Citation Nr: 21028685 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 15-44 624 DATE: May 11, 2021 ORDER Entitlement to a 20 percent rating, but not higher, for a left ankle disability as of February 9, 2015, but not earlier, is granted. Entitlement to an initial rating in excess of 10 percent for a left knee and leg disability is denied. Entitlement to an initial rating of 20 percent, but not higher, for left foot degenerative arthritis as of December 27, 2019, but not earlier, is granted. FINDINGS OF FACT 1. A left ankle disability has been manifested by marked limitation of motion, but not ankylosis, as of February 9, 2015, but not earlier. 2. A left knee and leg disability has been manifested by pain and stiffness; it has not been manifested by flexion limited to 45 degrees or less for an objectively sustained period, extension limited to 15 degrees or greater for an objectively sustained period, ankylosis, objective evidence of recurrent subluxation or lateral instability, impairment of the tibia and fibula, or genu recurvatum 3. Prior to December 27, 2019, a left foot disability was manifested by degenerative arthritis and complaints of painful motion. 4. As of December 27, 2019, a left foot disability has been manifested by x-ray evidence of moderate degenerative arthritis, compromised weight-bearing, and functional limitations which more closely approximate a moderately severe foot injury. CONCLUSIONS OF LAW 1. The criteria for a 20 percent rating, but not higher, for a left ankle disability, as of February 9, 2015, but not earlier, have been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.7, 4.71a, Diagnostic Codes 5003, 5271. 2. The criteria for entitlement to a rating in excess of 10 percent for a left knee/leg disability have not been met. 38 U.S.C. §§1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.59, 4.7, 4.71a, Diagnostic Codes 5003, 5260. 3. Prior to December 27, 2019, the criteria for an initial rating in excess of 10 percent for left foot degenerative arthritis with heel spurs have not been met. 38 U.S.C. §§1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.59, 4.7, 4.71a, Diagnostic Codes 5003, 5284. 4. From December 27, 2019, the criteria for an initial rating of 20 percent for left foot degenerative arthritis with heel spurs have been met. 38 U.S.C. §§1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.59, 4.7, 4.71a, Diagnostic Codes 5003, 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1966 to November 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision issued by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) in Muskogee, Oklahoma. In February 2019, the Veteran testified in a videoconference hearing before the undersigned Veterans Law Judge. A hearing transcript is of record. In April 2019, the Board remanded the issues of entitlement to a rating in excess of 10 percent for a left ankle disability, entitlement to a rating in excess of 10 percent for a left ankle disability, and entitlement to a rating in excess of 10 percent for a left foot disability for further development. In light of the further adjudicatory actions taken by the AOJ, the Board finds that there has been substantial compliance with the prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In initial rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. Fenderson v. West, 12 Vet. App. 119 (1999). The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, that does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). When rating musculoskeletal disabilities based on limitation of motion, the Board must consider 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. § 4.40. The Board must also consider whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Nonetheless, even when the background factors listed in 38 C.F.R. § 4.40 or 38 C.F.R. § 4.45 are relevant when rating a disability, the rating is assigned based on the extent to which motion is limited. A separate or higher rating under 38 C.F.R. § 4.40 or 38 C.F.R. § 4.45 is not appropriate. Thompson v. McDonald, 815 F.3d 781 (Fed. Cir. 2016). The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The words slight, moderate, and severe as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that decisions are equitable and just. 38 C.F.R. § 4.6. 1. Entitlement to an increased rating for a left ankle disability A March 1971 rating decision established service connection for a left ankle disability, and assigned a 10 percent rating. In August 2013, the Veteran filed a claim for a higher rating, stating that he had less mobility, more pain, and extreme cramps. The left ankle disability is rated under Diagnostic Code 5271. During the pendency of the appeal, the criteria for rating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). Those amendments revised select diagnostic codes to ensure that portion of the rating schedule used current medical terminology and provided detailed and updated criteria for the rating of musculoskeletal disabilities. 85 Fed. Reg. 230 (Nov. 30, 2020). If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria as of February 7, 2021. The criteria that are more favorable to the Veteran will be applied. Prior to the regulatory change, Diagnostic Code 5271 provided that limitation of motion of an ankle warranted a 10 percent rating when moderate and 20 percent rating when marked. 38 C.F.R. § 4.71a. As of February 7, 2021, under the amended criteria for Diagnostic Code 5271, the terms moderate and marked are defined. The new criteria provide that limitation of motion of an ankle warrants a 10 percent rating when moderate (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion); and a 20 percent rating when marked (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion). Normal range of ankle motion is from 20 degrees of dorsiflexion to 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. When, limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is generally for application. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. A rating for arthritis cannot be combined with a rating based on limitation of motion of the same joint. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Board notes that the left ankle disability has been manifested by pain, weakness, stiffness, tenderness, and reduced range of motion which is best rated on the basis of limitation of motion of the left ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271. The evidence of record does not show ankylosis of the ankle in plantar flexion (Diagnostic Code 5270), ankylosis of subastragalar or tarsal joint (Diagnostic Code 5272), malunion of the os calcis or astragalus (Diagnostic Code 5273), or astragalectomy (Diagnostic Code 5274), so as to support higher ratings under those Diagnostic Codes. 38 C.F.R. § 4.71a. Additionally, there is no showing or allegation that the left ankle has ever been replaced. The Veteran has a diagnosis of osteoarthritis of the ankle. However, the Veteran has been rated based on limitation of ankle motion under Diagnostic Code 5271. Consequently, a separate rating for arthritis of the left ankle is prohibited under previous and revised criteria for Diagnostic Code 5003 or 5010. A rating for arthritis cannot be combined with a rating for limitation of motion of the same joint, and the highest rating for arthritis of the ankle would be 10 percent, which is not more advantageous to the Veteran. 38 C.F.R. § 4.71a. Ratings for a joint based on limitation of motion require consideration of functional loss due to pain and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint. 38 C.F.R. §§ 4.40, 4.45. Thus, a higher rating may be assigned if there is additional limitation of motion from pain or limited motion on repeated use of the joint. DeLuca v. Brown, 8 Vet. App. 202 (1995). The terms moderate, moderately severe, and marked, as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities prior to recent amendments. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that Board decisions are equitable and just. 38 C.F.R. § 4.6. At a May 2014 VA examination, the Veteran described stiffness and limping due to a left ankle disability. He reported frequent, severe leg cramps at night. Flare-ups were noted with symptoms of stiffness and popping. On range of motion testing, left ankle plantar flexion to 35 degrees and dorsiflexion to 15 degrees were noted. There was evidence of pain on flexion and dorsiflexion, but with no additional limitation of motion. Range of motion was the same after repetitive use. There was no instability or ankylosis and the Veteran did not use an assistive device. X rays showed mild osteoarthritis, mild degenerative irregularity at the medical malleolus, and slight, old healed fracture deformity of the distal metaphysis of the fibula and tibia. At a November 2015 VA examination, the Veteran reported flare-ups characterized by stiffness, pain, and limping. On range of motion testing, dorsiflexion was 0 to 10 degrees and plantar flexion of 0 to 30 degrees. The Veteran had pain on dorsiflexion and plantar flexion, but with no additional limitation of motion. There was evidence of crepitus and pain with weight-bearing. After repetitive use, there was no additional loss of function or motion. The examiner was unable to say if repeated use over time or flare-ups significantly limited functional ability. The examiner found that additional limiting factors contributing to left ankle disability were less movement than normal, weakened movement, and interference with standing. There was no muscle atrophy, ankylosis, instability, or dislocation. The Veteran had no history of shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus or talus, or talectomy. The Veteran did not use an assistive device. The examiner found that the Veteran's ability to perform occupational tasks of climbing ladders and standing on roofs had worsened since the in-service left ankle fracture. The report of a February 2015 independent medical examination states that the Veteran has intermittent left ankle stiffness. The Veteran reported that pain and stiffness interfered with the ability to perform current occupational tasks. Range of motion testing showed 20 degrees plantar flexion, 5 degrees extension, 10 degrees inversion, 5 degrees eversion. The examiner concluded that the Veteran had a marked decrease in left ankle range of motion. In a February 2019 Board hearing, the Veteran testified that the ankle condition had worsened. Ankle motion was more limited and prevented him from putting his foot down on sloped roofs. He reported severe leg cramps, four or five times every couple of months. He used a prescription muscle relaxer for the cramps. At a December 2019 VA examination, the Veteran described decreased and painful range of motion, stiffness, and difficulty bending the foot. Range of motion testing found left ankle dorsiflexion of 20 degrees and plantar flexion of 20 degrees. There was evidence of pain on weight-bearing and crepitus. Repetitive use testing showed dorsiflexion of 0 to 15 degrees and plantar flexion of 0 to 10 degrees. The examiner found the limitation of motion consistent with the Veteran's statements of flare-ups and repetitive use over time. Factors causing the functional loss were pain, fatigue, weakness, lack of endurance and incoordination. Muscle strength on plantar flexion and dorsiflexion was 4/5. There was no ankylosis or instability. The examiner concluded that the disability causes difficulty walking on sloped or uneven roofs or other surfaces, difficulty with prolonged standing, climbing ladders and stairs, and difficulty squatting. The examiner found objective evidence of pain on non-weight bearing of the left ankle; passive range of motion the same as active; and pain on passive range of motion the same as on active. Under the previous criteria for Diagnostic Code 5271, the Board finds that a rating of 20 percent for the left ankle disability is warranted as of February 9, 2015, when marked limitation of motion was noted on the independent medical examination. The Board finds that the competent lay and medical evidence does not demonstrate marked limitation of motion of the left ankle prior to February 9, 2015, because the Veteran had movement in his left ankle, did not describe immobilization or other symptoms consistent with marked limitation, and no medical professional had concluded that motion was markedly limited. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Therefore, the Board finds that marked limitation of motion has been present from February 9, 2015. Accordingly, as the competent medical evidence shows that the limitation of motion of the left ankle is marked, with no evidence of ankylosis, a 20 percent rating, but not higher, is warranted from February 9, 2015, but not earlier. The Board finds that the preponderance of the evidence is against the assignment of any higher rating for the left ankle disability at any period under consideration. 38 U.S.C. § 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5271. 2. Entitlement to an increased initial rating for a left knee and leg disability A May 2014 rating decision established service connection for a left knee and leg sprain to include cramps, and assigned a 10 percent rating for painful motion of the knee, effective August 19, 2013. The Veteran asserts that the left knee disability is more severe than represented by the assigned ratings. The disability is rated under Diagnostic Code 5260. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, limitation of flexion of the knee is rated 10 percent for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limitation of extension of the knee is rated 10 percent for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Separate ratings may be assigned for compensable limitation of both flexion and extension, or for limitation of motion and instability or subluxation of the knee, or meniscal pathology. However, a separate rating can only be assigned where additional compensable symptomatology is shown that is not duplicative of that used to assign another rating. 38 C.F.R. § 4.14; VAOPGCPREC 09-04 (2004), 69 Fed. Reg. 59990 (2004); VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56704 (1998); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). At a December 2013 VA examination, the Veteran denied flare-ups. Initial range of motion testing showed left knee flexion to 120 degrees with objective evidence of pain beginning at 120. There was no limitation of extension and no evidence of pain on extension. No additional limitation of motion was found after repetitive use testing. There was no pain on palpation and stability tests were normal. X-ray reports of the left knee, tibia and fibula were normal. The examiner remarked that pain, weakness, fatigability, and/or incoordination affected functional ability. The examiner stated that flare-ups and repeated use over time cause additional limitation, but was unable to provide the degree of additional loss. At a November 2015 VA examination, the Veteran reported flare-ups during which he had weakness, pain, and a sensation that the knee was going out. On range of motion testing, flexion was 0 to 90 degrees and extension 90 to 0 degrees. There was evidence of crepitus and pain with weight bearing. The examiner was unable to say whether pain, weakness, fatigability or incoordination significantly limited functional ability after repetitive use or during flare-ups without resort to mere speculation. Interference with standing, weakened movement, and less movement than normal were contributing factors to disability. There was no ankylosis or instability. The Veteran did not use an assistive device. The examiner found that the Veteran was not able to climb ladders, stand on roofs or walk long distances. November 2018 X-ray studies of the left knee found preserved joint spaces, no evidence of acute fracture or dislocation, and moderate distention of suprapatellar bursa, likely due to joint effusion. In a February 2019 Board hearing, the Veteran testified that the left knee had not given way and that he had used a knee brace in the past. At a December 2019 VA examination, the Veteran described current left knee symptoms of decreased and painful range of motion and fatigue. Range of motion testing showed flexion of 0 to 90 degrees with pain and extension 90 to 0 degrees with pain. The limitation of motion causes difficulty squatting. There was evidence of crepitus and pain with weight bearing. On repetitive use testing, after repeated use over time, and during flare-ups, flexion was 0 to 70 degrees and extension 70 to 0 degrees due to pain, fatigue, weakness, and lack of endurance. Additional contributing factors were less movement than normal, weakened movement, disturbance of locomotion, and interference with standing. Muscle strength was normal. There was no ankylosis or instability. The Veteran did not use an assistive device. The examiner found that the Veteran was not able to climb ladders or stairs, stand on sloped roofs or other uneven surfaces. The examiner remarked that there was objective evidence of pain on non-weight bearing, passive range of motion was the same as active and pain was present on passive range of motion the same as on active range of motion. The Board finds that the preponderance of the evidence is against the assignment of a rating higher than 10 percent for left knee and leg sprain to include leg cramps and joint effusion. The evidence shows that the left knee disability has been manifested by no less than flexion of 0 to 70 degrees and extension of 70 to 0 degrees. The Board has carefully considered the Veteran's reports of functional loss following repetitive use, in addition to complaints of ongoing pain and an inability to use ladders and stairs. However, overall, the lay and medical evidence does not indicate limitation of extension or flexion that would warrant a 20 percent rating, even when considering pain, limitation on flare up, or other functionally limiting factors. Therefore, no higher rating is warranted based on limitation of left knee motion. The Board has considered the other Diagnostic Codes related to the knee and leg. Throughout the entire appeal period, the Board finds that Diagnostic Codes 5256 (ankylosis of the knee), 5257 (recurrent subluxation or instability ), 5258 (dislocated semilunar cartilage), 5259 (symptomatic removal of semilunar cartilage), 5263 (genu recurvatum), and 5262 (nonunion or malunion of the tibia and fibula) are not applicable, as the medical evidence does not show that the Veteran has those conditions in the left knee or leg. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of any higher or additional, separate rating for the left knee and leg disability and the claim for increased rating must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to an increased initial rating for left foot degenerative arthritis A May 2014 rating decision established service connection for left foot degenerative arthritis with heel spurs and assigned a 10 percent rating, effective from the date of claim, August 19, 2013. The Veteran asserts that the left foot disability is more severe than indicated by the assigned ratings. The disability is rated under Diagnostic Code 5284. The Veteran was awarded a temporary total disability rating from March 16, 2021, to July 1, 2021, and then a 10 percent rating as of July 1, 2021. Therefore, the Board will not address the left foot for that period of temporary total rating. The Board finds that an increased initial rating of 20 percent, but not higher, as of December 27, 2019, but not earlier, except a period of temporary total disability, is warranted for service-connected left foot degenerative arthritis. Under Diagnostic Code 5284, a 10 percent rating is assigned for foot injuries resulting in a moderate disability; a 20 percent rating is assigned for foot injuries resulting in a moderately severe disability; and a 30 percent rating is assigned for foot injuries resulting in a severe disability. 38 C.F.R. § 4.71a, Diagnostic Code 5284. The Note following those criteria indicates that disability with actual loss of use of the foot should be assigned a 40 percent rating. The terms moderate and severe are not defined by regulation. The regulatory scheme contemplates a 10 percent rating in cases such as ankylosis in good weight bearing position, or problems so disabling that there is atrophy, disturbed circulation and weakness, 10 percent being a minimum rating, or where there is inward bowing of the tendo achillis with pain on manipulation and use, or definite tenderness with dorsiflexion of the great toe and limitation of dorsiflexion of the ankle; a 30 percent rating is contemplated in cases of marked deformity. 38 C.F.R. § 4.71a, Diagnostic Codes 5276, 5277, 5278. During a December 2013 VA foot examination, the Veteran did not have Morton's neuroma, metatarsalgia, or hammer toe. Hallux valgus was noted, but the Veteran had no symptoms and had not needed surgery. There was no hallux rigidus, pes cavus, malunion or nonunion of tarsal or metatarsal bones, foot injuries, bilateral weak foot, or other pertinent findings. The Veteran did not use an assistive device. X-ray studies of the left foot showed degenerative arthritis, hallux valgus, and a heel spur. The examiner concluded that the Veteran's foot condition had no functional impact on the ability to work. The report of a February 2015 independent medical examination states that the Veteran's left great toenail had been removed. There was no tenderness, swelling, or erythema in the foot. At a November 2015 VA foot examination, the Veteran reported foot pain and stiffness. The symptoms were worse in cold weather or when jogging. Flare-ups were described as increased pain, stiffness, and cramps. The examiner noted mild degenerative arthritis of the left foot with heel spurs. Arthritis of the left foot was noted to chronically compromise weight bearing, but not require arch supports, custom orthotic inserts, or shoe modifications. Contributing factors were pain on movement and weight-bearing and interference with standing. Left foot pain, weakness, fatigability, or incoordination contribute to functional loss, including during flare-ups. The functional loss manifests as an inability to stand on the left foot for prolonged periods or walks long distances. The examiner concluded that the Veteran's ability to work was affected because he could not climb ladders or stand on roofs as he could before developing arthritis and a heel spur. At a December 2019 VA foot examination, the Veteran reported aching foot pain; flare-ups characterized by difficulty walking, climbing and with prolonged standing; and functional loss described as difficulty bending the left foot. Degenerative arthritis of the left foot was characterized as moderate; chronically compromising weight bearing; and not requiring arch supports, custom orthotic inserts, or shoe modifications. Left foot pain contributes to functional loss. The examiner noted other factors contributing to functional loss were less movement than normal, weakened movement, excess fatigability, pain on weight bearing, disturbance of locomotion, interference with standing, and lack of endurance. On repeated use over time, functional loss was reported as difficulty with prolonged standing or bending the foot. The Veteran did not use any assistive device. The examiner concluded that the functional impact of the left foot disability was difficulty standing on uneven surfaces, climbing ladders, and standing for prolonged periods. Prior to December 27, 2019, the evidence of record shows that the Veteran's left foot disability was manifested by mild degenerative arthritis with pain. Thus, the Veteran was appropriately assigned an initial 10 percent rating for painful motion. As of December 27, 2019, the evidence shows moderate degenerative arthritis and symptomatology that may be considered a moderately severe foot injury and to warrant a 20 percent rating under Diagnostic Code 5284. The evidence as of December 27, 2019, shows less movement than normal, weakened movement, excess fatigability, disturbance of locomotion, and lack of endurance. Thus, the Board finds that the Veteran's left foot symptoms more nearly approximate a moderately severe disability as of December 27, 2019. In coming to that conclusion, the Board finds the December 2019 VA examination report, showing increased symptoms and functional loss, highly probative. Moreover, the evidence of record shows that the Veteran's left foot disability was manifested by moderate osteoarthritis. Significantly, an initial rating in excess of 20 percent is not warranted because arthritis of the left foot has not required the use of an assistive devices and has not required medical intervention. Moreover, the evidence does not suggest that the Veteran's disability is analogous to actual loss of use of the foot, as it is clear that the Veteran's feet are functional. 38 C.F.R. § 4.71a, Diagnostic Code 5284, Note. Additionally, the evidence of record does not show that the Veteran has any other service-connected foot disabilities that would warrant a separate rating under a different Diagnostic Code. 38 C.F.R. § 4.14. Accordingly, the Board finds that the competent evidence of record shows motion limited by pain, but not to a degree to warrant a higher rating prior to December 27, 2019. The Board further find that the competent medical evidence shows that degenerative osteoarthritis of the left foot has been moderately severe as of December 27, 2019. Thus, a 20 percent rating, but not higher, is warranted from December 27, 2019, but not earlier. The Board finds that the preponderance of the evidence is against the assignment of any higher rating for the left foot disability at any period under consideration. 38 U.S.C. § 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5284. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Duke, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.