Citation Nr: 0814324 Decision Date: 05/01/08 Archive Date: 05/12/08 DOCKET NO. 04-26 081 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to an increased disability rating for chondromalacia of the right knee, currently evaluated as 20 percent disabling. 2. Entitlement to an increased disability rating for degenerative joint disease of the right knee, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Theresa M. Catino, Counsel INTRODUCTION The veteran served on active military duty from September 1972 to July 1977 and from March 1986 to October 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2003 rating action of the Department of Veterans Affairs Regional Office (RO) in Des Moines, Iowa. In February 2007, the veteran raised the issue of entitlement to a total disability rating based on individual unemployability (TDIU). In a letter dated in the following month, the RO informed the veteran and his representative of the duty to notify and duty to assist provisions of the Veterans Claims Assistance Act of 2000 (VCAA), as that law relates to the TDIU claim. The RO, however, has not adjudicated the TDIU issue. The matter is, therefore, referred to the agency of original jurisdiction (AOJ) for appropriate action. In a statement received at the RO in September 2007, the veteran raised the issue of whether new and material evidence has been received sufficient to reopen a previously denied claim for service connection for a back disorder, asserted to be secondary to the service-connected knee disabilities. This matter has not been adjudicated by the RO and is also referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The service-connected chondromalacia of the veteran's right knee is manifested by 2+ patellar crepitus; however, laxity, instability, weakness, dislocation, and subluxation of the right knee have not been shown. 2. The service-connected degenerative joint disease of the right knee is manifested by flexion no worse than 90 degrees, extension no worse than 10 degrees, some pain on motion, small effusion, and some erythema; however, warmth, redness, swelling, deformity, creaking on passive movement, tenderness over the medial or lateral joint line, and impairment in strength have not been shown. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 20 percent for chondromalacia of the veteran's right knee have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5257 (2007). 2. The criteria for a disability rating greater than 10 percent for the degenerative joint disease of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.40, 4.45, 4.71a, DCs 5003, 5260, 5261 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties To Notify And To Assist The VCAA, which was enacted on November 9, 2000, eliminated the concept of a well-grounded claim, redefined the obligations of VA with respect to the duty to assist, and imposed on VA certain notification requirements. Since the enactment of the law, the VCAA has been codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, & 5126. This change in the law is applicable to all claims filed on or after the date of enactment of the VCAA and to those claims which were filed before the date of enactment but which were not yet final as of that date. During the pendency of the current appeal, and specifically on March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006) which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that, upon receipt of an application for a service connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Dingess/Hartman, 19 Vet. App. at 488. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. With regard to increased rating claims in particular, § 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. 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 v. Peake, 22 Vet. App. 37 (2008). These notification requirements were partially satisfied by a July 2005 letter issued to the veteran. In particular, that letter informed him that, to substantiate his increased rating claim, he must submit evidence that his service-connected right knee disorders had increased in severity. The letter specifically stated that such evidence may include medical evidence (from hospitals, clinics, and private physicians) of treatment since military service and statements from other individuals "who are able to describe from their knowledge and personal observations in what manner . . . [his] disability has become worse." Also, the June 2004 statement of the case (SOC) and the February 2007 supplemental statement of the case (SSOC) provided the veteran with specific notice of the relevant rating (diagnostic code) criteria for his service-connected right knee disabilities. Further, the July 2005 correspondence notified the veteran that VA would make reasonable efforts to help him obtain necessary evidence with regard to his increased rating claims but that he must provide enough information so that the agency could request the relevant records. The letter also informed him of his opportunity to submit "any other evidence or information that . . . [he] think[s] . . . [would] support . . . [his] claim" as well as "any evidence in . . . [his] possession that pertains to . . . [his] claim." See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II); VAOPGCPREC 1-2004 (February 24, 2004); see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Also, in a March 2006 letter, the RO informed the veteran of the type of evidence necessary to establish an effective date (element #5). See Dingess/Hartman, 19 Vet. App. at 488. In any event, as will be discussed in the following decision, the Board finds that the evidence of record does not support a grant of the veteran's increased rating claims. Consequently, no effective dates will be assigned. Thus, the Board finds that there can be no possibility of any prejudice to the veteran in proceeding with the issuance of a final decision of the increased rating claims adjudicated in this decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Clearly, neither the July 2005, nor the March 2006, letters were issued before the AOJ's initial denial of the veteran's increased rating claims in July 2003. The Board finds, however, that any timing error was not prejudicial. This is so because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the veteran been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond, but the AOJ also readjudicated the case by way of the SSOC issued in February 2007. For these reasons, it is not prejudicial to the veteran for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. Pelegrini II, 18 Vet. App. at 122; see also VAOPGCPREC 7-2004 (July 16, 2004); Mayfield v. Nicholson, 444 F.3d at 1333. Any VCAA notification errors have not affected the essential fairness of the current adjudication. Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Specifically, because evidence of record demonstrates that the veteran has actual knowledge of the criteria necessary for an increased rating for his knee disabilities. See Vazquez-Flores, 22 Vet. App. 37 (2008) (citing Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) ("[a]ctual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrates an awareness of what was necessary to substantiate his or her claim")). Rating actions promulgated before the current appeal provided the specific rating criteria (e.g., diagnostic codes) pertinent to the veteran's service-connected knee disabilities. In the July 2005 letter, the RO informed the veteran of his opportunity to submit his own statement that "completely describe[s] . . . [his] symptoms, their frequency and severity, and other involvement, extension and additional disablement caused by . . . [his] disability." Importantly, at the several pertinent VA examinations and VA outpatient treatment sessions conducted during the current appeal, the veteran described the specific symptoms that he experiences in his right knee. Such statements exhibit an understanding of the criteria necessary for increased ratings for his service-connected knee disabilities. Moreover, the Board finds that the duty to assist provisions of the VCAA have been met with respect to the increased rating claims adjudicated in this decision. All relevant treatment records adequately identified by the veteran have been obtained and associated with his claims folder. In addition, he has been accorded pertinent VA examinations. Accordingly, the Board finds that VA has done everything reasonably possible to notify and to assist the veteran in the development of the issues on appeal. Under the circumstances of this case, additional efforts to assist in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case and that such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (which holds that remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Importantly, the veteran has pointed to no other pertinent evidence which has not been obtained. In fact, following receipt of the SSOC in February 2007, he responded in the following month that he had no other information or evidence to submit that would substantiate his claim. Consequently, the Board will proceed to adjudicate the following increased rating issues on appeal, based upon the evidence currently of record. See 38 U.S.C.A. §§ 5102, 5103 (West 2002); 38 C.F.R. § 3.159(b) (2007); Pelegrini II; Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. §§ 4.1 and 4.2 (2007). Initially, by a December 1988 rating action, the RO, in pertinent part, granted service connection for osteoarthritis and chondromalacia of the right knee (20 percent, effective from October 1988). By a March 2002 rating action, the RO redefined this service-connected disorder as chondromalacia of the right knee and confirmed the 20 percent evaluation for this disability. In addition, the RO granted service connection for degenerative joint disease of the right knee, associated with the service-connected chondromalacia of that joint, and awarded a separate compensable (10 percent) evaluation for this aspect of the veteran's right knee disability, effective from October 2001. The veteran's service-connected right knee disabilities remain evaluated as follows: 20 percent for chondromalacia and 10 percent for degenerative joint disease. Where entitlement to compensation has already been established and an increase in disability rating is at issue, however, the present level of disability is of primary concern. Although a review of the recorded history of a disability should be conducted in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practicably be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2007). Each service-connected disability is rated on the basis of specific criteria identified by diagnostic codes. 38 C.F.R. § 4.27 (2007). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2007). It is also necessary to evaluate the disability from the point of view of the veteran working or seeking work and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor. 38 C.F.R. §§ 4.2, 4.3 (2007). If there is a question as to which evaluation to apply to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2007). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2007). According to a relevant diagnostic code, evidence of moderate recurrent subluxation or lateral instability warrants a 20 percent rating. 38 C.F.R. § 4.71a, DC 5257 (2007). The highest evaluation allowable pursuant to this code, 30 percent, requires evidence of severe recurrent subluxation or lateral instability. Id. In addition, degenerative arthritis is rated based on limitation of motion of the affected part(s). 38 C.F.R. § 4.71a, DC 5003 (2007). Normal flexion and extension of the knee joint range from 140 degrees to zero degrees. 38 C.F.R. § 4.71, Plate II (2007). A compensable rating of 10 percent will be assigned with evidence of limitation of flexion of the leg to 45 degrees. 38 C.F.R. § 4.71a, DC 5260 (2007). The next higher evaluation of 20 percent requires evidence of limitation of flexion of the leg to 30 degrees. Id. The highest rating allowable pursuant to this diagnostic code, 30 percent, necessitates evidence of limitation of flexion of the leg to 15 degrees. Id. Limitation of extension of the leg to 10 degrees will result in the assignment of a 10 percent evaluation. 38 C.F.R. § 4.71a, DC 5261 (2007). The next higher rating of 20 percent requires evidence of limitation of extension of the leg to 15 degrees. Id. A 30 percent evaluation necessitates evidence of limitation of extension of the leg to 20 degrees. Id. A 40 percent rating requires evidence of limitation of extension of the leg to 30 degrees. Id. The highest evaluation allowable pursuant to this diagnostic code, 50 percent, necessitates evidence of limitation of extension to 45 degrees. Id. In the absence of limitation of motion, a 10 percent rating will be assigned with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Id. Also, a 20 percent evaluation will be awarded with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Id. These 10 percent and 20 percent evaluations based on X-ray findings may not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Note 1 following DC 5003 (2007). Although regulations recognize that a part which becomes painful on use must be regarded as seriously disabled, see 38 C.F.R. §§ 4.40 and 4.45, these provisions are qualified by specific rating criteria applicable to the case at hand. As the Board has discussed, evaluation of the service-connected degenerative joint disease of the right knee requires consideration of any associated limitation of motion of this joint. See 38 C.F.R. § 4.71, Plate II & § 4.71a, DC 5003, 5260, 5261 (2007). Problems such as pain on use must be considered when evaluating the veteran's disability. Specifically, when a diagnostic code provides for compensation based on limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must also be considered, and the examinations upon which rating decisions are based must adequately portray the extent of the functional loss due to pain "on use or due to flare-ups." DeLuca v. Brown, 8 Vet. App. 202 (1995); see also 38 C.F.R. § 4.59 (2007). Throughout the current appeal, the veteran has contended that the service-connected chondromalacia of his right knee, as well as the service-connected degenerative joint disease of his right knee, have increased in severity. In particular, he maintains that these service-connected disabilities are manifested by giving out, locking, stiffness, limitation of motion, pain, and swelling. See, e.g., July 2006 hearing transcript (T.) at 3-9. Pertinent treatment has included steroid injections as well as multiple arthroscopic meniscectomies. T. at 8. He also maintains that he uses a knee brace and a cane to ambulate. These lay descriptions are deemed to be competent evidence. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). However, the lay descriptions of these service-connected disabilities must be considered in conjunction with the clinical evidence of record as well as the pertinent rating criteria. With respect to chondromalacia of the right knee, the Board acknowledges the veteran's complaints of "giving out" of his right knee. In fact, medical evidence of record indicates that the veteran has 2+ right patellar crepitus and that he has been given a brace "set in neutral alignment for 'multidirectional instability.'" Importantly, however, numerous evaluations of the veteran's right knee have consistently demonstrated no laxity, instability, weakness, dislocation, or subluxation of this joint. Clearly, such evidence does not support an increased rating for the service-connected chondromalacia of the veteran's right knee at any time during the current appeal. See 38 C.F.R. § 4.71a, DC 5257 (2007) (which stipulates that evidence of moderate recurrent subluxation or lateral instability is necessary for a 20 percent rating and that evidence of severe recurrent subluxation or lateral instability is required for a 30 percent evaluation). With respect to degenerative joint disease of the right knee, during the current appeal, the veteran has undergone several VA examinations of his right knee, as well as numerous evaluations of this joint at outpatient treatment sessions. He lacked 20 degrees of extension at the September 2006 VA joints examination, 15 degrees of extension at a July 2006 VA outpatient treatment session, 14 degrees of extension at the February 2005 VA joints examination, and 10 degrees of extension at July 2003, August 2002, and December 2001 VA outpatient treatment sessions. In addition, he exhibited pain on motion, small effusion, and some erythema at the proximal suture sight. Significantly, however, the remaining (and numerous) evaluations completed on the veteran's right knee during the current appeal (including, most recently, a February 2007 VA outpatient treatment session) have demonstrated normal extension of this joint. In addition, these evaluations have shown limited flexion to no worse than 90 degrees, 5/5 strength, and no warmth, redness, swelling, deformity, creaking on passive movement, or tenderness over the medial or lateral joint line. As the veteran has exhibited no worse than 90 degrees of flexion of his right knee, a disability rating greater than the currently assigned evaluation of 10 percent for the service-connected degenerative joint disease of the right knee cannot be awarded based on impairment resulting from limitation of flexion of this joint. 38 C.F.R. § 4.71a, DC 5260 (2007) (which require evidence of limitation of flexion of the leg to 30 degrees for the assignment of a 20 percent rating). Further, despite the findings of some limitation of extension of the veteran's right knee, the vast majority of examinations of this joint during the current appeal have demonstrated normal extension of this joint. As such, the Board must conclude that the totality of the objective evaluation findings do not support a disability rating greater than 10 percent for this disability based upon impairment resulting from limitation of extension of the right knee. 38 C.F.R. § 4.71a, DC 5261 (2007) (which indicates that 10 degrees will result in the assignment of a 10 percent evaluation, 15 degrees warrants a 20 percent rating, and 20 degrees will result in a 30 percent evaluation). The Board has also considered the appropriateness of separate compensable ratings based upon limitation of flexion and limitation of extension of the veteran's right knee. See VAOPGCPREC 9-2004 (Sept. 2004) (in which the VA General Counsel determined that separate ratings may be awarded for disability of the same joint based upon findings of limitation of flexion and limitation of extension of the leg). Importantly, however, as the Board has discussed herein, the totality of the numerous examinations completed on the veteran's right knee during the current appeal have demonstrated no worse than 10 degrees of extension, and no worse than 90 degrees of flexion, of this joint. As such, separate compensable evaluations, based upon objective findings of limitation of flexion and limitation of extension of the veteran's right knee are not warranted. 38 C.F.R. § 4.71a, DCs 5260, 5261 (2007). Throughout the appeal, the veteran has complained of locking, stiffness, limitation of motion, pain, and swelling of his right knee. See, e.g., T. at 3-9. According to recent testimony, his right knee problems have resulted in limitation of his activities, including an inability to walk more than 75 to 100 yards, stand for long periods of time, or fish in a boat. T. at 4-5. Physical examinations of his right knee have shown some pain on motion, small effusion, and some erythema at the proximal suture sight. The February 2005 VA examiner concluded that the veteran's right knee problems "caus[e] . . . significant discomfort and inhibit . . . activities that involve weight bearing." Significantly, however, the numerous examinations that the veteran has undergone on his right knee during the current appeal have demonstrated no worse than 90 degrees of flexion or 10 degrees of extension, 5/5 strength, and no warmth, redness, swelling, deformity, creaking on passive movement, or tenderness over the medial or lateral joint line. Based on these evaluation findings, the Board concludes that the currently-assigned 10 percent rating for the service-connected degenerative joint disease of the veteran's right knee adequately portrays the functional impairment, pain, and weakness that he experiences as a consequence of use of this joint. See DeLuca, 8 Vet. App. at 204-207; see also 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DCs 5260, 5261 (2007). Of particular significance in the present case is the fact that, despite the veteran's complaints of locking, stiffness, limitation of motion, pain, and swelling in his right knee, multiple examinations of this joint have provided no more than mild findings. Under these circumstances, therefore, there is no basis to assign at any time during the appeal period a disability rating greater than the currently assigned 10 percent for the degenerative joint disease of the right knee. His appeal for a disability rating greater than 10 percent for the service-connected degenerative joint disease of his right knee must, therefore, be denied. In addition, with respect to both claims, the Board has considered the veteran's statements and sworn testimony regarding his service-connected disabilities. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the later is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. Layno, 6 Vet. App. at 470. As a lay person, however, he is not competent to offer opinions on medical diagnosis or causation, and the Board may not accept unsupported lay speculation with regard to medical issues. See Moray v. Brown, 5 Vet. App. 211 (1993); Espiritu v. Derwinski, 2 Vet. App. 482 (1992). Although his statements and sworn testimony are probative of symptomatology, they are not competent or credible evidence of a diagnosis, date of onset, or medical causation of a disability. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. at 494-95; Miller v. Derwinski, 2 Vet. App. 578, 580 (1992). As noted, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. The Board finds that the medical findings, which directly address the criteria under which the service-connected disabilities are evaluated, more probative than the subjective evidence of an increased disabilities. In addition, the Board does not find that consideration of an extraschedular rating under the provisions of 38 C.F.R. § 3.321(b)(1) is warranted for any time during the current appeal. That provision provides that, in exceptional circumstances, where the schedular evaluations are found to be inadequate, the veteran may be awarded a rating higher than that encompassed by the schedular criteria, as shown by evidence showing that the disability at issue causes marked interference with employment, or has in the past or continues to require frequent periods of hospitalization rendering impractical the use of the regular schedular standards. Id. Importantly, the service-connected degenerative joint disease of the veteran's right knee and the service-connected chondromalacia of this joint have not required frequent periods of hospitalization during the appeal period. In January 2007, treating medical personnel concluded that the veteran was unable to return to work as a greenhouse employee because such employment required "considerable bending, twisting, lifting, and squatting." Indeed, as the Board has noted in the Introduction portion of this decision, he has filed a claim for a total disability rating based on individual unemployability due to service-connected disability. In any event, 38 C.F.R. § 4.1 specifically sets out that "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." Factors such as requiring periodic medical attention are clearly contemplated in the Schedule and provided for in the evaluations assigned therein. What the veteran has not shown in this case is that his service-connected right knee disabilities have resulted in unusual disability or impairment that have rendered the criteria and/or degrees of disability contemplated in the Schedule impractical or inadequate at any time during the current appeal. Accordingly, the Board concludes that consideration of the provisions set forth at 38 C.F.R. § 3.321(b)(1) is not warranted for the veteran's service-connected right knee disabilities for any time during the current appeal. ORDER A disability rating greater than 20 percent for the service-connected chondromalacia of the right knee is denied. A disability rating greater than 10 percent for the service-connected degenerative joint disease of the right knee is denied. ____________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs