Citation Nr: 18142346 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 96-40 840 DATE: October 15, 2018 ORDER Entitlement to a rating in excess of 20 percent for rheumatoid arthritis prior to November 8, 1995 is denied. Entitlement to a rating in excess of 10 percent for arthritis of the right knee from November 8, 1995 through October 3, 2017 is denied. Entitlement to a rating in excess of 10 percent for arthritis of the left knee from December 31, 1996 through October 3, 2017 is denied. Entitlement to a rating in excess of 10 percent for arthritis of the right ankle from November 8, 1995 through October 3, 2017 is denied. Entitlement to a rating in excess of 10 percent for arthritis of the left ankle from November 8, 1995 through October 3, 2017 is denied. REFERRED ISSUE The record raises the issue of entitlement to an earlier effective date of entitlement to service connection for cervical and thoracolumbar rheumatic arthritis. This issue, however, is not currently developed or certified for appellate review. Accordingly, this matter is referred to the RO for appropriate consideration. FINDINGS OF FACT 1. Prior to November 8, 1995, rheumatoid arthritis was productive of no more than one or two exacerbations a year. 2. From November 8, 1995 through October 3, 2017, the appellant’s right knee arthritis was manifested primarily by subjective complaints of pain, flexion with pain to no less than 90 degrees, and extension to 0 degrees. 3. From December 31, 1996 through October 3, 2017, the appellant’s left knee arthritis was manifested primarily by subjective complaints of pain, flexion with pain to no less than 90 degrees, and extension to 0 degrees. 4. From November 8, 1995 through October 3, 2017, the appellant’s right ankle arthritis was productive of no more than a moderate limitation of motion. 5. From November 8, 1995 through October 3, 2017, the appellant’s left ankle arthritis was productive of no more than a moderate limitation of motion. CONCLUSIONS OF LAW 1. Prior to November 8, 1995, the criteria for a rating in excess of 20 percent for rheumatoid arthritis were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5002. 2. From November 8, 1995 through October 3, 2017, the criteria for rating in excess of 10 percent for arthritis of the right knee were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5260. 3. From December 31, 1996 through October 3, 2017, the criteria for rating in excess of 10 percent for arthritis of the left knee were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5260. 4. From November 8, 1995 through October 3, 2017, the criteria for rating in excess of 10 percent for arthritis of the right ankle were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5271. 5. From November 8, 1995 through October 3, 2017, the criteria for rating in excess of 10 percent for arthritis of the left ankle were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5271. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty from February 1956 to May 1958. In January 2000, the appellant had a hearing at the Department of Veterans Affairs (VA) Regional Office (RO) in Nashvillle, Tennessee before the Veterans Law Judge whose signature appears at the end of this decision. This case has been before the Board of Veterans’ Appeals (Board) previously. Initially, the issue was entitlement to a rating in excess of 20 percent for rheumatoid arthritis. In March 2011, VA found that the appellant’s rheumatoid arthritis was not then active and replaced it with separate ratings for osteoarthritis of the knees and ankles. Ultimately, VA assigned a 10 percent rating for the right knee disorder and each ankle disorder, effective November 8, 1995. The RO also assigned a 10 percent rating for arthritis of the left knee, effective December 31, 1996. The case was last before the Board in September 2014, when the Board remanded it for further development. In October 2017, VA confirmed and continued the appellant’s 10 percent ratings for arthritis of the right knee and each ankle for the period from November 8, 1995 through October 3, 2017. VA also confirmed and continued the appellant’s 10 percent rating for arthritis of the left knee for the period from December 31, 1996 through October 3, 2017. Effective October 4, 2017, VA found that the appellant’s multiple joint arthritis was more appropriately rated as rheumatoid arthritis. VA assigned a 100 percent schedular evaluation for rheumatoid arthritis, with involvement of the cervical and thoracolumbar spine and sacroiliac joints, both knees, and both ankles. Thereafter, the case was returned to the Board for further appellate consideration. The issues on the title page have been amended to reflect the current scope of the appeal. The Increased Rating Claims Disability evaluations are determined by comparing the manifestations of a particular disability with the criteria set forth in the Diagnostic Codes of the VA Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity (in civilian occupations) resulting from service-connected disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In determining the adequacy of assigned disability ratings, consideration is given to factors affecting functional loss. DeLuca v. Brown, 8 Vet. App. 202 (1995). Such factors include a lack of normal endurance and functional loss due to pain and pain on use, specifically limitation of motion due to pain on use including that experienced during flare ups. 38 C.F.R. § 4.40. Consideration is also given to weakened movement, excess fatigability, and incoordination, as well as the effects of the disability on a veteran’s ordinary activity. 38 C.F.R. § 4.10, 4.45. During the course of an appeal, a veteran may experience multiple distinct degrees of disability that might 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). Similarly, when service connection is granted and an initial rating award is at issue, separate ratings can be assigned for separate periods from the time service connection became effective. Fenderson v. West, 12 Vet. App. 119 (1999). Therefore, the following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Rheumatoid Arthritis: Prior to November 8, 1995 Rheumatoid arthritis is rated in accordance with the criteria set forth in 38 C.F.R. § 4.71a, Diagnostic Code 5002. A 40 percent rating is warranted when there are symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. A 20 percent rating is warranted when there are one or two exacerbations of rheumatoid arthritis a year in a well-established diagnosis. When there are residuals such as limitation of motion or ankylosis, favorable or unfavorable, rheumatoid arthritis will be rated under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. VA treatment records, dated from February to December 1994 show that the appellant was treated, in part, for arthritic pain, primarily in his back, knees, wrists, hands, and right shoulder. X-rays of the knees were negative. In September 1994, he appellant reported that he had gotten to the point where he had difficulty doing anything. During a May 1994 VA examination, the appellant reported that he had worked as a mechanic since service but that about six months prior to the examination, he had quit due to arthritis. He complained of early morning stiffness, as well as constant joint pain and difficulty bending and lifting objects. He also complained of intermittent swelling with a grinding sensation in his knees. He stated that he could walk up to a block and climb up one flight of stairs after which he had to stop due to the pain. The appellant reported that he got cramps in his legs but denied any color or temperature changes. He also reported that he avoided previously enjoyable sports and fishing. He noted a progressive worsening and stated that he had required local cortisone injection several times in the past. It was noted that he was taking Indocin for pain. On examination, the appellant’s ankles and knees revealed no swelling or crepitus. There was no localized tenderness or deformity, and he demonstrated a full range of motion. He had difficulty standing and walking on his toes or heels but could squat completely. He demonstrated no peripheral edema, and X-rays of his knees were normal. In January 2016, the appellant’s claims file was reviewed by a VA orthopedic surgeon to retrospectively examine and address the nature and extent of any limitation of motion in each knee and ankle for the period including that prior to November 8, 1995. Following that review, the VA examiner found no evidence of any additional limitation or change in motion noted after repetitive motion on any of the examinations documented above. The examiner noted that when the appellant left the clinical setting and returned to his usual day to day environment/activities, he could potentially have further limitation in range of motion, potentially have an increase in the amount of pain and potentially have further decrease in functional capacity during flare ups and/or with repetitive motion/use over time. The examiner stated, however, that those parameters could not be estimated and/or expressed as additional loss in degrees of motion without resorting to mere speculation. The rationale for his conclusions was that the metrics obviously could not be obtained, measured, or objectively quantified, as the examiners did not have access to the appellant for obtaining such metrics when the appellant was outside of the clinical arena. The examiner further stated that no amount of research in the medical literature would be of assistance in resolving the matter. Although the appellant complained of multiple joint pain, the evidence preponderates against finding a well-established diagnosis of rheumatoid arthritis. Moreover, there is no competent, credible evidence of one or two exacerbations of rheumatoid arthritis per year prior to November 8, 1995. Accordingly, the appellant does not meet or more nearly approximate the schedular criteria for a rating in excess of 20 percent for rheumatoid arthritis prior to November 8, 1995. The Right Knee from November 8, 1995 through October 3, 2017 and the Left Knee from December 31, 1996 through October 3, 2017 During VA treatment on November 8, 1995, a full body bone scan of the appellant’s revealed small foci of activity at the right knee, compatible with degenerative changes. In December 1996, the appellant was examined by the VA. He reported multiple joint pain, including his knees and feet, occasional swelling in the knees, and stiffness, especially in the morning. He used pain medication. The appellant stated that he had been unable to work for the past two years due to pain and stiffness. He also stated that his symptoms had gotten to the point where they interfered with the activities of daily living owing to slowness of movement and interference in fine motor coordination. On examination, the appellant’s knees were cool without a ballotable effusion. However, there was moderate tenderness when palpating over the patella, bilaterally, and the appellant flinched and grimaced with a moderate amount of apprehension. There was no swelling, deformity, subluxation or lateral instability in either knee. The drawer sign was negative, bilaterally, and the collateral ligaments were intact, bilaterally. The range of active knee motion was from 0 degrees to 125 degrees, bilaterally, and the McMurray sign was negative, bilaterally. Motor power in the lower extremities was 5/5 with normal bulk and tone. The range of motion of the feet consisted of plantar flexion to 35 degrees bilaterally, and dorsiflexion to 15 degrees bilaterally. There were no deformities in either foot. X-rays of the appellant’s knees were unremarkable. During VA treatment in January 1997, X-rays of the appellant’s knees were unremarkable with no effusion or joint space narrowing. In November 1997, he reported that he was stiff all over. At an October 1997 VA examination, the appellant reported substantial stiffness that improved during the day but that never went away completely. He stated that it was aggravated by minor trauma or by staying outdoors. The appellant noted that he used to go fishing in the evening and the next morning he would be sore with joint swelling. However, he stated that he had avoided those activities in the last couple of years and noted that he had not had episodes of swelling. It was noted that he did not use any orthopedic aids and had not had any injury or surgery. The appellant walked with a slight limp on his right leg with his right foot turned out slightly more than his left. He did not require a cane or other aid to walk. There was no ankylosis in any joint, and passive and active range of motion in all joints was within normal limits. There was no history of dislocation or recurrent subluxation of any joint. Following the examination, the relevant diagnosis was degenerative joint disease in the knees. The examiner commented that it appeared by history that the appellant had a severe polyarthritis in the mid-1960s that was diagnosed at the time as rheumatoid arthritis. The examiner stated that at the time of the examination there was insufficient evidence to make that diagnosis. The examiner acknowledged that the appellant may indeed have had the disease but that most joint abnormalities had resolved. The examiner stated that the appellant appeared to have relatively little residual disability and that the disability the appellant did have was primarily due to pain. Range of motion was found to be normal. During a May 1998 Social Security examination of the appellant there was no evidence of lower or upper extremity edema, erythema, tremor, or deformity, and his station and gait were within normal limits. His muscle size, tone, and strength were also normal, and no involuntary movements were noted. His coordination appeared adequate, and his sensory function appeared intact. Deep tendon reflexes were normal, and no pathological reflexes were elicited. In relation to the impairment, the Social Security examiner stated that the appellant retained the capacity to occasionally lift and/or carry a maximum of 20 pounds for up to one-third of an eight-hour work day; frequently lift and/or carry 10 pounds from one-third to two-thirds of an eight-hour work day; stand and/or walk with normal breaks for a total of at least two hours in an eight-hour work day; and sit with normal breaks for a total of about six hours in an eight-hour work day. In October 1998, it was noted that the appellant was receiving Social Security benefits primarily due to a back disorder and secondarily to a 70 percent blockage of the right internal carotid artery. During VA treatment in November 1998, the appellant reported that his legs bothered him when he went to bed. A full body bone scan revealed small foci of activity at multiple joints. These findings were reportedly compatible with mild degenerative changes. A hospital administrator and a doctor reviewed the bone scan from 1995 and allegedly told the appellant that it showed arthritis in 16 different locations and that he should not even be able to walk because of it. In February 2000, the appellant was treated by the VA for complaints of intermittent right knee pain. In May 2001, the appellant was examined by the VA. He had reportedly quit work in 1994 due to problems with his back. (The appellant was not service connected for a back disorder in 2001.) The appellant stated that he could no longer bend over to reach into an automobile or raise his arms above his head to make repairs. At that time, he was seen in the VA Outpatient Clinic and began an effort to obtain disability for his arthritis. It was noted that from 1995 until the present, he had had numerous visits to the VA Medical Center primarily for a painful back and shoulders associated with degenerative joint disease, and right internal carotid artery stenosis. The VA examiner noted that he had examined the appellant in 1997 for disability. At that time, the appellant reportedly limped slightly so as to favor the right lower extremity. On examination passive and active range of motion in all joints was normal. No joints were found to be hot, tender, or swollen. It was noted that the appellant had had numerous x-rays, including both knees, which were normal. During the examination the appellant stated that he continued to have constant pain in all of his joints, particularly his back. The pain was reportedly worse in the morning and was aggravated by bad weather. The appellant stated that he felt better when he engaged in minimal activity or when soaking in hot water. He also stated that he had occasional swelling in all of his joints and was being treated with prescription pain medication. The appellant reported that he did pretty well but if he overexerted himself, he would “pay for it” the next day. He stated that he could no longer work at his usual occupation as a mechanic and had not worked since 1995 due to back pain. The claimant stated that he was able to perform all the activities of daily living and that he had not required the use crutches, a brace, a cane, or corrective shoes to get around. The appellant did not appear to be in pain at the time of the examination, and his gait was entirely normal. He was well developed but thin. The range of motion of his hips, knees, ankles, and small joints of the feet were within normal limits. His reflexes were normal and equal at 2+, and his strength was normal at 5/5. The VA examiner stated that the appellant clearly had an inflammatory (rheumatoid) arthritis, which had been active during the mid-1960s, but that he had no detectable residual joint deformity during the examination. There was no longer inflammation in any joints usually associated with rheumatoid arthritis, and the appellant was not taking anti-inflammatory or disease modifying drugs. The examiner noted that during the previous five or six years, the appellant has been treated only for degenerative disease in the shoulders and in the cervical and lumbar spines, primarily with pain relievers. Although the appellant had reported findings from a previous bone scan, the examiner stated that there appeared to be very little objective findings from either the bone scan of 1998 or the one in 1995 to justify the diagnosis of rheumatoid arthritis, or active inflammatory arthritis. The examiner opined that the changes that were not really substantial and were more consistent with mild to moderate degenerative joint disease. The appellant was not service connected for degenerative joint disease. The examiner noted that the diagnoses by the Social Security Administration were correct that the appellant did appear to have degenerative changes in the shoulders and in the cervical, thoracic, lumbar spines. During VA treatment in December 2001, the appellant complained of a two-month history of ankle cramps. During a July 2006 VA examination, the appellant complained of constant bilateral knee pain. There was no locking of the joints or instability. The appellant described fatigability and poor endurance, and it was noted that his legs buckled at times when fatigued. This occasionally caused the appellant to fall but he had not suffered any fractures. The claimant believed that knee pain was aggravated by cold and weather changes and after mild to moderate use of his joints. He obtained some relief with medication. The appellant stated that he used a cane intermittently but no crutches, braces, or corrective devices. There is no history to indicate joint subluxation. It was noted that inflammatory arthritis had been present in the past but had not been documented since his last hospitalization. On examination, the appellant was well-developed and well-nourished. He demonstrated a full range and active range of right knee motion. The left knee showed about a 10 degrees loss of extension in both the sitting and supine positions. There was no evidence of instability or abnormal laxity, and McMurray’s sign was negative. There was modest fine crepitus in the left knee. Right ankle range of motion was normal. There was 40 degrees of total motion in the left ankle. Subtler motion was preserved. The VA examiner noted that radiographic studies had been performed intermittently which described occasional possible osteopenia but no evidence of erosion or joint space loss. Following the examination, the diagnosis was reactive arthritis with mild flexion contractures at the left knee and ankle. The examiner stated that the appellant’s activities of daily living substantially disrupted by his arthritic complaints. The appellant reportedly used a riding lawn mower to cut his lawn because he was unable to start a conventional mower with a pull string. He shopped only occasionally and spent most of his day watching television. He did not wash his car but did do a small amount of dishes and limited light housework. The claimant stated that he felt weak all over and that carrying his claims file 250 to 300 yards to the clinic had been strenuous. The examiner stated that the appellant’s symptoms varied from day to day as well as within any given day and that the episodes of worsening were compatible with flares of pain as opposed to flares of joint inflammation. In November 2006, during treatment by his VA primary care physician, the appellant complained of chronic neck and upper back pain. The examiner stated that there was no evidence of ankle edema. During a March 2007 VA examination, the appellant stated that since service he had had pain in all lower extremity joints including the knees and ankles. He reported that the pain was mild on a daily basis but could be exacerbated weekly if he was on his feet for a prolonged period of time. He used no assistive devices. He reported that pain was relieved by over-the-counter medication. The claimant stated that he had no flare-ups or swelling and that it did not affect his routine daily activities. It was noted that he was retired. An examination of the appellant’s right knee revealed tenderness to palpation along the medial joint line, as well as some crepitus. The range of bilateral knee motion was from 0 degrees to 130 degrees with pain from 90 to 130 degrees. There was no varus or valgus instability and McMurray’s sign, Hoffmann’s sign, and the anterior-posterior drawer sign were negative. There was no effusion. Repetitive range of motion testing did not cause increased pain, fatigability, or a decreased arc of motion. An examination of the appellant’s left knee revealed no knee pain, effusion, or crepitus. The joint was non-tender throughout. There were no skin changes. Active and passive ranges of motion were painless and from 0 to 130 degrees. There was no varus or valgus instability, and no anterior and posterior drawer signs. Lachman’s and McMurray’s signs were negative. Repetitive range of motion did not cause increased pain fatigability or decrease in arc of motion. The examination of the appellant’s right ankle revealed no skin changes, swelling or effusion. The repetitive range of motion consisted of dorsiflexion to 20 degrees and plantar flexion to 45 degrees actively and passively. The range of motion was painless. The appellant had a normal 10 degrees of valgus Achilles angle of the hind foot with weight bearing that corrected to neutral when non-weight bearing. Repetitive motion did not increase pain, fatigability or a decrease in the arc of motion. An examination of the appellant’s left ankle revealed no effusion or skin changes. The range of active and passive motion consisted of dorsiflexion to 20 degrees and plantar flexion to 45 degrees. The range of motion was painless throughout. Repetitive testing did not decrease the arc of motion or cause fatigability or increased pain. X-rays of the left knee revealed degenerative changes. X-rays of the right knee revealed mild degenerative changes medial and lateral compartments and small joint effusion. X-rays of the right ankle revealed a curvilinear sclerotic density in the talus, likely an artifact. Those of the left ankle revealed mild spurring of the calcaneus but no arthritic or degenerative changes. Following the examination, the VA examiner concluded that the appellant’s left knee and ankles were normal. There was mild degenerative joint disease in his right knee. The examiner stated that it was conceivable that pain could further limit the appellant’s function particularly after being on his feet all day. The examiner noted, however, that it was not feasible to attempt to express any of this in terms of additional limitation of motion as these matters cannot be determined with any degree of medical certainty. In March 2007, the VA examiner, who performed the July 2006 VA examination, recommended that the appellant have x-rays of the knees, ankles, and feet. The VA examiner also recommended that the appellant be evaluated by the Orthopedic Service for a range of motion assessment of the aforementioned joints, as well as an assessment of his endurance strength and any other possible functional limitations. In May 2007, the VA examiner, who performed the July 2006 VA examination, reviewed the appellant’s entire claims file, as well as his computerized patient records up to July 2006. It was noted that during service, the appellant had had active inflammation involving his left knee and that it had developed later in his right knee and right ankle. There was also evidence of early degenerative arthritis in the left knee and left ankle which was as likely as not late sequelae of the earlier reactive arthritis. There was no evidence of residual reactive arthritis or subsequent osteoarthritis in any joint other than the left knee and the left ankle. The examiner noted that the last possible evidence of a flare (described by the examiner as a period of active joint inflammation that can be detected by clinical means) of the reactive arthritis was in June 1970. The appellant described frequent episodes of increased joint pain which the examiner could not link to recurrence of the appellant’s reactive arthritis based upon a review of his medical records. The examiner noted that the appellant’s spells often included pain affecting the left knee and left ankle, and that there was more radiographic evidence to support the appellant’s description of left knee pain than left ankle pain. Otherwise the appellant’s lay statements were the dominant basis for his rheumatic complaints. In addition, the examiner noted that the frequency of episodes producing pain above the appellant’s baseline left knee and left ankle pain was variable and largely related to activity and weather. The examiner believed that such episodes clearly occurred weekly but often daily. The examiner stated that the duration of the episodes of increased osteoarthritic left knee and left ankle pain was unknown In June 2007, the VA further examined the appellant to determine the extent of his left knee and left ankle disabilities. The appellant reported that left knee pain limited his ability to walk at 100 feet. He stated that pain was more of a psychological stressor than physically limiting. He did not use a cane, crutch, or assistive device, nor did he wear a brace. He reported occasional swelling but denied frank flare-ups. The claimant stated that his ankle also hurt but did not limit his ability to walk. He noted that his knee was probably more limiting than the ankle in terms of functional capacity. He denied flare-ups at the ankle. On examination, the range of left knee motion was from 0 to 130 degrees actively and passively. The range of motion did not change with repetitive testing. There was no crepitus or pain with motion of the left knee. The knees were stable to virus and valgus stress and the anterior and posterior drawer test was negative. There was no effusion. There was tenderness to palpation. The appellant could dorsiflexion the left ankle to 5 degrees and plantar flex it to 50 degrees. He was able to invert the ankle to 40 degrees and to evert the ankle to 5 degrees. All ranges of motion were equal actively and passively and did not change with repetitive testing. There was no pain or effusion of the left ankle with range of motion testing. The appellant had some mild discomfort to palpation along the medial ankle. There was no virus/valgus instability or abnormal drawer testing. X-rays of the left knee revealed very mild early degenerative changes. X-rays of the left ankle were normal. Following the VA examination, the diagnoses were mild degenerative joint disease of the left knee and left ankle pain probably related to rheumatoid synovitis without evidence of osteoarthritic destructive changes. The examiner stated that the appellant had moderate discomfort during the examination and that it was conceivable that pain could further limit function with repetition. The examiner opined, however, that an attempt to express any of this in terms of additional limitation of motion could not be determined with any degree of medical certainty. In December 2008 and February 2009, during treatment by the VA Rheumatology Service, it was noted that the appellant had degenerative joint disease involving both knees. The appellant stated he had been doing fine except for intermittent pain in his cervical and lumbar spine for which he took medication. He denied any bone pain or joint swelling. On examination, there seemed to be generalized muscle wasting but with 4 +/5 power in all areas. The appellant had a good range of motion in all joints, and there was no evidence of an inflammatory component, no synovitis, and no swelling. In January 2010, the appellant fell on some ice and struck his right knee. There was no evidence of a fracture but the joint temporarily turned blue. During a January 2011 VA examination, it was reported that the arthritis in the appellant’s extremities did not flare that often, maybe every couple of months. Long walking reportedly made his knee swell, and weather changes like cold weather made them hurt more. He mentioned falling a few times because of weak knee joints. He stated that he tired easily. On examination, there was no knee swelling, erythema or deformity and no signs of instability. Crepitus was present bilaterally. The range of motion was from 0 to 120 degrees on both sides. The appellant complained of pain on both sides during passive range of knee motion. Repetitive motion produced the same results. An examination of the ankles revealed no swelling or deformity. There was an area of wasting just below the lateral malleolus on the left side, and the left foot appeared to be more dropped. There was muscle wasting in the dorsum of the foot on both sides, and the appellant complained of pain in each ankle on passive and active range of motion testing. Dorsiflexion was accomplished to 10 degrees on the right and to 15 degrees on the left. Plantar flexion of the ankles was accomplished to 45 degrees, bilaterally. Repetitive testing produced no change in the range of motion in either ankle. On further examination, the appellant’s deep tendon reflexes were 2+ and equal, and his sensation was intact. His muscle strength was full at 5/5, and his gait was normal. X-rays of the right knee revealed calcification in the popliteal artery. Otherwise, X-rays of the knees and ankles were negative for any abnormalities. Following the VA examination, the examiner concluded the appellant did not have active rheumatoid arthritis. The examiner stated that the appellant’s current symptoms in the knees and ankles were due to prior rheumatoid arthritis resulting in secondary osteoarthritis. In February 2011, the VA Rheumatology Service reported that the appellant had degenerative joint disease of his knees with no evidence of an inflammatory component. In November 2015, the appellant was examined to determine the severity of his bilateral knee disabilities. He reported knee flare-ups and difficulty standing. On examination, there was no ankylosis in either knee. His bilateral range of knee motion was from 0 to 120 degrees. He reported knee pain on flexion and weight-bearing, as well as tenderness to palpation. There was no objective evidence of crepitus. The appellant able to perform repetitive testing of his knees without additional functional loss. Pain, weakness, fatigability, or incoordination did not significantly limit his functional ability for either knee with repeated use over a period of time or during flare-ups. His bilateral knee strength was full at 5/5 without atrophy, and there was no evidence of instability or dislocation in either knee. It was noted that he regularly used a wheelchair for locomotion. X-rays confirmed the presence of arthritis in each knee. The examiner stated that the functional impact of the appellant’s bilateral knee disabilities was his inability to stand for prolonged periods of time. In November 2015, VA also examined the appellant to determine the severity of his bilateral ankle disability. The appellant complained of ankle pain and painful flare-ups. There was no evidence of ankylosis in either ankle, and the appellant’s range of ankle motion was full, bilaterally with dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. There was no evidence of pain with weight-bearing or tenderness to palpation. The appellant was able to perform tests of repetitive ankle motion without additional functional loss; and there was no evidence of pain, weakness, fatigability, or incoordination which would significantly limit his functional ability with repeated use over a period of time or during flare-ups. The appellant’s ankle strength was full at 5/5 without evidence of atrophy and no evidence or instability or dislocation of either ankle. Imaging studies did not confirm the presence of arthritis in either ankle. It was noted that the functional impact of the appellant’s bilateral ankle disorder was his inability to walk for prolonged periods of time; and he reportedly used a wheelchair for locomotion. In January 2016, the appellant was seen by the VA Physical Therapy Service. He reported that both knees gave out when he walked. He stated that he drove, occasionally, when no one can do so for him. He was also reportedly assisted in his other activities of daily living by son and grandson. He complained of pain in all major joints and required a rolling walker for balance. His bilateral lower extremity strength was 4-, and his endurance level was found to be fair. Following the physical therapy, power mobility was recommended. In January 2016, the appellant’s claims file was reviewed by a VA orthopedic surgeon to retrospectively examine and address the nature and extent of any limitation of motion in each knee and ankle for the period between March 6, 1995 and January 19, 2011. That review included the examination reports of all medical records delineated in the Board’s September 2014 Remand. Following the VA examiner’s review of the record, the examiner found no evidence of any additional limitation or change in motion noted after repetitive motion on any of the examinations documented above. The examiner found that the Deluca/Mitchell provisions could not be clearly delineated. The examiner noted that when the appellant left the clinical setting and returned to his usual day to day environment/activities, he could potentially have further limitation in range of motion, potentially have an increase in the amount of pain and potentially have further decrease in functional capacity during flare ups and/or with repetitive motion/use over time. The examiner stated, however, that those parameters could not be estimated and/or expressed as additional loss in degrees of motion without resorting to mere speculation. The rationale for his conclusions was that the metrics obviously could not be obtained, measured, or objectively quantified, as the examiners did not have access to the appellant for obtaining such metrics when the appellant was outside of the clinical arena. The examiner further stated that no amount of research in the medical literature would be of assistance in resolving the matter. Limitation of motion of knee is rated in accordance with 38 C.F.R. §§ 4.71a, Diagnostic Codes 5260 and 5261. A 10 percent rating is warranted when flexion is limited to 45 degrees or when extension is limited to 10 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees or when extension is limited to 15 degrees. A 30 percent rating is warranted when flexion is limited to 15 degrees or when extension is limited to 20 degrees. From November 8, 1995 through October 3, 2017, the treatment records and examination reports show that the appellant’s bilateral knee arthritis has been manifested, primarily by subjective complaints of pain and stiffness, crepitus, knee extension to 0 degrees, and knee flexion to no less than 120 degrees with pain at 90 degrees. Although the appellant takes pain medication and reportedly uses a wheelchair regularly, he has not been followed for right knee pain. The preponderance of the objective evidence has been negative for associated knee swelling, effusion, deformity, malalignment, heat, erythema, tenderness to palpation, subluxation or instability, loose motion, or locking. Moreover, power, tone, and bulk in associated muscles has been generally full without evidence of atrophy of disuse. Indeed, the preponderance of the evidence shows that generally, his gait has been normal throughout the period, and the objective evidence is negative for a lack of normal endurance and functional loss due to pain and pain on use, including that experienced during flare ups. In addition, there is no evidence of any associated sensory deficits, impaired reflexes, tremors, involuntary movements, or lack of coordination. On balance, such findings do not meet or more nearly approximate the schedular criteria for a rating in excess of 10 percent for right knee disability for the period from November 8, 1995 through October 3, 2017 or for left knee disability for the period from December 31, 1996 through October 3, 2017. The Ankles: November 8, 1995 through October 3, 2017 Limitation of motion of the ankle is rated in accordance with 38 C.F.R. § 4.71a, Diagnostic Code 5271. A 10 percent rating is warranted for moderate limitation of motion, while a 20 percent rating is warranted for severe limitation of motion. The terms "moderate" and "marked" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Since November 1995, the treatment records and examination reports show that the appellant’s arthritis of his ankles has been manifested, primarily by subjective complaints of pain and stiffness, dorsiflexion to at least 5 degrees on the left and 10 degrees on the right, and plantar flexion to at least 35 degrees, bilaterally. Although he takes prescribed pain medication, the preponderance of the objective evidence has, again, been negative for ankle swelling, effusion, deformity, malalignment, heat, erythema, crepitus, tenderness to palpation, subluxation or instability, loose motion, or locking. The preponderance of the objective evidence is also negative for findings of a lack of normal endurance and functional loss due to pain and pain on use, including that experienced during flare ups. In addition, the power, tone, and bulk in the associated muscles have been full without evidence of atrophy of disuse. The preponderance of the evidence shows that, generally, his gait has been normal throughout the period. In addition, there is no evidence of any associated sensory deficits, impaired reflexes, tremors, involuntary movements, or lack of coordination. Finally, there is no competent evidence that either ankle disorder is productive of any more than moderate impairment. On balance, such findings do not meet or more nearly approximate the criteria for a rating in excess of 10 percent for either of the appellant’s service-connected ankle disorders. Accordingly, those ratings are confirmed and continued. The claims are denied. (Continued on the next page)   In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Harold A. Beach, Counsel