Citation Nr: 0812475 Decision Date: 04/15/08 Archive Date: 05/01/08 DOCKET NO. 06-04 174 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an evaluation in excess of 20 percent for aseptic necrosis, right carpal lunate with secondary traumatic arthritis. 2. Entitlement to an evaluation in excess of 10 percent for residuals of a left hamstring injury with muscle rupture. 3. Entitlement to an evaluation in excess of 10 percent for degenerative joint disease of the left knee. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Kristi L. Gunn, Associate Counsel INTRODUCTION The veteran served on active duty from October 1974 to October 1978 and from October 1984 to September 1990. He also had a period of active duty for training (ACDUTRA) from June 8, 1996 to June 22, 1996. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2005 rating decision of the Waco, Texas, Department of Veterans Affairs (VA) Regional Office (RO), which continued the current evaluations for the veteran's service-connected aseptic necrosis, right carpal lunate with secondary traumatic arthritis; residuals of a left hamstring injury with muscle rupture; and degenerative joint disease of the left knee. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained. 2. The veteran's aseptic necrosis, right carpal lunate with secondary traumatic arthritis is manifested by no more than subjective complaints of pain and some limitation of motion. 3. The veteran's residuals of a left hamstring injury with muscle rupture consist of no more than a moderate disability to Muscle Group XIII. 4. The competent and probative evidence of record shows the veteran's service-connected degenerative joint disease of the left knee is characterized by subjective complaints of pain with no recurrent subluxation or lateral instability and slight limitation of motion. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for aseptic necrosis, right carpal lunate with secondary traumatic arthritis, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.7, 4.71a, Diagnostic Codes 5003, 5010, 5213 (2007). 2. The criteria for an evaluation in excess of 10 percent for residuals of a left hamstring injury with muscle rupture, Muscle Group XIII, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5106, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.7, 4.55, 4.56, 4.73 Diagnostic Code 5313 (2007). 3. The criteria for an evaluation in excess of 10 percent for degenerative joint disease of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.7, 4.71a, Diagnostic Codes 5003, 5010, 5257 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Decision General Law and Regulations Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2007). Separate diagnostic codes identify the various disabilities. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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). Although the Board has thoroughly reviewed all medical evidence of record, the Board will focus primarily on the more recent medical findings regarding the current level of disability related to the veteran's disability. The Board also notes that staged ratings may be appropriate in an increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The factors involved in evaluating, and rating disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. A. Aseptic Necrosis, Right Carpal Lunate with Secondary Traumatic Arthritis The veteran asserts that a higher evaluation is warranted for his service-connected right wrist disability. Factual Background In September 2005, the veteran underwent a VA examination for his service-connected right wrist disability. During the examination, the veteran reported a history of degenerative arthritis of the right wrist after he incurred a fracture of the wrist during his military service. He stated that he uses a brace for his wrist, but still has daily right wrist pain and stiffness. The veteran stated that his wrist disability affects his daily activities primarily with typing and driving. He noted some fatigue of the wrist and denied having any prosthesis in the body. Physical examination the right wrist revealed no pain on range of motion. Range of motion of the right wrist was dorsiflexion to 50 degrees, palmar flexion to 45 degrees, radial deviation to 17 degrees, and ulnar deviation to 30 degrees. The examiner opined that there was no additional functional impairment on the basis of fatigue, incoordination, pain, or weakness, and it would be speculative to describe any additional range of motion loss during flare-up or after repeated use. The examiner diagnosed the veteran with traumatic arthritis of the right wrist. VA and non-VA treatment records reflect continuing complaints and treatment for the veteran's service-connected right wrist disability. May 2005 VA outpatient treatment records noted right wrist pain complaints. In December 2005, private treatment records revealed continuing wrist pain with associated stiffness. It was noted that the wrist pain to the dorsum of the wrist joint does not radiate, but is constant, severe, sharp, throbbing, and aching. Examination of the right wrist reflected normal skin, soft tissue and bony appearance, and no gross edema or evidence of acute injury. Pain was elicited over the dorsal surface and dorsal jointline with no warmth