Citation Nr: 0811134 Decision Date: 04/04/08 Archive Date: 04/14/08 DOCKET NO. 04-40 844 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an increased evaluation for service- connected patellofemoral syndrome with chondromalacia of the left knee, currently evaluated as 10 percent disabling. 2. Entitlement to an increased evaluation for service- connected degenerative changes of the left knee associated with patellofemoral syndrome with chondromalacia of the left knee, currently evaluated as 10 percent disabling. 3. Entitlement to an increased evaluation for service- connected patellofemoral syndrome with chondromalacia of the right knee, currently evaluated as 20 percent disabling. 4. Entitlement to a total disability rating for compensation purposes based on individual unemployability. REPRESENTATION Appellant represented by: Kentucky Department of Veterans Affairs ATTORNEY FOR THE BOARD David S. Ames, Associate Counsel INTRODUCTION The veteran served on active duty from September 1976 to October 1982. This matter comes properly before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office in Louisville, Kentucky (RO). The issue of entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU) is addressed in the Remand portion of the decision below and is remanded to the RO via the Appeals Management Center, in Washington, DC. FINDINGS OF FACT 1. The medical evidence of record shows that the veteran's left knee disability is manifested by pain, crepitation, patellofemoral grinding, a Baker's cyst, and a range of motion from 100 degrees of flexion to 10 degrees of extension. 2. The medical evidence of record shows that the veteran's left knee lateral instability is slight. 3. The medical evidence of record shows that the veteran's right knee disability is manifested by pain, synovitis, a tear of the medial meniscus, patellofemoral grinding, crepitus, mild effusion, and a range of motion from 110 degrees of flexion to 5 degrees of extension. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for a left knee limitation of motion, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2007). 2. The criteria for an evaluation in excess of 10 percent for a left knee instability or subluxation, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2007). 3. The criteria for an evaluation in excess of 20 percent for a right knee disorder have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260, 5261 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the veteran's increased rating claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2007). Prior to initial adjudication, a letter dated in March 2003 satisfied the duty to notify provisions. An additional letter was also provided to the veteran in November 2006, after which the claims were readjudicated. See 38 C.F.R. § 3.159(b)(1); Overton v. Nicholson, 20 Vet. App. 427 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The veteran's service medical records, VA medical treatment records, and indicated private medical records have been obtained. VA examinations were provided to the veteran in connection with his claims. There is no indication in the record that additional evidence relevant to the issues decided herein is available and not part of the claims file. While the veteran was not provided with a letter notifying him of the criteria that must be satisfied for entitlement to an increased evaluation, the full text of the relevant diagnostic codes was provided to the veteran in a November 2004 statement of the case. See Vazquez-Flores v. Peake, No. 05-0355, (U.S. Vet. App. January 30, 2008). Accordingly, the Board finds that the veteran was supplied with information sufficient for a reasonable person to understand what was needed. Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. 473. Further, the purpose behind the notice requirement has been satisfied because the veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims, to include the opportunity to present pertinent evidence. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2007). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2007). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2007). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). This involves a factual determination of the current severity of the disability. Id. at 58. Service connection for chondromalacia, bilateral, postoperative on the left was granted by a November 1982 rating decision and a 10 percent evaluation was assigned under 38 C.F.R. § 4.71a, Diagnostic Codes 5099-5003, effective October 16, 1982. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27 (2007). The hyphenated diagnostic code in this case indicates that an unlisted musculoskeletal disorder, under Diagnostic Code 5099, was the service-connected disorder, and degenerative arthritis, under Diagnostic Code 5003, was a residual condition. See Id. (unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and "99"). Subsequently, a May 2003 rating decision discontinued the previous characterization of the veteran's bilateral knee disorder effective March 18, 2002, and separate ratings for patellofemoral syndrome with chondromalacia for both the left and right knees were granted, and a 10 percent evaluation for each knee was assigned under the provisions of 38 C.F.R. § 4.71a, Diagnostic Codes 5299-5260, effective March 18, 2002. The hyphenated diagnostic codes in this case indicate that an unlisted musculoskeletal disorder, under Diagnostic Code 5299, was the service-connected disorder, and limitation of flexion of the leg, under Diagnostic Code 5260, was a residual condition. See Id. A November 2004 rating decision assigned a temporary 100 percent evaluation for patellofemoral syndrome with chondromalacia, right knee, under 38 C.F.R. § 4.30, effective from August 9, 2002 to October 31, 2002. A November 2005 rating decision granted a separate evaluation for degenerative changes of the left knee, and assigned a 10 percent evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5010, effective March 18, 2002. Finally, a February 2007 rating decision assigned a 20 percent evaluation for patellofemoral syndrome with chondromalacia, right knee, under 38 C.F.R. § 4.71a, Diagnostic Codes 5299-5260, effective March 18, 2002. A January 2000 VA x-ray examination report was negative on views of the veteran's bilateral knees. A September 2001 VA outpatient medical report stated that the veteran complained of knee pain and swelling. In a February 2002 VA outpatient medical report, the veteran complained of knee pain. On observation, the veteran's knees had minimal, if any, swelling. There was no warmth or redness noted. The veteran had a full range of motion and there was no stress on the varus or valgus. The impression was chronic bilateral knee pain. A March 2002 VA outpatient medical report stated that the veteran complained of chronic knee pain. He also reported knee swelling in the right greater than the left for the previous 3 to 4 months and occasional warmth. On physical examination, the veteran's left knee had a protuberant boney abnormality below the patella. There was some palpable synovitis at the right knee. There was no effusion, instability, erythema, or warmth, bilaterally. Anterior drawer and McMurray's tests were negative, bilaterally. The assessment was knee pain, bilaterally, questionable osteoarthritis versus worsening chondromalacia. A March 2002 VA x-ray examination report stated that a deformity of the left tibial tubercle was identified, consistent with previous trauma. The impression was no evidence of arthritis and no significant change. An April 2002 VA magnetic resonance imaging (MRI) report gave an impression of a tear in the posterior horn of the medial meniscus on the right side and a small Baker's cyst on the left knee. An April 2002 VA medical report stated that the veteran complained of bilateral knee pain which had been increasing over the previous 2 years. On observation, there was effusion of the left knee. A May 2002 VA outpatient medical report stated that on physical examination, the veteran's bilateral lower extremity range of motion was within functional limits. On manual muscle testing, the bilateral lower extremities were both 5 out of 5. No laxity was noted. The assessment was bilateral knee pain with a right medial meniscus tear and a left Baker's cyst. A second May 2002 VA outpatient medical report stated that the veteran complained of bilateral knee pain, greater in the right than the left, with occasional popping of the right knee, but no locking. He rated the pain as a 7 on a scale from 1 to 10. On physical examination, the veteran's right knee had no effusion but was tender on the medial joint line. It was stable on varus and valgus testing and was negative on Lachmann's and posterior Drawer tests. McMurray's test was positive and the veteran had patellofemoral grinding and crepitus. The right knee range of motion was from 130 degrees of flexion to 0 degrees of extension. The veteran's left knee had no effusion or tenderness. It was stable on varus and valgus testing and was negative on Lachmann's, posterior drawer, and McMurray's tests. There was patellofemoral grinding and crepitus. The left knee range of motion was from 130 degrees of flexion to 0 degrees of extension. The impression was bilateral chondromalacia of the patella. A July 2002 VA outpatient medical report stated that the veteran complained of chronic bilateral knee pain which had increased over the previous 2 years. On physical examination, the veteran's gait was nonantalgic to the right. The veteran had a well-healed longitudinal post-surgical scar on the left anterolateral knee. There were small medial effusions of the bilateral pes anserinus bursae. There was bilateral patellofemoral grinding. No laxity was appreciated with bilateral anterior drawer tests of the knees. The veteran's active range of motion of the bilateral knees was "[f]unctional." In an August 2002 VA outpatient medical report, the veteran complained of bilateral knee pain in the right greater than the left. He reported that the pain was mostly on the lateral and anterior aspect of the knee. On observation, the veteran's right knee was tender to palpation over the lateral joint space and the patella. The was no varus or valgus instability, but there was mild effusion. On range of motion testing, the veteran's right knee had flexion to 110 degrees and extension to 5 degrees. The assessment was right knee pain secondary to arthritis, chondromalacia, and meniscal tear. An August 2002 VA surgical report gave a post-operative diagnosis of right knee medial meniscal tear. In a second August 2002 VA outpatient medical report, the veteran stated that his right knee felt better. On examination of the right knee, there was minimal effusion and no medial joint tenderness. The veteran's right knee range of motion was from 130 degrees of flexion to 0 degrees of extension. The impression was status post debridement of right knee medial meniscal tear. In a September 2002 VA outpatient medical report, the veteran complained of occasional pain in the right knee. On examination, there was minimal effusion and medial joint line tenderness. The veteran's right knee range of motion was from 130 degrees of flexion to 0 degrees of extension. The impression was right knee medial meniscal tear, status post debridement. In an October 2002 VA outpatient medical report, the veteran complained of knee pain that had improved for 2 weeks following surgery, but which had since returned to chronic status. In a November 2002 private medical report, the veteran complained of stiffness and swelling of the knees. He stated that he could stand and walk for approximately 30 to 40 minutes, had pain when sitting, and had difficulty squatting. On physical examination, the veteran had a slight bony abnormality inferior to the right knee. The range of motion was normal, but there was crepitus in the right knee. The veteran had a negative straight leg raise test in both the sitting and supine positions. There was no impairment in toe or heel walking, the veteran had no difficulty getting on and off the examining table, and he could stoop approximately 45 percent of the way down. The examiner stated that there was evidence of moderate restriction in the veteran's tolerance for stooping, but not for bending, reaching, handling, lifting, carrying, sitting, standing, moving about, or ability to travel. The impression was degenerative joint disease which caused "moderate impairment." In a November 2002 VA outpatient medical report, the veteran complained of knee pain that increased with ambulation and stair climbing, but which did not have mechanical symptoms. On physical examination, the veteran's bilateral knees had no effusion, no medial joint line pain, no lateral joint line pain, and were stable. The veteran's knee range of motion was from 130 degrees of flexion to 0 degrees of extension, bilaterally. The veteran's quadriceps muscles were weak, greater on the right than the left. The impression was knee pain, greater on the right than the left. In a December 2002 VA outpatient medical report, the veteran complained of bilateral knee pain. On observation, the range of motion of the veteran's bilateral lower extremities was within functional limits. Manual muscle testing of the bilateral lower extremities was grossly 5 out of 5. No laxity was noted. The assessment was bilateral knee pain with right arthroscopic surgery and left Baker's cyst. In a second December 2002 VA outpatient medical report, the veteran complained of unchanged symptoms with no improvement and persistent pain. An April 2003 VA joints examination report stated that the veteran's claims file had been reviewed. The veteran complained of pain, weakness, stiffness, occasional swelling, instability or giving way, and fatigability. He described his knee pain as ranging from 4 to 10 on a scale from 0 to 10, with pain occasionally at a level of 0 due to medication. On physical examination, there was a prominence of the left tibial tubercle and decreased extension of the left knee in standing. There was minimal varus deformity of approximately 2 degrees in the left knee in comparison with the right. The veteran's calf muscles were symmetrical. His bilateral knee range of motion was from 0 degrees of extension to 125 degrees of flexion. There was tenderness of the bilateral joint lines, bilateral medial joint lines, and left lateral joint line. The left knee had tenderness to patellar grind and on the patellar facets. The veteran reported numbness over the left knee scar, which was 15 centimeters in length. The left knee assessment was left patellofemoral syndrome, status post surgical procedure to lift the patellar tendon by bone graft onto the tibial tubercle, with scar numbness, left knee varus deformity, and reports of painful full extension. The right knee assessment was right knee patellofemoral syndrome and right knee medial meniscus tear, status post arthroscopic debridement. An April 2003 VA x-ray examination report gave an impression of mild varus deformity or angulation at the left knee and mild degenerative changes of the left knee. In an April 2003 VA outpatient medical report, the veteran complained of bilateral knee pain which was increasing and limiting activities of daily living. In a May 2003 private medical report, the veteran complained of bilateral knee pain which had increased over the previous 2 years. He reported that he could only walk short distances before he experienced significant pain. On physical examination, there were no joint deformities or decreased range of motion. There was some crepitus in the right knee and some bony deformity in the left knee. The veteran had negative straight leg raise tests in both the sitting and supine positions. There was no impairment in toe or heel walking. The veteran was unable to squad, but had no difficulty getting on and off the examination table. The impression was bilateral knee pain. The examiner stated that the veteran's knees had a "good" range of motion and "good" muscle strength. The only abnormality noted was crepitus and the examiner described the veteran's impairment as "mild." A second May 2003 private medical report stated that the veteran's patellofemoral joint was essentially normal with minimal chondromalacia. On examination, the veteran had a normal range of motion, strength, and stability. The report stated that the veteran's complains of pain "far exceed the objective evidence of direct observation of the joint damage." A May 2003 VA outpatient medical report stated that on physical examination, the veteran's right knee had a "good" range of motion, no joint pain, and no effusion. His left knee had a "good" range of motion and no effusion. There was pain in both knees that the veteran described as having an average severity of 4 on a scale from 1 to 10. In a June 2003 VA telephone report, the veteran reported that his bilateral knee pain was unchanged. In a July 2003 VA outpatient medical report, the veteran complained of knee pain which was increasing in severity. He reported "thickening" of the area around his right knee cap. The diagnosis was degenerative joint disease of the knees with a Baker's cyst of the left knee and thickening of the paripatellar areas of the right knee, causing increased pain. An August 2003 VA MRI report gave an impression of a tear in the posterior horn of the medial meniscus of the right knee, an old healed avulsion fracture of the left tibial tubercle, and minimal fluid anterior to the distal semimembranosus muscle. In a December 2003 VA outpatient medical report, the veteran complained of increased pain and swelling in his knees. On examination, the veteran's lower extremity passive range of motion was "[a]dequate." There was no edema or cyanosis. On x-ray examination, no bony abnormality was seen and the impression was a negative study. The assessment was degenerative joint disease of the knees. In a January 2004 VA outpatient medical report, the veteran complained of bilateral knee pain at a level of 9 on a scale from 1 to 10. He reported that the pain was aggravated by standing, sitting, and kneeling and occurred daily. On examination, there was no gross deformity or discoloration of the bilateral knees. There was a prominent Osgood- Schlatter's disease tubercle on the left knee. The veteran had a full active range of motion and he was neurovascularly intact. In a March 2004 VA outpatient medical report, the veteran complained of knee pain. On examination, there was varus alignment, no swelling, no patellar crepitation on extension, and a prominent tubercle on the left. A December 2004 VA spine examination report stated that the veteran's claims file had been reviewed. The veteran complained of pain, weakness, stiffness, occasional swelling, instability or giving way, and fatigability. He described his knee pain as ranging from 4 to 10 on a scale from 0 to 10. The veteran reported a lack of endurance secondary to pain and stiffness after sitting. On objective examination, there was a prominence of the left tibial tubercle and decreased extension of the left knee in standing. The left knee scar was over 10 centimeters in length, well healed, and non-adherent. The left knee had a varus deformity when compared to the right knee. The bilateral calves had a symmetrical muscle mass. The range of motion was from 0 degrees of extension to 110 degrees of flexion in the right knee, and 10 degrees of extension to 100 degrees of flexion in the left knee, with complaints of pain at the end range. The left knee assessment was left patellofemoral syndrome, status post surgical procedure to lift the patellar tendon by bone graft onto the tibial tubercle, with scar numbness, left knee varus deformity, left knee decreased extension, report of painful weight baring in full extension, mild laxity on the left greater than the right, and pain with patellar compression. The right knee assessment was right knee patellofemoral syndrome with pain with patellar compression, and right knee medial meniscus tear, status post arthroscopic debridement. In an August 2005 VA outpatient medical report, the veteran complained of chronic knee pain. On physical examination, there was no clubbing, cyanosis, or edema. The assessment was knee pain. A September 2005 VA MRI report gave an impression of tear within the posterior horn of the medial meniscus extending to the inferior surface. A November 2006 VA joints examination report stated that the veteran's claims file had been reviewed. The veteran complained of increasing bilateral knee pain. He reported no constitutional symptoms or incapacitating episodes of arthritis. The veteran reported being unable to stand for 15 minutes and unable to walk more than 50 yards. He reported a left knee deformity, bilateral pain, bilateral stiffness, and decreased range of motion, bilaterally. The veteran denied experiencing giving way, instability, weakness, dislocation, subluxation, locking, effusion, flare-ups, and inflammation. On physical examination, the veteran's weight-bearing joint was affected and his gait was antalgic. There was no loss of a bone or a part of a bone. There was no inflammatory arthritis or joint ankylosis. The veteran's left knee had crepitus, deformity, tenderness, tendonitis, and painful movement. There were no bumps consistent with Osgood- Schlatter's disease. There was crepitation, click or snaps, grinding, and abnormal subpatellar tenderness. There was no mass behind the knee, no instability, and no meniscus abnormality. There was no tendon or bursa abnormality, but there was a prominent tibial tuberosity. The veteran had left knee range of motion from 5 degrees to 120 degrees of flexion with pain at 100 degrees and from -5 degrees to -5 degrees of extension. There was no additional limitation of motion on repetitive use on either flexion or extension. The veteran's right knee had tenderness and painful movement. There were no bumps consistent with Osgood-Schlatter's disease, no crepitation, no mass behind the knee, no clicks or snaps, and no instability. There was grinding and the meniscus was surgically absent. There was no patellar abnormality, effusion, dislocation, or locking. There was a positive McMurray's test. The veteran had right knee range of motion from 0 degrees to 130 degrees of flexion with pain at 110 degrees and from 0 degrees to 0 degrees of extension. There was no additional limitation of motion on repetitive use on either flexion or extension. There was also a 10 centimeter long, well-healed scar over the anterior midline of the left knee. It did not adhere to underlying structures, was not elevated, and was not depressed. There was no inflammation, edema, or keloid formation. The scar was not hyperpigmented and was minimally disfiguring. The diagnoses were mild degenerative joint disease of the right knee, posterior medial meniscus tear of the right knee, status post arthroscopic anterior medial meniscus debridement of the right knee, patellar tendinosis of the left knee, surgical scar of the left knee, and status post tibial tuberosity advancement of the left knee. Degenerative arthritis, substantiated by x-ray findings, is rated on the basis of limitation of motion. However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is warranted for each major joint affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2007). For the purpose of rating disability from arthritis, the knee is considered to be a major joint. 38 C.F.R. § 4.45 (2007). Limitation of motion of knee joints is rated under Diagnostic Code 5260 for flexion, and Diagnostic Code 5261 for extension. See 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, flexion that is limited to 60 degrees is non- compensable, flexion that is limited to 45 degrees warrants a 10 percent rating, flexion that is limited to 30 degrees warrants a 20 percent rating, and flexion that is limited to 15 degrees warrants a 30 percent rating. Under Diagnostic Code 5261, extension that is limited to 5 degrees is noncompensable, extension that is limited to 10 degrees warrants a 10 percent rating, extension that is limited to 15 degrees warrants a 20 percent rating, and extension that is limited to 20 degrees warrants a 30 percent rating. The Board notes that standard motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2007). Under Diagnostic Code 5257, recurrent subluxation or lateral instability warrants a 10 percent rating if it is slight, a 20 percent rating if it is moderate, and a 30 percent rating if it is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Left Knee Ratings The veteran's left knee is currently assigned a 10 percent evaluation for arthritis, with limitation of motion, and a separate 10 percent evaluation for instability. The medical evidence of record shows that the veteran's left knee disability is manifested by pain, crepitation, patellofemoral grinding, a Baker's cyst, and a range of motion from 100 degrees of flexion to 10 degrees of extension. Accordingly, a rating in excess of 10 percent is not warranted for arthritis, with limitation of motion on extension, as the veteran's left knee has never been limited in extension to 15 degrees or less. 38 C.F.R. § 4.71a, Diagnostic Code 5261. In addition, a separate rating for arthritis with limitation of flexion is not warranted, as the record does not show that the veteran's left knee range of flexion has ever been limited to 45 degrees or less. See 38 C.F.R. § 4.71a, Diagnostic Code 5260; see also VAOPGCPREC 9-04, 69 Fed. Reg. 59990 (2004). The veteran has reported left knee pain on use, a contention which is substantiated by the medical evidence of record. However, the level of pain found during the December 2004 VA spine examination report, limited extension of the left knee to 10 degrees, and the November 2006 VA joints examination report found pain limited the veteran's left knee flexion to 100 degrees. Accordingly, there is no medical evidence of record that the veteran experienced pain which caused additional limitation of motion beyond that contemplated by the currently assigned evaluation. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2007); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). As for other provisions under the Schedule, the veteran's left knee has never been ankylosed, there is no nonunion or malunion of the tibia and fibula, there is no dislocated semilunar cartilage, there are no symptoms from the removal of semilunar cartilage, and there was no genu recurvatum. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 (2007); see also VAOPGCPREC 23-97, 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). The medical evidence of record shows that the veteran has a left knee scar secondary to his service connected left knee disability. However, a separate compensable evaluation is not warranted for this scar as it is not deep, does not cause limited motion, does not exceed 144 square inches, is not unstable, and is not painful on examination. See 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, and 7805 (2007). In addition, an evaluation in excess of 10 percent is not warranted for the veteran's left knee instability. While a left knee vargus deformity of 2 degrees was noted in April 2003 and again in December 2004, it was described as "minimal" on the April 2003 VA joints examination report and "mild" on the April 2003 VA x-ray examination report. In addition, no instability or subluxation was found on examination or reported by the veteran in medical records dated in September 2001, February 2002, March 2002, April 2002, May 2002, July 2002, August 2002, September 2002, October 2002, November 2002, December 2002, May 2003, June 2003, July 2003, August 2003, December 2003, January 2004, March 2004, August 2005, September 2005, and November 2006. Accordingly, as the veteran's left knee laxity was described in the medical records as "minimal" and "mild" and the vast majority of the medical evidence of record shows no instability or subluxation at all, the Board finds that the veteran's left knee lateral instability is slight. As such, a rating in excess of 10 percent for left knee recurrent subluxation or lateral instability is not warranted. After a review of the evidence, there is no medical evidence of record that would warrant a rating in excess of 10 percent for the veteran's left knee disability under any rating criteria at any time during the period pertinent to this appeal. 38 U.S.C.A. § 5110 (West 2002); see also Hart v. Mansfield, No. 05-2424 (U.S. Vet. App. Nov. 19, 2007). In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence does not show findings that meet the criteria for increased ratings for arthritis with limitation of motion of the left knee or instability of the left knee, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right Knee Ratings The medical evidence of record shows that the veteran's right knee disability is manifested by pain, synovitis, a tear of the medial meniscus, patellofemoral grinding, crepitus, mild effusion, and a range of motion from 110 degrees of flexion to 5 degrees of extension. Accordingly, a rating in excess of 20 percent is not warranted for arthritis with limitation of motion, as the veteran's right knee has never been limited in flexion to 15 degrees of less or in extension to 20 degrees or less. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5260, 5261. The veteran has reported right knee pain on use, a contention which is substantiated by the medical evidence of record. However, the level of pain found during the November 2006 VA joints examination report, limited extension of the left knee to -5 degrees and flexion to 110 degrees. Accordingly, there is no medical evidence of record that the veteran experienced pain which caused additional limitation of motion sufficient to warrant a compensable evaluation for either flexion or extension. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 206. As for other provisions under the Schedule, the veteran's right knee has never been ankylosed, there is no nonunion or malunion of the tibia and fibula, there is no dislocated semilunar cartilage, there are no symptoms from the removal of semilunar cartilage, instability, and there was no genu recurvatum. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5257, 5258, 5259, 5262, and 5263; see also VAOPGCPREC 23-97, 62 Fed. Reg. 63604; VAOPGCPREC 9-98, 63 Fed. Reg. 56704. After a review of the evidence, there is no medical evidence of record that would warrant a rating in excess of 20 percent for the veteran's right knee disability under any rating criteria at any time during the period pertinent to this appeal. 38 U.S.C.A. § 5110 (West 2002); see also Hart, No. 05-2424 (U.S. Vet. App. Nov. 19, 2007). In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence does not show findings that meet the criteria for an increased rating for the veteran's service-connected right knee disorder, the doctrine is not for application. Gilbert, 1 Vet. App. 49. ORDER A rating in excess of 10 percent for patellofemoral syndrome with chondromalacia of the left knee is denied. A rating in excess of 10 percent for degenerative changes of the left knee associated with patellofemoral syndrome with chondromalacia of the left knee is denied. A rating in excess of 20 percent for patellofemoral syndrome with chondromalacia of the right knee is denied. REMAND Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1) (2007). A total disability rating for compensation purposes may be assigned on the basis of individual unemployability: that is, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a) (2007). In such an instance, if there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Id. Individual unemployability must be determined without regard to any non-service connected disabilities or the veteran's advancing age. 38 C.F.R. §§ 3.341(a) (2007), 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). Service connection is currently in effect for patellofemoral syndrome with chondromalacia of the left knee, rated as 10 percent disabling, degenerative changes of the left knee associated with patellofemoral syndrome with chondromalacia of the left knee, rated as 10 percent disabling, patellofemoral syndrome with chondromalacia of the right knee, rated as 20 percent disabling, pelvic obliquity with myofascial back pain associated with bilateral chondromalacia, rated as 10 percent disabling, and bilateral hearing loss, rated as noncompensable. The veteran's combined disability rating is 50 percent when a bilateral factor of 3.5 percent is taken into account. See 38 C.F.R. § 4.25, Table I (2007). Therefore, the percentage criteria of 38 C.F.R. § 4.16(a) have not been met. A claim for TDIU may be referred to the Compensation and Pension Service when a veteran does not meet the percentage standards of 38 C.F.R. § 4.16(a) but is otherwise unemployable due to service-connected disabilities. 38 C.F.R. § 4.16(b) (2007). A March 2002 VA medical report stated that "the narcotic pain medication that [the veteran] requires to reduce the pain also prohibits him from climbing or performing any other duties which might be eff[e]cted by the altered mental status that could come from narcotic use." In July 2003, a VA Vocational Rehabilitation and Employment examiner stated that the veteran's daily use of a significant amount of pain medication made "the pursuit of successful employment . . . not currently feasible." A June 2004 private medical report stated that "the combination of the [veteran's] reduced attention and memory, his pain-related difficulties, his chronic depression, and his preoccupation with health-related matters likely produce a debilitating condition which renders the [veteran] unable to function effectively in every day life circumstances." Finally, an April 2004 Social Security Administration decision found that the veteran was entitled to a period of disability commencing March 9, 2002 on the basis of his physical disabilities and inability to "make an adjustment to any work that exists in significant numbers in the national economy." However, the RO did not consider the application of 38 C.F.R. § 4.16(b) in adjudicating the veteran's claim for TDIU. Accordingly, the issue of TDIU must be remanded for the following actions: 1. The RO must consider whether the veteran's service-connected disorders render him unemployable regardless of whether the percentage standard in 38 C.F.R. § 4.16(a) has been met. If the RO finds that the veteran is unemployable due to his service-connected disorders, the RO must refer the appeal to the Chief Benefits Director or the Director, Compensation and Pension Service, for extra-schedular consideration on the issue of entitlement to TDIU. 2. Thereafter, the RO must implement the determinations of the Director, Compensation and Pension Service, if so warranted. If the claim on appeal remains denied, the veteran and his representative must be provided a supplemental statement of the case. After the veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs