Citation Nr: 21032537 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-30 331 DATE: May 27, 2021 ORDER Entitlement to a rating greater than 50 percent for bilateral plantar fasciitis with microtenotomy surgical release with status post left foot neuroma removal and right third metatarsal stress fracture is denied. Entitlement to a rating greater than 10 percent for a stress fracture to the right tibia with knee strain is denied. Entitlement to a rating greater than 10 percent for a stress fracture to the left tibia with knee strain is denied. REMANDED Entitlement to a total disability based upon individual unemployability (TDIU). FINDINGS OF FACT 1. The Veteran's plantar fasciitis was manifested by extreme tenderness and symptoms not improved by orthopedic shoes or appliance. 2. The Veteran's right tibial strain manifested symptoms of pain involving the shin regions of the lower leg, pain on walking, standing, and at rest, and tenderness on palpation. The right tibial strain has not manifested any impairment of the range of motion of the knees or ankles. 3. The Veteran's left tibial strain manifested symptoms of pain involving the shin regions of the lower leg, pain on walking, standing, and at rest, and tenderness on palpation. The left tibial strain has not manifested any impairment of the range of motion of the knees or ankles. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating greater than 50 percent for bilateral plantar fasciitis with microtenotomy surgical release with status post left foot neuroma removal and right third metatarsal stress fracture have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.20, 4.71a, Diagnostic Codes (DC) 5276 (2020) and 5269 (2021). 2. The criteria for entitlement to a rating greater than 10 percent for a stress fracture to the right tibia with knee strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.20, 4.71.a, DC 5260-5262. 3. The criteria for entitlement to a rating greater than 10 percent for a stress fracture to the left tibia with knee strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.20, 4.71.a, DC 5260-5262. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from October 1994 to July 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2020, the Board remanded the issues of entitlement to a rating in excess of 10 percent for stress fracture at the junction of the mid and distal third left tibia, entitlement to a rating in excess of 10 percent for stress fracture at the junction of the mid and distal third right tibia, entitlement to a rating in excess of 10 percent for stress fracture of the right third metatarsal, entitlement to service connection for a right knee disability, entitlement to service connection for a left knee disability and entitlement to service connection for a left foot disability for additional development. In an August 2020 rating decision, the RO granted service connection for bilateral plantar fasciitis with microtenotomy surgical release with status post left foot neuroma removal and right third metatarsal stress fracture at a 50 percent rating, effective June 16, 2014. The rating decision noted that this was formerly evaluated as a stress fracture of the right third metatarsal healing and also claimed as a left foot disability and that this 50 percent rating served as a grant of service connection for a left foot disability. The August 2020 rating decision also continued 10 percent ratings for stress fractures of the mid and distal third left and right tibias with bilateral knee strains. The RO noted that the claims for service connection for a right and left knee disability were granted and were now incorporated into the 10 percent rating for the stress fractures of the mid and distal third left and right tibias. The Board notes that the increases did not constitute a full grant of the benefits sought. Accordingly, the issues listed above remain in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). Increased Ratings The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations 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. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2020). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2020). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2020). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). 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 (2020). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of his disabilities. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. 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. See 38 C.F.R. § 4.59. Although the first sentence of 38 C.F.R. § 4.59 refers only to arthritis, the regulation applies to joint conditions other than arthritis. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Entitlement to a rating greater than 50 percent for bilateral plantar fasciitis with microtenotomy surgical release with status post left foot neuroma removal and right third metatarsal stress fracture The Veteran filed a claim for an increased rating that was received by VA in August 2013. The Veteran is service-connected for bilateral plantar fasciitis with a 50 percent disability rating. The Veteran's bilateral plantar fasciitis is rated under 38 C.F.R. § 4.71a, DC 5276, for acquired flatfoot. Under DC 5276, a noncompensable rating is warranted for mild acquired flatfoot; symptoms relieved by built-up shoe or arch support. A 10 percent rating is warranted for moderate acquired flat foot; weight-bearing line over or medial to great toe, inward bowing of the tendo Achillis, pain on manipulation and use of the feet, bilateral or unilateral. A 20 percent rating is assigned for severe unilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is warranted for severe bilateral acquired flat foot; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 30 percent rating is also warranted for pronounced unilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. A maximum 50 percent rating is warranted for bilateral acquired flatfoot; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276. Prior to February 7, 2021, there was no specific diagnostic code for plantar fasciitis so the disability was rated by analogy to a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. See 38 C.F.R. § 4.20. The Veteran's private treatment records show that he has bilateral plantar fasciitis that required a Topaz microtenotomy plantar fascia bilaterally in October 2012. In February 2013, the Veteran returned to his private provider with complaints of having pain to the ball of his left foot that was diagnosed as left foot second intermetatarsal space neuroma which was temporarily resolved with an injection. The Veteran returned to his private provider in June 2013 with pain to both of his feet. The Veteran reported that he feels like he is walking walks on the outside of his feet. The Veteran did not want another injection and his provider modified his orthotics. Additional VA treatment records show the Veteran has continued to have pain to his feet. The Veteran was given a VA examination in March 2015. The examiner confirmed the Veteran's diagnoses of stress fracture of the right third metatarsal, healing, left foot neuroma and status post left foot neuroma removal surgery and bilateral feet plantar fasciitis, status post bilateral feet plantar fasciitis release surgery. The Veteran reported to the VA examiner that he has sharp pain to the forefront of his feet bilaterally and described the disability impact as being unable to stand or walk for extended periods. On examination, the examiner reported the Veteran as having accentuated pain on use and manipulation of his feet. The Veteran had swelling on use with his left foot but no characteristic callous were present. The examiner noted that the Veteran had arch support that provided relief bilaterally. The examiner did not find decreased longitudinal arch height on either foot on weight-bearing, objective evidence of marked deformity on either foot, or marked pronation on either foot. The examiner further reported that the Veteran did not have his weight-bearing line fall over or medial to the great toe, "inward" bowing of the Achilles' tendon or marked inward displacement and severe spasm of the Achilles' tendon (rigid hindfoot) on manipulation to either foot. The Veteran did have extreme tenderness of plantar surfaces to his left foot, Morton's neuroma and metatarsalgia to his left foot. The examiner opined that the Veteran's function impact is that he cannot stand or walk for prolonged periods. Pursuant to the Board's June 2020 remand, the Veteran was given a VA examination in July 2020. The examiner diagnosed the Veteran with bilateral plantar fasciitis; status post microtenotomy surgical release of the left foot and right third metatarsal condition/stress fracture of the right third metatarsal healing of the right foot. The Veteran reported to the VA examiner that he has right foot pain described as burning with non-weight bearing and is still there when he stands. After 5-10 minutes he has to shift his weight. The Veteran described the pain like "standing on a marble." The left foot pain is burning and worse with weight bearing and is rated 8 to 9 out of 10. The Veteran also reported experiencing flare-ups every day. On examination, the examiner reported the Veteran as having accentuated pain on use and manipulation of his feet. The Veteran had swelling on use with right foot but no characteristic callous were present. The examiner noted that the Veteran had arch supports but both of his feet remained symptomatic. The examiner did not find decreased longitudinal arch height on either foot on weight-bearing, objective evidence of marked deformity on either foot, or marked pronation on either foot. The examiner further reported that the Veteran did not have his weight-bearing line fall over or medial to the great toe, "inward" bowing of the Achilles' tendon or marked inward displacement and severe spasm of the Achilles' tendon (rigid hindfoot) on manipulation to either foot. The Veteran did have extreme tenderness of plantar surfaces to his left foot and Morton's neuroma to his left foot but not metatarsalgia. The examiner opined that the Veteran's function impact is pain in both feet while sitting still and on movement such as standing, walking, climbing stairs or walking on uneven surfaces and walking is limited to 50 to100 feet before he has to stop and sit down. The Veteran has assistive devices of a cane and custom orthotics for use of bilateral foot pain associated with plantar fasciitis and neuroma conditions. In September 2020, the Veteran submitted a written statement describing the symptoms and impact that his bilateral foot disabilities cause him. The Veteran described having pain and discomfort as well as the need to use assistive devices to include a cane, compression socks and orthotics. The Veteran also provided a list of therapies he has tried without success. The Board considered the amended rating schedule that created a new DC 5269 specifically to address plantar fasciitis. The amendments became effective on February 7, 2021. 85 Fed. Reg. 76, 453 (November 30, 2020). The amendments provide that the Board should apply the criteria which are more favorable to the Veteran. The criteria rating under the DC 5269 has the highest disability rating of 30 percent for plantar fasciitis when there is no relief from both non-surgical and surgical treatment affecting both feet. Id. Since the Veteran is in receipt of a higher 50 percent rating using the previous rating criteria that rate plantar fasciitis by analogy, it is more favorable to the Veteran to not use the revised rating criteria that added DC 5269 for plantar fasciitis. The Board acknowledges the Veteran's statements regarding the severity of his symptoms and the impact of his disabilities. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disabilities has been provided by the medical personnel who have examined him or his medical records during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective observations. As the Veteran is in receipt of the highest schedular rating for acquired flat foot throughout the period on appeal, there is no basis to award a higher rating. The Veteran's representative in a March 2021statement raised the issue of an extraschedular award for the Veteran's plantar fasciitis. However, the Board finds that the Veteran's bilateral plantar fasciitis disability picture is reasonably contemplated by the assigned schedular evaluation; therefore, the rating is adequate and referral for extraschedular consideration is not warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). This is especially evident in that the Veteran is in receipt of a higher rating than the new DC 5269 provides for bilateral plantar fasciitis. Furthermore, the Veteran's disability was unlisted prior to February 2021 and rated by analogy. In this regard, Diagnostic Codes 5277-5284 are not applicable and would not otherwise result in disability ratings in excess of the currently assigned Diagnostic Code. In summary, the preponderance of the evidence is against finding for a rating greater than 50 percent for bilateral plantar fasciitis with microtenotomy surgical release with status post left foot neuroma removal and right third metatarsal stress fracture. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Thus, the benefit of the doubt doctrine is not for application. Entitlement to a rating greater than 10 percent for a stress fracture to the right tibia with knee strain Entitlement to a rating greater than 10 percent for a stress fracture to the left tibia with knee strain The Veteran contends that he is entitled to a higher disability rating for his right and left stress fractures to his tibias and knee strain. The Veteran is currently evaluated at 10 percent for each of his right and left stress fractures to his tibias and knee strain using 38 C.F.R. § 4.71a, DC 5260, limitation of flexion of the knee, DC 5261, limitation of extension of the knee and DC 5262, impairment of the Tibia and fibula. Separate ratings may be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the amendments did not change the criteria under Diagnostic Codes 5256, 5258, 5259, 5260, or 5261. Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, if flexion of the knee is limited to 45 degrees a 10 percent rating is in order. If flexion of the knee is limited to 30 degrees a 20 percent rating is in order. If flexion of the knee is limited to 15 degrees a 30 percent rating is in order. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, if extension of the knee is limited to 10 degrees a 10 percent rating is in order. If extension of the knee is limited to 15 degrees a 20 percent rating is in order. If extension of the knee is limited to 20 degrees a 30 percent rating is in order. Under the criteria in effect prior to February 7, 2021, under Diagnostic Code 5262, pertaining to impairment of the tibia and fibula, a 10 percent disability rating is assigned for malunion with slight knee or ankle disability, and a 20 percent disability rating is warranted for malunion with moderate knee or ankle disability. A 40 percent disability rating is appropriate where there is nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under the revised criteria, Diagnostic Code 5262 now provides a 30 percent evaluation for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities; a 20 percent rating is warranted for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity, a 10 percent rating is warranted for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities; and a noncompensable rating is warranted for shin splints that have treatment less than 12 consecutive months, one or both lower extremities. Under the criteria in effect prior to February 7, 2021, Diagnostic Code 5257 provides a 10 percent rating for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). The terms "mild," "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2020). The use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2020). VA General Counsel has also held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260, and a compensable limitation of extension under Diagnostic Code 5261 provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 09-04; 69 Fed. Reg. 59990 (2004). The basis for the opinion was a finding that a limitation in planes of movement were each compensable. Id. A claimant who has arthritis and instability of the knee may also be rated separately under Diagnostic Code 5003 and Diagnostic Code 5257, and rating a knee disability under both of those codes does not amount to pyramiding under 38 C.F.R. § 4.14 (2020). VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63604 (1997); Esteban v. Brown, 6 Vet. App. 259 (1994). However, a separate rating must be based on additional compensable disability. Under the revised criteria, Diagnostic Code 5257 for recurrent subluxation and instability now provides a 30 percent rating for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation or a sprain incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. A 20 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted 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 (e.g., cane(s), crutch(es), walker) or bracing for ambulation. For patellar instability under the revised Diagnostic Code 5257, a 30 percent rating is warranted for 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. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 10 percent rating is warranted for 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. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. The Veteran was given a VA examination in March 2015. The examiner diagnosed the Veteran with a bilateral knee strain and stress fracture of the junction of the mid and distal third left tibia, in remission to both the right and left extremity. The Veteran reported to the examiner that his knee pain has worsened in the past few years. He further reported difficulties with balance, work and everyday functions. He has difficulty with standing and walking long distances. He was given orthotics which helped "to a degree." The Veteran also reported flare-ups which resulted in instability and is unable to walk short or long distances. He reported having to take work off for physical therapy. On examination, the Veterans initial ROM for the right knee was forward flexion of 0 to 130 degrees (with painful motion) and extension of 130 to 0 degrees. Initial ROM for his left knee was forward flexion of 0 to 140 degrees or greater and flexion of 140 to 0 degrees. After repetitive use testing three times, the Veteran's ROM remained the same. Muscle strength and joint stability testing was normal. The Veteran did not have patellar subluxation or dislocation, a meniscal condition. The Veteran did have bilateral shin splints and stress fractures. The Veteran also did not use assistive devices. The examiner noted that the Veteran's function impact is no prolonged walking or running. Pursuant to the Board's June 2020 remand, the Veteran was given a VA examination in July 2020. The examiner diagnosed the Veteran with a bilateral knee strain and stress fracture of the junction of the mid and distal third left tibia, in remission to both the right and left extremity. The Veteran reported to the examiner that he has discomfort in his shins and knees daily that varies on his activity level. He also reported being unable to stand too long or "do quick motions" and that twisting motions make it worse. The Veteran further stated that walking and standing is limited to five to ten minutes and that he also cannot sit too long. On examination, the Veterans initial ROM for the right knee was forward flexion of 0 to 110 degrees and extension of 110 to 0 degrees. Initial ROM for his left knee was forward flexion of 0 to 120 degrees or greater and flexion of 120 to 0 degrees. The Veteran showed objective evidence of painful motion on flexion and crepitus in both knees. He also had pain on weight bearing in the right knee. The examiner considered the Veteran's ROM after repetitive use to be consistent with his statements concerning functional loss and was estimated by the examiner to be right knee forward flexion of 0 to 105 degrees and extension of 105 to 0 degrees and left knee forward flexion of 0 to 115 degrees and extension of 115 to 0 degrees. The examiner estimated the loss of motion during fare-ups to be the same loss of ROM after repetitive use. The examiner did not find any muscle atrophy, ankylosis, subluxation or a meniscal condition. Joint stability testing was normal. The Veteran did have stress fractures that was described as intermittent aching and throbbing pain in the shins that is worse with weight bearing. The Veteran is prescribed and does not wear assistive devices. The examiner reported that the functional impact the Veteran's disabilities cause is waling and standing limited to five to ten minutes; limited impact and twisting activities involving his lower legs; very limited kneeling and squatting. However, sedentary work is not limited by his knee and shin conditions. In September 2020, the Veteran submitted a written statement describing the symptoms and impact that his bilateral knee and tibial stress fracture disabilities cause him. The Veteran described having pain and discomfort as well as the need to use assistive devices that include a cane, compression socks and orthotics. The Veteran also provided a list of therapies he has tried without success. The Board finds that a rating greater than 10 percent for the Veteran's right and left knee disabilities with stress fractures do not warrant a rating greater than 10 percent for each extremity. At no time during the period on appeal was the Veteran's limitation of flexion or extension meet the criteria for a compensable rating. Furthermore, the Veteran is already currently rated for at least the minimum compensable rating for painful motion under 38 C.F.R. § 4.59. Regarding, higher evaluations based on limitation of motion, the Veteran notably did not demonstrate flexion limited to 30 degrees or extension limited to 15 degrees in his left or right knee to warrant a rating in excess of 10 percent under Diagnostic Codes 5260 or 5261. Notably, on VA examination in July 2020, flexion of the right knee was forward flexion of 0 to 110 degrees and extension of 110 to 0 degrees range of motion for his left knee was forward flexion of 0 to 120 degrees or greater and flexion of 120 to 0 degrees. These range of motion readings demonstrate range of motion limitations in both the left and right knees that warrant the current 10 percent disability ratings. Further, there is no evidence to support a higher disability rating for the right and left knees based on consideration of limitation of motion or with functional loss, as the Veteran has not exhibited a sufficient degree of limited flexion or extension, even when accounting for the factors of functional loss. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 206. The Board notes that on his July 2020 VA examination, the Veteran reported that he had flare-ups. However, to the degree that he has reported limited function, the Board notes that the July 2020 VA examiner specifically noted that during flare-ups and with repeated use over time, pain limited functional ability in both knees as right knee forward flexion was from 0 to 105 degrees with extension of 105 to 0 degrees and left knee forward flexion was from 0 to 115 degrees with extension of 115 to 0 degrees. As a result, even considering these functional limitations of a decrease of 10 degrees in range of motion, the adjusted range of motions do not equate to higher ratings of 20 percent under Diagnostic Code 5260. Additionally, as noted above, there was no instability, no patellar abnormality, no meniscus abnormality and no abnormal tendons or bursae. Thus, based on the Veteran's reported history, even if there was additional limitation of motion during any flare-ups that were specifically described as mild, based on the Veteran's reported functional ability, the Board finds that the overall impairment resulting from his left and right knee disabilities would still more closely approximate no more than 10 percent evaluations due to his painful motion. Therefore, even when considering functional limitations due to pain and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, the Board does not find that the Veteran's functional losses equate to the criteria required for a 20 percent or greater rating under either 38 C.F.R. § 4.71a, Diagnostic Code 5260 or Diagnostic Code 5261, or separate compensable ratings under these same Diagnostic Codes. 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.45, 4.71a; DeLuca. Additionally, there is no showing of instability. Despite the Veteran's complaints of instability, locking and giving way, all of the VA examination reports showed no instability, even upon specific instability testing. As the medical findings showed no laxity and no objective evidence of subluxation, the Board concludes that a separate disability rating under Diagnostic Code 5257 is not warranted for either knee. As noted above, DC 5262 was used by analogy to rate the Veteran's left and right leg shin splints because "tibial stress fractures" are not listed as a specific disability under the Rating Schedule. When a disability is not listed in the Rating Schedule, it may be rated by analogy to a closely related disease or injury in which not only the functions affected, but also the anatomical area and symptomatology are closely analogous. 38 C.F.R. § 4.20. In rating by analogy not every element will be shown; requiring such would make rating by analogy pointless. Given the foregoing, the Board has considered all diagnostic codes that are potentially applicable when evaluating the Veteran's right and left tibial stress fractures. However, the Board finds that no separate or higher rating would be warranted under any other potentially applicable diagnostic code. The Board has also considered the amended rating schedule that revised the criteria for DC 5262. The amendments became effective on February 7, 2021. 85 Fed. Reg. 76, 453 (November 30, 2020). The amendments provide that the Board should apply the criteria which are more favorable to the Veteran. The criteria rating under the DC 5262 removed marked, moderate and slight from malunion of the tibia and fibula and added medial tibial stress syndrome (MTSS) or shin splints. A noncompensable rating is assigned for medial tibial stress syndrome (MTSS) or shin splints requiring treatment for less than 12 consecutive months of one of both lower extremities. A 10 percent rating is assigned for MTSS or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to either show orthotics or other conservative treatment of one or both lower extremities. A 20 percent rating is assigned for MTSS or shin splints requiring. treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment for one lower extremity. A 30 percent rating is assigned for MTSS or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment of both lower extremities. A 40 percent rating is assigned for nonunion of the tibia and fibula, with loose motion, requiring brace. Malunion of the tibia and fibula must 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. The ratings for the knees remained unchanged. Id. The Board finds that the revised criteria are not more favorable to the Veteran's stress fracture to the right and left tibia with knee strain disabilities. The Board acknowledges the Veteran's statements regarding the severity of his symptoms and the impact of his disabilities. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disabilities has been provided by the medical personnel who have examined him or his medical records during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective observations. In summary, the preponderance of the evidence is against finding for a rating greater than 10 percent for stress fracture to the right and left tibia with knee strain. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Thus, the benefit of the doubt doctrine is not for application. REASONS FOR REMAND The issue of TDIU was raised by the Veteran's representative in a March 2021 statement that the Veteran meets the established criteria for TDIU. TDIU is also part and parcel of any increased rating claim. See Rice v. Shenseki, 22 Vet. App. 447 (2009). However, the Board cannot make a fully informed decision on the issue of TDIU, because additional development is necessary. The last information in the record pertaining to the Veteran's employment status in from a June 2011 administrative decision on the Veteran's application for vocational rehabilitation and employment services. On remand, the Veteran should be furnished with an application for TDIU (VA Form 21-8940) for him to complete and submit for adjudication for TDIU. The matters are REMANDED for the following action: (Continued on the next page) Provide the Veteran with a VA Form 21-8940, Application for TDIU, and request that he submit the completed form, with all appropriate information. Thereafter, take all appropriate action on the TDIU claim, to include extraschedular referral to the Director of Compensation Benefits if, the AOJ determines that it is appropriate. James A. DeFrank Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. G. Perkins, 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.