Citation Nr: 1034331 Decision Date: 09/13/10 Archive Date: 09/21/10 DOCKET NO. 09-44 210 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for osteoarthritis, previously evaluated as polyarthritis, left knee, prior to June 4, 2003. 2. Entitlement to an evaluation in excess of 30 percent for osteoarthritis, previously evaluated as polyarthritis, left knee, status post total knee arthroplasty, from August 1, 2004. 3. Entitlement to an evaluation in excess of 10 percent for osteoarthritis, previously evaluated as polyarthritis, right knee, prior to November 30, 2004. 4. Entitlement to an evaluation in excess of 30 percent for osteoarthritis, previously evaluated as polyarthritis, right knee, status post total knee arthroplasty from January 1, 2006. 5. Entitlement to an evaluation in excess of 10 percent for osteoarthritis, right hand, previously evaluated as polyarthritis. 6. Entitlement to an evaluation in excess of 10 percent for osteoarthritis, left hand, previously evaluated as polyarthritis. 7. Entitlement to an evaluation in excess of 10 percent for osteoarthritis, right ankle, previously evaluated as polyarthritis. 8. Entitlement to an evaluation in excess of 10 percent for osteoarthritis, left ankle, previously evaluated as polyarthritis. 9. Entitlement to an effective date earlier than November 30, 2004, for special monthly compensation. 10. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Virginia A. Girard-Brady WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The appellant had active service from October 1944 to June 1946. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2000 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota, which denied the appellant's claim for a compensable evaluation for polyarthritis of the knee, hands and ankle, and a May 2009 rating decision, which denied entitlement to TDIU. The appellant's claim for entitlement to a compensable evaluation for polyarthritis of the knee, hands and ankles was denied by the Board in a February 2002 decision. However, the appellant had submitted a request for a hearing before the Board in January 2002. The request had not been associated with the claims folder at the time of the February 2002 decision. In August 2002, a Travel Board hearing was held before a Veterans Law Judge and a transcript of that hearing is of record. In November 2002, in two separate decisions, the Board vacated the previous denial of February 2002 and denied the appellant's claim. The appellant filed an appeal of the November 2002 denial with The United States Court of Appeals for Veterans Claims (Court). A Joint Motion for Remand was filed by the Court. The Court granted the motion for remand in December 2003. In August 2004, the claim was remanded by the Board for additional procedural development. In July 2005, the Board wrote to the appellant, asking whether he wished to have another hearing in light of the fact that the Veterans Law Judge who had conducted the August 2002 hearing was no longer employed at the Board. The appellant responded in the negative in August 2005. In August 2005, the Board denied the claim for a compensable evaluation for polyarthritis of the knee, hands and ankles. The appellant again appealed to the Court. A Joint Motion for Remand was filed with the Court in May 2007. The Court granted the motion for remand in June 2007. In October 2007, the Board remanded the claim for entitlement to a compensable evaluation for service-connected polyarthritis of the knees, hands, and ankles for a VA examination. For the reasons discussed below, the Board finds that the RO substantially complied with the mandates of the October 2007 remand and will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Based on the November 2007 VA examination, in a June 2008 rating decision, the RO granted separate evaluations for service- connected: (1) osteoarthritis of the left knee, status post total knee arthroplasty; (2) osteoarthritis of the right knee, status post total knee arthroplasty; (3) right hand osteoarthritis; (4) left hand osteoarthritis; (5) right ankle osteoarthritis; (6) left ankle osteoarthritis (all formerly evaluated as polyarthritis as the knees, hands, and ankles); and (7) entitlement to special monthly compensation based on housebound criteria being met from November 30, 2004, to January 1, 2006. The Court has held that a "decision awarding a higher rating, but less than the maximum available benefit . . . does not . . . abrogate the pending appeal . . . ." AB v. Brown, 6 Vet. App. 35, 38 (1993). Therefore, the Board has jurisdiction of these claims. The Board notes that the appellant's representative requested 90 days to submit additional evidence and/or arguments after the case was certified to the Board in a January 2010 letter. In July 2010, notice was issued that the case had been certified to the Board and that under the Board's Rules of Practice, the appellant has 90 days from the date of this letter, or until the Board issues its decision in the case, whichever comes first, to send additional evidence concerning the appeal. The appellant's representative and the appellant have not indicated that they intend to submit any specific evidence. Therefore, the Board may proceed with the adjudication of the appeal. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Prior to June 4, 2003, the appellant's service-connected left knee osteoarthritis was manifested by slight recurrent subluxation and instability, pain, crepitus, and tenderness, with normal extension and flexion limited to more than 60 degrees, and no additional limitation of motion following repetitive motion. 2. From August 1, 2004, the appellant's left knee osteoarthritis, status post total knee arthroplasty, was manifested by pain, with normal extension and flexion limited to more than 60 degrees, and no additional limitation of motion following repetitive motion. 3. Prior to November 30, 2004, the appellant's right knee osteoarthritis was manifested by pain, with normal extension and flexion limited to more than 60 degrees, and no additional limitation of motion following repetitive motion. 4. From January 1, 2006, the appellant's right knee osteoarthritis, status post total knee arthroplasty, was manifested by pain with normal extension and flexion limited more than 60 degrees, and no additional limitation of motion following repetitive motion. 5. The appellant's right hand osteoarthritis has been manifested by pain, with no loss of range of motion of the wrist or a compensable loss of motion of the digits of the finger, and no additional loss of range of motion with repetition. 6. The appellant's left hand osteoarthritis has been manifested by pain, with no loss of range of motion of the wrist or fingers, and no additional loss of range of motion with repetition. 7. The appellant's right ankle osteoarthritis has been manifested as pain, with no limitation of range of motion, and no additional loss of range of motion on repetitive use. 8. The appellant's left ankle osteoarthritis has been manifested as pain, with no limitation of range of motion, and no additional loss of range of motion on repetitive use. 9. Prior to November 30, 2004, the appellant did had one disability evaluated at 100 percent disabling, but did not have additional service-connected disabilities independently ratable at 60 percent or more, and there is no evidence that he was permanently housebound due to his service-connected disabilities. 10. The appellant's service-connected disabilities have not been shown by the evidence of record to render him unable to obtain and retain substantially gainful employment consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. The criteria for a separate disability evaluation of 10 percent for instability due to osteoarthritis, left knee, previously evaluated as polyarthritis, have been met, prior to June 4, 2003. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5256, 5257, 5258, 5259, 5261, 5262, 5263 (2009). 2. The criteria for a disability evaluation greater than 30 percent for osteoarthritis, previously evaluated as polyarthritis, left knee, status post total knee arthroplasty, from August 1, 2004, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5055, 5256, 5257, 5258, 5261, 5259, 5262, 5263 (2009). 3. The criteria for a disability evaluation greater than 10 percent for osteoarthritis, previously evaluated as polyarthritis, right knee, prior to November 30, 2004, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5256, 5257, 5258, 5259, 5261, 5262, 5263 (2009). 4. The criteria for a disability evaluation greater than 30 percent for osteoarthritis, previously evaluated as polyarthritis, right knee, status post total knee arthroplasty from January 1, 2006, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5055, 5256, 5257, 5258, 5261, 5259, 5262, 5263 (2009). 5. The criteria for a disability evaluation greater than 10 percent for osteoarthritis, right hand, previously evaluated as polyarthritis, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5215 (2009). 6. The criteria for a disability evaluation greater than 10 percent for osteoarthritis, left hand, previously evaluated as polyarthritis, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5215 (2009). 7. The criteria for a disability evaluation greater than 10 percent for osteoarthritis, right ankle, previously evaluated as polyarthritis, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5271 (2009). 8. The criteria for a disability evaluation greater than 10 percent for osteoarthritis, left ankle, previously evaluated as polyarthritis, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5271 (2009). 9. The criteria for entitlement to an effective date prior to November 30, 2004, for an award of special monthly compensation have not been met. 38 U.S.C.A. §§ 1114(s); 5101(a), 5107, 5110; 38 C.F.R. §§ 3.151, 3.155, 3.400 (2009). 10. The criteria for the award of TDIU benefits have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16, 4.17, 4.18, 4.19, 4.25, 4.26 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the appellant's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions as to the appellant's claims. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2009). Duty to Notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his 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) (West 2002); 38 C.F.R. § 3.159(b) (2009). The United States Court of Appeals for Veterans Claims (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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2008); 38 C.F.R. § 3.159(b) (2009); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice 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. VCAA notice should 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 (2004); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In March 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess/Hartman held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, 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. Upon receipt of an application for "service connection," therefore, VA is required 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. This includes notice that a disability rating and/or an effective date will be assigned if service connection is awarded. Because the Court's decision is premised on the five elements of a service connection claim, it is the consensus opinion within the VA that the analysis employed can be analogously applied to any matter that involves any one of the five elements of a "service connection" claim, to include an increased rating claim. The appellant's increased rating claims were initially adjudicated prior to the enactment of the VCAA. VCAA notice letters dated in February 2003 and August 2004, informed the appellant of what evidence was required to substantiate his increased evaluation claims, and of his and VA's respective duties for obtaining evidence. Although these letters were not sent prior to initial adjudication of the appellant's claim, this was not prejudicial to him, since he was subsequently provided adequate notice, he was provided time to respond with additional argument and evidence and the claims were readjudicated and additional supplemental statements of the case were provided to the appellant. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). With respect to notice requirements under Dingess/Hartman, the Board notes that no specific letter with the required notice has been sent to the appellant. However, the May 2009 supplemental statement of the case, issued notice of the rating criteria, and the reasons as to why higher evaluations were not warranted under the appropriate criteria were identified. The lack of effective date notice was also harmless because the Board is not assigning an effective date in his decision. This matter will be addressed by the Regional Office upon implementation of any grant awarded herein. As to the denials of the appellant's claim, Dingess/Hartman notice is moot. There is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case. Based on the foregoing, the Board finds that the appellant is not prejudiced by moving forward with a decision on his claims for increased evaluations, and that VA has essentially complied with the procedural requirements of 38 U.S.C.A. §§ 5104, 7105(d), and 38 C.F.R. § 3.103(b), as well as the holdings in Dingess/Hartman, 19 Vet. App. 473 (2006) and Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) (rev'd in part) Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Regarding the appellant's claim for entitlement to TDIU, in correspondence to the appellant dated in January 2009, VA informed the appellant of what evidence was required to substantiate his claims, of his and VA's respective duties for obtaining evidence, and how VA determines the disability rating and effective date. The Board, therefore, finds that the requirements of Quartuccio and Dingess/Hartman are met and that the VA has discharged its duty to notify concerning the claim for entitlement to TDIU. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187; Dingess/Hartman, 19 Vet. App. at 490. As for the claim for an earlier effective date for the award of special monthly compensation, the Board notes that these are downstream issues from the original grant of such benefit. See Dingess/Hartman, 19 Vet. App. at 490; see also Goodwin v. Peake, 22 Vet. App. 128 (2008); Grantham v. Brown, 114 F.3d 1156 (1997). No VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In this case, the appellant's special monthly compensation claims were granted and an effective date was assigned. As such, no additional notice is required because the purpose the notice is intended to serve has been fulfilled. See 38 C.F.R. § 3.159(b)(3); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Duty to Assist The Board also concludes VA's duty to assist has been satisfied. The appellant's service treatment records are in the file. Private medical records identified by the appellant have been obtained, to the extent possible. In a December 2007 VA Form 21- 4142, Authorization and Consent to Release Information, the appellant requested records from Bethany Good Samaritan from December 2005 concerning rehabilitation after right knee surgery. The VA sent a letter to Bethany Good Samaritan to request the records in February 2008. There is no indication in the claims file that Bethany Good Samaritan responded to the request. The June 2008 rating decision and May 2009 supplemental statement of the case noted that VA made a request for information from Bethany Good Samaritan. Thus, the appellant was notified of the request to Bethany Good Samaritan and that records had not been obtained. The Board finds that the RO has made a reasonable attempt to obtain those records. The appellant has at no time referenced additional outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the appellant. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the appellant's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2009). The RO provided the appellant an appropriate VA examinations in December 1999, October 2000, February 2001, November 2007, and February 2009. The appellant has not reported receiving any recent treatment specifically for his service-connected disabilities, and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the appellant's service-connected disorders since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11- 95. The VA examination reports are thorough and supported by private medical records. The examinations in this case are adequate upon which to base a decision. In October 2007, the Board remanded the claims to schedule the appellant for an examination to determine the current severity of his service-connected polyarthritis of the knees, hands and ankles. The Board remand noted that that examiner should specifically indicate whether the appellant currently had polyarthritis of the knees, hands and ankles, which was diagnosed in 1946, as opposed to the later-diagnosed osteoarthritis of the multiple joints. The Board was seen for a VA examination in November 2007. The VA examiner found that the appellant currently has osteoarthritis of the knees, hands and ankles and opined that it is more likely as not that this is the same disease he had in the military because he had never been diagnosed with rheumatoid arthritis or other inflammatory arthritis. A December 1946 rating decision found that polyarthritis was incurred in service. Consequently, the Board finds that as the VA examiner's statement indicates that the osteoarthritis was related to the polyarthritis, and that there has been substantial compliance with the October 2007 Board remand. See Dyment, 13 Vet. App. at 146-147; Stegall, 11 Vet. App. at 271. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). II. Increased Evaluation Claims Legal Criteria Disability evaluations are determined by comparing a veteran's present symptomatology with the criteria set forth in the Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. 4.1 (2009). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the appellant. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Nevertheless, where, as here, the appellant is appealing the rating for an already established service-connected condition, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. 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). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 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. A. Knee Disability Evaluations The appellant's knee disabilities are currently evaluated under Diagnostic Code 5055. Diagnostic Code 5055 provides for a minimum evaluation of 30 percent for a knee replacement. To warrant a 60 percent disability evaluation under Diagnostic Code 5055, the evidence must demonstrate chronic residuals consisting of severe painful motion or weakness in the knee. A 100 percent evaluation is warranted for one year following implantation of prosthesis. Under Diagnostic Code 5257, a 10 percent evaluation contemplates slight knee impairment due to recurrent subluxation or lateral instability. A 20 percent rating contemplates moderate impairment due to recurrent subluxation or lateral instability, and a maximum 30 percent rating is warranted for severe impairment of the knee. Under 38 C.F.R. § 5003, degenerative arthritis, including osteoarthritis, is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Under Diagnostic Code 5258, a 20 percent evaluation, the highest and only rating available under that schedular provision, may be assigned where there is evidence of dislocated semilunar cartilage, with frequent episodes of 'locking,' pain, and effusion into the knee joint. Diagnostic Code 5259 provides for a 10 percent evaluation for removal of semilunar cartilage, symptomatic. Standard motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of leg motion is governed by Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 concerns limitation of leg flexion. A 10 percent evaluation is for application where flexion is limited to 45 degrees. A 20 percent evaluation is for application where flexion is limited to 30 degrees, and a 30 percent rating applies where flexion is limited to 15 degrees. Diagnostic Code 5261 pertains to limitation of leg extension. Under that Code section, a 10 percent evaluation is for application where extension is limited to 10 degrees. A 20 percent evaluation is for application where extension is limited to 15 degrees. A 30 percent evaluation applies where extension is limited to 20 degrees. A 40 percent evaluation applies where extension is limited to 30 degrees. Under Diagnostic Code 5262, a 30 percent evaluation is for assignment for malunion of the tibia and fibula with marked knee or ankle disability. A 40 percent evaluation is warranted for nonunion of the tibia and fibular with loose motion, requiring a brace. Under Diagnostic Code 5263, genu recurvatum, acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated, warrants a 10 percent evaluation. VAOPGCPREC 9-2004 (September 17, 2004) holds that a claimant who had both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. Further regarding the question of entitlement to separate evaluations, VAOPGCPREC 23-97 provides that a claimant who has arthritis and instability of the knee may, in some circumstances, be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 9-98. As a general matter, the Board observes that the words 'slight,' 'moderate,' and 'severe' as used in the various diagnostic codes 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.' See 38 C.F.R. § 4.6 (2009). The appellant's polyarthritis was evaluated under Diagnostic Code 5009, for arthritis, other types, which provides that the disability should be evaluated as rheumatoid arthritis. Under Diagnostic Code 5002, for rheumatoid arthritis, a 20 percent evaluation is warranted for one or two exacerbations a year in a well-established diagnosis. A 40 percent evaluation is warranted for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year. A 60 percent evaluation is warranted for constitutional manifestations less than criteria for a 100 percent evaluation, but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring four or more times a year or a lesser number over prolonged periods. A 100 percent evaluation was warranted for an active process with constitutional manifestations associated with active joint involvement, totally incapacitating. i. Left knee osteoarthritis, prior to June 4, 2003 The appellant's claim for an increased evaluation for polyarthritis of the knees, hands and ankles was received on October 8, 1999. As such, the rating period on appeal is from October 7, 1998. 38 C.F.R. § 3.400(o)(2). In the June 2008 rating decision, the RO assigned a 10 percent evaluation, prior to June 4, 2003, for left knee osteoarthritis, based upon the opinion of a November 2007 VA examiner that the appellant's osteoarthritis was the same condition which was shown in service and for which the appellant was service-connected. The appellant was seen for a VA examination in December 1999. The December 1999 VA examination report indicated that the left knee appeared to be grossly normal with no local tenderness or effusion. The left knee appeared to be slightly lax with anteroposterior movements. Lateral instability also seemed to be present, although he had no complaint of pain with movement. There was no crepitation of the knee with flexion and extension movements. The left knee had normal flexion of 0 to 140 degrees and normal extension. An October 2000 VA examination report indicates that the appellant seemed to have pain and stiffness on passive range of motion of the knees. When asked to squat down, he was able to do that. The VA examiner noted that an x-ray of the knee showed tri-compartment osteoarthritis. There was no acute sign of internal knee disorder. McMurray and Lachman tests were negative. The knee was stable and there was no drawer sign. An October 2000 Northern Orthopedics medical record indicated that the appellant had pain in his left knee with ambulation. He also had crepitus on flexion/extension medially in the left knee. A February 2001 VA examination report indicated that the appellant rated his knee pain as a 6 on a 1 to 20 scale. The VA examiner noted that he was quite active and continued to walk. The appellant's knees both showed thickening of the pre-patella bursa. Cruciate and collateral ligaments were intact. There was no joint effusion or warmth. X-rays of the left knee indicated there was mild loss of medial joint space and sharpening of the tibial spine. A May 2001 Northern Orthopedics medical record indicates that the appellant continued to have knee pain. On examination, he had pain with flexion and extension and a limited range of motion. A December 2001 Northern Orthopedics medical record reflects that the appellant continued to have pain over the medial aspect of the left knee. He had crepitus on flexion and extension. He had a positive medial McMurray's, positive Apley's sign and positive patellar grinding sign. X-rays revealed moderate arthrosis of the knee. A Northern Orthopedics medical record dated in March 2002 indicates that the appellant had increased range of motion and reported a decrease in knee pain at that time. In an August 2002 Northern Orthopedics medical record, the physician noted that the appellant had pain and crepitus with flexion/extension and reported pain when going up and down stairs and squatting. As noted above, under Diagnostic Code 5003, osteoarthritis is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. Although several of the appellant's private medical records indicated that he had a decreased range of motion of his left knee due to pain, these records did not provide measurements of his range of motion. The December 1999 VA examination report indicated that the left knee had normal flexion of 0 to 140 degrees and normal extension of 0 degrees. The next-higher evaluation of 20 percent is warranted for flexion of 60 degrees and extension limited to 15 degrees. The medical evidence from prior to June 4, 2003, does not indicate that the appellant had compensable limitation of the range of motion of the left knee warranting a higher evaluation. Under 38 C.F.R. § 4.59, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Under Diagnostic Code 5003, if the limitation of motion is noncompensable, an evaluation of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. If limitation of motion is absent, an evaluation of 20 percent may be granted for x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. For the purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f)(2009). Although there is x-ray evidence that the appellant has arthritis in both knees, indicating the involvement of two or more major joints, the appellant did not report having occasional incapacitating exacerbations. The February 2001 VA examiner noted that the appellant was quite active and continued to walk. Similarly, although his private medical records indicated he experienced pain, there was no indication he had experienced incapacitating exacerbations. The board has also considered if the principles outlined in DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995), and 38 C.F.R. §§ 4.40 and 4.45 could afford the appellant a higher evaluation. The Board finds there has been no demonstration of functional impairment comparable to the criteria for the next-higher evaluation. The December 1999 VA examiner noted the appellant did not have pain with movement. Although the private medical records indicated that pain limited the range of motion of his left knee, there was no demonstration that he had functional impairment comparable to the criteria for a 20 percent evaluation. The Board has considered other knee-related Diagnostic Codes to determine whether any would result in an evaluation in excess of 10 percent, but finds none. Diagnostic Code 5256 is not applicable because there is no medical evidence of ankylosis associated with his left knee disability. Diagnostic Code 5258 is inapt because there is no medical evidence of dislocated semilunar cartilage. As there is no medical evidence of removal of semilunar cartilage, Diagnostic Code 5259 is not applicable There is also no evidence of nonunion or malunion of the tibia or fibula, or of acquired recurvatum with weakness and insecurity of weight bearing, thereby negating the application of Diagnostic Codes 5262 and 5263. The Board has considered whether the appellant is entitled to a higher evaluation under Diagnostic Code 5009, for other types of arthritis, as he was originally service-connected for polyarthritis of the knees. Under Diagnostic Code 5009, other types of arthritis are evaluated as rheumatoid arthritis. Under Diagnostic Code 5002, a 20 percent evaluation is warranted for rheumatoid arthritis as an active process with one or two exacerbations a year in a well-established diagnosis. There is no evidence the appellant had symptoms of rheumatoid arthritis during the period on appeal. Thus, the appellant is not entitled to a higher evaluation under Diagnostic Code 5009. The evidence indicates the appellant had some lateral instability of his left knee. The December 1999 VA examiner noted that lateral instability seemed to be present, although the appellant had no complaint of pain with movement. In contrast, the December 2000 VA examination report found that McMurray and Lachman tests were negative. The knee was stable and there was no drawer sign. A December 2001 Northern Orthopedics medical record reflects had a positive medial McMurray's test, positive Apley's sign and positive patellar grinding sign. Giving the appellant the benefit of the doubt, as he demonstrated lateral instability of the left knee in the December 1999 VA examination and the December 2001 Northern Orthopedics medical record reflects that he had a positive medial McMurray's test, the Board finds that the appellant had slight lateral instability of the left knee, prior to June 4, 2003, warranting a separate 10 percent evaluation, but no higher, under Diagnostic Code 5257. ii. Left knee osteoarthritis, status post total knee arthroplasty, from August 1, 2004 The appellant had a total left knee replacement in June 4, 2003. See November 2004 St. Joseph's Medical Center record. He was granted a temporary 100 percent evaluation from June 4, 2003 to August 1, 2004 under 38 C.F.R. § 4.30 and Diagnostic Code 5055, which provides for a 100 percent evaluation for one year following implantation of prosthesis. His left knee disability is currently evaluated under Diagnostic Code 5055. As noted above, a 60 percent evaluation is warranted for chronic residuals consisting of severe painful motion or weakness in the affect extremity. With intermediate degrees of residual weakness, pain or limitation of motion is rated by analogy to Diagnostic Codes 5256, 5261, or 5262. The appellant was seen for a VA examination in November 2007. He reported that he had pain with prolonged walking. He stated that he used a cane. He denied having incapacitating episodes of arthritis. He was able to stand for 15 to 30 minutes and walk a quarter of a mile. There was no deformity, giving way, or instability of the knees. There were no episodes of dislocation or subluxation, locking episodes, or effusion. There were no flare-ups of joint disease or inflammation. The VA examiner described the appellant's gait as antalgic. The report noted that there was evidence of abnormal weight bearing, with increased wear outside the edge of the heel of the left and right shoes. The November 2007 VA examination report includes range of motion testing of the knees. The report indicated the appellant had right and left knee flexion of 0 to 125 degrees, with no additional limitation of motion on repetitive use. In a February 2009 VA examination, the appellant had left knee flexion of 120 degrees without pain, and normal extension of 0 degrees without pain. Passive range of motion was the same as active range of motion. Following repetitive motion, there was no further decrease in range of motion of the left knee for any reason. The VA examiner also noted that the appellant had a nontender left knee, and no effusion. The left knee also had a negative varus valgus stress test, a negative drawer test and a negative McMurray's test. The appellant reported that he was only able to squat halfway due to knee pain. He had a negative straight leg test. He stated that during a flare-up of his left knee condition he is unable to stand or walk. Based upon the medical evidence of record, the Board finds that the appellant is not entitled to an evaluation in excess of 30 percent from August 1, 2004. There is no indication the appellant had severe painful motion or weakness in the affected extremity. The November 2007 VA examination indicated there with no additional limitation of motion of flexion of the left knee on repetitive use. Similarly, the February 2009 VA examiner noted there was no further decrease in range of motion following repetitive motion. The appellant is also not entitled to a higher evaluation for residual weakness, pain or limitation of motion by analogy to Diagnostic Codes 5256, 5261 or 5262. Diagnostic Code 5256 provides for an evaluation for ankylosis of the knee. However, there was no indication the appellant had ankylosis of the knee. A higher evaluation is not warranted under Diagnostic Code 5261 for limitation of extension of the leg because the February 2009 VA examination indicated the appellant had normal extension of the knee with no limitation. Finally, a higher evaluation is not warranted under Diagnostic Code 5262 for impairment of the tibia and fibula. The November 2007 VA examination and February 2009 VA examination did not indicate there was any impairment of the tibia and fibula. The Board has considered other knee-related Diagnostic Codes to determine whether any would result in an evaluation in excess of 30 percent, but finds none. The November 2007 and February 2009 VA examinations do not indicate that the appellant had compensable limitation of motion of the left knee. The February 2009 VA examination indicated the appellant had left knee flexion of 120 degrees. Flexion limited to 45 degrees is required for a compensable evaluation under Diagnostic Code 5260. Therefore, Diagnostic Codes 5260 and 5261 for limitation of flexion and extension of the left knee are not applicable. If compensable limitation of motion is absent, the highest evaluation under Diagnostic Code 5003 is 20 percent, less than the appellant's current 30 percent evaluation. Diagnostic Code 5262 is not applicable because there is no evidence of ankylosis. As there is no evidence of recurrent subluxation or lateral instability, Diagnostic Code 5257 is inapplicable. There is also no evidence of impairment of the tibia and fibula, rated under Diagnostic Code 5262 or genu recurvatum, under Diagnostic Code 5263. The appellant is not entitled to a higher evaluation under Diagnostic Code 5002 for rheumatoid arthritis or 5009 for polyarthritis, as there is no evidence he has symptoms of active process rheumatoid arthritis. The November 2007 VA examiner specifically noted that the appellant had never been diagnosed with rheumatoid arthritis or other inflammatory arthritis. In sum, the Board finds that the evidence does not support an evaluation in excess of 30 percent for the left knee disability from August 1, 2004. While the appellant is competent to report the symptoms he experiences, and the Board finds him credible in this regard, except where in contrast to objective clinical findings, the reported symptoms are consistent with the assigned schedular evaluation. The evidence does not indicate that the appellant had severe painful motion of weakness in his left knee or intermediate degrees of residuals weakness, pain or limitation of motion. There was no indication the appellant's left knee range of motion decreased to a compensable degree. See DeLuca, 8 Vet. App. at 206-07. Further, there was no evidence of laxity or other problems with the left knee that would warrant a separate evaluation under another Diagnostic Code. However, it is the intention to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum rating for the joint. 38 C.F.R. § 4.59 (2009). Consequently, the Board finds that the appellant is not entitled to an evaluation in excess of 30 percent for the left knee disability, from August 1, 2004. The Board has been mindful of the benefit- of-the-doubt rule, but in this case, there is not such an approximate balance of the positive and negative evidence to permit a more favorable determination. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). iii. Right knee osteoarthritis, prior to November 30, 2004 In the June 2008 rating decision, the RO assigned a 10 percent evaluation, prior to November 30, 2004, for right knee osteoarthritis. In the December 1999 VA examination, the appellant reported that he had constant pain in his right knee. He had weakness and stiffness, but denied any swelling, redness or localized heat. He controlled the pain with Tylenol. He did not use an assistive device for walking. The right knee had no local tenderness or effusion, although there was no pain elicited. Lateral instability seemed to be present to a slight degree. There was no crepitation. Otherwise, the knee seemed to be stable. The December 1999 VA examination report found the appellant had normal flexion of the left knee, at 0 to 140 degrees, and normal extension of 0 degrees. The October 2000 VA examiner noted that the appellant had pain and stiffness on passive range of motion of the knees. He was able to squat. There was no acute sign of an internal knee disorder. McMurray's and Lachman's tests were negative. The knees were stable with no drawer sign. A June 2000 St. Joseph's Medical Center record indicated that the appellant fell off a ladder, injuring his right knee. A June 2000 discharge summary reflected that the appellant had sustained a fracture of the right patella. A July 2000 Northern Orthopedics record indicated that the appellant had good alignment on x-ray of his right knee. An October 2000 Northern Orthopedics medical record indicated x-rays showed that the right knee had some irregularity on the medial femoral condyle, but good alignment of the patella fracture. As noted above, the February 2001 VA examination indicated the appellant was quite active and continued to walk. He rated his knee pain as 6 out of 10. Both knees showed thickening of the pre-patella bursa. Cruciate and collateral ligaments were intact. There was no joint effusion or warmth. Alignment was excellent. There was no tenderness to light or firm palpation or crepitus of the patella tendons. X-rays showed there was mild loss of medial joint space, more so on the right knee, and sharpening of the tibial spine. Early osteophyte formation was noted on the right knee medially. The evidence of record prior to November 30, 2004, does not indicate that the appellant is entitled to an evaluation in excess of 10 percent for right knee osteoarthritis. The December 1999 VA examination indicated the appellant had normal flexion and extension of the right knee. Therefore, the appellant's right knee did not have flexion or extension limited to a compensable degree under Diagnostic Codes 5260 or 5261. Additionally, the evidence does not support a 20 percent evaluation under Diagnostic Code 5003 for x-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. The appellant did not report having occasional incapacitating exacerbations. The February 2001 VA examination specifically indicated the appellant was quite active and continued to walk. In the August 2002 Board hearing, the appellant stated that he was working building houses for his children. The Board has also considered if the principles outlined in Deluca, 8 Vet. App. 206-07, and 38 C.F.R. §§ 4.40 and 4.45 could afford the appellant a higher evaluation. The Board finds that there has been no demonstration of functional impairment comparable to the criteria for the next-higher evaluation. The Board has considered other knee-related Diagnostic Codes to determine whether any would result in an evaluation in excess of 10 percent. Diagnostic Code 5256 is not applicable because there is no medical evidence of ankylosis associated with the appellant's right knee disability. Diagnostic Code 5258 is not applicable because there was no medical evidence of dislocated semilunar cartilage. As there was no medical evidence of the removal of semilunar cartilage, Diagnostic Code 5259 is inapt. There is also no evidence of nonunion or malunion of the tibia or fibula, or of acquired traumatic genu recurvatum with weakness and insecurity of weight bearing, thereby negating the application of Diagnostic Codes 5262 and 5263. The December 1999 VA examination noted that the right knee was somewhat lax with anteroposterior movements, though there was no pain elicited. The VA examiner also noted that lateral instability seemed to be present to a slight degree. However, the December 2000 VA examination report indicated that the knee was stable and that the McMurray and Lachman tests were negative. The February 2001 VA examination report indicated that the appellant's knee alignment was excellent. There was no crepitus of the patellar tendons. Additionally, a July 2000 Northern Orthopedics medical record indicated that the appellant had good alignment on an x-ray of his right knee. Although the December 1999 VA examiner noted that there was sight lateral instability of the knee, there is no other evidence of record that the appellant had lateral knee instability prior to January 1, 2006. The appellant did not report symptoms of knee instability. Consequently, the Board finds that a preponderance of the evidence is against granting the appellant a separate evaluation for lateral instability under Diagnostic Code 5257. In sum, the Board finds that the appellant is not entitled to an evaluation in excess of 10 percent for right knee osteoarthritis prior to January 1, 2006. While the appellant is competent to report the symptoms he experiences, and the Board finds him credible in this regard, except where in contrast to objective clinical findings, the reported symptoms are consistent with the assigned schedular evaluation. The appellant's right knee did not have flexion or extension limited to a compensable degree under Diagnostic Codes 5260 or 5261. The Board has been mindful of the benefit-of-the-doubt rule, but in this case, there is not such an approximate balance of the positive and negative evidence to permit a more favorable determination. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). iv. Right knee osteoarthritis, status post total knee arthroplasty, from January 1, 2006 The appellant received a total right knee replacement in November 2004. A December 2004 discharge summary from St. Joseph's Hospital indicated that the appellant had a range of motion of 0 to 90 degrees upon discharge. In the November 2007 VA examination, the appellant's right and left knee had flexion of 0 to 125 degrees, with no additional limitation of motion on repetitive use. The right knee had extension of 125 to 0 degrees, with no additional limitation of motion on repetitive use. As noted above, the appellant used a cane for walking, but there was no evidence of incapacitating episodes of arthritis. The appellant was able to stand for 10 to 15 minutes and walk a quarter of a mile. There were no episodes of dislocation or subluxation or locking episodes. The appellant had increased wear outside of the edge of his right and left shoes and an antalgic gait. In the February 2009 VA examination, the appellant's right knee had flexion of 110 degrees without pain and extension of 0 degrees. The passive range of motion was the same as the active range of motion. Regarding DeLuca, following repetitive motion, there was no further decrease in range of motion of the right knee. The appellant's gait was antalgic. He could squat only halfway due to knee pain. Based upon the medical evidence of record, the Board finds that the appellant is not entitled to an evaluation in excess of 30 percent for his right knee disability from August 1, 2004. There is no indication the appellant had severe painful motion or weakness in the affected extremity. The February 2009 VA examiner noted there was no further decrease in range of motion for any reason following repetition. The appellant is also not entitled to a higher evaluation for residual weakness, pain or limitation of motion by analogy to Diagnostic Codes 5256, 5261 or 5262. Diagnostic Code 5256 provides for an evaluation for ankylosis of the knee. However, there was no indication the appellant had ankylosis of the knee. A higher evaluation is not warranted under Diagnostic Code 5261 for limitation of extension of the leg because the February 2009 VA examination indicated the appellant had normal extension of the knee with no limitation. Finally, a higher evaluation is not warranted under Diagnostic Code 5262 for impairment of the tibia and fibula. The November 2007 VA examination and February 2009 VA examination did not indicate there was any impairment of the tibia and fibula. The Board has considered other knee-related Diagnostic Codes to determine if any would result in an evaluation in excess of 30 percent, but finds none. The November 2007 and February 2009 VA examinations do not indicate that the appellant had a compensable limitation of motion of the right knee. The February 2009 VA examination indicated the appellant had flexion of 110 degrees. Flexion limited to 45 degrees is required for a compensable evaluation under Diagnostic Code 5260. Therefore, Diagnostic Codes 5260 and 5261 for limitation of flexion and extension of the right knee are not applicable. If limitation of motion is absent, the highest evaluation under Diagnostic Code 5003 is 20 percent, less than the appellant's current 30 percent evaluation. Diagnostic Code 5262 is not applicable because there is no evidence of ankylosis. As there is no evidence of recurrent subluxation or lateral instability, Diagnostic Code 5257 is inapplicable. There is also no evidence of impairment of the tibia and fibula, rated under Diagnostic Code 5262 or genu recurvatum, under Diagnostic Code 5263. The appellant is not entitled to a higher evaluation under Diagnostic Code 5002 for rheumatoid arthritis or 5009 for polyarthritis, as there is no evidence he has symptoms of active process rheumatoid arthritis. In sum, the Board finds that the evidence does not support an evaluation in excess of 30 percent for the right knee disability from January 1, 2006. While the appellant is competent to report the symptoms he experiences, and the Board finds him credible in this regard, except where in contrast to objective clinical findings, the reported symptoms are consistent with the assigned schedular evaluation. The evidence does not indicate that the appellant had severe painful motion of weakness in his right knee or intermediate degrees of residuals weakness, pain or limitation of motion. There was no indication the appellant's right knee range of motion decreased to a compensable degrees. See DeLuca, 8 Vet. App. at 206-07. Further, there was no evidence of laxity or other problems with the right knee that would warrant a separate evaluation under another Diagnostic Code. However, it is the intention to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum rating for the joint. 38 C.F.R. § 4.59 (2009). Consequently, the Board finds that the appellant is not entitled to an evaluation in excess of 30 percent for the right knee disability, from January 1, 2006. The Board has been mindful of the benefit-of-the-doubt rule, but in this case, there is not such an approximate balance of the positive and negative evidence to permit a more favorable determination. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). B. Hand Disability Evaluations The appellant contends that his bilateral hand disabilities warrant evaluations in excess of 10 percent. For the reasons that follow, the Board concludes that higher evaluations are not warranted. Under Diagnostic Code 5215, an evaluation of 10 percent is warranted for dorsiflexion of less than 15 degrees or palmar flexion limited in line with the forearm. 38 C.F.R. § 4.71a. The 10 percent evaluation is warranted for either dominant or non-dominant wrist. 38 C.F.R. § 4.69. For the purpose of rating disabilities from arthritis, the wrist is considered a major joint. 38 C.F.R. § 4.45. i. Right hand osteoarthritis In the December 1999 VA examination, the appellant reported that he had problems with pain and stiffness in his fingers, especially the right hand. He noticed more problems during cold and damp weather. On physical examination, both hands appeared grossly normal and symmetrical. The tip of his thumb could proximate all the fingers and the tips of his fingers could approximate the median transverse fold of the palm. The grasping ability and strength of both hands and fingers was normal. Writing with both hands seemed normal. He reported having a problem with twisting and sometimes grasping or gripping pipes. On VA examination in October 2000, the appellant reported doing woodcarving as a hobby and having no problems with it. He also did not have any problems with gross motor activity like chopping wood. Upon physical examination, the VA examiner did not find any problems with his hands. The VA examiner noted that he did not see any disability of his hands at all functionally and physically, and his hands seemed perfectly normal for his age. Upon VA examination in February 2001, the appellant's wrists had no swelling, erythema, warmth, or tenderness. He had good range of motion of his wrist for his age. He formed an 80 percent fist bilaterally. The November 2007 VA examination report reflected that the appellant had right and left wrist radial deviation of 0 to 20 degrees with no additional loss of motion on repetitive use. The right wrist had palmar flexion of 0 to 60 degrees with no loss of motion on repetitive use. In the February 2009 VA examination, the appellant reported continuing problems with right hand pain, decreased strength and decreased dexterity. He described his pain as a 2 out of 10, with flare-ups to 7 out of 10 four to five days per month. The appellant reported having an injury with a skill saw 30 years ago, injuring his third, fourth and fifth digits of his right hand. He reported having tendon repair in July 1979. He reported problems with pain, weakness and stiffness, but he did not report swelling, heat, or redness. He noted that his grip had gotten worse over the last two years. The February 2009 VA examiner found that the appellant's grip strength was diminished 4+ out of 5 for both his right and left hands. The appellant's right hand had no tissue tenderness to palpation. He had nontender digits and metacarpals and no tenderness at the snuff box. He was able to oppose his thumb to all five fingers bilaterally with normal strength. Due to his past injury, the third, fourth and fifth digit did not touch the palmar crease, but he was able to touch all fingers to the palm. There was a decreased range of motion in the joint. Active range of motion of the metacarpophalangeal joint of the right hand was 90 out of 90. Proximal interphalangeal extension was 0 out of 0 for the thumb, index and middle finger and -5 degrees from full extension for the ring and small fingers. Proximal interphalangeal flexion was 100 out of 100 for the thumb and index finger, 90 out of 100 for the middle finger, 90 out of 100 for the ring finger, and 85 out of 100 for the fifth finger. Distal interphalangeal extension was 0 out of 0 for the index, middle, ring, and fifth finger. Distal interphalangeal flexion was 70 out of 70 for the index finger, 60 out of 70 for the middle finger, and 0 out of 70 for the ring finger and fifth digit. All range of motion of the right hand was without pain. Passive range of motion was the same as active range of motion. Following repetitive motion, there was no further decrease in the range of motion of the joints of the right hand. The VA examiner noted that the appellant's third finger was 1/4 inch beyond the palmar crease, and the fourth and fifth digits were 1 1/2 inches from the palmar crease due to the past traumatic saw injury, which is not service-connected. The evidence does not indicate that the appellant's right wrist had dorsiflexion of less than 15 degrees or palmar flexion limited in line with the forearm. Therefore, a compensable evaluation is not warranted under Diagnostic Code 5215 for limitation of motion. The appellant's right hand osteoarthritis is currently evaluated at 10 percent under Diagnostic Code 5003, for x-ray evidence of the involvement of two or more major joints. An evaluation of 20 percent is not warranted under Diagnostic Code 5003 because there is no evidence of occasional incapacitating exacerbations. The October 2000 VA examiner noted that he did not see any disability of his hands at all functionally and physically, and the February 2001 VA examiner noted that the appellant had good wrist range of motion for his age. Further, the February 2009 VA examiner noted that all range of motion of the right hand was without pain. The Board has also considered whether the appellant would be entitled to a higher evaluation for the right hand disability under another Diagnostic Code. There is no evidence of ankylosis of the appellant's right digits. Consequently, Diagnostic Codes 5216 through 5227 are not applicable. Regarding limitation of motion of individual digits, although the February 2009 VA examination indicated that the ring and little finger of the right hand had some limitation of motion, any limitation of motion of the ring or little finger is noncompensable under Diagnostic Code 5230. The February 2009 VA examination also indicated that the appellant's third finger was 1/4 inch beyond the palmar crease and had proximal interphalangeal flexion of 90 out of 100 for the middle finger. Diagnostic Code 5229 provides for a noncompensable evaluation for a gap of less than one inch between the middle fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and extension limited by no more than 30 degrees. Therefore, a higher evaluation is not warranted for limitation of motion of the middle finger. The February 2009 VA examination indicated the range of motion of the thumb and index finger was normal. There was no further decrease in range of motion of the joints of the right hand following repetition. See DeLuca, 8 Vet. App. at 206-07. The Board has considered whether the appellant is entitled to a separate evaluation for scars on the right hand. The February 2009 VA examination report indicates that the appellant had an injury with a skill saw 30 years ago, after service, that required tendon repair surgery. The appellant did not report having problems with a scar. The February 2009 VA examination report reflects that there was no swelling, heat, redness, or tenderness of the hand. Therefore, the Board finds that a separate evaluation for a scar is not applicable. In sum, the Board finds that the appellant is not entitled to an evaluation in excess of 10 percent for right hand osteoarthritis. While the appellant is competent to report the symptoms he experiences, and the Board finds him credible in this regard, except where in contrast to objective clinical findings, the reported symptoms are consistent with the assigned schedular evaluation. The evidence does not indicate the appellant has a loss of range of motion of the wrist or compensable loss of range of motion of the digits. Further, there is no evidence of occasional incapacitating exacerbations. Thus, an evaluation higher than the currently assigned 10 percent is not warranted on any basis, to include DeLuca considerations. As the preponderance of the evidence is against the claim, and increased evaluation is denied. ii. Left hand osteoarthritis The appellant also contends that he is entitled to an evaluation in excess of 10 percent for left hand osteoarthritis. For the reasons that follow, the Board finds that a higher evaluation is not warranted. As noted above, the December 1999 VA examiner found that both the appellant's hands appeared normal and symmetrical. The tip of his thumb could proximate all the fingers and tips of his fingers could approximate the median transverse fold of the palm. The October 2000 VA examination report indicates that the appellant is left-handed and that the appellant had no problems with fine or gross motor activity. The VA examiner noted that he did not see any disability of his hands at all functionally and physically, and his hands seemed perfectly normal for his age. The February 2001 VA examination report indicated that the appellant reported having pain in his left wrist as a 7 out of 10. The VA examiner noted that there was an old laceration affecting the left fourth and fifth proximal interphalangeal joints in the volar surface with some loss of motion. He had early Herberden and Bouchard nodes particularly in the second and fifth digits. There was some rotation of the fingers with the index finger and the fifth finger turning inward toward the longer finger. Upon VA examination in November 2007, the appellant's right and left wrists had radial deviation of 0 to 20 degrees with no additional loss of motion on repetitive use. Left palmar flexion was 66 degrees, but all other left wrist movements were within a normal range. In the November 2009 VA examination, the appellant reported having no problems with left hand pain and no history of trauma to the hands or fingers. He noted having a fracture to the left wrist more than 20 years ago. He reported decreased strength, but normal dexterity and no limitation of motion or functional impairment. He did not report having flare-ups. Upon examination, the left hand had no tenderness. He was able to oppose his thumb to all fingers with normal strength. The active range of motion of the metatarsophalangeal joints was normal. Flexion and extension of the proximal and distal interphalangeal joints was also normal. There was no pain during the range of motion tests. Passive range of motion was the same as active range of motion and there was no further decrease in range of motion of the left hand following repetitive motion. The appellant's left hand is currently evaluated under Diagnostic Codes 5215-5003. The evidence of record does not indicate that the appellant's left wrist had dorsiflexion of less than 15 degrees or palmar flexion limited in line with the forearm. Consequently, a compensable evaluation is not warranted under Diagnostic Code 5215 for limitation of motion. Further, an evaluation of 20 percent is not warranted under Diagnostic Code 5003 because there is no evidence of occasional incapacitating exacerbations of the disability. The VA examiner noted that he did not see any disability of his hands at all functionally and physically. In the February 2009 VA examination, the appellant reported having normal dexterity and no limitation of motion or functional impairment of his left hand. The February 2009 VA examiner also noted that all range of motion of the left hand was without pain. The Board has also considered whether the appellant would be entitled to a higher evaluation for the left hand osteoarthritis under another Diagnostic Code. There is no evidence of ankylosis of the appellant's left digits. Consequently, Diagnostic Codes 5216 through 5227 are not applicable. Regarding limitation of motion of individual digits, the February 2009 VA examination indicated that the appellant's the range of motion of the appellant's left digits was normal. There was no further decrease in range of motion of the joints of the right hand following repetition. See DeLuca, 8 Vet. App. at 206-07. Additionally, there is no evidence that appellant had a scar on his left hand. Therefore, a separate evaluation under the diagnostic criteria for scars is not warranted. In sum, the Board finds that the appellant is not entitled to an evaluation in excess of 10 percent for left hand osteoarthritis. While the appellant is competent to report the symptoms he experiences, and the Board finds him credible in this regard, except where in contrast to objective clinical findings, the reported symptoms are consistent with the assigned schedular evaluation. The evidence does not indicate the appellant has a loss of range of motion of the wrist or digits. Further, there is no evidence of occasional incapacitating exacerbations. Thus, an evaluation higher than the currently assigned 10 percent is not warranted on any basis, to include DeLuca considerations. As the preponderance of the evidence is against the claim, it is denied. C. Ankle osteoarthritis Under Diagnostic Code 5271, moderate limitation of motion of the ankle warrants a 10 percent disability evaluation, and marked limitation of the ankle warrants a 20 percent disability evaluation. The average normal range of motion of the ankle is from zero to twenty degrees of dorsiflexion and from zero to forty-five degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II. The December 1999 VA examination report indicates that the appellant's ankles appeared normal with no restricted range of motion, local tenderness or deformities. The October 2000 VA examination report reflects that the appellant's ankle had full range of motion and good strength for his age. There was no pain on palpation of joints of the ankle against resistance, flexion and palpation. The February 2001 VA examination report indicates that there was minimal ankle joint tenderness at the Achilles insertion on the heel. There was no swelling, redness, or palpable effusion at this area. There was also no warmth. X-rays showed large Achilles spurs bilaterally and some mild degenerative joint disease. The VA examiner noted that symptoms of long standing Achilles tendonitis with bone spurs were being exacerbated by current footwear. The November 2007 VA examination report reflects that the appellant's right and left ankles had dorsiflexion of 0 to 20 degrees with no additional loss of motion on repetitive use. The right and left ankles had plantar flexion of 0 to 45 degrees with no additional loss of motion on repetitive use. i. Right ankle osteoarthritis In the February 2009 VA examination, the appellant reported that his right ankle condition had been increasing in severity. He reported problems with pain, weakness, and fatigue. He denied any stiffness, swelling, heat, redness, instability, giving way, and locking. He stated that the pain was 3 out of 10, flaring up to 5 out of 10 two times per month and lasting a few hours. Regarding additional limitation of motion and functional impairment during a flare up, he stated that he needs to sit down an rest. He denied any surgery or injury to the ankle. There was no dislocation or recurrent subluxation. The appellant reported that he felt somewhat unsteady with his gait. Upon physical examination, the appellant had no tissue tenderness to the right Achilles tendon, medial or lateral malleoli, or dorsum of the foot. The right ankle was ligamentously stable without deformity. Active range of motion of the right ankle revealed plantar flexion of 45 out of 45 without pain and dorsiflexion of 20 out of 20 without pain. Passive range of motion was the same as active range of motion. Following repetitive motion, there was no further decrease in range of motion. The Board finds that the evidence indicates that the appellant is not entitled to an evaluation in excess of 10 percent for right ankle osteoarthritis. The VA examinations indicate that the appellant's right ankle had a full range of motion. For a compensable evaluation of 10 percent under Diagnostic Code 5271, moderate limited motion of the ankle is required. Although the appellant reported right ankle pain, in the February 2009 VA examination, there was no additional loss of range of motion upon repetition due to pain. See DeLuca, 8 Vet. App. at 206-07. As the appellant did not report having occasional incapacitating exacerbations, an evaluation of 20 percent is not warranted under Diagnostic Code 5003. The current evaluation of 10 percent under Diagnostic Code for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups is consistent with the appellant's right ankle symptoms. The Board has considered whether a higher evaluation is warranted under another Diagnostic Code, but finds none. As the evidence does not indicate that the appellant had ankylosis of his ankle, Diagnostic Code 5270 for ankylosis of the ankle is not applicable. There was also no evidence of ankylosis of the subastragalar or tarsal joint, malunion of os calcis or astragalus, or an astragalectomy. Thus, Diagnostic Codes 5272, 5273 and 5274 are not applicable. In sum, the Board finds that the appellant's current evaluation of 10 percent is consistent with the appellant's right ankle symptoms, and that a higher evaluation is not warranted. While the appellant is competent to report the symptoms he experiences, and the Board finds him credible in this regard, except where in contrast to objective clinical findings, the reported symptoms are consistent with the assigned schedular evaluation. The evidence does not indicate that the appellant had a loss of range of motion of his ankle or any incapacitating exacerbations. Thus, an evaluation higher than the currently assigned 10 percent is not warranted on any basis, to include DeLuca considerations. As the preponderance of the evidence is against the claim, it is denied. ii. Left ankle osteoarthritis The February 2009 VA examination report indicates that the appellant reported that his left ankle condition had increased in severity. He reported problems with pain, weakness and fatigue, but denied any stiffness, swelling, heat, redness, instability, giving way, and locking. The pain was 1 out of 10, flaring up to 3 out of 10, usually two times per month for up to an hour. He denied any surgery or injury. There was no dislocation or recurrent subluxation, or additional loss of range of motion or functional impairment during a flare up. He reported that he unable to walk for any distance and can no longer go up and down a ladder. Upon physical examination, the February 2009 VA examiner noted that the appellant's left ankle had no tissue tenderness. The left ankle was ligamentously stable without deformity. The active range of motion of the left ankle revealed a normal range of motion with plantar flexion of 45 out of 45 without pain. Dorsiflexion was 20 out of 20 without pain. Passive range of motion was the same as active range of motion. There was no further decrease in range of motion of the left ankle following repetitive motion. The Board finds that the evidence indicates that the appellant is not entitled to an evaluation in excess of 10 percent for left ankle osteoarthritis. The VA examinations indicate that the appellant's left ankle had a full range of motion. For a compensable evaluation of 10 percent under Diagnostic Code 5271, moderate limited motion of the ankle is required. Although the appellant reported left ankle pain, in the February 2009 VA examination, there was no additional loss of range of motion upon repetition due to pain. See DeLuca, 8 Vet. App. at 206-07. As the appellant did not report having occasional incapacitating exacerbations, an evaluation of 20 percent is not warranted under Diagnostic Code 5003. The current evaluation of 10 percent under Diagnostic Code for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups is consistent with the appellant's left ankle symptoms. The Board has considered whether a higher evaluation is warranted under another Diagnostic Code, but finds none. As the evidence does not indicate that the appellant had ankylosis of his ankle, Diagnostic Code 5270 for ankylosis of the ankle is not applicable. There was also no evidence of ankylosis of the subastragalar or tarsal joint, malunion of os calcis or astragalus, or an astragalectomy. Thus, Diagnostic Codes 5272, 5273 and 5274 are not applicable. In sum, the Board finds that the appellant's current evaluation of 10 percent is consistent with the appellant's left ankle symptoms, and that a higher evaluation is not warranted. While the appellant is competent to report the symptoms he experiences, and the Board finds him credible in this regard, except where in contrast to objective clinical findings, the reported symptoms are consistent with the assigned schedular evaluation. The evidence does not indicate that the appellant had a loss of range of motion of his left ankle or any incapacitating exacerbations. Thus, an evaluation higher than the currently assigned 10 percent is not warranted on any basis, to include DeLuca considerations. III. Extraschedular The Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extraschedular consideration referral). The schedular evaluations for the appellant's disabilities are not inadequate. The appellant has not reported significant treatment, hospitalization or symptoms unaccounted for by the ratings schedule. As a result, it does not appear that the appellant has an "exceptional or unusual" disability. He does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. Therefore, the available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is moot. See Thun, 22 Vet. App. at 115. IV. Special Monthly Compensation The appellant contends that he is entitled to an earlier effective date, prior to November 30, 2004, for the grant of special monthly compensation based on housebound status due to his service-connected disabilities. Special monthly compensation provided by 38 U.S.C.A. § 1114(s) is payable where the Veteran has a single service-connected disability evaluated as 100 percent and, (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. This requirement is met when the Veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 C.F.R. § 3.350(i). The June 2008 rating decision granted the appellant special monthly compensation based on housebound criteria effective November 30, 2004, based on one service-connected disability evaluated at 100 percent disabling and other multiple disabilities with a combined evaluation of at least 60 percent. 38 U.S.C.A. § 1114(s), 38 C.F.R. § 3.350(i). The record shows that effective November 30, 2004, the appellant had a 100 percent evaluation due to his right knee total arthroplasty, a 30 percent evaluation for his left knee osteoarthritis, status post total knee arthroplasty, a 10 percent evaluation for right hand osteoarthritis, a 10 percent evaluation for left hand osteoarthritis, a 10 percent evaluation for right ankle osteoarthritis, and a 10 percent evaluation for left ankle osteoarthritis. Although the appellant had a 100 percent evaluation effective June 4, 2003, for a left total knee arthroplasty, his other service-connected disabilities did not have a combined evaluation of at least 60 percent. The record shows that effective June 4, 2003, the appellant had a 10 percent evaluation for right knee osteoarthritis, a 10 percent evaluation for right hand osteoarthritis, a 10 percent evaluation for left hand osteoarthritis, a 10 percent evaluation for right ankle osteoarthritis, and a 10 percent evaluation for left ankle osteoarthritis. The combined evaluation of the service-connected disabilities other than the 100 percent left knee disability, including the bilateral factor, was less than 60 percent. Therefore, the appellant did not meet the criteria for special monthly compensation at the housebound rate based on his service- connected disabilities. Additionally, the evidence does not show that the appellant was substantially confined to his home by reason of his service- connected disabilities prior to November 30, 2004. In the February 2001 VA examination, the appellant reported that he was quite active and continued to walk. In the August 2002 hearing, the appellant noted that he worked helping his children build houses. See August 2002 Hearing Transcript, at page 6. Thus, there is no legal basis for making the effective date of special monthly compensation at the housebound rate earlier than November 30, 2004. Further, there is no indication the appellant filed a claim for special monthly compensation prior to the June 2008 rating decision, which granted entitlement to special monthly compensation. In sum, the evidence of record does not indicate that the appellant was entitled to special monthly compensation at the housebound rate earlier than November 30, 2004. The appellant has not provided or identified any evidence that he was substantially confined to his home and his service-connected disability evaluations did not meet the criteria of 38 U.S.C.A. § 1114(s). As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54- 46 (1990). V. Entitlement to TDIU The appellant has asserted that he is unemployable as a result of his service-connected disabilities and is thus entitled to TDIU. For the reasons below, the Board concludes that entitlement to TDIU is not warranted. Total disability ratings for compensation may be assigned where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of a service-connected disabilities: Provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). To meet the requirement of "one 60 percent disability" or "one 40 percent disability," the following will be considered as one disability: (1) disability of one or both upper extremities, or one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). To establish a total disability rating based on individual unemployability, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. In reaching such a determination, the central inquiry is whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Unemployability associated with advancing age or intercurrent disability may not be used as a basis for assignment of a total disability rating. 38 C.F.R. § 4.19 (2009). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation; provided that permanent total disability shall be taken to exist when the impairment is reasonably certain to continue throughout the life of the disabled person. 38 C.F.R. § 4.15. The appellant filed a claim for TDIU in December 2008. During the period on appeal, the appellant has been service-connected for osteoarthritis, left knee status post total knee arthroplasty, evaluated as 30 percent disabling; osteoarthritis, right knee status post total knee arthroplasty, evaluated as 30 percent disabling; right hand osteoarthritis, evaluated as 10 percent disabling, left hand osteoarthritis, evaluated as 10 percent disabling; right ankle osteoarthritis, evaluated as 10 percent disabling, and left ankle osteoarthritis, evaluated as 10 percent disabling. From January 1, 2006, the appellant's combined evaluation is 80 percent. 38 C.F.R. § 4.25 (2009). Since disabilities of one or both upper extremities, or one or both lower extremities are treated as one disability, the appellant's knee and ankle disabilities are treated as one disability rated at more than 40 percent. Consequently, the appellant's combined disability rating is 70 percent or more and he has at least one disability ratable at 40 percent or more. Thus, the record indicates that the appellant meets the schedular criteria listed in 4.16(a). However, for the appellant to prevail on his claim for TDIU, the record must reflect that he is precluded from engaging in substantially gainful employment consistent with his education and occupational experience. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the appellant is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose, 4 Vet. App. 361, 363 (1993). In evaluating an appellant's employability, consideration may be given to his level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In a VA Form 21-894, Application for Increased Compensation based on Unemployability, received in December 2008, the appellant indicated that he worked as a contractor from 1946 to January 2007. He noted that he worked part-time from 1987 to 2007. He reported that he completed three years of high school and got his General Equivalency Diploma (GED). He also noted that he got his plumber's license in 1959, and most recently renewed it in 2008. The appellant reported that he worked as a construction contractor since leaving service, and had worked until 2007 when he was unable to do it anymore due to the arthritis in his joints. He reported that he could not get up and down or crawl around like he needs to because of his service-connected arthritis of the knees and ankles. He stated that arthritis in his hands makes it difficult to use the tools of his trade. In the February 2009 VA examination, the appellant reported that he had a head injury with loss of consciousness in January 2007 after falling off a ladder. He reported that he used to be very active with his son's construction business prior to the fall, but stated that since the time of the accident, he has been unable to perform the tasks that he did in the past on a regular basis. He reported that he continued to drive and had no limitations regarding driving. He reported that from discharge until 1987 he worked fulltime as a self-employed building contractor. From 1987 through 2007, at the time of his injury, he was working part-time for his son who was a building contractor. He reported that the last time he did any plumbing work was in September 2008. He stated that he now mostly assists his son in a supervisory capacity. The appellant reported that he has been advised by his providers that he could not get up on a ladder and could not be crawling around on his knees on a regular basis. The February 2009 VA examiner opined that the appellant is fully capable of gainful employment based on intact cognition. He had full use of his upper and lower extremities. Speech was intact. However, he was unable to continue to perform duties required of a master plumber. He reported that he was unable to perform the tasks of a plumber due to his inability to walk any distance or stand for any prolonged period of time. Therefore, the VA examiner opined that although, in his medical opinion, he was fully capable of gainful employment, he was not capable of gainful employment in his previous career as a master plumber. The evidence of record does not indicate the appellant's service- connected disabilities have resulted in functional impairment to such a degree as to preclude employability, including of a sedentary nature. The February 2009 VA examination indicates that the appellant lives independently, prepares his own meals, picks up his house, and continues to drive. In the February 2009 VA examination, he also reported that he assists his son with his construction business in a supervisory capacity. Although the appellant has asserted that he cannot work due to his service-connected disabilities, the medical evidence of record shows that the appellant has no exceptional or unusual factor associated with his service-connected disabilities that render the regular schedular standards impracticable. The appellant indicated in his application that he became too disabled to work in 2007. In an August 2002 hearing, the appellant stated that he retired fourteen years previously when he was 62. See August 2002 Hearing Transcript, at page 6. He reported that it was regular retirement, not on the basis of disability. Id. He stated that although he was retired, he still worked helping his children build houses. Id. The Board finds the appellant is not precluded from securing and maintaining substantially gainful employment, consistent with his educational and occupational experience, due to his service- connected disabilities. The February 2009 VA examination indicates the appellant is still able to perform activities of daily living and assist his son in his construction business in a supervisory capacity. The February 2009 VA examiner noted that the appellant was unable to continue to perform duties required of a master plumber because he cannot climb up and down ladders and has a difficult time kneeling due to his service-connected knee disabilities. However, he opined that the appellant was fully capable of gainful employment based on intact cognition. He had full use of his upper and lower extremities and speech was intact. Consequently, the Board finds that the appellant is capable of gainful employment, and schedular TDIU is not warranted under 38 C.F.R. § 4.16(a). The Board has also considered whether the appellant is entitled to referral for extra-schedular consideration under 38 C.F.R. § 4.16(b). However, there is nothing in the record to indicate that his service-connected disabilities cause impairment with employment over and above that which is contemplated in the assigned schedular rating of 80 percent. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). As discussed above, the appellant's disabilities have not affected his activities of daily living and there is no indication the appellant's service-connected disabilities have impaired his employment beyond the level of impairment contemplated by a schedular rating of 80 percent. The Board therefore has determined that referral of this case for extra- schedular consideration pursuant to 38 C.F.R. § 4.16(b) is not warranted. For the reasons above, the Board concludes that the preponderance of the evidence is against the appellant's claim for a TDIU. Thus, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54- 56 (1990). ORDER 1. A separate evaluation of 10 percent for lateral instability of the left knee is granted, prior to June 4, 2003. 2. Entitlement to an evaluation in excess of 30 percent for osteoarthritis, previously evaluated as polyarthritis, left knee, status post total knee arthroplasty, from August 1, 2004, is denied. 3. Entitlement to an evaluation in excess of 10 percent for osteoarthritis, previously evaluated as polyarthritis, right knee, prior to November 30, 2004, is denied. 4. Entitlement to an evaluation in excess of 30 percent for osteoarthritis, previously evaluated as polyarthritis, right knee, status post total knee arthroplasty from January 1, 2006, is denied. 5. Entitlement to an evaluation in excess of 10 percent for osteoarthritis, right hand, previously evaluated as polyarthritis, is denied. 6. Entitlement to an evaluation in excess of 10 percent for osteoarthritis, left hand, previously evaluated as polyarthritis, is denied. 7. Entitlement to an evaluation in excess of 10 percent for osteoarthritis, right ankle, previously evaluated as polyarthritis, is denied. 8. Entitlement to an evaluation in excess of 10 percent for osteoarthritis, left ankle, previously evaluated as polyarthritis, is denied. 9. Entitlement to an effective date earlier than November 30, 2004, for special monthly compensation, is denied. 10. Entitlement to a total disability rating based on individual unemployability (TDIU), is denied. ____________________________________________ J. K. BARONE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs