Citation Nr: 21011485 Decision Date: 03/02/21 Archive Date: 03/01/21 DOCKET NO. 10-05 591 DATE: March 2, 2021 ORDER Entitlement to a disability rating in excess of 10 percent for service-connected left inferior pubic ramus stress fracture with hip strain (a left pelvic disability) is denied. Entitlement to a disability rating in excess of 10 percent for service-connected right hallux rigidus with degenerative arthritis (a right foot disability) is denied. Entitlement to a disability rating in excess of 10 percent for service-connected right tibia/knee stress reaction with patella femoral syndrome (a right knee disability) is denied. FINDINGS OF FACT 1. The Veteran’s service-connected left pelvic disability is manifested by pain and slight limitation of motion; hip flail joint, fracture of the femur, and ankylosis are not shown. 2. The Veteran’s service-connected right foot disability is manifested by subjective complaints of pain, with impairment consistent with no more than moderate symptoms. 3. The Veteran’s service-connected right knee disability has been manifested by subjective complaints of pain and limitation of motion. Flexion has not been limited to 30 degrees, nor has the disability resulted in limitation of extension, malunion or nonunion of the tibia and fibula, shin splints requiring treatment, dislocation or removal of semilunar cartilage, recurrent subluxation, or instability. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for a service-connected left pelvic disability have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5250 to 5255. 2. The criteria for a disability rating in excess of 10 percent for a service-connected right foot disability have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5010-5284. 3. The criteria for a disability rating in excess of 10 percent for a service-connected right knee disability have not been satisfied. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5257, 5260, 5261, 5262. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2001 to June 2002, with additional time served in the Army National Guard. These matters are before the Board of Veterans’ Appeals (Board) from a November 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). By way of history, the Veteran was awarded service connection for her left pelvic, right foot, and right knee disabilities in May 2004. The Veteran filed a claim for increased ratings for these disabilities in June 2008, and they were denied by the RO in the rating decision presently on appeal. The appeal then came before the Board in February 2012, May 2014, April 2015, December 2016, and September 2017, where they were remanded to the agency of original jurisdiction (AOJ) for additional development. They returned to the Board in November 2018 where the claims were denied. Thereafter, the Veteran appealed the Board’s denials to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a July 2019 Joint Motion for Remand (JMR) filed by the parties, the Court vacated the Board’s decision and remanded it back for further adjudication. It was noted that the Board remanded the claims to the AOJ in December 2016 to obtain new VA examinations. Although the VA examination was afforded in January 2017, which led to the denial of the Veteran’s appeal by the Board in November 2018, the JMR found it did not comply with the Board’s previous remand directives in December 2016 or the Court’s holding in Correia v. McDonald, 28 Vet. App. 158, 169-70 (2016). As such, the Board again remanded the appeal to the AOJ in December 2019 to obtain a new VA examination. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter then returned to the Board in May 2020, where it was again remanded. Notably, the Board’s December 2019 remand required new physical examinations of the Veteran by an orthopedist. However, only an opinion was provided in February 2020, not a full physical examination, as an orthopedist was unavailable. Review of the record since the Board’s previous remand reveals that complete VA examinations were afforded for the Veteran’s claims in August 2020. They were not, however, completed by an orthopedist. The Board notes that it initially requested an orthopedist in December 2019 to ensure compliance with the Court’s July 2019 JMR and its holding in Correia, specifically, examinations to test for pain with range of motion actively, passively, in weight-bearing, in non-weight-bearing, and after repetitive use. After physical examination, opinions were also to be obtained as to whether there was additional range of motion loss during flare-ups and/or as a result of pain, weakness, fatigability, or incoordination. While not an orthopedist, the physician who conducted the August 2020 examination was able to answer these questions by either providing estimates or stating that there would be no significant effects on functioning in the above instances. As such, despite not being conducted by an orthopedist, the Board finds there has been substantial compliance with its previous remand directives and remand for an examination by an orthopedist is not necessary. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board also acknowledges additional argument received from the Veteran, on September 9, 2020, and again on January 27, 2021, since its previous denial in November 2018 and the Court’s July 2019 Order. Of note, the record contains diagnostic reports from a private radiologist pertaining to her claims. Page one of these reports, however, relates to a different patient, and the Veteran states this page should instead contain an X-ray report related to her left foot. As such, she asserts that her most recent Privacy Act request is unfulfilled. The Board disagrees, however, as the Privacy Act request was for the entire claims file in the possession of VA, which has been provided. To the extent she asserts that the apparent missing left foot X-ray amounts to a failure in VA’s duty to obtain missing records, any private radiology report relating to the Veteran’s left foot is irrelevant to any claim on appeal. Although she has argued in her previous correspondence in September 2020 that her service-connected right foot has now affected her left foot, there is currently no claim for benefits related to a left foot disability before the Board. Thus, the Board finds that remand for this missing record is unnecessary. If the Veteran wishes to file a claim for service connection for a left foot disability, she can do so on the appropriate form prescribed by the VA Secretary, at which time she can identify medical treatment records relevant to that claim. Finally, in September 2011 the Veteran testified at a videoconference hearing with a Veterans Law Judge (VLJ) who is no longer at the Board. The Veteran was offered another hearing, and in September 2014 the Veteran testified at a videoconference hearing before the undersigned VLJ. Transcripts of both hearings are of record. Neither the Veteran nor her representative has raised any other issues with the duty to notify or duty to assist. Increased Ratings Disability ratings are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). 1. A left pelvic disability. The Veteran contends that severity of her left pelvic disability has warranted a higher disability rating during the entirety of the period on appeal. Based on the following, the Board concludes that the Veteran’s disability picture, to include her statements, does not more nearly approximate the degree required for a higher or separate rating. The Veteran’s left pelvic disability is rated as a disability of the hip and thigh and has been assigned a 10 percent rating by analogy under Diagnostic Code 5299-5255 for malunion of the femur. 38 C.F.R. § 4.71a. Additionally, a recent rating decision by the RO awarded separate, noncompensable (zero percent) ratings for limitation of flexion and limitation of internal rotation of the left thigh effective August 4, 2020. Limitation of flexion and internal rotation of the thigh are rated under Diagnostic Codes 5252 and 5253, respectively. Id. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including Diagnostic Code 5255, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic code only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended versions and rate based on whichever is most favorable to the Veteran. Prior to the regulatory change, under Diagnostic Code 5255, a 10 percent rating is warranted where there is malunion of the femur with slight knee or hip disability. A 20 percent rating is warranted where there is malunion with moderate knee or hip disability. A 30 percent rating is warranted where malunion produces marked knee or hip disability. Higher ratings are assignable under Diagnostic Code 5255 when there is fracture of the surgical neck with false joint, or for fracture of the shaft or anatomical neck of the femur with nonunion. 38 C.F.R. § 4.71a, Diagnostic Code 5255 (2020). As of February 7, 2021, Diagnostic Code 5255, instead of assigning ratings, provides that malunion of the femur is to be evaluated under Diagnostic Codes 5256, 5257, 5260, or 5261 for the knee, or 5250-5254 for the hip, whichever results in the highest evaluation. The ratings for fracture of the surgical neck with false joint, or for fracture of the shaft or anatomical neck of the femur with nonunion, were unaffected by the regulatory change. 38 C.F.R. § 4.71a, Diagnostic Code 5255. Diagnostic Code 5250 provides ratings for ankylosis of the hip. Diagnostic Codes 5251 and 5252 provide ratings for limitation of extension and flexion of the thigh, respectively, with Diagnostic Code 5253 providing ratings for limitation of abduction and rotation of the thigh. Diagnostic Code 5254 provides only an 80 percent rating for hip flail joint. 38 C.F.R. § 4.71a. These Diagnostic Codes were unaffected by the February 7, 2021 regulatory changes. Normal range of motion of the hip are from hip flexion from 0 to 125 degrees and hip abduction from 0 to 45 degrees. 38 C.F.R. § 4.71, Plate II. As an initial matter, the Board acknowledges the Veteran’s contention at one point during the appeal that her left pelvic disability is improperly rated by analogy to an impairment of the femur under Diagnostic Code 5255. When a particular service-connected disability is not listed in the rating schedule, it may be rated by analogy to a closely-related disability in which not only the functions affected, but also the anatomical location and symptomatology, are closely analogous. 38 C.F.R. § 4.20. The assignment of a particular Diagnostic Code is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factor as an individual’s relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the Board has considered whether another code is “more appropriate” than the one used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The Board has identified no more appropriate diagnostic code, and neither has the Veteran. The anatomical location fits the medical evidence. Moreover, there is no medical evidence of muscle or nerve involvement, which would possibly warrant the assignment of different diagnostic codes. Turing to the evidence, the Veteran was first afforded a VA examination for her increased rating claim in September 2008. However, as the Veteran asserted in a contemporaneous statement, no examination of her pelvic disability was performed other than noting the Veteran’s report of pain on palpation over the superior and inferior ramus. Subsequently, the Veteran’s increased rating claim was denied, resulting in the present appeal. At a Board hearing in September 2011, she described pain at the left pubis exacerbated by prolonged sitting, standing, and walking. Pursuant to the Board’s first remand in February 2012, an additional VA examination was afforded in February 2013 where she described flare-ups of lateral hip tightening associated with back pain and prolonged sitting. Physical examination confirmed pain to palpation, however, the examination report notes the Veteran as having no functional loss and/or functional impairment of the hip and thigh, with normal range of motion, no evidence of painful motion, or decrease in function after repetitive-use testing. Muscle strength testing was normal, and no other condition was diagnosed including degenerative or traumatic arthritis. The matter was returned to the Board in May 2014, where it was again remanded to afford the Veteran an additional hearing. At her hearing before the undersigned in September 2014, the Veteran reported pelvic pain from sitting, prolonged standing, walking, and climbing stairs. She also described numbness and tingling down her legs that she noted may have been due to either her pelvic disability or her service-connected low back disability. Based in part on her testimony, the Board remanded the Veteran’s claim again in April 2015 and in December 2016 for additional VA examinations, which were afforded in August 2015 and January 2017, with the latter performed by an orthopedic specialist. Both examination reports were consistent in their findings, with the Veteran continuing to report dull pelvic pain when seated, with flare-ups of pain in her pelvic area when seated that radiated anteriorly and aggravated her interstitial cystitis. Physical examination on both occasions noted normal flexion, extension, abduction, and rotation, including after repetitive-use testing. There was also no evidence of pain with weight bearing, pain on palpation, or crepitus. The Board notes that only the August 2015 examination was conducted immediately after repetitive use over time, with neither conducted during a flare-up. The examiners noted, however, that the findings in either examination were neither medically consistent or inconsistent with the Veteran’s statements describing functional loss after repetitive use or during a flare-up. Finally, muscle strength testing was normal and there was no ankylosis. Both examiners opined that the Veteran’s disability did not impact her ability to perform any type of occupational task. The Board does acknowledge, however, the Veteran’s consistent reports of pain when seated. As noted previously, the Board denied the Veteran’s claim in November 2018, and she appealed the denials to the Court. The JMR found the January 2017 VA examination did not comply with the Board’s December 2016 remand directives or the Court’s holding in Correia. Specifically, the January 2017 examiner was instructed to test range of motion actively, passively, in weight-bearing, and in non-weight-bearing, and after repetitive use. Further, the Board instructed the examiner to opine whether there was additional range of motion loss in the left hip due to flare-ups and/or as a result of pain, weakness, fatigability, or incoordination. If so, the examiner was asked to describe the additional loss in degrees, if possible. As such, the Board again remanded the appeal in December 2019 to obtain a new VA examination. However, in February 2020, only an opinion was provided that there was no additional range of motion loss in the left hip during flare-ups and/or as a result of repetitive movement during the previous examination in January 2017. As a full physical examination was not afforded in February 2020, a complete VA hip and thigh examination was afforded in August 2020 after the Board’s most recent remand. The Veteran reported to the examiner that the pain associated with her left pelvic fracture increases when sitting for long periods, including during her regular occupation. The Board notes that, in addition to her previous diagnosis of left inferior pubic ramus stress fracture residuals, a hip strain was also diagnosed in August 2020 that the examiner opined was a progression of her service-connected disability. Physical examination revealed ROM reduced by 5 degrees during flexion and internal rotation, to 120 and 35 degrees, respectively. No additional functional loss was observed after observed repetitive use after three repetitions. Estimated range of motion after repetitive use over time was unchanged from those observed during ROM testing. No additional estimation of loss of motion was necessary as the Veteran reported flare-ups of pain when seated for long periods, rather than flare-ups of reduced motion. Finally, muscle strength was again normal and there was no ankylosis or any other pertinent physical findings, complications, conditions, signs or symptoms associated with her left pelvic disability. The remainder of the evidence is essentially consistent with the above examination findings, with medical treatment records during the period on appeal noting the Veteran engaging in pelvic strengthening therapy from April to May 2014 to improve weakness in her core due her past pelvic fractures. A physical examination at the time revealed normal hip flexion, extension, and abduction. Internal and external pelvic floor examinations were also normal, as well as hip strength testing. While a mild deviation of symmetry was noted in her pelvis, it was attributed to her service-connected back disability. While additional private orthopedic records dated in 2017 show the Veteran treated for continued left leg pain, review of these records reveals that her leg pain was again related to her back condition. There is, however, a leg length discrepancy noted on the left side in September 2017, which the Veteran also noted in her September 2020 and January 2021 statements in support of her claim. No VA examinations related to her pelvic disability, however, indicate any leg length discrepancy, and review of these orthopedic records suggest that any leg length discrepancy was due, in part, to her back disability. This leg length discrepancy also appears to have been temporary, as the Veteran was performing lumbar and hip stretching with good progress, and no other medical records prior to or since 2017, to include her most recent VA examinations, indicates any leg length discrepancy associated with her left pelvic disability to any compensable level. See. 38 C.F.R. § 4.71a, Diagnostic Code 5275. To the extent the Veteran argues that any leg length discrepancy was caused or aggravated by her left pelvic disability on a secondary basis, she has not filed such a claim. Based on the foregoing, the Board finds that the residuals of the Veteran’s stress fracture of the left inferior pubic ramus do not warrant a higher rating under Diagnostic Code 5255 during the period on appeal. While the Veteran’s disability is currently rated as 10 percent disabling under the version of Diagnostic Code 5255 prior to the February 7, 2021 regulatory changes, treatment records and examinations are silent with respect to femur malunion, of the surgical neck with false joint, or fracture of the shaft or anatomical neck with nonunion. Detection or mention of these particular conditions would be expected if they existed. The Veteran’s pain is indicative of no more than slight hip disability. Thus, a higher rating continues to be unwarranted for impairment of the femur. 38 C.F.R. § 4.71a, Diagnostic Code 5255 (2020). The Board again notes that the RO awarded noncompensable ratings under Diagnostic Codes 5252 and 5253 effective the date of the August 2020 VA examination that showed slightly reduced ROM in flexion and internal rotation. Absent flexion limited to 45 degrees, or any further limitation of rotation, abduction, or adduction of the thigh, higher ratings are not warranted from that date under these Diagnostic Codes. Limitation of extension was also not shown during the August 2020 examination to warrant any rating under Diagnostic Code 5251. 38 C.F.R. § 4.71a. Physical examinations during the period on appeal prior to the RO’s award of separate noncompensable ratings effective August 2020 have not shown any loss of range of motion to warrant ratings under Diagnostic Codes 5251, 5252, or 5253. The Board acknowledges that flexion and internal rotation were shown to be “mildly limited” in the same September 2017 medical treatment record where a leg length discrepancy was suggested, there is no suggestion that flexion and rotation were reduced to any compensable degree under Diagnostic Codes 5252 and 5253. Id. During the examinations the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed, to include testing for pain and testing to reveal any additional functional limitations in certain circumstances, such as after repetitive use. No report suggests that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran’s lay statements. While the Veteran has essentially stated that she has pain with difficulty sitting due to her pelvic injury, she has not described any loss of range of motion which would warrant a higher rating, and no treatment record shows greater limitation of motion than the examination findings. Range of motion estimate after repetitive use over time has been obtained and the most recent examiner indicated flare-ups would not result in additional functional limitation. Simply put, the evidence in no way suggests the requisite limitation of motion required for higher or separate ratings, to include during flare-up or after repetitive use over time. The Veteran has pain with slight limitation of motion at worse. The Board has considered whether a separate or higher rating is warranted under any other diagnostic code pertaining to disabilities of the hip and thigh, but has found none. As the evidence does not reflect ankylosis or a hip flail joint, Diagnostic Codes 5250 and 5254 are also not warranted. 38 C.F.R. § 4.71a. Finally, the Board again acknowledges that the February 7, 2021 regulatory changes provide that malunion of femur under Diagnostic Code 5255 should be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or, 5250-5254 for the hip (which it has done above) whichever results in the highest evaluation. The Board does not find, however, that consideration of the Diagnostic Codes pertaining to the knee is appropriate here, as the evidence indicates that the pain associated with her left pelvic disability is localized to the hip area. The Veteran has not asserted, nor does the evidence suggest, impairment of the femur anywhere near the knee or any left knee disability that may be associated with her service-connected left pelvic disability. In sum, as the evidence is against a finding that the severity of the Veteran’s left pelvic disability warrants a rating higher than that currently assigned, the claim for an increased rating must be denied. 38 C.F.R. §§ 4.3, 4.7. 2. A right foot disability. The Veteran contends that severity of her right foot disability has warranted a higher disability rating during the entirety of the period on appeal. Based on the following, the Board concludes that the Veteran’s disability picture, to include the Veteran’s statements, does not more nearly approximate the degree required for a higher or separate rating. The Veteran’s right foot disability is assigned a 10 percent disability rating by analogy pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5299-5284. Diagnostic Code 5284 addresses other foot injuries and provides for a 10 percent disability rating for moderate injuries, a 20 percent rating for moderately severe injury, and a 30 percent rating for severe injury. 38 C.F.R. § 4.71a. Turning to the evidence, in a June 2008 statement submitted in support of her increased rating claim, the Veteran described a dull, throbbing pain in her feet, more on her right side, and especially on the top and metatarsals. She also reported swelling, pain with physical activity, and the use of arch supports. The Veteran was first afforded a VA examination in September 2008. Physical examination of the right foot revealed mild discomfort on palpation over the lateral foot and mild aching of the right calcaneus, with a normal longitudinal arch and no pain over the plantar fascia. The Veteran had full range of motion in all metatarsal joints as well as the right ankle. The examiner noted that diagnostic testing did not indicate any new fractures or bone destruction. At her Board hearing in September 2011, she described pain upon standing and walking, as well as swelling, aching, and tingling. At an additional VA examination afforded in April 2012, physical examination and diagnostic testing of the Veteran’s right foot revealed no other foot diagnosis other than pain, including degenerative arthritis, and her stress fractures were noted as long-healed. Her feet were both noted to be tender in the dorsum, with no warmth, redness, bruising, swelling, or deformity, and her gait was observed to be normal. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms associated with her in-service right foot stress fracture. The matter was returned to the Board in May 2014, where it was again remanded to afford the Veteran an additional hearing. At the additional hearing in September 2014, the Veteran reported foot pain, stiffness, use of orthotics, and that she was restricted in her choice of footwear. Based in part on the Veteran’s testimony, the Board remanded the Veteran’s claim again in April 2015 to afford her an additional VA examination by an orthopedic specialist. Upon VA examination in August 2015, the Veteran reported continued right foot pain on the top of her right foot, and the examiner noted no additional foot disability other than her reported pain. However, while the examiner noted right foot pain that did not contribute to functional loss, no explanation was given as to why the pain did not contribute to functional loss or cause additional limitations. Moreover, despite the Veteran’s assertions, the examiner opined that her right foot pain did not impact her ability to perform any occupational task (such as standing, walking, etc.). Additionally, the examination was conducted by an internist, rather than an orthopedic specialist. Thus, an additional examination was provided in January 2017 by a confirmed orthopedic specialist. The January 2017 examiner noted the Veteran’s previously diagnosed right foot fracture and reported pain. It was also noted that the Veteran did not report having any functional loss or functional impairment of the right foot, nor did flare-ups impact the function of the foot. Physical examination noted no other right foot disability other than the pain from her stress fracture, which the examiner opined was mild in severity. The right foot disability did not chronically compromise weight bearing or contribute to functional loss or additional limitations. As with the August 2015 examiner, it was opined that her right foot pain did not impact her ability to perform any occupational task. The Board notes that the examination report indicates that the Veteran did not use an assistive device for her foot disability, such as arch supports or custom orthotic inserts. The Board does acknowledge the Veteran’s assertions in various statements to the contrary, however. Indeed, in a private medical evaluation for right foot pain also in January 2017, an additional diagnosis of hallux rigidus (a disorder of the first metatarsophalangeal (MTP) joint) with hypermobility syndrome was indicated, and orthotics for additional arch support were provided. As noted previously, the Board denied the Veteran’s claim in November 2018, and she appealed the denials to the Court. As with her left pelvic claim, the JMR found the January 2017 VA examination did not comply with the Board’s December 2016 remand directives or the Court’s holding in Correia. As such, the Board again remanded the appeal in December 2019 to obtain a new VA examination. However, in February 2020, only an opinion was provided that there was no additional range of motion loss in the right foot due to flare-ups and/or as a result of repetitive movement during the previous examination in January 2017. As a full physical examination was not afforded in February 2020, a complete VA foot examination was afforded in August 2020 after the Board’s most recent remand. Upon examination, both the Veteran’s previous finding of hallux rigidus was documented as well as mild osteoarthritis in the first MTP joint. The examiner opined that the arthritis was the result of the trauma to her right foot, progressing to the hallux rigidus of the same MTP joint. Diagnostic testing revealed no other abnormalities. Physical examination revealed pain on weight bearing on the right foot. Although the examination notes no flare-ups that impact functioning of the foot, the Veteran did describe that prolonged standing and waking results in a dull, throbbing pain that is difficult to alleviate. There were no other symptoms attributed to her right foot disability, and the examiner determined that the severity of her hallux rigidus was mild or moderate. The remainder of the evidence is essentially consistent with the above examination findings, with VA treatment records during the period on appeal noting right foot pain and stiffness. Based on the foregoing, the Board finds that a higher rating during the period on appeal for the Veteran’s right foot disability continues to be unwarranted. The Veteran’s right foot disability has been manifested primarily by pain, and was not noted to be more than moderate at any point during the period on appeal to warrant a higher, 20 percent rating under Diagnostic Code 5284. 38 C.F.R. § 4.71a. Even with consideration of pain with prolonged standing and walking, the Veteran’s right foot disability has not more nearly approximated moderately-severe foot injury. In fact, the medical assessment by the VA specialist in January 2017 was that the right foot disability was of only mild severity. Her more recent VA examination found her right foot disability to be no more than moderate in severity. Both examiners considered the Veteran’s reports of symptoms, the examination findings, and the assessments of impairment and functional loss when making this assessment. No other medical record suggested that the pain and the other symptoms reported by the Veteran results in additional limitation of function to a degree which more nearly approximates moderately-severe disability. The Board also acknowledges the Veteran’s continued use of orthotics, which is not specifically noted in Diagnostic Code 5284. However, the symptoms corrected or alleviated by the use of such have been addressed, and the Veteran’s medical treatment records and VA examinations describe the level of her disability when she is not using such an appliance and those symptoms are contemplated under the rating criteria. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) (holding that the Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria). The Board has also considered whether a higher disability rating is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See also DeLuca, 8 Vet. App. 202. The evidence shows that, for the entire appeal period, the service-connected right foot disability has been manifested by pain and ambulatory pain, and these symptoms and functional loss are contemplated in her 10 percent rating for moderate foot injury. Finally, there is no indication that the disability is more appropriately rated under a separate Diagnostic Code. The Board acknowledges the Veteran’s argument in September 2020 that her right foot disabilities should be rated separately. However, while hallux rigidus was diagnosed in 2017, the rating criteria does not offer a compensable evaluation for hallux rigidus unless the disability is severe and equivalent to amputation of the great toe, which is not the case here. 38 C.F.R. § 4.71a, Diagnostic Codes 5280, 5281. If the Board were to rate the foot disability under Diagnostic Code 5003 for arthritis the disability would be rated at 10 percent and the rating under Diagnostic Code 5284 would have to be discontinued as rating under either code would require consideration of the foot pain. Rating the foot pain twice would result in impermissible pyramiding. 38 C.F.R. § 4.14. Thus, there is no appropriate diagnostic code which would allow for a higher rating nor is there a combination of diagnostic codes which could be used to award separate compensable ratings in this case. Thus, as the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for a right foot disability, the claim must be denied. 38 C.F.R. §§ 4.3, 4.7. 3. A right knee disability. The Veteran contends that the severity of her right knee disability has warranted a higher disability rating during the entirety of the period on appeal. Based on the following, the Board concludes that the Veteran’s disability picture, to include the Veteran’s statements, does not more nearly approximate the degree required for a higher or separate rating. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), instability and recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Ratings can also be assigned for knee instability or subluxation under Diagnostic Code 5257. 38 C.F.R. § 4.71a. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including Diagnostic Code 5257, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic code only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to the regulatory change, recurrent subluxation and lateral instability of the knee warranted a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). “Slight,” as relevant to a physical condition, is defined as “small of its kind or in amount.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed February 11, 2021). It is similar to “mild,” which is defined as “not severe” or temperate; with “Temperate” being defined as “keeping or held within limits” and “not extreme or excessive.” “Moderate” is defined as “tending toward the mean or average amount,” “not violent, severe, or intense,” and “limited in scope or effect.” Id. “Severe” is defined as “very painful or harmful” or “of a great degree.” Id. Within the context of the old version of Diagnostic Code 5257, which established a successive, tiered rating structure, “severe” represented the highest or most extreme level of disability. As of February 7, 2021, Diagnostic Code 5257 contains two sections for rating other impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The first is for recurrent subluxation or instability. The second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. Id.; see also 38 C.F.R. § 4.31. “Persistent” is defined as “continuing or inclined to persist in a course” with “continuing” defined as “constant” and “persist” defined as “to continue to exist.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed February 11, 2021). Under these criteria, a 30 percent rating is assigned with unrepaired or failed repair of complete ligament tear which causes persistent instability and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned with either (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 10 percent rating is assigned for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability without a prescription from a medical provider for an assistive device or bracing for ambulation. Regarding patellar instability, a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker warrants a 30 percent rating, which is the highest allowable rating for patellar instability. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker warrants a 20 percent rating. A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent rating. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1). A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id., Note (2). Ratings can also be assigned when a knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. As an initial matter, the evidence does not reflect, and the Veteran does not allege, that she has any meniscal disability in her right knee. As such, those diagnostic codes are not for application Finally, ratings can be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 93 (30th ed. 2003). In this case the evidence does not reflect, and the Veteran does not allege, that she has genu recurvatum or ankylosis of the knee. As such, those diagnostic codes are also not for application. Here, however, the Veteran’s disability has been rated as a tibia/fibular impairment under Diagnostic Code 5262. As with Diagnostic Code 5257 for instability, the rating criteria for evaluating a tibia/fibular impairment under Diagnostic Code 5262 were amended during the pendency of the appeal effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to the regulatory change, malunion of the tibia and fibula with slight knee or ankle disability warrants a 10 percent rating; malunion of the tibia and fibula with moderate knee or ankle disability warrants a 20 percent rating; malunion of the tibia and fibula with marked knee or ankle disability warrants a 30 percent rating; and nonunion of the tibia and fibula with loose motion and requiring a brace warrants a 40 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2020). Effective February 7, 2021, nonunion of the tibia and fibula, with loose motion and requiring a brace, warrants a 40 percent rating. Malunion of the tibia and fibula is to be evaluated under Diagnostic Codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Diagnostic Code 5262 also provides ratings for medial tibial stress syndrome (MTSS) as of February 7, 2021, also known as “shin splints.” MTSS with treatment less than 12 consecutive months, on or both lower extremities, warrants a noncompensable (zero percent) rating. MTSS requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities, warrants a 10 percent rating. MTSS requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity, warrants a 20 percent rating. MTSS requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities, warrants a maximum 30 percent rating. Id. Turning to the evidence, the Veteran asserted in a June 2008 statement in support of her increased rating claim that she experienced pain, weakness, stiffness, swelling, heat, redness, drainage, instability, locking, abnormal motion, and numbness/tingling. She also asserted deformity and malunion of her knee. In September 2008, a private orthopedic specialist, Dr. C.W., submitted a summary of an August 2008 knee evaluation. Doctor C.W. diagnosed bilateral patellofemoral knee pain, with reduced flexion and extension in the right knee only, and any radiographic abnormalities were only on the left. The Veteran was first afforded a VA examination for her right knee increased rating claim in September 2008, where she reported pain in both knees, but more so in the right. Physical examination of the right knee revealed normal configuration and no effusion. There was mild discomfort on palpation around the right kneecap. The Veteran had full range of motion, including after repetitive-use testing, although increased pain, fatiguability, and lack of endurance were observed after repetitive use. The examiner noted good stability of all ligaments, and McMurray and Lachman tests were negative. The final diagnosis was patellofemoral syndrome with chronic pain. At a Board hearing in September 2011, the Veteran described knee pain when kneeling, squatting, and standing, often with “popping” and “cracking,” and that running, walking long distances, and climbing stairs aggravated her knee pain. The Veteran also noted instability and locking, and that she purchased an over-the-counter knee brace for days when her pain was elevated. Pursuant to the Board’s first remand in February 2012, an additional VA examination was afforded in April 2012. She reported pain with bending, squatting, and kneeling, as well as an inability to walk, sit, or stand long periods of time and a complete inability to run. Physical examination of the Veteran’s knees revealed bilateral subpatellar tenderness and palpable grinding indicative of chondromalacia patella. No other knee disorder was diagnosed, and diagnostic testing revealed no significant findings. Range of motion testing indicated right knee flexion to 130 degrees and normal extension. There was no objective evidence of painful motion or hyperextension. Repetitive use testing resulted in right knee flexion further reduced to 100 degrees, as well as additional pain and interference with sitting, standing, and weight bearing, bilaterally. Strength and joint stability testing were normal and there was no evidence or history of recurrent patellar subluxation/dislocation. Other than a history of shin splints on the right side, no other tibia/fibular impairment was noted nor was any meniscal condition. The matter was returned to the Board in May 2014, where it was again remanded to afford the Veteran an additional hearing, which was held via videoconference before the undersigned in November 2014. The Veteran reported knee pain and stiffness with “popping” and “clicking,” and that pain was aggravated when standing up, climbing stairs, and squatting. Based in part on the Veteran’s above testimony, the Board remanded the Veteran’s claim again in April 2015 to afford her an additional VA examination by an orthopedic specialist. Upon VA examination in August 2015, with an addendum the following February, the Veteran reported continued right knee pain that inhibited squatting, sitting, running, walking on an incline, and climbing stairs. She reported flare-ups of knee pain with the above activities as well as functional loss; however, range of motion testing revealed normal flexion and extension, including during repetitive use. Strength and stability testing were also normal. However, as the Board would later note in December 2016, no diagnosis was provided by the examiner, nor was it clear whether there was testing on active and passive range of motion or with weight-bearing and nonweight-bearing. Additionally, the examination was conducted by an internist, rather than an orthopedic specialist. Thus, an additional VA examination was provided in January 2017 by a confirmed orthopedic specialist. In January 2017, the specialist noted the Veteran’s previously diagnosed right tibia stress fracture and her reported pain. The examiner diagnosed no other disability other than shin splints, and noted that assistive devices were not used for the knee as a normal mode of locomotion. Flare-ups were not reported. It was also noted that the Veteran did not report having any functional loss or functional impairment of the right knee, however range of motion testing revealed a decrease in flexion to 130 degrees with pain noted. Extension was normal. Repetitive use-testing revealed no additional functional loss, and there was no evidence of pain on weight bearing, localized tenderness or pain on palpation of the joint or associated soft tissue, or crepitus. While the Veteran was not being examined immediately after repetitive use over time, the examiner opined that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing her functional loss with repetitive use over time. Additionally, muscle strength was not decreased and there was no instability. The examiner opined that her disability did not impact her ability to perform any occupational task. As noted previously, the Board denied the Veteran’s claim in November 2018, and she appealed the denial to the Court. The JMR found the January 2017 VA examination did not comply with the Board’s December 2016 remand directives or the Court’s holding in Correia. As such, the Board again remanded the appeal in December 2019 to obtain a new VA examination. However, in February 2020, only an opinion was provided that there was no additional range of motion loss in the knees during flare-ups and/or as a result of repetitive movement during the previous examination in January 2017. As a full physical examination was not afforded in February 2020, a complete VA knee examination was afforded in August 2020 after the Board’s most recent remand. The Veteran reported to the examiner that her knee pain manifests when standing, walking, and climbing stairs. While the examination report indicates that the Veteran denied flare-ups, the Board acknowledges her reports throughout the appeal of increased pain, fatigue, weakness, lack of endurance, “popping,” and “cracking” sounds with prolonged use. Physical examination of the right knee revealed flexion to 115 degrees and normal extension, to include after repetitive use testing. Testing after repetitive use over time revealed right knee flexion to 140 degrees and normal extension. The examiner indicated that pain, weakness, fatigability and incoordination would not significantly limit functional ability during flare-ups. On examination, muscle strength was not decreased and there was no instability. The examiner opined that the disability did impact the Veteran’s ability to perform any occupational task, noting an impact on standing, walking, and climbing stairs. The remainder of the evidence is essentially consistent with the above examination findings, with the Veteran reporting in various lay statements that right knee pain and stiffness contributes to difficulty with sitting, standing, running, walking long distances, climbing, and squatting. The Board notes that medical treatment records during the period on appeal contain sparse evidence of knee treatment outside of the above evaluations. The Veteran has specifically stated a lack of desire in any medical treatment provided by VA, and she has provided no additional private records pertaining specifically to her right knee since those dated in 2017. Based on the foregoing, the Board finds that the Veteran’s right knee disability does not warrant a higher rating during the period on appeal. Again, the Veteran’s service-connected stress reaction of the right tibia and knee is currently rated under Diagnostic Code 5262 for impairment of the tibia and fibula. Although shin splints were noted upon examination, the evidence is negative for any finding that the Veteran’s disability manifests malunion of the tibia in order to warrant a higher 20 percent rating under the previous criteria. 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2020). Notably, the significant symptoms include pain, stiffness, and slight limitation of motion. This is representative of no more than slight knee disability under Diagnostic Code 5262. While, effective February 7, 2021, ratings are available specifically for shin splints, the medical evidence does not currently reflect treatment for shin splints for 12 consecutive months, unresponsive to either shoe orthotics or other conservative treatment as would be required for a compensable rating. While shin splints were noted upon VA examination through 2017, the evidence does not reflect specific shin splint treatment for 12 consecutive months. Notably, a VA examination in August 2020 is negative for shin splints. While the Board also acknowledges the Veteran’s use of a right shoe orthotic during the appeal, as noted previously in this decision this orthotic is specifically for the pain associated with her service-connected right foot disability. There is no evidence of their use to alleviate shin splints. As to other applicable Diagnostic Codes, range of motion testing was performed during multiple VA examinations, and was at worst 100 degrees of flexion (after repetitive use testing in April 2012). Extension has been normal. At the examinations, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed by the examiner, to include testing for pain and testing to reveal any additional functional limitations in certain circumstances, such as after repetitive use. The reports do not suggest that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran’s lay statements. In fact, range of motion estimate after repetitive use over time has been obtained and the most recent examiner indicated flare-ups would not result in additional functional limitation. While the Veteran has essentially stated that she has reduced motion in her knee, she has not described a range of motion less than that found on examination. In this regard, the Veteran has reported flare-ups during certain activities consisting of increased pain, stiffness, and “popping,” as opposed to a measurable reduction in motion. The Veteran’s statements do not show the requisite limitation of motion necessary for a higher rating, and no treatment record shows greater limitation of motion than the examination findings. Importantly, range of motion in the Veteran’s knee would need to be reduced to 45 degrees flexion or 10 degrees extension to warrant a compensable rating based on limitation of motion, a stark contrast from her 100 degrees of flexion at its worst. Simply put, the evidence in no way suggests the requisite limitation of motion required for higher or separate ratings, to include during flare-up or after repetitive use over time. Given the above, even when considering the knee pain’s impact on physical activities, a higher or separate rating is not warranted based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. As to a separate rating for instability or subluxation of the knees, the Board notes that the Veteran has taken to using a knee brace. Regarding the version of Diagnostic Code 5257 in effect prior to February 7, 2021, a separate rating is not warranted as the evidence is against a finding of any lateral instability or recurrent subluxation. See 38 C.F.R. §§ 4.31, 4.71a, Diagnostic Code 5257 (2020). Notably, there are specific medical tests that are designed to reveal instability and laxity of the joints. These tests were administered by medical professionals in this case during the multiple VA examinations during the appeal and, in each instance, testing revealed no instability or laxity. Given the tests performed are generally recognized in the medical community as diagnostic for instability and subluxation, the results are afforded high probative value. In addition, the examination findings are given more probative weight than the Veteran’s lay statements. To the extent the Veteran may experience a feeling that her knee may give way or is unstable, if subluxation or lateral instability were present to a slight degree, as required for a separate compensable rating, the Board would expect that this would have been identified at least once during the multiple tests that were performed. The examiners were aware of the Veteran’s subjective complaints but still found that, overall, there was no history of recurrent subluxation or instability. The medical opinions were fully informed and made based on diagnostic testing results and consideration of the Veteran’s statements. The findings of the VA examiners of no history of instability or subluxation are the most probative evidence on this point. Regarding the version of Diagnostic Code 5257 in effect since February 7, 2021, a higher rating based on recurrent subluxation or instability is not warranted because the evidence is against a finding of persistent instability. Notably, diagnostic testing for stability at the VA examinations did not reveal any instability, which is strong evidence against a finding of persistent instability. Put another way, when multiple medical tests for instability fail to detect instability, constant instability is not present. A rating is not warranted for patellar instability either as the evidence does not show surgical repair involving the patellofemoral complex (quadriceps tendon, the patella, and the patellar tendon), and, as discussed above, the evidence is against a finding of recurrent instability. Hence, the most probative evidence is against a separate rating under Diagnostic Code 5257. 38 C.F.R. § 4.71a. As the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for a right knee disability, the claim must be denied. 38 C.F.R. §§ 4.3, 4.7. Regarding all the claims being denied herein, the Board is sympathetic to the Veteran’s lay statements that her disabilities are worse than currently evaluated and those statements have been considered. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to her through her senses. Layno v. Brown, 6 Vet. App. 465 (1994). She is not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disabilities have been provided by the medical personnel who have examined her during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings as a whole (as provided in the examination reports and the clinical records) directly address the criteria under which the disabilities are evaluated. The medical and lay evidence has been assessed by the Board in determining the overall disability ratings. The Board notes that it can nevertheless determine whether the Veteran’s claims should be referred to the Director of VA’s Compensation Service (Director) for consideration of an extraschedular rating. 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the schedular ratings, as a whole, are inadequate when comparing the level of severity of the disability with the established criteria. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and an assigned rating is adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In the second step of the inquiry, however, if the schedular rating does not contemplate the claimant’s level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant’s exceptional disability picture exhibits other related factors such as those provided by the regulation as “governing norms.” 38 C.F.R. § 3.321(b)(1) (related factors include “marked interference with employment” and “frequent periods of hospitalization”). When the rating schedule is inadequate to evaluate a claimant’s disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Director for completion of the third step – a determination of whether the claimant’s disability picture requires the assignment of an extraschedular rating. Id. To facilitate proper analysis of Thun, the Court recently provided six non-exhaustive guiding principles in Long v. Wilkie, No. 16-1537 (Vet. App. Dec. 30, 2020). First, the sole focus of the first step in Thun is on the ability of the rating schedule to evaluate a veteran’s symptomatology; extraschedular consideration is not applicable to claims that may be properly evaluated with conventional schedular rating tools. See Morgan v. Wilkie, 31 Vet. App. 162, 168 (2019). Second, it deals exclusively with whether a veteran’s functional impairments are exceptional, whereas the second step in Thun considers the functional effects of those impairments. See Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). Third, where a symptom or impairment is not compensable under the rating schedule, as is the case for psychiatric conditions without a valid DSM-5 diagnosis (see Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 404 (2020)), it also does not warrant extraschedular consideration as this would amount to a backdoor means to obtaining compensation for a condition the rating schedule intends to exclude. Fourth, extraschedular consideration is not warranted for symptoms or effects that lack a nexus to service or to a service-connected disability. Fifth, the Board is only required to discuss the theories of entitlement raised by a veteran or reasonably raised by the record. Sixth, in reviewing the Board’s analysis of referral for extraschedular consideration, the Court will be mindful of the rule against prejudicial error. Here, the Board finds that all the symptomatology and impairment caused by the orthopedic disabilities on appeal are contemplated by the rating schedule, and no referral is required. The Veteran’s disabilities have been manifested by symptoms that include limitation of motion of the joints, pain, stiffness, disturbance of locomotion, interference with standing, sitting, weight-bearing, and squatting, difficulty climbing stairs, and localized tenderness. The Rating Schedule provides ratings for painful joints and limitation of motion, including motion limited due to orthopedic factors such as pain, stiffness, and swelling, as well as interference with sitting, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5255, 5262, 5284. Thus, in this case, the problems reported by the Veteran are specifically contemplated by the rating schedule. While the Board again acknowledges the Veteran’s possible leg length discrepancy, as noted above neither the medical evidence nor the Veteran’s statements indicates any compensable level of impairment. Moreover, extraschedular consideration is not warranted for symptoms or effects that lack a nexus to service or to a service-connected disability. Here, no medical provider has opined that any leg length discrepancy is related to any service-connected disability on appeal. Additionally, the Veteran has argued in a recent correspondence that she has hypermobility syndrome (double-jointedness), and suggests that the rating schedule is not an accurate measure of the functional loss associated with her disabilities, i.e., hypermobility syndrome results in a greater range of motion in her joints as opposed to similarly-situated veterans. The Board notes, however, that the record does not suggest hypermobility syndrome throughout all of the Veteran’s joints; rather, private treatment records reflect hypermobility syndrome diagnosed only in at the first MTP joint in her right foot. Further, disability of the joints is measured by abnormalities of motion, which includes both limitation of motion or hypermobility, as well as instability, pain on motion, or the inability to perform skilled motions smoothly. Notably, Diagnostic Code 5284 is a diagnostic code that looks generally at the level of severity and can include all symptoms causing impairment, including hypermobility. Even were the first prong of Thun met, which the Board finds it is not, the record indicates that the Veteran continues to be employed full-time despite any limitations caused by her disabilities, and marked interference with employment is not otherwise shown. Additionally, there is no indication that the Veteran’s disabilities have necessitated frequent hospitalizations. The Board also points out that during much of her appeal for the increased rating claims for the pelvic, knee and foot disabilities being denied herein, the Veteran’s arguments concerning her symptomology and functional impairment included symptoms related to additional disabilities of the right pelvis, sacrum, and low back for which she was seeking service connection. In November 2015 and March 2016 rating decisions, the additional service connection claims were granted. Thus, in the absence of exceptional factors associated with the disabilities on appeal, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Scarduzio, 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.