Citation Nr: 0810752 Decision Date: 04/01/08 Archive Date: 04/14/08 DOCKET NO. 03-09 800 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to service connection for a low back disability. 3. Entitlement to an initial increased rating for patellofemoral syndrome of the right knee, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARINGS ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD Theresa M. Catino, Counsel INTRODUCTION The veteran served on active military duty from March 1974 to July 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from multiple rating actions of the Department of Veterans Affairs Regional Office (RO) in Winston-Salem, North Carolina. Specifically, in a July 2002 decision, the RO denied service connection for left knee and low back disabilities. In June 2004, the Board remanded the veteran's left knee claim to the RO for further evidentiary development. In addition, the Board denied service connection for a low back disability. The veteran appealed the Board's denial of his low back claim to the United States Court of Appeals for Veterans Claims (Court). In September 2005, the Court granted a Joint Motion For Remand (Joint Motion) and, in so doing, vacated the Board's denial of this issue and remanded the matter to the Board for additional evidentiary development. In March 2006, the Board remanded the veteran's low back claim to the RO for further evidentiary development consistent with the Joint Motion. By a September 2006 rating action, the RO granted service connection for patellofemoral syndrome of the right knee and awarded a 10 percent evaluation for this disability, effective from April 2003. Following receipt of notification of that decision, the veteran perfected a timely appeal with respect to the rating initially assigned to his service-connected right knee disability. A complete and thorough review of the claims folder indicates that the development requested in the June 2004 and March 2006 remands has been completed. In March 2007, the RO continued to deny the claims for service connection for left knee and low back disabilities. In October 2007, the veteran presented testimony before the undersigned Veterans Law Judge at the RO. The veteran's claims folder has been returned to the Board for further appellate review of the issues on appeal. FINDINGS OF FACT 1. The veteran did not exhibit a left knee disability in service or arthritis of this joint within one year of separation from service, and no diagnosed left knee disorder is associated in any way with his active military duty. 2. The veteran did not exhibit a low back disability in service or arthritis of his lumbar spine within one year of separation from service, and no diagnosed low back disorder is associated in any way with his active military duty. 3. The service-connected patellofemoral syndrome of the right knee is manifested by complaints of an aggravating pain, tenderness, swelling, crepitus, stiffness, limitation of motion, instability, and weakness which require the use of a brace (except during flare-ups of gout, which cause pain) and by an antalgic gait but also by objective evaluation findings of normal extension, no worse than 125 degrees limitation of flexion, and no additional limitation of flexion or extension on repetitive use, instability, dislocation, subluxation, or locking. CONCLUSIONS OF LAW 1. A left knee disability was not incurred or aggravated in service, and arthritis of this joint may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 2. A low back disability was not incurred or aggravated in service, and arthritis of the lumbar spine may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 3. The criteria for an initial disability rating greater than 10 percent for patellofemoral syndrome of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.40, 4.45, 3.59, 4.71a, Diagnostic Codes 5003, 5014, 5260, 5261 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Claims A. Duties To Notify And To Assist The Veterans Claims Assistance Act of 2000 (VCAA), which was enacted on November 9, 2000, eliminated the concept of a well-grounded claim, redefined the obligations of VA with respect to the duty to assist, and imposed on VA certain notification requirements. Since the enactment of the law, the VCAA has been codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, & 5126. This change in the law is applicable to all claims filed on or after the date of enactment of the VCAA and to those claims which were filed before the date of enactment but which were not yet final as of that date. During the pendency of the current appeal, and specifically on March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006) which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that, upon receipt of an application for a service connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Dingess/Hartman, 19 Vet. App. at 488. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. In a May 2001 letter in the present case, the RO provided the veteran with the criteria for his service connection claims. Additionally, the correspondence notified the veteran that VA would make reasonable efforts to help him obtain necessary evidence with regard to this issue but that he must provide enough information so that the agency could request the relevant records. In addition, the letter informed the veteran of his opportunity to submit "any additional information or evidence that . . . [he] want[ed] . . . [the agency] to try to get for . . . [him]." An August 2004 letter reiterates this notification for the veteran's left knee claim in particular. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II) and VAOPGCPREC 1-2004 (February 24, 2004). See also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). A March 2006 letter informed the veteran of the type of evidence necessary to establish the degree of disability (element #4) and an effective date (element #5). See Dingess/Hartman, 19 Vet. App. at 488. In any event, however, as will be discussed in the following decision, the Board finds that the evidence of record does not support a grant of the veteran's service connection claims. Consequently, no ratings or effective dates will be assigned. Thus, the Board finds that there can be no possibility of any prejudice to the veteran in proceeding with the issuance of a final decision of the service connection claims adjudicated in this decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Court has also held that VCAA notice should be provided to a claimant before the initial unfavorable decision on the claim by the agency of original jurisdiction (AOJ). Pelegrini II. See also VAOPGCPREC 7-2004 (July 16, 2004) and Mayfield v. Nicholson, 444 F.3d at 1333. In the present case, only the May 2001 letter (and not the August 2004 and March 2006 correspondence) was issued prior to the initial denial of his service connection claims in July 2002. In any event, the veteran was "provided the content-complying notice to which he [was] entitled." Pelegrini, 18 Vet. App. at 122. Furthermore, in March 2007, the service connection issues were readjudicated, and a supplemental statement of the case (SSOC) was issued. Consequently, the Board finds that nothing about the evidence or any response to the RO's notification suggests that the service connection claims adjudicated in this decision must be re-adjudicated ab initio to satisfy the requirements of the VCAA. Moreover, the Board finds that the duty to assist provisions of the VCAA have been met with respect to the service connection claims adjudicated in this decision. The veteran has been accorded pertinent VA examinations. All relevant treatment records adequately identified by the veteran have been obtained and associated with his claims folder. Accordingly, the Board finds that VA has done everything reasonably possible to notify and to assist the veteran in the development of the issue on appeal. Under the circumstances of this case, additional efforts to assist the veteran in accordance with the VCAA would serve no useful purpose. See, Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (which holds that strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case and that such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran). See also, Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (which holds that remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Importantly, the veteran has pointed to no other pertinent evidence which has not been obtained. In fact, in a statement received at the RO in December 2007, the veteran admitted that he had no additional medical evidence to submit. Consequently, the Board will proceed to adjudicate the following service connection claims on appeal, based upon the evidence currently of record. See 38 U.S.C.A. §§ 5102 and 5103 (West 2002); 38 C.F.R. § 3.159(b) (2007); Pelegrini II; Quartuccio v. Principi, 16 Vet. App. 183 (2002). B. Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2007). Service connection may be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2007). Additionally, service connection for certain diseases, such as arthritis, may be established on a presumptive basis by showing that they manifested themselves to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2007). 1. Left Knee Throughout the current appeal, the veteran has asserted that he sustained repeated trauma to his left knee as a result of his in-service responsibilities as a parachuter, including one incident in particular in which the platform on which he stepped broke and he was slammed against the airplane. He describes continued pain in this joint since service. See, e.g., May 2003 hearing transcript (2003 T.) at 1-7 & October 2007 hearing transcript (2007 T.) at 4-5, 8-12. Family, friends, and co-workers have submitted statements in which they discuss their observations of the veteran's left knee problems since shortly after he returned home from military duty. Service medical records are negative for complaints of, treatment for, or findings of a left knee disability. At the March 1976 separation examination, the veteran denied ever having experienced a "trick" or locked knee. The examination demonstrated that the veteran's lower extremities were normal. A post-service medical record dated in September 2000 reflects the veteran's complaints of left knee pain. In August 2001, he underwent an arthroscopy with arthroscopic debridement, partial lateral meniscectomy, and chondroplasty of the medial femoral condyle of the left knee. The post-operative diagnosis was characterized as a degenerative tear of the lateral meniscus, severe chondromalacia, and denudation of the cartilage on the medial condyle with a corresponding area of chondromalacia of the tibial plateau and synovitis of the left knee joint. Subsequent medical records reflect continued treatment for, and evaluation of, a left knee disability variously diagnosed as probable patellar tendonitis, early osteoarthritis, status post medial meniscectomy, and chondromalacia. [Although X-rays taken of the veteran's left knee in March 2006 showed moderate narrowing of the patellofemoral joint space and mild narrowing of the medial femorotibial joint space without associated degenerative changes, the VA joints examination subsequently conducted in November 2006 provided a diagnosis of post-traumatic degenerative joint disease of the left knee and status post arthroscopic debridement with residuals.] At several outpatient treatment sessions conducted during the current appeal, the veteran has reiterated his assertions that he had sustained an in-service injury to his left knee. Specifically, at a January 2001 VA outpatient treatment session, the veteran described chronic knee pain since the 1970s. At a March 2001 VA outpatient treatment session, he complained of left knee pain approximately "10 years after a parachute injury . . . [that] . . . slammed [his knee] into a wall." At an October 2004 outpatient treatment session, he reported injuring his left knee in a parachute accident in February 1975. The examiner assessed status post medial meniscectomy, including early osteoarthritis, of the left knee and concluded that this disability "is likely to be related to his [the veteran's] . . . [service-connected] injury." The probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale" to support his or her opinion. Bloom v. West, 12 Vet. App. 185, 187 (1999). Significantly, as the Board has discussed in this decision, despite the veteran's assertions of continued knee pain since an in-service knee injury, service medical records are negative for treatment for any such symptoms. Further, post-service medical records first reflect treatment for left knee pain in September 2000 and a diagnosis of a left knee disability in August 2001, many years after his separation from active military duty. As such, the Board does not find the October 2004 physician's statement (as to any potential association between the veteran's current left knee pathology and his active military duty) to be probative. See Black v. Brown, 5 Vet. App. 177, 180 (1993); Swann v. Brown, 5 Vet. App. 229, 233 (1993); & Reonal v. Brown, 5 Vet. App. 458, 460 (1993) (in which the Court held that medical opinions have no probative value when they are based on an inaccurate factual predicate, such as the veteran's self-reported and inaccurate history). In this regard, the Board notes that, following a review of the claims folder and an examination of the veteran's left knee in November 2006, a VA examiner diagnosed post-traumatic degenerative joint disease of the left knee and status post arthroscopic debridement with residuals (including slight limitation of motion with some pain and minimal crepitus). Significantly, the examiner was unable to associate this disability with the veteran's active military duty. In support of this conclusion, the examiner referenced the lack of documentation of a left knee injury in the service medical records, the absence of left knee pathology at the service separation examination, and the presence of an initial diagnosis of a left knee disability many years thereafter. The fact remains that the claims folder in the present case contains no competent evidence associating the veteran's diagnosed left knee disability with his active military service. Based on such evidentiary posture, the preponderance of the evidence is clearly against the veteran's claim for service connection for a left knee disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The benefit-of-the-doubt rule does not apply, and this service connection claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). 2. Low Back Throughout the current appeal, the veteran has asserted that his in-service duties as a parachuter caused repeated trauma to his low back. In particular, he described one occasion when, in 1975, he attempted to jump out of an airplane, the platform on which he was standing broke, and wind threw him against the airplane. He also maintains that in 1974 he slipped and fell in a bathroom and re-injured his low back. He describes continued low back pain since service. See, e.g., May 2003 T. at 1-7 & 2007 T. at 4-8. Family, friends, and co-workers have submitted statements in which they discuss their observations of the veteran's low back problems since shortly after he returned home from military duty. According to the service medical records, the veteran was treated on several occasions in December 1974 for mild lumbar strain. He denied having any history of trauma. In March 1976, he sought treatment for back pain after falling in the shower. A physical examination was positive for tender musculature of the right buttock. A bruise was assessed. At the separation examination conducted one week later in March 1976, the veteran denied ever having experienced recurrent back pain. That examination demonstrated a normal spine. Post-service medical records reflect treatment for, and evaluation of, a low back disability variously diagnosed as low back pain, lumbar strain, chronic lumbosacral strain, lumbar radiculopathy, mild sensory motor polyneuropathy, as well as degenerative disc disease at L4-L5 and L5-S1 with stenosis at L4-L5 and a herniated nucleus pulposus at left L5-S1, since December 1987. The veteran underwent lumbar fusions in July 2004 and March 2006. According to a December 1987 report, the veteran had twisted his back while carrying a piano down stairs at work in August 1987. Also, a non-VA medical record dated in February 2001 indicates that, while driving a dump truck in 1991, the veteran hit the ceiling of the vehicle and was diagnosed with three bulging discs. Without attempting to differentiate between any current low back symptomatology associated with these post-service injuries and that which may be related to service, the Board has considered solely the question of whether the veteran's currently diagnosed low back disability is related to the in-service episodes of low back pain. In so doing, the Board finds that the claims folder simply contains no competent evidence associating the veteran's currently diagnosed low back disability with the in-service episodes of low back pain. Recently, in May 2006, the veteran underwent a VA examination of his spine. Following a review of the claims folder and an examination of the veteran's low back at that time, the examiner diagnosed degenerative disc/joint disease of the lumbosacral spine and status post fusion X2, with residuals (including limitation of motion with stiffness as well as "quite reduced" and atrophied musculature in the buttocks). Significantly, the examiner expressed his opinion that this disability is not associated with the in-service episodes of low back pain. In support of this conclusion, the examiner cited the lack of chronicity of low back symptomatology during service and for many years thereafter. The claims folder contains no medical opinion refuting the conclusion set forth by the May 2006 VA examiner. The fact remains that the claims folder in the present case contains no competent evidence associating the veteran's diagnosed low back disability with his active military service. Based on such evidentiary posture, the preponderance of the evidence is clearly against the veteran's claim for service connection for a low back disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The benefit-of-the-doubt rule does not apply, and this service connection claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). II. Initial Increased Rating Claim For Service-Connected Right Knee Disability A. Duties To Notify And To Assist As noted in the previous portion of this decision, on November 9, 2000, the President signed into law the VCAA, Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, & 5126 (West 2002 & Supp. 2006)). The VCAA imposes obligations on VA in terms of its duty to notify and to assist claimants. Upon receipt of a complete or substantially complete application for benefits, VA is ordinarily required to notify the claimant and his/her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2006); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record that is necessary to substantiate the claim, that VA will seek to provide, and that the claimant is expected to provide and must ask the claimant to provide any evidence in his/her possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). Pelegrini v. Principi, 18 Vet. App. 112, 121 (2004). VCAA notice is not required in every case, however. The Court recently held, for example, that such notice is not required under circumstances where a claim for service connection is granted, a rating and effective date are assigned, and the claimant files an appeal as to the effective date. See Dingess v. Nicholson, 19 Vet. App. 473, 491 (2006) (in which the Court held that, "[i]n cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated-it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled"). Rather, under those circumstances, the provisions of 38 U.S.C.A. §§ 5104 & 7105 and 38 C.F.R. § 3.103 are for application. Id. Here, the veteran's increased rating claim essentially falls within this fact pattern. Following receipt of notification of the September 2006 grant of service connection for patellofemoral syndrome of the right knee, the veteran perfected a timely appeal with respect to the assignment of the initial 10 percent rating for that disability. Consequently, no section 5103(a) notice is required for the veteran's increased rating claim. [As section 5103(a) no longer applies to the veteran's appeal-e.g., his initial increased rating claim-the additional notification provisions for increased rating claims recently set forth by the Court are not applicable in the present case. See Vazquez-Flores v. Peake, No. 05-0355 (U.S. Vet. App. Jan. 30, 2008).] As for the provisions of 38 U.S.C.A. §§ 5104 & 7105 and 38 C.F.R. § 3.103, the record shows that the veteran has been provided with various communications (including the September 2006 notification of the rating decision promulgated earlier that month as well as a March 2007 statement of the case) that contain notice of VA's rating communication, his appellate rights, a summary of relevant evidence, citations to applicable law (diagnostic codes), and a discussion of the reasons for the decision made by the agency of original jurisdiction. In short, the procedural requirements of the law have been satisfied. No further due process development is required. Additionally, the VCAA requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his/her claim. 38 U.S.C.A. §§ 5103A (West 2002); 38 C.F.R. § 3.159(c), (d) (2007). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his/her claim, whether or not the records are in Federal custody, and that VA will provide a medical examination and/or opinion when necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2007). In the present case, the Board finds that the duty to assist provisions of the VCAA have been fulfilled with respect to the increased rating issue on appeal. All relevant treatment records adequately identified by the veteran have been obtained and associated with his claims folder. The veteran has been accorded a pertinent VA examination. There is no suggestion on the current record that additional evidence, relevant to this matter, exists and can be procured. Consequently, the Board concludes that no further evidentiary development of the veteran's increased rating claim is required. B. Analysis In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. §§ 4.1 and 4.2 (2007). Initially, by the September 2006 rating action, the RO granted service connection, and awarded a 10 percent evaluation effective from April 2003, for patellofemoral syndrome of the right knee. This service-connected disability remains evaluated as 10 percent disabling. As the present appeal arises from an initial rating decision which, in essence, established service connection and assigned an initial disability rating, the entire period is considered for the possibility of staged ratings. In other words, consideration will be given to the possibility of separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practicably be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2007). Each service-connected disability is rated on the basis of specific criteria identified by diagnostic codes. 38 C.F.R. § 4.27 (2007). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2007). It is also necessary to evaluate the disability from the point of view of the veteran working or seeking work and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor. 38 C.F.R. §§ 4.2, 4.3 (2007). If there is a question as to which evaluation to apply to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2007). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See, 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2007). In the present case, the RO has evaluated the service-connected patellofemoral syndrome of the veteran's right knee, by analogy, as impairment resulting from osteomalacia. According to the relevant diagnostic code, osteomalacia is rated based on limitation of motion of the affected part(s), as with degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5014 (2007). Normal flexion and extension of the knee joint range from 140 degrees to zero degrees. 38 C.F.R. § 4.71, Plate II (2007). A compensable rating of 10 percent will be assigned with evidence of limitation of flexion of the leg to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2007). The next higher evaluation of 20 percent requires evidence of limitation of flexion of the leg to 30 degrees. Id. The highest rating allowable pursuant to this diagnostic code, 30 percent, necessitates evidence of limitation of flexion of the leg to 15 degrees. Id. Limitation of extension of the leg to 10 degrees will result in the assignment of a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2007). The next higher rating of 20 percent requires evidence of limitation of extension of the leg to 15 degrees. Id. A 30 percent evaluation necessitates evidence of limitation of extension of the leg to 20 degrees. Id. A 40 percent rating requires evidence of limitation of extension of the leg to 30 degrees. Id. The highest evaluation allowable pursuant to this diagnostic code, 50 percent, necessitates evidence of limitation of extension to 45 degrees. Id. The Board acknowledges that the diagnostic code which rates impairment resulting from degenerative arthritis stipulates that, in the absence of limitation of motion, a 10 percent rating will be assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Id. Also, a 20 percent evaluation will be awarded with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Id. Significantly, however, these 10 percent and 20 percent evaluations based on X-ray findings may not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. 38 C.F.R. § 4.71a, Note 2 following Diagnostic Code 5003 (2007). Clearly, therefore, consideration of these provisions may not be given in the present case, where the service-connected patellofemoral syndrome of the veteran's right knee has been evaluated, by analogy, as impairment resulting from osteomalacia. 38 C.F.R. § 4.71a, Diagnostic Code 5014 (2007). Although regulations recognize that a part which becomes painful on use must be regarded as seriously disabled, see 38 C.F.R. §§ 4.40 and 4.45, these provisions are qualified by specific rating criteria applicable to the case at hand. As the Board has discussed, evaluation of the service-connected patellofemoral syndrome of the veteran's right knee requires consideration of any associated limitation of motion of his right knee joint. See 38 C.F.R. § 4.71, Plate II & § 4.71a, Diagnostic Code 5003, 5014, 5260, 5261 (2007). Problems such as pain on use must be considered when evaluating the veteran's disability. Specifically, when a diagnostic code provides for compensation based on limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must also be considered, and the examinations upon which rating decisions are based must adequately portray the extent of the functional loss due to pain "on use or due to flare-ups." DeLuca v. Brown, 8 Vet. App. 202 (1995). See also 38 C.F.R. § 4.59 (2007). Throughout the current appeal, the veteran has contended that the service-connected patellofemoral syndrome of his right knee is more severe than the current 10% evaluation indicates. In particular, he maintains that his service-connected right knee disability is manifested by an aggravating pain, tenderness, swelling, crepitus, stiffness, limitation of motion, instability, and weakness which require the use of a brace (except during flare-ups of gout, which cause pain). See, e.g., 2007 T. at 12, 16-20. The veteran's lay descriptions are deemed to be competent evidence. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). However, the lay descriptions of this service-connected disability must be considered in conjunction with the clinical evidence of record as well as the pertinent rating criteria. Evidence of record does not reflect any inpatient or outpatient treatment for the service-connected patellofemoral syndrome of the veteran's right knee since April 2003 (the effective date of the grant of service connection, and award of the 10 percent rating, for this disability). X-rays taken of this joint in March 2006 showed mild narrowing of the patellofemoral joint space without associated degenerative changes. At an August 2006 VA joints examination, the veteran complained of right knee pain (which worsens with activity and improves with rest), instability, stiffness, weakness, limitation of motion, swelling, and tenderness. A physical examination of the veteran's right knee demonstrated an antalgic gait, active flexion from zero to 125 degrees (with pain from 110 degrees to 125 degrees), passive flexion from zero to 135 degrees (with pain from 110 degrees to 135 degrees), crepitus, and moderate lateral patellar displacement but no active or passive limitation of extension, instability, dislocation, subluxation, locking, or radiographic abnormality. As these examination results illustrate, the veteran has exhibited limitation of flexion no worse than 125 degrees, as well as normal limitation of extension, of his right knee. 38 C.F.R. § 4.71, Plate II (2007). Clearly, therefore, a disability rating greater than the currently assigned evaluation of 10 percent for his service-connected right knee disability cannot be awarded based on impairment resulting from limitation of motion of this joint. 38 C.F.R. § 4.71a, Diagnostic Codes 5260 & 5261 (2007) (which require evidence of limitation of flexion of the leg to 30 degrees, or limitation of extension of the leg to 15 degrees, for the assignment of a 20 percent rating). In this regard, the Board has considered the appropriateness of separate compensable ratings based upon limitation of flexion and limitation of extension of the veteran's right knee. See VAOPGCPREC 9-2004 (Sept. 2004) (in which the VA General Counsel determined that separate ratings may be awarded for disability of the same joint based upon findings of limitation of flexion and limitation of extension of the leg). Importantly, however, as the Board has noted, a recent examination of the veteran's right knee has shown normal extension and no worse than limitation to 125 degrees of flexion of this joint. As such, separate compensable evaluations, based upon objective findings of limitation of flexion and limitation of extension of the veteran's right knee are not warranted. 38 C.F.R. § 4.71a, Diagnostic Codes 5260 & 5261 (2007). Further, throughout the current appeal, the veteran has repeatedly complained of right knee pain. In addition, he has asserted that, due to his service-connected right knee disability, he is unable to stand longer than 10 minutes or to walk more than 1/4 mile to 1 mile. He describes weekly severe flare-ups of his right knee symptomatology (involving increased limitation of motion as well as effusion), and a recent VA examination of his right knee confirms pain on motion of this joint. Importantly, however, such evaluation also showed no additional limitation of flexion or extension on repetitive use, instability, dislocation, subluxation, or locking. While the examiner concluded that the veteran's right knee pathology causes severe exercise and sports activity limitations, the doctor also found that such symptomatology results in only mild dressing impairment (e.g., in putting on shoes) and no restriction in feeding, bathing, toileting, or grooming activities. Based on these evaluation findings, the Board concludes that the currently assigned 10 percent rating for the service-connected patellofemoral syndrome of the veteran's right knee adequately portrays the functional impairment, pain, and weakness that the veteran experiences as a consequence of use of this joint. See Deluca, 8 Vet. App. at 204-207. See also 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260 & 5261 (2007). Moreover, at the recent VA examination, the veteran denied experiencing any episodes of dislocation, subluxation, or locking in his right knee. As such, a separate compensable rating based upon impairment resulting from recurrent subluxation or lateral instability of the right knee is not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2007) and VAOPGCPREC 9-2004 (Sept. 2004). Of particular significance in the present case is the fact that, despite the veteran's complaints of an aggravating pain, tenderness, swelling, crepitus, stiffness, limitation of motion, instability, and weakness of his right knee, the recent examination of this joint has provided no more than mild findings. Under these circumstances, therefore, a basis upon which to assign a disability rating greater than the currently assigned evaluation of 10 percent for the service-connected patellofemoral syndrome of the right knee has not been presented. The veteran's appeal for an increased rating for this service-connected disability must, therefore, be denied. Moreover, the Board does not find that consideration of an extraschedular rating under the provisions of 38 C.F.R. § 3.321(b)(1) is warranted for any time during the current appeal. That provision provides that, in exceptional circumstances, where the schedular evaluations are found to be inadequate, the veteran may be awarded a rating higher than that encompassed by the schedular criteria, as shown by evidence showing that the disability at issue causes marked interference with employment, or has in the past or continues to require frequent periods of hospitalization rendering impractical the use of the regular schedular standards. Id. Importantly, the service-connected patellofemoral syndrome of the veteran's right knee has not resulted in marked interference with employment and has not required frequent periods of hospitalization. 38 C.F.R. § 4.1 specifically sets out that "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." Factors such as requiring periodic medical attention are clearly contemplated in the Schedule and provided for in the evaluations assigned therein. What the veteran has not shown in this case is that the service-connected patellofemoral syndrome of the right knee has resulted in unusual disability or impairment that rendered the criteria and/or degrees of disability contemplated in the Schedule impractical or inadequate at any time during the current appeal. Accordingly, the Board concludes that consideration of the provisions set forth at 38 C.F.R. § 3.321(b)(1) is not warranted for the veteran's service-connected right knee disability for any time during the current appeal. ORDER Service connection for a left knee disability is denied. Service connection for a low back disability is denied. An initial disability rating greater than 10 percent for patellofemoral syndrome of the right knee is denied. ____________________________________________ D. C. Spickler Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs