Citation Nr: 1817506 Decision Date: 03/22/18 Archive Date: 04/03/18 DOCKET NO. 14-20 555A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to a compensable evaluation for left ankle tendonitis prior to March 2, 2017. 2. Entitlement to an evaluation in excess of 10 percent for left ankle tendonitis from March 2, 2017. 3. Entitlement to a compensable evaluation for right ankle tendonitis prior to March 2, 2017. 4. Entitlement to an evaluation in excess of 10 percent for right ankle tendonitis from March 2, 2017. 5. Entitlement to an initial evaluation in excess of 20 percent for lumbar strain with intervertebral disc syndrome. 6. Entitlement to an initial evaluation in excess of 20 percent for left leg sciatica. 7. Entitlement to an initial evaluation in excess of 10 percent for left patella femoral syndrome. 8. Entitlement to an initial evaluation in excess of 10 percent for right patella femoral syndrome. 9. Entitlement to an initial compensable evaluation for costochondritis. 10. Entitlement to service connection for left leg vascular pain as a separate ratable entity. 11. Entitlement to service connection for right leg vascular pain as a separate ratable entity. 12. Entitlement to an initial evaluation in excess of 10 percent for varicose veins, left leg. 13. Entitlement to an initial evaluation in excess of 10 percent for varicose veins, right leg. ATTORNEY FOR THE BOARD W. R. Stephens, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1987 to February 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The matter is now before the RO in Roanoke, Virginia. The issue of the initial evaluations for varicose veins of the legs are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the entire period, left ankle tendonitis manifested with pain, stiffness, and tenderness, and no more than moderate limitation of motion. 2. For the entire period, right ankle tendonitis manifested with pain, stiffness, and tenderness, and no more than moderate limitation of motion. 3. For the entire period, lumbar strain with intervertebral disc syndrome manifested with pain and muscle spasm resulting in abnormal gait. Remaining forward flexion is better than 30 degrees. 4. For the entire period, left leg sciatica manifested with moderate incomplete paralysis, but not moderately severe incomplete paralysis. 5. For the entire period, the Veteran's left knee patella femoral syndrome manifested with painful motion. Remaining functional flexion is better than 45 degrees. 6. For the entire period, the Veteran's right knee patella femoral syndrome manifested with painful motion. Remaining functional flexion is better than 45 degrees. 7. For the entire period, costochondritis manifested with tenderness of the sternum upon palpation, but not removal or resection of ribs. 8. Claimed lower extremity vascular pain has not been attributed to pathology other than varicose veins. CONCLUSIONS OF LAW 1. Prior to March 2, 2017, left ankle tendonitis was 10 percent disabling. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2017). 2. The criteria for an evaluation in excess of 10 percent for left ankle tendonitis have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2017). 3. Prior to March 2, 2017, right ankle tendonitis was 10 percent disabling. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2017). 4. The criteria for an evaluation in excess of 10 percent for right ankle tendonitis have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5271 (2017). 5. The criteria for an initial evaluation in excess of 20 percent for lumbar strain with intervertebral disc syndrome have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5243-5242 (2017). 6. The criteria for an initial evaluation in excess of 20 percent for left leg sciatica have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.124a, Diagnostic Code 8520 (2017). 7. The criteria for an initial evaluation in excess of 10 percent for left patella femoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5019, 5256, 5258, 5260, 5261, 5262 (2017). 8. The criteria for an initial evaluation in excess of 10 percent for right patella femoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5019, 5256, 5258, 5260, 5261, 5262 (2017). 9. The criteria for an initial compensable evaluation for costochondritis have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5297 (2017). 10. Lower extremity vascular pain is not a distinct ratable entity. 38 C.F.R. § 4.14 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist The Veteran has not 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 duty to assist argument). II. Evaluations Generally 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. The ratings are intended to compensate impairment in earning capacity due to a service-connected disease or injury. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4. 40, 4.45, 4.59. Pain may result in functional loss if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). III. Evaluation of Ankles The Veteran is in receipt of noncompensable evaluations for tendonitis of both ankles prior to March 2, 2017. She is in receipt of a 10 percent evaluation for each ankle effective March 2, 2017. The Veteran's ankles are evaluated under Diagnostic Code 5271. She has challenged the initial evaluation, effective March 1, 2011. Under this Diagnostic Code, a 10 percent rating is warranted for moderate limitation of ankle motion, and a 20 percent rating is warranted for marked limitation of motion. Further, under appropriate VA regulations, full range of ankle dorsiflexion is from zero to 20 degrees, and full range of ankle plantar flexion is from zero to 45 degrees. 38 C.F.R. § 4.71, Plate II. The descriptive terms "moderate" and "marked" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for an "equitable and just" decision. 38 C.F.R. § 4.6. As noted below, the Board has determined that a uniform evaluation is appropriate for both ankles for the entire period on appeal. See Hart, supra; Fenderson, supra. At a December 2010 VA examination, the Veteran reported bilateral weakness, stiffness, swelling, giving way, tenderness, and pain. She reported flare-ups with no functional impairment or limitation of motion. Range of motion was within normal limits. At a March 2017 VA examination, the Veteran's dorsiflexion was limited to 15 degrees bilaterally and plantar flexion was limited to 40 degrees bilaterally. There was pain on examination but it did not result in or cause functional loss. Repetitive motion testing was performed on both ankles with no additional limitation of motion. Muscle strength was normal bilaterally. There was no instability. Upon careful review of the evidence of record, including VA treatment records, the Board finds that an initial evaluation of 10 percent is warranted for both ankles, prior to March 2, 2017. However, an evaluation in excess of 10 percent is not warranted for either ankle. Here, we accept as credible that the appellant has and had periarticular pathology productive of painful motion. 38 C.F.R. § 4.59. In order to receive a 20 percent evaluation under Diagnostic Code 5271, the Veteran must demonstrate marked limitation of motion of the ankle. The Board finds that the ranges of motion documented by VA examinations are consistent with the overall record and do not result in "marked" limitation of motion for either ankle, as required for a 20 percent evaluation. The Board has considered the Veteran's contentions during this time period, however, finds that her symptoms are not analogous to those associated with a marked disability of either ankle, as she has only moderate limitation in range of motion in the ankles, and the clinical evidence of record does not otherwise demonstrate marked symptoms of either ankle disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). With regard to assigning a higher disability rating according to 38 C.F.R. § 4.40 and 4.45, the Board acknowledges the Veteran's reported complaints of pain and painful motion. However, as noted above, there is no objective evidence of record reflecting that the Veteran experiences additional functional loss or limitation of motion due to symptoms such as pain, weakness, weakened movement, excess fatigability, or incoordination. In other words, the Board finds that the 10 percent evaluation now assigned for the entire period contemplates the degrees of functional loss due to pain, and additional limitation of motion or functional impairment. Upon review of all relevant evidence of record, the Board finds that the aforementioned limitation of motion findings are not marked in severity for either ankle. As such, an evaluation in excess of 10 percent for either ankle cannot be afforded under this Diagnostic Code. In essence, we conclude that there is pain on motion, however, the functional restriction does not approximate marked limitation of motion. Rather, she retains significant functional motion as demonstrated by the more probative medical evidence. The Board has also considered whether a higher evaluation is available under other provisions of the code. The Veteran, however, is not shown to have ankylosis of either ankle to warrant an evaluation under Diagnostic Code 5270. There is also no evidence of ankylosis of the subastragalar or tarsal joint, malunion of the os calcis or astragalus, or astragalectomy to warrant ratings under Diagnostic Codes 5272-5274. See 38 C.F.R. § 4.71a . As a result, a separate evaluation or evaluation in excess of 10 percent is not warranted for either of the Veteran's ankle disabilities under other Diagnostic Codes. Accordingly, the preponderance of the evidence is against assignment of an increased evaluation in excess of 10 percent for the Veteran's service-connected ankle disabilities. IV. Evaluation Lumbar Strain The Veteran's service-connected lumbar strain with intervertebral disc syndrome has an initial 20 percent evaluation effective March 1, 2011, under Diagnostic Codes 5243-5242. The Veteran has challenged the initial evaluation. Disabilities of the spine are rated under either the General Formula for Diseases and Injuries of the Spine (General Formula) or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating. Under the General Rating Formula, a 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or 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 evaluation is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. The rating criteria further explain under Note (1), that any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. The Veteran has separate evaluations for her associated neurological disabilities of the lower extremities which will not be addressed in this section. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (in pertinent part), a 10 percent evaluation is warranted with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent evaluation is warranted 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 evaluation is warranted with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) for purposes of evaluations under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, defines an incapacitating episode as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. As noted below, the Board has determined that a uniform evaluation is appropriate for the lumbar spine disability for the entire period on appeal. See Hart, supra; Fenderson, supra. At a December 2010 VA examination, range of motion testing resulted in 80 degree flexion with pain at 70 degrees and extension of 20 degrees with pain at 10 degrees. Flexion and extension were limited by 10 degrees upon repetitive motion testing. The Veteran reported that her lumbar spine disability had not resulted in any incapacitation in the previous 12 months. There was muscle spasm that produced an abnormal gait. At a March 2017 VA examination, flexion was limited to 80 degrees and extension to 20 degrees. There was pain on examination which did not result in addition limitation of motion. Repetitive use testing was performed with no additional limitation of motion. There was no pain on weightbearing. The Veteran had IVDS but had not been prescribed bed rest by a physician in the previous 12 months. A review of VA treatment records reveals symptoms consistent with the VA examinations. The current evaluation contemplates pain on motion and spasm. It is consistent with forward flexion better than 30 degrees. In order to warrant a higher evaluation, there must be the functional equivalent of limitation of flexion to 30 degrees or less. 38 C.F.R. §§ 4.40, 4.45 (2017). The Board acknowledges the Veteran's reported complaints of pain and painful motion. However, as noted above, there is no credible evidence of record reflecting that the Veteran experiences additional functional loss or limitation of motion due to symptoms such as pain, weakness, weakened movement, excess fatigability, or incoordination consistent with a higher evaluation. To the extent that she states or implies that flexion is restricted to 30 degrees or less, her lay evidence is less probative and less credible than the observations of a professional. In addition, there is no evidence of prescribed bed rest. Upon careful review of the evidence of record, the Board finds that the Veteran is not entitled to a rating in excess of 20 percent for her lumber spine disability. In other words, the preponderance of the evidence establishes that remaining forward flexion is better than 30 degrees. In addition, there is no evidence of incapacitating episodes consistent with Diagnostic Code 5243, note 1. V. Evaluation Left Leg Sciatica The Veteran's service-connected left leg sciatica has an initial 20 percent evaluation under Diagnostic Code 8520. The Veteran has challenged the initial evaluation, effective March 1, 2011. Under Diagnostic Code 8520, paralysis of the sciatic nerve: a 10 percent rating is warranted for mild incomplete paralysis, a 20 percent rating is warranted for moderate incomplete paralysis, a 40 percent rating is warranted for moderately severe incomplete paralysis, and a 60 percent rating is warranted for severe incomplete paralysis with evidence of marked muscular atrophy. 38 C.F.R. § 4.124a. Complete paralysis will be evaluated as 80 percent disabling for such symptoms as foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. Id. The terms "slight," "moderate," and "severe" are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124 (a). Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated at a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. As noted below, the Board has determined that a uniform evaluation is appropriate for left leg sciatica for the entire period on appeal. See Hart, supra; Fenderson, supra. At a December 2010 VA examination, there was no pain or weakness. The left leg reflexes were +2 for knee jerk and ankle jerk. There was sensory deficit of the left lateral thigh, left front leg, and left medial leg with motor weakness of left hip abduction and left knee extension of 4/5. There was also sensory deficit of the left lateral leg, left dorsal foot, and left lateral foot with motor weakness of left foot extension, left great toe extension, and left hip abduction of 4/5. At a March 2017 VA examination, there was decreased sensation of the left upper anterior thigh, the thigh/knee, the lower leg/ankle, and the foot/toes. The straight leg test was positive. There was mild constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness of the left leg. The sciatic nerve was the nerve affected. The examiner indicated that the left leg sciatica was moderate in severity. The Board has reviewed VA treatment records and they are consistent with the VA examinations Based on the evidence of record, the Board finds that an evaluation in excess of 20 percent is not warranted for left leg sciatica. Objective medical findings are consistent with a 20 percent evaluation. Specifically, there is mild weakness, pain and sensory changes. However, there is no muscle atrophy and the pain is not excruciating. These findings are consistent with moderate neuropathy. See as guides 38 C.F.R. §§ 4.123, 4.124. There is no evidence of the left leg sciatica manifesting in moderately severe incomplete paralysis. The Board has not overlooked the statements by the Veteran with regard to the severity of her disability. See Jandreau, supra; Washington, supra. The Board has considered the Veteran's reports along with the medical evidence of record. Here, the most probative evidence consists of the VA examinations and treatment records. VI. Evaluations Patella Syndrome The Veteran is in receipt of initial 10 percent evaluations for patella femoral syndrome of both knees under Diagnostic Codes 5099-5019. The Veteran has challenged both initial evaluations, effective March 1, 2011. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional code to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.27. Unlisted disabilities requiring rating by analogy will be coded first with the numbers of the most closely related body part and "99." 38 C.F.R. §§ 4.20, 4.27. The Veteran's patella femoral syndrome of both knees has been evaluated by analogy under Diagnostic Code 5019. Diagnostic Code 5019 (bursitis) is to be evaluated on limitation of motion of the affected parts. The knees, including limitation of motion, are covered by Diagnostic Codes 5256-5263. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. Diagnostic Code 5260 is used to denote the rating criteria for the limitation of flexion of the leg. 38 C.F.R. § 4.71a. Limitation of flexion is rated as follows: flexion limited to 60 degrees warrants a noncompensable rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 evaluates limitation of extension as follows: extension limited to 5 degrees warrants a noncompensable rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 30 degrees warrants a 40 percent rating; and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Diagnostic Code 5257 is used to evaluate recurrent subluxation or lateral instability of the knee. Severe symptoms warrant a 30 percent rating; moderate symptoms warrant a 20 percent rating; and slight symptoms warrant a 10 percent rating. 38 C.F.R. §§ 4.71a , Diagnostic Code 5257. The terms "slight," "moderate," and "severe" are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Separate evaluations may be assigned for limitation of flexion and extension of the same joint. See VAOPGCPREC 09-04 (September 17, 2004). Specifically, when a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Id. As noted below, the Board has determined that a uniform evaluation is appropriate for both knee disorders for the entire period on appeal. See Hart, supra; Fenderson, supra. At a December 2010 VA examination, the Veteran denied fatigability, subluxation, and dislocation. Range of motion findings were 120 degree flexion bilaterally with pain at 110 degrees, bilaterally. Extension was 0 degrees bilaterally. Repetitive motion testing did not result in additional limitation of motion of either knee. There was no instability. At a March 2017 VA examination, range of motion findings were bilateral 140 degree flexion and bilateral extension of 0 degrees. Repetitive motion testing did not result in additional limitation of motion of either knee. There was no instability. Based on the medical evidence of record, the Board finds that the preponderance of the evidence is against a finding that an evaluation in excess of 10 percent for either knee is warranted for any period on appeal. The current evaluation contemplates pain on motion. In addition, it is consistent with limitation of flexion to 45 degrees. A higher evaluation may be assigned for the functional equivalent of limitation of flexion to 30 degrees. Separate evaluations may be assigned for compensable limitation of extension, instability or subluxation. With respect to the Veteran's current 10 percent evaluation for both knees, the evidence is against a finding that a higher evaluation is warranted. Specifically, the evidence establishes that remaining functional flexion has been significantly greater than 45 degrees. Furthermore, extension has been full, rather than being restricted to 10 degrees. We also note that the objective evidence establishes that there is no instability or subluxation. The Veteran has not exhibited a sufficient degree of limited flexion or extension, even when accounting for the factors of functional loss to warrant higher or separate evaluaitons. 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra. There is no indication that the Veteran experiences any additional functional loss due to pain, weakness, fatigability, incoordination or pain on movement of a joint to warrant a higher rating. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca, supra. Flare-ups have not been shown to result in additional limitation. With respect to other potentially applicable rating criteria, the claims folder contains no competent lay or medical evidence indicating that the Veteran's knee disabilities have been manifested by ankylosis, dislocation of cartilage, impairment of the tibia and fibula, or symptoms other than those discussed above at any time during either period on appeal. A higher rating is similarly unwarranted under Diagnostic Code 5258 because the Veteran has not been diagnosed with dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Although the Veteran has reported episodes of pain, no evidence of dislocated semilunar cartilage is of record. As such, an increased rating cannot be assigned for either knee for any time period under Diagnostic Codes 5256, 5258, or 5262-5263. 38 C.F.R. § 4.71a. To the degree that the Veteran has asserted any symptoms consistent with such disability ratings, these assertions are outweighed by the more probative findings of the VA examiners, because the examiners' determinations are based on greater medical knowledge and experience. Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999); Guerrieri v. Brown, 4 Vet. App. 467 (1993). All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against initial evaluations in excess of 10 percent for either knee. For these reasons, the claims are denied. VII. Evaluation of Costochondritis The Veteran is in receipt of an initial noncompensable evaluation for costochondritis under Diagnostic Codes 5299-5297. The Veteran has challenged the initial evaluation, effective March 1, 2011. Under Diagnostic Code 5297, a 10 percent rating is warranted for removal of one rib or resection of two or more ribs without regeneration. A 20 percent rating is warranted for removal of two ribs. A 30 percent evaluation is warranted for removal of three or four ribs; 40 percent for removal of five or six ribs; and, a 50 percent rating is warranted for removal of more than 6 ribs. As noted below, the Board has determined that a uniform evaluation is appropriate for costochondritis for the entire period on appeal. See Hart, supra; Fenderson, supra. A review of the record does not indicate that the Veteran has had a rib removed, or in the alternative, resection of two or more ribs. Chest and rib x-rays were normal. Chest and lungs were normal upon examination. There was tenderness of the sternum due to costochondritis. Based on the evidence of record, the Board finds that an initial compensable evaluation is not warranted for costochondritis. The Board has not overlooked the statements by the Veteran with regard to the severity of her disability. See Jandreau, supra; Washington, supra. The Board has considered the Veteran's reports along with the medical evidence of record. Here, the most probative evidence consists of VA examinations. All potentially applicable Diagnostic Codes have been considered. See Schafrath , supra. The preponderance of the evidence is against an initial compensable evaluation for costochondritis. For these reasons, the claim is denied. VII. Lower Extremity Vascular Pain Service connection has been granted for varicose veins of each lower extremity. She has appealed the denial of service connection for vascular pain of each lower extremity. Generally, service connection may be granted for disability due to disease or injury incurred in or aggravated by service. In addition, service connection may be granted for disability that is proximately due to, the result of or aggravated by service connected disease or injury. 38 C.F.R. § 3.310 (2017). Here, she has complained of vascular pain. However, service connection has been granted for varicose veins. The rating criteria specifically contemplates aching and fatigue. No other vascular pathology that has been identified. The regulations establish that the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2017). Here, there is no legal or medical basis to separately rate the complaint of vascular pain separately from the already service-connected varicose veins. Such a grant would clearly violate the regulation regarding pyramiding. ORDER Entitlement to an evaluation of 10 percent for left ankle tendonitis prior to March 2, 2017, is granted. Entitlement to an evaluation in excess of 10 percent for left ankle tendonitis is denied. Entitlement to an evaluation of 10 percent for right ankle tendonitis prior to March 2, 2017, is granted. Entitlement to an evaluation in excess of 10 percent for right ankle tendonitis is denied. Entitlement to an initial evaluation in excess of 20 percent for lumbar strain with intervertebral disc syndrome is denied. Entitlement to an initial evaluation in excess of 20 percent for left leg sciatica is denied. Entitlement to an initial evaluation in excess of 10 percent for left patella femoral syndrome is denied. Entitlement to an initial evaluation in excess of 10 percent for right patella femoral syndrome is denied. Entitlement to an initial compensable evaluation for costochondritis is denied. Service connection for lower extremity vascular pain as a distinct ratable entity is denied. REMAND In the Veteran's November 2010 compensation claim, she sought compensation for "vascular leg pain (left + right)." In the May 2011 rating decision on appeal, the RO granted service connection for varicose veins of the right and left legs, with separate evaluations of 10 percent. The RO also denied service connection for right and left leg vascular pain. In the Veteran's May 2012 Notice of Disagreement (NOD), she indicated disagreement with "right and left varicose veins." In the NOD she reported that her "varicose veins cause continual swelling with moderate to severe pain." In the April 2014 Statement of the Case (SOC) issued in response to the NOD, the RO again denied service connection for right and left leg vascular pain. It did not address an increased rating for varicose veins. The Veteran perfected her appeal in June 2014 with respect to all issues listed on the SOC. A subsequent Supplemental Statement of the Case (SSOC) again denied service connection for right and left leg vascular pain, but did not address the evaluation for varicose veins of the legs. A review of the May 2012 NOD clearly indicates that the Veteran sought to challenge the initial 10 percent evaluations for varicose veins of each leg. As the SOC and SSOC issued by the RO did not address entitlement to an evaluation in excess of 10 percent for varicose veins of both legs, a remand is necessary to issue the Veteran an SOC regarding these issues. See Manlicon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: Issue a statement of the case with respect to the issues of entitlement to an initial evaluation in excess of 10 percent for varicose veins of the right and left leg. Inform the Veteran of the requirements to perfect an appeal with respect to these issues. The appellant has the right to submit additional evidence and argument on the matter or matters 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs