Citation Nr: 1808613 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 10-34 537 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for right ankle arthritis. 2. Entitlement to an initial rating in excess of 10 percent for degenerative changes of the left knee and in excess of 20 percent for lateral instability and subluxation of the left knee. 3. Entitlement to an initial compensable rating for a chip fracture of the right middle finger. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Rachel E. Jensen, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from January 1985 to January 1989. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. That decision granted service connection for right ankle arthritis at 10 percent disabling, left knee degenerative changes at 10 percent disabling, and status post chip fracture of the right middle finger at 0 percent disabling, all effective October 3, 2005. The Veteran submitted a Notice of Disagreement and subsequently perfected his appeal. In July 2013, the Veteran underwent right ankle surgery and was later granted a temporary 100 percent rating from July 31, 2013, to August 31, 2013. In a July 2015 rating decision, the Veteran was granted a separate 20 percent rating for lateral instability and subluxation of the left knee, effective from April 2015 These matters came before the Board in March 2015, September 2016, and May 2017, at which time they were remanded for further development. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in December 2016. FINDINGS OF FACT 1. Prior to July 2013, the Veteran's ankle disability was productive of no more than moderate limitation of motion. 2. From August 31, 2013, the Veteran has exhibited marked limitation of motion of his right ankle with, at best, dorsiflexion to 20 degrees and flexion to 25 degrees, and at worst, dorsiflexion to 2 degrees and plantar flexion to 10 degrees, together with disturbance of locomotion, interference with standing, and difficulty with stairs. 3. The Veteran's left knee range of motion has not been limited to at least 60 degrees in flexion or 5 degrees in extension. 4. There is no probative evidence of incapacitating exacerbations of the Veteran's left knee disability or ankylosis of the knee. 5. The Veteran's left knee has had moderate lateral instability, with no evidence of recurrent subluxation or severe lateral instability. 6. Although the Veteran has reported locking and pain in his left knee, there is no history of frequent effusions in the joint. 7. The Veteran's right middle finger disability is productive of normal range of motion; a gap between the middle finger and the proximal transverse crease of the hand on maximal flexion is not demonstrated, and there is no probative evidence of pain on motion, or ankylosis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for right ankle disability prior to July 2013 are not met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5003, 5010, 5270, 5271 (2017). 2. The criteria for a 20 percent disability rating for a right ankle disability have been met from August 31, 2013. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5003, 5010, 5270, 5271 (2017). 3. The criteria for an initial rating in excess of 10 percent for degenerative changes of the left knee and in excess of 20 percent for lateral instability and subluxation of the left knee have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5003, 5256, 5257, 5258, 5259, 5260, 5261 (2017). 4. The criteria for an initial compensable rating for a right middle finger disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5229 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Additionally, where a veteran has a noncompensable rating and complains of pain on motion, he or she is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Id. In evaluating joint disabilities, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath, 1 Vet. App. at 592. I. Right Ankle The Veteran's right ankle disability is currently rated 10 percent disabling under 38 C.F.R. § 4.71a, DC 5010. Limitation of motion of the ankle is rated under DC 5270 and DC 5271. DC 5010 provides that arthritis due to trauma, substantiated by x-ray findings, is rated as degenerative arthritis. 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. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, and a rating of 20 percent is for application for each such major joint or group of minor joints affected by limitation of motion when there are occasional incapacitating exacerbations, to be combined, not added, under DC 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, DC 5003, 5010. DC 5271 provides ratings based on limitation of extension of the ankle. Moderate limitation of motion of the ankle is rated as 10 percent disabling, and marked limitation of motion of the ankle is rated as 20 percent disabling. 