Citation Nr: 1822017 Decision Date: 04/12/18 Archive Date: 04/25/18 DOCKET NO. 14-27 770 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to a higher initial disability rating for thoracolumbar spine strain (back disability) in excess of 10 percent from October 1, 2011. 2. Entitlement to a higher (compensable) initial disability rating for left ankle talonavicular joint degenerative joint disease (left ankle disability) from October 1, 2011 to June 6, 2014, and in excess of 10 percent from June 6, 2014. 3. Entitlement to a higher (compensable) initial disability rating for right ankle talonavicular joint degenerative joint disease (right ankle disability) from October 1, 2011. 4. Entitlement to a higher (compensable) initial disability rating for left knee patellofemoral syndrome (left knee disability) from October 1, 2011 to June 6, 2014, and in excess of 10 percent from June 6, 2014. 5. Entitlement to a higher (compensable) initial disability rating for right knee patellofemoral syndrome (right knee disability) from October 1, 2011 to June 6, 2014, and in excess of 10 percent from June 6, 2014. 6. Whether a separate rating is warranted for left knee instability. 7. Whether a separate rating is warranted for right knee instability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD E. Choi, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from September 1991 to September 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision of the RO in Winston-Salem, North Carolina. Jurisdiction over this case is currently with the RO in Roanoke, Virginia. The January 2012 rating decision, in pertinent part, granted service connection for a back disability, left ankle disability, right ankle disability, left knee disability, and right knee disability, assigned an initial 10 percent rating for the back disability from October 1, 2011 (the day after service separation), and a noncompensable rating for the left ankle disability, right ankle disability, left knee disability, and right knee disability from October 1, 2011. In an April 2017 rating decision, the RO assigned a higher 10 percent rating for the left ankle disability, left knee disability, and right knee disability from June 6, 2014. In October 2017, the Veteran testified at a Board Videoconference hearing in Roanoke, Virginia, before the undersigned Veterans Law Judge (VLJ) sitting in Washington, D.C. A transcript of the hearing has been associated with the electronic file. The Board has reviewed the electronic file on "Virtual VA" and the Veterans Benefits Management System (VBMS) to ensure a complete review of the evidence in this case. The issue of a higher initial rating for the right ankle disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO. FINDINGS OF FACT 1. For the entire initial rating period on appeal from October 1, 2011, the back disability has been manifested by painful limitation of motion of the thoracolumbar spine and limitation of forward flexion between 60 and 85 degrees. 2. Throughout the initial rating period on appeal from October 1, 2011, the back disability has not been manifested by limitation of forward flexion between 30 and 60 degrees, the combined range of motion of the thoracolumbar spine not greater than 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 3. For the entire initial rating period on appeal from October 1, 2011, the left ankle disability has been manifested by symptoms of painful noncompensable limitation of motion, without marked limitation of motion, malunion of the os calcis or astragalus, and/or ankylosis of the ankle, subastragalar joint, or tarsal joint, and the Veteran did not undergo an astragalectomy. 4. For the entire initial rating period on appeal from October 1, 2011, the left knee disability has been manifested by flexion greater than 60 degrees, extension greater than 5 degrees, and painful motion, without ankylosis, recurrent subluxation, dislocation or removal of semilunar cartilage, nonunion or malunion of the tibia and fibula, or genu recurvatum. 5. For the entire initial rating period on appeal from October 1, 2011, the right knee disability has been manifested by flexion greater than 60 degrees, extension greater than 5 degrees, and painful motion, without ankylosis, recurrent subluxation, dislocation or removal of semilunar cartilage, nonunion or malunion of the tibia and fibula, or genu recurvatum. 6. For the initial rating period on appeal from October 30, 2013, the left knee disability has also been manifested by slight instability. 7. For the initial rating period on appeal from October 30, 2013, the right knee disability has also been manifested by slight instability. CONCLUSIONS OF LAW 1. For the entire initial rating period on appeal from October 1, 2011, the criteria for a higher initial disability rating in excess of 10 percent for the back disability have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242-5237 (2017). 2. Resolving reasonable doubt in favor of the Veteran, for the initial rating period on appeal from October 1, 2011 to June 6, 2014, the criteria for a higher initial disability rating of 10 percent, but no higher, for the left ankle disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2017). 3. For the initial rating period on appeal from June 6, 2014, the criteria for an initial disability rating in excess of 10 percent for the left ankle disability have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2017). 4. Resolving reasonable doubt in favor of the Veteran, for the initial rating period on appeal from October 1, 2011 to June 6, 2014, the criteria for a higher initial disability rating of 10 percent, but no higher, for the left knee disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). 5. For the initial rating period on appeal from June 6, 2014, the criteria for an initial disability rating in excess of 10 percent for the left knee disability have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). 6. Resolving reasonable doubt in favor of the Veteran, for the initial rating period on appeal from October 1, 2011 to June 6, 2014, the criteria for a higher initial disability rating of 10 percent, but no higher, for the right knee disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). 7. For the initial rating period on appeal from June 6, 2014, the criteria for an initial disability rating in excess of 10 percent for the right knee disability have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2017). 8. Resolving all reasonable doubt in favor of the Veteran, for the rating period on appeal from October 30, 2013, the criteria for a separate 10 percent disability rating for mild instability of the left knee have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.71a, Diagnostic Code 5257 (2017). 9. Resolving all reasonable doubt in favor of the Veteran, for the rating period on appeal from October 30, 2013, the criteria for a separate 10 percent disability rating for mild instability of the right knee have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.71a, Diagnostic Code 5257 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b) (2017). Such notice should also address VA's practices in assigning disability ratings and effective dates for those ratings. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the Agency of Original Jurisdiction's initial unfavorable decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran is challenging the initial disability ratings assigned following the grant of service connection for a back disability, left ankle disability, left knee disability, and right knee disability. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United State Court of Appeals for Veterans Claims (Court) have held that regarding the downstream element of the initial rating that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (noting that, once an initial VA decision awarding service connection and assigning a disability rating and effective date has been made, 38 U.S.C. § 5103(a) notice is no longer required); 38 C.F.R. § 3.159(b)(3) (no VCAA notice required because of filing of a Notice of Disagreement). With respect to the issues of a higher initial disability rating a back disability, left ankle disability, left knee disability, and right knee disability, no additional notice is required regarding this downstream element of the service connection claims. Thus, the Board concludes that VA satisfied its duty to notify the Veteran. VA has also satisfied its duty to assist the Veteran in the development of the claim by fulfilling its duty to seek and assist in the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Specifically, the information and evidence that have been associated with the claims file includes the military personnel records, service treatment records, VA treatment records, private treatment records, VA examination reports, and lay statements. The Veteran was afforded VA examinations in August 2011 and March 2017, the examination reports for which are of record. To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The August 2011 and March 2017 VA examination reports reflect that the VA examiners reviewed the claims file, personally interviewed and examined the Veteran, including eliciting a history, conducted an in-person examination, and provided detailed findings supported by clinical testing. Based on the foregoing, the Board finds that all relevant documentation has been secured and all relevant facts have been developed. There remains no question as to the substantial completeness of the issue on appeal. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). Disability Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2017). Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2017). It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). Here, the Board will evaluate the issue for a higher rating of the original award. In such cases, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Id. The Board has considered whether a staged rating is warranted with respect to the issue of entitlement to a higher initial rating for the back disability and finds that the severity of the back disability has not changed during the course of the appeal so as to warrant staged ratings, as explained below; with respect to the issues of a higher initial rating for the left ankle disability, left knee disability, and right knee disability, the RO has already assigned staged ratings as discussed below. When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. See Barr, 21 Vet. App. 303. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by, or obtained on behalf of, the appellant be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Initial Rating for the Back Disability For the entire initial rating period on appeal from October 1, 2011, the Veteran is in receipt of an initial 10 percent disability rating for the service-connected back disability under Diagnostic Code 5242-5237. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the rating assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. The Veteran contends that a higher initial rating is warranted for the back disability due to motion limited to 30 degrees flexion, combined range of motion in the thoracolumbar spine less than 120 degrees, abnormal gait, scoliosis, and degenerative changes noted at the L4-5 in the lumbar spine. See July 2014 VA Form 9. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine for Diagnostic Codes 5235 to 5243, unless 5243 is rated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (IVDS Rating Formula). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula provides a 10 percent disability rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range-of-motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is provided for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range-of-motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is provided for forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of the entire spine. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately rated under an appropriate diagnostic code. Note (2) (See also Plate V) provides that, for VA compensation purposes, normal forward flexion of the lumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range-of-motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range-of-motion of the lumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range-of-motion. Note (3) provides that, in exceptional cases, an examiner may state, that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range-of-motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range-of-motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range-of-motion is normal for that individual will be accepted. Note (4) instructs to round each range-of-motion measurement to the nearest five degrees. Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire lumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Under Diagnostic Code 5243 (Intervertebral Disc Syndrome), a 10 percent disability rating is assigned with incapacitating episodes having a total duration of at least 1 weeks but less than 2 weeks during the past 12 months; a 20 percent disability rating is assigned with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating is assigned with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a maximum 60 percent disability rating is assigned with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) provides that if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment should be evaluated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher rating for that segment. After a review of all the lay and medical evidence of record, the Board finds that, for the entire initial rating period on appeal from October 1, 2011, the back disability has been manifested by painful limitation of motion of the thoracolumbar spine and limitation of forward flexion between 60 and 85 degrees, and has not more nearly approximated limitation of forward flexion between 30 and 60 degrees, the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. Although earlier service treatment records show that the back disability manifested in limitation of forward flexion that more closely approximates the 20 percent rating criteria under the General Rating Formula following an in-service motor vehicle accident, subsequent service treatment records and post-service treatment records demonstrate that symptoms and function of the back improved; therefore, based on the Veteran's overall disability picture, the criteria for a 20 percent initial rating is not warranted. Service treatment records show the Veteran was involved in a vehicle accident in April 1993. Thereafter, forward flexion in the thoracolumbar spine was limited to between 40 and 60 degrees (criteria for a 20 percent rating). See April 1993 service treatment record; May 1993 service treatment record; October 1994 service treatment record; see also October 1995 service treatment record; April 1996 service treatment record. Subsequent treatment records show that range of motion in the thoracolumbar spine had improved. An August 1996 service treatment record reflects the service examiner's assessment that the Veteran had been experiencing a mechanical type back pain that was not amenable to surgical correction and that range of motion was mildly limited without too much pain. A February 2008 service treatment record shows range of motion was only slightly limited, and a December 2010 service treatment record shows forward flexion was measured to 70 degrees with a combined range of motion of 230 degrees. In August 2011, the Veteran underwent a VA examination to assess the back disability. During the August 2011 VA examination, the Veteran reported a history of degenerative disc disease and a herniated disc for the last 17 years following a motor vehicle accident. The Veteran endorsed symptoms of stiffness, fatigue, muscle spasms, decreased motion, weakness, paresthesia, numbness, and episodes of flare-ups involving pain and weakness. Upon examination of the Veteran, the VA examiner noted a normal gait, that spinal contour was preserved but with tenderness observed, muscle tone was normal, and no evidence of muscle spasms, radiating pain on movement, guarding of movement, weakness, muscle atrophy, or ankylosis of the thoracolumbar spine. Ranges of motion in the thoracolumbar spine were within normal limits and noted to be without pain, and the VA examiner assessed no additional functional impairment upon repetitive use testing. X-rays of the thoracic spine were also within normal limits. An October 2016 VA treatment record shows the Veteran complained of discomfort in the lower back without loss of bowel or bladder control. X-rays of the thoracic and lumbar spines revealed an old mild compression deformity at the L2 level and normal body height and alignment in the thoracic spine, although moderate L4-L5 disc space narrowing was seen in the lumbar spine. The VA provider assessed stable multilevel degenerative changes, stable L2 compression deformity, and stable moderate L4-L5 degenerative changes. The Veteran underwent another VA examination in March 2017, the examination report for which reflects the Veteran reported worsening back symptoms including pain, numbness, swollen knots, back pain, and loss of movement treated with lidocaine patches. The Veteran also endorsed episodes of flare-ups anytime he uses the back to bend, walk, or stand. Ranges of motion in the thoracolumbar spine were measured to 70 degrees flexion (criteria for a 10 percent rating) with a combined range of motion of 180 degrees (criteria for a 10 percent rating ). Although pain was noted on examination on all planes, the VA examiner assessed that pain did not contribute to functional loss. The March 2017 VA examination report reflects negative findings for pain with weight bearing, additional functional loss and motion after repetitive use testing, guarding, muscle spasms, localized tenderness resulting in abnormal gait or spinal contour, muscle atrophy, ankylosis, neurologic abnormalities, IVDS, and use of assistive devices. Based on the foregoing, the Board finds that a higher initial rating in excess of 10 percent for the service-connected back disability is not warranted under Diagnostic Code 5237. The evidence of record does not demonstrate that the Veteran's overall disability picture more nearly approximates forward flexion of the thoracolumbar spine limited to less than 60 degrees, a combined range of motion of 120 degrees or less, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, nor has the Veteran been found to have IVDS or incapacitating episodes resulting therefrom. For these reasons, the Board finds that the preponderance of the evidence is against the appeal for a higher initial disability rating in excess of 10 percent for the service-connected back disability for any period. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5237. Initial Rating for the Left Ankle Disability The Veteran is in receipt of an initial noncompensable rating for the left ankle disability from October 1, 2011 to June 6, 2014, and a 10 percent disability rating from June 6, 2014 under Diagnostic Code 5271. 38 C.F.R. § 4.71a. The Veteran contends that a higher initial rating is warranted for the left ankle due to symptoms that more nearly approximate ankylosis of the left ankle. See July 2014 VA Form 9. During the October 2017 Board hearing , the Veteran testified that the left ankle causes difficulty with mobility, that the ankle gives out, and that he wears ankle braces at all times to increase stability. Diagnostic Code 5271 contemplates disability of the ankle manifested by limitation of motion. Under this code, a 10 percent rating is assigned when limitation of motion is moderate, and a 20 percent rating is assigned when limitation of motion is marked. Normal ranges of motion of the ankle are dorsiflexion from 0 degrees to 20 degrees, and plantar flexion from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II (2017). Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limitation of motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. See Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the Board had failed to address painful motion and the applicability of 38 C.F.R. § 4.59 to an initial disability rating for residuals of a left shoulder injury with surgical repair). If the left ankle disability does not warrant a compensable rating under the appropriate diagnostic codes based on limitation of motion, the minimum compensable rating (10 percent) may be assigned where there is satisfactory evidence of painful motion. 38 C.F.R. § 4.59; Burton, 25 Vet. App. at 1. After a review of all the evidence, lay and medical, the Board finds that for the initial rating period on appeal from October 1, 2011 to June 6, 2014, the criteria for a higher initial 10 percent disability rating for the left ankle disability by analogy to Diagnostic Code 5003, applying the principles of 38 C.F.R. § 4.59, for painful motion that is manifested to a noncompensable degree, is supported by the evidence in this case. Further, the evidence of record reflects that the Veteran has been diagnosed with degenerative joint disease in the left ankle during the appeal period. See June 2014 VA treatment record. Based on the above, for the initial rating period from October 1, 2011 to June 6, 2014, the Board finds that the criteria for a 10 percent initial disability rating under Diagnostic Code 5003 have been met for the left ankle disability. 38 C.F.R. § 4.3, 4.7, 4.71a. The Board further finds that a higher initial rating in excess of 10 percent under Diagnostic Code 5003 for the left ankle disability is not warranted for any part of the initial rating period from October 1, 2011 forward. A rating in excess of 10 percent (20 percent) under Diagnostic Code 5003, which in turn would be rated under Diagnostic Codes 5270, 5271, or 5272 for limitation of motion, requires ankylosis of the left ankle in less than 30 degrees of plantar flexion, marked limitation of motion in the left ankle, or ankylosis of the subastragalar or tarsal joint in poor weight-bearing position. For the entire initial rating period on appeal from October 1, 2011, the left ankle disability has not been manifested by symptoms that more nearly approximate ankylosis or marked limitation of motion, as needed for a 20 percent rating, even with consideration of any additional limitation due to pain, stiffness, and swelling. See 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca. Further, throughout the entire initial rating period on appeal, the left ankle disability has not been manifested by malunion of the os calcis or astragalus, and the Veteran did not undergo an astragalectomy; thus, a higher initial rating in excess of 10 percent is not warranted for any period. Service treatment records show the Veteran experienced left ankle pain without limitation of motion. See November 1991 service treatment record; April 1993 service treatment record; July 1996 service treatment record. The Veteran underwent a VA examination in August 2011, during which the Veteran reported left ankle pain that developed insidiously without a history of trauma. The Veteran also reported symptoms of weakness, stiffness, swelling, giving way, lack of endurance, locking, fatigability, tenderness, and pain, with episodes of flare-ups occurring as often as twice a month involving symptoms of pain and difficulty standing and walking. Upon examination of the Veteran, the VA examiner noted no evidence of deformity or ankylosis and range of motion in the left ankle was measured to be within normal limits in dorsiflexion and plantar flexion. Further, the VA examiner assessed the no additional functional limitation or loss of motion following repetitive use testing. X-rays of the left ankle were normal and revealed no malunion to the os calcis or malunion of the astragalus. While a July 2015 VA treatment record shows range of motion in the left ankle was measured to 8 degrees dorsiflexion and 35 degrees plantar flexion, a September 2015 VA treatment record reflects the Veteran met his physical therapy goal of improving dorsiflexion in the left ankle to 0 degrees and plantar flexion to 45 degrees. The Veteran underwent another VA examination in March 2017, the examination report for which shows the Veteran reported worsening left ankle symptoms including pain and decreased range of motion; the Veteran also reported episodes of flare-ups and regular use of ankle braces. Ranges of motion in the left ankle were measured from 0 to 10 degrees in dorsiflexion and from 0 to 40 degrees in plantar flexion, which the Board finds does not constitute a "marked" limitation of motion as is required for a 20 percent rating under Diagnostic Code 5271. Although painful motion was noted on examination, the VA examiner assessed that pain did not result in functional loss. The March 2017 VA examination report also reflects negative findings for additional functional loss or loss of motion following repetitive use testing, ankylosis, malunion of the os calcis or astragalus, and a history of an astragalectomy in the left ankle; however, the VA examiner did note left ankle instability that required regular use of an ankle brace for support and that the Veteran had difficulty with prolonged walking and standing due to the left ankle disability. The Board has given consideration to the Veteran's contention of having left ankle ankylosis. While the Veteran is competent to offer lay statements regarding orthopedic pain felt at any time, here, as a lay person, under the facts of this case, the Veteran does not have the requisite medical training or credentials to be able to render a competent medical diagnosis of ankylosis of the left ankle. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (whether lay evidence is competent regarding a particular disability is determined on a case by case basis; holding that ACL injury is too "medically complex" for lay diagnosis); King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2009) (holding that it was not erroneous for the Board to find that a lay veteran claiming service connection for a back disorder and his wife lacked the "requisite medical training, expertise, or credentials needed to render a diagnosis" and that their testimony "could not establish medical causation nor was it a competent opinion as to medical causation"); Clyburn v. West, 12 Vet. App. 296, 301 (1999) (holding that a veteran is not competent to relate currently diagnosed chondromalacia patellae or degenerative joint disease to the continuous post-service knee symptoms); Savage v. Gober, 10 Vet. App. 488, 496-97 (1997) (requiring that a veteran present medical nexus evidence relating currently diagnosed arthritis to in-service back injury). Additionally, the Veteran's assertions of having left ankle ankylosis is not shown by the medical evidence of record throughout the entire initial rating period on appeal, including in the March 2017 VA examination report. Accordingly, the Board finds that a higher initial rating in excess of 10 percent for the left ankle disability under Diagnostic Codes 5270 (ankylosis of the ankle), 5272 (ankylosis of the subastragalar or tarsal joint), 5273 (malunion of the os calcis or astragalus), or 5274 (astragalectomy) is not warranted at any time during the entire initial rating period on appeal. 38 C.F.R. § 4.71a. Initial Rating for Left and Right Knee Disabilities The appropriate diagnostic codes for rating limitation of motion of the right knee are Diagnostic Codes 5260 and 5261. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. In VAOPGCPREC 9-2004, the VA General Counsel interpreted that when considering Diagnostic Codes 5260 and 5261 together with 38 C.F.R. § 4.71, a veteran may receive a rating for limitation in flexion only, limitation of extension only, or, if the 10 percent criteria are met for both limitations of flexion and extension, separate ratings for limitations in both flexion and extension under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension). Under Diagnostic Code 5260, limitation of knee flexion is rated 30 percent disabling where flexion is limited to 15 degrees; 20 percent disabling where flexion is limited to 30 degrees; 10 percent disabling where flexion is limited to 45 degrees; and noncompensable where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, limitation of knee extension is rated 50 percent disabling where extension is limited to 45 degrees; 40 percent disabling where extension is limited to 30 degrees; 30 percent disabling where extension is limited to 20 degrees; 20 percent disabling where extension is limited to 15 degrees; 10 percent disabling where extension is limited to 10 degrees; and noncompensable where extension is limited to 5 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5257 contemplates "other impairment" of the knee including recurrent subluxation or lateral instability. Under Diagnostic Code 5257, where impairment is severe, moderate or slight, disability evaluations of 30, 20, and 10 percent are assigned, respectively. 38 C.F.R. § 4.71a. Diagnostic Code 5262 contemplates impairment of the tibia and fibula, assigning a 40 percent rating for nonunion of the tibia and fibula, and 10, 20, and 30 percent ratings for slight, moderate or marked knee or ankle disabilities. Id. The words "slight," "moderate," "severe," and "marked" as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." Id. Under Diagnostic Code 5256, disability ratings are assigned when ankylosis is present. Id. Diagnostic Code 5258 provides a 20 percent disability rating when a dislocated semilunar cartilage is present with frequent episodes of "locking," pain, and effusion into the joint. Id. Diagnostic Code 5259 provides for a 10 percent disability rating when semilunar cartilage has been removed and related symptoms are present. Id. A 10 percent disability rating is assigned under Diagnostic Code 5263 when genu recurvatum is identified. Id. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings is to be evaluated on the basis of limitation of motion under the appropriate diagnostic code 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 code, an evaluation 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 DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is assignable for X-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups. A 20 percent evaluation is assignable for X-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. 38 C.F.R. § 4.71a. Notes (1) and (2) under Diagnostic Code 5003 provides the following: Note (1) provides that the 20 percent and 10 per cent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-rays findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. VA's Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. VA's General Counsel stated that compensating a claimant for separate functional impairment under Diagnostic Code (DC) 5257 and 5003 does not constitute pyramiding. See VAOPGCPREC 23-97. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban, 6 Vet. App. 259, 262. In VAOPGCPREC 9-98, VA's General Counsel reiterated that, if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. In addition, the General Counsel considered a hypothetical situation in which a knee disability was evaluated under Diagnostic Code 5259 that was productive of pain, tenderness, friction, osteoarthritis established by X-rays, and a slight loss of motion. For the purposes of the hypothetical, it was assumed that Diagnostic Code 5259 did not involve limitation of motion. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under Diagnostic Code 5003 in light of sections 4.40, 4.45, 4.59 must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). Absent X-ray findings of arthritis, limitation of motion should be considered under Diagnostic Codes 5260 and 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant a rating under Diagnostic Codes 5260 or 5261. The General Counsel further noted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under Diagnostic Code 5259, and the provisions of 4.40, 4.45, and 4.59 must be considered. For the initial rating period on appeal from October 1, 2011 to June 6, 2014, the Veteran is in receipt of an initial noncompensable rating for both the left and right knee disabilities, and for the initial rating period from June 6, 2014, the Veteran is in receipt of an initial 10 percent rating for the left and right knee disabilities under Diagnostic Code 5260. While the left and right knee disabilities were assigned 10 percent disability ratings for the initial rating period from June 6, 2014 based on limitation of flexion under Diagnostic Code 5260, this was not the actual rating criteria used because, as will be discussed below, neither the left or right knee disabilities have been manifested by limitation of flexion to at least 60 degrees (as needed for a noncompensable rating under Diagnostic Code 5260). The record reflects that, when assigning the Diagnostic Codes under which the left and right knee disabilities were rated, what the RO did in actuality was assign the minimum compensable rating of 10 percent for painful motion of the right and left knee under 38 C.F.R. § 4.71a, Diagnostic Code 5003, by applying 38 C.F.R. § 4.59. After a review of all the evidence of record, the Board finds that, for the initial rating period on appeal from October 1, 2011 to June 6, 2014, the service-connected left and right knee disabilities have been manifested by painful motion and noncompensable limitation of motion. See May 2005 service treatment record (full range of motion without lateral instability); December 2006 service treatment record (range of motion from 0 to 135 degrees bilaterally); January 2007 service treatment record (range of motion from 0 to 135 degrees bilaterally); June 2008 service treatment record (full range of motion with pain). The evidence of record also shows that the Veteran has been diagnosed with degenerative joint disease in the bilateral knees during the appeal period. See June 2014 VA treatment record. Based on the foregoing, the Board finds that the criteria for higher initial 10 percent ratings under Diagnostic Code 5003 for the left and right knee disabilities have been met. 38 C.F.R. §§ 4.3, 4.7, 4.71a. The Board further finds that higher disability ratings in excess of 10 percent under Diagnostic Code 5003 for the left and right knee disabilities are not warranted for any part of the initial rating period from October 1, 2011. A higher rating in excess of 10 percent (20 percent) under Diagnostic Code 5003, which in turn would be rated under Diagnostic Codes 5260 and 5261 for limitation of motion, requires flexion limited to 30 degrees or less or extension limited to 15 degrees or more. For the entire initial rating period from October 1, 2011, limitation of motion of the left and right knees did not more nearly approximate extension limited to 15 degrees or more, or flexion limited to 30 degrees or less, as needed for a 20 percent rating, even with consideration of the additional limitation due to pain, stiffness, and swelling. See 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca. The evidence also does not show compensable limitation of motion of extension (10 degrees) and limitation of motion of flexion (45 degrees) to warrant separate compensable ratings for both limitation of extension and limitation of flexion for the left or right knees. See VAOPGCPREC 09-04 (separate ratings may be awarded for compensable limitation of flexion and limitation of extension of the same knee joint). Rather, the evidence of record shows that the Veteran had, at worst, left and right knee flexion to 130 degrees and extension to 0 degrees as noted on the March 2017 VA examination report, which does not more nearly approximate limitation to 30 degrees of flexion or 15 degrees of extension as needed for a higher (20 percent) rating. See VAOPGCPREC 9-98 (interpreting that painful motion is considered limited motion at the point that the pain actually sets in). Therefore, a higher initial disability rating in excess of 10 percent is not warranted under Diagnostic Codes 5260 or 5261 for limitation of flexion and extension of the left and right knees for the entire initial rating period from October 1, 2011. 38 C.F.R. § 4.71a. The Board has considered whether higher disability ratings for the left and right knees are warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See also DeLuca. Here, there is no question that the left and right knee disabilities have caused pain, stiffness, and swelling, which has restricted overall motion. The Veteran has consistently, in statements made for the purpose of treatment, reported chronic knee pain and difficulty with prolonged walking, standing, and ascending and descending stairs; however, as noted above, even taking into account additional functional limitation due to pain, the VA examination reports and treatment records indicate ranges of motion that do not more nearly approximate the 20 percent criteria. The March 2017 VA examination report notes that left and right knee flexion was limited to, at worst, 130 degrees. Based on the above, the degree of functional impairment does not warrant a higher rating based on limitation of motion for the left and right knees. Separate Rating for Left and Right Knee Instability The Board has also considered whether a separate disability rating is warranted for any other left or right knee disability. As the evidence of record does not reflect that the left or right knee is ankylosed, that the semilunar cartilage is dislocated with frequent episodes of locking, pain, and joint effusion, that the semilunar cartilage has been removed, that there is malunion or nonunion of the tibia and fibula, that there is a current diagnosis of genu recurvatum, and/or that the Veteran's left or right knee disability has been manifested by limitation of flexion or extension to a compensable degree, a separate disability rating is not warranted under Diagnostic Codes 5256, 5258, 5259, 5261, 5262, or 5263. 38 C.F.R. § 4.71a. The evidence of record does indicate symptoms of slight left and right knee instability. An October 2013 VA treatment record reflects that knee braces were ordered to assist in off-loading weight from the knees as the Veteran was having difficulty re-balancing weight between the knees due to chronic knee pain. Additionally, a January 2016 VA treatment record notes the Veteran's bilateral chronic knee pain with intermittent instability. Finally, during the March 2017 VA examination, the Veteran reported symptoms of unstable walking and using knee braces for support. After a review of all the lay and medical evidence, and resolving reasonable doubt in favor of the Veteran, the Board finds that, for the initial rating period on appeal from October 30, 2013, the left and right knee disabilities have manifested in slight instability manifested primarily as unstable walking and difficulty with weight-bearing with the use of knee braces to manage the disability. Such symptomatology represents a "slight" impairment of the Veteran's left and right knee functionality. The Board finds that, based upon all the evidence, lay and medical, and resolving all reasonable doubt in favor of the Veteran, the service-connected left and right knee disabilities have shown "slight" instability, therefore, separate 10 percent ratings for the left and right knee disabilities are warranted under Diagnostic Code 5257. 38 C.F.R. §§ 4.3, 4.7, 4.71a. Extraschedular Referral Consideration The Board has considered whether referral for extraschedular consideration is warranted for the service-connected back, left ankle, left and right knee disabilities. Ratings shall be based as far as practicable upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2017). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Yancy v. McDonald, 27 Vet. App. 484 (2016); Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances); Sowers v. McDonald, 27 Vet. App. 472, 478 (2016) ("[t]he rating schedule must be deemed inadequate before extraschedular consideration is warranted"). Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 116. Third, if the first two Thun elements have been satisfied, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun at 116. In other words, the first element of Thun compares a veteran's symptoms to the rating criteria, while the second element considers the resulting effects of those symptoms; if either prong is not met, then referral for extraschedular consideration is not appropriate. Yancy, 27 Vet. App. at 494-95. Turning to the first step of the Thun extraschedular analysis, the Board finds that all the symptomatology and impairment caused by the service-connected back disability are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's back disability has manifested in painful movement, muscle spasm, guarding, and limitation of motion due to pain and during flare-ups. The schedular criteria for rating the back disability specifically provide for ratings based on the presence of painful motion, whether or not such pain radiates; limitations of motion of the spine including due to pain and other orthopedic factors that result in functional impairment (38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, Mitchell); and other clinical findings such as muscle spasm, guarding, abnormal gait, and abnormal spinal contours; and on the basis of incapacitating episodes. See Schafrath at 592(read together with schedular rating criteria, 38 C.F.R. §§ 4.40 and 4.45 recognize functional loss due to pain); Deluca at 206-07 (functional limitations are applied to the schedular rating criteria to ascertain whether a higher schedular rating can be assigned based on limitation of motion due to pain and during flare-ups, and should be expressed in schedular rating terms of degree of range-of-motion loss); Burton v. Shinseki, 25 Vet. App. 1, 4 (2011) (the majority of 38 C.F.R. § 4.59, which is a schedular consideration rather than an extraschedular consideration, provides guidance for noting, evaluating, and rating joint pain); Sowers v. McDonald, 27 Vet. App. 472 (2016) (38 C.F.R. § 4.59 is limited by the diagnostic code applicable to the claimant's disability, and is read in conjunction with, and subject to, the relevant diagnostic code); Mitchell at 33-36 (pain alone does not constitute functional impairment under VA regulations, and the rating schedule contains several provisions, such as 38 C.F.R. §§ 4.40, 4.45, 4.59, that address functional loss in the musculoskeletal system as a result of pain and other orthopedic factors when applied to schedular rating criteria); see also Mitchell at 45 (Footnote 2) and Vogan v. Shinseki, 24 Vet. App. 159, 161 (2010) (when a condition is not listed in the VA disability schedule, VA may undertake rating by analogy where the disability in question is analogous in terms of the functions affected, the anatomical localization, and the symptomatology of the ailments). All the symptomatology and functional impairment described above result from the limitation motion of the thoracolumbar spine, to include as due to pain, stiffness, muscle spasm, and all the symptoms described by the Veteran are contemplated in the schedular rating assigned under the General Rating Formula for Spine Disabilities either directly as limitation of motion or muscle spasm or tenderness, or indirectly as orthopedic factors that limit motion and function. See 38 C.F.R. §§ 4.40, 4.45, 4.59 4.71a; DeLuca, 8 Vet. App. at 206-07. The schedular rating criteria specifically include tenderness, spasm, and any and all limitations of motion of the spine in any direction, including in flexion, extension, lateral flexion, and rotation of the spine. 38 C.F.R. § 4.71a, Plate V. Such symptoms and impairment are part of or similar to symptoms listed under the schedular rating criteria. See 38 C.F.R. § 4.20 (schedular rating criteria provides for rating by analogy based on similar functions, anatomical location, and symptomatology); Mauerhan v. Principi, 16 Vet. App. 436 (2002) (the schedular rating criteria also include analogous symptoms that are "like or similar to" listed schedular rating criteria). Moreover, the Veteran's back disability has also manifested in bilateral lower extremity radiculopathy, for which service connection has already been granted and the Veteran has been rated and compensated. Therefore, the Board finds that the record does not reflect that the back disability is so exceptional or unusual as to warrant referral for consideration of the assignment of a higher disability rating on an extraschedular basis. With respect to the Veteran's left ankle disability, the disability picture has manifested primarily as painful limitation of motion of the left ankle with flare-ups, instability, giving way, stiffness, weakness, and difficulty standing and walking. As discussed above, painful limitation of motion with painful flare-ups is specifically considered under the schedular rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202 (additional limitation of motion due to orthopedic factors are incorporated as part of the schedular rating criteria). Additionally, under Diagnostic Code 5271, in evaluating the Veteran's limitation of motion of the ankle, VA is to consider whether the limitation is moderate or marked, rather than on actual degrees lost. As such, in determining whether limitation is moderate or marked the evaluator should consider all factors that may limit motion including pain, instability, giving way, stiffness, and weakness; therefore, these symptoms are specifically considered under the schedular rating criteria. Further, the functional limitations imposed by the Veteran's left ankle disability, including difficulty standing and walking and interference with occupational and daily activities that involve use of the ankle, are primarily the result of the ankle pain, including flare-ups, caused by engaging in these activities; therefore, as recognized in DeLuca, the effects of the Veteran's ankle pain and associated limitations on occupational and daily life are specifically contemplated by the schedular criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the functional limitations and the effects on daily life. Next, the Board finds that the symptomatology and functional impairment caused by the service-connected the left and right knee disabilities are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria provide for limitation of motion due to pain, weakness, and instability, and DCs 5256-5263, specifically provide for disability ratings based on limitation of motion, including as due to pain, lack of endurance, weakness, fatigability, and other limiting orthopedic factors. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a; see also Schafrath at 592; Deluca at 206-07. The Board has additionally considered ratings under alternate schedular rating criteria, and has granted separate ratings for the left and right knee disabilities due to instability. See 38 C.F.R. § 4.20; Mauerhan, 16 Vet. App. 436. Therefore, the Board finds that the record does not reflect that the Veteran's left and right knee disabilities are so exceptional or unusual as to warrant referral for consideration of the assignment of an extraschedular rating. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is potentially an element of all rating issues. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, as distinguished from the facts in Rice, the evidence of record does not indicate that the Veteran is unemployed or unemployable due to service-connected disabilities. Rather, the Veteran testified during the October 2017 Board hearing that he is currently employed. As such, the Board finds that the issue of entitlement to a TDIU has not been raised and, therefore, the issue is not before the Board on appeal. ORDER For the entire initial rating period on appeal from October 1, 2011, a higher initial disability rating in excess of 10 percent for the service-connected back disability is denied. For the initial rating period on appeal from October 1, 2011 to June 6, 2014, a higher initial disability rating of 10 percent, but no higher, for the left ankle disability is granted; for the initial rating period on appeal from June 6, 2014, a disability rating in excess of 10 percent is denied. For the initial rating period on appeal from October 1, 2011 to June 6, 2014, a higher initial disability rating of 10 percent, but no higher, for the left knee disability is granted; for the initial rating period on appeal from June 6, 2014, a higher initial disability rating in excess of 10 percent for the left knee disability is denied. For the initial rating period on appeal from October 1, 2011 to June 6, 2014, a higher initial disability rating of 10 percent, but no higher, for the right knee disability is granted; for the initial rating period on appeal from June 6, 2014, a disability rating in excess of 10 percent is denied. For the initial rating period on appeal from October 30, 2013, a separate 10 percent disability rating, but no higher, for slight instability of the left knee is granted. For the initial rating period on appeal from October 30, 2013, a separate 10 percent disability rating, but no higher, for slight instability of the right knee is granted. REMAND Initial Disability Rating for Right Ankle Disability In July 2012, the Veteran submitted a timely Notice of Disagreement (NOD) to the January 2012 rating decision on appeal that granted service connection for the right ankle disability and assigned a noncompensable disability rating from October 1, 2011; specifically, the July 2012 NOD disagreed with the initial disability rating assigned for the bilateral ankle disabilities. To date, no Statement of the Case (SOC) has been issued as to the issue of a higher (compensable) initial disability rating for the service-connected right ankle disability from October 1, 2011. Once an appellant submits a NOD, VA must issue a SOC regardless of how much time has passed. See Myers v. Principi, 16 Vet. App. 228 (2002) (VA procedural error in failing to recognize a NOD can cause a claim stream to remain open, awaiting issuance of a SOC, regardless of the length of time that has passed); Manlincon v. West, 12 Vet. App. 238 (1999) (where there is a NOD, the proper action is to remand the issue to the RO for issuance of a SOC); Acosta v. Principi, 18 Vet. App. 53 (2004) (Court found veteran's writing was a clear expression of disagreement and was sufficient to constitute a NOD, the NOD remains pending, and case must be remanded for VA to issue a SOC); Fenderson v. West, 12 Vet. App. 119 (1999) (the remedy for a timely NOD to is remand for VA to issue a SOC). Therefore, the issue of a higher initial disability rating for the right ankle disability must be remanded for the issuance of a SOC. See 38 C.F.R. § 19.9(c) (2017), codifying Manlincon, 12 Vet. App. 238. Accordingly, the issue of a higher initial disability rating for the right ankle disability is REMANDED for the following action: Issue a SOC that addresses the issue of a higher initial disability rating for the right ankle disability. The Veteran and representative should be given the appropriate opportunity to respond to the SOC. The RO should advise the Veteran that the claims file will not be returned to the Board for appellate consideration of the issue following the issuance of the SOC unless the Veteran perfects the appeal. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs