and extension, or for limitation of motion and instability or subluxation of the knee, or meniscal pathology. However, a separate rating can only be assigned where additional compensable symptomatology is shown that is not duplicative of that used to assign another rating. 38 C.F.R. § 4.14 (2017); VAOPGCPREC 09-04 (2004), 69 Fed. Reg. 59990 (2004);VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56704 (1998); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Diagnostic Code 5003 provides 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 (2017). When, limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is generally for application. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. A rating for arthritis cannot be combined with a rating based on limitation of motion of the same joint. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2017). Service connection for a left knee disability was established in a November 2008 RO decision. During the course of the appeal, a 10 percent rating was assigned, effective November 14, 2008. The Veteran disagreed with the initial rating assigned. An X-ray taken in September 2008 found minimal degenerative changes of the left knee. On VA examination in September 2008, the Veteran reported stiffness, lack of endurance, and locking of the left knee. He did not have weakness, swelling, heat, redness, giving way, fatigability, or dislocation. He reported pain that rated an 8 on a 1 (low) to 10 (high) pain scale. The left knee showed no signs of edema, effusion, weakness, tenderness, redness, heat, subluxation or guarding of movement. There was no locking pain, genu recurvatum, or crepitus. Flexion of the left knee was to 140 degrees. Extension was to 0 degrees. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Stability testing was within normal limits. At the September 2011 Board hearing, the Veteran reported experiencing pain and limited motion of the left knee. He stated that he experienced locking. On VA examination in June 2015, the examiner indicated that the Veteran had osteoarthritis of the left knee. The Veteran stated that he could not run or exercise. Left knee flexion was to 120 degrees. Extension was to 0 degrees. Pain was noted on both flexion and extension. There was evidence of pain with weight bearing. No additional loss of motion was observed after repetitive use testing. Flare-ups were not reported. There was no reduction in muscle strength. No ankylosis was present. There was no history of recurrent subluxation or instability. Joint stability testing was conducted, and there was no joint instability. On VA examination in July 2017, the examiner diagnosed left knee osteoarthritis. The Veteran reported intermittent pain in the left knee that increased when sitting. The Veteran remarked that the left knee disability did not interfere with his current job as a supervisor for the Border Patrol. The Veteran reported flare-ups of stabbing pain. Left knee flexion was to 135 degrees. Extension was to 0 degrees. There was no pain noted on examination. There was no evidence of pain on weight bearing. No additional loss of motion was observed after repetitive use testing. There was no reduction of muscle strength, and the Veteran did not have muscle atrophy. No ankylosis was observed. Joint stability testing was performed, and no instability was found. Passive motion was unchanged from active motion findings. The Board finds that the preponderance of the evidence is against the assignment of any higher or separate disability rating under Diagnostic Code 5260 for limitation of flexion of either knee at any time during the course of the appeal. Concerning the left knee, the evidence shows that flexion of the knee was limited, at worst, to 120 degrees, with consideration of pain. The flexion measurements are consistent with no more than a 0 percent rating under Diagnostic Code 5260. The Board also finds that the weight of the evidence is against assigning a higher or separate rating throughout the period of appeal under Diagnostic Code 5261 for limitation of extension. The evidence shows that extension of the left knee was limited, at worst, to 0 degrees, with consideration of pain. Those findings do not meet the criteria for a compensable rating under Diagnostic Code 5261, or for any higher rating. However, the Veteran has repeatedly reported that he experiences pain. He has reported pain to each medical examiner, and he has additionally discussed his pain in repeated submissions to the RO and at the Board hearing. Because of the Veteran's painful, yet noncompensable, limitation of left knee motion, and other symptoms, the presently assigned disability rating of 10 percent based on painful motion for the left knee is warranted. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40, 4.45, 4.59 (2017). However, the Board finds that the preponderance of the evidence is against the assignment of any higher or additional separate rating for limitation of motion of the left knee. The ratings assigned have considered additional functional loss due to pain and other factors. Turning to instability, the Board concludes that a compensable rating under Diagnostic Code 5257 is not warranted at any time throughout the period of appeal for the left knee. Objective observations of instability have not been noted in the VA or private treatment records. Significantly, all of the VA examiners and treatment providers indicate that the Veteran's left knee was stable on objective observation. To whatever extent the Veteran may assert that the left knee is unstable, the Board finds that the objective medical evidence outweighs the subjective complaints, as the medical evidence was created by trained health care providers objectively performing their professional duties. The Board finds that those objective medical findings are more persuasive because of the training and experience of the medical professionals. In light of those medical records, the Board finds that a separate disability rating is not warranted at any time during the period of appeal for instability of the left knee, pursuant to Diagnostic Code 5257. In addition, subluxation of the knee is not shown. None of the treatment records, to include X-ray and MRI findings, show dislocated or removed semilunar cartilage of the left knee. Thus, Diagnostic Codes 5258 and 5259 cannot serve as a basis for an increased or separate rating for either knee. Finally, in considering the applicability of other diagnostic codes, the Board finds that Diagnostic Codes 5256 (ankylosis of the knee), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum) are not applicable, as the medical evidence does not show that the Veteran has any of those conditions. The Board notes that the Veteran's functional loss was considered as the medical evidence shows that the Veteran has consistently complained of pain. 38 C.F.R. §§ 4.40, 4.45 (2017). However, the limitation of motion and functional loss documented in the medical records as resulting from pain, including flare-ups, is contemplated in the disability rating now currently assigned. Moreover, although the Veteran had pain on repetitive motion, that pain did not result in limitation of flexion or extension to the level that any separate or higher rating would be warranted. There is otherwise no evidence of additional significant impairment of motor skills, muscle function, or strength attributable to the Veteran's knee disability, beyond what is already being compensated. Consequently, the Board finds that a higher rating based on functional loss is not warranted for the left knee. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of any higher or separate rating for a left knee disability and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). Extraschedular Ratings The Board has also considered whether the Veteran's disabilities present an exceptional or unusual disability picture as to make impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. 38 C.F.R. § 3.321(b)(1) (2017); Bagwell v. Brown, 9 Vet. App. 337 (1996). The threshold factor for extraschedular consideration is a finding that the established schedular criteria are inadequate to describe the severity and symptoms of the claimant's disability. Thun v. Peake, 22 Vet. App. 111 (2008). The Board notes that the schedular criteria are designed to compensate for average impairments in earning capacity resulting from service-connected disability. 38 U.S.C. § 1155 (2012). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular ratings are found to be adequate. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40 (2017). For disabilities of the joints in particular, the rating schedule specifically contemplates factors such as weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59 (2017); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). While the Veteran has complained that he can no longer run, play sports, or walk long distances due to pain, those complaints are contemplated by the rating criteria and provisions of 38 C.F.R. §§ 4.40, 4.45 and 4.59, as those situations arise because of the above factors. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular ratings are found to be adequate. Accordingly, the Board concludes that referral for extraschedular consideration is not warranted. TDIU It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16 (2017). A finding of total disability is appropriate, when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a)(1), 4.15 (2017). Substantially gainful employment is that employment which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides. Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a) (2017). A total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disability if the service-connected disability is rated at 60 percent or more. 38 C.F.R. § 4.16(a) (2017). A claim for a total disability rating based upon individual unemployability, presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for TDIU because of subjective factors that the objective rating does not consider. Vettese v. Brown, 7 Vet. App. 31 (1994). In evaluating a veteran's employability, consideration may be given to his level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). The Veteran is service-connected for a lumbosacral spine disability, rated 40 percent; a right ankle disability, to include neurologic symptoms, orthopedic symptoms, a scar, and hallux valgus of both feet, rated 40 percent; a right hip disability, rated 10 percent; a left hip disability, rated 10 percent; a right knee disability, rated 10 percent; a left knee disability, rated 10 percent; tinnitus, rated 10 percent disabling; temporomandibular joint dysfunction, rated 10 percent; allergic rhinitis, rated 0 percent; and herpes simplex virus, rated 0 percent. Therefore, he meets the schedular criteria for consideration of the assignment of TDIU, and the Board's consideration thus turns to whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. The fact that a Veteran is unemployed or has difficulty finding employment is not enough, as a high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the claimant is capable of performing the physical and mental acts required for employment, not whether the claimant can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The evidence shows that Veteran has been employed throughout the period of appeal and is currently employed as a supervisor for the Border Patrol. The evidence does not show, and the Veteran has not claimed, that his employment is less than gainful. As the Veteran is gainfully employed, that is highly persuasive evidence he is capable of performing the physical and mental acts required for employment, for which his is qualified. As he is employed, he is accordingly not unemployable due to service-connected disabilities. Because the evidence preponderates against the claim, the claim for TDIU must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). ORDER Entitlement to a higher initial rating for a thoracolumbar spine disability, rated 10 percent from November 14, 2008, to September 7, 2011; 20 percent from September 8, 2011, to June 2, 2015; and 40 percent as of June 3, 2015, is denied. Entitlement to an initial rating of 40 percent, but not higher, for a right ankle disability is granted. Entitlement to an initial rating higher than 10 percent for a right hip disability is denied. Entitlement to an initial rating higher than 10 percent for a left hip disability is denied. Entitlement to TDIU is denied. ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs