Citation Nr: 21076202 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 16-52 272 DATE: December 22, 2021 ORDER An initial disability rating in excess of 20 percent for lumbar strain is denied. An initial disability rating in excess of 10 percent for right knee patellofemoral syndrome is denied. An initial disability rating in excess of 10 percent for left knee patellofemoral syndrome is denied. An initial 10 percent disability rating for right ankle strain prior to July 14, 2016, is granted. A disability rating in excess of 10 percent for right ankle strain from July 14, 2016, is denied. An initial, 10 percent disability rating for left ankle strain prior to July 14, 2016, is granted. A disability rating in excess of 10 percent for left ankle strain from July 14, 2016, is denied. An effective date earlier than July 14, 2016, for the award of a 10 percent rating for right ankle sprain is dismissed. An effective date earlier than July 14, 2016, for the award of a 10 percent rating for left ankle sprain is dismissed. REMANDED Entitlement to service connection for costochondritis is remanded. Entitlement to service connection for bilateral pes cavus is remanded. FINDINGS OF FACT 1. The Veteran's lumbar strain has not been manifested by forward flexion limited to 30 degrees or less, unfavorable ankylosis of the entire thoracolumbar spine, neurologic impairment, and/or incapacitating episodes as defined by VA of a duration of at least 6 weeks during a 12-month period. 2. The Veteran's right and left knee patellofemoral syndrome has been manifested by painful motion; flexion limited to 30 degrees or less, extension limited to 10 degrees or greater has not been demonstrated. 3. Throughout the appeal period prior to and from July 14, 2016, the Veteran's right and left ankle strain have been manifested by no more than moderate limitation of motion; marked limitation of motion or limitations of dorsiflexion to 5 degrees or less or 10 degrees or less have not been shown. 4. By virtue of the Board's decision assigning 10 percent ratings for right and left ankle sprain throughout the entire rating period, the claims for earlier effective dates have been granted. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 20 percent for lumbar strain have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2020). 2. The criteria for an initial disability rating in excess of 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2020). 3. The criteria for an initial disability rating in excess of 10 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2020). 4. The criteria for an initial 10 percent disability rating for right ankle sprain, prior to July 14, 2016, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2020). 5. The criteria for a disability rating in excess of 10 percent for right ankle sprain, from July 14, 2016, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2020). 6. The criteria for an initial 10 percent disability rating for left ankle sprain, prior to July 14, 2016, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2020). 7. The criteria for a disability rating in excess of 10 percent for left ankle sprain, from July 14, 2016, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2020) 8. Entitlement to an effective date earlier than July 14, 2016, for the award of a 10 percent disability rating for right ankle sprain is dismissed. 38 U.S.C. § 7105(d)(5). 9. Entitlement to an effective date earlier than July 14, 2016, for the award of a 10 percent disability rating for left ankle sprain is dismissed. 38 U.S.C. § 7105(d)(5). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 2008 to July 2012. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from a November 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the Board issued a decision denying the claims for service connection for bilateral pes cavus and costochondritis. The Board also remanded the increased rating and earlier effective date claims noted on the title page of this decision. The Veteran appealed the Board's December 2018 denial of the claims of entitlement to service connection for bilateral pes cavus and costochondritis to the U.S. Court of Appeals for Veterans Claims (Court). In an order dated May 2019, pursuant to a September 2019 Joint Motion for Partial Remand, the Court vacated the Board's decisions as to these issues. In March 2020, the Board remanded those issues for additional development. In October 2020, the Board remanded all of the issues on appeal to the agency of original jurisdiction for additional development. The case has since returned to the Board for the purpose of appellate disposition. The Board has considered the Veteran's representative's May 2021 statement that the February 2021 VA examinations were not in the claims file at the time of their review and requesting remand to add these records to the file. Review of the Veterans Benefits Management Center file indicates that these examinations were uploaded to the file in February 2021; regardless, the examinations pertain to the claimed costochondritis and pes cavus, which are being remanded herein. Accordingly, the Board finds that there is no prejudice in proceeding with appellate disposition as to the remaining issues. Increased Rating Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim 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); Fenderson v. West, 12 Vet. App. 119 (1999). To the extent that staged ratings have been assigned for some of the Veteran's service-connected disabilities, the Board will consider the propriety of the rating for each stage. In addition, 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. 1. Entitlement to an initial rating in excess of 20 percent for lumbar strain The Veteran asserts that she is entitled to a higher rating for her lumbar spine disability. Her lumbar spine disability, lumbar strain, is rated as 20 percent disabling under the criteria of 38 C.F.R. § 4.71A, Diagnostic Code 5237, which provides that lumbar strain is to be evaluated unde the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating for Intervertebral Disc Disease (IVDS) based on Incapacitating Episodes. At the outset, the Board notes that while portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the rating criteria for the spine and IVDS were not changed. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine; and 100 percent for unfavorable ankylosis of the entire spine. Note 1 to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note 2 states that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. IVDS (preoperatively or postoperatively) is to be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. A 10 percent disability rating is assigned for incapacitating episodes having a total duration of at least one week but less than two weeks during the past twelve months, with higher evaluations for incapacitating episodes of increased duration. Note 1 states that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note 2 indicates that if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, the rater is to evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. On predischarge examination in November 2011, the Veteran reported onset of back pain in service due to injury. She could walk without limitations, but endorsed the following symptoms: stiffness, spasms, paresthesias, and numbness. She did not experience fatigue or decreased motion. The Veteran also reported weakness of the spine and leg. The pain traveled to her neck and legs, and the pain level was moderate, and could be exacerbated by physical activity and stress. At the time of pain, she experienced functional impairment which was described as inability to pick up certain items and limitation of the joint in bending and twisting. The condition had not resulted in incapacitation. Overall functional impairment included pain with walking, running, sit ups, bending, and twisting. Objectively, the examination revealed no evidence of radiating pain on movement. Muscle spasm was absent. There was tenderness in the paraspinal area of the lower lumbar region. Spinal contour was preserved, though there was tenderness. There was no guarding of movement. There examination did not reveal any weakness and muscle tone and musculature was normal. Straight leg raising was negative bilaterally. Neurologic examination of the lower extremities was normal. There was no ankylosis present or signs of intervertebral disc syndrome. Range of motion revealed flexion to 40 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 30 degrees. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Inspection of the spine revealed a normal head position with symmetry in appearance. The examiner diagnosed lumbar strain. A July 2016 VA examination report indicates that the Veteran reported back pain and that it hurt when she bent over. The pain was mainly located in the low back. She was never treated for the back and had no physical therapy since she was on active dutyshe stated that the therapy did not help. During flare-ups, she felt numb and tingly in the back and could not lay on her back at night. This lasted the whole night. Functional impact included inability to sleep or to bend over to tie her shoes. Range of motion testing revealed forward flexion to 60 degrees, extension to 15 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 20 degrees. Pain was noted on examination and caused functional loss. There was no evidence of pain with weight bearing. She was tender to light touch and palpation throughout the back. On repetition, the Veteran repeated forward flexion 1 time and flexion was to 40 degrees. The examiner expressed that the exam was being conducted after repeated use over time and during a flare-up, and that pain, fatigue, weakness, and lack of endurance limited functional ability. However, he was unable to describe in terms of range of motion and did not provide an estimate. There was localized tenderness but no guarding or muscle spasm. Reflex and sensory examination was normal. The examiner was unable to perform straight leg raising tests. The Veteran did not have radicular pain or other signs or symptoms due to radiculopathy. The Veteran did not have other neurologic abnormality or intervertebral disc disease. The examiner diagnosed lumbosacral strain. Functional impact included pain and inability to bend or stand for prolonged periods of time. The examiner commented that the Veteran's physical examination and pain description was not explained by back strain. Her pain to touch and movement was unlikely due to muscle strain alone. On VA examination in May 2019, the Veteran endorsed back pain, but did not report flare-ups or functional loss. Range of motion testing revealed forward flexion to 50 degrees, extension to 10 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 30 degrees. Pain was noted on examination but did not contribute to functional loss. There was no evidence of pain with weight bearing or tenderness or pain on palpation of the joints or soft tissue of the thoracolumbar spine. There was no additional loss of function of range of motion after three repetitions. The examiner indicated that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. He estimated that flare-ups resulted in 10 percent loss of range of motion 1 time per month. She had muscle spasm, but it did not result in an abnormal gait or abnormal spinal contour. Strength, reflex, and sensory examination of the lower extremities yielded normal findings. Straight leg raising test results were negative, and there were no signs and symptoms due to radiculopathy. The Veteran did not have ankylosis of the spine or any other neurologic abnormality. She also did not have intervertebral disc disease of the spine. The examiner diagnosed lumbosacral strain and indicated that the disability did not affect the Veteran's ability to work. After review of the competent medical evidence, the Board finds that the weight of the evidence is against a disability rating in excess of 20 percent for the lumbar spine disability. This is also consistent with the medical evidence of record, which fails to show that the Veteran's forward flexion of the thoracolumbar spine is less than 30 degrees. Moreover, the evidence fails to show that the Veteran has favorable ankylosis of the entire thoracolumbar spine. In addition, as noted above, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to 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, weakness, premature or excess fatigability, and incoordination. See DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. In this case, the estimated range of motion was a 10 percent loss of range of motion, which does not equate to 30 degrees of flexion or less. There is nothing otherwise to suggest forward flexion of the spine limited to less than 30 degrees or the functional equivalent of ankylosis of the thoracolumbar spine. With regard to separate ratings for neurological abnormalities or chronic neurologic manifestations, although the Veteran indicated radiating pain on examination in 2011, no neurological abnormality has been demonstrated on examination and neurological examinations of the lower extremities in 2011, 2016, and 2019 have largely yielded normal findings. The Board acknowledges that the Veteran was unable to perform straight leg raising tests in 2016; however, these tests were negative in 2011 and 2019, and there is no other indication of radiculopathy in the record. Accordingly, the Board concludes that the preponderance of the evidence does not support separate ratings for radiculopathy. The Board has considered a rating on the basis of IVDS. However, intervertebral disc disease and/or incapacitating episodes have not been shown. In light of the foregoing, the Board finds that a higher rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is not warranted. Accordingly, the Board concludes that a rating in excess of 20 percent for lumbar strain is not warranted. In denying an increased rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome of the right knee 3. Entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome of the left knee The Veteran's service-connected patellofemoral syndrome of the right and left knees are rated as 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5260. The normal flexion of the knee is 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion to 60 degrees warrants a 0 percent rating. Flexion limited to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The normal range of extension of the knee is 0 degrees. Limitation of extension to 5 degrees warrants a 0 percent 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. Extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Symptoms associated with the removal of semilunar cartilage warrant a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Impairment in the form of recurrent subluxation or lateral instability warrants a 10 percent rating if slight, 20 percent if moderate, and 30 percent if severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the majority of these diagnostic codes were not changed. The only relevant change is to Diagnostic Code 5257, which provides that a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability, or for sprain/ligament tear causing persistent instability without prescription for an assistive device, while a 20 percent rating is warranted for: a) sprain, incomplete ligament tear, or repaired complete ligament tear causing permanent instability, and a medical provider prescribed brace or assistive device for ambulation, or; b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribed assistive device or bracing for ambulation, or for a diagnosed condition involving the patellofemoral complex with recurrent instability requiring prescription for a brace and a cane or walker. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (effective February 7, 2021). On VA pre-discharge examination in 2011, the Veteran reported right and left knee pain, weakness, stiffness, giving way, lack of endurance, locking, fatigability, tenderness, and subluxation. She had flare-ups as often as 7 time per week lasting for 1 day. The severity was a level of 9 on a scale to 10 on the right, and 2 out of 10 on the left. Flare-ups were precipitated by physical activity and alleviated by rest and tramadol. During flare-ups, prolonged standing, walking and running were limited and she was unable to bend all the way. Objectively, there was tenderness bilaterally, but no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, and drainage. There was no subluxation. Examination revealed no locking pain, genu recurvatum, or crepitus. There was no ankylosis. Range of motion of both knees was from 0-140 degrees flexion and extension. There was pain at 30 degrees flexion on the right, and at 15 degrees on the left. The examiner indicated that joint function was not additionally limited by pain fatigue, weakness, lack of endurance, or incoordination after repetitive use. Stability testing yielded normal findings. X-rays were normal. The examiner diagnosed bilateral chondromalacia patella. A July 2016 VA examination report reflects the Veteran's report that her knees hurt when she got up from a chair and walked more than 20 minutes. The pain was located laterally and behind the patella. She endorsed flare-ups with worse pain that limited walking and standing. The examiner was unable to test right and left knee range of motion due to severe pain. There was evidence of pain with weight bearing. She reported pain around the patella. There was pain on palpation around the patella. There was no objective evidence of crepitus. With respect to repetitive use over time, the examiner noted that he was unable to provide any estimate as to additional functional loss as it was unclear if the Veteran's pain was due to a service-connected condition. The examiner indicated that the exam was being conducted during a flare-up and that pain, fatigue, weakness, and lack of endurance limited functional ability during a flare-up. Right knee strength was 4/5 and left knee strength was full. The Veteran did not have muscle atrophy. There was no ankylosis and there was no instability or history of recurrent effusion. The Veteran did not have a meniscal condition. She did not use an assistive device. The examiner diagnosed bilateral patellofemoral pain syndrome. Functional impact included pain with ambulating, standing and kneeling. On VA examination in May 2019, the Veteran reported patellofemoral syndrome with treatment of rest and medication. She did not report flare-up or functional impairment. Range of motion bilaterally was from 0-120 degrees flexion and extension. Pain was noted on examination but did not result in or cause functional loss. There was no evidence of pain with weight bearing, localized tenderness or pain on palpation, or evidence of crepitus. There was no additional limitation in motion on repetitive range of motion testing. The examiner indicated that the Veteran was not being examined immediately after repetitive use over time, but that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. There was no pain on passive range of motion or in non-weight bearing. The examiner estimated a 10 percent loss in range of motion on flare-up one time per month. Muscle strength testing was full and there was no ankylosis. Joint stability testing was negative. There was no history of a meniscus condition. The Veteran did not use an assistive device. The examiner diagnosed bilateral patellofemoral syndrome, and indicated that the disability did not impact her ability to work. With respect to the currently assigned 10 percent ratings for the left and right knees under Diagnostic Code 5260, the 10 evaluation contemplates pain on motion. It is also consistent with flexion limited to 45 degrees. In order to warrant a higher evaluation, there must be the functional equivalent of flexion limited to 30 degrees. 38 C.F.R. § 4.7; DeLuca. A separate rating may also be assigned for limitation of extension. In this case, the medical evidence establishes flexion to well over 100 degrees and full extension of either knee. As flexion is not limited to 30 degrees or less, and extension is not limited to 10 degrees or more an evaluation in excess of 10 percent is not warranted (and a separate evaluation for limited extension is not warranted). The Board acknowledges that the Veteran was unable to complete range of motion testing on the 2016 examination, which potentially suggests higher rating is warranted, as argued by the Veteran's representative. However, given that the examiner indicated that he was unsure as to whether the Veteran's pain was due to service-connected disability and that the other examinations, including the examination subsequent to 2016, reflect nearly full range of motion, the Board finds that these examination findings do not support a higher rating. In addition, as noted above, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to 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, weakness, premature or excess fatigability, and incoordination. See DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Here, while the Veteran has reported increased limitation, neither the medical nor lay evidence suggests that he is limited to 30 degrees flexion or compensable limitation of extension. The 2019 examiner indicated that functional ability would result in 10 percent limitation of motion, which does not equate to flexion to 30 degrees or less or compensable loss of extension. As a result, the 10 percent ratings for her left and right knee patellofemoral syndrome adequately compensates her for her symptoms. In this case is no credible evidence of ankylosis, symptoms related to dislocation or removal of the semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum of the knee. With respect to instability, although the Veteran reported giving way and weakness on exam, further problems with instability have not been documented, with instability testing yielding normal findings across all examinations and no recurrent subluxation or lateral instability indicated. The Board acknowledges that Diagnostic Code 5257 does not require objective medical evidence of lateral instability for a rating to be assigned. See English v. Wilkie, 30 Vet. App. 347, 349 (2018). The Court further held that "[t]he Board [cannot] categorically find objective medical evidence more probative than lay evidence with respect to [DC 5257] without supporting its conclusion with an adequate statement of reasons or bases." Id. However, in this case, in addition to not being accompanied by objective evidence of instability, the Veteran's reports have been non-specific and inconsistent as to instability. Accordingly, the Board finds that the preponderance of the evidence does not support a separate rating on the basis of instability. Moreover, as recurrent instability or sprain/ligament tear have not been demonstrated, a separate compensable rating under the revised criteria is also not warranted. In conclusion, the Board finds that the evidence is against ratings in excess of 10 percent for bilateral chondromalacia patella. In reaching this determination, the Board has considered the benefit of the doubt doctrine. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Entitlement to an initial, compensable rating for right ankle strain prior to July 14, 2016 5. Entitlement to a rating in excess of 10 percent for right ankle strain from July 14, 2016 6. Entitlement to an initial, compensable rating for left ankle strain prior to July 14, 2016 7. Entitlement to a rating in excess of 10 percent for left ankle strain from July 14, 2016 The Veteran's status post left ankle sprain has bee has been rated as noncompensable and 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5271. Under Diagnostic Code 5271, a 10 percent rating contemplates moderate limitation of motion. A maximum 20 percent rating is assigned for marked limitation of motion. Portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, including Diagnostic Code 5271. Under the revised criteria, moderate limitation of motion (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) warrants a 10 percent rating. A 20 percent rating is assigned for marked limitation of motion of less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. Normal ankle motion is measured from 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. 38 C.F.R. § 4.71a, Plate II. A 2011 pre-discharge VA examination reflects that there was tenderness of the ankles, but no signs of edema, instability, abnormal movement, effusion, redness, heat, deformity, guarding of movement, malalignment, or drainage. There was no ankylosis. Range of motion was full bilaterally, with 0-20 degrees of dorsiflexion and 0-45 degrees of plantar flexion. The joint was not additionally limited on repetitive use. X-rays were within normal limits. A December 2012 VA treatment reflects the Veteran's report of worsening left ankle pain since she injured her ankle on active duty. The left ankle had a visible bruise over the dorsal surface of the foot. Sensation was intact. She was assessed with left ankle pain likely secondary to bruising/soft tissue swelling. X-ray was negative. A July 2016 VA examination report indicates that the Veteran reported bilateral ankle pain with standing more than 20 minutes. She had discomfort around the ankle in a bracelet distribution. Moving was easier than standing still. She endorsed flare-ups, noting that she had throbbing pain at night. Functional impairment included inability to stand for over 20 minutes. Range of motion testing revealed right and left ankle range of motion to 20 degrees dorsiflexion, and 45 degrees plantar flexion, or full range of motion. Pain was noted on examination but did not cause functional loss. There was diffuse tenderness or pain on palpation, but no pain with weightbearing or evidence of crepitus. There was no additional change in range of motion upon repetition. The examiner indicated that although the Veteran was not being examined immediately after repetitive use over time or during flare-up, there was no indication that pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated used over time. Right ankle strength was 4/5 while left ankle strength was 5/5. There was a tremor in the left foot with strength training. The examiner diagnosed bilateral ankle strain. Functional impact included limitations on standing and walking. On VA examination in May 2019, the Veteran reported bilateral ankle pain with ambulation. She did not report flare-ups. Range of motion testing revealed right ankle dorsiflexion to 10 degrees and right ankle plantar flexion to 30 degrees. Pain was noted on examination but not result in functional loss. There was no evidence of pain with weigh bearing, crepitus, localized tenderness, or pain on palpation. Left ankle dorsiflexion to 10 degrees and left ankle plantar flexion to 30 degrees. Pain was noted on examination but not result in functional loss. There was no evidence of pain with weigh bearing, crepitus, localized tenderness, or pain on palpation. The Veteran was able to perform repetitive use testing with at least 3 repetitions with no additional loss of function or range of motion. The examiner indicated that the examination was neither medically consistent with the Veteran's statements describing functional loss with repetitive use over time; however, pain, weakness, fatigability, or incoordination did not significant limit with repeated use over time. There was no pain with passive range of motion or when non-weight bearing. Flare-up estimate was loss of range of motion of 10 percent, 1 time per month. Muscle strength was full bilaterally. No ankylosis was present, and joint stability testing yielded normal results. The examiner diagnosed bilateral ankle strain, and indicated that the Veteran's disability did not impact her ability to perform any type of occupational task. Based upon the foregoing, the Board finds that the aforementioned evidence supports entitlement to a 10 percent evaluation throughout the appeal period for both ankles, prior to and from July 14, 2016. In reaching this determination, the Board notes that the evidence has varied. However, given the Veteran's consistent report of ankle pain and worsening symptoms prior to 2016, the lack of findings on flare-up and repeated use over time, and the length of time between the 2011 and 2016 examinations, the Board resolves reasonable doubt in the Veteran's favor and finds that the 2016 examination findings of reduced range of motion, indicative of moderate limited of motion, are applicable throughout the appeal period. However, range of motion has not been shown to be significantly reduced, with the Veteran's range of motion shown to have been limited to, at worst, 10 degrees dorsiflexion and plantar flexion to 30 degrees on examination. Therefore, as marked limitation of motion has not been demonstrated. With respect to the revised criteria, a higher rating is also not warranted as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion have not been demonstrated. Accordingly, the criteria for a 20 percent rating have not been met. In addition, as noted above, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to 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, weakness, premature or excess fatigability, and incoordination. See DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Here, while the Veteran has reported increased limitation, neither the medical nor lay evidence suggests that limitation of dorsiflexion or plantar flexion is marked. Reports of flare-ups have been inconsistent across examination, and the 2021 examiner indicated that the there was no indication of additional limited functional ability with repeated use over time and only 10 percent reduction on limitation of motion on flare-up, the 10 percent ratings for her right and left ankle disabilities adequately compensates her for her symptoms, regardless of whether the former or revised criteria are used. The Board has also considered other potentially applicable diagnostic codes; however, the Veteran's right and left ankle disabilities are not shown to involve any other factor that would warrant evaluation of the disability under any other provisions of the rating schedule, to specifically include ankylosis of the subastragalar or talar joint, or malunion of the os calcis or astragalus, or astragalectomy. As such, a rating under Diagnostic Codes 5272, 5273, or 5274 is not appropriate. In conclusion, the Board finds that uniform 10 percent rating are warranted for the Veteran's bilateral ankle strains prior to and from July 2016, but that ratings in excess of 10 percent must be denied. In reaching this determination, the Board has considered the benefit of the doubt doctrine. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Effective Date 8. Entitlement to an effective date earlier than July 14, 2016, for the award of a 10 percent rating for right ankle strain 9. Entitlement to an effective date earlier than July 14, 2016, for the award of a 10 percent rating for right ankle strain The effective date of an award of increased compensation to a Veteran shall be the earliest date as of which it is ascertainable that an increase in disability has occurred, if application is received within one year of such date. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400(o)(2); Harper v. Brown, 10 Vet. App. 125 (1997). Otherwise, the effective date is the date of receipt of claim. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400(o)(2). In this case, although the Veteran separately appealed the effective date of the assignment of the 10 percent ratings in the August 2016 rating decision, the matter was essentially already in appellate status by virtue of the Veteran appeal seeking entitlement to increased initial ratings for the right and left ankle disability as assigned in the November 2012 rating decision. The Board's decision above grants entitlement to 10 percent ratings throughout the appeal period. Accordingly, earlier effective dates for the 10 percent ratings from the Veteran's discharge from service have been assigned. There is no legal authority to assign an earlier effective date. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). As no case or controversy remains, these matters are dismissed. 38 U.S.C. § 7105 (d)(5). REASONS FOR REMAND The Board's review of the record reveals that additional development on the remaining claims on appeal is warranted, even though such will, regrettably, further delay an appellate decision. 1. Entitlement to service connection for pes cavus The Veteran's service treatment records indicate that she was diagnosed as having suspected pes cavus following radiology of the bilateral feet in October 2010. Pes cavus was subsequently listed among the problems list in service treatment records dated from February 2011 to October 2011. She filed a claim for service connection prior to her discharge, and was afforded a VA examination. However, the November 2011 VA examiner found no evidence to render a diagnosis of pes cavus. In light of the Court's joint motion for partial remand in September 2019, the Board remanded the claim in 2020 for examination to determine whether the Veteran still had a disability for compensation purposes on the basis of functional impairment. See Saunders v. Wilkie, 886 F.3d 1356 (2018). On VA examination in September 2020, the examiner diagnosed acquired pes cavus. The examiner opined that the disability was less likely than not related to service. In the December 2020 remand, the Board noted that this opinion was inadequate as the examiner failed to acknowledge the Veteran's competent lay statements of recurring and worsening bilateral foot pain since 2008, as well as the fact that the Veteran has diligently pursued her claim since discharge from service in 2012. In addition, the examiner failed to consider the continued reports noting pes cavus in service in 2011. Accordingly, the Board remanded this issue to obtain additional examination and opinion as to the nature and etiology of the claimed pes cavus. On February 2021 VA examination, the examiner indicated that the feet were normal. The examiner provided a negative nexus opinion, noting that objective exam was normal and that he was unable to document "flat feet" clinically. In the "remarks" section on the foot examination the examiner noted "suggest podiatric examination and evaluation. I could not find imaging of [the Veteran's] feet and cannot make diagnosis without these. The feet appear normal with some tenderness. The discrepancy was noted but I do not believe that a diagnosis of flat feet clinically is warranted." The 2021 examiner did not consider and address the prior diagnoses of pes cavus, and appears to have believed that the exam was for flat feet, or pes planus, instead of pes cavus. The examiner further did not provide an opinion as to etiology given the lack of diagnosis. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given the foregoing, the Board finds that remand is warranted to afford the Veteran an additional examination with medical opinion based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly-stated rationale. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Barr, 21 Vet. App. at 312. 2. Entitlement to service connection for costochondritis Similarly, costochondritis (Tietze syndrome) was noted in service treatment records in May 2009 and indicated in the chronic problems list in service from 2010 to 2011. She filed a claim for costochondritis prior to her discharge from service, and although a November 2011 VA examiner noted subjective symptoms of constant chest pain, there was no pathology to render a diagnosis of costochondritis. The Board also remanded the claim in light of the Court's joint motion for partial remand indicating that consideration of whether disability was present pursuant to Saunders was warranted. On VA examination in 2020, the examiner diagnosed costochondritis and provided an opinion against the claim, noting that the Veteran was only seen once in service and there was no objective evidence of chronicity of care. The Board again found this examination inadequate in the December 2020 remand, as the examiner failed to consider the Veteran's competent lay statements as well as service treatment records documenting costochondritis in 2009 and continued documentation of costochondritis in service treatment records problems lists in 2010 and 2011. The Veteran was afforded another VA muscles examination in February 2021, at which time the Veteran reported an onset of injury related to the wrists but did not discuss chest pain. The examiner indicated that there was "no diagnosis of tendonitis." The examiner indicated that costochondritis was "not part of this report." It does not appear that the 2021 examiner performed an examination as to the claimed costochondritis, and mistakenly took a history from the Veteran related to the wrist. The examiner further did not provide an opinion as to etiology given the lack of diagnosis. Given the foregoing, the Board finds that remand is warranted to afford the Veteran an additional examination with medical opinion based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly-stated rationale. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; Barr, 21 Vet. App. at 312. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed pes cavus. Any indicated tests should be accomplished. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history. The examiner should address whether it is at least at likely as not that the Veteran's pes cavus, or any other bilateral foot disorder(s) had its onset in service or within one year of discharge, or is otherwise related to service. The examiner should note that the Veteran has already been diagnosed with pes cavus during the pendency of the claim, as indicated on the examination September 2020, and opinion is required regardless of whether pes cavus is diagnosed on examination. In so opining, the examiner must address the October 2010 in-service diagnosis of "suspected pes cavus" as well as subsequent service treatment records which categorize pes cavus as a chronic problem. The examiner is also advised that the Veteran is competent to report symptoms and treatment and that her reports, including her reports as to the onset, progression, and nature of her symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinions. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed costochondritis. Any indicated tests should be accomplished. The examiner should review the record prior to examination, and elicit from the Veteran a detailed medical history. The examiner should address whether it is at least at likely as not that the Veteran's costochondritis had its onset in service or within one year of discharge, or is otherwise related to service. The examiner should note that the Veteran has already been diagnosed with costochondritis during the pendency of the claim, as indicated on the examination September 2020, and opinion is required regardless of whether costochondritis is diagnosed on examination. In so opining, the examiner must address the May 2009 in-service diagnosis of "costochondritis (Tietze syndrome)" as well as subsequent service treatment records which categorize costochondritis as a chronic problem. The examiner is also advised that the Veteran is competent to report symptoms and treatment and that her reports, including her reports as to the onset, progression, and nature of her symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinions. (Continued on the next page) The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. JEREMY J. OLSEN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. E. Wilkerson, 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.