or masses present. Muscle strength of the wrist flexors, extensors, pronators and supinators were 5/5 graded muscle strength, and the veteran exhibited limited active and passive range of motion. The right wrist was negative for the Phalen's test, Tinel sign, Finkelstein test, and snuffbox sign. Neurovascular testing revealed normal light touch and pain sensory of C7, C8, T1 including peripheral distribution, brisk radial pulse, and digital refill. X-rays showed avascular necrosis of the lunate with collapse of the lunate and arthritic changes of the radiocarpal portion of the joint. The veteran was assessed with primary localized osteoarthritis of the right wrist. The veteran was afforded a second VA examination in September 2006. The veteran informed the examiner that he injured his right wrist in 1980 while lifting weights, and since that time, he has endured pain in his right wrist. He rated the pain between a four and five on a scale of one to ten in terms of intensity, and complained of fatigability and lack of endurance of the wrist. The veteran stated that he took Ibuprofen three times a day and has had no side effects. He reported no flare-ups, but admitted to using a carpal tunnel- type brace for his right wrist when he is at home. Upon physical examination, the examiner noted that the veteran was right-handed. The right wrist was not painful, but the veteran exhibited some tenderness of the wrist. There was no objective evidence of painful motion, edema, effusion, instability, weakness, redness, heat, abnormal movement, or guarding of movement. The examiner reported no ankylosis of the right wrist or evidence of inflammatory arthritis. Right wrist range of motion testing noted palmar flexion to 70 degrees, dorsiflexion to 60 degrees, radial deviation to 20 degrees, and ulnar deviation to 25 degrees. There was no change in range of motion between active, passive, and repetitive range of motion. The examiner opined that there was no additional functional impairment on the basis of fatigue, incoordination, pain, or weakness. The examiner further added that to describe any additional range of motion loss during flare-up or after repeated use would be speculative. X-rays revealed remodeling of the lunate bone possibly from an old trauma. The radial carpal joint space was noted as being narrowed and the adjacent articular surfaces were mildy sclerotic. The examiner diagnosed the veteran with degenerative arthritis of the right wrist. Applicable Law and Regulations The veteran is currently rated as 20 percent disabling under Diagnostic Codes 5010-5213. See 38 C.F.R. § 4.27 (A hyphenated code is used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation). The evidence shows that the veteran is right-handed, and thus the ratings for the dominant (major) arm apply. Under Diagnostic Code 5213, limitation of supination of either forearm to 30 degrees or less warrant a 10 percent rating. Limitation of pronation of the forearm of the major upper extremity warrants a 20 percent evaluation if motion is lost beyond the last quarter of the arc and the hand does not approach full pronation. A 30 percent evaluation requires that motion be lost beyond the middle of the arc. 38 C.F.R. § 4.71a, Diagnostic Code 5213. Diagnostic Code 5213 also provides for a 20 percent rating for bone fusion with loss of supination and pronation of the forearm of the major upper extremity if the hand is fixed near the middle of the arc or in moderate pronation; a 30 percent rating requires that the had be fixed in full pronation. A 40 percent rating requires that the hand be fixed in supination or hyperpronation. 38 C.F.R. § 4.71a, Diagnostic Code 5213. VA's Adjudication Procedure Manual, M21-1MR, Part III, Subpart iv, Chapter 4, Section A, provides guidance for considering impairment of supination and pronation, including the following: full pronation is the position of the hand flat on a table and full supination is the position of the hand palm up. When examining limitation of pronation, the arc is from full supination to full pronation, and middle of the arc is the position of the hand, palm vertical to the table. This guidance states that the lowest 20 percent evaluation is to be assigned when pronation cannot be accomplished through more than the first three-quarters of the arc from full supination. Normal forearm pronation is from 0 to 80 degrees, and normal supination is from 0 to 85 degrees. See 38 C.F.R. § 4.71, Plate I. Arthritis due to trauma is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by x-ray findings is rated according to limitation of motion for the joint or joints involved. Where limitation of motion is noncompensable, a rating of 10 percent is assigned for each major joint (including the ankle and the knee) or group of minor joints affected by limitation of motion to be combined not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion a 10 percent rating is assigned where there is x-ray evidence of involvement of two or more major joints, or two or more minor joint groups; and a 20 percent evaluation is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2007). Under Diagnostic Code 5214, a 50 percent rating is assigned for ankylosis of the major wrist when ankylosis is unfavorable, in any degree of palmar flexion, or with ulnar or radial deviation. A 40 percent rating is assigned for ankylosis of the major wrist when there is ankylosis in any other position except favorable. A 30 percent rating is assigned for ankylosis of the major wrist that is favorable in 20 degrees to 30 degrees dorsiflexion. Extremely unfavorable ankylosis will be rated as loss of use of the hands under Diagnostic Code 5125. 38 C.F.R. § 4.71a, Diagnostic Code 5214. Diagnostic Code 5215 provides for a 10 percent rating for limitation of motion of the wrist where dorsiflexion is less than 15 degrees or where palmar flexion is limited in line with forearm. 38 C.F.R. § 4.71a, Diagnostic Code 5215. For VA purposes, normal dorsiflexion of the wrist is from 0 to 70 degrees, and normal palmar flexion is from 0 to 80 degrees. Normal ulnar deviation of the wrist is from 0 to 45 degrees, and normal radial deviation is from 0 to 20 degrees. Normal forearm pronation is from 0 to 80 degrees and normal forearm supination is from 0 to 85 degrees. 38 C.F.R. § 4.71, Plate I (2007). Analysis Based upon the evidence of record, the Board finds a higher evaluation for the veteran's service-connected right wrist disability is not warranted. As previously mentioned, the veteran's right wrist disability is currently rated 20 percent disabling by analogy to Diagnostic Code 5213 for impairment of supination and pronation of the elbow. However, the clinical findings of record do not support a higher evaluation for the veteran's right wrist disability under Diagnostic Code 5213. The veteran's right wrist disability also does not warrant a higher rating under Diagnostic Code 5010. While both VA examiners diagnosed the veteran with traumatic and degenerative arthritis of the right wrist, the service- connected disability is not shown to involve two or more major joints or two or more minor joint groups and there is no objective evidence of swelling, muscle spasm, or painful motion. Thus, no disability rating in excess of 20 percent is warranted under Diagnostic Code 5010. The Board has also considered evaluation of the veteran's right wrist disability under all other potentially appropriate diagnostic codes. In this case, the veteran's right wrist does not have ankylosis. The September 2006 VA examiner reported no ankylosis of the right wrist, and the veteran exhibited movement of his right wrist in planes of excursion (dorsiflexion, palmar flexion, radial deviation, and ulnar deviation) during both VA examinations. Thus, Diagnostic Code 5214 is not for application. See 38 C.F.R. § 4.71a, Diagnostic Codes 5214. Diagnostic Code 5215 is not applicable because the veteran is currently receiving 20 percent and the code only allows for 10 percent as the maximum. No additional consideration is necessary in this regard. The Board must also consider whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In this regard, the Board observes that the veteran has complained of daily pain on numerous occasions, but when viewed in conjunction with the medical evidence, his complaints do not tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. As noted above, during both VA examinations, the veteran's range of motion of the right wrist was noted as not being limited by pain, fatigue, weakness, lack of endurance or incoordination. The degree of limitation of motion is contemplated in the current rating. Therefore, the Board finds that the holding in DeLuca and the provisions of 38 C.F.R. §§ 4.40 and 4.45 do not provide a basis for a higher rating. Finally, the Board has considered whether the veteran is entitled to a "staged" rating for his service-connected aseptic necrosis, right carpal lunate with secondary traumatic arthritis, as the Court indicated can be done in this type of case. See Hart v. Mansfield, supra. However, upon reviewing the longitudinal record in this case, we find that at no time during the claim and appeal period has the service-connected right wrist disability been more disabling than as currently rated under the present decision. The veteran is competent to report his symptoms, and the Board does not doubt the sincerity of the veteran's belief that his service-connected disability has worsened; however, the objective clinical findings do not support his assertions for the reasons stated above. As the preponderance of the evidence is against the veteran's claim for an increased rating for his right wrist disability, the benefit-of-the- doubt doctrine is not for application, and an increased rating must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55. B. Residuals of a Left Hamstring Injury with Muscle Rupture The veteran contends that his service-connected residuals of a left hamstring injury with muscle rupture are worse than the current evaluation contemplates Factual Background By history, it is noted that the service medical records show that the veteran injured his left hamstring after running a 100 meter dash in June 1996. The veteran was assessed with a left hamstring pull. Thereafter, in pertinent part, in September 2005, the veteran was afforded a VA examination for his service-connected residuals of a left hamstring injury with muscle rupture. During the examination, the veteran reported that he injured Muscle Group XIII in 1990 after participating in a running exercise. He was treated with heat and capsaicin type cream to relieve the pain, but since that time, he has endured recurrent muscle pain in the posterior left thigh when he walks to a distance of one mile. The veteran stated that he did not have any surgery, and there were no associated injuries of the bones, nerves, tumors, or vascular structures. He rated his pain as a seven on a scale of zero to ten in terms of intensity. Upon physical examination of the veteran, the examiner noted no entry or exit wounds, as well as no tissue loss or scar formation. There were no adhesions, tendon damage, or bone, joint, or nerve damage. The veteran exhibited good muscle strength with no muscle herniation and no affect on the joint. The examiner observed the veteran squat and rise four times, and noted that he demonstrated good muscle strength with no hamstring muscle deformity present. Active, passive, and repetitive range of motion of Muscle Group XIII was tested, and the veteran did not exhibit any pain, fatigue, weakness or lack of endurance following repetitive movements. X-rays of the left thigh were taken, and the examiner diagnosed the veteran with status post left hamstring muscle tear with minimal loss of function. In September 2006, the veteran underwent a second VA examination for his service-connected left hamstring disability. The veteran informed the examiner of his history of a left hamstring injury in 1990, which now causes residual muscle cramping and flare-ups that occur approximately every other day. Prolonged standing aggravates his cramps in his left posterior thigh, which is alleviated by muscle relaxers. The veteran denied having any additional limitation of motion or functional impairment during a flare-up, and there were no associated injuries affecting the bone structures, nerves, or vascular structures. The veteran also indicated that there were no tumors of the muscle, and the joint was not affected. Physical examination of the left hamstring muscle revealed no injury or exit wound as well as no tissue loss. There was no scar, adhesion, or tendon damage. The veteran demonstrated good muscle strength, with no bone, joint, or nerve damage present. The examiner noted that there was no muscle herniation, and the veteran does not have any loss of muscle function. The left knee moved through its range of motion with the joint not being affected. There was no objective evidence of painful motion, spasm, weakness, or tenderness, and there was no change in the range of motion with active, passive, or repetitive range of motion. The examiner opined that there was no additional functional impairment on the basis of fatigue, incoordination, pain, or weakness, but to describe any additional range of motion loss during flare-up or after repeated use would resort to speculation. The examiner diagnosed the veteran with status post left hamstring injury with occasional episodes of cramping. Applicable Law and Regulations The veteran's service-connected residuals of a left hamstring injury with muscle rupture are currently evaluated under Diagnostic Code 5313. Diagnostic Code 5313 provides evaluations for disability of Muscle Group XIII. The functions of these muscles are as follows: extension of hip and flexion of knee; outward and inward rotation of flexed knee; and acting with rectus femoris and sartorius (see XIV, 1, 2) synchronizing simultaneous flexion of hip and knee and extension of hip and knee by belt-over-pulley action at knee joint. The muscle group includes the posterior thigh group, hamstring complex of 2-joint muscles: (1) biceps femoris; (2) semimembranosus; and (3) semitendinosus. The veteran's 10 percent disability rating is based on a moderate injury to the muscle group. A moderately severe injury warrants a 30 percent rating, while a severe injury warrants a 40 percent rating. See 38 C.F.R. § 4.73, Diagnostic Code 5313 (2007). As set forth in the above criteria, disabilities resulting from muscle injuries are classified as slight, moderate, moderately severe, and severe. 38 C.F.R. § 4.56(d) (2007). "Slight" muscle disability contemplates a simple wound of the muscle without debridement or infection; a service department record of a superficial wound with brief treatment and return to duty; healing with good functional results; and no cardinal signs or symptoms of muscle disability. Objectively, there is a minimal scar; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(1). "Moderate" muscle disability contemplates a through and through or deep penetrating wound of short track from a single bullet, small shell, or shrapnel fragment, without the explosive effect of a high velocity missile, residuals of debridement, or prolonged infection; a service department record or other evidence of in-service treatment for the wound; and a record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objectively, there are entrance and (if present) exit scars that are small or linear, indicating a short track of missile through muscle tissue; and some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). "Moderately severe" muscle disability contemplates a through and through or deep penetrating wound by a small high velocity missile, or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring; a service department record or other evidence showing hospitalization for a prolonged period for the wound; a record of consistent complaint of cardinal signs and symptoms of muscle disability; and, if present, evidence of inability to keep up with work requirements. Objectively, there are entrance and (if present) exit scars indicating track of missile through one or more muscle groups; indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscle compared with the sound side; and tests of strength and endurance compared with the sound side demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). "Severe" muscle disability contemplates a through and through or deep penetrating wound due to a high velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding, and scarring; a service department record or other evidence showing hospitalization for a prolonged period for treatment of the wound; a record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries; and, if present, evidence of inability to keep up with work requirements. Objectively, there are ragged, depressed, and adherent scars indicating wide damage to muscle groups in the missile track; palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in the wound area; muscles swell and harden abnormally in contraction; and tests of strength, endurance, or coordinated movements indicate severe impairment of function when compared with the uninjured side. If present, the following are also signs of "severe" muscle disability: (a) x-ray evidence of minute, multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; (b) adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum, or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (c) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (d) visible or measurable atrophy; (e) adaptive contraction of an opposing group of muscles; (f) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (g) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lower threshold of fatigue, fatigue-pain, impairment of coordination; and uncertainty of movement. 38 C.F.R. § 4.56(c) (2007). When evaluating musculoskeletal disabilities, VA must, in addition to applying schedular criteria, consider granting a higher rating in cases in which the veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45 (2007); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Analysis Based upon the evidence of record, the Board finds that the evidence does not support a finding that the veteran's residuals of a left hamstring injury with muscle rupture results in a moderately severe disability under Diagnostic Code 5313. The evidence is devoid of findings or complaints defined by regulation as cardinal signs and symptoms of muscle disability. In particular, no examiner has found any loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, or uncertainty of movement in the veteran's left posterior thigh. Additionally, there is no evidence of muscle damage, nor is there evidence of tendon, artery, nerve, or bone damage. The evidence simply does not support a finding that the muscle injury is anything more than moderate, and accordingly, a rating in excess of 10 percent is not warranted. The Board has also considered application of 38 C.F.R. §§ 4.40 and 4.45 in light of the Court's ruling in DeLuca v. Brown, 8 Vet. App. 202 (1995). In that regard, the veteran has complained of pain of the left thigh. The Board finds that an additional evaluation for pain and limitation of function under these provisions is not warranted. The veteran has complaints of pain in his left thigh, however, the recent VA examination reports, reflect no objective evidence of fatigability or weakness. The veteran has already been compensated consistent with his symptoms for impairment of Muscle Group XIII under Diagnostic Code 5313. Thus, he has already been compensated for painful motion and any functional loss. 38 C.F.R. §§ 4.40, 4.45, DeLuca, supra. The Board also finds that staged ratings are not warranted here, as the degree of impairment due to his service- connected residuals of a left hamstring injury with muscle rupture have not varied significantly during the appeal period. See Hart v. Mansfield, supra. The veteran is competent to report his symptoms, and the Board does not doubt the sincerity of the veteran's belief that his service-connected disability has worsened. However, the objective clinical findings do not support his assertions for the reasons stated above. As the preponderance of the evidence is against the veteran's claim for an increased rating for his residuals of a left hamstring injury with muscle rupture, the benefit-of-the-doubt doctrine is not for application, and an increased rating must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55. C. Degenerative Joint Disease of the Left Knee The veteran contends that his left knee disability warrants a higher evaluation, in excess of the current 10 percent. Factual Background VA and non-VA treatment records reflect continuing complaints of left knee pain. In December 2005, private treatment records note the veteran's left knee pain, with an onset of four years ago. The treatment record states that the veteran was scheduled for arthroscopic surgery after Magnetic Resonance Image (MRI) results revealed a complex tear of the posterior horn of the medial meniscus, but the veteran subsequently canceled the surgery. Examination of the left knee exhibited normal skin, soft tissue and bony appearance, and no gross edema or evidence of acute injury. Pain was noted at the medial jointline, and sensation was intact to light touch and pain. There was brisk popliteal pulse and 2/4 patellar tendon reflex. Muscular strength was 5/5, and the examiner reported limited active and passive range of motion. The veteran's left knee was positive for McMurray's sign, but negative for posterior drawer, Lachman's, lateral collateral instability with varus, medial collateral instability with valgus, patellar apprehension sign, patellar-femoral grind, and patellar ballottement. X-rays of the left knee showed slight narrowing of the medial joint space with no fractures or lytic lesions, but there were some small spurs medially. The physician diagnosed the veteran with left knee pain and derangement of posterior horn of medial meniscus. The physician recommended arthroscopic surgery for his left knee, which was scheduled and performed thereafter. In September 2006, the veteran was afforded a VA examination for degenerative joint disease of the left knee. The veteran informed the examiner that he has pain in his left knee, between a four and five on a scale of one to ten in terms of intensity. He denied having heat or redness, but noted weakness, stiffness, swelling, and instability of the joints. The veteran stated that he has some locking of the left knee, and also complained of fatigability and lack of endurance of the joint. He denied experiencing flare-ups, and episodes of dislocation, recurrent subluxation, or inflammatory arthritis. The veteran reported that his left knee disability affects his daily activities; he does not use a crutch, cane, brace, or corrective shoes; and left knee surgery was performed in December 2005. Physical examination of the veteran revealed joints that were not painful. There was no objective evidence of painful motion, edema, effusion, instability, weakness, redness, heat, abnormal movement, or guarding of movement. The examiner stated that the veteran exhibited some tenderness of the left knee, but there were no callosities, breakdown, or unusual shoe-wear pattern that was indicative of abnormal weightbearing. There was no ankylosis of any joints or inflammatory arthritis, and both legs were of equal length. Range of motion testing revealed flexion to 120 degrees, with no change in range of motion between the active, passive, and repetitive range of motion. All ligaments appeared intact, and the medial and lateral meniscal test was negative bilaterally. The examiner opined there was no additional functional impairment on the basis of fatigue, incoordination, pain, or weakness, and it would be speculative to describe any additional range of motion loss during a flare-up or after repeated use. X-rays of the left knee were taken, and the examiner diagnosed the veteran with degenerative arthritis of the left knee. Applicable Law and Regulations The veteran's left knee disability is currently rated as 10 percent disabling under Diagnostic Codes 5010-5257. Under Diagnostic Code 5257, recurrent subluxation or lateral instability warrants a 10 percent rating if slight, a 20 percent rating if moderate, and a 30 percent rating if severe. The Board observes that the words "slight," "moderate," 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," under 38 C.F.R. § 4.6. It should also be noted that use of descriptive terminology such as "mild" by medical examiners, 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 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. Arthritis due to trauma is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by x-ray findings is rated according to limitation of motion for the joint or joints involved. Where limitation of motion is noncompensable, a rating of 10 percent is assigned for each major joint (including the ankle and the knee) or group of minor joints affected by limitation of motion to be combined not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion a 10 percent rating is assigned where there is x-ray evidence of involvement of two or more major joints, or two or more minor joint groups; and a 20 percent evaluation is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2007). Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2007). The normal range of motion for the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2007). Under Diagnostic Code 5260, flexion of the leg limited to 60 degrees warrants a noncompensable evaluation; flexion limited to 45 degrees warrants a 10 percent evaluation; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to 15 degrees warrants a 30 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2007). Under the criteria for limitation of extension for the leg, a noncompensable rating is assigned for a limitation of extension of the leg to 5 degrees. When extension is limited to 10 degrees, a 10 percent rating is assigned. A 20 percent rating is appropriate where extension is limited to 15 degrees. A 30 percent rating is assigned in the case of extension limited to 20 degrees. A 40 percent rating is appropriate where extension is limited to 30 degrees. A 50 percent rating is assigned for limitation of extension to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2007). Analysis The Board has carefully reviewed the evidence of record, and finds that the preponderance of the evidence is against an evaluation in excess of 10 percent based upon laterally instability or subluxation. Specifically, the evidence of record does not support the contention that the veteran has moderate recurrent subluxation or instability of the left knee. As previously stated, the December 2005 private treatment report notes that physical examination of the veteran revealed no lateral instability with varus or medial collateral instability with valgus. Furthermore, the veteran reported during the September 2006 VA examination that he experienced instability of the left knee, but on physical examination, the examiner stated that the left knee did not exhibit instability. Such clinical findings establish that the veteran does not, in fact, have recurrent subluxations or lateral instability in the knee. Thus, the Board finds that the veteran's service-connected left knee disability would not warrant a compensable rating under this provision. Thus, a rating in excess of 10 percent is not warranted either. The Board notes that VA's General Counsel has advised that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5010 and 5257, without pyramiding under 38 C.F.R. § 4.14. See VAOPGCPREC 23-97. While the veteran has mild degenerative arthritis of the knee, as noted above, no evidence of instability or subluxation is present. Additionally, neither a higher nor a separate rating is warranted under Diagnostic Codes 5260 or 5261 either. During the September 2006 VA examination, the veteran demonstrated range of motion from 0 to 120 degrees with no objective evidence of painful motion. As such, while the veteran's left knee exhibits some limitation of motion, it is not sufficient to warrant a noncompensable rating under Diagnostic Codes 5260 and 5261. In addition, pursuant to VAOPGPREC 9-98 (August 14, 1998), a separate rating for arthritis could also be based on x-ray findings and painful motion under 38 C.F.R. § 4.59. Under 38 C.F.R. § 4.59, it states that the intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It further states that it is the intent to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable evaluation for the joint. Id. While there are subjective complaints of left knee pain, there is no objective evidence of record that states the veteran has pain while demonstrating range of motion. Furthermore, given the absence of a large quantifiable diminution in range of motion, the current 10 percent rating already in effect adequately compensates the veteran for the level of impairment demonstrated, and the assignment of a schedular evaluation in excess of 10 percent is not warranted on the basis of 38 C.F.R. § 4.59. The Board has also considered whether the veteran's service- connected left knee disability may be rated under any other diagnostic codes related to the knee and leg. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Several of these diagnostic codes are simply not applicable to the veteran's service-connected disability. It is neither contended nor shown that the veteran's service-connected disability involves ankylosis of the knee (Diagnostic Code 5256), dislocated semilunar cartilage (Diagnostic Code 5258), removal of semilunar cartilage (Diagnostic Code 5259), impairment of the tibia and fibula (Diagnostic Code 5262), or genu recurvatum (Diagnostic Code 5263). The Board notes the application of DeLuca v. Brown, 8 Vet. App. 202 (1995) (addressing 38 C.F.R. §§ 4.40, 4.45) to the evaluation of the veteran's service-connected disability under Diagnostic Code 5257 is not appropriate, as that Diagnostic Code does not contemplate limitation of motion and thus could not serve as a basis to the grant of an increased evaluation. See Johnson v. Brown, 9 Vet. App 7, 11 (1996) (holding that Diagnostic Code 5257 is not predicated on loss of range of motion and thus 38 C.F.R. §§ 4.40 and 4.45 are not applicable to a disability rated under that Diagnostic Code). Moreover, as noted above, the 10 percent rating adequately compensates the veteran for the degree of disability shown. The veteran is competent to report his symptoms; however, to the extent that he has asserted he warrants more than a 10 percent evaluation for his left knee disability, the objective clinical findings do not establish a basis for a higher evaluation for any period of time during the course of the appeal. Hart v. Mansfield, supra. The preponderance of the evidence is against a finding that the service-connected left knee disability is any more than slightly disabling for the reasons stated above. The benefit-of-the-doubt rule is not for application. See Gilbert, 1 Vet. App. at 55. II. Duty to Notify & Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA in terms of its duty to notify and assist claimants. When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004), the Court held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide; and that (4) VA will request that the claimant provide any evidence in his possession that pertains to the claim. For an increased-compensation claim, section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22. Vet. App. 37 (2008). Further, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Vazquez-Flores, supra. In this case, the RO sent letters to the veteran in July 2005 and May 2006 regarding the VCAA notice requirements for increased rating claims. In the letters, the veteran was informed that the evidence necessary to substantiate the claims for increased evaluations would be evidence showing that his disabilities are worse than the current evaluations contemplate. The letters also informed the veteran that he must provide medical or lay evidence demonstrating a worsening of his disabilities and the impact on his employment and daily life, which can also be substantiated by sending statements from other individuals who are able to describe in what manner the disability has become worse. It also informed him that on his behalf, VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. The letters stated that he would need to give VA enough information about the records so that it could obtain them for him. Finally, he was told to submit any evidence in his possession that pertained to the claims. While the Board acknowledges the two letters, the VCAA duty to notify has not been satisfied because the letters did not specifically advise the veteran of the criteria necessary to warrant higher evaluations for his service-connected disabilties. In Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit held that any error by VA in providing the notice required by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial, and that once an error is identified as to any of the four notice elements the burden shifts to VA to demonstrate that the error was not prejudicial to the appellant. The Federal Circuit stated that requiring an appellant to demonstrate prejudice as a result of any notice error is inconsistent with the purposes of both the VCAA and VA's uniquely pro-claimant benefits system. Instead, the Federal Circuit held in Sanders that all VCAA notice errors are presumed prejudicial and require reversal unless VA can show that the error did not affect the essential fairness of the adjudication. To do this, VA must show that the purpose of the notice was not frustrated, such as by demonstrating: (1) that any defect was cured by actual knowledge on the part of the claimant, see Vazquez-Flores v. Peake, 22. Vet. App. 37 (2008) ("Actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim.") (citing Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007)); (2) that a reasonable person could be expected to understand from the notice what was needed; or (3) that a benefit could not have been awarded as a matter of law. Sanders, 487 F.3d at 889. Additionally, consideration also should be given to "whether the post-adjudicatory notice and opportunity to develop the case that is provided during the extensive administrative appellate proceedings leading to the final Board decision and final Agency adjudication of the claim ... served to render any pre-adjudicatory section 5103(a) notice error non-prejudicial." Vazquez-Flores v. Peake, 22. Vet. App. 37 (2008). In this case, the Board finds that the notice errors did not affect the essential fairness of the adjudication because the veteran had actual knowledge of what was necessary to substantiate his claims for increased rating, which is shown by his statements contending that his disabilities have worsened in severity and affect his overall daily functioning. The Board finds that by way of the veteran's actual knowledge and the overall development of his claims throughout the pendency of this appeal, the errors of notice are non-prejudicial to the veteran. In addition to the foregoing analysis, to whatever extent the recent decision of the Court in Dingess v. Nicholson, 19 Vet. App. 473 (2006), requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date, the Board finds no prejudice to the veteran in proceeding with the present decision. Since the claims are being denied, any such effective date questions are moot. The veteran has had ample opportunities to meaningfully participate in the adjudicative claims process. Any error or deficiency in this regard is harmless, and not prejudicial. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2007). In connection with the current appeal, VA obtained the veteran's service medical records, VA outpatient treatment records dated February 1996 to May 2005, and private medical records from May 2002 to January 2006. The veteran was also provided VA examinations in connection with his claims. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims. The evidence of record provides sufficient information to adequately evaluate the claims. Therefore, no further assistance to the veteran with the development of evidence is required, nor is there notice delay or deficiency resulting in any prejudice to the veteran. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). ORDER Entitlement to an evaluation in excess of 20 percent for aseptic necrosis, right carpal lunate with secondary traumatic arthritis is denied. Entitlement to an evaluation in excess of 10 percent for residuals of a left hamstring injury with muscle rupture is denied. Entitlement to an evaluation in excess of 10 percent for degenerative joint disease of the left knee is denied. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs