Citation Nr: 1808563 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 10-13 887 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for chronic left ankle sprain. 2. Entitlement to an evaluation in excess of 10 percent for chronic left knee strain. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD J.Lee, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Marine Corps from July 1996 to September 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In that rating decision, the RO continued a 10 percent evaluation for a left ankle disability and 10 percent evaluation for a left knee disability. In February 2011, the Veteran testified before a Veterans Law Judge (VLJ) who is no longer employed by the Board. A transcript of the hearing is associated with the record. The Veteran was offered the opportunity for a new Board hearing before a different VLJ in May 2017. As the Veteran did not respond within 30 days, and has not since requested to appear at another Board hearing before a different VLJ, this opportunity is deemed waived. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's chronic left ankle sprain manifests pain and other symptoms resulting in no more than moderate limitation of the left ankle. 2. For the entire period on appeal, the chronic left knee strain manifests flexion to not less than 130 degrees and limitation of joint motion. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for a disability rating in excess of 10 percent for the service-connected chronic left ankle sprain have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5271-5010 (2017). 2. For the entire period on appeal, the criteria for a disability rating in excess of 10 percent for the service-connected chronic left knee strain have not been met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to higher evaluations for left knee and left ankle disabilities. Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates such criteria. 38 C.F.R. § 4.7. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21. While a veteran's entire history is reviewed when making disability evaluations, in increased rating claims, it is the present level of disability that is of primary concern. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991); and Francisco v. Brown, 7 Vet. App. 55, 58 (1994). If the disability has undergone varying and distinct levels of severity throughout the entire time period that the increased rating claim has been pending, it is appropriate to apply staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. For disabilities evaluated on the basis of limitation of motion, the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment apply. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. For these purposes, painful motion alone does not constitute limited motion for rating under the diagnostic codes pertaining to limitation of motion, as opposed to assignment of a minimum compensable rating for arthritis under Diagnostic Code 5003. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance, as provided in sections 4.40 and 4.45. Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. I. Left ankle sprain The Veteran seeks a higher evaluation for his chronic left ankle sprain. The Veteran's left ankle disability is currently evaluated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5271-5010. Moderate limitation of motion of the ankle will be assigned a 10 percent rating. To warrant the next higher rating of 20 percent, there must be marked limitation of the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271. The terms "moderate" and "marked" are not defined, and VA must evaluate all the evidence to determine the appropriate rating. 38 C.F.R. § 4.6. Normal range of motion of the ankle is from 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. 38 C.F.R. § 4.71a, Plate II. VA treatment records from March 2008 to June 2017 include treatment for left ankle pain. Throughout this time, the Veteran consistently described his pain as acute, aching, and throbbing. He also described his left ankle as giving way, unstable, stiff, weak, and tender. In September 2008, the Veteran was seen in the emergency room due to ankle pain that he associated with his left knee pain. He reported that the left knee pain occasionally radiated to the ankle with a sensation of pins and needles. In January 2009, the Veteran was seen by his primary care physician for complaints of throbbing pain by the end of the day after working. The physician objectively noted that the Veteran showed some slight swelling at the joint line, but mostly when the Veteran walked. During an orthopedic surgery consult in February 2009, the Veteran's ankle was described as having constant pain, inferior to lateral malleolus and slightly anterior. There was also pain to the Achilles tendon, which increased after more usage. The physician observed that the left ankle was tender with palpation and eversion. He did not find any laxity, and found no other abnormalities or deformities. The Veteran exhibited full range of motion, and the VA physician opined he was neurovascularly intact throughout. Additionally, he reviewed x-rays taken in January 2009, and noted that although the film of the Veteran's left foot was unremarkable, a small spur off the lateral calcaneus was shown. The physician diagnosed the Veteran with chronic sprain and mild osteoarthritis. The Veteran was advised to do regular strengthening exercises, use an ankle brace, and wear above-the-ankle supportive shoes; and found that surgery was not warranted. On the same day, the Veteran was issued and fitted for an assistive brace. A private treatment record from March 2009 reflects the Veteran's complaints of sharp pain in his ankle. However, the record is silent for any further range of motion testing. The Veteran was provided with VA examinations in April 2009, March 2010, and January 2012. In April 2009, the examiner noted the Veteran's complaints of his ankle giving way, instability, pain, stiffness, weakness, and tenderness. Deformity, incoordination, episodes of dislocation or subluxation, locking episodes, and effusions were not endorsed. The Veteran reported that tenderness did not affect the joint motions nor were there flare-ups of joint disease. The Veteran stated he was unable to stand for more than a few minutes, and able to walk a quarter of a mile. The examiner found that the Veteran's left ankle exhibited crepitus; but had no ankle instability, tendon abnormality, or angulation. Upon examination, the examiner found the Veteran to have 0 to 20 degrees of dorsiflexion, and 0 to 45 degrees of plantar flexion. No objective evidence of pain or additional limitations of range of motion were found after repetitive testing. No joint ankylosis was found. The examiner further noted that the Veteran was observed walking with a slight antalgic gait entering the appointment, but walked normally when leaving the building. An x-ray taken of the Veteran's ankle was normal. In March 2010, the examiner noted the Veteran had complaints of giving way, instability, pain, stiffness, weakness, incoordination, decreased joint motion speed, swelling due to inflammation, and repeated effusions. He also reported experiencing locking episodes daily or more often, and dislocation and subluxation several times a week. Deformity and flare-ups of joint disease were not endorsed. The Veteran reported he was only able to stand for 10 minutes, maximum, and could walk only a quarter mile with pain. He reported intermittently and frequently using his ankle brace. Upon examination, the examiner noted antalgic gait, crepitus, tenderness, and pain to the lateral malleolus and post heel of the left foot. No ankle instability, tendon abnormality, or angulation was found. Upon examination, the examiner found the Veteran to have 0 to 15 degrees of dorsiflexion, and 0 to 45 degrees of plantar flexion. There was no objective evidence of pain with active motion or repetitive motion, and no additional limitation after repetitive motion. No joint ankylosis was found. An x-ray of the ankle showed joint spaces was normal, no bony abnormalities, and a normal ankle was the final impression. During his March 2010 VA examination, the Veteran also reported that he could only walk on tip toe due to pain. He stated that he was unable to walk normally, on his heel, due to pain in his left heel. Upon x-ray review, minimal plantar calcaneal spurring, and minimal degenerative changes in the tarsal bones were found. The examiner opined that the bones and joints were otherwise normal, and that it was a normal foot. In January 2012, the Veteran was found to have 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. There was no objective evidence of pain. After repetitive testing, the examiner found no additional limitations. He did find functional loss after repetitive testing with the Veteran reporting pain on movement, swelling, and interference with sitting, standing, and weight bearing. No anterior drawer or talar tilt test instabilities were found, as well as no ankylosis. The Veteran reported not using an assistive device, including his brace. X-rays showed degenerative or traumatic arthritis in the left ankle. The Veteran reported his ankle pain limited his ability to stand and walk for prolonged periods of time. During the January 2012 VA examination, a neurological examination was also conducted. The Veteran was not found to have a peripheral nerve condition or peripheral neuropathy; nor any symptoms associated with a peripheral nerve condition. Upon sensory examination, the Veteran exhibited mild hypersensitivity in his left lower leg/ankle. The Veteran was observed as having an abnormal gait as he was limping, with mild favoring of the left leg. He was found to have mild neuralgia of his left musculocutaneous nerve, which is not in his left lower extremity. Furthermore, during the January 2012 VA examination, the Veteran was also examined for a heel spur, per Board remand instructions. Upon x-ray review, the Veteran was found to have heel spurs on both feet. Functionally, the Veteran reported the heel spur caused frequent leg cramps and burning pain in his left heel, which radiated up the lateral aspect of his left to the knee after prolonged walking. The examiner found no other issues associated with the heel spur on the left foot, and opined that both heel spurs were minimal, and consistent with age appropriate degenerative changes. In October 2014, a VA physician opined that the Veteran had normal ankle reflexes after examination. In January 2015, the Veteran was afforded a VA examination for individual unemployability. Here, the Veteran's left ankle was examined, and found to have abnormal range of motion, observed with dorsiflexion and plantar flexion motions. However, the abnormal range of motion was not found to contribute to functional loss and although pain was noted, it also did not contribute to functional loss. Objectively, the examiner found evidence of localized tenderness or pain on palpation on the medial ankle. Flare-ups were reported by the Veteran as occurring daily, severely, and lasting for hours. The Veteran reported not using an assistive device, including his brace. Functionally, the Veteran reported that he could not work due to pain so severe that it radiated all day. No degenerative arthritis was found upon x-ray review. In March 2015, the Veteran complained of increasing left ankle pain, due to his left knee pain. He reported that the cold weather and increased activity made the pain worse, and that he had increased his pain medication dosage on his own accord. In November 2016, the Veteran complained of ankle pain that felt as if his ankle were broken. He also complained of his left lower extremity feeling as if it was burning, and that he had initially noticed the pain in 2015. After an electrodiagnostic assessment, the physician found the examination to be minimally abnormal, and that fibrosis that was noticed in the tibialis anterior area was consistent with the scars after a high school track injury. The Board finds that entitlement to an evaluation in excess of 10 percent for the Veteran's ankle disabilities is not warranted. Although the Veteran's private and VA treatment history show that the Veteran experienced pain, the Veteran's ankle does not reveal loss of motion. In addition, the Veteran was observed to have minimal functional loss or functional impairment, other than his own self-reports. These reports, such as the report by the January 2015 VA examiner, described moderate limitation of the ankle. The January 2015 VA examiner noted the Veteran's medical history which included lifting an outdoor fountain in May 2009, playing basketball in September 2009, and also the Veteran's report to the January 2015 VA examiner that he was very active with his three children. The January 2015 VA examiner included all of the above when opining that the Veteran's disabilities did not prevent him from being employable. In other reports, although the Veteran was found to have difficulty with some daily activities such as chores, exercise, or shopping, he was also found to be able do other daily activities such as bathing, feeding, and dressing himself with no issue. Repetitive-use testing did not show any further reduction of the range of motion and the range of motion was not accompanied by objective evidence of pain. Furthermore, the January 2012 VA examiner opined that the Veteran's left musculocutaneous nerve neuralgia or heel spurring was not related to his ankle disability. The Board notes that the Veteran's left ankle was diagnosed with arthritis in February 2009 and January 2012. In February 2009, the VA orthopedist reviewed x-rays taken in January 2009, and diagnosed the Veteran with mild osteoarthritis. In January 2012, the VA examiner reviewed x-rays and diagnosed the Veteran with degenerative or traumatic arthritis. Under Diagnostic Code 5003, degenerative arthritis, when substantiated by x-rays, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Where there is x-ray evidence of arthritis and limitation of motion, but not to a compensable degree, a 10 percent rating is assigned for each major joint affected. 38 C.F.R. § 4.71, Diagnostic Code 5003. The ankle is considered a major joint. 38 C.F.R. § 4.45. Ratings for arthritis cannot be combined with ratings based on limitation of motion of the same joint. As discussed below, while the Veteran additionally has arthritis in his left knee, each of those disabilities is already separately and compensably rated. Therefore, a 20 percent rating is not warranted under Diagnostic Code 5003 for x-ray evidence of involvement of two or more major joints, because the Veteran's other major joints that are service connected are already separately rated, and pyramiding is not permitted. See 38 C.F.R. § 4.14. For the foregoing reasons, an increased disability evaluation for the Veteran's service-connected chronic left ankle sprain is not warranted. Clinicians have evaluated the ankle disability to determine the extent of the disability, and the findings do not show that the Veteran had sufficiently greater limitation of function in either ankle as to warrant rating in excess of those currently assigned. In other words, the objective clinical findings consistently fail to show that the ankle disability meet the criteria for increasing ratings, and the Board concludes that those findings outweigh the Veteran's lay assertions regarding severity. Thus, as the Veteran's left ankle does not reveal more than a moderate limitation of motion, entitlement to a higher evaluation is denied. The Board has considered the Veteran's assertions and weighed them against the medical evidence of record. Although the Veteran would disagree with the weight the Board assigns to his lay evidence, the evidence of record does not demonstrate that the Board's assignment of greater weight to the medical evidence is erroneous. See 38 U.S.C. § 7261 (a)(4); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); Gilbert v. Derwinski, 1 Vet. App. 49, 52 (1990). II. Left knee strain The Veteran seeks a higher evaluation for his chronic left knee strain. The Veteran's left knee disability is currently evaluated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5260. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 10 percent evaluation is assignable 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003. 38 C.F.R. §§ 4.40 and 4.45 require that the disabling effect of painful motion be considered when rating joint disabilities. Deluca, 8 Vet. App. 202, 205-06 (1995). Pursuant to 38 C.F.R. § 4.40, "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." Further, functional loss "may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant 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." Id. Under Diagnostic Code 5260, knee flexion limited to 60 degrees warrants a noncompensable rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to only 15 degrees warrants the maximum rating of 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The standard range of motion of the knee is 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. A separate rating can be provided for limitation of knee extension under Diagnostic Code 5261. Under Diagnostic Code 5261, extension limited to 5 degrees or less warrants a noncompensable rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 30 degrees warrants a 40 percent rating; and extension limited to 45 degrees warrants the maximum rating of 50 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The standard range of motion of the knee is zero degrees of extension. 38 C.F.R. § 4.71, Plate II. A separate rating for arthritis can be awarded on the basis of X-ray findings and painful motion under 38 C.F.R. § 4.59; VAOPGCPREC 9-98 (1998). Diagnostic Code 5257 provides a 10 percent evaluation for lateral instability or recurrent subluxation of a knee that is slight, a 20 percent rating when those symptoms are moderate, and a 30 percent rating when severe. Again, the terms "mild," "moderate," and "severe" are not defined in the 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." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Alternatively, dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Private treatment records from March 2009 reflect the Veteran's complaints of increased pain. However, the record is silent for any further range of motion testing. VA treatment records from March 2008 to June 2017 reflect on-going treatment for a left knee disability including complaints of continued knee pain. During this time, knee pain was reported by the Veteran as constant, burning, and aching. Pain was increased with activity and alleviated by resting. In January 2009, an x-ray showed mild narrowing of the medial compartments, to both knees. Otherwise, both knees were found unremarkable. In January 2009, the Veteran's primary care physician noted that his left knee showed no effusion; no pain with internal or external rotation; and pain at the joint line. In February 2009, an orthopedist provided a surgery consultation. Here, the Veteran reported constant pain that increased with stair walking and twisting movements. The orthopedist, objectively, found the knee to be unremarkable with some mild tenderness noted to the lateral aspect, and no laxity. He diagnosed the Veteran with left knee arthralgia with a history of chronic sprain. In May 2008, the Veteran reported walking up the stairs, when his knee "gave way." The Veteran was provided with VA examinations in April 2009, March 2010, June 2010, and January 2012. The April 2009 examiner noted that the Veteran complained of instability and pain. Giving way, instability, stiffness, weakness, incoordination, decreased speed of joint motion, dislocation or subluxation, locking episodes, and flare-ups were not reported. The examiner noted evidence of crepitus. There was no evidence found of clicking or snapping, grinding, or patellar or meniscal abnormality, effusions or joint ankylosis. On examination, the examiner found the Veteran to have flexion to 130 degrees and full extension, with no objective evidence of pain following repetitive motion and no additional limitations after repetitive testing. The March 2010 examiner noted that the Veteran complained of pain, stiffness, weakness, and decreased speed of joint motion. Giving way, instability, incoordination, episodes of dislocation or subluxation, locking episodes, and effusions were not endorsed. Tenderness was noted as a symptom of inflammation, affecting the joint. Flare-ups were reported by the Veteran as severe, occurring on a weekly basis, and lasting for hours. Flare-ups occurred with activity such as bending and turning; and alleviated with rest and ice. On examination, the examiner found the Veteran to have flexion to 140 degrees and full extension, with no additional limitations after repetitive testing. The examiner noted evidence of crepitus and grinding; and found no evidence of instability, clicking/snapping, or patellar or meniscal abnormality. The examiner did not make any remarks on whether the Veteran exhibited ankylosis. There was no objective evidence of pain following repetitive motion and no additional limitations after repetitive motion. Upon x-ray review, the bones and joints were deemed normal, with no joint effusion, and an overall impression of a normal knee. The June 2010 physician noted that the Veteran complained of giving way, instability, pain, stiffness, weakness, incoordination, and repeated effusions. Locking episodes were reported to occur weekly; and flare-ups were described as moderate, occurring weekly, and lasting for hours. Decreased speed of joint motion, and dislocation or subluxation was not endorsed. On examination, the examiner found the Veteran to have flexion to 130 degrees and full extension, with no objective evidence of pain following repetitive motions or additional limitations after repetitive testing. Range of motion of flexion after repetitive motion testing was to 120 degrees. X-rays showed a normal knee. No ankylosis was present. The January 2012 examiner noted that the Veteran complained of pain, instability, and giving way, since 1997. On examination, the examiner found evidence of mild crepitus and no clear instability. On examination, the examiner found the Veteran to have flexion to 140 degrees and full extension, with no additional limitation in range of motion after repetitive testing, no functional loss after repetitive testing, and no tenderness or pain to palpation at the joint line. No patellar subluxation or dislocation was found, no semilunar cartilage condition was found, and medial-lateral instability testing proved normal. The examiner diagnosed the Veteran with chronic exertional compartment syndrome after the Veteran reported burning dysesthesias in his left lateral shin with prolonged walking or standing. X-rays of the Veteran's tibia and fibula showed a normal left leg. In June 2013, the Veteran underwent an electrodiagnostic assessment which showed a minimally abnormal examination. The physician found there to be no convincing evidence of general peripheral neuropathy or localized entrapment. He stated that the Veteran's complaints of burning dysesthesias from his left lateral knee down after prolonged walking and standing were probably a result of the Veteran's high school track injury. In January 2015, the Veteran was afforded a VA examination for individual unemployability. Here, the Veteran's left knee was examined. On examination, the examiner found the Veteran to have flexion to 135 degrees and full extension. Although flexion and extension exhibited pain, it was not found to contribute to or cause functional loss. After repetitive testing, no additional functional loss was found. The Veteran complained of flare-ups occurring daily and severely, lasting for hours. No ankylosis was found. No evidence was found of recurrent subluxation or lateral instability. Mild, daily recurrent effusion was found. Based on the objective medical evidence, the Board finds that the Veteran's left knee limitation of flexion does not more nearly approximate the level of severity contemplated by a 20 percent rating. While the Veteran has reported limitation of motion and other symptoms, the Board finds that these statements are outweighed by the objective range of motion testing conducted by the April 2009, March 2010, June 2010, August 2010, and January 2012 VA physicians, which clearly showed that at no point during the period on appeal has the Veteran's limitation of flexion of his left knee approached the level of severity contemplated by a 20 percent rating, even when considering additional limitations due to pain, fatigue, and other factors. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Indeed, the objective range of motion testing of record shows that the Veteran has a full range of motion, which well exceeds the limitation of flexion to 30 degrees contemplated by a 20 percent rating. In evaluating the Veteran's current level of disability functional loss was considered. 38 C.F.R. §§ 4.40, 4.45. The medical evidence shows that the Veteran has, at different times, complained of pain, limitations on motion and mobility, giving way, flare-ups, burning, stiffness, tenderness, numbness, soreness, and weakness, all of which the Veteran is competent to report. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Further functional loss due to pain, fatigue or other symptoms after repetitive testing was noted only in June 2010. While there is no objective evidence of further limitation of function, the Veteran's statements concerning additional functional loss, specifically the tendency of his left knee to give way, are already contemplated by his assigned ratings. The Veteran is in receipt of a 10 percent rating for chronic left knee strain based on pain present in the affected joint. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Thus, the current 10 percent rating contemplates those instances of reduced function. As such, the Board finds that the Veteran's statements concerning further limitation are already fully contemplated by his assigned 10 percent rating for chronic left knee strain. 38 C.F.R. §§ 4.40, 4.45, 4.59. The Board notes that the Veteran was diagnosed arthritis in April 2009 and January 2012. X-rays taken in April 2009 showed very mild degenerative joint disease and x-rays taken in January 2011, then remarked upon by the January 2012 VA examiner, showed mild osteoarthritic degenerative changes. Under Diagnostic Code 5003, degenerative arthritis, when substantiated by x-rays, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Where there is X-ray evidence of arthritis and limitation of motion, but not to a compensable degree, a 10 percent rating is assigned for each major joint affected. 38 C.F.R. § 4.71, Diagnostic Code 5003. The knee is considered a major joint. 38C.F.R. § 4.45. Ratings for arthritis cannot be combined with ratings based on limitation of motion of the same joint. As the knee is the only major joint affected by arthritis, only a 10 percent rating can be assigned for his arthritis under Diagnostic Code 5003. As discussed above, while the Veteran additionally has arthritis in his left ankle, each of those disabilities is already separately and compensably rated. Therefore, a 20 percent rating is not warranted under Diagnostic Code 5003 for x-ray evidence of involvement of two or more major joints, because the Veteran's other major joints that are service connected are already separately rated, and pyramiding is not permitted. See 38 C.F.R. § 4.14. No additional higher or alternative ratings under different Diagnostic Codes for the left knee disability can be applied in this case. For the purposes of Diagnostic Code 5256, ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing SAUNDERS ENCYCLOPEDIA AND DICTIONARY OF MEDICINE, NURSING, AND ALLIED HEALTH 68 (4th ed. 1987)). As the Veteran is able to move his knee, it is clearly not ankylosed and VA physicians specifically noted that the Veteran did not exhibit ankylosis at any time. All range of motion testing of record shows that the Veteran has full extension of the left knee. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Therefore a higher or separate and compensable rating based on limitation of extension of the left knee is not warranted. All examiners noted that the Veteran's left knee was stable. 38 C.F.R. § 4.71a, Diagnostic Code 5257. There is no medical or lay evidence of dislocated semilunar cartilage or nonunion or malunion of the tibia and fibula. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5262. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against an initial rating in excess of 10 percent for the Veteran's service-connected chronic left knee strain. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim is denied. ORDER Entitlement to a rating in excess of 10 percent for chronic left ankle sprain is denied. Entitlement to a rating in excess of 10 percent for chronic left knee strain is denied. ____________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs