Citation Nr: 21001348 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 11-27 024 DATE: January 7, 2021 ORDER Entitlement to a rating in excess of 30 percent for right foot/ankle Achilles tendonitis with traction spurs and plantar heel spurs is denied. Entitlement to a rating in excess of 20 percent for left foot/ankle Achilles tendonitis with traction spurs and plantar heel spurs is denied. Entitlement to a separate 10 percent disability rating for the foot symptoms of right and left foot/ankle Achilles tendonitis with traction spurs and plantar heel spurs, is granted, subject to the laws and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. At no point during the period on appeal did the Veteran’s right ankle disability manifest ankylosis in plantar flexion at more than 40 degrees, or dorsiflexion at more than 10 degrees or with abduction, adduction, inversion, or eversion deformity. 2. At no point during the period on appeal did the Veteran’s left ankle disability manifest ankylosis in plantar flexion, between 30 and 40 degrees, or in dorsiflexion between 0 and 10 degrees. 3. During the period on appeal the Veteran’s foot disabilities manifested separate symptoms analogous to an evaluation of moderate bilateral pes planus. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for the ankle symptoms of right foot/ankle Achilles tendonitis with traction spurs and plantar heel spurs have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5270. 2. The criteria for a rating in excess of 20 percent for the ankle symptoms of left foot/ankle Achilles tendonitis with traction spurs and plantar heel spurs have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5270. 3. The criteria for a separate rating of 10 percent, and no higher, for the foot symptoms associated with right and left foot/ankle Achilles tendonitis with traction spurs and plantar heel spurs have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5276. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1972 to December 1975. The Veteran testified at a hearing before the undersigned in February 2016. A transcript of the hearing has been associated with the claims file. The Board most recently remanded this claim in March 2019 for additional development and consideration. The Board finds there has been substantial compliance with the remand directives for the claim decided herein.  Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating 1. Entitlement to a rating in excess of 30 percent for right foot/ankle Achilles tendonitis with traction spurs and plantar heel spurs. 2. Entitlement to a rating in excess of 20 percent for left foot/ankle Achilles tendonitis with traction spurs and plantar heel spurs. The Veteran seeks higher evaluations for his right and left foot/ankle disabilities. Ratings for service-connected disabilities are determined by comparing the veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two 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. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal exertion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the Codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating 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. 38 C.F.R. § 4.59. The Veteran's right and left foot/ankle Achilles tendonitis with traction spurs and plantar heel spurs disabilities are currently evaluated at 30 percent and 20 percent, respectively, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5020-5270. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. See 38 C.F.R. § 4.27. Here, the hyphenated Diagnostic Code indicates that the Veteran's disabilities were rated, by analogy, under the criteria for ankylosis of the ankle. Under Diagnostic Code 5270, a 40 percent rating is warranted when there is ankle ankylosis in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. A 30 percent rating is warranted when there is ankle ankylosis in plantar flexion, between 30 and 40 degrees, or in dorsiflexion between 0 and 10 degrees. A 20 percent rating is warranted for ankle ankylosis in plantar flexion less than 30 degrees. In a February 2012 podiatry note, the Veteran was noted to have Achilles tendinopathy. He presented for painful posterior right heel. The pain was mostly along the insertion of the Achilles tendon and that it got worse with ambulation. He wore a walking boot in the house and had no pain when he was in the boot. There was 5 out of 5 muscle power strength in anterior, posterior, lateral, and intrinsic muscle groups bilaterally. There was full fluid range of motion without crepitus of the metatarsophalangeal joint (MTJ), subtalar joint (STJ) bilaterally. STJ inversion was 10 and eversion was 5, bilaterally. Ankle joint (AJ) range of motion was decreased bilaterally. There was pain with AJ dorsiflexion on the right. There was pain on palpation at the Achilles tendon insertion, pain was worst at 2 inches above tendon insertion. He was unable to perform single leg raise due to increase pain. There were no gross deformities noted bilaterally. In April 2012 the Veteran was noted to have a history of pain and swelling in the bilateral Achilles tendons with the right greater than the left. His right ankle was bothering him a lot and that he was unable to bear weight. Examination showed the right Achilles tendon tender to palpation. Foot x-rays in February 2012 were noted to show posterior calcaneal enthesophyte with a spur off the plantar aspect of the calcaneous on the right and possible Achilles enthesopathy on the left. In August 2012 the Veteran had right ankle pain. He was noted to have Achilles tenosynovitis with Haglund. Pain was worse with activity and initial steps; and was better with rest. He had difficulty with walking and standing. He was assessed with Achilles tenosynovitis, Haglund with calcifications of distal Achilles, severe pain; acquired equinus deformity; and excessive foot pronation. A magnetic resonance imaging (MRI) of the right ankle dated in September 2012 showed an enlarged distal Achilles tendon with disruption of fibers adjacent to the attachment to the calcaneus with increased signal intensity consistent with a partial tear or prominent focal tendinosis. In an addendum the MRI was noted to show a tear of some Achilles tendon fibres and retrocalcaneal bursitis. In October 2012 there was some limitation of ankle range of motion bilaterally and the right had pain with range of motion. There was enlargement around the distal Achilles and maximal was tender to palpation at area of insertion. There was some bogginess just proximal to the insertion. The tendon was clinically intact. Otherwise, there was adequate pain free range of motion of all major joints with adequate strength of all major muscle groups. There were not deformities present. There was antalgic gait. He favored the right foot and avoided heel off and coming onto the midfoot in gait. The pathology appeared to be associated with the Achilles tendon and its insertion into the calcaneus. Chronic insertional Achilles tendinitis with possible bursitis. The condition was exacerbated when he did not have appropriate support. Upon VA ankle examination October 2012 the Veteran was diagnosed with Achilles tendinitis bilaterally, Achilles tendon tear of the left, and calcaneal spurring bilaterally. The medical history indicated that the Veteran had very strong pain in the left ankle a year prior and that he was informed by a treatment provider that he had a tear in the Achilles tendon on that side. He used a boot for about 6 months. They were trying to relieve pressure on his Achilles, but it was not helping. The boot kept the ankle stable and then as soon as it was off he cannot step on the foot with ease. He used a cane at night when his boot was off. He had flare-ups of the ankle. The Veteran had significant pain with walking and standing for minutes. Short walks can increase pain for hours. Initial range of motion was measured as 45 degrees or greater of right ankle plantar flexion with no objective evidence of painful motion. There was 20 degrees or greater of right ankle dorsiflexion with no objective evidence of painful motion. There was 15 degrees of left ankle plantar flexion with objective evidence of painful motion beginning at 5 degrees. There was 5 degrees of left ankle dorsiflexion with objective evidence of painful motion beginning at 5 degrees. After repetitive use testing right ankle plantar flexion ended at 45 degrees or greater and right ankle dorsiflexion ended at 20 degrees or greater. After repetitive use testing left ankle plantar flexion ended at 15 degrees and left ankle dorsiflexion ended at 5 degrees. After three repetitions of range of motion in all vectors, there was no decrease in range of motion due to pain, weakness, fatigue, or lack of endurance. The Veteran had no functional loss for right lower extremity attributable to the claimed condition. Functional loss of the left lower extremity was reported to be less movement than normal, weakened movement, pain on movement, swelling, instability of station, disturbance of locomotion, and interference with sitting, standing and weight-bearing. There was pain on palpation on the left. Muscle strength testing was normal on the right and reduced (3 out of 5) on the left; however, there was marked pain on the left making the muscle testing unreliable. Joint stability tests were noted to show no laxity compared with the opposite side. However, the examiner thereafter identified the right side as demonstrating laxity and the Veteran complained of so much pain that he was unable to tolerate the test. There was no ankylosis. The Veteran was noted to have Achilles tendonitis or Achilles tendon rupture bilaterally. He regularly used a cane and constantly used a boot. He had functional impact identified as requiring a boot for walking and that he could only stand and walk for minutes at a time. The Veteran had a left Achilles tendon tear with significant symptoms including antalgic gait, need for a boot with all walking, a significant decrease in range of motion in all directions with pain, and obvious swelling on that side. He had a significant decrease in functionality in terms of daily living because he was unable to stand and walk for any extended period of time. The Veteran had a long course of treatment for the tear without resolution. The examiner found that his present condition represents a progression of his Achilles tendinitis. Upon VA foot examination in October 2012 the Veteran was diagnosed with hammer toes, hallux valgus, and calcaneal spurs, osteoarthritis. He described pain in his heels, but he had regular episodes of tendinitis, and he had a left Achilles tendon tear. The pain was increased because of his tendon condition and was a major limiting factor in terms of walking. He had not had specific treatment such as steroid injections for his heel pain, though he had worn orthotics. He had hammer toes of the second, third, fourth, and little toes on both feet. The examiner noted that the Veteran did not have symptoms due to hallux valgus; but noted that he had mild or moderate symptoms on the right side. Imaging studies of the feet were noted to show degenerative arthritis of the right foot. Bilateral calcaneal spurs, hammer toes in digits 2 through 5, and hallux valgus (mild) on the right. He had increased pain in his heels with standing and walking for an extended time. He can stand and walk very little because of a left Achilles tendon tear, but he stated that he had foot pain after standing on the job for more than about 30 minutes when he was working years ago. He had bilateral tenderness of the heels, and had an antalgic gait that was mostly due to a left Achilles tendon tear. He described some heel pain with standing. On physical exam there was decreased range of motion. He has never required any treatment specifically for his heel pain. The Veteran's condition did not appear to have demonstrated a progression. In December 2012 the Veteran was noted to have limited range of motion bilaterally and right had pain with range of motion. The tendon was clinically intact. In January 2013, the assessment was chronic Achilles tendinitis right with significant inflammation of the tendon. In a July 2013 VA examination addendum, the examiner noted that pain, weakness, fatigability, or incoordination significantly limit functional ability during flare-ups or when the joint is used repeatedly over time with the left ankle. The examiner noted that the right ankle range of motion will remain the same during flare-ups. He could have an additional 5 degrees loss in ranges of motion of the left ankle during flare-ups. At the hearing before the undersigned the Veteran reported that his ankles swell up when he walks. He reported difficulty standing. Upon VA ankle examination in February 2017 the Veteran was diagnosed with tendonitis (Achilles/peroneal/posterior tibial) of both ankles. He did not report flare-ups of the ankle. Pain began on arising and getting on his feet which increased during the course of the day with excruciating pain when he gets on his toes. Initial range of motion of the right ankle was 0 to 20 degrees of dorsiflexion and 0 to 40 degrees of plantar flexion. The range of motion contributed to functional loss because it included the Achilles tendon function. Pain was noted on examination and caused functional loss. There was pain on dorsiflexion, plantar flexion, and pain with weight bearing. The right tendon was markedly tender on palpation and pressure and also nodular. There was moderate tenderness at the calcaneal insertion. The left ankle showed 0 to 15 degrees of dorsiflexion and 0 to 35 degrees of plantar flexion. The range of motion contributed functional loss because it included the Achilles tendon function. Pain was noted on examination and caused functional loss. There was pain on dorsiflexion and with weight bearing. The Veteran was able to perform repetitive use testing and there was loss of function due to pain, fatigue, weakness, and lack of endurance in both ankles. In the right ankle the range of motion was 0 to 15 degrees of dorsiflexion and 0 to 35 degrees of plantar flexion. In the left ankle there was 0 to 10 degrees of dorsiflexion and 0 to 30 degrees of plantar flexion. The Veteran was not examined immediately after repetitive use over time. Pain, weakness, fatiguability or incoordination significantly limited functional ability with repeated use over a period of time due to pain, fatigue, weakness, and lack of endurance. However, the examiner was unable to describe in terms of range of motion because the Veteran was not examined over time. The examiner identified swelling, disturbance of locomotion, interference with standing as additional contributing factors to the disabilities and described them as no pain while sitting, but difficulty with pain on getting up. Muscle strength was 4 out of 5 for plantar flexion and dorsiflexion bilaterally. There was no ankylosis and no instability or dislocation suspected. He occasionally used braces and regularly used canes. Upon VA foot examination in February 2017 the Veteran was diagnosed with bilateral achilles tendonitis. The Veteran did not report flare-ups impacting the function of the foot. The Veteran had a striking increase in pain on the right ankle and foot which was followed by pain in the left Achilles. The questions regarding pes planus were addressed. He had pain in both feet that was accentuated on use. He had pain on manipulation of the feet and the pain was accentuated on manipulation. He did not have characteristic callouses. There was swelling on use on the right. The Veteran did not have extreme tenderness or plantar surfaces, decreased longitudinal arch height on weight-bearing, objective evidence of marked deformity, or marked pronation. The weight-bearing line did not fall over or medial to the great toe. There was no lower extremity deformity other than pes planus causing alteration of the weight-bearing line. The Veteran did not have inward bowing of the Achilles tendons. He did not have marked inward displacement and severe spasm of the Achilles tendon on manipulation of the feet.. Foot pain contributed to functional loss identified as less movement than normal, weakened movement, excess fatigability, pain on movement, pain on weight-bearing, swelling, disturbance of locomotion, interference with standing, and lack of endurance. He had increased Achilles tendon pain with weakness on any function of the foot and ankle of both feet. The Veteran was reported to regularly use braces and canes. The Veteran was afforded a VA ankle examination in September 2017. The Veteran was diagnosed with tendonitis and calcaneal spur bilateral. He reported flare-ups. He had pain and swelling issues with walking or standing longer than 30 minutes. Flare-ups occurred off and on during the day depending on how active he was. He was as sedentary as he can be to control both his Achilles tendon pains. He reported functional loss. He cannot walk or stand longer than 30 minutes before he had to sit down. His Achilles were very tight on arising in the mornings. The ankles severely curtailed his ability to exercise and get around. It was hard to drive a car because of the ankle pain. Initial range of motion of the right ankle was 0 to 10 degrees of dorsiflexion and 0 to 40 degrees of plantar flexion. The range of motion contributed functional loss because it caused a mild limp, tightness of the Achilles tendon causes the decrease in range of motion. Pain was noted on examination and caused functional loss. There was pain on dorsiflexion and pain with weight bearing. The right tendon was moderately tender on palpation and there was moderate tenderness at the calcaneal insertion. The left ankle showed 0 to 15 degrees of dorsiflexion and 0 to 40 degrees of plantar flexion. The range of motion contributed functional loss because caused a mild limp, tightness of the Achilles tendon causes the decrease in range of motion. Pain was noted on examination but it did not cause functional loss. There was pain on dorsiflexion and with weight bearing. The left tendon was mildly tender on palpation and there was mild tenderness at the calcaneal insertion. The Veteran was able to perform repetitive use testing and there was no additional loss of function or range of motion. Repeated use over time was not examined and the examination was not conducted during a flare-up. The examiner was unable to say whether pain, weakness, fatiguability or incoordination significantly limited functional ability without mere speculation. Muscle strength testing was 5 out of 5 on plantar flexion and 4 out of 5 on dorsiflexion bilaterally. The muscle strength reduction was due to the claimed condition. There was no muscle atrophy. He had no pain when non-weight bearing. His pain came immediately on attempts to rise from a sitting position to a standing, then walking position. There was no ankylosis or instability or dislocation suspected. He occasionally used braces and regularly used canes. He used a brace occasionally for swelling. He used a cane upon arising from bed or a chair to help stabilize him from the initial pain with weight bearing. Upon a VA foot examination in September 2017 the Veteran was diagnosed with hammer toes, degenerative arthritis, and calcaneal (heel) spurs, bilaterally, and hallux valgus on the right. He had mid to proximal arch pain, especially on first weight bearing in the morning and with excessive walking. At times his arches are too painful to weight bear, so he must sit down. This occurred off and on throughout the day. He was limited in the amount of time he can walk and stand. No high impact activities. The Veteran was reported to have pain on use of both feet that was accentuated with use. There was pain on manipulation of the feet and the pain was accentuated with manipulation. There was swelling on use of the feet. He did not have callouses characteristic of pes planus. Arch supports and built-up shoes were tried but the Veteran remained symptomatic. He did not have extreme tenderness of the plantar surfaces, decreased longitudinal arch height of one or both feet on weight-bearing, objective evidence of marked deformity of one or both feet, marked pronation of one or both feet, lower extremity deformity other than pes planus, causing alteration of the weight-bearing line, "inward" bowing of the Achilles tendon (i.e., hindfoot valgus, with lateral deviation of the heel) of one or both feet, or marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation of one or both feet. The weight-bearing line did not fall over or medial to the great toe. The examiner reported that the pes planus section of the examination was completed to reflect the Veteran’s pain issues and that the Veteran did not have pes planus. There were hammer toes of the second, third, fourth, and little toes of both feet. There were mild or moderate symptoms of hallux valgus on the right side. There was pain in the right and left foot on physical examination that contributed to functional loss. There was pain on movement, pain on weight-bearing, disturbance of locomotion, and interference with standing on both sides. There was pain in mid to proximal arch with weight- bearing activities on both sides. There was no other functional loss during flare-up or when the foot was used repeatedly over a period of time. The Veteran regularly used a cane to help stabilize balance when first weight-bearing on arising in the mornings or arising from sitting down. The examiner identified pain on active range of motion, passive range of motion, and weight bearing. There was no pain with non-weight bearing. Pursuant to the most recent Board remand, the Veteran was afforded a VA foot examination in October 2019. The Veteran was diagnosed with plantar heel spurs associated with Achilles tendonitis, right foot/ankle with traction spurs and plantar heel spurs associated with Achilles tendonitis, left foot/ankle with traction spurs. The Veteran reported that both of his heel hurt. Flare-ups did not impact function of the feet. He did not report having any functional loss or functional impairment of the feet being evaluated. He was reported to have pain on use of both feet that was accentuated with use. There was pain on manipulation of the feet and the pain was accentuated with manipulation. There was no swelling on use of the feet. He did not have callouses characteristic of pes planus. Orthotics effected relief of symptoms. The Veteran had extreme tenderness of the plantar surfaces of the feet that was improved by orthotic shoes or appliances. He did not have decreased longitudinal arch height of one or both feet on weight-bearing, objective evidence of marked deformity of one or both feet, marked pronation of one or both feet, lower extremity deformity other than pes planus, causing alteration of the weight-bearing line, “inward” bowing of the Achilles tendon (i.e., hindfoot valgus, with lateral deviation of the heel) of one or both feet, or marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation of one or both feet. The weight-bearing line did not fall over or medial to the great toe. Sections on hammer toe and hallux valgus were not completed. Pain was noted to be intermittent in both feet. The Veteran did not have functional loss for the left or right lower extremity attributable to the claimed condition. There was no pain, weakness, fatiguability, or incoordination that significantly limited functional ability during flare-ups or when the feet were used repeatedly over a period of time. The Veteran did not use any assistive devices. The examiner found that there was a worsening of the Veteran’s symptoms; however, there was no change to the service-connected diagnosis and no additional diagnoses were rendered. The Veteran was afforded a VA ankle examination in October 2019. The Veteran was diagnosed with Achilles tendonitis, right foot/ankle with traction spurs and plantar heel spurs and Achilles tendonitis, left foot/ankle with traction spurs and plantar heel spurs. The Veteran did not report flare-ups of the ankle and did not report having any functional loss or impairment of the joint or extremity being evaluated. Initial range of motion of the right ankle was 0 to 15 degrees of dorsiflexion and 0 to 40 degrees of plantar flexion. The range of motion did not contribute to functional loss. Pain was noted on examination but did not result in functional loss. There was pain on plantar flexion. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no pain with weight bearing or objective evidence of crepitus. The left ankle showed 0 to 15 degrees of dorsiflexion and 0 to 40 degrees of plantar flexion. The range of motion did not contribute to functional loss. Pain was noted on examination but did not result in functional loss. There was pain on plantar flexion. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no pain with weight bearing or objective evidence of crepitus. The Veteran was able to perform repetitive-use testing and there was no additional loss of function or range of motion in either ankle. The Veteran was not examined immediately after repetitive use over time. The examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner noted that pain, weakness, fatiguability, or incoordination did not significantly limit functional ability with repeated use over a period of time in either ankle. The range of motion was described as 0 to 15 degrees of dorsiflexion and 0 to 40 degrees of plantar flexion in both ankles. The Veteran was not examined during a flare-up. The examination was medically consistent with the Veteran’s statements describing functional loss during flare up. There was no pain, weakness, fatigability, or incoordination that significantly limited functional ability with flare-ups. The examiner was unable to describe in terms of range of motion. Passive range of motion was the same as active range of motion. Muscle strength testing was normal bilaterally. There was no muscle atrophy and no ankylosis. There was no ankle instability or dislocation suspected. The Veteran did not have or ever had “shin splints”, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of the calcaneus or talas, or had a talectomy. The Veteran did not use any assistive devices. The examiner found that there was a worsening of the Veteran’s symptoms; however, there was no change to the service-connected diagnosis and no additional diagnoses were rendered. Based on a review of the record, the Board finds that the preponderance of the evidence is against assigning increased ratings for either ankle. At no point during the period on appeal did the Veteran’s right ankle disability manifest ankylosis in plantar flexion at more than 40 degrees, or dorsiflexion at more than 10 degrees or with abduction, adduction, inversion, or eversion deformity. For the left ankle, there was no evidence during the period on appeal that the disability manifest ankylosis in plantar flexion, between 30 and 40 degrees, or in dorsiflexion between 0 and 10 degrees. None of the VA examinations or treatment records show ankylosis in either ankle. Therefore, entitlement to higher evaluations for the right and left ankle/foot disabilities pursuant to Diagnostic Code 5020-5270, is denied. The Board further finds that entitlement to a separate 10 percent rating is warranted for the Veteran’s foot pain symptoms that are not contemplated by the ankle rating criteria, as analogous to bilateral flat feet under Diagnostic Code 5276. The Board has considered other applicable rating codes under which to rate the separate symptoms by analogy but finds Diagnostic Code 5276 the most appropriate. The medical evidence does not demonstrate that he suffers from ankylosis of the subastragalar or tarsal joint, or malunion of the os calcis or astragalus, or that he had an astragalectomy. 38 C.F.R. § 4.71a, Diagnostic Code 5272, 5273, 5274, 5284. Yancy v. McDonald, 27 Vet. App. 484 (2016). Under that Diagnostic Code 5276, a 10 percent rating is warranted for moderate acquired flat foot; weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is assigned for severe unilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is warranted for severe bilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. The Veteran’s foot symptoms not contemplated by the ankle evaluation most nearly approximate symptoms of bilateral moderate acquired flat foot. The Veteran’s feet manifest pain on manipulation and use, notations of pain accentuated on use, and notations of swelling. The criteria for a 10 percent rating are met. However, there is no evidence of objective evidence of deformity, characteristic callosities, marked pronation, marked inward displacement, or spasm. In addition, there is a notation that orthotics do not affect relief; however, later it is noted that they do effect relieve. Therefore, the criteria for a separate evaluation of 20 percent are not met or more closely approximated. The Board finds that there are no other applicable rating codes under which to rate the Veteran’s service-connected disability, as the medical evidence does not demonstrate that he suffers from ankylosis of the subastragalar or tarsal joint, or malunion of the os calcis or astragalus, or that he had an astragalectomy. The symptoms not contemplated by the service-connected bilateral ankle disabilities are pain in the foot, most analogous to flat feet. 38 C.F.R. § 4.71a, Diagnostic Code 5272, 5273, 5274. M.E. LARKIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Robert J. Burriesci, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.