Citation Nr: 0812863 Decision Date: 04/18/08 Archive Date: 05/01/08 DOCKET NO. 04-44 591 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for service-connected residuals of a left knee injury, torn meniscus, and retropatellar pain syndrome, prior to January 1, 2008. 2. Entitlement to an initial rating in excess of 10 percent for the veteran's service-connected left knee disability, beginning January 1, 2008. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Mark Vichich, Associate Counsel INTRODUCTION The veteran served on active duty from May 2003 to November 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The veteran testified before the undersigned Veterans Law Judge at a travel board hearing in January 2008; a transcript is of record. At her travel board hearing in January 2008, the veteran submitted additional evidence pertinent to this appeal. The veteran has waived initial RO consideration of this evidence. 38 C.F.R. § 20.1304(c) (2007). Consequently, the Board will proceed with the adjudication of this claim notwithstanding that the RO has not considered this evidence. In a rating decision dated in October 2007, the RO reduced the rating for the veteran's left knee disability from 30 percent to 10 percent, effective January 1, 2008. The veteran has not appealed this decision and the Board has no jurisdiction over it. 38 C.F.R. § 20.202 (2007). However, as this is an appeal of an initial rating, the Board will consider the ratings assigned throughout the entire appeal period. See Fenderson v. West, 12 Vet. App. 119 (1999). FINDINGS OF FACT 1. The competent medical evidence does not show that the veteran's service-connected residuals of a left knee injury, torn meniscus, and retropatellar pain syndrome was manifested by extension limited to 30 degrees or more, malunion of the tibia and fibula, or ankylosis, at any time during the course of this appeal during which the veteran was not granted a temporary total disability rating. 2. The competent medical evidence shows that the veteran's service-connected left knee disability was manifested by frequent falling and dislocations, swelling, decreased range of motion, stiffness, instability, subluxations, and effusion throughout the entire appeal period despite her rehabilitation efforts and multiple surgeries. CONCLUSIONS OF LAW 1. The schedular criteria for a rating in excess of 30 percent for service-connected left knee injury, torn meniscus, retropatellar pain syndrome, have not been met or approximated at any time during the appeal period. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.40-4.46, 4.59, 4.71a, Diagnostic Code 5299-5257 (2007). 2. The schedular criteria for an initial rating of 30 percent for service-connected left knee injury, torn meniscus, retropatellar pain syndrome, beginning January 1, 2008 have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.159, 4.1-4.14, 4.40-4.46, 4.59, 4.71a, Diagnostic Code 5299-5257 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA with respect to its duty to notify and assist a claimant in developing a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2007); 38 C.F.R. § 3.159 (2007). Under the VCAA, upon receipt of a complete or substantially complete application for benefits, VA is required to notify the veteran and her representative, if any, of any information and medical or lay evidence necessary to substantiate the claim. The United States Court of Appeals for Veterans Claims (hereinafter the Court) has held that these notice requirements apply to all five elements of a service connection claim, which 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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA law and regulations also indicate that part of notifying a claimant of what is needed to substantiate a claim includes notification as to what information and evidence VA will seek to provide and what evidence the claimant is expected to provide. Further, VA must ask the claimant to provide any evidence in her or his possession that pertains to the claim. 38 U.S.C.A. § 5103 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.159(a)-(c) (2007). VCAA notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). For an increased-compensation claim, VCAA requires, at a minimum, that VA notify the claimant that the evidence demonstrates a worsening or increase in severity of the disability and the effect that worsening has on the veteran's employment and daily life. Vazquez-Flores v. Peake 22 Vet. App. 37 (2008). 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. Id. The Board finds that the VA has no further duty to notify prior to Board adjudication. The RO initially provided notice to the veteran in correspondence dated in January 2004. In that correspondence, which was provided to the veteran prior to initial adjudication of her service connection claim, the RO advised the veteran of what the evidence needed to show to establish entitlement to service- connected compensation benefits. The RO advised the veteran of VA's duties under the VCAA and the delegation of responsibility between VA and the veteran in procuring the evidence relevant to the claim, including which portion of the information and evidence necessary to substantiate the claims was to be provided by the veteran and which portion VA would attempt to obtain on behalf of the veteran. The RO also essentially requested that the veteran send any evidence in her possession that pertained to the claim, namely by requesting any additional evidence concerning the claimed condition and enough information for the RO to request records from the sources identified by the veteran. In correspondence dated in March 2006, the RO informed the veteran that when service connection is granted, a disability rating and effective date of the award is assigned. The RO also explained how the disability rating and effective date are determined. The Board finds that in issuing this letter, the RO has satisfied the requirements of Dingess/Hartman. The veteran has also demonstrated actual knowledge that to support her claim for a higher rating, she needed to show worsening or increase in severity of the disability and the effect that worsening had on her employment and daily life. For example, in her VA Form 9, dated in December 2004, the veteran alleged that she could not bend her left knee and had to sit with the knee fully extended. The veteran also stated that surgery would be necessary to increase knee motion. In a statement dated in May 2004, the veteran stated she was unable to bend her knee to sit properly in a chair. The veteran also claimed her doctors told her they were unable to fix the knee and that it would get worse over time. The veteran's descriptions of such signs pertaining to her left knee disability are evidence that she knew what type of evidence pertained to the disability rating determination. Such knowledge cures any timing or content defects of the notice as it pertains to the veteran's increased rating claim. In July 2007, the RO readjudicated the claim and issued a supplemental statement of the case. The issuance of compliant notice followed by a readjudication of the claim remedied any timing defect with respect to issuance of compliant notice. See Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006). Finally, the Board finds that the RO has satisfied VA's duty to assist. The RO has obtained the veteran's service medical records and VA Medical Center (VAMC) treatment records. The veteran has not requested that VA obtain any private medical records on her behalf. The RO has also provided the veteran with four VA examinations throughout the course of this appeal to determine the severity of her left knee disability. The veteran has not made the RO or the Board aware of any other evidence relevant to her appeal and no further development is required to comply with the duty to assist the veteran in developing the facts pertinent to her claim. Accordingly, the Board will proceed with appellate review. Evidence A Physical Evaluation Board, in November 2003, found the veteran unfit for duty because of her retropatellar pain syndrome of the left knee following injury (patella subluxation). In a VA joints examination report, dated in January 2004, Dr. J.R. noted diffuse edema of moderate amount both anteriorly and posteriorly in the left knee. Dr. J.R. also reported range of motion of the left knee to be from zero to 50 degrees, which produced "severe pain." There was also marked laxity with lateral compression, no crepitus. There was marked tenderness inferiorly and laterally. Dr. J.R.'s impression was left knee with pain and meniscal tear, marked limitation of motion, severe disability with progression. In a VAMC orthopedic outpatient note, dated in May 2004, Dr. J.M. found the veteran's left knee to be mildly swollen. Range of motion was decreased with approximately 5 degrees lacking full extension to about 50 degrees of flexion. She had no varus or valgus instability. Lachman's sign was negative. The veteran had a slight amount of tenderness to palpation surrounding the entire patella, but this did not sublux and tracked well throughout the arch of motion. X- rays showed an old zygon fracture or a healed capsular avulsion. X-rays were otherwise normal. Dr. J.M.'s assessment was arthrofibrosis. Dr. J.M. stated that the plan would be for the veteran to regain her range of motion. Dr. J.M. prescribed physical therapy, but noted the possibility of arthroscopic surgery. In a VA orthopedic outpatient follow-up note, dated in July 2004, Dr. C.T. reported the following findings. Left knee was mildly edematous. The veteran lacked 5 degrees of extension and could only flex to 60 degrees, at which point she experienced "a significant amount of pain." There was no instability of the patella and no tenderness to palpation medially or laterally on the patella. There was tenderness to palpation over the lateral collateral ligaments and very mild tenderness medially. There was no noted varus or valgus instability and no anterior drawer sign. Dr. C.T. noted, however, that parts of the examination were limited secondarily to pain and non-compliance secondary to pain. X-rays showed a small bulge, which appeared to be a segund fracture, chronic in nature. A magnetic resonance imaging (MRI) showed all ligaments intact and small concerning area of her posterior medial meniscus, which could represent degenerative versus small tear. Dr. C.T.'s assessment was left knee arthrofibrosis with possible internal derangement. Dr. C.T. recommended arthroscopic surgery. A VA operative report, dated July 19, 2004, showed the veteran underwent diagnostic arthroscopy, with debridement. Dr. C.R. summarized as follows. Despite numerous conservative measures, the veteran's range of motion was from 5 to 60 degrees, which Dr. C.R. described as very poor. The range of motion was always limited by pain. Given these findings, the veteran underwent an MRI, which showed intact ligaments, but a possible meniscal tear of the medial meniscus. The tear, however, was not very obvious. After the veteran had been brought under anesthesia, the veteran's range of motion was from zero to 140 degrees. Diagnostic arthroscopy revealed a very large suprapatellar plica and a mild bit of synovitis. Lateral compartment showed an intact meniscus with no significant chondromalacia. There was a small, frayed area of cartilage that was not articular at the medial aspect of the lateral femoral condyle. In a VA examination report, dated in September 2004, J.M., Physician Assistant, Certified, reported the following subjective complaints. The veteran was not doing well since her arthroscopy in July 2004. The veteran was unable to walk 20-30 feet without falling and had to use crutches all the time. She had fallen in the shower because of the knee giving away. She was unable to do housework, dress, or do other activities of daily living without problems. The veteran currently took Etodolac and Vicodin daily to control the pain. She regularly wore a sports brace for support. On examination, J.M. noted the veteran walked with the assistance of crutches and had a limp. Range of motion was from zero to 130 degrees, but with pain throughout the range. At 30 degrees, the knee would not bend any further in spite of her being well relaxed. There was a mechanic block to the flexion of the knee. Knee was stable to varus and valgus stress and the anterior drawer and Lachman's were negative. J.M.'s impression was lateral patella dislocation of the left knee in service with loss of significant range of motion. The veteran had significant arthrofibrosis and contraction of the quadriceps mechanism and probably the joint capsule and other supporting structures of the knee causing her loss of motion at the present. This was a significant limitation for the veteran. J.M. stated that the veteran would probably need more surgery in the future. Her convalescence was not known at that time, but appeared to be "many more months." In an orthopedic outpatient follow-up note, dated in October 2004, the examiner reported range of motion from 5 to 60 degrees. In an orthopedic outpatient follow-up note, dated in January 2005, Dr. E.V. reported that range of motion was from zero to 35 degrees. Dr. E.V. stated that there were no surgical solutions at that point and that she would be referred to the pain clinic for solutions. In a radiology report, dated in January 2005, Dr. D.N. reported findings of normal appearing menisci. The anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments appeared normal in signal and architecture. Soft tissue surrounding the knee appeared to be normal. No abnormalities were seen. In a VA examination report, dated in August 2005, J.M. noted the veteran's complaints of knee locking. J.M. stated that the MRI and arthroscopic surgery showed no reason for instability or locking. On examination, active range of motion was from 5 to 30 degrees, with resistance and complaints of discomfort at 30 degrees. Passive range of motion was to 110 degrees with some discomfort. On repetitive motion, range was from 5 to 40 degrees. There was no increased pain, loss of motion, weakness, fatigability, or incoordination. J.M.'s impression was chronic left knee pain with greatly decreased range of motion and functional overlay. J.M. stated there was no definite diagnosis of why she was having so much knee pain and such a limited range of motion. The MRI was normal and arthroscopic examination was essentially normal except for some arthrofibrosis and a plica, which was resected. There was some functional overlay and poor pain tolerance affecting her left knee. There was no evidence of reflex sympathetic dystrophy or neurological problems. In a treatment record from North Central Texas Orthopaedics and Sports Medicine, dated in September 2006, Dr. W.M. reported that he had reviewed MRI arthrography of the left knee. According to this record, the veteran reported pain with activity, twisting, turning, and during the nighttime. Dr. W.M. stated that the veteran's degenerative posterior horn medial meniscus tear was "pretty significant." Dr. W.M. also noted significant lateral subluxation of the kneecap. Dr. W.M. stated that the veteran would need a partial posterior horn medial meniscectomy versus meniscal repair with a lateral retinacular release on the left knee, with possible open medial retinacular repair. In an operative report, dated September 30, 2006, Dr. W.M. reported he had performed left knee arthroscopy with partial medial meniscectomy and arthroscopic lateral patellofemoral retinacular release. Dr. W.M. diagnosed lateral patellofemoral subluxation with anterior horn medial meniscus tear. In a report of a left knee MRI, dated in September 2006, Dr. P.M. noted a small joint effusion, mildly high riding patella, mild lateral patellar subluxation, prominent intra- meniscal signal posterior horn medial meniscus, thought to be consistent with horizontal degenerative tear. The evidence included several follow-up visits to Dr. W.M. In a note of one follow-up visit, dated in December 2006, Dr. W.M. stated that the veteran had fallen twice because of her left knee. The veteran had an unstable knee with an anterior drawer sign. Dr. W.M. stated that the veteran may have re- injured her knee and torn an anterior cruciate ligament. In a radiological report, dated in December 2006, Dr. P.M. found no evidence of medial or lateral menisci tear. Physical therapy progress notes from Fit-N-Wise showed that the veteran was seen 24 times. In the last progress note of treatment, dated in December 2006, the physical therapist reported that the veteran had not been able to progress in therapy appropriately secondary to reports of knee pain. The veteran received physical therapy at Wise Regional Rehabilitation from January 2007 to March 2007, but did not meet her progress goals and was discharged. In a VA examination report dated in April 2007, G.D., PA-C, recorded the following subjective complaints. The veteran still had 6 to 7/10 knee pain following the surgery in September 2006. The knee pain was worse with prolonged standing, walking, bending, squatting, prolonged sitting, or climbing stairs or inclines. The veteran reported rare, intermittent episodes of lateral patellar subluxation, but that her symptoms had improved since the surgery in September 2006. The veteran denied use of orthopaedic devices. G.D. reported the following physical examination findings. The veteran walked without an antalgic gait. Left knee was non-tender without sign of inflammation or infection. There was tenderness of bilateral inferior patellar margins. Patellar compression test was positive without crepitus and McMurray sign was negative. Flexion was to 108 degrees; 100 degrees on repetition. Extension was to zero degrees, both initially and after repetition. There was no apparent weakness, fatigability, or loss of coordination during or following three repetitions of range of motion. The veteran complained of pain throughout the entire arc of motion. G.D.'s assessment was left knee chondromalacia of patella, left knee status post arthroplasties in July 2005 and September 2006, and lateral release performed September in 2006. The report also included an addendum, dated July 2, 2007. In that addendum, G.D. stated that the claims file and history had been reviewed and that there was no change in history or assessment. The veteran underwent another surgery from Dr. W.M. in July 2007. In a follow-up note dated in August 2007, Dr. W.M. reported that the veteran was status post open medial retinacular repair. Dr. W.M. reported that the veteran still had dramatic patella femoral changes, dislocations, and subluxations, despite her long effort towards rehabilitation, conservative care, straps, a previous arthroscopy, and a lateral release. Dr. W.M. was pleased with how hard the veteran was working to "get her quad back." At the veteran's travel board hearing in January 2008, she provided the following testimony in support of her claim for an increased rating. The veteran reported falling three to five times a day and described her instability as severe. She stated that when she falls, she dislocates her kneecap and the knee swells. The veteran estimated her knee swelled three times its normal size. The veteran reported wearing a knee brace daily. When it was swollen, the veteran stated, she was unable to bend it past 30 degrees. The veteran testified she was unable to walk up or down stairs. The veteran testified she had received three surgeries. The surgeon who had performed the second and third surgeries told her she would need a total knee replacement at some point, but that she was too young for such a procedure. After the surgeries, the veteran stated, she had fewer problems with falling, but that the knee stiffened more. Regarding effects on employment, the veteran testified that her performance diminished after 30 or 45 minutes because she could not walk. The veteran reported an inability to do things she would normally do socially and that she could not "have a life." She claimed to get fewer than three hours of sleep a night. The veteran also testified that her knee had "definitely worsened" since the last time she had an evaluation. The veteran's representative alleged the evidence was flawed because a VA examination report dated on July 2, 2007 was in the file, but that the veteran received surgery from a private practice physician on that date. The representative also asserted that because the veteran had surgery in July 2007, her left knee was of a severity that did not support the rating reduction. Legal Criteria The veteran is appealing the initially assigned disability rating for her service-connected residuals of a left knee injury, torn meniscus, and retropatellar pain syndrome. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2007); 38 C.F.R. § 4.1 (2007). When the initial evaluation is at issue, the Board must assess the entire period since the original claim was filed to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods since the date the original claim was filed. See Fenderson, 12 Vet. App. at 119. Individual disabilities are assigned separate diagnostic codes. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower evaluation will be assigned. 38 C.F.R. § 4.7 (2007). All benefit of the doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3 (2007). The veteran's service-connected left knee injury, torn meniscus, retropatellar pain syndrome is currently rated by analogy to Diagnostic Code 5299-5254. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" as follows: The first two digits will be selected from that part of the schedule most closely identifying the part or system of the body involved; the last two digits will be "99" for all unlisted conditions. Hyphenated diagnostic codes, such as that employed here, are used when a rating pursuant to one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2007). 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. Id. Here, the RO assigned an initial disability rating of 30 percent pursuant to Diagnostic Code 5299-5257, effective November 27, 2003. Effective January 1, 2008, the RO reduced the veteran's disability rating to 10 percent. During the course of this appeal, the veteran was granted temporary total ratings on two occasions. The veteran's ratings for the veteran's service-connected left knee disability throughout the course of this appeal are as follows: 30 percent effective November 27, 2003; 100 percent effective July 19, 2004; 30 percent effective April 1, 2005; 100 percent effective September 30, 2006; 30 percent effective December 1, 2006; and 10 percent effective January 1, 2008. For the purpose of this appeal, the Board will only consider whether higher ratings are warranted for the periods during which the veteran's left knee disability was rated less than 100 percent. Under Diagnostic Code 5257 (other impairment of knee), a 20 percent evaluation is assigned for moderate recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2007). A 30 percent evaluation is assigned for severe recurrent subluxation or lateral instability. Id. A 30 percent rating is the highest available under that code. Limitation of motion of the knee is rated under Diagnostic Codes 5260 and 5261. Diagnostic Code 5261 applies to limitation of extension of leg. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2007). Diagnostic Code 5261 provides that a 20 percent rating is to be assigned where extension is limited to 15 degrees and a 30 percent rating where extension is limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2007). A 40 percent rating is assigned where extension is limited to 30 degrees, and a 50 percent rating where extension is limited to 45 degrees. Id. Diagnostic Code 5260 provides that a 20 percent rating is to be assigned where flexion is limited to 30 degrees, and a 30 percent rating for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2007). A 30 percent rating is the highest available under that code. Ratings for knee disabilities in excess of 10 percent are also found in Diagnostic Codes 5256, 5258, or 5262. Diagnostic Code 5256 provides that where there is ankylosis of the knee at a favorable angle in full extension, or in slight flexion between zero and 10 degrees, a 30 percent evaluation is warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5256 (2007). Where there is ankylosis of the knee in flexion between 10 and 20 degrees, a 40 percent evaluation is assigned. Id. Diagnostic Code 5258 provides for 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). Under Diagnostic Code 5262 (impairment of tibia and fibula), nonunion of the tibia and fibula, with loose motion, requiring a brace, warrants a 40 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 2562 (2007). Ratings of 30 and 20 percent are warranted for malunion that with either marked or moderate disability of the knee and ankle. Id. VA regulations, set forth at 38 C.F.R. §§ 4.40, 4.45, and 4.59 provide for consideration of a functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. 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 (2007). The Court has held that a higher rating can be based on "greater limitation of motion due to pain on use." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). However, any such functional loss must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." 38 C.F.R. § 4.40 (2007). Analysis Upon reviewing the evidence in light of the ratings criteria, the Board first concludes that a rating in excess of 30 percent is not warranted at any time during the course of this appeal. Only Diagnostic Codes 5262, 5265, and 5261 provide for ratings in excess of 30 percent for knee disabilities. There is no medical evidence of nonunion of the tibia and fibula and thus, Diagnostic Code 5262 does not apply. Although the medical evidence shows that the veteran's left knee range of motion is quite limited, there is no evidence that the joint was immobile during the periods for which she was not rated totally disabled. Absent findings of immobility, the Board finds no basis for a rating under Diagnostic Code 5256 for ankylosis. Finally, at no time during the course of this appeal has the evidence shown an inability to extend the knee to less than 30 degrees. To the contrary, the veteran was able to extend to 5 degrees or less at all times during the appeal. The Board also considered the representative's concerns regarding the integrity of the evidence, given that the claims file included a report from the VAMC dated on July 2, 2007, the same day the veteran received surgery from a private practice physician. As noted above, this document was an addendum to the earlier VA examination report, and was not a report of another physical examination. Thus, nothing in this report raises any logical inconsistencies with other evidence of record. Next, the Board considers whether the veteran should be granted a rating higher than 10 percent for the period beginning January 1, 2008. Upon reviewing the evidence in its entirety, the Board finds that a rating of 30 percent should apply. Prior to January 1, 2008, the competent medical evidence was significant for instability, joint effusion, patellar subluxation, limited range of motion, and meniscal tear for much of the appeal period. These objective signs, considered with the veteran's reports of falling, pain, and locking, support a 30 percent rating. Although the VA examination report of April 2007 suggests that the veteran's left knee disability had improved by that time, other evidence suggests that the severity of her knee disability persisted. For example, Dr. W.M.'s report in July 2007 that the veteran still had "dramatic" patella femoral changes, dislocations, and subluxations despite her rehabilitation efforts and multiple surgeries, indicates that her left knee had not improved substantially at that time. The need for an additional surgery at that time is another indicator that her left knee disability persisted to be more severe than a 10 percent rating. The veteran's testimony at her travel board hearing in January 2008 also supports a finding that her left knee disability failed to improve substantially throughout the appeal period. Her testimony that she continued to frequently fall and dislocate her kneecap, and continued to experience swelling, decreased range of motion, and stiffness, is indicative that her disability remained unchanged. Again, these signs approximate the criteria for a 30 percent rating. The record does not contradict the veteran's testimony; to the contrary, the objective medical evidence tends to support her testimony and the Board deems it to be credible. In short, there is little evidence that the veteran's left knee disability improved during the course of this appeal. Accordingly, the Board concludes that a staged rating is not in order and a 30 percent rating is appropriate for the entire period of the veteran's appeal. Fenderson, 12 Vet. App. at 119. Essentials of Evaluative Rating Lastly, the Board notes that there is no evidence of record that the veteran's service-connected left knee disability causes marked interference with employment (i.e., beyond that already contemplated in the assigned evaluation), or necessitated any frequent period of hospitalization, such that application of the regular schedular standards is rendered impracticable. Moreover, the veteran has not raised such an issue. Hence, the Board is not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) (2007) for assignment of an extraschedular evaluation. Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). ORDER An initial rating in excess of 30 percent for service- connected residuals of a left knee injury, torn meniscus, and retropatellar pain syndrome is denied. A rating of 30 percent for service-connected residuals of a left knee injury, torn meniscus, and retropatellar pain syndrome, beginning January 1, 2008 is granted, subject to the law and regulations controlling the award of monetary benefits. ____________________________________________ John E. Ormond, Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs