Citation Nr: 21003336 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 16-15 070 DATE: January 21, 2021 ORDER Entitlement to service connection for left lower extremity varicose veins is granted. Entitlement to service connection for a vascular disability, to include thrombophilia (claimed as blood clots), right lower extremity varicose veins, deep vein thrombosis with pulmonary embolism, and post-phlebitic syndrome, is denied. Entitlement to an initial disability rating in excess of 10 percent for left ankle degenerative arthritis, open reduction and internal fixation, is denied. FINDINGS OF FACT 1. The Veteran’s left lower extremity varicose veins began during active service. 2. The preponderance of the evidence of record is against finding that the Veteran has had right lower extremity varicose veins or post-phlebitic syndrome at any time during or approximate to the pendency of the claim. 3. The preponderance of the evidence is against finding that the Veteran’s deep vein thrombosis with pulmonary embolism began during active service, is otherwise related to an in-service injury or disease, or is secondary to a service-connected disability. 4. The Veteran’s thrombophilia due to protein S deficiency, a congenital defect, was not aggravated beyond its natural progression by an in-service injury, event, or illness. 5. The Veteran’s left ankle disability is manifested by symptomatology most closely associated with moderate limitation of range of motion. CONCLUSIONS OF LAW 1. The criteria for service connection for left lower extremity varicose veins are met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 2. The criteria for service connection for a vascular disability, to include thrombophilia, right lower extremity varicose veins, deep vein thrombosis with pulmonary embolism and post-phlebitic syndrome are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306, 3.307, 3.309 (2019). 3. The criteria for an initial disability rating in excess of 10 percent for left ankle degenerative arthritis, open reduction and internal fixation, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1961 to October 1971 and October 1971 to July 1986. These matters come to the Board of Veterans’ Appeals (Board) from a November 2014 rating decision which, in pertinent part, granted service connection for residuals of a left ankle open reduction and internal fixation, rated as a scar, evaluated as noncompensable, effective August 29, 2013, and denied entitlement to service connection for thrombophilia. In December 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board videoconference hearing. A copy of the transcript is of record. Based on the Veteran’s description of his disability, the Board has expanded the Veteran’s claim of service connection for thrombophilia as one for a vascular disability, to include thrombophilia, bilateral lower extremity varicose veins, deep vein thrombosis with pulmonary embolism, and post-phlebitic syndrome. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In March 2019, the Board, in pertinent part, denied entitlement to an initial compensable rating for left ankle open reduction and internal fixation, rated as a scar, and remanded entitlement to an initial compensable rating for residuals of a left ankle open reduction and internal fixation based on x-ray evidence of traumatic degenerative arthritis. The Board also remanded entitlement to service connection for thrombophilia for an addendum VA opinion, to include whether the Veteran’s varicose veins, deep vein thrombosis with pulmonary embolism, and post-phlebitic syndrome were caused or aggravated by thrombophlebitis or varicose veins treated in service. In a September 2020 rating decision, the RO granted an initial 10 percent evaluation for left ankle degenerative arthritis, open reduction and internal fixation, effective August 29, 2013. As this does not represent a maximum grant of the benefit sought on appeal, the increased rating issue remains pending before the Board. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that “Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of a “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With a chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). A veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, except where clear and unmistakable evidence demonstrates that an injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. Thus, veterans are presumed to have entered service in sound condition as to their health. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulation provides expressly that the term “noted” denotes “[o]nly such conditions as are recorded in examination reports,” 38 C.F.R. § 3.304(b), and that “[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions.” Id. at (b)(1). If a disorder was not “noted” on entering service, the government must show clear and unmistakable evidence of both a preexisting condition and a lack of in-service aggravation to overcome the presumption of soundness. A lack of aggravation may be shown by establishing that there was no increase in disability during service or that the “increase in disability [was] due to the natural progress of the preexisting condition.” 38 C.F.R. § 3.306; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). If the government fails to rebut the presumption of soundness, the claim is one for service connection, not aggravation. Wagner, 370 F.3d at 1097. In explaining the meaning of an increase in disability, the Court has held that “temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered “aggravation in service” unless the underlying condition, as contrasted to symptoms, is worsened.” Hunt v. Derwinski, 1 Vet. App. 292, 297 (1992); see also Davis v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002) (explaining that, for non-combat veterans, a temporary worsening of symptoms due to flare ups is not evidence of an increase in disability). However, the increase need not be so severe as to warrant compensation. Browder v. Derwinski, 1 Vet. App. 204, 207 (1991). Of note is that the burdens and evidentiary standard to determine whether conditions noted at entrance into service were aggravated by service are different than the burdens and evidentiary standard to determine whether conditions not noted at entrance into service were aggravated. If a preexisting condition noted at entrance into service is not shown to have as likely as not increased in severity during service, the analysis stops, and the claim is denied. Only if such condition is shown by an as likely as not standard to have increased in severity during service does the analysis continue. In such cases, the increase is presumed to have been due to service unless there is clear and unmistakable evidence that the increase during service was not beyond the natural progression of the condition. See 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Congenital or developmental defects are not diseases or injuries subject to service connection. 38 C.F.R. §§ 3.303(c), 4.9. However, if a disease or injury is superimposed over the congenital or developmental defect during service, service connection may be warranted for the resultant disability. 38 C.F.R. §§ 3.303(c), 4.9; see Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993), citing Hunt v. Derwinski, 1 Vet. App. 292 (1991); VAOPGCPREC 82-90. The VA General Counsel explained there is a distinction under the law between a congenital or developmental “disease” and a congenital “defect” for service connection purposes in that congenital diseases may be recognized as service connected if the evidence as a whole shows aggravation in service within the meaning of VA regulations. A congenital or developmental defect, on the other hand, because of 38 C.F.R. § 3.303(c), is not service connectable in its own right, though service connection may be granted for additional disability due to disease or injury superimposed upon such defect during service. VAOPGCPREC 82-90. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. Entitlement to service connection for a vascular disability, to include thrombophilia, bilateral lower extremity varicose veins, deep vein thrombosis with pulmonary embolism, and post-phlebitic syndrome. The Veteran contends that service connection is warranted for thrombophilia, claimed as blood clots. As discussed above, based on the Veteran’s description of his disability, the Board has expanded the Veteran’s claim as one for a vascular disability, to include thrombophilia, bilateral lower extremity varicose veins, deep vein thrombosis (DVT) with pulmonary embolism (PE), and post-phlebitic syndrome. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board finds that while the Veteran has a current diagnosis of thrombophilia due to protein S deficiency, it constitutes a congenital defect for which service connection may not be granted. However, the Veteran’s left lower extremity varicose veins represents a superimposed disease or injury for which service connection may be granted. As discussed further below, the Board finds that service connection is not warranted for DVT with PE, right lower extremity varicose veins, or post-phlebitic syndrome. Turning to the evidence of record, service treatment records contain May 1961 enlistment, July 1965 and July 1969 reenlistment, and October 1971 separation examinations that were objectively normal regarding the Veteran’s vascular system, skin, and lower extremities. A July 1975 reenlistment examination report shows varicose veins of the left lower leg. A September 1979 periodic examination was objectively normal with regards to the Veteran’s vascular system, lower extremities, and skin. During a September 1980 annual examination, the Veteran was found to have varicosities of the left lower leg with venous stasis and increased swelling at the calf. A September 1980 vascular consult found large varicose veins on the Veteran’s left calf and he reported a strong family history of varicosities. An associated October 1980 venogram showed partial obstruction of superficial femoral vein with incompetent perforator. A September 1981 periodic examination continued to show varicosities on the left leg. In September 1982, the Veteran sought treatment for pain and red streaking on his left thigh lasting for seven days. The Veteran reported a family history of phlebitis and that he had had varicose veins for two years. Upon examination, varicose veins were present on the left calf and the Veteran’s left leg appeared swollen. The Veteran was diagnosed with thrombophlebitis and prescribed bed rest. Eight days later, the Veteran’s thrombophlebitis was noted as resolved. During a January 1986 annual examination, the examiner noted mild varicosities on both lower legs. On a May 1986 retirement examination, the Veteran was noted to have varicose veins on his left leg and the Veteran reported wearing support stockings since 1979 to reduce swelling in his ankle, improve circulation, and relieve pain. Post-service treatment records reflect that in February 1994, the Veteran reported a history of phlebitis and use of compression stockings. In March 1994, he experienced an episode of superficial phlebitis and was advised to continue use of compression stockings. A June 1994 treatment record reflects a diagnosis of varicose veins which were doing well with use of compression stockings. In November 1994, the Veteran was admitted to the hospital for pneumonia when he developed DVT with PE and superficial thrombophlebitis. He was diagnosed with thrombophilia and underwent hematologic testing which revealed a protein S deficiency. Treatment records dated since continue to show a history of varicose veins with use of compression stockings and protein S deficiency with history of DVT and PE. An August 2014 VA examination report reflects the Veteran reported developing blood clots in service and again in 2011. The examiner provided a diagnosis of left leg varicose veins and post-phlebitic syndrome resulting in intermittent edema and relieved by compression hosiery. The examiner noted that while the Veteran had an episode of thrombophlebitis in 1982, it resolved without chronicity of care or blood clots. The examiner additionally noted that a 1980 venogram showed partial obstruction of the superficial femoral vein. However, the examiner indicated that there was no supporting evidence for blood clots or chronicity of care for blood clots during service. The examiner further noted that post-service treatment records revealed a diagnosis of thrombophilia in 1994 and a protein S deficiency with pulmonary emboli in 2011. The examiner explained that protein S deficiency is a rare blood disorder and one of several known risk factors for thrombophilia. Furthermore, protein S deficiency can increase the risk of blood clots such as DVT and PE. On the other hand, medical literature did not show supporting evidence that trauma, such as the Veteran experienced to his left ankle during service, could induce the condition. After reviewing the Veteran’s medical records and medical literature, the examiner indicated that the Veteran clearly had a strong family history for protein S deficiency as a genetically inherited condition and that his protein S deficiency was not associated with or aggravated by service. Thus, the examiner opined that it was less likely than not that the Veteran’s thrombophilia was incurred in or caused by service. In March 2019, the Board found that while the Veteran had a predisposition for the development of blood clots, it was a genetic, inherited condition not associated with or aggravated by service. However, service connection could still be granted for a disease or injury that was superimposed on thrombophilia during service. Thus, the Board remanded the issue for an addendum opinion as to whether the Veteran’s 1994 DVT with PE or currently diagnosed left lower extremity varicose veins and post-phlebitic syndrome were caused or aggravated by the congenital thrombophilia or varicose veins and thrombophlebitis treated during service. In a May 2019 addendum opinion, the examiner explained that the Veteran’s thrombophilia is due to a protein S deficiency, a congenital coagulation disorder that predisposes one to development of thrombosis and/or embolus. The examiner further explained that while the Veteran’s protein S deficiency was not diagnosed until 1994, many years after discharge from service, it was present since birth. Thus, the examiner opined that the Veteran’s thrombophilia was less likely than not incurred in or caused by service. The May 2019 examiner further opined that the Veteran’s thrombophilia, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner explained that thrombophilia due to protein S deficiency manifests primarily by increased risk of venous thromboembolism (VTE), which involves blood clots that develop in the veins and then move through the bloodstream. Three factors known to contribute to VTE include altered blood flow, such as stasis; vascular endothelial damage; and altered characteristics of the blood. A 1980 venogram confirmed partial obstruction of the left femoral vein due to thrombus and incompetent valves in the superficial veins of the left lower extremity, confirming left lower extremity thrombophlebitis with varicose veins and venous stasis. The Veteran was managed conservatively by use of compression stockings to improve blood flow. The Veteran developed left leg swelling in September 1982 and left lower extremity thrombophlebitis was again diagnosed and managed conservatively. The examiner indicated that as the Veteran had stasis of blood flow and associated inflammation of the superficial veins of the left lower extremity as predisposing factors to develop thrombus, no further evaluation for the etiology of the Veteran’s thrombophlebitis was pursued during service. As only the superficial venous system was involved and the thrombophlebitis episodes resolved without invasive intervention or prolonged anticoagulation therapy, no progressive or aggressive disorder was suspected. The examiner further explained that although the Veteran did have left lower extremity thrombophlebitis episodes during service as initial VTE manifestations of protein S deficiency, with the venous stasis of varicose veins contributing, the Veteran did not have thrombophlebitis upon separation from service and the self-limited and resolved status of the Veteran’s left lower extremity thrombophlebitis in service did not represent any progression of the underlying protein S deficiency beyond its normal progression. The examiner explained that much more significant and serious VTE events often present as initial manifestations of protein S deficiency and the Veteran’s superficial thrombophlebitis would represent a mild presentation. Likewise, treatment records were silent for any VTE, including thrombophlebitis, even without anticoagulation therapy, until 1994, eight years after discharge from service, when DVT with PE was diagnosed. Thus, the Veteran’s protein S deficiency had not progressed beyond its natural course expected for the inherited coagulation disorder and no aggravation of the protein S deficiency due to any cause could be identified during or since service. As to the Veteran’s varicose veins, the May 2019 VA examiner indicated that the development of varicose veins was a separate and distinct disorder not due to or caused by thrombophilia, as thrombophilia does not affect the competency of the vasculature itself. The Veteran independently developed varicose veins in the lower extremities as early as 1975, creating venous stasis as documented in 1980 when the Veteran presented with persistent left leg swelling and visible varicosities. A 1980 venogram confirmed varicose veins and venous stasis which was managed conservatively by use of compression stockings to improve blood flow. As of 1986, the Veteran had also developed right lower extremity varicose veins, but the bilateral varicose veins were noted to be mild. At the time of the 2014 VA examination, only left lower extremity varicose veins persisted. As the Veteran did not have a current diagnosis of right lower extremity varicose veins, there was no causal relationship or aggravation. On the other hand, the examiner explained that the Veteran’s current left lower extremity varicose veins developed in part during service. However, the examiner noted the Veteran had also undergone left saphenous vein harvesting for coronary artery bypass graft. Thus, it could not be established if the Veteran’s current left varicose veins and left varicose veins in service involved all or only some of the same veins without resorting to speculation. As to DVT with PE, the May 2019 VA examiner noted that in 1994, the Veteran was admitted to the hospital for pneumonia, during which he developed bilateral lower extremity DVT with PE. As the Veteran was relatively young, further hematological evaluation was completed and the protein S deficiency diagnosis confirmed. The examiner explained that the Veteran’s 1994 DVT and PE developed during immobilization in the hospital for other illness. Immobilization with compromised blood flow is a known acquired independent risk factor for the development of DVT and PE. As the Veteran had no evidence for ongoing or recurrent thrombophlebitis from 1982 to 1994, and as his varicose veins improved during service with compression treatment to mild as of 1986, with no documented problems due to varicose veins from 1986 to 1994, the examiner opined it was less likely than not that the Veteran’s 1994 DVT and PE developed due to previous thrombophlebitis or varicose veins. Similarly, that examiner opined that the Veteran’s thrombophlebitis and varicose veins did not aggravate DVT and PE as the lack of any documented issues with thrombophlebitis or varicose veins from 1986 to 1994 indicated that those conditions in no way affected the development or progression of the Veteran’s 1994 DVT and PE. As to the August 2014 VA examiner’s diagnosis of post-phlebitic syndrome, the May 2019 examiner noted the Veteran developed thrombophlebitis twice during service but that it resolved without sequelae and there was no documentation of left thrombophlebitis after service. While the August 2014 VA examiner diagnosed the Veteran with post-phlebitic syndrome, this appeared to be based on the finding of intermittent swelling of the left leg. However, the Veteran’s DVT and left saphenous vein harvesting significantly increased the Veteran’s risk for chronic and/or recurrent leg swelling. Thus, the diagnosis of post-phlebitic syndrome could not be established. Rather, the swelling in his left was due to DVT, saphenous vein harvesting, and varicose veins of the left leg, and not to any distant history of resolved thrombophlebitis in service. The Board finds the August 2014 and May 2019 VA opinions, taken together, are adequate and probative. The examiners’ opinions are based on their medical expertise and are supported by adequate rationale with consideration of the medical literature and the Veteran’s in-service and post-service medical history. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Based on these opinions, the Board finds that a preponderance of the evidence is against the claim of service connection for thrombophilia. The evidence of record reflects that the Veteran’s thrombophilia due to protein S deficiency constitutes an inherited, congenital defect. Regarding the question of aggravation, the Board finds that there is no medical evidence that the Veteran’s thrombophilia due to protein S deficiency was aggravated beyond its natural progression by service. In order to support a finding of aggravation, the evidence must establish that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). As to the Veteran’s varicose veins, the Board finds that these represent a superimposed disease or injury eligible for service connection. Furthermore, because the Veteran first began to experience varicose veins during service and the May 2019 VA opinion that the Veteran’s current left lower extremity varicose veins began, at least in part, during service, the Board finds that the Veteran’s left lower extremity varicose veins first manifested during service and have continued since. While the examiner was unable to determine whether the Veteran’s current left lower extremity varicose veins involved all or only some of those that manifested during service, or whether some were due to nonservice-connected left saphenous vein harvesting for coronary artery bypass graft, the Board will resolve all reasonable doubt in the Veteran’s favor. See Mittleider v. West, 11 Vet. App. 181 (1998) (when it is not possible to separate the effects of the service-connected condition from a non-service-connected condition, 38 C.F.R. § 3.102 requires that reasonable doubt on any issue be resolved in the Veteran’s favor, and that such signs and symptoms be attributed to the service-connected condition). Affording the Veteran the benefit of the doubt, service connection for left lower extremity varicose veins is warranted. On the other hand, the Board finds that a review of the competent medical evidence of record shows that the Veteran does not have a current diagnosis of right lower extremity varicose veins or post-phlebitic syndrome. The Veteran’s May 2014 VA examination was normal as to the right lower extremity and the August 2019 VA examiner indicated that swelling in the Veteran’s left lower extremity was due to DVT, saphenous vein harvesting, and varicose veins rather than to post-phlebitic syndrome. Therefore, the service connection for right lower extremity varicose veins and post-phlebitic syndrome must be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997). As to the Veteran’s DVT with PE, the Board finds that a preponderance of the evidence is against the claim of service connection for DVT with PE. A review of the competent medical evidence of record shows that the Veteran’s DVT with PE developed due to immobilization from pneumonia and compromised blood flow rather than to his varicose veins or resolved in-service thrombophlebitis. The evidence also shows that the Veteran’s DVT with PT was not aggravated by his varicose veins or in-service thrombophlebitis, as his left lower extremity varicose veins were noted to be mild upon separation from service and in-service occurrences of thrombophlebitis resolved, and no evidence that the Veteran had any documented issues with varicose veins or thrombophlebitis from 1986 to 1994 when he developed DVT and PE. As to the Veteran’s own contentions, he is competent to observe lay symptoms but does not have the requisite medical knowledge, training, or credentials to be able to render a competent medical opinion regarding the progression of a medically complex disorder which has been determined to have preexisted service or whether his current vascular conditions are related to service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Accordingly, the Board gives more probative weight to the competent VA medical opinions as discussed above. In sum, resolving all reasonable doubt in favor of the Veteran, the probative evidence of record demonstrates that the Veteran’s currently diagnosed left lower extremity varicose veins were incurred in or otherwise related to service. Thus, service connection for left lower extremity varicose veins is warranted. As it pertains to the remaining claims, the preponderance of the evidence is against the claims of service connection for thrombophilia, right lower extremity varicose veins, deep vein thrombosis with pulmonary embolism and post-phlebitic syndrome. There is no doubt to be resolved, and service connection is not warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Within that context, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a “staged rating.” See Fenderson v. West, 12 Vet. App. 119 (1999). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The standard of proof to be applied in decisions on claims for veteran’s benefits is set forth in 38 U.S.C. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 2. Entitlement to an initial disability rating in excess of 10 percent for left ankle degenerative arthritis, open reduction and internal fixation. The Veteran contends that an increased rating is warranted for his left ankle disability. The Veteran is currently assigned a 10 percent rating under Diagnostic Code (DC) 5003-5271. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, the Veteran’s left ankle has been partially described as degenerative arthritis (DC 5003), which has been rated on the basis of limitation of motion under DC 5271. The normal range of motion for the ankle is from 45 degrees of plantar flexion to 20 degrees of dorsiflexion. See 38 C.F.R. § 4.71, Plate II. Under DC 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is non-compensable, a rating 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 20 percent evaluation is merited for X ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, DC 5003. Under DC 5271, which rates impairment based on limitation of motion, a 10 percent rating will be assigned with evidence of moderate limitation of motion and a 20 percent rating will be assigned with evidence of marked limitation of motion. 38 C.F.R. § 4.71a, DC 5171. The words “slight,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for “equitable and just decisions.” 38 C.F.R. § 4.6. An August 2014 VA examination report reflects the Veteran denied subjective and objective signs or symptoms associated with his left ankle disability, including flare-ups, as well as any hindrance in activities of daily living. Upon examination, there was no painful motion and range of motion testing was normal. There was no loss of strength or instability and the Veteran denied using an assistive device. While imaging studies revealed left ankle degenerative or traumatic arthritis, the examiner indicated that there was no subjective or objective evidence that pain, weakness, fatigability, flare-ups or incoordination significantly limited functional ability or after repeated use over time. During the December 2018 Board hearing, the Veteran testified that his leg hurts constantly and sometimes he must sit down for half an hour until the pain passes and he can bear weight on his leg. He indicated that he had not sought treatment for his left ankle and that he did not use a brace or insert. An August 2020 VA examination report reflects the Veteran reported flare-ups after walking for too long or during cold weather, and that he took NSAIDS to treat his pain. Range of motion was to 10 degrees of dorsiflexion and 20 degrees of plantar flexion in both active and passive motion. While pain was noted in both dorsiflexion and plantar flexion on examination, it did not result in or cause functional loss and there was no additional loss of function or range of motion after repetitive use, repeated use over time, or during flare-ups. The Veteran’s left ankle was tender on palpation and there was evidence of pain in weight-bearing but not in nonweight-bearing. The Veteran reported pain when standing or walking for long periods of time and that he used a cane constantly. The examiner indicated this would result in disturbance of motion and interference with standing and that the Veteran was unable to ambulate without a cane, but there was no evidence of muscle weakness, atrophy, ankylosis, or joint instability. Associated imaging studies revealed degenerative changes within the ankle and soft tissue swelling in the malleolar region. The above evidence reflects that during the claim period, the Veteran’s left ankle disability has been manifested by subjective reports of pain after walking or standing for long periods and the use of a cane. Imaging studies revealed degenerative changes but there was no objective evidence of ankylosis, instability, or deformity. Range of motion studies revealed limitation of range of motion to at most, 10 degrees of dorsiflexion and 20 degrees of plantar flexion in both active and passive motion, with evidence of pain in weight-bearing. These ranges of motion take into account any additional loss of motion during flare-ups or after repetitive use and are more closely approximated by moderate limitation of range of motion of the ankle. Thus, the Veteran’s symptomatology warrants no more than a 10 percent rating under DC 5271. Furthermore, as x-ray evidence does not reflect involvement of two or more major joints or two or more minor joint groups, a higher evaluation of 20 percent is not warranted for degenerative arthritis under DC 5003. To the extent that the Veteran would argue that his functional loss (other than painful motion) would warrant a separate rating, the Board finds that his functional loss is already contemplated under the assignment of a diagnostic code that contemplates a joint disability. 38 C.F.R. § 4.45 notes that joint disabilities cause functional impairment that may include: less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, and atrophy from disuse. The Board notes that each diagnostic code for a joint disability specifically contemplates these types of functional loss, which are factored into the assigned disability ratings for the joint disability. Here, the Board finds that the functional impairments of the Veteran’s left ankle has been contemplated by the Veteran’s assigned diagnostic. See 38 C.F.R. §§ 4.14, 4.40. 4.45. The Board finds that the Veteran’s left ankle symptoms have not been shown to be so disabling to actually or effectively result in marked limitation of motion, which is the requirement for a 20 percent rating for limitation of ankle range of motion under DC 5271. Hence, a rating in excess of 10 percent for a right ankle disability is not warranted at any time on appeal. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, DC 5271. The Board has also considered whether a separate or higher rating is warranted under 38 C.F.R. § 4.71a, DCs 5270, 5272-5274. However, the Veteran is not entitled to a rating under these codes as there is no evidence of ankylosis, malunion of the os calcis or astragalus, or astragalectomy at any time during the claim period. In adjudicating the claim, the Board has assessed the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences; for example, he is competent to report that he experiences certain symptoms such as left ankle pain. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds the Veteran to be credible in his reports of the symptoms he experiences. However, when the Veteran’s account of his symptomatology is viewed collectively with the other medical evidence of record, the resulting disability picture is consistent with the assigned rating. That is, the Board finds that the lack of any subjective or objective or physical evidence of limitation of range of motion more closely approximated by marked limitation of range of motion or instability such that it would warrant a separate rating. Bastien v. Shinseki, 599 F.3d 1301, 1306 (Fed. Cir. 2010) (“The evaluation and weighing of evidence and the drawing of appropriate inferences from it are factual determinations committed to the discretion of the fact finder.”); Jackson v. Virginia, 443 U.S. 307, 319 (1979) (it is “the responsibility of the trier of fact fairly to... weigh the evidence, and to draw reasonable inferences from basic facts to ultimate facts.”). In sum, the Board finds that for the reasons and bases discussed, the preponderance of the evidence is against the claim for an initial rating in excess of 10 percent for the Veteran’s left ankle degenerative arthritis, open reduction and internal fixation. There is no reasonable doubt to resolve in the Veteran’s favor, and this claim must be denied. 38 C.F.R. §§ 4.3, 4.7. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Owen, Associate 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.