38 C.F.R. § 4.71a, DC 5271. Under DC 5270, ankylosis of an ankle warrants a 20 percent evaluation if it is in plantar flexion, at less than 30 degrees. A 30 percent evaluation is warranted if the ankylosis is in plantar flexion, between 30 and 40 degrees, or in dorsiflexion, between 0 and 10 degrees. 38 C.F.R. § 4.71a , DC 5270. Normal ranges of motion of the ankle are dorsiflexion from zero to 20 degrees, and plantar flexion from zero to 45 degrees. See 38 C.F.R. § 4.71, Plate II (2017). In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups, and the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination must be considered. See DeLuca v. Brown, 8 Vet. App. at 202. The Board notes that the words "moderate" and "marked" are not defined in the VA 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." See 38 C.F.R. § 4.6 (2017). The Veteran underwent several VA examinations to determine the severity of his right ankle disability. In an April 2010 examination, the Veteran displayed dorsiflexion to 20 degrees and plantar flexion to 40 degrees. The same range of motion was observed after repetition, with no obvious signs of fatigability, lack of endurance, or incoordination. No deformities, heat, or effusion were found. Slight medial and lateral laxity was noted, but the ankle was found to be overall stable. X-ray examination revealed evidence of previous trauma about the medial malleolus with possible tendon rupture associated with ossification. At a September 2010 examination, active range of motion was dorsiflexion to 15 degrees and plantar flexion to 40 degrees. There was evidence of pain with active motion. There were no limitations following repetition. The Veteran's ankle was negative for ankylosis. X-ray examination revealed no significant interval change. Degenerative changes were noted in the mid-foot area. X-rays in March 2013 and April 2013 showed degenerative joint disease and ossifications of the right ankle and noted continued chronic pain despite conservative treatment. Another x-ray examination in July 2013 demonstrated medial malleolus corticated and sclerotic bony fragments without associated soft tissue swelling. Joint spaces were narrowed and sclerosis of the distal fibula was found. In July 2013, the Veteran had an arthroscopy with chondroplasty surgery and debridement on his right ankle, after which he had extensive physical therapy. A temporary 100 percent rating was granted from July 31, 2013, to August 31, 2013. He was prescribed a boot to aid in healing and strengthening. At the end of his therapy in December 2013, his range of motion was active and passive dorsiflexion to 2 degrees, active plantar flexion to 35 degrees, and passive plantar flexion to 40 degrees. Muscle strength upon dorsiflexion and plantar flexion were both determined to be 4 out of 5. He continued to experience aches and pains. The Veteran was awarded Social Security disability benefits effective July 2013 due to osteoarthrosis and allied disorders and unspecified arthropathies of the bilateral ankles and knees. A January 2014 examination done in conjunction with his Social Security claim revealed an unsteady gate, limited range of motion in his ankle, difficulty balancing on his heels, difficulty squatting, and difficulty lifting his toes. Active and passive motion on dorsiflexion was to 15 degrees and on plantar flexion was to 20 degrees. Muscle strength was 5 out of 5. The Veteran reported using an ankle brace and cane. An October 2014 x-ray revealed joint space loss in the tibiotalar joint with subchondral sclerosis and both medial and lateral osteophytes. There was evidence of ankle effusion, with no acute fracture or dislocation. VA treatment records indicated that the Veteran had a slow, very antalgic gait, had edema of the right ankle, and had a restricted, painful range of motion of the right ankle joint. The Veteran reported "shifting of bones that produce audible noises." He also stated that the July 2013 arthroscopy and debridement helped temporarily, but that he felt like his pain was worse than before the surgery. The possibility of an ankle fusion was discussed with his clinician. In May 2015, the Veteran underwent another VA examination that revealed dorsiflexion to 10 degrees and plantar flexion to 25 degrees. Pain was noted upon examination with range of motion and upon weight-bearing. No localized tenderness, pain on palpation, crepitus, instability, or dislocation were observed. The Veteran's ankle was negative for ankylosis. He reported regular use of an ankle brace. Upon x-ray examination, the examiner noted moderately severe osteoarthritis in the tibiotalar joint. The examiner determined that the functional impact of the ankle disability was to limit the Veteran's ability to walk extended distances. A February 2016 VA ankle examination revealed dorsiflexion to 20 degrees and plantar flexion to 10 degrees, with pain exhibited on each type of motion. The abnormal range of motion was reported to produce difficulty with walking, standing, and taking stairs. Range of motion testing after three repetitions was dorsiflexion to 15 degrees and plantar flexion to 10 degrees. Marked swelling on the lateral ankle and tenderness distal to the medial and lateral malleolus were observed. Pain upon weight-bearing and crepitus were found. The examination was conducted during a flare-up and the examiner noted that pain significantly limited functional ability with flare-ups. Less movement than normal, disturbance of locomotion, interference with standing, and difficulty with stairs were reported as contributing factors to the disability. Muscle strength on dorsiflexion was rated a 5 out of 5 and on plantar flexion, a four out of 5. Instability or dislocation was suspected and the Talar Tilt Test was positive for laxity. In a May 2016 VA treatment record, the clinician observed crepitation and decreased range of motion to the right ankle and subtalar joints. The assessment was severe osteoarthritic arthritis and pain. At a VA hearing in December 2016, the Veteran stated that he experienced a lack of flexibility in his right ankle. He described the ankle locking up in the morning, with the eventual ability to move and flex it. He stated he experienced pain and swelling, for which he would ice down the ankle. He reported shooting, throbbing, and stabbing pain in the right ankle, shooting up his leg. At a June 2017 VA ankle examination, the Veteran demonstrated dorsiflexion to 10 degrees and plantar flexion to 20 degrees. Pain was noted upon examination, but was not determined to result in a functional loss. There was evidence of pain on weight-bearing and localized tenderness or pain on palpation of the ankle joint. There was also evidence of crepitus. The Veteran was able to perform repetitive use testing without additional loss of function. Less movement than normal, disturbance of locomotion, and interference with standing were reported as contributing factors to the disability. Muscle strength on dorsiflexion was 5 out of 5 and on plantar flexion was 5 out of 5. Right ankle instability or dislocation was not suspected. Pain from arthritis was exhibited on passive range of motion testing and no pain was observed in nonweight-bearing. X-ray examination revealed moderate tibiotalar osteoarthritis with osteophytes at the tibial plafond and subchondral sclerosis and cystic changes at the talar dome. Mild arthropathy at the tarsal articulation was unchanged from prior studies. The Veteran has consistently been prescribed pain and anti-inflammatory medications for his symptoms. As noted above, the Veteran underwent surgery in July 2013, largely to remove loose debris in the right ankle. Prior to the surgery, the Veteran's range of motion was mildly limited. No incapacitating exacerbations were of record and no ankylosis was noted. As such, a 10 percent rating under DC 5010 continues to be warranted prior to the July 2013 surgery. Following that surgery and recuperation period, the Veteran's range of motion was markedly limited, tenderness and swelling were noted, and effusion and crepitus were observed. The x-ray evidence indicates degenerative changes have worsened, as well. Since July 2013, at best, the Veteran's dorsiflexion has been to 20 degrees and flexion to 25 degrees, with much more limited range of motion demonstrated overall. At worst, his dorsiflexion has been to 2 degrees and plantar flexion to 10 degrees. The functional impacts have been determined to be less movement than normal, disturbance of locomotion, interference with standing, and difficulty with stairs. The Board finds that, giving the Veteran the benefit of the doubt, the totality of his current symptoms most closely approximates marked limitation of motion. Accordingly, a 20 percent disability rating is warranted under DC 5271. As the Veteran received a 100 percent temporary disability rating from July 31, 2013, to August 31, 2013, for his ankle surgery and convalescence, a 20 percent rating is merited following that period. A 20 percent rating is the highest possible rating under both DC 5010 and DC 5271. Additionally, no ankylosis has been diagnosed at any time throughout the appeal period to warrant a higher rating under DC 5270. Therefore, a 20 percent disability rating is granted from August 31, 2013. II. Left Knee The Veteran's left knee disability currently receives a rating of 10 percent for degenerative changes under 38 C.F.R. § 4.71a, DC 5010 effective from October 2005, and a rating of 20 percent for lateral instability and subluxation under 38 C.F.R. § 4.71a, DC 5257, effective from April 2015. Under DC 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling, moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. The terms "mild," "moderate" and "severe" are not defined in the Rating Schedule. As noted above, the Board must evaluate all of the evidence for an "equitable and just" decision. 38 C.F.R. § 4.6. Other diagnostic codes relevant to a knee disability include DC 5256, DC 5258, DC 5259, DC 5260, and DC 5261. Under DC 5256, ankylosis of the knee warrants a 30 percent evaluation for favorable angle in full extension, or in slight flexion between 0 and 10 degrees; a 40 percent evaluation when in flexion between 10 and 20 degrees; a 50 percent evaluation when in flexion between 20 and 45 degrees; and a 60 percent evaluation for extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more. Under DC 5258, a claimant is entitled to a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under DC 5259, a 10 percent evaluation is assigned for symptomatic removal of semilunar cartilage. Id. Under DC 5260, limitation of flexion of the leg is rated 0 percent when limited to 60 degrees, 10 percent when limited to 45 degrees, 20 percent when limited to 30 degrees, and 30 percent when limited to 15 degrees. Id. Under DC 5261, limitation of extension of the leg is rated 0 percent when limited to 5 degrees, 10 percent when limited to 10 degrees, 20 percent when limited to 15 degrees, 30 percent when limited to 20 degrees, 40 percent when limited to 30 degrees, and 50 percent when limited to 45 degrees. Id. Normal ranges of motion of the knee are to 0 degrees for extension and to 140 degrees for flexion. See 38 C.F.R. § 4.71a, Plate II. Prior to and during the appeal period, the Veteran has undergone several arthroscopies of his left knee. In an April 2006 VA examination, flexion of the knee was to 125 plus degrees and extension of the knee was to zero degrees. Repetition was performed with the same degrees of motion with each repetition with no obvious increase in pain, fatigability, lack of endurance, or incoordination. No heat, effusion, or Baker's cyst were observed. Slight tenderness was found over the medial and lateral joint line and about the patella. Some crepitus was noted with range of motion. It was stable with a negative McMurray's test and a negative Drawer's sign. X-ray examination revealed degenerative changes with small joint effusion but no acute fractures. At a September 2010 VA examination, active range of motion of the left knee was flexion to 130 degrees and extension was normal. There was objective evidence of pain following repetitive motion but no additional limitations after three repetitions. X-ray examination revealed degenerative changes of the knee which appeared to have increased compared to the April 2006 x-ray. A March 2012 VA x-ray examination revealed that the Veteran's left knee had worsened since prior x-rays, showing internal degeneration of the posterior horn of the medial and lateral meniscus with no apparent tear, internal derangement, probable mucoid degeneration of the anterior cruciate ligament (ACL) with the possibility of a partial thickness tear, small joint effusion, moderate chondromalacia of the medial tibial femoral compartment, and tricompartmental degenerative joint disease moderate to severe in the medial tibiofemoral compartment with possible loose articular bodies. As noted above, the Veteran has received Social Security disability benefits since July 2013 based on bilateral knee and ankle disabilities. At a January 2014 examination done in conjunction with his claim for benefits, the Veteran displayed active flexion to 140 degrees and extension to 0 degrees. He reported intermittent pain and the use of knee braces and a cane. An unsteady gait was observed. October 2014 and November 2014 VA x-rays displayed medial compartment osteoarthritis, knee joint effusion, and possible intra-articular loose bodies. A January 2015 x-ray showed laxity of the ACL with probable mucoid degeneration, moderate to severe chondromalacia in the medial compartment with subchondral edema, moderate subchondral edema extending from the lateral to the medial aspect of the lateral tibial plateau, a tiny joint effusion, and a tiny popliteal cyst. A May 2015 VA examination demonstrated flexion to 100 degrees and extension to 1 degree. Pain was noted upon flexion and upon weight-bearing. Localized tenderness was noted at the lateral back of the knee joint. No crepitus, effusion, or ankylosis was observed. It was noted that the Veteran had a history of moderate recurrent subluxation and a history of slight lateral instability. A joint stability test was done and no instability was observed. The Veteran reported constant use of a knee brace and that his ability to squat and bend his knee was limited. X-ray examination revealed small, tricompartmental osteophytes that were unchanged. The medial joint space was moderately narrowed, which appeared slightly increased since the prior examination. Two osseous bodies projecting over the anterior and posterior joint spaces and a moderate sized spur arising from the superior pole of the patella were unchanged. No acute fracture, dislocation, or joint effusion was noted. At a February 2016 VA examination, the Veteran demonstrated painful flexion to 95 degrees and extension to 0 degrees. The abnormal range of motion contributed to difficulty with standing, walking, bending, climbing, and squatting. Tenderness was observed along the medial joint line. There was evidence of pain with weight-bearing and objective evidence of crepitus. After three repetitions, flexion was to 90 degrees and extension to 0 degrees. The examination was conducted during a flare-up. Pain was determined to significantly limit functional ability with flare-ups. Additional contributing factors of disability were noted to be less movement than normal, disturbance of locomotion, interference with standing, and difficulty climbing and squatting. Muscle strength was 4 out of 5 with flexion and 4 out of 5 with extension. No history of subluxation was determined and a history of moderate lateral instability was noted. Joint stability testing was performed and medial instability was observed. At the December 2016 hearing, the Veteran reported he had had no improvement in his left knee since his last VA examination, at which he found the examiner to be flippant. He reported no ongoing treatment for his left knee. He stated that when his knee locks up he goes to the emergency room where he is given shots to stop inflammation and given crutches for a week to two weeks. He reported taking Atenolol, Tramadol, and Aleve for pain. He stated he experienced pain at 5 out of 10 on average days and 11 out of 10 on bad days. He described his symptoms as popping with sharp, shooting pain; swelling; and instability. He reported always wearing compression braces and exterior custom braces, and using a cane, walker, or crutches. In June 2017, the Veteran underwent another VA examination and displayed painful flexion to 110 degrees and painful extension to 0 degrees. There was no evidence of pain with weight-bearing or localized tenderness or pain on palpation. Objective evidence of crepitus was observed. There was no additional functional loss or range of motion after three repetitions. Additional contributing factors of disability were determined to be less movement than normal, disturbance of locomotion, interference with sitting, and interference with standing. Muscle strength was 5 out of 5 on flexion and extension. There was no history of recurrent subluxation or effusion and a history of moderate lateral instability. Joint stability testing was performed and medial instability of zero to 5 millimeters was demonstrated. There was evidence of pain on passive range of motion but no evidence of pain upon nonweight-bearing. An x-ray examination revealed joint space loss of the knee, moderate in the medial tibiofemoral compartment, small osteophyte formation seen in all compartments, unchanged multiple osteochondral loose bodies, superior patellar enthesopathy, and no fracture, dislocation, or joint effusion. VA treatment records indicate the Veteran continues to take pain and anti-inflammatory medications for his left knee and to use a knee brace. The Board notes that the ranges of motion observed over the appeal period do not warrant a compensable rating under DC 5260 or DC 5261. See 38 C.F.R. § 4.71a, DC 5260, DC 5261. Under DC 5010, the Veteran continues to warrant a 10 percent disability rating. There is no medical evidence of incapacitating exacerbations to merit a 20 percent rating. The Veteran did state that when his knee locks up he goes to the emergency room and is given crutches for a week or more, however, there is no record of this in the VA treatment notes or treatment notes obtained from the Social Security Administration. With no medical evidence of incapacitating exacerbations, the more probative evidence is against a higher evaluation under DC 5010. The medical evidence of record indicates that the Veteran has had at most, a history of lateral moderate instability, as evidenced by the findings in the February 2016 and June 2017 VA examinations. As such, the left knee disability continues to warrant a 20 percent evaluation for lateral instability under DC 5257. At no point has recurrent subluxation been noted, clinicians have not characterized the lateral instability as severe, and no further evidence has been presented to warrant a higher rating. There has also been no diagnosis of ankylosis throughout the appeal period to warrant consideration under DC 5256. The Veteran has noted that his knee sometimes locks up and he does experience pain. However, he does not have a history of frequent effusions in the joint. As such, an additional rating under DC 5258 is not merited. Further, consideration under DC 5259 is not appropriate, given the nature of the Veteran's disability and treatment history. Accordingly, entitlement to a rating higher than 10 percent under DC 5010 and higher than 20 percent under DC 5257 has not been demonstrated. III. Right Middle Finger The Veteran's right middle finger disability has been rated noncompensable under DC 5229. Under DC 5229, contemplating limitation of motion of the index or long finger, a noncompensable rating is warranted where there is a gap of less than one inch (2.5 cm) between the fingertip of either the major or minor hand and the palm crease, with the finger flexed to the extent possible, and a maximum 10 percent rating is warranted where there is a gap of one inch (2.5 cm) or more between the fingertip of either the major or minor hand and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or with extension limited by more than 30 degrees. 38 C.F.R. § 4.71a, DC 5229. Also relevant to consideration of the Veteran's right middle finger disability is DC 5226. Under 5226, favorable or unfavorable ankylosis of the long finger of either the major or minor hand is rated 10 percent disabling. 38 C.F.R. § 4.71a, DC 5229. Normal range of motion flexion of the distal interphalangeal joint (DIP) joint is to 70 degrees, of the proximal interphalangeal (PIP) joint is to 100 degrees, and of the metacarpophalangeal joints (MCP) joint is to 90 degrees. Normal extension of each joint is neutral. A Note following diagnostic codes 5224 (relative to ankylosis of the thumb), 5225 (relative to ankylosis of the index finger), 5226, and 5227 (relative to ankylosis of the ring finger) provides that whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand should also be considered. The Veteran underwent several VA examinations to determine the severity of his right middle finger disability. In an April 2006 examination, flexion was to 10 degrees and the Veteran could extend the finger back to normal. He was able to touch all digit tips to the thumb and pull all fingertips down into the palm. He was able to make a fist and his grip strength was appropriate. At a September 2010 examination, extension of the right DIP joint, PIP joint, and MCP joint were all normal (finger aligned with the hand). There was no gap between the middle finger and the proximal transverse crease of the hand on maximal flexion. There was no objective evidence of pain and no evidence of pain after repetitive motion. An examination done in January 2014 in conjunction with the Veteran's application for Social Security disability benefits reported normal active range of motion of the Veteran's hands and fingers. A May 2015 VA examination revealed maximum extension of the DIP, PIP, and MCP joints to zero degrees, flexion of the DIP joint to 70 degrees, flexion of the PIP joint to 100 degrees, and flexion of the MCP joint to 90 degrees. There was no gap between the middle finger and the proximal transverse crease of the hand on maximal flexion. No pain was noted upon examination or with use of the hand, no ankylosis was found, and hand grip strength was 5 out of 5. There was no objective evidence of localized tenderness or pain on palpation of the joint or soft tissue. X-ray examination revealed no acute fracture, no dislocation, and no significant bony abnormality. No functional impact was reported. The Veteran underwent a VA examination in February 2017 which displayed maximum extension of the DIP, PIP, and MCP joints to zero degrees, flexion of the DIP joint to 70 degrees, flexion of the PIP joint to 100 degrees, and flexion of the MCP joint to 90 degrees. There was no gap between the middle finger and the proximal transverse crease of the hand on maximal flexion. No pain was noted upon examination or with use of the hand, no ankylosis was found, and hand grip strength was 5 out of 5. There was no objective evidence of localized tenderness or pain on palpation of the joint or soft tissue. There was no evidence of pain on passive range of motion and no evidence of pain on nonweight-bearing. Initially, the Board notes that the Veteran is noted to be ambidexterous in several VA examinations and right-hand dominant in others. However, because the diagnostic codes at issue contain similar ratings for the major (dominant) and minor (non-dominant) extremities, this is not at issue. Throughout the entire appeal period, the Veteran's right middle finger disability displayed normal range of motion, no gap between the middle finger and the proximal transverse crease of the hand on maximal flexion, and no objective evidence of pain on motion. Additionally, no ankylosis has been diagnosed. Accordingly, a noncompensable rating is warranted. Further, the Board finds that the effect of the Veteran's right middle finger disability as indicated by the above evidence does not warrant a separate rating under the Note following diagnostic codes 5224, 5225, 5226, and 5227. There is no evidence of limitation of motion of other digits or interference with overall function of the hand. Therefore, a compensable rating is not merited. ORDER A rating in excess of 10 percent for right ankle arthritis prior to July 2013, is denied. Subject to the law and regulations governing the payment of monetary benefits, a rating of 20 percent for right ankle arthritis from August 31, 2013, is granted. An initial rating in excess of 10 percent for degenerative changes of the left knee and in excess of 20 percent for lateral instability and subluxation of the left knee is denied. An initial compensable rating for a chip fracture of the right middle finger is denied. ____________________________________________ M. E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs